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HomeMy WebLinkAboutBRISTOW LT 2Bristow Lot 2 #017-091-69 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 PHONE 9NEW 1 / LL VV,�7J Aet�o j< ❑UPGRADE MAILING ADDRESS ,> / 1 L /C ,%S I -j— W_ LEGAL DESCRIPTION U -S. T /2 sv VV _ .^'I _ A Lc. LOCATION NO. OF BEDROOMS WellAbsorption area Dwelling PERMIT NO. v DISTANCE TO: /00 4_ ZU C)/ 8,90/S4 _Y wQ Manufacturer Materia' No. of compartments Z H N Liq. capacit1r in gallons /.;;L 5 6 I IF HOMEMADE: Inside length Width Liquid depth DISTANCE TO: Well Dwelling PERMIT NO. Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well Foundation Nearest lot line PERMIT NO. lDt nui in No. of lines Length of each line Total length of lines Trench width Distance between lines `Z ' 21 inches / Top of tile to finish grade 1 Material beneath the Total effective absorption area inches Length Width Depth PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area DISTANCE TO: Well Building foundation Nearest lot line J J Class �/ Depth /00 Drille L' Distance to lot line -2'5/ PERMIT NO. �+�� w DISTANCE TO: Building foundation 1�/0 / Sewer line oovSrrt gv7 Septic tank !O }— Absorption area(s) , (s0 (— OTHER PIPE MATERIALS SOIL TEST RATING Z �j- I� 1B INSTALLER +vr b vl REMARKS Van fie- i)& -r n/ T ""s '_ -170 P 4 ` C11V -� L JA,54 IV OF A L 0., k �a Q•O•s•s••ovC01" /�► 'i-J� ©os O �%• a S. w9 � •0 0 0. `^gDnIn R. Me reit No. 205 E'�+.•'�� FESSI ILI APPROVED DATE LEGAL 72-013 (Rev. 3/78) 1" I I� lq+ MUN I f-- I V r-iL- I -rq-e "_ F= n N C H Q F -'F--1 Q e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ' E05 L STREET, ANCHORAGE, HK 99501 264-47;20 L4E:L-L- �E=Fz_>l"l I -r PERMIT NO: 840130 HAND WRITTEN DATE ISSUED: 04/04/84 APPLICANT: WILLIAM & MARY WESTBROOK ADDRESS: 4103 MINNESOTA DRIVE ANCHORAGE.- HK 99503 CONTACT PHONE: 561-4884 LEGAL DE5CRIP: SUBDIVISION: BRISTOW LOT: 2 BLOCK: NH SECTION: 35 TOWNSHIP: 12N RANGE: ] LOT SIZE: 55171 (SQ.FT. OR ACRES) LOT LOCATION: ' RABBIT CREEK ROAD � I CERTIFY THAT: ' `^ l. l RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE ' MUNICIPALITY OF ' (MOH) AND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTEM IN H CORDANCE WITH ALL MOH CGDE$, Fft4D REGULATIONS.- AND EGULHTI8NS,8ND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMI,�T'. 3. I WILL ADHERE TO ALL i1OH AND STATE OF ALASKA REQUIREMENTS FOR THESET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL 5YSTE11OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOR BUILDING CODES, ' THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) A5-E9HI[-T5 WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE ELECTRICAL WORK MUST BE DONE BY H LICENSED ELECTRICIAN. SIGNED DATE: - - - - - - - - - - - - - - wDnn__ k, APPLICANT: W LIA & .. WESTB ISSUED BY DATE: ... _____ ° MUNICIPALITY OF ANCHORAGE Department -f Health and Environmental 71rotection 825 Street, Anchorage, AK. J501 264-4720 Permit # # # # HANDWRITTEN PERMIT # # WELL AND/OR ON-SITE SEWER PERMIT Applicant: -rte �i�lZy/ 4�1 ling Address: L,%/A,L 1jJ't25dr, q' Location:AUST66U Phone Number: Legal Description: Z_r :2 - X1,1/4— Lot Size: Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating(sq.ft/br) 2(}�° The Required Size of the Soil Absorption ' System Is: c � / DEPTH 02► 4a LENGTH c16' _ GRAVEL DEPTH �� WIDTH c;5 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 = tS� 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. * PERMIT EXPIRES DECEMBER 31, 1 9 3 I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include mor that bedrooms. Signed: C/cam Issued by• 4.p licant Date: SWP/024 (1/81) ������I r-7' F -'l L_ 1: -T'g-e u --j F�:' ��V-1 C-3 V--, Fl #:a EE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, HK 99,501 264-4720 0:::# �'A _1 -T- FE ����fR,: !!i,:; ���� F::, IF: F;-, 1-1 l -T- PERMIT NO: DATE ISSUED APPLICANT ADDRESS: CONTACT PHONE 840130 HAND WRITTEN 04/04/84 WILLIAM & MARY WESTBROOK 4102 MINNESOTA DRIVE ANCHORAGE, HK 99503 561-4884 LEGAL DESCRIP: SUBDIVISION: BRISTOW LOT: 2 BLOCK: NH ccrYrnm- SM rm"mcurM' ^,u mmmcc. � LOT SIZE: 55171 (SQNT. OR