HomeMy WebLinkAboutSUN VALLEY TR C-2Sun Volley
Tract C2
#078 - 131 - 06
MUNICIPALITY OF ANCHORAGE nr
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 r;
http://www.muni.org/onsite
u
Department
On -Site Wastewater Disposal System Permit
Permit Number: OSP221463 Effective Date: 12/9/2022
Work Type: SepticTank Upgrade Expiration Date: 12/9/2023
Tax Code Number: 07813106000
Site Legal Address: SUN VALLEY TR C-2 G:0858
Site Mailing Address: 3336 SUN VALLEY DR, Eagle River
Owner: HENDRIX THOMAS J & Lot Size in Sq Ft: 83416
Design Engineer: NORTH RIM ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: 15 S v1� 3 70�-) - 2 M
Issued By:
Date:
Date: 2- Z
MUNUP UTY OF ° HC HO's„ OE
Development Services Departments Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 07813106000
Property owner(s) HENDRIX THOMAS
Mailing address 3336 SUN VALLEY DR
Site address same
Day phone 622-3379
Legal description (Sub'd., Block & Lot) SUN VALLEYTR C-2
Legal description (Township, Range & Section)
Lot Size 83,416 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
(® all that apply)
Absorption Field
❑
Initial ❑
Septic Tank
El
Upgrade
Holding Tank
❑
Renewal ❑
Privy
❑
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
TYPE OF DWELLING:
Single Family (SF) El
(w/wo ADU)
Duplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
Distance:
certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 02 a �r Waiver Fees:
Date of Payment: it �� �2 Date of Payment:
Receipt Number: G WelD Receipt Number:
Permit No. 05 P2a N&O Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
SteveEng.com Sun Valley Tract C-2
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is an existing 3-bedroom, single family home. This is a
developed subdivision with large lots. A new 1500 gallon STEP tank is to replace the old
septic tank/lift station. The existing trench to be connected to new STEP tank. No adverse
impacts are expected from tank upgrade. No conflicts to the other lots will take place by
this septic system construction upgrade. Measurements were made with owner present;
the measured overland/horizontal distance from the new tank to nearest surface water is
at 100 95 Overland/horizontal distance from the absorption trench to nearest surface
water is at 105 98 Owner reports stream has moved away from property over the
years. The main stream channel is further distant. Decommission old tank/lift station per
UPC. Easements depicted in the area, private water wells serve these lots. Recommend
survey prior to construction.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
New two compartment, 1500 gallon STEP tank. Install Double Cleanouts prior to
tank if no foundation cleanout.
Decommission old tank/lift station per UPC.
MOA-Spec material under tank.
10 minimum between the tank- trench, tank- house. 10 to property lines,
4 of cover or insulation is required for tank.
Tank & solid pipe must be set on well compacted, stable soil.
4 inch diameter cleanouts with airtight caps are required 1 to 4 from foundation
wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two
adjacent opposing cleanouts between the tank and the absorption field, not more than
10 from the tank positioned to provide cleanout access towards the tank and towards
the absorption field.
All cleanouts must extend to at least ground level.
In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
Trench to be placed level, minimum of 4 to groundwater, 6 to bedrock from drain-
rock.
The finish grade must be mounded to promote drainage away from tank.
Insulation must be placed over any pipe installed under driveways or parking areas.
Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
Sewer Service Line is minimum 2% slope.
Septic Tank to be pumped every two years or when required.
Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221463, Curtis Townsend, 12/09/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221463, Curtis Townsend, 12/09/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221463, Curtis Townsend, 12/09/22
q1MUNICIPALITY OF ANCHORAGE
//
t t 4
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�
—O-liee:
-- N( \ 6—fCtt C
PHONE
EW
• UPGRADE
MAILING ADDRE
15 v X S-1.01 t;Prc, L --e=. -1 v&(L A -K. `l
q; 5-,"7
LEGAL DESCRIPTION
—F-13 N C 1 w Sisc_ 4 ` 1 t l- C;- -2-
LOCATION
LOCATION `r
Sur V F 6 -Let
NO. OF BEDROOMS I
U Y
DISTANCE TO:
Well —Nr
I Absorption arerl_/
Dwelling (,j,
PERMIT N OI I
F- Z
CI. FQ-
Manufacturer
r
- .�
MafgsjalNo,
JT)i&: t
of compartment
m
Liq. a ac ty`�n gallons
goo
IF HOMEMADE:
Inside length
..-__._
Width
.�...-----
Liquid deptl`_a
O S'
Jt7z
DISTANCE TO:
Well ^ /
v
Dwelling
PERMIT NO,
= z N
Manufacturer
Material
Liquid capacity in gallons
TILE I
DR TRENCHSEEPPITAGE
DISTANCE TO:
Well
Foundation� j _ 7
Nearest lot Hu /
.S-0 `L
PERMIT NO, /p,
�/
No. of lines /
Length of Iipe
Total lentoyin/s
/
Trench wid�/,,
if({ inches
Distance between IinesA//4
Top of tile to finish grade/
Material beneath tile
Total effec ve2absor on.I
LL'L'_
3-4L inches
�area
J-0 /
Length
Width
Depth
PERMIT NO.
