HomeMy WebLinkAboutSTOCKHAUSEN LT 3CStockhausen
Lot 3C
#051-065-02
Municipality of Anchorage Page I of a
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 a Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: SLA) g501t3 PID Number: [7510(03'3L
Name:Wastewater
RICHARD �I-t_IS
System: ❑ New �U rade
Y P9
Address:-:,O Bdm 78 q
ABSORPTION FIELD
Phone:
No. of Bedrooms: d14
ZDeep Trench ❑Shallow Trench ❑Bed 11 Mound ❑ Other
LEGAL DESCRIPTION
Soil Rating:
Total Depthfromm original grade:
O. S GPD/Sq. FL
I
Lot: Block: Subdivision:
3E> STOCk+W, e NI
Depth to pipe bottom from original grade:
Gravel depth beneath pipe
&� I
—
Ft.
Ft.
Township: --
Range: —�
Section:
Fill added above original grade:
,
Gravel length: r
I
co . - • S Ft.
Ft.
WELL,,,,,,, �❑ New ❑Upgrade
Gravel width: Z. S f
Number of
Distance between lines:
Ft.
Ft.
Classification (Private, A, B,C):
Total Depth:
Cased To:
Total absorption area:
Pipe materiel: A$TM
-Pr t,/ATIE
Ft.
Ft.
Som% SQ. Ft.
FSIO n3b3
Driller:
Date Drilled:
Static Water Level:
Installer:
Date installed:
Ft.
°D8CANI Cola5T, •
%- I S-4S
Yield:
Pump Set at:
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION
DISTANCES
34septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift Holding
Public/Private
Manufacturer:
T
Capacity in gallons:
IMSA
From
Tank
Field
Station Tank
Sewer Lines
hi L*0IRA¢7RF 1i47j K,
Well
IIOI
I
I 1
a�f+
Material: S7�L �r -
Number of Compartments: •t
Surfac
loo'+
100 '4-
LIFT STATION
Water
Lot
H 5 1
1N 1
.�
Size in gallons:
Manufacturer:
Line
Foundation
16 I
36 I
�
�
�
"Pump on" level at:
"Pump off" at:
High water alarm at:
Curtain
O
E KN
W
Pump Mak
Electrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description:
SILL F20Ni
L9
UO2
n q -
h
Assumed Elevation:
E
S & S ENGINEERING Rad, No.
River Loop awes:
Inspections performed by:l"u Eagle 1 st
Eagle River, Alaska 995772nd I g' 97
-P ROBERT C. COWAN 4?
c1 CE-8aol
Department of He d H Services approval
`,`+��•fA
Reviewed and approved Date:
/
12-013 (Rev. 9/91) MOA 25
Perrnit No. SW950113 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH 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 Description: LOT 3B, STOCKHAUSEN S/D
05106386
PID No.:
72-013 A (1193) -
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW950113
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:ELLIS RICHARD M & LOLA C
OWNER ADDRESS:P.O. BOX 784
CHUGIAK, AK 99567
PARCEL ID:05106386
LEGAL DESCRIPTION:
STOCKHAUSEN LT 3B
LOT SIZE: 68791 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
na�r�
DATE ISSUED: 6/14/95
EXPIRATION DATE: 6/14/96
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 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL
RECEIVED
ISSUED B
DATE:
DATE:
S&
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERINGSTUDIES
AND REPORTS
WELLINSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
ROBERT C. COWAN, P.E.
ROBERTA. SHAFER, P.E.
June 5, 1995 CIVILENGINEERS
(907)694.2979
FAX(907)694-1211
MUNICIPALITY OF ANCHORAGE
Depaatment o6 Health and Human Senv.ices
P.O. Box 196650
Anchoaage, AK 99519
REFERENCE: Lot 3B; Stockhausen
Request you .iasue a petwit to upgaade .the septie Ayatem aeaving the
Souk bedxoom house on the Left wAced puopexty.
During a site .inspection box Heatth Autho& ty Approval puaposes we
bound the existing system to be .in a satuaated state and thene6one
.inadequate.
