HomeMy WebLinkAboutGEORGE SEHM LT 16· Lo t 1'
1 - 102-2,8
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904AR �ael of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number:. el S A C t Qg Z PID Number:
Dwelling: ;K Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New J�7Upgrade
Name: C
,4�P� song' �s T�.��
ABSORPTION FIELD -
❑ Deep Trench El Shallow Trench El Bed ❑ Mqund
Address
.23115 7—VA1 4 11?h R 05 9
0 Other
Phone `7Number
2 �Z 1.s3
of Bedrooms
Soil Rating JTotal
depth from original grade
[
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivisio c Block Lot
fE %{,1'1A�tA�
Fill added above original grade
Ft.
Gravel length
Ft.
F J
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer.
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Fe
Ft.
Well
TANK 4Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer /�
4 � Alk
Capacity
/a Ll Q Gal.
Surface Water
/D/I f
% D�
AJ
NSC(
Material
CS L
Number of compartments
�-
l/
Lot Line
%Q
A14-
e%A
NA
Foundation
S /.f
f p
"V 4
/1//q
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
�{/
714
f
Remarks
Pump on level at
Pump off level at
High water alarm at
in.
in.
in.
Pump make and model
Electrical Inspections performed by
Installer
PIPE MATERIAL House to tank Tank to
- � r drainfield �.ST/h
� � � �
Drainfield CO/MT .3o3
Inspector /V OIT �l !'_•K
BENCH MARK (Assumed elevation) ft
Inspection 1# 3 Z3 !6' 2ie 23 (d�
dates:
Location and description Gn �` �� I Q� p
, li ,
3m 2 /6r 4 h
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
EngineersStai;;
Conditional Approval: Date
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ApprovedDate 3-12
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AS -BUILT MEASUREMENTS
A B
STl 16 25
ST2 22 29
DCO 25 32
MT 63 54
Rosebud Row Ave
15' Electric Easement
Existing _ _
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xisting MT
Lot 17 DCO New 1000 Gallon
ST Septic Tank w/DC❑'s
Decommissioned [Rd
Septic Septic Tank
° PER UPC
Septic
3 Bdrm o
C Lot 15
d
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Q
NOR THRI M
ENGINEERING
PO Box 770724
Eagle River, Alaska 99577
907.694.7028
Tundra Rose Ave
GEORGE SEHM S/D
LOT 16
WASTEWATER RECORD
REPLACE SEPTIC TANK
1" = 40'
RECORD
LAYOUT
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,,~.~ 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
MA~UNG ~?RESS
LEGAL DESCRIPTION
LOCATION
.J~NEW
[] UPGRADE
NO. OF BEDROOMS
] Well v'"')~ / I Absorption area~ /
DISTANCE TO: ] ~-~/__~ ] .~'-
Manufacturer ' '' ' ~
DISTANCE TO' Well ~// Dwelhng
' I fY/. I
Manufacturer /~
Well / I Foundation /--
~ST*~CETO: ] /~ I ~ 'z
No of lines I Length ~f each n~ I Total length 9~s
' Z I ~ I ~ ~
Top of tile to finish grade ~ / Material beneath t~le
~ /~L, I
Length Width J Depth
Type of crib Crib diameter ~ Crib depth
/f
Well Building foundation
DISTANCE TO:
Class p~th /_ Driller
DISTANCE~ Building foundation Sewer line
Dwelling _ I*
/~_ ~
M at e r~7-~__~~
Width __
Material
Nearest lot !i~,~) /
Trench wi~.~) inches
3~ ~inches
PERMIT NO,
No. of compartments
Liquid depth..
PERMIT NO.
Liquid capacity in gallons
PERMIT NO. E i ~
Distance between lines ~/~
TotaLe f f e ¢ t~)o r~vt i on area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorption area(s)
OTHER
PIPE MATERIALS
?trc
SOIL TEST RATIO/
/OO /~-~
INSTALLER ! '-
REMARKS
DATE
7//2-,~ l~r/R e v. 3/78) ~
~ Department825 ~f Health Street, and Anchorage,Envir°nmenta'AK. ~J9501?r°tectl°n ~
- 264-4720 t.: :~
~'~/'~ * * * HANDWRITTEN PERMIT * * * ~'~
Permit
__!~ELL~ND/OR ON-SITE SEWER PERMIT _/ ~
Applicant: ~/~ <~//~~ Mailing Address.'~~~ ~
/ / /
Location: Phone Number:
Legal
Description:
/
Type of Soil Absorption System Is:
Drainfield: ~._ Seepage Bed: Holding Tank:
Trench:
Maximum Number of Bedrooms:~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:'
DEPTH ~--~----/LENGTH ,-~-~- GRAVEL DEPTH ~ WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or ~it is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
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.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public 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. Well logs are required
and must be returned to this department within 30' days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
· *.* PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(!) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I
(3)
S igne~~~/
~i~install the~ystem in accordance with codes, i .
