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HomeMy WebLinkAboutDELUCIA LT 7 i 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 PHONE [~hEW MAILING ADDRESS LEGAL DESCRIPTION LOCATION , /~_ NO. OF BEDROOMS J Wel P ~ = Manu[acturer z' /')/ Mat~ial, . No. of ~mpartments Liq. capgqity in gallons Inside length Width Liquid depth ~q~ IF HOMEMADE: ~ Well Foundation z Nearest lot line~ ~ DISTANCE TO: J'/C /'"d". /,~,/. /:,'~. /'~t /~, ~ No. o~,n/s U~n~,h o~ ~,~h ,... ~ot~ ~,%th ~ ~.,~ T,~n~h width ~i~n~ ~,tw~n ~in,~ -- Material beneath tile-- Total effective absorptio~area ; ~ ~ ~ Top of tile to finish grade~ ~:.~ . Z~~ inches Length Width Depth PERMIT NO.  Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. m Building foundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER PIP~ MATERIALL SOIL TEST RATING -- REMARKS ~{~ A~V ED //// /' DATE LEGAL 72-013 (iR.¢ 3/78) ! '~f.: "' ..... ,. f, l:::'t~' ~/'f' :, FINE:' "FHE7 EEITTfi~H OF' THE S NF~ '-'~-T _ z,~: HID'TH FOR (3F:f:i'v'F:L DEPTH IrE; THE7 h! ]J N ! HI.tN .......... ~",F' ...... -" .... ~ ,.., ..... E ?f'T 3f'! f3F' THE Et:.::C':F!',.,'f:~T ~:~7 ~:~E E~:'~ :E~;: E:E: F:" "-~" :17~ C-?: t.:[ (3f~N'f' HFI~5 THE ?f~?TF'ON~'~;I F~: ]'t '[ T"r' !'i"~ 'f "~ "' r N;j::'['~:::&_! .f::i-[' ]:("l~'~ .... ~.~ ~. ,:: ~:, [:' f-' "r 'r O1'-,~:~,;..,, ..... . , .~ I"IF .... f~['~'T' F:E"~;i[',E:NE:~T:~ THFIT THE: I,..ELI. H'.?LL '~E~R'v'E. F~;"R: FI PR];'.,,'Ft'f'E b. IEZ. L; ::'~:Eq:) FEET FF::Ohi t~ F'UEL...~C' I,EL.L /~'-o / UNITED STATES ~ ~ DEPARTMENT OF THE INTERIOR ~.~-. 3 7 c, GEOLOClCAL SURVEY WATER RESOURCES DIVISION WELL SCHEDULE Dab ............. --'7~---~--k-~----~--~- ..................... ,9_.kA ~,:~d No ............. lZecord by .......... ~ ............................................. Office No ................ /)&,~ ~-,~ ~ .i ..... ~__~___~ ................................ Source of data ..................... - ........... :~-- ............. ~/ 3t ~cc. T N R W Tenant ......................................Addre~ ............................ ~? ,~ z' ~ g ._~/__~_~:_: ................. 3. TopoFraphF ................................................. ft above 4..t~;levaiion .............. below ...................... 5. 6. ?. CasinF: Diam._~ ..... in., to ........ in., Type ...... Depth _l_~-~--- ft., Finish _~?:-~-~---~-~-~- ........... g. (-Ji{¢.fA~ui/~ .............................. From ............. ft. to .............. ft. Others ...................................................................................... above 23 9. Water Ieee! __f .......... ft. meas. - .......................... ~ which is ..... ft. ,a._b,o~ surface 10. Pump: Type ................................ Capacity ............... G. M ............. Power: Kind ......................................... tlorsepower ......................... 11. Y{dd: Flow ........... G.M.,Pump .............. G.M.,Meas.,llept. Est .......... Drawdown --/-/- .... ft. after ..... -~ ....... hours pumping .... -g-~-~-- ........... G. M. 12. Use'~, Stock, PS., I~R., Ind., Irt., Ohs .............................................. Adequacy, permanence ...................................................................... Tcmp ................. 'II'- 13. Quality ........................................................... Yel~ Taste, odor, color .......................................... Sampl8 No ............. Unfit for ........................................................................................ 14. t~marks: ~ Analyses, etc.) ......................................................... b~-illing Co. Driller 0 & C 92Iii LEE H. GOHR MINOR MARTIE Well owner Dooet~0n-(address of; Township, ~uge, & section, if'known; or distance from main DO Nfff FILL IN USGS No. Area Use cf well Static water level 142 feet (akin(below) land surface. Finish 6f well (check one) Open end-(XX); Soreen ( ); Perforated ( ). Describe screen or perforationa Well pumping test at 600 11 fee%'of-drawdown from static level Remarks Water at 72 Ft. Well_ Log ..