Type of crib
Crib • i
Crib depth
Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depthr
-
Driller
Distance to lot line
PERMIT NO.
Absorption area(s)
W��
DISTANCE TO:
on
Builth -da i°1
Swer 11-n e
Septic tank
OTHER
^
a"iS'C-2-V1cori
o nL
PIPE MATERIALS
,PVC
SOIL TEST RATING
/D'�
IILLS
I
INSTALLER
<,C-7) . Flt
4i f
F-
pentint
R EMAR KS in
SG, y
u L,. v -
�
5,'
fr
vA
.A
__sl—F
1--Iet ST/9-11
m -+J g Ismu'7- 1
CA.,
—«
fx'fC
= 3 i
dee
111
�j
_
V ti
0�
r .1
Robert A. Shafer
i1
.
e ,, `re,hda. 145/.k
Q``..vee Jf
19t 8°FESSO '
APPR.r
.
DATE LEGAL
V�7 r` / a E:JSiIfJCIf11Nki
ORB 190X
it,;dagovER, ALASKA 895n
72-013
ev. 3/78)
, u�4•;e0f
(In atirb� a ICng
by
��TTII��IIAA�� 'Irry.�.TI Doc Co. d//b[b��[.],ayy• ,,ii yy WELLS S LYOI�.,'4'S.1 W WAST E ¢,F; W ELL S
P. O. BOX 272, CHUGIAK, ALASKA 99567 o TELEPHONC. 6682759
OWNER OF LAND NJ J 1 /,d3 % o
ADDRESS `"- /2 C l- j .{'(t 1 /Zi
DEPTH OF WELL
STATIC LEVEL OF WATER FT g I /'/otiI At 6
LEGAL DESCRIPTION_ 1 Y. -r.;--• d / !1,1•e,J RI hJ `1.11? %' ThRAW DOWN FT.
DATE • Started %'/ /1" ?r Ended _St//:27121 GALS. PER HR `T Q!)
PERMIT NUMBER
KIND OF CASING S: o (7
ICIND OF FORMATION:
From Ft to 5 Ft o •1 <7.i%'77:r,.1
From -' Ft. to! '2 Ft. " ":^-/ti C ( if ✓.: =G.
From. = Ft. to Ft c. t. ,V .i 641,4
From. -.__:_Ft. to 7 S Ft �., �� �•-"� .+ 1
From Ft to Ft ?-0/LP�Li 'Ft.••
to Ft CC( :'7 e' L (c ;104.7.
From "i Ft. to `../ c:, Ft. JJ ei"J /2 4 12. 4, 6
Froin__ Ft to Ft
From Ft to Ft.
From Ft to Ft.
From Ft to Ft_
From Ft to Ft
From
Ft. to Ft
From Ft. to Ft.
From___Ft. to Ft. ...c.),/,,r c L_'- From Ft. to Ft.
Fron, Ft. to Ft. From Ft to Ft.
From _Ft. to Ft From_ Ft. to Et.
From Ft to Ft From Ft to Ft
Froin Ft to Ft From Ft to Ft
From Ft to Ft From Ft to Ft
From Ft to Ft From._ _Ft. to_ Ft
From Ft. to Ft Fpm Od BOE Ft to Ft.
From Ft. to Ft. MON10�EPyGOH�)T101S Ft to Ft.
From Ft. to Ft iN�IRONMStJtAL
Fron Ft to Ft
t CtIN" ®
MISCL. INFORMATION:
DRILLER'S NAME . •-
Permit # ce R •
MUNICIPALITY OF ANCHORAGE
Department r` Health and Environmental protection
825 Street, Anchorage, AK. . 501
264-4720
* * HANDWRITTEN PERMIT * *
WELL AND/OR ON-SITE SEWER PERMIT
NQS
Applicant: Sou 'N ot-1CeASt Mailing Address: CSX 5-G1 79 C77
Location: `> uun U /a��t(1 Phone Number: _ <cc/ LPS 1
Legal Description: I 1314 RI W'a-trric_T C_-2- Lot Size: S 3 CI (lV
Type of Soil Absorption System Is:
Trench: ✓ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: 3 Soil Rating(sq.ft/br) ( 1 0
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH 1 GRAVEL DEPTH WIDTH CN\ 11
The length
depth of a
the.bottom
The gravel
the bottom
dimension is the length(in feet) of the trench or drainfield. The
trench or pit is the distance between the surface of the ground and
of the excavation(in feet). There is no set width for trenches.
depth is the minimum depth of gravel between the outfall pipe and
of the excavation(in feet).
�" REQUIRED SEPTIC(HOLDING) TANK SIZE = 1000 GALLONS
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.
* *
I certify that:
Signed:
* * PERMIT EXPIRES DECEMBER 31, 1 9 8 3
I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
I will install the system in accordance with codes.
I understand that the on-site sewer system may require enlargement if
th .residency is remodeled to include more that 3 bedrooms.