.nde~s~a~ t~/~he on-site sewer system may require enlargement if
~ re/s~d~e/i~//remod~led to include more tha~ 3 bedrooms/~
~~~/~ Issued by:
llcant
'- - C/L/ Date:
SWP/024(1/81)
SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
6
7
8
9
/--/6
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
Co,.,.
~PrNb¥
[] PERCOLATION
TEST
DATE PERFORMED: ;.~
SITE PLAN
10
11
12
13
14
15
16
17
18
19-
20~
COMMENTS
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
:~!, , ?
PERCOLATION RATE ~/~ (minutes/inch)
TEST RUN BETWEEN , FT AND __ FT
~.- Department. -' Health and Environmenta.~ ~rotection
v. , ~. 825 ~ Street, Anchorage, AK. ~JE01
264'4720
* * * HANDWRITTEN PERMIT * * *
Permit ~
WELL A _ PERMIT
~pplicant: /,(J;~+~_ {/~/~,%'~,$'A~-~-~ Mailing Address: ~,(~. ~)d~ 7~ ,l
Location: ~-{5-/t; ~fUO ~?,e~ Phone Number: ~fz/-.~/~/~
Legal Description: ~Of/G ~o~ec,~ ..~./u*~' ~/~) Lot Size: X3/'~q_
TYpe of Soil Absorption System I~:
Trench: Drainfield: Seepage Bed: __ Holding Tank
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) n3//~
DEPTH
The Required Size of the Soil Absorption System Is:'
~//c LENGTH ~/~ GRAVEL DEPTH ?/~ WIDTH' ~/,/b-
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). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet). ~/~
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = GALLONS * *
Permit applicant has the responsibility to inform this department during the
insgallation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public 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. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(!) 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 codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
~ppii~ant ~ / -/I D' ~/~/~j 0 ~/'
Date:
SWP/024 (1/81)
E Pti+#JS
MUNICIPALITY OF ANCHORAGE
Development Services Department `\i ._-
Phone: 907-343-7904
On-Site Water& Wastewater Section Fax: 907-343-7997
Certificate of On-Site Systems Approval
Parcel I.D. 051-102-28 Expiration Date: . ?" l - ' I
1. GENERAL INFORMATION
Complete legal description GEORGE SEHM LOT 16
Location (site address) 23115 TUNDRA ROSE AVENUE,CHUGIAK,AK 99567
Current property owner(s) AARON TRAVELSTEAD Day phone
Mailing address 23115 TUNDRA ROSE AVENUE,CHUGIAK,AK 99567
Real estate agent Day phone
2. TYPE OF DWELLING:
❑ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex) Ros
3. NUMBER OF BEDROOMS: 3
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Private Septic
Private Well ❑ Holding Tank ❑
Water Storage ❑ Community ❑
Community Well ❑ Public Sewer ❑
Public Water System
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ S.F0 Waiver Fee $
Date of Payment 57g Wig Date of Payment
Receipt Number 63g(-WO Receipt Number
COSA# OS C17/a/ 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. I acknowledge that On-Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION&ENGINEERING Phone 345-3377
Address 4640 SHOSHONI DRIVE,ANCHORAGE,AK 99516
Engineer's Printed Name MICHAEL N.ANDERSON,PE Date 05/27/2019
Comments:This investigation was completed in compliance with MOA guidelines,regulations, �_`
and best industry practices/methods. The assessment of the condition of the well and septic � �
applies only to the conditions as of the day tested.The flow and absorption rates may changeAP- PF 1�,1
due to subsurface conditions that may not be observed from the surface,changes in land use, ASS. . � ,
local soil characteristics,groundwater levels that may fluctuate during the year,quality of
construction(workmanship&materials),the water usage of the family being served by the �2757 system and maintenance. The operational life of all well and septic systems are subject to * :4 9 ni *
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore,any estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments,deficiencies or � N. ANDER90N.
discrepancies exist can be given by Ft S and Anderson Construction&Engineering. `1V. No. CE 9489 •.�4:
5/27/19
6. DSD SIGNATUREsatotu•- i
System #1 Approved for 3 bedrooms \���`
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the followingio( /lith :
k1/4��Y OF,q�!/���i
--- --- - � ON-SITE
WATER AND �^
o WASTEWATER i
o�
. PROGRAM ea
p
J////AtSER\l1G��4
11111)))11
1 _
Original Certificate Date: S 42./ ( -(
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA)based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
COSA Checklist
Legal Description: GEORGE SEHM LOT 16 Parcel ID: 051-102-28
If more than 1 septic system on lot: COSA Checklist# of_ Structure served by this system
A. WELL DATA— PUBLIC
0 Well log is filed with Onsite (or attached) Well production at time of test_gpm
Date drilled Water storage tank volume gallons
Total depth ft Well disinfected for coliform test? ❑ Yes ❑ No
Cased to_ft ❑ Coliform bacteria is Negative
0 Sanitary seal is functioning correctly Nitrate_mg/L 0 Nitrate less than MRL (ND)
0 Wires are properly protected Arsenic ug/L 0 Arsenic less than MRL (ND)
Casing height(above ground) in. Collected by
Date of flow test for COSA Date of Sample
Static water level at beginning of test _ft.