~..-.~.. ~round surface and heftiness. O to 2 TOP SOIL 2 ly to SOIL, SAND & CR~VEL 19 to 22 LARGE ROCK 22 +~ 55 TILL, GRAY 55 to 72 CLAY & GRAVEL 72 ,~ 75 75 ~ 100 to ClAY & GRA~F~ ( WAT R SEFPAGE) 100 CLAY & GRAYF~ 108 CLAY & LARGE BOLD~:HS 108 to 113 CLAY, SAND & GRAYEL (WAT2.~ SEEPAGE) CLAY & LARGE I~.OLDLRS CLAY C!.~Y, S?~D & GR~VEL (SJi~ WATi,'R) GR~Y STO~'~ (WAT!;R BEARI~IG) 113 to 122 122 to 147 159 to 166 to to to to to to O 8' E GEG. ECHNICAL ~ DEVELJPMENT 'CO/.' Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl EII/~ 694-2774 SOIL LOG 688-2280 Soils ~ Foundations Land Developr~nt Performed for: Hame: Hat]tng Address: Legal Description: ~QT- Depth (feet) So~! Chmractertsttc~ 10 11 13 14__ 15, 16 Ground Proposed Comments: Water Encountered: Yes No~ ~ If yes, what depth Installation: Seepage Pit Drain Field_ ~ Performed by: Date:~-? ~-- /~ MUNICIPALITY Of ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 051 -141 -22 HAA# ~.~,~O~.O-~_~ ,~'~(~t. 1. GENERAL INFORMATION Complete legal description Lot 7; Delucia Subdivision Location (site address or directions) 19735 Ra~h 9~ Chug~ a~, AK-" Jack Woodland Property owner Mailing address p.o. Rox 1047 Lending agency Day p9one 688-0600 AK 99577 Day phone Mailin. g address Agent Address Larry Suiter/Prudential Vista Day phone 727-0403 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site XX Holding tank Community on-site Public sewer 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 verifythat 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, fnspection. ordinances, and regulations in effect,~a..~d~tg~, t~i.'_ Name o~ Firm ' Wastewat, er, Con~ ~i~r's signature ~ /~~ Alaska Water & Wastewater Consultants, Iht.at' Shall be PAID $ /~0© ~ or prior to, closing for the = DHH8 SIGNATURE I,// A.p. proved for __ Disapproved. /~'~] ('//4~ bedrooms. __ Conditional approval for Phone Date bedrooms, with thee following stipulations: Additional Comments 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, Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 o (907) 343-4744 Legal Description: A. WELL DATA Well type PRIVATE Log present (Y/N) Total depth 400' Sanitary seal (Y/N) Health Authority Approval Checklist DELUClA S/D; LOT 7 ParcelI.D.: 051-141-22 If A, B, or C, attach ADEC letter. ADEC water system number YES Date completed. Cased to 163' YES FROM WELL LOG Date of test 12/13/84 Static water level 275' Well production 1.0 WATER SAM PLE RESULTS: Coliform 0 Nitrate Date of sample: 10/5/99 B. SEPTIC/HOLDINGTANK DATA Date installed 7/28/78 Tank size Foundation cleanout (Y/N) YES N/A Casing height (above ground) 2'+ Wires properly protected (Y/N) YES AT INSPECTION 8/12/99 161' *0.28 g.p.m, g.p.m. ~'A NEW 500 GALLON STORAGE TANK HAS BEEN INSTALLED IN THE GARAGE. THE WATER STORAGE TANK IS NSF APPROVED AND ALL COMPONENTS COMPLY WITH THE CURRENT UN FORM PLUMBING CODE. 2.24 mg/L Collected by: Other bacteria A.W.W.C., INC. 2 1250 Number of Compartments 2 C eanouts (Y/N) YES Depression (Y/N) NO High water alarm (Y/N) NO (IN 3HE U~UTY ROOM) Date of Pumping 7/28/99 C. ABSORPTION FIELD DATA Date installed 7/28/78 Length **29' Width Effective absorption area 348 SQ FT Date of adequacy test 8/16/99 Pumper JR PUMPING I**PER INSPECTION REPORq' AND PREVIOUS H.A.A.] Soil rating (g.p.d./fF or fF/bdrm) *'3' Gravel thickness below pipe Monitoring Tube present (Y/N) YES PASS Results (Pass/Fail) **85 System type TRENCH *'6' Total depth 9.25' Depression over field (Y/N) __ 4 For Fluid depth in absorption field before test (in.); 0" Immediately afted 000 gal. water added (in.): Fluid depth 0" (ins) Minutes later: 0 Absorption rate = 600+ g.p.d. Peroxide treatment (past 12 months) (Y/N). NONE KNOWN If yes, give date - NO bedrooms 0~ 72-026 (Rev. 3/96)* D. LIFT STATION ~ Date installed - "Pu ~ Manhole/Access (Y/N) ~~;~]evel at" "Pump off" level at* High water~/ *Datum C~f.