HCRES) LOT LOCATION: RABBIT CREEK ROAD I CERTIFY THHP 1. I HM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET ' FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOH) AND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOH CODES AND REGULATIONS., AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. I I WILL ADHERE TO ALL MOH AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. IF H LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOH BUILDING CODES, THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) HS-BUILTS WILL NOT CHL INSPECTION REPORT/ AND (]) THE ELECTRICAL SED ELECTRICIAN. ` SIGNED DATE: ------ ------------------------- --�-~-7~~—�---- APPLICANT: WILLI��/& M�RY WESTBROOK ' k��ISSUED BY ' DATE: -------------_____________ __-�r�.._'- MUNICIPALITY OF ANCHORAGE Department of Health and Environments' Protection 825 Street, Anchorage, AK. ;9501 264-4720 / 3`/ # # HANDWRITTEN PERMIT # # # Permit # WELL AND/OR ON-SITE SEWER PERMIT Applicant: %�iL_c rte: Mailing Address: �/i a J Location: �Cl_ . �� « %J Phone Number: S 6, A, Legal Description: ZG>7- Z _4j Lot Type of Soil Absorption System Is: Trench: Drainfield: ?� _ Seepage Bed: Maximum Number of Bedrooms: Soil Rating(sq.f Size71 Holding Tank: t/br) ,_ o 6 ,4,,,, The Required Size of the Soil Absorptio System Is: : 4 - � 7�4-z_. r i rr DEPTH 2-0 LENGTH / �O GRAVEL DEPTH WIDTH 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 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-+ I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence isremodeled to include more that 3 bedrooms. Signed: Issued by: Applicant Date: SWP/024(1/81) /- 5d SOILS LOG MUNICIPALITY OF ANCHORAGE • �1 DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: J/L-L W"Jzr,�QDpK DATE PERFORMED: /0 LEGAL DESCRIPTION: L Z Bk IS-Xb\A) r 1 r/2 N W DEPTH SLOPE SITE PLAN (FEET) Di/�i��1RL"�� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 COMMENTS SM --,;/) ' G F2AcrueED RK • WAS GROUND WATER S ENCOUNTERED? No L O P IF YES, AT WHAT E DEPTH? Reading Date Gross Time Net Time� Depth to Water Net Drophvc.% FT AND ! FT - 30 '�kly z 3 ' 2. 00 &, /5 y 2"15 /s 7S I& I. z-aD (3.y ,9 — PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND ! FT 5E P0-6. TSi�EcpF aim EZ7Gt X as 8U/kr PERFORMED BY:2.2 j , CERTIFIED BY: DATE: 72-008 (6/79) 5d SOILS LOG -� MUNICIPALITY OF ANCHORAGE (• �.e� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 1W PERCOLATION /JJ TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: L�I v t>( �� ts` G' 1 /,/� Depth to Water Net Drop DATE PERFORMED: 2LI5 JcP 1 J� 00 jAs LEGAL DESCRIPTION:_ Ldi $ �i^r57C1G.�t/yfgr,afy� � d Mr.l /fin f k 'G 16- 1617 go L 17 Fr SLOPE SITE PLAN 101 J I e t^ I.) Kerr' 11 IYK Date Gross Time Net Time Depth to Water Net Drop 1 J� 00 jAs 5 15- � ��-• / � d Mr.l /fin f k 'G 16- 1617 go L 17 Fr CE. ,t -4.- 2c IV 18- 19-1 3 •` 4 'l , •� 5 t� 7 B ROCK 0 aEN 9 �19d_ 101 J I e t^ I.) Kerr' 11 IYK 20 COMMENTS WAS GROUND WATER S ENCOUNTERED? IVa L axpe 0 2� P IF YES, AT WHAT E DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop J� 00 jAs 5 15- � ��-• / � d Mr.l /fin f k 'G 16- 1617 go L 17 Fr CE. ,t ��a,,,,, rel: IV 18- 19-1 20 COMMENTS WAS GROUND WATER S ENCOUNTERED? IVa L axpe 0 2� P IF YES, AT WHAT E DEPTH? Reading Date Gross Time Net Time Depth to Water Net Drop ti � ��-• / � d Mr.l /fin f k 'G go L G Fr �,•{�_�<�;_;� ��a,,,,, rel: 9.relr PERCOLATION RATE l �% M/114t 4(minutes/inch) TEST RUN BETWEEN G FT AND FT PERFORMED BY: �1A6 {� �c �bz CERTIFIED BY: I,r�� s f%rrs���i f /1 SSar. DATE: 41141&1 72-008 (6/79) ... REATER ANCH(;kn(A 1,ORMU oepartment of [ iiv i ronm(,n to 1 (qua h i.y 1 3330 "C" `trect- Anchorage , Alaska 1)9 0'J1 SOILS LM; PEAU) )ATION TEIST Performed for_..._ _ N _ _ l_ S_7A_4^�_Date Perforried 6-2g-7,6 Legal Description: ->/z 'r u t z This form reports: Soils log____ 41 Percolation test Depth Feet ' - <---y /L G 2- 3- 4- 5 - �-/ SSS C /i, 7- 3- , 9 - . 10- hick, 11 - 12 - 13 - 14 - S/0 Was ground water encountered? /I."C) If yes, at w0at depth? Reading Date Gross Time Net Time Jeptn to Water I Net Drop Vercolation rate / minute. -Proposed installation. Seepage Pit ­ __._.