Applicant
SWP/07.4(1/81)
Issued by:
Date:
l9 Q,;, Rs
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 2644720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: L
LEGAL DESCRIPTION:
9 / /3/v
DATE PERFORMED:
9
SOILS LOG
I.TJ PERCOLATION
TEST
»21%c 83
SLOPE SITE PLAN
1'
1
M
14x9(
r
.CR2kgs_
J
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Ne
Time
Depth to
Water
Net
Drop
PERCOLATION RATE �1� (minutes/inch)
TEST RUN BETWEEN
ci-rti�, tl'At iiipt t
$fl 1 11)5
PERFORMED BY: iT ;;Y13s Em FT. AY A`in/S 4ip '.
01144x97
72-008 (6/79)
FT AND
DATF�
N 6-
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C V FtvE' DATA
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Y 7.09 '-t9. 76
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CHORD PEAR IN f-
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Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.orglonsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 07 8 -1 31-0 L
1.
COSA # OLP 0 118
Expiration Date: 1 1 - 30-0 G
GENERAL INFORMATION
Complete legal description Tract 'C -,.Sun Valley Subdivision
Location (site address) 3336 Sun Valley Dr. Eagle River, AK 99577
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent Eva Loken
Mailing Address Prudential Real Estate
Unless otherwise requested, COSA will be held by DSD for pickup.
John McCann Day phone 696-4890
sane
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
3
0
Day phone 689-6464
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
(Y�
0
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given In paragraph 4 by an independent professional civil
engineersegisteredJn-1heStatetAlaskarCertificates-0f-OnSiteSystemsApprovalare requiredtor_thelransfer-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 structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm S & S Enrinperinr
Address17034 N. Earle River Loop
Engineer's Printed Name RCSEA-7-C .
Ste. 204 Facie
5. DSD SIGNATURE
✓ Approved for 3 bedrooms.
Disapproved.
Conditional approval for
Phone 694-9979
River, AK 99577
Date SS A Y /0
bedrooms, with the following stipulations:
Additional Comments
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
NitrateAdvisory
By:
dttt`t sY)OFAAbc
Q���C�QP'•, O
�o WATANON-SERITE
D : m=
WASTEWATER : E
PROGRAM '
�,�V �l)))A,lll\
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev. 11i05)
Original Certificate Date: O— 3 0— 06
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: l G4GT' G- :Z j soN Vi4tcx? S/n
A. WELL DATA
Well type-PC/PIE If A, B, or C provide PWSID #
Date completed '1/1 Z/s3 Sanitary seals 4) SS
Total depth 95' 3s ft. Cased to
Date of test
Static water level
Well production 16.0
g p•m•
WATER SAMPLE RESULTS:
Coliform D colonies/100 mL Nitrate D•3S1mg/L
Arsenic: mg/I Date of sample: e/s /et
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material '&P TI C 'S
/ ,&c
Tank size /006 gal. Number of Compartments 2
Foundation cleanout€ 1) kt>
Date of pumping lin 4 G
C. ABSORPTION FIELD DATA . .
Date installed 13 Soil rating (g.p.d./ft2 o
Length SP 1 ft. Width W
Total depth S Sift. Eff. absorption area
Date of adequacy test a l `s Pio Resu
Fluid depth in absorption field before test O in.
Elapsed Time: II Inmin. Final fluid depth a II i
Any rejuvenation treatment (past 12 mo.) (Ye type)
� u
FROM WELL LOG
9/12f 213
Frorec /sl!>Vft.
Parcel ID:
Dib -L3/ -O6
Well Log 61) /E'S
Wires properly protected3N) "Jcs
Casing height (above ground)l :.Lin.
AT INSPECTION
3•`t
ft.
g.p.m.
Other bacteria 1 colonies/100 mL
S 4 S Fj1U6rIc1te12.1/ay
Collected by:
Date installed /13/83
CleanouteN) 'Vied%
Depression over tank (Y I& ►.10 High water alarm (Y3 leo
Pumper TA J Pot -testi G
#Q System type
Gravel below pipe y,� * toofcs
Monitoring tube !`S Depression over field 40
aila_FFor bedrooms
�✓ r
Water added gal. New depth 3'? in.
n. Absorption rate >= 1160+ g.p.d.
1Jo
If yes, give date
D. LIFT STATION
ratty.(
Date installed 51134 3 Size in gallons 132 ro J Manhole/Acces
"Pump on" level at /00.5in. "Pump off" level at Jdin High water alarm level at /08
in.
Datum 1-0? of tnr mo{ -E" Cycles tested z Meets alarm & circuit requirements? "('F S
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
/15
/30'
N/A
On adjacent lots
On adjacent lots
Ilbr
tool+
Public sewer main Public sewer manhole/cleanout t4 n
st I p
Animal containment areas 501+
Manure/animal excrete storage areas /CO 11-
Sewer
t
Sewer /septic service line 12S It Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation X 1 Property line /6 + Absorption field 5 1
Water main HP/ Water service line /6 1-1-• Surface water sal*
Wells on adjacent lots / 00 f
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line r/0 t+ Building foundation S / 1 Water main
r
Water Service line /0 * Surface water 90. r 1e Driveway, parking/vehicle storage 10 4
Curtain drain NOA?E 1400 00/0 Wells on adjacent lots 100
F. COMMENTS
/4- #1.07.9 .nrY1 S
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 COS/Aguidelines in effect on this date.