A te6t hole was excavated and a peacotation teat pex6onmed .in the akea
o6 the puposed upgaade. The appuox.imate location os the teat hole is
located on the attached site plan.
At the time o6 excavation no water was encounteaed and aster seven day
ga.ound water mon itoh i.ng, the monitoting tube =6 bound to be dry.
Attached .is the proposed upgrade design.
We do not anticipate any adverse e66ect6 on neighbo&i.ng wett6, septic
systems oh dxa,inage patteans by the .insta tation o6 the proposed
septic system.
Thefi.e cute no points o6 contamination within the paoposed wet %adiu6
which can be seen on the attached site plan.
The pxoposed 1250 gat2on septic tank .is to be placed outside the we -U
puotective radius. Attached .is a site plan which depicts the location
o6 the proposed tank.
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16 you aequi4e additi.onat .in6onmation, please contact us.
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17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
1" = 40' UPGRADE SITE PLAN
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PROPOSED 1250 m o y
\ \ \ \� ---� — om ►� GAL SEPTIC TANK IA o
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Municipality of Anchorage
DEPARTMENT OF HEALTH i£ HUMAN SERVICES
625 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: P1La-2X��s.1�C -� \S �T DATE
LEGAL DESCRIPTION:+ .7`J J'CCL ,,0%1&,joWnshlp, Range, Section:
�2dai O� SLOPE
1�VAL- E= E
6
2 0
U
3
4-
6-
7 6 7 a
8 •/
9 0
10 "o'
11 -� e
12-4, •-
13- '
14
6
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT L
DEPTH? O
P
E
DepthMonitoring?
ontt to Water
MoniWAft_ 1io �j r
ring7 gate:
SEAL)
OF
SITE PLAN
®�/��®®®m
ON m'
--
PERCOLATION RATE IQ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN <.5'- FT AND --L2"5-FT
COMMENTS
S & S ENGINEERING(I
PERFORMED BY: n`4n Loop
Read New 4114 r -A-CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH 44A'iFtMN8IIVIf7nnG197GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-OD8 (Rev. 4/85) o . L
a
GREATER ANCHORAGE AREA BORO
Department of Environmental Qu ty
3330 "C" Street
* Anchorage, Alaska 99503
R:' :V17D
SO 1 .s 1974 06
Q1TER ANCHORAGE AREA BOROUGH
8iPT: of C. .....NTAI QUAWTY
SOILS LOG - PEROLATION TEST
Performed for Rick Ellis Date Performed 9/7/74
Legal Descriptio— o ocio—
This form reports: Soils log a Percolation test
Depth
feet
Reddish Silt
2
3 -
Grey Silty Gravelly Sand
4 - 150 SF/BR
5 -
6
7-
8-
9 _ Grey Sandy Gravel
120 SF/BR
10 -
11 -
12
13 -
14 -
S1,ope
Was ground water encountered? No — If yes, at what depth?
Reading Date Gross Time Net Time Depth to Water Net Drop
Percolation rate minute.
Proposed installation: Seepage Pit Yes Drain Field
Depth of Inlet Depth to bottom of pit or trench
COMMENTS: 3-BH--Eouse—. —No Groundwater or Bedrock encountered_
Performed By: Neal Ha�aTlCertified By:r�n4t,,,�tion_�es�ate:__�/��
Lab
EQ -040 (6/74)
Municipality of Anchorage ¢* ·
On-Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEHS APPROVAL
Parcel I,D.
1. GENERAL INFORMATION
Complete legal description
Expiration Date:
Location (site address)
25716 DOLLY AVENUE *CHUGIAK 99567
Current Property owner(s) VICKERS, ROBERT & TAMI
Day phone
Mailing address
Real Estate Agent
REBECCA BAKER
Day phone 947-8990
2. TYPE OF DWELLING: · Single Family (w/wo ADU)
[] Duplex
[] Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
JUL ! 8 2014
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
individual Water Storage
Community Class Well
Public Water System
Individual On-site ·
individual Holding tank []
Community On-site []
Public Sewer []
WaivedVadance request
COSA to be released to the engineer unless olherwis~ire~ques ed by he eng neet
Date:
COSA Fee $ ~
Receipt Number
COSA¢
Waiver Fee $
Date of Payment
Receipt Number
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.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 10I * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
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 repotted results described the performance of the
Phone 537-6179
system under the conditions encocotered at the time of the test, and separation
distances measured to readily identifiable features. The operational fife 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 evaluatar of the system. Satisfactory test
results de 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 repor~ is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or patty is not authorized, nor w/lilt confer any legal right whatcoeve~
DSD SIGNATURE
System #1 Approved for ,l~ bedrooms.