__._.___... Drain Field Depth of Inlet Depth to -- bottom of pi t or trench �_._..._..------ C 0 MM E N T S _._._COMMENTS4e ciw�Rv _Certified By: as%rv�,���?� EQ -040 (6/74) " -- ti z,Z.97 09-2z-S5w Ivt t+' 'o -D r- x (D (A - - • 1 _. _�_.t._..�C' 46 1 � '"rte � iT' p ..__,-� _ �• *;.p-_ .E '1i � o %lo N � N p r) 11 b C� r �o al N oq. �x N ID - 1 -ni h N CD .. CTt fD 'S N. C N J a n i R °', 'y a Z S rn co Ru , -� O t LAM L p ]7 4 t=2 co o C5 O v n - 0) C) O V1 r• -:z O / N a o0NCCpO r.+ : N ten" `.'s r0 ` m m tA 77 CD y N O O '`•� a� I'.�.►-� cn rn —moi rn m 0,6%, �� }1h 4a�a tN's 4.'5,4d,t ( '7,, .*""•` t'i`j �a r vax�w�k k tj�f.•"° r :; , , x }. � i j -� s .r Y -N t � �� d .j .< < {1 l x ,yy-•^+' ys .Yi � 4 1 WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological a Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either la, Ib or Ic.) A.D.L. No. 1/44trs. Section No. Township N� Range E❑ Meridian To Borough I Subdivision Lot Block Faf—of—of_ S❑ W❑ Ic. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL: Address Street Address and Area of Well Location 2. WELL LOG Feet Below Surface Material Type Top Bottom 4. WELL DEPTH ('final) ft. 5. DATE OF COMPLETION g, Q Cable toolRota►y ❑ Driven ❑ Dug ❑ Auger ❑ Jetted ❑ Bored ❑ Other: "+ '' ' i•i i '.='' }'r', I F .g r„ ?.USE: ❑ Domestic ❑ Public Supply ❑ Industry ❑irrigation Recharge ❑ Commerical ❑ Test Well ❑ Other: T `` i a )£ ' 8, CASING: ❑ Threaded ❑ Welded diem. In. to ft. Depth Weight ibs./ ft. diem. in. to ft. Depth Stickup ft. 9. FINISH OF WELL: Type G1,- <<'S Diameter: Slot/Mesh Size: Length: Set between ft. and ft. Backfilling Gravel pack \� & M� pgpt•0 R .�P� 10. STATIC WATER LEVEL: L ; ft,ro - ❑ Above or ❑ Below land surface Date Equipment used ):_ �Nv,R hap, 1 I I , PUMPING LEVEL below land surface and YIELD ft, afterhrs, pumping g. p, m. ft. after hrs. pumping g.p.m. 12.GROUTING Well Grouted: ❑ Yes ❑ No Material: ❑ Neat Cement Ej Other: 13. PUMP: ( If available) HP Length of Drop Pipe ft. capacity g.p.m. ❑ Subm. ❑ Jet ❑ Centrifical Other 14. REMARKS: 1. 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Temperature F ❑ C This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief; Registered Business Name' Contract License Number Address: ^ _, Signed: ZDate: Authorized Representative Form 02-WWR (11/81) Copy Distribution: WHITE -State DGGS, PINK -Driller, CANARY -Customer k Municipality of Anchorage On -Site Water & Wastewater Program (907) 343-7904 �U CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I. D. 017-091-69 Expiration Date: 1. GENERAL INFORMATION Complete legal description BRISTOW LOT 2 Location (site address) 7150 RABBIT CREEK ROAD *ANCHORAGE AK Current Property owner(s) PATRICK MARTINEZ Day phone Mailing address Real Estate Agent 7150 RABBIT CREEK ROAD *ANCHORAGE AK 2. TYPE OF DWELLING: 0 Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: Day phone 952-6613 TYPE OF WASTEWATER DISPOSAL: Individual Well E Individual On-site 0 Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ j.; Received by: Date: ' z COSA to be released to the engineer, unless othenxise requested by the engineer. COSA Fee $ o Date of Payment Receipt Number COSA # O5G /3,1= vS `Waiver Fee $ Date of Payment Receipt Number Waiver* 6. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. i further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E. Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal right whatsoever. 