Engineer's Printed Name /2M 44r C. CaAoh-,
Date Si 73 y /0
-7 fit
j
\VROBERT c owIA.
/,c
.'-Ek'=4,1
5601
COSA Fee $
q3 0_
Date of Payment c67 a r /0 6
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
SGS RefJ
Client Name
Project Name/t/
Client Sample ID
Matrix
1064637001
S & S Engineering
Tract C-2 Sun VAllcy SD
Tract C-2 Sun Valley S/D
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 08212006 16:59
Collected Date/Time 08/11/2006 14:50
Received Date/Time 08/11/2006 15:40
Technical Director Stephen C. Ede
Samplc Remarks:
Parameter
Results
PQL
Units Method
Allowable Prep I Analysis
Container ID Limits Date Date Ink
Metals by ICP/MS
Arsenic
Waters Department
Nitratc-N
Microbiology Laboratory
Total Coliform
ND
0.351
1 OD. No Coli
5.00 ug/L EP200.8
0.100 mg/L EPA 300.0
col/100mL SM2092228
C (<10) 08/15/06 08/18/06 MI1
D (<10) 08/11/06 08/12/06 DSII
A (<1) 08/11/06 TLF
/ l
T••
•
'SN.VN
\"i .o
\.ar
\• /Van yb reF
c�
0
cam` ^1.•.,•
•••-•T
.rrr,•r' 74,4
ASBUILT-NO CORNERS SET THIS DATE.
00.05£
4rq ,fa7tdi1 Nil
yli3, 10�£Of
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
/Uv_!!y tweet, Teter C•c
AND THAT NO ENCROACHMENTS EXIST EXCEPT AS
'OICATED. IT IS THE RESPONSIBILITY OF THE
_.MER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SURD!
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
SEWARD & ASSOCIATES LAND SURVEYING 688-4566
SCALE+
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DATE:
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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. # LZ12,.-1211' (ID
1. GENERAL INFORMATION
Complete legal description
HAA# \APicr-)Di.11to
Duct C-2 Sun Vattey SubctLv.L&.Lon
Location (site address or directions)
Sun Va.CCey Road
Property owner Davie and Fnan E.ZU6ton Day phone 696-5227 (h)
P.U. Box 104002 Anekan.a e, AK 99510 271-5285 (w)
Mailing address 9
Lending agency Day phone
Mailing address
Agent Eva Loken/REMAX PROPERTIES Day phone
Address 16600 Cen,tvt&Leed 17rc.Lve, Eag& R.Lve2, AK 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3 N
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
XXX
694-4200
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
XXX
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 1121
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 lY034 ragh. River 1 or,,
Eagle River, Alaska 9$577
Address
Engineer's signature
A No. 204
6. DHHS SIGNATURE
KApproved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Phone 6f -f' 2-9 7 9
Date 772J/? 3
Additional Comments
ByCzP
Date 7-2 -93
CAUTION
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.
72-025 (Rev. 1/91) Bock MOA 1121
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
I ww c
Legal Description:�P-p L- Z Sort \ltxrcei I.D. _
ek,Tr7� \Rtw
A. Well Data
Well type 4�N,ter(k-
If A B or C, attach ADEC letter. ADEC water system number
Log presentaN) Date completed _ ck \ L -03 Driller C¼)\_4_,\ \cp.aS
Total depth 9 "7 Cased to `j S '3 Casing height 1-7
Sanitary seal YN) �f Wires properly protected ON) 7
FROM WELL LOG AT INSPECTION
Date of test °1 - 1 2 - S 3 • _ • - Lo -°13 ry`in
l -
Th
Static water level c --t-0 \-3 vrJ crk \fit rri
Well flow \S• o g.p.m. (-o • v g.p.m. c
rr't
Pump levell 04— 4)6 r 0
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
\\c;\
• On adjacent lots
• On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform 0 Nitrate 0 •3lo Other bacteria 0
Date of sample: 1 -\ to - cl'7 Collected by: _S & S ENGINEERING
17034 Eagle River Loop Road No. 204
B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99577
Date installed \`I o3
Tank size
\boo Compartments_ Z
Cleanouts Y N) � Foundation cleanout&N) Depression N)
High water alarm (Ye Alarm tested (Y/N)
Date of pumping --Za3
Pumper cSpao L.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
ac -t
72-020 (3/93)' Front
\ \� On adjacent lots 11.U\
\O A4 sorption field 4861
't
Foundation 13'
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed 19 65 Manufacturer 314— - LC1--,1/41
Size in gallons 2 \ 1 k Manhole/Access) 7
\I
Vent Q'N) 1 "Pump on" level at 1-1lA "Pump oft" Level at '2-1
High water alarm level _27\
Meets MOA electrical codes �Y N) 9
Cycles tested 3
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot 130' On adjacent lots \ bo Surface water e A�
S6,( o rsGe A,vc \,.\ ,nom V w e- ,9-6-&,-)k-c----r
D. ABSORPTION FIELD DATA II
Date installed \°183 Soil rating (GPD/Ft2) \\ o t - System type i c.,r1
Length '271 1 Width 170 N Gravel thickness 4,c' Total depth Ca 1
Total absorption area "5'15 4 Cleanout present (SAN) Depression over field (Y/g h-1
Date of adequacy test 1 -2a %13 Results aii) PDQ=s for 3 Bedrooms
Water level in absorption field before test 1-27 After test \ c µ
Peroxide treatment (past 12 months) (YO nto If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 1'270 On adjacent lots \ Oo Property line 1 D `
To building foundation 213 ` To existing or abandoned system on lot
On adjacent Tots �� Cutbank 1 nr
Water main/service line \ o 45 -
Surface water
01 0 Driveway, parking/vehicle storage area
Curtain drain h\`p<
c( t? rry CTDtact VI5,1r
ENGINEER'S CERTIFICATION
I certify that I have checked, verified,_o conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's
Date
c 41PrTGIN al
-5 I, ; River Leo', Roast
Eagle er, Alaaka 99577
2-
HAA Fee $ 176 `d-
Date of Payment 7- 2 3 ?_
Receipt Number o'Ly'� 'J Z ry/y2--)
72026 (3/93)• Back
.oi>.rI A. $i,a<-,A
No. 14:13,-
HAA
4 7
Waiver Fee $ LJ ZO c
Date of Payment 7- 2 3 -`13
Receipt Number °..27(3 7('%%Z?)