~ed E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line 100'+ On adjacent lots t 00'+ 100'+ On adjacent lots 100% N/A Public sewer manhole/cleanout 25'+ Lift station N/A N/A SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON LOTTO: Foundation 5'+ Property line 5' Absorption field Water main/service line 10'+ Surface water/drainage 100'+ Wells on adjacent lots 5'+ 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line **'14' Building foundation 10' Water main/service line 10'+ · Sudace water 100'+ Driveway, parking/vehicle storage area Curtain drain ENGINEER'S CERTIFICATION I certify that l ~-~te/ ~ in conformance with~/ Signature ~,~ ~/ Engineer's Name/ ~ ' Date ~ NONE KNOWN Wells on adjacent lots ***RIGHT OF WAY ENCROACHMENTI PERMIT HAS BEEN iSSUED PER 11/25/86 H.A.A. inspections and review of Municipal recc nes in effect on this date. JEFFREY A. GARNESS 100'+ HAA Fee $. Waiver Fee $ Date of Payment Date of Payment Receipt Number Receipt Number 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Lot 7 Block _ of ~. [JC //~ Subdivision, the well's productivity was determined to be o~ gallons per minute. The minimum well productivity required by this Department (AMC 15.55) for a ~ bedroom residence is , ~ lA gallons per minute. Altkcug~ the subject well currentlyq%~t~h1%~/~ minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of ncn-critical water uses such as washing cars ~nd watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Apprcva!. L N DTHER THAN NOTED, DA?ED AT ANCHORAGE, ALASKA THIS 0,CT-08'99 18:32 FRO~CT; EFI¥1RONk~NTAL zTK C T&E Environmen[al Serv,ces Inc* 5615301 T-753 P.OZ/05 F-358 CT&£ Ref.# Client Name Project NameY~ Client Sample ID Matrix Ordered By PWSID Sample 995460001 AK Water & Wastewazer Consultants Inc. N/A Delucla S/D Lot 7 liiTchen Sink Drinking Water 0 Client PO// Printed Dale/Time 10/08/!19 14;50 Collected Date/Time 10/05/99 09:00 R~eived Date/Time 10/05/99 16:30 Teclmical Director: ~fephen C, lilde 2.24 0.500 mg/L AltOuabte Prep AnaLySiS SH1B 92228 10/05/99 JOT EPA 300.0 10 max 10/05/99 10/05/99 SCL MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # ¢)5'/o /y'/- ~-~--- HAA # 1. GENERAL INFORMATION Complete legal description Lot 7 Delucia Subdivision jA A q -oG II 941 67 Location (site addreSs or directions) 19735 Ranch Road Property owner Mailing address Lending agency Mailing address Agent Address Jack woodland P,O. Box 1047, Eaqle River, NBA KristineMartin Alaska Day phone (907) 99577 Day phone (907) 688-0600 257-3611 Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well Community well Public water X NOTE: If community well system, provide written confirmation from State ADEC attest- .,' ,.~ lng to the legality and status of system. ,,,,' ,, TYPE OF wASTEWATER DISPOSAL: ,,' ~:~. Individual on-site X : ,71, ~1 Holding tank , ' 'L',',,, Community on-site ~ ~.~,~,..,, , Public Sewer " NOTE: If community wastewater system, proWde Written confirmation from Sta~e A~EC attesting ~o 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 ~_~ngi~.ee~__t __7LDHI t'~n-~--~-~, -,.~ Phone ~907) 345-1385 P.O. Address ,-'-,~, Anchorage, ~as~ 99511-1349 Engineefs signature--~ Date / ~ ~' /~ ~e High, P.y ~ ' DHHS SIGNATURE Approved for 3 bedrooms.' Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments · . [ he Mfmcil~ality of .A,p'~horage Department of Health and Human Services (DHHS) issues Health Authority "'.,'A:pProval C~hificate~.bas~d only upon the representations given in paragraph' 5 above by an independent ~pr'of~.~ionalen~li~q~'~egisteredintheStateofAlaska TheDHHSdoesthisasacourtes to urchase f ,,-.:.,t.~.,.~ .. ~,x~, ' y p rso homes ana..m, e~F I~nmng ~nstitutions in order to satisfy certain federal and state requirements. Employees of DHHS do not cond~t'inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ..,; . ~, . ( 72.025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST 94167 Legal Description: ~.