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HomeMy WebLinkAboutSNYDER LT 2Snyder Lot 2 #075-064-02 ►'IUr4 I C: I F„C-1L I -Ir *-e Ci F= Rr-4CHl_iF:Rr�E DEPARTMENT HEALTH AND ENVIRONMENTALI"ROTECTION 820 STREET, ANCHORAGE, AK:. a_ _jl 264-4720 44EL.L F>EF&Vl I T PERMIT NO. { 780240 ) APPLICANT JAY PFPGSTRAND 1414 TURPIN 333 5261 LOCATION CROW CREEK: HWY LEGAL T12N R2E S17 NWll4 E112 L35 LOT SIZE 0 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DI`•POSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL: OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER. REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'EF_rl I T [-=::-4F- I F'E�7- C -C- CEMe-E:F2 Z3:1, 1 �_ c: I CERTIFY THAT 1: I AM FAMILIAR. WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. SIGNED ISSUED BY JAY V3. 2 MUNICIPALITY OF ANCHORAGE Development Services Department v Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 075-064-02 Legal description SNYDER LT 2 Site address 1845 ALYESKA HWY Expiration Date: Current property owner(s) Paul, Heath and Nicholas Thomson 6/16/23 X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By: Original Certificate Date: 3/16/23 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval_June 2022 MUHMPAUTY OF ANCHORAGE Development Services Department ��� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Application 1. GENERAL INFORMATION Parcel I.D. 075-064-02 Complete legal description Snyder Lot 2 Location (site address) 1845 Alyeska Hwy, Girdwood, AK 99587 Current property owner(s) Paul, Heath, Nicholas Thomson Day phone 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS 3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑■ Community Septic or Public Sewer 5. SEPTIC TANK: P SteelIa#-iG P GeRGFeteP-Piberglass Age - See advisory if steel older than 20 years Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ g D Waiver Fee $ Date of Payment 311 S ).-;2U�23 Date of Payment COSA # OSCE 3 )053 Waiver # COSA Application—June 2022 Snyder Lot 2 075-064-02 5/19/78 56 56 18 3/7/22 Forge Engineering 41.2 3/1/23 > Benjamin Schiller, P.E. N/A N/A *23 N/A N/A (907) 522-7773 R jj5 " Municipality of Anchorage Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.orglonsite (907) 343-7904 A At CERTIFICATE OF ON-SITE SYSTEMS APPROVAL IL`' /FOR A SINGLE FAMILY DWELLING G Parcel I.D. 0 7-S' D N" O Z COSA# 10 7 O :2 0Z-7, 1. GENERAL INFORMATION Expiration Date: 9 - a 2 - O 7 Complete legal description SNYDER S/D; LOT 2 Location (site address) 1845 ALYESKA HIGHWAY • GIRDWOOD. AK Current Property owner(s) BRIAN do JANICE SNYDER Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing address Day phone 754-7345 HEIDI SNYDER w/PRUDENTIAL Day phone 727-0816 3801 CENTERPOINT DRIVE ► ANCHORAGE. AK 99503 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site ❑ Individual Holding tank ❑ Community On-site ❑ Public Sewer 0 The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of Onsite Systems 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 engineers 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 Certificate of On -Situ 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. 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 is(are) 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 %I zgcq Engineer's Comments: In conducting this evaluation, GEG, VD. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines d Regulations. The reported results described the performance of the system under the conditions encountered at the time of the lest, 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 V110, Approved for 3 bedrooms. Disapproved. erlr�sm�ssmsa� tciP ness.