6. DSD SIGNATURE _ Z System #1 Approved for bedrooms. System #2 Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following Phone 337-6179 Date 7�Zk�f3 i... . .... .............. •. e f A. jorness: i a 9 Q u rOfessio�°o� ��O0000�� Jam' ON-SITE 15 ilatto WATER AND s 1d WAST EWATER Original Certificate Date: (( The thunicipalf, or A'a Develop,emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the represenatati6 s green 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. ATTCHMENTS: COSA Checklist - Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other (Rev. 11105) If more than 1 septic system is on the lot: COSA Checklist # _of_ Structure served by this system Certificate of On -Site Systems Approval Checklist Legal Description: BRISTOW, LOT 2 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 7/2/84 Sanitary seal (Y/N) YES Total depth 350 ft. Date of test Static water level Cased to 24 ft. FROM WELL LOG 3/5/89 Parcel ID: 017-091-69 Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 18+ in. AT INSPECTION 7/8/13 20 ft, Well production 0.48 g.p.m. 2.34 g.p.m. WATER SAMPLE RESULTS: Coliform (D colonies/100 ml. Nitrate b J mg./L. Collected by: GEG. Ltd. Arsenic: mug./L. Date of sample: 7/8/13 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Tank size 1250 gal. Number of Compartments ? Date installed 10/26/84 Cleanouts(Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (Y/N) NO High water alarm (Y/N) N/A Date of pumping 81LI Zv f Z Pumper; GtGt r �5 C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE Date installed 10/26/84 Soil rating (g.p.d./ft or �/bdrm 19D System type BED Length 70 ft. Width 18 ft. Gravel below pipe 0.5 ft. Total depth *3.6+ ft. Eff. absorption area 1260 ft' Monitoring tube YES Depression over field NO Date of adequacy test 7/25/2013 Results (Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test E in. Water added 670 gal. New depth E in. Elapsed Time: = min. Final fluid depth E in. Absorption rate >= 600+ g,p,d, Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access (YIN "Pump on" level at in. "Pump off' level High water alarm level at in. Cycles tested Meets alarm & circuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Public sewer manhole/cleanout Sewer/septic service line 25'+ Holding tank Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain F. COMMENTS NONE KNOWN Wells on adjacent lots 100'+ WELL DEEPENED ON 10/85, 3/5/1989 Ne--� Z( X-rr-l" wtr r:/o wM Af 7/Zf/7OU 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 Fame JEFFREY A. GARNESS Date -714.113 j3 (Rev. 11/05) A. ness. 795 �j3. Municipality of Anchorage s Community Development Department's Development Services Division On -Site Water and Wastewater Program 4700 Elmore Street P.O. Box 196650 Anchorage, AK 99519-6650 www.muni.org/onsite (907) 343-7904 Nitrate Advisory Certificate of On -Site Systems Approval # 131367 A Certificate of On -Site Systems Approval inspection and test of potable water was recently conducted on the well water supply on Block , Lot 2 of Bristow subdivision. This inspection revealed a nitrate concentration of 6.15 milligrams per liter (mg/L) was reported for the property's well water sample. The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On - Site Systems Approval. Municipality of Anchorage •. • j Development Services Department Building Safety Division On -Site Water & Wastewater Program \ /1 4700 Bragaw Street ,J/,(tl P.O. Box 196650 n 1"vly y Anchorage, AK 99519-6650 ` U, www.muni.org/onsite (907)343-7904 (,A, CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. O (q -bol l- Coq COSA# brM,1 y 1. GENERAL INFORMATION Expiration Date: /0 —.a— O % Complete legal description Location (site address) Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address BRISTOW SUBDIVISION; LOT 2 7150 RABBrr CREEK RD. 0 ANCHORAGE, AK 99516 PATRICK do PATRICIA MARTINEZ Day phone C/O AGENT 7150 RABBIT CREEK RD. • ANCHORAGE, AK 99516 Day phone AMBER JOHNSON w/ JOHNSON PROPERTIES Day phone 350-4495 1537 OTTER ST. * ANCHORAGE. AK 99504 Unless otherwise requested, COSA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ TYPE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues COSAs upon request to homeowners. Certificates of 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 samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional 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. 