~t 7 Deiucia Subdivision Parcel I.D. 051-141-22 A. Well Data Well type Individual Log present (Y/N) ~" Total deplh Sanitary seal (Y/N) If A, B, or C, attach ADEC lelter. ADEC water system number Date completed ,z-Is- ~5/ Driller / Casing height Cased !o Y Wires properly protected (Y/N) 2' ~ Y ~ FROM WELL LOG AT INSPECTION Date of test / / Static water level ~. 75 / '7 ~'. / r'.j.-r;c · Well tlow /. Pump level1 3 ~'5" j, ,I'5 / (~ g.p.m. SEPARATION DISTANCES FROM WELL~(~. Septic/holding tank on lot I O (~ ; On adjacent lots Absorption field on lot /zo ; On adjacent lots Public sewer main Sewer service line Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform -- O- Date of sample: Nitrate ~z. ~.,1/ Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed 1978 Cleanouts (Y/N) ¥ High water alarm (Y/N) Date of pumping Tank size 1 250 Foundation cleanout (Y/N) N lA ?-//-~4 Compartments ~ Y (~ Depression (Y/N) Alarm tested (Y/N) N/A Pumper JR' s Dumping N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /~,' On adjacent Iols /0,5' / To property line 5' Absorption field ~/' Surface water/drainage 100 + / Foundation 7~ Waler main/service line 25 + 7~-0~ (~)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons 3 o 9,,~. Vent (Y/N) Y (~ "Pump on" level at Manhole/Access (Y/N) ~ ® ",~,~,.,. 7'~'~ "Pump off" Level at Cycles tested High water alarm level Y Meets MOA electrical codes (Y/N) ~ (D SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot $o' +/- On adjacent lois D. ABSORPTION FIELD DATA Date installed Length 29' (~ Total absorption area Date of adequacy lest 1978 Width 348 Soil rating (GPD/FF) 85 SF 3" (~ Gravel thickness Cleanout present (Y/N) Water level in absorption field before test //- 7- ? '-/ Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) / BR (1) System type Trench 6' (~D Total depth ~ ~/- Y Depression over field (Y/N) N PA ~$eO for .3 ~ Bedrooms After test ~/Z" (~ N If yes, give date .... SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / zo To building foundation On adjacent Iols Sudace water On adjacent lots //O' -,'- (~ Properly line I~'//,~ ~ ¢', C..O To existing or abandoned system on lot /~/,A- 50 + Cutbank__ N/A (~ . Water main/service line 100 + ~D Driveway, parking/vehicle storage area 20 + (~) Curtain drain E. ENGINEER'S CERTIFICATION HAA Fee $ Date of ayment Receipt Numar Waiver Fee $ Date of Payment Receipt Nuinber i~ T~I$ "cREE~4ENT, made. this ~ ....... ~.g86, betweer. MUNIC~ ~ALiTY' OF ANCE ~GE, Grantor, ~ Jeff ilheeler , Grantee~ ~i, --WiTNESSET~{: The Granto~ does hereby grant an Enc~oach- ~ment Permit in the following described Public Right-of-Way ~,~asement .Ar%a to Wit: De.~_ac']4 S~b.<ivisicna Lot 7 located w.ith[n j, the .... . . .. ~-~ ~s described as and limited to the encroachment hereby autho?:] ~.d the followinG: That portion o[ i~ach fie~d_~ha~ncroi4~]Z~~%Q unnamed ~.iqht-of.-Wa:' between Wildwood DcJve an,~{~ qee¢_le~ Road a:~; r~hown on the as-build : '~'!..~ shown In consideration f.~'~, th..~s permit, the Grantee agrees that he will indemnify an8 hold harmless the Granto~ against any and all clairts which may ~rise o~ be caused by the construction, alteration o~ maint,:nance and ex [stence of tho above desc~ ].bed encroachP~ent :~,.~r~ any dameg~s whatsoever_ ar~sipq....~ out of the ~.a%ting of this permit. The G~antot [eselves the zight to revoke this Delmit UDOP t'~?nty (20) days wr!tt~r, not~ce to t~e Grantee. The ?.Iantee~ acr. ees upon :~aid notice of revocation, to immediately re(~ove sal.J encroachment flor0 the easement, street or pt~biic ~%i<j~t-of-way. S*~ould the G~ant. ee refuse ,'31 fail to comDly ~ith '' -'e ot~ may ithout ~u~ther no e i::::e Gru,~tee, ~nc, ve or cause, to }~,~ removed the encroach~:leilt, r and :lncldenta]. t(.. the ~.emova~ thereof. ~'h~ Gkantee hereby agrees Lo ~pay '~n annual fee c~ $ IN %~ITN~SS WHEREOF, the pa,:ties herato have hc~teunto ~,set their bands and sf~al.b the d~y and yea[ r!l~s~ above written. [~l~rantee: ~~,.