- —79 3 Conditional approval for bedrooms, with the slowing stipulations: Attachments: COSA Checklisty Arsenic Advisory Septic System Advisory Maintenance Agreements Well Flow Advisory Supplemental Engineer's Reort Nitrate Advisory Other -SITE :• WATER AND WASTEWATER )•• PROGRAM ��/////lnl)111111 By: 0 Original Certificate Date: �o — a 2 — 07 tR«. n nsl Municipality of Anchorage Development Services Department Building Safety Division OnSke Water b Wastewater Program 47W Sragaw Street P.O. Sox 195650 Andxwage, AK 995198650 www.munLorycnske (907)343.7904 CERTIFICATE OF ON—SITE SYSTEMS APPROVAL CHECKLIST Legal Description: SNYDER S/D: LOT 2 Parcel ID: O is -O 6 ! - 0:.? - AL :.?- A. WELL DATA Wen type PMM It A, B, or C provide PWSID# N/A Data completed 5/19/1978 Sanitary seal (YM) YES Total depth 58 ft. Cased to 58 ft. FROM WELL LOG Date of test 5/19/1978 Static water level 25 ft, Well production 10 g.p.m. Well Log (YM) YES Wires properly protected (YM) YES Casing height (above ground) 12+ in. AT INSPECTION 10/2/2006 41 ft. 4.62 g.p.m. WATER SAMPLE RESULTS: Conform colonies/100 ml. Nitrate D * 4f M- gA. Other bacteria -0--colonies/100 ml. Arsenic: tJD ugA. Date of sample: tqjll&Collectedby: GB B. SEPTIC(HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Tank size.gal. Foundation cleanout (YM) C. ABSORPTION FIELD DATA Number of Compartments Pumper tank (YM) Date installed (Y/N) High water alar (YM) Date installed Soil rating (g.p.dJft2or ft%bdr) _ System type Length ft. Width ft. Gravel bsl ft. Totai depth ft. Eft. absorption area_ ft' Monkoringto Depression over field Data of adequacy test Resuns ail) For bedrooms Fluid depth in absorption field before t _ in. Water added _gal. New depth _in. Elapsed Time: Final fluid depth _ in. Absorption rate >= g.p.d. treatment (past 12 mo.) (YM a type) If yes, give date D. LIFT STATION Date installed Size In gallons Manhole/Access (Y 'Pump on' level at _in. 'Pump oT le High water alarm level at in. Cycles tested Meets alar 8 circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots N/A Absorption field on lot N/A Public sewer main 75'+ On adjacent lots N/A Public sewer manhole/deanout 100'+ Sewer /septic service line '23' Holding tank N/A Animal containment areas 50'+ Manurelanimal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO: Building foundation Property line Absorption field — Water main Wells on Water SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property fine Surface water Building foundation Water Water service line Surface Curtain Wells on adjacent lots parkinglvehicle storage F. COMMENTS • 23' PER 1/4/1993 HAA G. ENGINEER'S CERTIFICATION -ij&'t,,." w 9 r I cantly that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effed on this , • • • • • • • • • • • • • date. P '•. . Go ess.: Engineer's Printed Name JEFFREY A GARNESS a '• — ` Date G/iz /n:F Pr .6 COSA Fee S %ao .00 Date of Paymenti��1� U Receipt Number QQa6S (Rev. 11105) Waiver Fee E Date of Payment Receipt Number 09/27/2006 09:93 FAX U002 w�orrop RAM 1°'a �m,"1 a rano 1-O 7-/ :e.We elTueT ', , AM IIACNG an.o1 � r R'N1 PALw iRM1 9 ' V' 7 i3'S �,� N• .` . . Sbb• O Alf 'Ver c_ ..+ ,jgA. K • P� �GrN�Et Ik-,. " Dkr.klf ; • a- .ice ��a` �`'`, •. . r $_ Ba 7 zs: 113 . - o o •, to \ �S Al 34 91 O . � g,• D ID 66o `/ES/s A H/f�11WAY lqG SURVEY CERT*W-'A ON i Prepered by . +beoaaaa�cd��Y �N- lv ,LM waN �a . 