Comments
B. TANK DATA—3/2016 1000-Gal C. LIFT STATION
Age of tank(s) 3 years ❑ Required maintenance completed
Tank type/material SEPTIC/STEEL Age of lift station years
Measured operating fluid level in septic tank 51.5" Lift station material
® Standpipes/foundation cleanout per record drawing Comments:
Date of pumping 7/31/2018 -
D. ABSORPTION FIELD DATA— 35'L x 5'W x 3'ED—@ 100 sf/br=300SF
Which system tested (date installed) 6/19/1983 Adequacy test date 5/23/2019
® ALL standpipes present per record drawing Results El Pass For 3 bedrooms
Total measured depth from grade 5.2 ft(max) Fluid depth prior to test 20 in (Including missing 0.8')
Measured depth to pipe invert from grade 3.0 ft(min) Water added 450 gal
❑ N/A—pressurized field
New depth 30_in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min
depth into effective 2.2'
® Code-required soil cover over field & W/ INSUL. Final fluid depth 19 in
CI System presoaked Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test)
Gallons introduced _gallons If yes, enter date
Comments/Deficiencies: •S
COSA Checklist yellow Public Water Class A copy.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot> 100' Community Sewer Manhol- -anout> 100'
® Yes if No ft Z Yes if No ft
Neighboring Tank > 100' 0 Yes if No ft Pr' - - ewer/Septic Line > 25' Z Yes if No_ ft
Absorption Field on Lot> 100' ® Yes if No Holding Tank> 100' Z Yes if No ft
Neighboring Absorption Fields > 1I ' Animal Containment> 50' ® Yes if No ft
2 Yes if No ft
Manure/Animal Excreta Storage > 100'
Communit er Main > 75' ® Yes if No ft ® Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ® Yes if No ft Wells on Adjacent Lots:
Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No ft
Absorption Field > 5' ® Yes if No ft
Water Main > 10' ® Yes if No ft
Community Wells > 200' ® Yes if No ft
Water Service Line > 10' ® Yes if No ft
If septic tank is under driveway comment below
Surface Water> 100' ® Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ® Yes if No ft If absorption field is under driveway comment below
Property Line > 10' ® Yes if No ft Wells on Adjacent Lots:
Water Main > 10' ® Yes if No ft Private Wells > 100' ® Yes if No ft
Water Service Line > 10' ® Yes if No ft Community Wells > 200' ® Yes if No ft
Surface Water> 100' ® Yes if No ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION / , . �F' .
I certify that I have determined through field inspections and review � �� ° '
of Municipal records that the above systems are in conformance / 1,-".:.4.9 TH * I
with MOA COSA guidelines in effect on this date. I 4
MICHAEL N. ANDERSON:
� � No. CE 9469 ..•.�
COSA Checklist yellow Public Water Class A copy.docx •
'••.5/27/1.9••• '/
Ftsstoxla' i
\`_1111PP.
Municipality of Anchorage
Development s rVices Department
Building Safety Division
On-Site Water and Wastewater Program,
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(9O7) 343-79O4
CERTIFICATE .OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D; 051-102-28
COSA# 0-~C! 0 I
Expiration Date: _~-
GENERAL INE, ORMA'FION
COmptetelegal descriPtion ]'.0% 16, George. Sehm Su.bdivision
' Location (site address)! 2311.5 Ttmdra Rose ~ Chugia~ ~ Alaska
Current Property owner(s) hells Fargo Financial AK Day phone
Mailing address 475 S~ 5th S%ree%, Des Moines, iowa 50309-4608
Lending agency
Mailing address
Day phone
m
Real' Estate Agent ' Ei~zabeth Mac~uiien Day phone(907 ) 775-1812
Mailing. __3_1_6_1_._E ........ P-ai,,e~._.~asiiia_.]~a~.~._.Sni~.e..1:.,~/. _..~/as~.i~a,~..~ A.[. ~9654 ~
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF. BEDROOMS: 3
3. TYpE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class. Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site
Public Sewer
-r'
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (CO.SA) .based only upon the representations given in paragraph 4 by an independent professional civil
engineer registereo in the State of Alaska. Certit"K',ates 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 On-Site 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 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 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 struct, ure indicated herein. I further verify that based on the information
Obtained from the* Mun{~pality of AnChorage files and from my investigation *and inspe.cyn, the on-site water
supply andt°r wastewat~: disposal system is(are) in compliance With all applicable MuniCi~)al and State codes,
ordinances, and regulations in effect at the time of installation.
Name of.Firm Pinard Engineering
Address PO Box '871347 ~dasiiia ~ Alaska
Engineer's Printed Name Paul E. Pinard ~ P.E.