~ ..... Grantor: ~ ~.! u ,; ..... i~ Municip~l Engineer ~STATE ,n? ALASK~ ) HIRD JUDICIAL DIS'FP!CT ) THIS IS T(') CERTIFY that on ti]is day of [ before the under3igned~ a ~o?ary ~t~D]. :~ C ~ n and fo~. th-~Stat~ of A!a,~ka, duly co~m, issioned swc;n ~s such, per;sonally appeared J, David No, ton, known to ~to be the Municipal Engiaeer for the Municipality of Anchorac3e, ~laska, who executed the fore.~oing inst~ ument, and he ~cknowledged to me that ]~e executed said instrument as the f~ee ~md volunt.~ty act and deed of said corporation for the uses and PUtDOSeg therein m~ationed, an'-] t~lat he was authorized to execute !said in&~t rument ~ ~,~.~c~.~,,~,,:: my hand end c~fficia! seal_ on t~.e day and yna first aDove w~.itten. !this lqc~TARY PUBLIC in and for Alaska My Comnission Exp~.res: STATE OF ALASKA ~ ss. ?H!RD JUQICIAL DISTRICT ) THiS IS TO C?~TIFY that on this ,,~___. day . , lg~, before m~:, the uadersio:~ed, a Not~ry Public ~i'{~ and f6'~--'the ~tate of Al.asta, du].v commissioned and swo~n as ~such, pe~sona!iy ~pneared ~- ?/L~.~,~ ~ known to me ~lbe the' individual ~,amed he~~-~xe~'{&~"~foreGoing instru- ~[tarily for the u~s and ~crpos~s therein mentioned, an~ on oath ~stated that g/be was autho~:lzed to execute sa!d lnstrumenu. WITNESS my hand add official sea! the ~ay and yeat in certificate first abcve written. ...... NOTARY PUB~.IC in ~nd fo~ Ala,ska MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~:.~, .~.~ - \ ._~'-"[ '~ OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date //O/.-.~J~'//~ ~/ GENERAL INFORMATION (a) (b) (c) Legal Description (include lot, block, subdivision, sect_ion, township, range) A~plicant Name ~(~,~ -'~/~_.~.~.4~./ Telephone:Home Ap p licant A ddres¢ ~¢/Lf'~-~:~' ~/,~:2 ? ?/_~- ~r~,.~ ~/~~ Applicant is (check one): Lending Institution []; Owner/builder,[;~'; Buyer [] · Other [] (explain); (d) Lending Institution f,~t~f~ F~ Telephone Address ~q._'~L~O'~'~'' /~~/ ' ~~ ~ /- . . (e) Real Estate Company and Agent ~ Address e (f) '-Meff'the HAA to the following address: / TYPE OF RESIDENCE Single-Family,~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well/~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite/l~ Public [] Community l-'1 Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11,,84) ENGINEERING FIRM PROVIDINU INSPECTIONS, TESTS, FILE SEARCH, DA, A AND INFORMATION 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 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. Telephone Name of Firm Address Date DHEP APPROVAL Approved for "P~F~'~'"~. iedroomsby~~'~'~ ''~' '~~ Approved ~ Disapproved Conditional Date Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 72-025 m/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: Lc~ ~UNICIPAUTY OF ANCHOP'AG'~ DEPT. OF HEAL'IH & Ej,,IViRONN'tENI'^L PROTECT'ON WELL DATA Well Classification Well Log Present Total Depth Static Water Level Cased to Casing Height Above Ground Electrical Wiring in Conduit(~'/N) Separation Distances from Well: If A, B, C, D.E.C. Approved (Y/N) Date Completed (//,t?--. Yield /~'" Depth of Grouting ~'- Pump Set At ~/,'- Sanitary Seal on Casing (~YN) Depression Around Wellhead (Y/~ To Septic/Holding Tank on Lot /42 O '4 ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /oo/4- ; On Adjoining Lots To Nearest Public Sewer Line /'v'~,~ To Nearest Public Sewer Cleanout/Manhole /~//'// To Nearest Sewer Service Line on Lot Water Sample Collected by ~ ~'-~ C~.,,,.4~,/,,,.fcc~lZ-J,'.J~ ; Date I,/ Water Sample Test Results ~ ~~r-~''/~' ~- ./~ ~'~---~"'/ Comments ~W/'~z.~ V,'~=-~?> ?¢-.