1 ?roes=tonal Lord Surv_-yort" .. h W A.•, N r.w.. tie ••'. wa 1 1.•.� • .Awr..r w w. M w.,w (.�-.• / ! 710c; Mw DF.. 1 AN:.!ICh0.:A LLA 09SDi jw Lot S.F. r..� PIR1 nP Nc. rMMDATIDN AS -BUILT - •. ... .. .....•. .. 7 e ' �' l!:i6=«. r_ 1•r+T • ' 9.11 - Cu:• 3v"'n d: Dr.rm 0 ' �iEJ J.MAAO D% rw� r`1.: _ w u... �...., irc __i •• 7-11-06 ISl7 Uata U.•own: I lie: 1 7-16-06 483.4 W.O. 6233 " "' ♦ '. 4T ti -5 r' [�e MAL STRIICT7RC AS- XLr a. / •' �i+r IS u 1 ivrn - �: - 1nwY �IYr Mr I f , ..............• or, r 2 Fw• Y�M4M.,MwrWr 4� ... ..... . f,}iiatl9 fY tY. 17.a6Ya'lt� - _.. . S•r-j a." CuLL77CA.1V15�0.`l .. .. _ ... .. r�ww .w.rw.....w.. Lm -VRYn SURVEY 1`fiE SYMBOLS U F2MA^.]N AS -BOLT - .: r..... • SM, 4E3AZ' ASPHALT } DRA:NA•:c� U /}IAL LTTULNRE A}-aULT ❑ .... ICT 9aMT ... ICWTY ted, rD.Ki RRR .1WC FC.CND•,NnC•,RE A MT wcvw ,aMw AS-aR• on a - NZ'un uE rAL F[Nn' IKfK PLOT PLANS k LOTSURyEYS N:TE i IT IS THE RE-PON5131LITY OF THE PUILOFN OR OwNLN. YRIGR TO t ON •r TxO= IMr+ROV•VM-!T= AaCV: CROUNO ANO %ASIMLE WU- re CCNSTRVCTION, TO VERIFY MEOPO::[U bUILDiNG MADE RFI.AT,VC 1 R ". fl!nCSs. %-_u.-.. •1•nC CLCA.NOUTs, ••IOCWALK2. ufd'AWAYS' TO FINISHED CRADF. AND UTp TTY CnNNRCMU4Y AND IO I;LIU<iARkL j [T=- ARC ZKOIW IN TH:IR APPRCX!MATF I.nf.ATION, ONLY. SNOW THE EX:STENCC Or ANY CA='.CNTS, COVLNANIS ON k_•S^r.IL �:rN;' ' MAY FNEVFNT Srn:E IMPROVEMENTS FROM MINO SEEN AND LOCATM: VMPPH DO NOT APPEAR ON TNF RFrnanF) RI19 �IV'S'G\' FLAG AL'. ^!RTANf:FR AMP m-f•(•a ' ►Q� Y•,+-..' IA L7�K ND QK„U13TAl4CC ^ICLL•AV A%-DL:ST 5C UM rtit CC'NuT7UCTI0H 11A .'rXc FATAN I wf: RnI1NDAnY Or rCNS U1495 THE sirvLTOrt TAKES RCSPONSISILTy FOR rw INM,.L TRARCLNCTON ONLY AND ATVMES RItMVAL LASRrI•! ONLY FOR IFIR COST Cr' ill: SJRVCY- QVIrD UMANCEi PRCwaL OVER S-NJNO. R?•ROCIUV ION MAY O.MIST [.RAMS W RIALF. ' Municipality of Anchorage Development Services Departmen Building Safety Division Onsite Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. o 15-- 04 y—// HAA# H R eta t70c7 Expiration Date: 1. GENERAL INFORMATION Complete legal description T</ Location (site addressor directions) Current Property owners) efu /z2FC4..i eH ,. f��,n'<<-a Day phone Mailing address.. R o. 14o�� r,,.Q/, ,,,,,,/ 4 /r 9 9 �8 I Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, NAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: _ q 3. TYPE OF WATER SUPPLY:* TYPE OF WASTEWATER DISPOSAL: Individual Well 14 Individual On-site ❑ Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ 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 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 welts or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineers work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat 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 Phone •QN,�T f� 3 Address'luin Engineer's Printed Name iZ Date � �j 5. DSD SIGNATURE JG Approved for 3 bedrooms. Disapproved. Conditional approval for Additional Comments bedrooms, with the following stipulations: ON-SITE Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: i / CtJ. Original Certificate Date: 3 - Z 2- O Z (Rw 0IM2) jMunicipality of Anchorage De ' velopment Services Department Building Safety Division � + On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 995196650 www.ci.anchorage.ek.