Chemlab Ref.#
Client Sample
Matrix
Client Name
Ordered By
Project Name
Project#
PWSID
COMMERCIAL TESTING & ENGINIEERING CO.
ENVIRONMENTAL LABORATORY SERVICES
REPORT of ANALYSIS
:93.3459-7
ID :TRACT C-2, SEC. 4 T13N R1W SUN VALLEY
:WATER
:8 & S ENGINEERING
:R. SHAFER
:UA
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562.2343
FAX: (907) 561-5301
WORK Order :68433
Report Completed :07/20/93
Collected :07/16/93 @ 10:30 hrs.
Received :07/16/93 @ 14:15 hrs.
Technical. Director:STEP ENS. EDE
Released By
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: RAY.
QC
Parameter Results Qual. Units
Nitrate -N
Method
Allowable Ext. Anal
Limits Date Date Init
0.36 mg/L EPA 353.2/300.0 10
* See Special Instructions Above
** See Sample Remarks Above
U = Undetected, Reported value is the practical quantification limit.
D = Secondary dilution.
ASGS Member of the SGS Group (Societe Generale de Surveillance)
07/19 LLH
UA = Unavailable
NA = Not Analyzed
LT = Less Than
GT = Greater Than
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
Tom Fink,
Mayor
Muni ipality of Ane_.orage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
September 2, 1993
Robert Shafer, P.E.
S & S Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject: Waiver Request for Tract C2 Sun Valley Subdivision
Waiver Request #WR930045, PII) 4078-131-06, HA930416
Dear Mr. Shafer:
Your request for a waiver(s) of the required 100 foot horizontal
separation of a septic system to the surface water has been
approved. The approved separation distance(s) are septic tank to
the surface water (river) of 88 feet and the leachfield to surface
water (river) of 90 feet.
This waiver approval applies to the existing septic system to
surface water separation only. Any future upgrade to the septic
system will require all separation distances be met or another
approval from this department. Should the operation of the
subject wastewater disposal system cause any contamination or
degradation of the subject surface water, this waiver will
become void.
Sincerely,
1 - ,o
Daniel J. Roth
Civil Engineer
On-site Services
DR/ljm
MUNICIPALITY OF ANCHORAGL
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# WR930045 PID# 078-131-06 HA# HA930416 Permit #
Date Received: July 23, 1993
Legal Description: Tract C2 Sun Valley Subdivision
-Engineer:
Robert Shafer, P.E., S & S Engineering
17034 Eagle River Loop Road, Suite 204, Eagle River 99577
Applicant: --Davie & r ^.-E- liston
Waiver Requested: Septic tank to surface water (river) of 88 feet
Leachfi.eld to surface water (river) of 90 feet,
Criteria:
1. Geology:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
Points::
3. Other:
Waiver is Granted:
Waiver is NOT Granted:
List Conditions or Reasons for above: tiCe-4.317-4--CHL 42
Date:
By:
*
frf
F =me . - -eviewer
Rec #. 24937/9142 Amount: $ 590.00 Date Paid: 7-23-93
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HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
July 22, 1993
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Tract C-2 Sun Valley S/D
Sec.4, T13N, R1W, S.M.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
LL)
Request you issue the attached Health Authority Approval and
grant the following waivers; The distance between the river
and the septic tank and leachfield at 88 ft. and 90 ft.
respectfully.
The requested waivers should be granted for the following
reasons.
1. The river only encroaches the 100 ft. separation
during seasonal high water periods.
2. The ground around the septic area is relatively flat
with light vegetation growth. Any sewage overflow would
be detected prior to reaching the river.
In our opinion, the separation distance requirements
prescribed by 18AAC.021 is not necessary in this case.
If you require additional information for your review, please
contact us.
Sincer
ert A. Shafer, P.E.