%.'7 /Or._) B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~¢',~ N ) Depression over Tank (Y~_~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line { To Water Main/Service Line ' ~ ~C. Course Size / ~-~,~¢~ No. of Compartments Air-tight Caps ((~/N) Foundation Clean0ut (Y,~ Date Last Pumped // -.3~ -~ ,k//~ 'for ~ Temporary Holding Tank Permit (Y/N) To Building Foundation ~0 ' To Disposal Field 1(5 / To Stream. Pond, Lake, or Major Drainage Comments Page I of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absorption Area Depression over Field (YN~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot TO Water Main/Service Line Depth of Field Gravel Bed Thickness Standpipes Present Date of Last Adequacy Test ( e~ r)r '-.,c To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Length of Field :~.~ To Property Line -~ To Existing or Abandoned System on · On Adjoining Lots ~c_~1 -4- To Cutbank (if present) /"¢/Zt "'"/A D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed SJJ B 196X Company ~,,GLE PdVER, ,AK 995T~4°A No. ~"'",¢'- ~' ~ Receipt No. 2~? ~O ~- ~ of.a, en, Amount: $ ~ Page 2 of 2 72-026 (11/84) ~ _ ,:~ ~;_.-~ MUNICIPALITY OF ANCHORAGE .... 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION ~ Telephone264-4720 i~EC~i ~,~ ~ REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES , DIRECTIONS: Complete all parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing.  PHONE PROPERTY RESIDENT (If different from above) PHONE , ~, ~ PHONE MAI LING ADDRESS Z~q 3, LENDIN~ INSTITUTION PHONE MAILING ADDRESS 4. REALTOR/AGENT ] PHONE I MAILING ADDRESS 6. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] One [] Four J~ SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY ~ Three [] Six [] Other 7. WATER SUPPLY [] INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY ~}FTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY (~ *~ individual/on-site, give installation date ~/7"~ '~. -- If system is over two (2) years old an adequacy test is req~jired by this Department. / / NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN/I~E INITIATED. -Il .... THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME FIME TIME DATE DATE DATE I NSPECTO R t NSPECTOR INSPECTOR DIRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY [] ONE [] THREE [] FIVE [~] TWO [] FOUR [] SIX 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE [~PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED iNSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [] OTHER Septic/Holding Tank IAbsorption Area ISewer Line Nearest Lot Line [~ APPROVED FOR ¥ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION 72-010 (Rev. 3~78) I hereby ct~'rti~ t.h~t I, h~ve ~esi~tt;ea AS-BUILT ' I hereby certify ~at I h~ve s~v~yed the following [' Anchorage Recording ~eeinct, ~sk~' and that the improvements situated ~eon ~e within the p~perty lines and do not overlap or en~nCh on th~ ~p~' lying adjacent thereto, .~t no tinpr~eh~.on, prop- queshon and that ~ere are no roadw~s, ~ansmts~wn Ii.es or otht-r visiblo e~emen~ 0n ~id prope~ e~ept" .4 ,~8~ l~tm~ NUN lC l PALIT Y OF ~NCH~GB ~ ~unto[ ~n~ ~tt tn the foll~ng doec[t~d ~blic ~lgh~-of~Y o~ tO orison o I ....... w. nv da~;a .s whatm~voz arising out o~ the The Gzant. ot [lle~vel the %tght to %evoke thte iVoa tventy {20) d~ys v~itten notice to the G[intle ;~=ntee~ ag=ee, upon ~a~d notice ot [ev~ation, to em~e maid emc[oachmemt [tom the eaaoment, at,met ight-o~-eaY. Should the G~antee [elule o~ fail to lid ~it.tem notice, the G[antot, may without tultheg notice to .hi ~fantee, remove o[ cause to be [emoved the enc[oac~ent, and incidental to the ~emoval the[eot The G~antee he~ebM ag~eel to pay mn annual fee of $ 1O.p0 :_. IN ~ITNZSS ~HEREOF, the p~itie, hereto hove hl%e~to let thllt handl and seals the day and yeai fi~/t abort STATE ~F A~SKA ) ' ~ ~"'~'; ~ ~'~ ~:' THIS IS ~ C~TIF~ that on this ~ day of ..' , 19a~, bo[o[e me, th~nde~ll~n~ 'Ub~'ic in "and-~oz the 9tnt~ oe Alaska, duly nwozn nn such, pezsonally nppenzed J. David No, ton, : al En lnee~ fo[ the Hunicl~nlity off to ~ t~e ~unicip O ....... .