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: U s_s nu j; r F_ Parcel ID:_o •7 A. WELL DATA Well type j,:/.,e4 fts It A. B, or C provide PWSID # _ Weil Log (Y/N) Y c �) Data completed X --Ly - 7 g Sanitary seal (Y/N) L Wires properly protected (Y/N) (r Notal depth _gUL_1t U 7Cased to_ftCasing height (above ground) 2 2 f in. FROM WELL LOG c' 7 AT INSPECTION Date of test ; - i'r- 7 S 2 - A u --Q tL Static water level A d` fL 14z, - G fL Well production /D g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform _O_colonie3/100 ml. Nitrate I lie omg.A. Other bacteria _0 colonies/100 ml. Arsenic: •gL 2 mg.A. Date of sample: g.=Iq-o2 Col1ectedby:.44*&aa,,/0..m B. SEPTICMOLDING TANK DATA COV A) Tank size gal. Number of Compartments _ Foundation cleanout ) _ Depression over tank (YM) _ Date of pumping Pumper C. ABSORPTION FIELD DATA CAI A Date installed Soil rating (g.p.d. Length 2 0 Total depth _ fL ER. abso on area ft= Monito Date o"dequacy test Results (Pass/Fail) Date installed Cleanouts High v ptirr'alarm (Y/N) System type Gravel below pipe Depression over field Fluid depth in ab n field before test _ in. Water added_ gal. \ Elapsed _ min. Final fluid depth _ in. Absorption rate >= m treatment (past 12 rno.) (Y/N & type) For _ bedrooms New depth_ in. If yes, give date MIM o. uptawnolsl Ciif A Date installed 'Pump on' level at_ in. Cycles tested E. SEPARATION DISTANCES 6^401r - SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankilift station on lot Absorption field on lot ) Public sewer main 410 rt c c ) Sewer /septic service line A3 r f,a FG O water alarm level at Meets alar d On adjacent lots On adjacent lots 0 1 Public sewer manhole/cleanout /7 5" ( -J- Holding Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: NA Building foundation Property line Absorption field Water main Water service line Surface water Weiss on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: CN /- Property line Building foundation Water main Water Service line I Curtain drain Surface water Wells on adjacent lots Driveway, parkingNehide storage F. COMMENTS(/) / Tory Mo•R 0 A rd a N AA rcCq ,I4 u/� G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. ti Engineer's Printed Name / _✓vv A - Mrylr. r IjX Date 3 - a !- v ? am PC 845 HAA Fee $ .3 2, S"• ©O Waiver Fee $ _ Date of Payment 3 -;;k' I - 0 -Z- Date of Payment Receipt Number i) / % Receipt Number (Rev. 12ret) in. WEST 1/2 LOT 35 / Ot 50 N\GO P� WEST 1/2 LOT 36 �° . a E N ro 2 wocwco sr, EXCLUSION NOTES: It is the owners responsibility to determine LLULNU: 5ET FND JACK CHRISTENSEN the existence of any easements, covenants, or restrictions 5/8 -AS w/CAPpe s/R' RD O whlCh do not appear on the recorded subdirision plot. NOTE: 3.25' ALYON Qj MONUMENT UI n0 circumstances should any data hereon be used fa NUR Q TACK p tonalrucHon or for establishing property lines. FENCE - SURVEY CERTIFICATION: LANTECH hos Conautted o —x— z — OVERHANG - physical survey of this property as shown on this WOOD DECKS - drawing and that the ImProvemenls situated there CONCRETE- [� on are within the properly lines and no encroach- ASPHALT- - ■ mems exist Other than noted. GRAVEL- � A S —BUILT OF: LEGAL DESCRIPTION: LAND & CONSTRUCTION SURVEYORS -PLANNERS -ENGINEERS SEPTIC STAHDPIPESS- Q WATER WELL - WEST BENSON BLVD. a 103 -6626 ANC ANCHORAGE, ALASKA 99503 07)fox) 6 (907) 562-5291 EAST ONE-HALF OF LOT 35 WORK ORDER NUMBER: DAR: SCN[: 2, 2002 ,-_4D •wn Fxato sr wa N814 0.At ruse[e D5/PO eoa •cc: U.S. SURVEY N0. 3044 ALASKA 2002-L-45MARCH . . DMD. t. 4814 543/70 MUNICIPALITY OF ANCHORAGE ' DEPARTMENT OF HEALTH & HUMAN SERVICES rljr 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 Parcell.D.