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER, ALASKA 99577
Tido ifo�77�fi
ASBUILT-NO CORNERS SET THIS DATE.
__
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
-r-414! .s -Vet _... W7e.— —C- -.AND THAT NO :
ACHMENTS .EXIST EXEWAS
INDICATED. IT IS THE RESPONSIBILITYCOF THE
OWNER TO DETERMINE THE EXISTENCE OP' ANY
ICCOVENANTS, OR H DOT NSOT APPEAR ON THE RECORDEDRESTRICTIONS
PIAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES,
SEWARD & ASSOCIATES LANMM SURVEYING 688-4565
4.4."{:or- At to
LI- 9th i
ti
Duane Merk Seward I
y'. LS -6918a
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. 07i / °(o
HAA # G7'et et
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Sun Valley Sub Tract C2 T13N. R1W Sec.4
Location (address or directions)
NLIN Siin Vc
- •
AK
(b) Property owner 9111 & Myrna ,Tohnston Telephone : (home) 694-9766 Business
Mailing Address P C R 770324, Eagle River, AK 9957.L
(c) Lending Institution N/A Telephone
Mailing Address
(d) Real Estate Company and Agent N/A
Address
Telephone
(e) Mail the HAA to the following address: (or check here 0, if hold for pick up.)
List contact person and day phone number below:
Pick-up by Engineer C.
/U 1/, it/o4 /2L 5'1 6 9Y- 974
2. TYPE OF RESIDENCE
Single-Familya Number of bedrooms
3
3. WATER SUPPLY
Individual Well a Community 0 Public 0
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-siteja Public 0 Community 0 Holding Tank 0
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. 7/86)
Page 1 of 2
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A. WE
Well Classification Prrvwte
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description __T"4 "." aLl9
7"/3ry /e/w sec
Well Log Present (Y/N) /
Date Completed 9//)-%,3
Total Depth 7e / Cased to 9/3 `Depth of Grouting
/
Static Water Level /d' Arkr/mom b/eedaFf
Casing Height Above Ground „
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot //S • On Adjoining Lots //6
To Nearest Edge of Absorption Field on I of / 30
�✓/A
If A, B, C, D.E.C. Approved (Y/N) 4'/4
Yield 9,S" o/°n, /o/Fs
Pump Set At N/A t6 y'
Sanitary Seal on Casing (Y/N) i
Depression Around Wellhead (Y/N) /-1
; On Adjoining Lots /"° /
To Nearest Public Sewer Line ></ten' To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot gb /
Water Sample Collected by E^'S/w • Date /o/1.741 -
Water Sample Test Results C'/ 4 r d "'/'^"'`t c 0.35 "5/t.
Comments
B. SEPTIC/HOLDING TANK DATA
a
Date Installed/ /7 r3 Size /000y No of Compartments ^Z
Standpipes (Y/N) / Air -tight Caps (Y/N) _ t' Foundation Cleanout (Y/N) 7
Depression over Tank (Y/N) AJ Date Last Pumped /obs Trek
Pumping/Maintenance Contact on File (Y/N) /IA
Holding Tank High -Water Alarm (Y/N) 't/ a
• for 4'h
Temporary Holding Tank Permit (Y/N) N lir
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well //S/
/
To Building Foundation /3
To Property Line 5d To Disposal Field S /
To Water Main/Service Line fr/O /
To Stream, Pond, Lake or Major Drainage Course /oo'
Comments
72-026 (Rev. 7/88) Front
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata //0 Type of System Design
Date Installed /CS' 3 Length of Field 37 e
Width of Field 3o" Depth of Field S
,
Square Feet of Absortion Area .333 0
/
Gravel Bed Thickness
Statndpipes Present (Y/N)
Depression over Field (Y/N) N Date of Last Adequacy Test
Results of Last Adequacy Test S4 /'r tee. y F16(ro,-4 7-4e ,f 4 ie )4 v
/a//F/d'4
r .B? tree.
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well / 3O / To Property Line 9S /
To Building Foundation 2Y / To Existing or Abandoned System on
Lot Ai/4 ; On Adjoining Lots t Ja
To Water Main/Service Line +70 / To Cutback (if present) A/Ai
To Stream, Pond, Lake, or Major Drainage Course /00/
To Driveway, Parking Area, or Vehicle Storage Area "`/°'
Comments
D. LIFT STATION
Date Installed /?S 3 Dimensions
3 /4'
/2 '- b"
dezio
Size in Gallons r a /1 App•°A Manhole/Access (Y/N) `/
"Pump On" Level at /3 4 6 o ve eery. "Pump Off" Level at S7 IS „ Above 4 *too,.
Vent (Y/N) Y
Pumping Cycles during Adequacy Test.
High Water Alarm Level at 3/ " A a'
Tested for g
Meets MOA Electrical Codes (Y/N) Y '*
Comments ' mEEf5 rjE i«t CnCkF- G..5 per /9s' 0.u_u'lari-i-3
rc� 5+5 s" • . W cis' Tei- . -fir
tIr1 1
ae
Coc e v / / ua 6 &Tn &w$5 W Z. Czc ✓ rk- l `i c ens Ed -I-0 coo 50 .