__ i..tzu~t, ed~, hl~, Ckuowled~ed to me that he executed said inatzu~nt nd voluntary act and deed o[ said co[po~ation fo~ utpome, thelein mentioned, and that he was ~uthoilled HIgh,SS ~ hand an~ official .esl on the d~y trait abovo ~TATE OF A~S~ ) '" ,,/~t~he,~tll indemnify and hold ha~lesa the Gtant. o~ &gaLnn5 ~hMnt or ~o~ any d.~ag~, vhetmoeve~ arising out 'of tasting of tht~ ~,~tt '' The Grant. et tlS,EVeS the tight to revoke thii': Emit twenty {20) days wttLt~n no~tce k~ the Grantee, :'~e :antoe~ a~roon upon said notice of tev~ntion, to :e~e 18ld oncro8ch~ ~tom the easement, .~teet or publlO', : lgh~-of-wey.. Should the Gtan~e refuoo et ~mil to lid vrit~e~ no, ice, the Gt8~o[~ ~ay vithou~ further no,ice ~o~ ~ean~o, to~ove et cau~ t~ h~ re~oved the on~oe~en~e end" ~t. antee h.teby agrees to reimburse tho Grantor fot'lll~eOlt:: incidental to the t~oval thereof. Tho Grantee hereby, agrees .. IN ~l~g~S ~NE~EoF, ~he pat~loo her~to have horeuflt°:??. their hands and sells the day and year first ~-- ........... ALAgRA ) ) ~UDICIAL DIf~T~ICT ) THIS IS ~ CERTIFY that on thin day:'of the St~t~ o~ AIAoka~ duly ouch, personally appeared J. David ~ott~, kno~"to~ t~e Wunicip~l Engineer fo~ the ~unicipality who executed tho ~oregolng inntru~nt ~ ,. ~owl~dged to me that ho executed 8nid innttu~nt voluntary net and deed of said corporation therein m~ntionud, and thnt he wan nuthotltod WITNESS ~y hand ~nd official seal on the oF ALARKA ) ) RS, IRD JtIOICIAL DIRT~ICT ) Tills IS TO CERTIFY that on this _~ day o~ , 19 .~, before mo, tho undera-T~-ne~, a and foe tho ~atn of Alum duly c~issiofled and p~tooflall7 ~p~at , kno~ to M/to tho individual named h exe, ' regoing inlet{ , and n/h~ ncknowledo ~d that n/he did no freely and :Volufl- ly got t~e usqs And putpo~.o therein ~entlonod, ~ntod that ~/h+ wan authot ized to exocuto laid i~ltrumon~.' t{ITN~SS ~y hand and official neal the day s certificate fttst above written. bp/op2 ~-% ,;,/ // ; _ ~OTA_~Y ~[II~IC in &nd EOLAI~k'~ ,"~'~ ; i i ; · ~. ,:.;., .:~::-: ..... ...:.~ Commercial Testing & Engineering Co. Drinking Water Analysis,Report for Total Coliform Ba6teria R~dD INSTRUCTIONS ON REVERXE SIDE BEFORE COLLECTING SAMPLE .MUST BE COMPLETED BY WATER SUPPLiER ]g~ PRIVATE WATER SYSTEI~I [] Send Res'u~ [] Send Fh~r,e [Number Fag humber [] Send Resulls [] Send lm,aice eo,=p,~y.,',..-,, David R. va .yt~n_ P.E. 20210_Donalar Chuglak, Alaska 99~&7 Year S/,2vW LE TYTE: ~ Routine El Treated Water [] Repeat Sample (for routine sample ~ Untreated Water with lab ret'. no. ) [3 Special Purpose SAMPLE LOCATION Time Collected Collected By 12- ~.~--" "' Ple~e Fret 5633 B Street Anchorage, AK 9951 8-1 600 Tel: (907) 562-2343 Fax: (907) 561-5301 TO BE COIt~LETED BY LABORATORY Analysis shows this Water SAlvff'LE to be: Satisfaetoo' Unsatisfactory [] Sample over 30.houzs old, results mav be unreliable [] Sample too long in transit; smmple should not be over 48 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Received / ~_d_J Date Time Received Analysis Began Analytical iMethod: ~ Membrane Filter [] MM&MUG * Number ofcoto~des/lO0 nfl. Lab Ref. No. Result* Sent to A.D.E.C. ~ Fbk~ , Anah'st .Jun Date: ~,__q[~.~r4. Time: Client notified of unsatisfactory results: Phoned Spoke Date: Time: Faxed Comments: 1MMO-MUG Result: Total Colifoma l~lembrane Filter: Direct Count Verification: LTB Fecal Coliform Confirmation Final Membrane Filter Results BACTERIOLOGICAL WATER ANALYSIS RECORD E Coli BGB COLIF[RM ! Colonies/100 mi Coliform/tOO ml Dale /O, I2-9t7/ Time ['3'~0 hfs TNTC - Too Nurn~,ous To Count Member of the SGS Group (Soci(}t~ G~n~rale de Surveillance} OB - Otb ~- ENVIRONMENTAL FACILITI£S IN ALASIC~,. COLORADO. FLORIDA. ILLINOIS. MARYLAND. N~L~,' JERSEY, OHIO, UTAH WzST VIRGINIA zTF_ Cite. nb ~omple ID :L7 r~LU¢I~ Commercial Testing & Engineering Co, Environmental Laboratory Services 6633 l~ Street REPORT o~' AR&t,¥GI~ Anchorage, AK 99518-1600 Tel: (907) 682-2343 Fax: (907) 561-5301 Clientl~e ,O~VID D~YTON, P.K. I~OFKOrder ~82976 Ocdeced By , Prln~ed Oate ,10/14/94 ~ t9~30 hts. Collected Oete ,t0/t0/94 e t2,00 Pro~e~t ~e , Recetv~ ~e =tO/t1/94 ~ t2:45 hrs. eco~ec~l : Techntcal - -~ple Re~etk~, ROLrrlh~ 8~1~%1~ COLL~L~I~J I~Y, ~lloweble Ext. ~nel Results {~a.