1 further verify that based on the information obtained from the Municipality of Anchorage riles and from my investigation and inspection, the on-site water supply and/or wastewater disposal system Is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of Installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SURE 101 * ANCHORAGE, AK 99507 II Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 6/ZI /q Engineer's Comments: In conducting this evaluation, GEG, LtD. attempted to provide a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines B Regulations. The reported results described the performance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there are no hidden defects or encroachments. GEG, LTD. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report Is for the solo benefit of the owner listed above. Any reliance upon or use of this report by any other person or party Is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE L/ Approved for bedrooms. Disapproved. i ey A�amess� e •� o,. e 7 53 e••(ofF.�i�o%•.�000 4 di'rof °a esslo�o ��0000gg�i rrrfrrrrr,,� Jam': ON-SITE WATER AND •: ASTEWATER Conditional approval for bedrooms, with the fllowing stipulations: Attachments: COSA Checklist Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Reort Other W PROGRAM o' By: ��G/L%/ _ l� �O C// — Original Certificate Date: -7-2-07 (R.. 11,W) Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 Bragaw Street P.O. Boa 196650 Anchorage, AK 99519-6650 www.munl.orglonsits (907) 3437904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: 13RISTOW SUBDIVISION; LOT 2 Parcel ID: 1117-071-41 A. WELL DATA Well type PRIVATE If A, B. or C provide PWSID# N/A Data completed 7/2/1984 Sanitary seal (Y/N) YES Total depth 350 ft. Cased io 24 ft. FROM WELL LOG Date of test 3/5/1989 Static water level 26 ft. Well production 0.48 g.p.m. WATER SAMPLE RESULTS: Coliform 0 oolonies/100 ml. Nitrate 0.871 mg./L. Well Log (YIN) YES Wires properly protected (Y/N) YES Casing height (above ground) 18+ in. AT INSPECTION 5/23/2007 33 ft, 3.05 g.p.m. Other bacteria 0 colonies/100 ml. Arsenic: NQ ug./L. Data of sample: 5/21/07 Collected by: GEG Ltd. B. SEPTICIHOLDING TANK DATA Tank Type/Material SEPTIC/STEEL Date installed 10/26/1984 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES Foundation cleanout (Y/N) YES Depression over tank (YIN) NO High water alarm (Y/N) N/A Date of pumping 9/26/2006 Pumper ISAAC'S PUMPING SERVICE C. ABSORPTION FIELD DATA Date installed 10/26/1954 Soil rating .p.d. or ft'/bdrm) 190 Length 70 ft. Width 18 ft. System type BED Gravel below pipe 6 ft. Total depth •3.58-3.92 ft. Eff. absorption area 1260 ft' Monitoring tube YES Depression over field NO Date of adequacy test 5/21/07 Results (PasslFeil) PASS For 4 bedrooms Fluid depth in absorption field before test DRY DRY in. Water added 607 gal. New depth 6/DRY in. Elapsed Time: 1102 min. Final fluid depth DRY DRY in. Absorption rate >= 600+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) NONE KNOWN If yes, give date D. UFT STATION Date installed Size in gallons "Pump on" level at _in. "Pump oft E. SEPARATION DISTANCES Manhole/Access water alarm level at in. Cycles tested Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/ilft station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main N/A Sewer /septic service line 25'+ Public sewer manhole/cleanout N/A Holding tank N/A Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main N/A Water service line 1o'+ Surface water 1 DO'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 1o'+ Building foundation 10'+ Water main N/A Water service line 10'+ Surface water 100'+ Driveway, parkingivehicle storage 10'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ F. COMMENTS 'DEEPENED 10/1985. DEEPENED 3/5/1989 G. ENGINEER'S CERTIFICATION I certify that I have determined through held 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 JEFFREY A. GARNESS Date ro'z1 %e-4 COSA Fee S tz—zo• U d Date of Payments 2 77 f 07 Receipt Number. (P v. 11105) Waiver Fee $ Date of Payment Receipt Number Sc�L� • .. it • cRE°/• "/ � �. ."17 ° C Ti. J N 0«e lJYY 117. " M11 O •a Y. f 2rJ p.�al f,� • � i / t1 .1 �T� • 1 , t /JT1� 1S EASEMENTS Of OECOEO, OTHER THAN THOSE $NOLYN ON TME AECON010 A •�Y FLAT. AAE NOT SHOWN MEAEON. 