System #2 Approved for bedrooms. WATER AND
. PeOO Atv
Conditional approval for bedrooms with the follow ng stipulations- ~', O.~ ,~.~
~ . ~ , · · . c~/~ ~_~
by--l~
By: ?~-~'_~.~.~//_~, ~(~ Original Certificate Date: -'7"'~ 1/-//~
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska,
The Municipality of Anchorage is not responsible for e~rs or omissions in the professional enginee¢s wo~.
7. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Other
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: STOCKHAUSEN LT3C Parcel ID: 051 -(~=5'=-8~--
*PER GEG INSPECTION
A. WELL DATA **NO PERFORATIONS TO 104' PER SULLIVAN WATER WELLS (SEE ATI'ACHED STATEMENT)
Well type PRIVATE IfA, B, or C provide PWSID# N/A Well Log (Y/N) NO
Date completed UNK Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth '114 ft, Cased to *'104+ft, Casing height (above ground) 18+ in.
FROM WELL LOG
Date of test
Static water level
Well production ~ g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 coloniesfl00 mi.
Arsenic: ND ug,/L
B, SEPTIC/HOLDING TANK DATA
ATINSPECTION
7/3/2014
83 ff.
0.6 g,p.m,
Foundation cleanout (Y/N) YES
Date of pumping 6/16/14
C. ABSORPTION FIELD DATA
Date installed ?/ls/95
Length 71 ft.
Nitrate 5.84 mg./L.
Date of sample: 7/7/2014
Collected by: GEG. Ltd,
Date installed 7/17-7/18/1995
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
Tank Type/Material SEPTIC/STEEL
Tank size 1250 gal. Number of Compar[ments 2
Depression over tank (Y/N) NO
Pumper JR'S
[*BELOW EXISTING GRADE]
Soil rating ~r ft2/bdrm) 0.8
Width 2.5 ft.
Totaldepth *9,88 ff. Eft, absorption area 825 ft2 Monitoring tube YES
Date of adequacy test 7/3/14 Results (Pass/Fail) PASS
Fluid depth in absorption field before test 58.5 in. Water added *'922ga1.
Elapsed Time: 292 min. Final fluid depth ****69.5 in. Absorption rate >= 600+
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date
**THE LAST 444 GALLONS INTRODUCES ONLY CAUSED A RISE OF 8,5 INCHES
**'1/2 IN BELOW TOP OF DISTRIBUTION PIPE
***'1 INCH BELOW INVERT LEVEL. RECOMMEND ISSUANCE OF AN ADVISORY LETTER.
System type DEEP TRENCH
Gravel below pipe 6 ft.
Depression over field NO
For ~- bedrooms
New depth ***74.5 in.
g.p,d.
D. LIFT STATION
Data installed Size in gallons Manhole/Access (Y/N} ~
Pump on" level at in~gh watar alarm level
at
Datu______~m ~
Cycles tested Meets alarm & circuit requirements~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot 100'+
Public sewer main N/A
Sewer/septic service line 25'+
Animal containment areas. * 15'+
100'+
On adjacent lots. 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
~t ~t leo ~,~,~u~
Manure/animal excrete storage areas ~--,+~ ~ '
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Ab,~orption field
Watar main N/A Water service line 1 O' + Surface wata~
Wells on adjacent lots 100'+
5"+
100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
Watar main N/A
Driveway, parking/vehicle storage 10'+
*SEPARATION TO BARN WAS APPROVED BY MOA 6/2/95. SEE ATTACHED WAIVER REQUEST
G. ENGINEER'S CERTIFICATION
I cen'ify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
data.