[ Uotts ~ethc~l blurts oete Date [nit N.ttrete-N 2.24 E'P~ 353.2/300.0 to t0/t2 NC.K See t~pec.tal tnstructton~ ~bove U~ - Unavetleble Bee ~e~ple Re~cks ~bove N~ - Not ~naly~ed IJnde[edted, Reported veLue ts the prec[tcal q~anbtftce~.ton ltmt~. LT = bess Than Seeonctary dtLu~ton. ' GT = GreaLec Then ENVI~OF~MENT^L ~CILITIE$ IN ALASKA. COLO~AQO. FLORIDA, ILLIHOI~, MARYL~FID. NEW JERSEY. ONIO, UTAtt, WEST VIRGINIA 10/25/99 10:20 FAA 907 273 8440 pRL~ENTIAL VISTA REAL ES ~00g ENCROACHMENT PERMIT THIS AGREEMENT, made this 27_ day of ~g~<--%~- [986, between MUNICIPALITY OF ANCHORAGE, Grantor, and Jeff Wheeler ,'Grantee· WITNESSETH: The Grantor do~s hereby grant an Encroach- ~ent Permit in the following described Public Right-of-Way or Easement Area to Wit: Delucia Subdivision~ Lot 7 located within the SE~ ~f $~ct~n 9, T~5N. R1W. S.M- Ala~ks .... GRID NW 1259 ~he encroachment hereby a~ihoriz~ is described as and limited to' the following~ That portion of le~¢h field that encroaches into unnamed Right-of-wa~between~il~wood-~ive _and N~edles Loop___ Road as shown on the..as-build survey ~hown as attachment 'A' In consideration for this permit, the Grantee agreas that he will indemnify and'hold harmless the Grantor against any and all claims which may arise cz be caused by the construction, alteration cz ~aintenance and existence o~ the above described ncroachment or for any damages whatsoever arising out o~ the ranting of this permit. The Grantor reserves the right to revoke this permit )on twenty (20) days written notice to the Grantee. The G~antee, agrees upon said notice of revocation, to immediately :emove said encroachment from the easement, st=eet or public ~ight-of-way. Should the Grantee refuse cz fail to comply with ~aid written notice, the Grantor, may without further notice to :he Grantee, remove or cause to be removed the encroachment, and 5he Grantee hereby agrees to reimburse the Grantor for all cost incidental to the removal thereof. The Grantee hereby agrees to )ay an annual fee of $ .!0..00 · IN WITNESS WHEREOF, the parties hereto have hereunto ~et their hands and seals the day and year first above written. ~TATE OF ALASKA ) ) SS. Mu~iciDal ~ngmheer JUDICIAL DISTRICT ) T. IS IS TO CERTIFY that on this · 198 ~ , before me, the unde sip , Y Public in and for the state of Alaska, duly co~issioned and ~worn as such· personally appeared J. David Norton, known to me to be the Municipal Engineer for the Municipality of Anchorage, Alaska, who executed the fore~oing instrument· and he acknowledged to me that he executed said instrument as the free and voluntary act and deed of said corporation for the uses and ~urposes therein mentioned, and ~at he was authorized to execute said instrument. WITNESS my hand and official seal on the day and year first above written. OTARY PUBLIC i, and for Ala-sk'a .TATE OF ALASKA ) My ~ ) Ss. 'HIRD JUDICIAL DISTRICT ) THIS IS T9 CERTIFY that on this ,~__.Oay oz~ ........ , 19_~, before me, the unde ~r-~g~ed, a Not&fy PUblic i~ and for the State of A~ska, duly commissioned and sworn as such, personally appeared ~.~//~//~_~ j k,o~n t? m? to be the individual named he.~whO ·xecut~ the zoregoxng xns=ru- ment, and s/he acknowledg%d that s/he did so freely and volun- tarily for the uses and purposes therein mentioned, and on oath stated that s/he was authorized to execute said instrument. WITNESS my hand and official seal the day and year in this certificate first above written. NOTARY ~UB~IC in ~nd forAlaska '. My Commission ~pires= ~/~/~ --/ l-' bp/ep2 10/~'5/g9 21 l-iX 907 273 8440 PRUDENTIAL VISTA REAL ES ~uoo l r-~ '~~,; ~ ~ - ' ...... /I719, o.: ,_ ; ,q..,.D~'~...... ~.~