# C11i—(`tn\-\\ HAA# %A00'InCr)'A 1. GENERAL INFORMATION Complete legal description U.S. Survey 3044, Lot 35, E2 Location (site address or directions) NHN Alveska Highway, Girdwood Property owner Jay Bergstrand Day phone 333-5361 Mailing address 1414 Turpin ,_Anchorage, Alaskal99504 Lending agency Day phone Mailing address — Agent George McCoy / JACK WHITE COMPANY Day phone 563-5500 Address 3201 C Street Suite 100 Anchorage, Alaska 99503 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well 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 Holding tank Community on-site Public sewer xxx N NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72a25la«.1/911 Fran 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 furtherverify 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 8 S ENGINEERING Name of Firm Phone Address Eagle River, Alaska 99577 Engineer's signature 6. DHHS SIGNATURE By: 49— Approved for bedrooms. t Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments W FA • 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. 7242: (iw. u1) BK Moi m Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Us� Eyi eP ZT 39 Parcel I.D. '07566 A (s IRDWOop A. WELL DATA, � Well type) al OX(F If A, B, or C, attach ADEC letter. ADEC water system number* Log presentaYN) YC -s Date completed S"�`%' �u DrillerM-w rr� Total depth G8 YES: to � Casing height aZy 11// Sanitary seal (Y/N) ZES Wires properly protected &N) Y,!FS!!-11 W N FROM WELL LOG AT INSPECTION 0 0 Date of test >-17-?8 j r & Static water levelt3 . _. t M L -U Well flow g.p.m. ?r0 g'p' W LU o. t.r LL Pump level qy t'} cr C& SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot NSA ; On adjacent lots A Absorption field on lot ✓�/R ; On adjacent lots Public sewer main ��� I� Public sewer manhole/cleaa/L/l nout ``f f Sewer service line oZ 3� IU F C • o - Petroleum tank NOn1C Luu J IN A('(.OIIDAnscr W/7H R£GUCA-71&N WATER SAMPLE RESULTS: A -Z '%/ME OF 1Ns-,r4a.+7I0 Coliform 1Nitrate Other bacteria Date of sample: a3'y2 Collected by: S4, 5-1, �NCNNEF�21/J� B. SF`TIC/HOLDINq TANK DATA {�0�>77� 2ut=0 13y R,& Date Cleanouts(Y/N) High water alarm (Y/N) Date of pumping —Tank size Foundation cleanout (Y/N) SEPARATION DISTANCES FROM i Well(s) on lot— To property line Surface er/d '6 (Rev. 7191) Front I. Onadjacentlots field Depression (Y/N) tested (Y/N) Pumper TANK TO: ,main/service line ON BACK PAGE C. TSTATIO/Vj atInstal D Size In gallons Vent(Y/N) _ High water alarm level "Pump on" teveJl at Meets MOA electrical codes (Y/N) SEPARATION Ui —Manufacturer Manhole/Access (Y/N "Pump off" level at LIFT STATION TO: On adjacent lots D. ABSORPTION FIIE%L DATA `Date Installed,' " L ngth -,•.Width ('Notal absorption area ` �;Depression'overfield (Y/N) \ Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSC Well on lot To building foundation On adjacent lots Surface water= curtp-orain E. ENGINEER'S CERTIFICATION Cycles tested Surface water Soil rating System type _Gravel thickness Total d, Cleanouts present (Y/N) Date of adeauacv te- for If yes, give date TO: lots Property I To existing or abandoned system ooNo Water main/service line Driveway, parking/vehicle storage area _ bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines In effect 94Nb4 to of this inspection. _� 0-,h tiFq��1L S 8 5 ENGINEERING �p'(•••..•••••.♦••qs '0 17034 Eagle River Loop Road No. 204 aw Oj�• i Signature Eag1a Rivar, Alaska 99S77 N f49�j •••�*�� ♦ •1♦•••IMIM �• Engineer's Name DateRooF. AFER��� r rr •. No. 82 . J HAA Fee $ Waiver Fee: $ Date of Payment /01 ��yd Date of Payment Receipt Number Receipt Number 72-026 tR".'SN1) B"k MOA 21