Engineer's Prin~d/iName JEFFREY A. GARNESS
Date "'7//'7/J ~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Water Well Advisory
Certificate of On-Site Systems Approval (COSA) # 141341
During a recent COSA on-site inspection and test of the potable water
supply well on Block , Lot 3C of Stockhausen subdivision, the well's
productivity was determined to be 0.6 gallons per minute. The minimum
well productivity required by this Department (AMC 15.55) for a 4-bedroom
residence is 0.4 gallons per minute. Although the subject well currently
exceeds this minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction of non-critical
water uses such as washing cars and watering lawns and gardens may be
required.
This advisory must be attached to all copies of the subject Certificate of On-
Site Systems Approval.
Municipality of Anchorage
Community Development Department
Development Services Division
On-Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519~6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisory
Certificate of On-Site Systems Approval # 141341
A Certificate of On-Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block , Lot
3C of Stockhausen subdivision. This inspection revealed a nitrate
concentration of 5.84 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of ~vater from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory, must be attached to all copies of the subject Certificate of On-
Site Systmns Approval.
P.O. Box 570269 Chu§iak, AK 99567
P: (907) 8882759 F: (907) 588-2259
July 12, 2014
Camera Inspection Report
Tam[e Vickers
23716 Dolly Ave,
Chugiak, AK 99567
Sullivan Water Wells ran a camera down the well to 104' and there were no perforations or
seeping in casing, There were two sets of pump wires inside the well
The static water level was at 77',
Thank you,
Cote Su
GARNESS ENGINEERING GROUP, Ltd
CIVIL & ENVIRONMENTAL ENGINEERS
July 8, 2014
Municipality of Anchorage
Development Service Department
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Waiver Request for Well on Stockhausen Lot 3C to Horse Stall;
To whom it may concern:
The existing 4 bedroom house is served by a private well and septic system. We request
you grant a 15 foot separation distance waiver from the well on the referenced property
to the horse stall on the referenced property. The following items are justification for the
waiver:
· The Horse stall is located downhill from the well and if there was any surface flow, it
would not travel towards the well head.
· The encroachment existed in 1997 when the last HAA was approved.
· The encroachment has existed for at least 17 years.
· Recent water samples indicate arsenic levels were non-detectible, nitrates were
5.84mg/L and coliform was negative.
Based upon the aforementioned facts, it appears that there is minimal risk associated
with the 15 foot separation distance waiver.
Presi,'~e~GaXm~sJ, P.E., M.S.
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907)337-6179' Fax: (907)338-3246*Website: www,garnessengineering.com
DOLLY AVENUE 8400Y
N89°53'00"E 198.99
Wood fence-,
hed
/ /~
/ /
/ /
Lot 3A
metal corcall
fence
Well
O
Septlc~vent
CO "Se~)~c vents
Wood f
#
N89°50'31"E 75,83
Lot 5 /
/
EASEMENTS OF RECORD, OTHER THAN
THOSE SHOWN ON THE RECORDED
PLAT ARE NOT SHOWN HEREON. Fb 14-6, pg 45-46, ABS
BE
AS-BUILT
/
/
/
/
/
/
1
SCALE: 1"= 40'
'ower line Easment
NO CORNERS SET THIS DATE
hereby certify that I have performed a Mortgagee's inspection
of the following described property: LOT
STOCKHAUSEN SUBDIVISION
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not ovedap or encroach on the property tying
adjacent thereto, that no improvements on the property tying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage, Alaska
this 16th day of July ,2014.
FRED WALATKA & ASSOCIATES
Engineers and Surveyors
(~n7-?4R-1 ~)
MUNICIPALITY OF ANCHORAGE AL
• DEPARTMENT OF HEALTH & HUMAN SERVICES ALEM
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 l.D.# 0S1r063-�r (o �
HAA#`,O-V\1LLI(�J
1. GENERAL INFORMATION
Complete legal description
Lot 3B; Stockhausen Subdivision
Locatioq (site address or directions) NHN Dolly Avenue
Chugiak AK
- 'Richard Ellis 688-6676
-,Property owner - Day phone
Mail'ingaddress ... P.O. Box 784 Chuaiak, AK 99567
Lending agency Day phone
Mailing address'
Day phone
Address
Unless otherwise requested, HAA will be held for pickup
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well t 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 MOAN21
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.