Phone (907) 232-13/+7
99687
Date 8:~ ~ ~,~
~. . ~.
bedrooms, with the foll~in~ ~tipulafions:
DSD SIGNATURE
DisapproYed.
Conditional approval for
bedrooms.
Attachments:
COSA Checklist
Septic System Advisory
Well .FIo~ Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By.:
(Rev. 11105)
Original Certificate Date:
-/o
Municipality of Anchorage.
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description:
'A. WELL DATA -
Well type
Date completed ~
Total depth ft.
Date of test
Static water level
Well production
Lot 16, George Sehm Subdivision
PUBLIC WATER
IfA, B, or C provide PWSID #,
Sanitary seal (Y/N).
Cased to ft.
FROM WELL LOG
g.p.m.
mg/L
WATER SAMPLE RESULTS:
,. Coliform ~colonies/100 mL Nitrate
· Arsenic: ug/L date of sample:.
B; SEPTIC/HOLDING TANK DATA
Tank Type/Material Stee'i
Tank size .1000 gal.
Foundation cleanout (Y/N) Y
Date of pumping 8/1 1/10
. C. ABSORPTION FIELD DATA
Septic
Number of Compartments' 2
Depression over tank (Y/N) 1~1
Pumper JRs Pu,,,ping
Parcel ID:051-1 02-28
Well Log (Y/N)
Wires properly protected (Y/N)
casing height (above ground)
AT INSPECTION
in.
Other bacteda
Collected by:
g.p.m.
Date installed 6/1 9/8.3
Cleanouts (Y/N) Ye a
High water alarm (Y/N) N'A
'coloniesll00 mL
Date installed 6/i 9/83 Soil rating~(~ or ff2/bdrm) 100
Length 3 5 ft. Width 5 ft.
Total depth 5.5 ft. Eft. absorption area.3OO ftz Monitoring tube Y
Date of adequacy test ?/30/10 Results (Pass/Fail) Pass.
Fluid depth in absorption field before test O in. Water added 540 gal.
Elapsed Time~65 min. Final fluid depth O in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (WN & type) ~lone Known
System type 5 Wide Shai]~ow Trench
Gravel below pipe 3 ft.
Depression over field N
For. 3 bedrooms
New depth 6 in.
/+50+ g.p.d.
If yes, give date
D. LIFT STATION - NA
Date installed
"Pump on" level at .. in.
Datum
SEPARATION DISTANCES
Size in gallons
"Pump off" level at.
Cycles tested
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
· SEPARATION DISTANCES FROM WELL ON LOT TO: - NA
Septic tank/lift station -on lot
Absorption field on lot
*Public sewer main
Sewer/septic service line
Animal containment areas '
On adjacent lots
On adjacent lots .~
Public seWer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10 ~ + Property line 10 ~ + Absorption field
Water main ,30 ~ + Water service line ;30 ~ + Surface water
'Wells on adjacent lots 100 ~ +
lO~+
100~+-,;
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 3 ': See Building foundation 1 0 ~ +
Waiver 10/24/96
Water Service line 30 ' + Surface water 1 oo ' +
Curtain drain None Known Wells on adjacent lots
F. COMMENTS
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 COSA guidelines in effect on this date.
Engineer's Printed Name Paul E. Pinard, P.E.
Date 8/16/t 0
Water main ;':':30 ' +
Driveway, parking/vehicle storage ~0 ' +
100'+
COSA Fee $
Date of Payment
Receipt Number ,,
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
PINARD ENGINEERING
P.O. Box 871347
Wasilla, AK 99687
(907) 357-ENGR (3647)
ADEQUACY TEST
LOCATION: Lot 16, George Sehm Subdivision
APPLICANT: Wells Far_go Financial AK
475 SW 5"' Street
Des Moines, Iowa 50309~,608
SEPTIC TANK TYPE/SIZE: Steelll000 Gallons, per MOA Records
ABSORPTION SYSTEM: 5 Wide Shallow Trench, per MOA Records
DAILY FLOW:
3 BEDROOMS x 150 GAL/BR = 450 Gallons
JOB NUMBER: 10-198
DATE OF TEST: 7/30110
FIELD STAFF: PJ Pinard
NUMBER OF BEDROOMS: 3
SCUM: 0.0' SLUDGE: Minimal
NEEDSTO BE PUMPED: Yes No XX
CURRENTLY IN USE: Yes No XX
TEST DATA
Time Flow Volume Cumulative Septic Tank Septic Soil Absorption System Comments
Rate Volume Tank
AM (GPM) (GALs) (GALs) Liquid Level A Level Monitor b SAS Monitor A SAS
* Tube 1' Level Tube 2* Level
10:45 6.0 4.0' o.0' Start Flow -
11:00 6.0 90 90 4.1' 0.1' 0.0' 0.0'
11:15 6.0 90 180 4.1' 0.0' 0.1' 0.1'
11:30 6.0 90 270 4.1' 0.0' 0.2' 0.1'
11:45 6.o 90 360 4.1' 0.0' 0.3' 0.1'
12:00 6.0 90 450 4.1' 0.0' 0.4' 0.0'
12:15 90 540 4.1' 0.0' 0.5' 0.1' Stop Test -
RECOVERY
Date Time ST MT SAS MT
7/30 12:40 4.0'/-0.1' 0.37-0.2'
PM
7/30 8:00 0.0'/-0.3'
PM
*ALL MEASUREMENTS IN FT.