11. G,wr,l hl 7r Onr bM w.. Lw w.. 1 ,.wt • M Ir SNI I Iw...n_/..1 w N�M+.r aOIF! Mr..M. 41 HM _� E OF At %I QA'/3�'OW .. dDD. wr.e..e. wre.e.a OrlLw� ♦rw...•. u•1 F� �........ It w. N.•w'.wnll YIwM .Ir�w w. _.14. IN IYrfY Mw Y..O M .IH •.MY• M ��` 1 v`fr .._r..el. .w IN MO✓h r/MI Mwd1 IN..r. IN. M I�r•...rr11, •. INh I y 4.n Iw.erl, I.w ru .ww.H. r w H. .r w e+_I« .... a.. Iwwl rl .• ror_.Y.. I� w 9111 �I�I 1,.•,.rMrn Iww u ♦w. Y..,H. ....w_.11 e. Mr Yee.w1 H.rM w YK�oI.• Iden. � i � - ���fff• • �.rnH.Ii wlrw // OCT. 1994 Municipality of Anchorage • Development Services Departmentiae Building Safety Division On-Site Water and Wastewater Program ' f 4700 South Bragaw St. s. e.. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-091-1!0 HAA #_ 6'_� Q ZZ - Expiration Date: C%' 1. GENERAL INFORMATION Complete legal description kot 2, 8ru'l6cv S'ID Location (site address or directions) 7/.S0 Ra h b; /- Cffe k i•?o( Current Property owner(s) ,Tc 9 £ fw; e- PA-'ke r- Day phone 3 yS-- 3.rY 2 Mailing address Lending agency Mailing address Real Estate Agent Mailing Address -71,6-0 Ra S b;f (free k Rcl.. Ane tiar-ee cq /}cc 99.5 11,11 Day phone rs 90 Day phone Unless otherwise requested, HAA will he held by DSD for pickup. FIC Com,. U o, W 4er s• Wke n 2. NUMBER OF BEDROOMS: _ly S;/- 3. ;/-3. TYPE OF WATER SUPPLY:' TYPE OF WASTEWATER DISPOSAL: Individual Well Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ Individual On-site Individual Holding tank ❑ Community On-site ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (NAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B 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 Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Flcr Fhi ,d3 Ser✓;c�✓ Phone 3 4'S-- /3 s'S- Address .Echo 5�.. Jl��Aaws-1 Engineer's Printed Name 7-&-o 1:P0,-9 E. m00 P -e. Date _ rl�v Zb, ZOO 5. DSD SIGNATURE Approved for 1— bedrooms. Disapproved. f�roralS$b` rr.�yy,,��.l!��.' �� •.. •�. �.: Cly mob;—['',.�' �•: j �/J%j��n Z.••i..e•�i��M...• 0 >'1 -r• THEODORE F. JUQORE; CE -3589 i - t. ; •..•••.• G may. e .,,A ..L�ff Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other By: Original Certificate Date: 3- 03 (Rev. 01102) i i Municipality of Anchorage *At Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6850 www.ci.anchorage.ek.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: %o f 3-"'1 916 w Parcel ID: 017 -04 / - 69 A. WELL DATA Well type , w f If A, B, or C provide PWSID # _ Well Log (Y/N) _Y Date completed� 151 %89 Sanitary seal (YIN) Y Wires properly protected (YM) i d •�� to aai Total depth ft. Cased to 2 y ft. Casing height (above ground) ?Q n. 3510 FROM WELL LOG AT INSPECTION Date of test 3 / S / 8 9 57/ 13 10-3 Static water level 26 ft. 2 2 • s ft. Well production O.yB g.p.m. g.p,m. WATER SAMPLE RESULTS: Coliform C colonies/100 ml. Nitrate ?. 20 mg./l. Other bacteria 0 colonies/100 ml. Arsenic: — mg.A. Date of sample:. S'//3/03 Collected by: F/cxt6E:R TicA SvC S. SEPTICIHOLDING TANK DATA Tank Type/Material SAgti s, / S/tec / Date installed 140 / ?-15'11641 _ Tank size 12 s7- gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) �_ Depression over tank (YIN) _!1L High water alarm (Y/N) Al- A Date of pumping r. % p Pumper Lrx as cs �%o G C. ABSORPTION FIELD DATA Date installed j±Z Z06Y Soil rating (g.p.d.te or fe/bdrm) _� System type MeVrww Length 70 ft. Width /8 ft. Gravel below pipe o,e' ft. Total depth IjL ft. Eff. absorption area 1260f12 Monitoring tube r Depression over field N Date of adequacy test S-1 13 !03 Results (Pass/Fail) Pakr For Y bedrooms O b Fluid depth in absorption field before test *1 in. Water added?O( gal. New depth„ in. 0 Elapsed Time: &- min. Final fluid depthin. Absorption rate >= 6GG g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) 8&44. k--ga ewo) If yes, give date N. A. D. UFT STATION N• �• Date installed "Pump on" level at _ in. Datum Size in gallons "Pump off* level at _ in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot l 10 ' JOVI'l► C. a. Absorption field on lot 101 FtV,n in, f• Public sewer main No. h. Sewer /septic service line > ZS-' F. G. Manhole/Access (Y/N) High water alarm level at Meets alarm 8 circuit requirements? On adjacent lots > I00 ' On adjacent lots ZI oa Public sewer manhole/cleanout Al. A _ Holding tank N• A . SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 2 Z' Property line 6s ' Absorption field Z Z' i6 c• a• Water main P.,4. Water service line > 10 ' Surface water > Iva Wells on adjacent lots �2t 100_ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line - 50' Building foundation _ I s ' Water main _ ► . A. Water Service line > t o ' Surfacewater > ttuy' Driveway, parkingNehide storage 56' Curtain drain None Seen Wells on adjacent lots >I a0' in. COMMENTS IrbC F(uia( o(e,4tA in eocA M0AV110r` iUle ren'r421170e.( uncbcrnge� f>hro �+o�f fie a6tra/t[r? of �t IWA Ali¢ gLli -excy d[fr�n►��o✓✓hoz ENGINEER'S CERTIFICATION woJ Sole eg o,* f4e lar ofeo oos/*hav(tce,7e' ac -/y •Y^v I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name 7AeorAo F Pt'007 Date r•tu4 7- 0, ' ZOO 3 _ HAA Fee $ 3 7S Orc Waiver Fee $ Date of Payment S/ Z 6 // O 3 Date of Payment Receipt Number o ('TIE Receipt Number (Rev. 12101) VA - sw $� `r `k . A s • THECDCRE F, rAC>CRE ` CE-35so �M '• _ter; ��•.•.•.••' CIVIL. & ENVIRONMENTAL ENGINEERING • ENERGY CONSERVATION & ANALYSIS THEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345.1355 June 3, 2003 ANCHORAGE, ALASKA 99516 Jeff Poet, M.O.A. DSD P.O. Box 196650 Anchorage, AK 99519-6650 Dear Mr. Poet: In response to your "Pink Sheet" query regarding whether or not the soil absorption bed on Lot 2 of Bristow S/D is level I would submit the following. This 18' by 70' bed was installed in 1984 and, unlike many other beds, has apparently functioned without problems ever since. The only two monitor tubes are located quite close together at the extreme northeast end of the bed, so they give little indication of the levelness of the bed. The fact that one of the tubes had 4 inches of fluid in it throughout the duration of my recent adequacy test while the other remained dry does not, in my opinion, indicate that the bed itself is out of level. Rather, it appears to me that, either one monitor tube penetrates deeper into the bottom of the bed than the other, or the other one has become partially filled with dirt over the course of the years. Thus, there does not appear to be any basis to conclude that the bed itself is out of level. I should add that while both tubes have remained dry during several of the previous adequacy tests, during a 1989 test when 11800 gallons of water was put into the bed, I noted a similar discrepancy in fluid levels in the two monitor tubes. In response to your other question, the separation distance between the septic tank and wells on neighboring lots is greater than 100 feet. Please give me a call if the above does not resolve your questions regarding this HAA request. Sincerely, Ted Moore, P.E. cc: Susan and Jeffrey Parker '� 09i2di98 13:44 FAX 9072583887 DAN WOLF 12108 sot I \ I I v I� !o aoetiy r� L m . � Arvoras • .� � . . /3z. �a • 6r C . d . •r Pf by 1 h .. .. � , " N •� 'F':o y 23raRY �" 41 VI N J. • I;V/ itiet� fir.., �• .. jov 11p .».., IV ::.t.;. MINIMUM Of 3M slWMWj& C@,qfUWk III few to"I ►til a M OPur n .. . U eC "Im" u.AMWa• $a 1l•Oo �' 'LL ! ��I Y. go Lift U141 9W W1 �,f^ ••,� ICytj. • f . . ' boob bo r1C M tfmw�-ton w Ar �3 _ w V eao Encs/uGiRf CERr 'W. .4191• -357+��� lt"o Y clbrulrc.r R Y• '' IWM//MpM•I4W oillb•MM 1M�•.NII/I .h.IIAM .~"a� oom,I/L�N �/1- .• .t.,'.• •N.I MM "W � YN/INI W. WOW ow #UAv=YETAe « NQ n 1• w/ w.«/ lceENoi MIT c L90N9LY0. •I t '•j ... 1n•�s.�n • v •.n. OUNp •... `r tJIQJIMALAIKA106tL9 N7•t!N w � b: A" V%Ualclrr Q Nr ►• R 4_E5C 1 ti.••. �yrfl�O�cll I.tsr _ T u •n� •�.�w.e.Yv� 3oS9 LF MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH & HUMAN SERVICES .. i 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. # 0i*7 - 0 R 1 -- lv 9 1. GENERAL INFORMATION HAA # ^-\Q9 ,, C,L\ SYS Complete legal description 1 s 1 & \.& I 1_ cu i 2 Location (site address or directions) -So l C-2 Property owner RE,i 62 -D'. 