5 & 5 ENGINEERING
Name of Firm17034 Eagle Rivar Lacy Road No. 204 Phone G `f °f — a y 7 y
Address Eagle River, Alaska 99577
Engineer's signature XI t_l2! ZIA, Date "n /4 /q 7
6. DHHS IGNATURE
Approved for f �V bedrooms.
0
Disapproved.
Conditional approval for bedrooms, with the foidowing stipulations:
Additional Comments
UITIC
Date /0. 17- '?�-
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 621
ENVIR0144WALSERVICES DIVISION
OCT 06 1997
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES E C E I V E
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description:S �cx_! Haas<; Parcel I.D.: ot-)10 6,3
A. WELL DATA
B.
A
Well type PIZ I OT!?. If A, B, or C, attach ADEC letter. ADEC water system number
LL/ -1 iVjL1- .Ntq oru kr-; r ,rte.{. 4pw
Log present( /h Date completed �'Irr -• ro .VcvI IV4
Total depth 1( _ \t
Cased to _ 'f'j; i Casing height (above ground) 1 Z
Sanitary seal (Y ) S Wires properly protected 6) ildh
1
Date of test
Static water level
Well production
FROM WELL LOG
Cl0 ne, -fou n c1
it tl
WATER SAMPLE RESULTS:
AT INSPECTION
�9g.p.m. g.p.m.
Coliform 0 Nitrate 4, C: Other bacteria 0
Date of sample: "�f Collected by: �'/` 5 & S ENGINEERING
17034 Eagle River In -n Road No. 204
SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577
Date installed�� Tank size IZ60 Number of Compartments L CleanoutslY/
Foundation cleanout I�Q(N) �V Depression (Y� High water alarm (Y/N) f,
Date of Pumping �— Pumper C - I r� /
ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) 4 System type ?r/vlC fF
Length Width s Gravel thickness below pipe _ Total depth t)
Effective � absorption area r
p Monitoring Tube presentY�N) ifL Depression over field (Y(N) I U
Date of adequacy test Resultsas /,Fail) rw?-5�, For �ir/A bedrooms
�J/
Fluid depth in absorption field before test (in.); rives Immediately aftergal. water added (in.):
�r _
Fluid depth �C (ins) Minutes later: %fa M,n Absorption rate = k, c' g.p.d.
Peroxide treatment (past 12 months) (Y/N) A/OmC Hive,,, If yes, give date
72-026 (Rev. 3/96)*
IFT STATION
Date instal
Manhole/Access (Y/N)
High water alarm level at* _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at* "Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot (p; j On adjacent lots
Absorption field on lot
On adjacent lots icao'f
Public sewer main 7.6(4. Public sewer manhole/cleanout
Sewer /septic service line 62614- Lift station 140 `f
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation !a Property line Absorption field � f
Water main/service line X . f Surface water/drainage 4W J + Wells on adjacent lots /LIV 4
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10' i Building foundation fnI L Water main/service line j6 S4
Surface water I u] /4 Driveway, parking/vehicle storage area I01 *
Curtain drain "- - KdOW4 Wells on adjacent lots
F. ENGINEER'S CERTIFICATION r
l certify that I have determiinneedpthru field inspections and review of Municipal records
in conformance with MOA s guid "nes in effect on this date.
Signature
Engineer's Name A13 h URl
r
Date r ° `► cj 7
HAA Fee $ 5
Date of Payment 16,106
Receipt NumberZkZ
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
carr e: cowAn
CE -8801
are
MUNICIPALITY OF ANCHORAGE
M E M O R A N D U M
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL N0. NA9iot4 6
During a recent Health Authority Approval on-site inspection
and test of the potable water supply well on Lot 1�z_
Block of �j��(gp(j Subdivision, the well's
productivity was determined to be 0,9 gallons per minute.
The minimum well productivity required by this Department
(AMC 15.55) for a fOL�Z_ bedroom residence is ()_1.A2 gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies of the subject
Health Authority Approval.
X