TEST: PASSED XXX FAILED
COMMENTS: System appears to be functioning satisfactorily. There was no measurable liquid in the SAS MT
prior to beginning the test. With the addition of 540 gallons to the system (more than the design
daily flow), the level rose to 0.5', leaving most of the depth of the SAS still available. Recovery
measurements showed satisfactory absorption, with a full recovery in less than 24 hours.
Reviewed by: Paul Pinard ~)
Date: 812/10
88/16/2818 07:15 9073449821
JRs ]Pumping
PO Box 773415
'Eagle R~ver.. AK 99577
(907) 6~4.~54
r_Billing Information__
Remax of Wastlla
3161 Palmer Hwy Suite # 1
Palmer, AK 99654
(907) 775-1812
J~.b Site Information
Elizabeth
23115 Tundra Rose
Chugiak, AK 99567
775-1512
JRS SEPTIC PAGE 01
Serv,ce Agreement
Number: 031638
Order Date: 09-Aug-2010
Service Date: 11-Aug-2010 12:0
Job Description: 1000g
P.O. Number;
Tarms: Net 30
Saiesrep: Dawn-Dawn
Map Book:
Cross Streets: Foul Wheel Drive
Job Comments: ILast So,vice Unknown
Itank normal
lc baCk flushed 2 times=clean
lean outs ok
Additional Location Comments Diagram:
Big - 4 - Sale Sign in front yard
3 - Bdrm Septic ~ back of Home
Pump ~rom Rosebud
Technician: Mike
TaX %: 0
Job Type: Repeat
Map Grid: 28 - -
1000g
S:\Diaarams~1638.bm~
Gallons Planned: 1000
Gal. Actual: .... _..
Hose Length:
Double Tank: [] .__._
Pump System: []
Baffles inlet: []
Baffles Outlet: [] ..._.._
Service Type
Septic Sew 1000K
Qty PHce Each Tax?
1 $185.00 No
Extension Actual
$185O0
NonTaxable Total Taxable Total
Estimated Charges: $185.00 $0,00
Tax Total Grand Total
$0.o0 $185.00
Actual Charges;
Customer agrees tO th~ terms ana conditions shown. THIs isa BINDING AGREEMENT.
Sljlnalure e~ ~f Cu~mer Repm~ntat~e - ' 0ate
F°r y°ur added c~enl~, we ~ePt; Ameri°an ~pre", DIc°vee. ~" and M~'e' Card payme,ts over the ~oM.
After 30 Days ae~, ~ed over te COLLECTIONS. ~30.o0 For NSF C~cks Re~rned.
Parcel I.D. #
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
- .., HAA #
Complete'legal description ~Z~'~ _
Location (site address or directions)
Prope~y owner ,~ ~/e~.5~ D~y phone
Mailing address
Lending agency
Mailin. g address
Agent
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water ~
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Cc mmunity on-site
NOTE:
72*025(Rev, 1/91) Front MOA#21
Public sewer ' ~'
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 K~I~ l~n~[ ~.,,. Phone
20441 Ptam~iga~ Blvd.
Address ~'~. ,,~ ............
Engineer's signature ~~ ~ Date /,/'~//~'
DH2 SIGNATURE
Approved for ~-~.F_~_
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with th-e following stipulations:
Additional Comments
II If: ,'lll:fli
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 8tare of Alaska. The DHH8 does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHH8 do not'
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omi~ione in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA ~21
Legal Description:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICE~A
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (~r~c~o~e
Health Authority Approval Checklist
A. WELL DATA
Well type. . ' /,//.,/~. //~ A, B, or C, attach ADEC letter. ADEC water system number
Total depth Cased to ~'~ Casing height (above ground)
Sanitary seal (Y/N) ,.~ ..~ Wires properly protected (Y/N)..
FROM WELL LOG AT INSPECTION
Date of test /~
Static water level
Well production g.p.m, g.p.m.