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelirie5;in`O`at Pn the date of this
inspection.
Signed
Company .t/C5,5
Date In /A ti �y
MOA No. ST -a6r
Receipt No. // (J 76362
/ Receipt No
Date of Payment /0 O y Waiver Fee' $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
Amount. $ h Od
' fk. " A
o oco °eau nacte.c,:EC''cm.Lu n
Engineer's Seal
Louis A, Butera 4%11
h�t °eCE-6736
f� , . O
1
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
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
7:t. – _ ! y ( y JZV/1 "J I>
Location (address or erections)
(b) Applicant Name a/".,�0/1na-mow Telephone: Home 6 9 – Husine/s�s �t'�9�'" 9S�s
�ai
Applicant Address �( %2O a'��/ C de- L «-n-s-77
Applicant is (check one): Lending Institution ❑ ; Owner/builder,J2(; Buyer C] ; Other 0 (explain)
(c)
(d) Lending Institution — E2a> VI 6 Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(I) Mail the HAA to the following address:
S & S ENGINEERING
SR B 196X
EAGLE -RIVER, AK 99671
2. TYPE OF RESIDENCE
Single -Family Multi -Fancily 0 Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well p' Community 0 Public 0
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite Public 0 Community 0 Holding Tank 0
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 (11/94)
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto arid 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.
S t& S ENGINEERING p 6 9l�L_Z9
Name of Firm Telephone
SRR 196X
EA.GLER1V E R,AIIl9577---
Address
Date
JUN 311986 -
CLD)
6
1986-
6DHEP APPROVA/ , /// (�/
Approved for bedrooms b - e- L G Uate / " ` J
Approved (�� Disappr ye Conditional
C J ///
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 (11/84)
A. WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264.4720
_ .. _... _.I .-.nnWL
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
! U N 0 4.1986
RECEIVED
Legal Description:
If A, B, C, D.E.C. Approved (Y/N)
Well Log Present d)N) _ Date Completed 0)-12"BS Yield IS ??n
Total Depth X- :1 rf Cased to -ro ;' Depth of Grouting
Static Water Level - riko've.) tr1c., in lA4-.! Pump Set At J1}i�
Casing Height Above Ground p1 Sanitary Seal on Casing N)
Electrical Wiring in ConduitON) Depression Around Wellhead (Y0
Separation Distances from Well:
To Septic/kleldirig Tank on Lot t ' ; On Adjoining Lots k.[ -c' fk-
To Nearest Edge of Absorption Field on Lot lr� k ; On Adjoining Lots — lei 14
To Nearest Public Sewer Line �r" To Nearest Public Sewer ( L
Cleanout/Manhole 1.11 r- To Nearest Sewer Service Line on Lot 2$ 1
Water Sample Collected by `fir;'' G t.r31-"g1L TM6i • Date ! c L
>
Water Sample Test Results`4r
Comments
B. SEPTIC/Met-D1 TANK DATA
Date Installed 3" (z33 Size -1Sv No of Compartments 2 -
Standpipes
Standpipes (SPN) Air -tight Caps PXIN) Foundation CIeanout4 'N)
Depression over Tank (YdS))Date Last Pumped r%
Pumping/Maintenance Contract on File (Y/N) aA ,for
te
Holding Tank High -Water Alarm (Y/N) _ �/� Temporary Holding Tank Permit (Y/N) /1/434
Separation Distances from Septic/Hekfing-Tank:
To Water -Supply Well 1 Ho 1-1- To Building Foundation 2-t7
To Property Line - (o/h" To Disposal Field
" 1
1
To Water Main/Service Line 10 4"" To Stream, Pond, Lake, or Major Drainage
Course
7
1 tc>
Comments erlAt
UsE-ries-a...ki 1.0- .�cLelo
Page 1 of 2
\l1 4W 4j•4JZ/ (OCA -D � I.f)e y iJLV(g ,
- F,_n 0 Q e S xZitJ � rz U�� A/LJ
72-026(11/84)): ., /) /02& 45-6_
4, X/f !-�✓��%
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ¢3-13-5-J
Width of Field vat
r
Square Feet of Absorption Area
Depression over Field (V
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well dR7 l f To Property Line k
To Building Foundation To Existing or Abandoned System on
Lot a ; On Adjoining Lots
(
To Water Main/Service Line to To Cutbank (if present)
Type of System Design
err
Length of Field
Depth of Field
Gravel Bed Thickness
30* Standpipes Presents 'N)
Date of Last Adequacy Test fes-)
SIA
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
ltIrr
Alps
Comments 9)* ilk- 4C-F9ilc '6`-j
U IJTI L. �/5 l) 1 li 0A
D. LIFT STATION
Date Installed e -i3 - 6 3
Dimensions ri0
12.11z I 'P
Size in Gallons 1-7-52,- ea, f &y Cyt 1V&E Manhole/Acces�V N)
"Pump On" Level at
High Water Alarm Leve at di
Tested for A
Electrical Code ,. -
Comments L-Irer sciNin15V\ 14 er 1t•-• ase ,
"Pump 011 Level at
Vent ON)
IZr
Pumping Cycles during Adequacy Test
Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
Icertify thstalse Zeittithminll,orconformedtoall MOA and HAA guidelines in effect on the date of this inspection.
Signed SR B 196X Date —JUN 3 1986
CompanEAGLE_RPNER Ai9577— MOA No St—C--C703
Receipt No io(Qo )
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
A
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
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
i?Acy e Stan) �4“- q0 /$sEsc XA rt Iv s,ttJ
Location (address or directions)
(b) Applicant Name '4J1L w ' % art- /3-S tP1.• 3Telephone: Horne ( '+ _C) (7 (UL" Business
Applicant Address 2 C:), �C `� rJ 6`a')L4I -- r:f • R \1, '`" � 9ICS'r%
(c) Applicant is (check one): Lending Institution 0 ; Owner/builder Y Buyer 0 ; Other ❑ (explain); _
(d) Lending Institution 4 tr Telephone
Address
(e) Real Estate Company and Agent
Address 4i9 rv.rf'~,
Telephone
WA -hi; ��r
(1) CA HAA to the following address:
)HLI 'f9r ea
•a.� av L ,_6 i ';of,:1NI iliWV:;004
2. TYPE OF RESIDENCE
Single -Family- Multi -Family 0 Other
Number of Bedrooms
3. WATER SUPPLY
Individual Well �Z3
Community LI Public 0
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite$ Public 0 Community 0 Holding Tank 0
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
/2-025 (11.04
5. ENGINEERING FIRM PROVIDING ..,SPECTIONS, TESTS, FILE SEARCH, DM. 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.
Name of Firm
Address
Date
Telephone
[T
cif
G-171.-15
6. DHEP APPROVAL.
Approved for bedrooms by ®"" Date 6 —SO
Approved _ Disapprov d Conditional
Terms of Conditional Approval
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 DEEP does this as a courtesy to purchasers of hornes arid their lending
institutions in order to satisfy certain federal and state requirements. Employees of DI -IEP 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 (11. e4)
A. WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOM)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ,l
Sti .I
MUNIC.I(7,1: Y C
DEPT, Or lb,=
ENVIRONMENTA4 hM++si�
H 0.31985)
acr G-'LECE1V-ED
1/41-4.6y 570
SES 4 „ 773n), /2%1,0 a)
If A, B, C, D.E.C. Approved (Y/N) (� f p
Well Log Present ON) Date Completed 49- I2 -B3 Yield IS-
Total
S
Total Depth c16 3 Cased to
615 3 Depth of Grouting
irs,t-*-D Pump Set At
Static Water Level �I-ot.JuJfa_/>¢
Casing Height Above Ground
,amu
Electrical Wiring in ConduitN)
Separation Distances from Well:
To Septic/I4eleng Tank on Lot 1.c 2ci 1 ; On Adjoining Lots ___Lc‘"1"
Sanitary Seal on Casing6(9N)
Depression Around Wellhead (YS
• To Nearest Edge of Absorption Field on Lot —1 t�� k' ; On Adjoining Lots _L' -c' f-'
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole � 4.
To Nearest Sewer Service Line on Lot 2-6 4
Water Sample Collected by>"xtn%- ; Date 19
Water Sample Test Results S"*`T'1`�t ` — -
Comments
B. SEPTIC/Fft3EDT 1C TANK DATA
Date Installed g- ($ - 83 Size \ ECO No of Compartments
Standpipes ON Air -tight Capsc'N) Foundation Cleanout (9\1)
Depression over Tank (Ye Date Last Pumped ME=1�
Pumping/Maintenance Contract on File (Y/N) Irl ; for
Holding Tank High -Water Alarm (Y/N) .1-.)T+4 Temporary Holding Tank Permit (Y/N)
7_
Separation Distances from Septic/Holding Tank:
l t� (
To Water -Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
7-0'
Comments Sterni' Syi2E- in/
cis
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata //o 4'13 Type of System Design TREA.)GI-t
Date Installed
Width of Field
B-13-83
Length of Field
Depth of Field
Gravel Bed Thickness
27�
Sr
Sri "
Square Feet of Absorption Area 330'P Standpipes Present ®N)
Depression over Field (Ye Date of Last Adequacy Test Afee✓
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well /00 14- To Property Line / 04-
To Building Foundation 3s ' To Existing or Abandoned System on
Lot n.. I/� . On Adjoining Lots 30 Li -
i
To Water Main/Service Line /0 'f To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course /40
To Driveway Parking Area, or Vehicle Storage Area 30 /
Comments 5EP7-"/C 3yS?b14 A/rct/E!L /,u Li ..CE
nJ4
D. LIFT STATION
Date Installed
8-/3-83
Dimensions 3c"" P/4, /2 //3 Dee
Size in Gallons /32 HAA "Am ad ro Off Manhole/Access ON)
"Pump On" Level at 1/4' "Pump Off' Level at /Z 1
I
High Water Alarm N Leel at ?i Vent ON)
Tested for A NEW 5/57%1 Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes t(N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOAan HAA uidelines in effect on the date of this inspection.
Date 8 3� cS
Signed NOINVEHINC4
SHB
ALASf s° 8 S - Crt�
Company MOA No
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
9 - 3-%5"
yle