WATER SAMPLE RESULTS:-
Coliform /~ Nitrate oll~t~d Other bacteria/~
Date of sample: by:
/ ,/
Number of Compartments ~- Cleanouts (Y/N)
High water alarm (Y/N)
B. SEPTIC/HOLDING TANK DATA
Date installed ~'"/~'~ Tanksize
Foundation cleanout (Y/N) ¢ Depression (Y/N) //~//
Detect Pumping ~Y //~-~¢ Pumper ~'~'~/
C. ABSORPTION FIELD DATA
Date installed ~_~ '*/¢ '
Length ~.~ ~' Width
Effective absorption area
Soil rating (~ ~ /D
.~! Gravel thickness below pipe
Date of adequacy test
Fluid depth in absorption field before test (in.); ._~
Fluid depth ¢ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Monitoring Tube present (Y/N) '¢
¢~/~ Results (Pass/Fail) ~<' .~
Syst e m type ~/,~.~///z.J
Total depth
Depression over field (Y/N)
For ~ .bedrooms
__ Immediately after/'~//)gal, water added (in.):
Absorption rate = Y.~-/--.) '~/" g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N) / "Pump on" level at*
High wat, er alarm leve'l at~ *Datum
Cycles tested /./'
Size in gallons /
"Pump off" level at*
E. SEPARATION DISTANCES
Septic/holding tank on lot
Absorption field on lot y
Public sewer main
Sewer/septic service line ,/
SEPARATION DISTANCES FROM WELL ON LOT TO:
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout /
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /'~-} / 4- Property line ///~P /"/f' /
Absorption field ,/~',',~ ~
Water main/service line ..~ ~/' ~
Surface water/drainage f/--.)O "~ Wells on adjacent lots IO4::~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line J~ / '¢~ ~' /z) --~2¢'-~ ¢, /
/.c)~/¢tF~ Building foundation //~__.~ ¢ Water main/service line
Surface water ,/¢:~)(~ /n/ Driveway, parking/vehicle storage area
Curtain drain /¢¢?/~' ~¢'/-M,,--) Wells on adjacent lots /¢¢¢:2 ~
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review r~.... __~b . ,,~ ~ -.. are
~n c~nf~rmance w~h M~A HAAg~d~e~n e~ec~n ~his da~e~ ~f Mun~c~pa~rec~."~°~*~.~°~.~w`~?~e~{~ys~ems
~ ,, ~-- ...~-~
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY 0f 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
ParcelI.D.# O J' I - ) o D- - D~ f~
1. ' GENERAL INFORMATION
Complete legal description
Lot 16; George S~n Subdivision
Location (site address or directions)
23155 Tundra Rose
Chuqiak, AK
PrOperty owner_ Loydale & Darrell McDonald
Mailing address P.o. Box 670947 Chuqiak, AK
Lending agency
Mailing address
Agent Susan Bickman/ Jack White Real Estate
Day phone 688-2944
99567
Day phone
Day phone
.-: Address
Unless otherwise requested, HAA will be held for pickup.
'~ 2. NUMBER OF BEDROOMS: 3
-?:_ '-: -. - 3. TYPE OF WATER SUPPLY:
; :_ .- :- . ..~: NOTE: If commumty well system, prowde written confirmation fromState ADEC attest-
-t~:' 4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
-_-. 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
Address
Engineer's signature
$ & S ENGINEERING
i~0~,4. Eagle River Loop
Eagle River, Alaska 99577
Date
DHHS SIGNATURE
X Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Depadu,ent 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 inthe 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'~5[Rev. 1/91) Back MOA~'Y21
~NVIRONMENTAL ~J:KW~ u~ v ~'~,~,,
of Anchorage OCT 1
Municipality
DEPARTMENT OF HEALTH & HUMA~ SERVICES
Environmental Services Division ~ ~ ~ E
825 L Street, Room 502 · Anchorage, Alaska 99501 * (907) 343:4'744
Health Authority Approval Checklist
Legal Description: Lo r' /6 (;--,b¢,C~¢ ..~¢¢-/,~ f
Parcel I.D.: O.~ 1-/0 P- -~o¢
A. WELL DATA
Well type
Log present (WN)
Total depth
Sanitary seal (WN)
Date of test
Static water level
Well production
' cW~;~rRm SA~:
Date- ~o~sample:
If A, B, or C, attach ADEC letter. ADEC water~m6er
Date completed
Cased to as.~ing height (above ground)
~Wires properly protected (Y/N)
FROM WELL LOG~' AT INSPECTION
g.p.m.
Nitrate Other bacteria
Collected by:
g.p.m.
SEPTIC/HOLDING TANK DATA
Date installed ~/t~/f' '3 Tanksize
Number of Compartments D_ Cleanouts ~/N). ¥~3
Foundation cleanout ~)N) ¥ ~' ~ Depression (Y/'4N.~ ~ o High water alarm (Y/'~ /¢ '~
Date of Pumping to/~ W / e ( Pumper ~" ~' /%.~ ¢ '"~ 4'
ABSORPTION FIELD DATA
Date installed (~/z~l/~' ~
Length' ~) ~" Width
Effective absorption area ~ oD
Date of adequacy test t¢ //0//
Fluid depth in absorption field before test (in.);
Fluid depth t O (ins) Minutes later:
Soil rating (g.p.d./fF or ft~.~ / ~ O System type
Gravel thickness below pipe ~ Total depth
Monitoring Tube present (~/N) ye )' Depression over field (Y~ ¢¢ o
Results ~ail) ¢¢I ¢ ~ For
Immediately after II ~ gal. water added (in.):
Absorption rate = ~ 5-~ + .g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~c '~¢ ~'~'~ '~'
If yes, give date
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons~.,_---~--~-
Manhole/Access (Y/N) "Pump on" le.~vel-~ "Pump off" level at*
High water alarm level at*..~_.-.~*Datum
Cycles test.~~'~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: 2,~ / ~ - ~ ~, ,~ ~. ~ ¢
Septic/holding tank on lot
On adjacent lets
Absorption field on lot
Public sewer main
Sewer/~s..e, pti sc~ervice line Lift station
SEPARATION
FROM~E~_I_I~HOLDING TANK ON LOT TO:
DISTANCES
Foundation ~ '+- Propertyline $~ -/ Absorption field
Water main/service line
Public sewer manhole/cleanout
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ~ ~/ ,~¢~-~t Building foundation ~ o Water main/service line
Sudace water / 0 o v-* Driveway, parking/vehicle storage area
Curtain drain ~0 ~ ~ ~o w~ Wells on adjacent lots /
ENGINEER'S CERTIFICATION
I certify that l have determined thru field inspections and review of Municipal reco~4hE'Eb,~'~ms are
in conformance with M,pAz/HA/A gpidelines in effect on this date.
Signature --
,
HAAFee $ ~) '~
Date o, Payment
Receipt Number ~7'7 ~ (~-/
72-026 (Rev. 3/96)*
Waiver Fee $ ,//' ~-~ ,~
Date of Payment
Mtmicipality of Anch ?e
Department of Hes2a ! , satrn ,l"luman Set'
RickMystrom, P.O. Box 196650 Anchorage, Alaska 99519-6650
Mayor
October 24, 1996
Robert C. Cowan, P.E ....
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject:
Waiver Request for Lot 16 George Sehm Subdivision
Waiver Request # WR960056, PID #051-102-28, HA~50453
Dear Mr. Cowan:
Your request for a waiver of the required 10 foot separation between an on-site
wastewater disposal system and a lot line has been approved. The waived distance is 3
feet from the leachfield to the north Property line.
This approval applies to the existing on-site wastewater disposal system lot line separation
only. Any future upgrade to the on-site wastewater disposal system will require all
separations be met or another approval from this department.
If there are any further questions or concerns regarding this waiver, please call our office
at 343-4744.
Sincerely,
Robert W. Robinson
Civil Engineer
On-site Services
RWR/ljm:McDonald
WR# I_U~O~) ~[D PID# 051-102-28
Date Received: October 14, 1996
"</MUNICIPALITY OF ANCHORAGE~
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
HA# ~o~[~ Permit
Legal Description: Lot 16 George Sehm Subdivision
Engineer: Robert C. Cowan, P.E., S & S Engineering
17034 Eagle River Loop Road, Suite 204, Eagle River, Alaska 99577
Applicant: Loydale & Darrell Mc Donald ·
Waiver Requested: Lot line waiver of the leachfield and the north property line
of 3 feet.
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorpti0n
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. Other:
Waiver is Granted:
List Conditions or Re, sons for above:
. / .... .
Date:
~Ame of kevie~er
Rec ~: 02272/2951 Amount: $ 115.00 Date Paid: October 14, 1996
1
?hejinformation hereon is for the use of lending
Lns~itutions showing the relationship of existing
ttructures and'platted easefi~ents and lot.lines.
Ct i~,no~ to. be u~ed for ~o~itioning additional'
structures or fencelines.
Anchorage Ba¢onfling Pre¢inetl Alaska, and that the
m~n~ si~usi.~d th~eon ~ v/i~ ihe pro.my ~n~s and
no~ overlap or enr~oach on th~ pro~ty lying adjacent
~, that no hnp~vcmen~ on pro~ lying ~djac~ng
en~oach on the pten~e~ ~ question ~d ~a~ ~
roadways, ~ion lines or; other Vis/hie
Da~ed at ~orag~
mis 1 ~ ~--a~ o~cch
6 $- 566
A$ BU'ILT'Eo oorners set .this date
I hereby c~l'tify that ! have lxu-lormed a MO~ag:e'a
~peclioa of the IoHow~g d~i~d propeay: ,
.George Sehm Addn. ;'T,nt l.fi
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
October 11, 1996
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORllY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER&WATER
iNSPECTION
ENGINEERING STUDIES
ANDREPORTS
WELL INSPECTION
& FLOW TEST
SiTE pLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
INSPECTIONS ~
ONSITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
MUNICIPALITY OFANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 16; George Sehm Subdivision
RECEIVED
OCT 1 4 1996
Municipality of A~cl?rag, e
Dept. Health & Human Serwces
Request you issue a Health Authority Approval on the referenced
property and grant a waiver for the horizontal separation distance
between the leachfield and the north property line at 3 feet.
We do not anticipate any adverse effect on the property to the north,
as it's septic system is not in close proximity to the subject
property's leachfield.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
17034 NORTH EAGLE RIVER LOOP ° SUITE 204 ° EAGLE RIVER, ALASKA 99577
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
0 5' /-- /o .~ - ~ ~ HAA# ~ ~0 O ;z. ?.S/'
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Lot 16, George Sehm
Location (address or directions)
NHN Tundra Rose
(b) Property owner AHFC ~51314 Telephone: (home)
Mailing Address 520 E. 34th, Anch., Ak.. 99503
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent Re/Max Sharon Minsch
Address 16600 Centerfield Dr., ~201, Eagle River, Ak. 99577
Telephone 694-4200
(e) Mail the HAA to the following address: (or check here[-I, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 ~%,1. ~!v~ L-"-"p RO.'.
Eagle River, Alaska 99577..
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms '4
3. WATER SUPPLY
Individual Well [] Community [] Public I~
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [22X Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
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/'~--~-'%,O~ MUNICIPALITY OF ANCHORAGE (MOA)
O~[[,~\s\Ot4, ,..~..,Health Authority Approval (NAA)
.,c.~' ~ ~ CHECKLIST - FEBRUARY 1984
~ ,~ ~ ~"~ 343-4744
t~tO ~ 9 ~ ' Legal Description: ~
A. WELL DATA~c~x~ t~
Well Classification
Well Log Present (Y/N) __
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
Date Completed
Depth of Grouting
To Septic/Holding Tank on Lot
To Nearest Ec~ge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
IfA, B, C, D.E.C. Approved(~lN)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
~ ~ ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
Date
B. SEPTIC/HOLDI~GTANK DATA
~,/~
Date Installed ~/~ Size
Standpipes ~/N) ~ Air-tight Caps~P/N)
Depression over Tank (Y/~
Pumping/Maintenance Contact On Eile (Y/~,~
Holding Tank High-Water Alarm (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
No. of Compartments ~
Founda.~ Cleanout ¢!~'N) y
Date Last Pumped ~ ~ ~ - ~::)¢)
~'~/,~ ;for
/
Temporary Holding Tank Permit (Y/N) ~//,Z~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
'~:2 ~::~ !,Jr'- To Building Foundation
~ O I'/r' To Disposal Field
To Stream, Pond, Lake or Major,Drainage Course
Comments-~ ~ ~/~ ~i
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~- lq- ~'..~
Width of Field ~ t
/ ~ '¢¢'//~'~-'~ Type of System Design
Length of Field ~ ~-!
Square Feet of Absortion Area
Depression over Field (Y/,..~
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~ t,~
To Building Fou nda~/~Lot "~' ~'" '
Depth of Field
Bed Thickness
,c~ Gravel
"'~ ~=' ~ Statndpipes Present
~ Date of Last Adequacy Test
To Water Main/Service Line /~ / "/'
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~---'~/
To Property Line ! c~
To Existing or Abandoned System on
; On Adjoining Lots % tO.
To Cutback (if present) ""~/'~
/~ ~.f-
D. LIFT STATION
Date I n st a I I e'~..,....~ Dimensions
,S, ize in Gal ons %.. Manhole/Access (Y/N)
Pump On' Level at ~~._ "Pump Off" Level at
High Water Alarm Level at ~ Vent (Y/N)
Tested for ~~Pump'mg Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request** .~.?.~,~,:. ,~
I certify that l have checked, verified, or conformed to all MOA and HAA guidelines~i~-,~~.e.~,~.t¢ c
inspection. ~ ~, ~~. ~.~,4'~,;~, ~,
Signed 5 ~ ~ ¢~c~iNEERING ~'~%% ~' , ';
17034 Eagle River [,~p Eoa~ No, 204 ~ "~"~ ~
~Seal
Date ~/~/~ ///~f'~ t~~ '~'~"'?,~¢ ;
Receipt No. ~ ~ ¢/~ ~/~
Date of Payment F--¢ ~¢ O
Amount: $ /2 ¢~ O¢~
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
APPLIC HT FILLS ouT'uppER HA[ ONL
Phone
Address ¢~ ¢"4/ /~/' 5; -/~ I,~ ZiP Code
Phone
~--
Legal Description : '- ' .... ,
Type of Residence
Single Family
Multiple Family No. of Bedroo~ ~
~ Other
Water Supply
~'lndividual A~ACH WELL LOG. A well log is required for all wells drilled since June 1975.
¢ Community For wells drilled prior to that date, give well depth (attach tog if available).
~ Public Utility
Year Individual Installed:
~4 Individual
~ ~u~lic UtiHW ~hen Gonnoctod to ~ubli¢ ~tHity:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time
Date Date , Date Date
Inspector Inspector Inspector Inspector
· , ~,~unic~p¢itY ¢ Anchofag~
( ~APPROVED BEDROOM~ ~CONDITION~¢~
( ) DISAPPROVED
Soils Rating Date ~wer Inslalled Well To Absorption Area / ~ ~' Well Log Received