0-0 N E C Day phone 7 — 3 Mailing address 7 i5 c7 a Lending agency Day phone Mailing address Agent T) c,VA 1b L ax. Day phone x-764-76/ -76 Address Cr3 _r ✓a Unless otherwise requested, HAA will/be held for pickup. MUN<! �, t.trgl,tL Ur AN F 2. NUMBER OF BEDROOMS: CN RpNMEIvr yokqG AL S[�ylr•ES pIVISIpy `/ 3. TYPE OF WATER SUPPLY: QCT res Individual well 1r - Community well ECEI VED Public water NOTE: If community well system, provide written confirmation from State ADEC attest- - ing to the legality and status of system. -- 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site V Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front 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 thatomy 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 I v e L4 p Phone 7 Address v2.0 44 o .3 Engineer's signature <� Date Q< `/l,' ' 0 3, 6. DHHS SIGNATURE Approved for �albedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments i ne 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) Back MOA #21 [ RONIM�NOF Municipality of AnchoragerA &/ON Gk;DEPARTMENT OF HEALTH & HUMAN SERVICES 0C%7yr Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) %343-°� 'VEE Health Authority Approval Checklist U Legal Description: s i d til% r--.0-1 Parcel 1. D.: D /7- 0 91 - C�) A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water syste number 3�'Y4 .h! d PQye / cle pe+��� Loy present (Y/N) \Z Date completed 1 0785 1 r f/ Total depth 35-01 Cased to a9- Casing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION P! Date of test 's �8 9' 7d1 9 b Static water level Well production ©., g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate ZD 6 llc � Other bacteria Date of sample: ' B/4// gCollected by: �. B. SEPTIC/HOLDING TANK DATA Date installed '`A&18 4 Tank size /d- 6O Number of Compartments 0- Cleanouts (Y/N)_Y Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Date of Pumping Y ..19 9 L, Pumper /J6 a-4- e- s C. ABSORPTION FIELD DATA N Date installed I O1 z b 4 `l Soil rating ft2/bdrm) I cl D System type -1'� r=- D Length 70 Width / y Gravel thickness below pipe o`tal pth Effective absorption area / �D Monitoring Tube present (Y/N)� Depression over field (Y/N) Date of adequacy test Results (Pass/Fail) For y bedrooms Fluid depth in absorption field before test (in.); Immediately after �Vgal. watgr added (in.): (o �U Fluid depth (ins) Minutes later: Absorption rate = %®1 g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)" D. LIFT STATION NA 1 Date installed J y� Manhole/Access (Y/N) _ High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* I Septic/holding tank on lot i /05 On adjacent lots Absorption field on lot 10A lo C-0. On adjacent lots > f � Public sewer main N %A Public sewer manhole/cleanout Sewer /septic service line �> 7-6 Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: r -VA t 1 i Foundation o21 Property line ^> JD Absorption field C U c. C) . Water main/service line Surface water/drainage f� Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: t � Property line > 3y Building foundation 50 Water main/service line > so i Surface water T`t Driveway, parking/vehicle storage area >-SD Curtain drain ` O Wells on adjacent lots 7% !UO F ENGINEER'S CERTIFICATION r " d 1 certify that 1 have determined thru field inspections and review of Municipal recq thatrthe above 5ystiRms are in conformance with MOA HAA guidelines in effect on this date. r, Signature ! ' ; _ caw h En meer's Name cy�%t ✓ �t �( �7 °� -�- S7 T 4>F Date ' HAA Fee $ . 4.10 Date of Payment r�� Receipt Number 4E s,21' 6,;5 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number L'o a��o� I I I I i aba� WID _ z ul .. ?-aq , 1 1Yf�l�j to 3 leu "w' Srn�1 (�'ep, (� v it (pIC 1.� 5v d2 : 2 0 = ; 3 h>rp r► ,�1,2:iciv wr •'► t i k�. N► T-C� 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. # (W-1 — Q0A 1 — L n°i 1. GENERAL INFORMATION Complete legal description Z01 2 RRISTOW N % & O Location (site address or directions) 71So RASRi7- CRE eK RD Property owner Rb SERI 14 L LEN Day phone 34,5-0179 Mailing address `715° RASB ►r CREEK RD. ANCN• AK q2S/6 Lending agency G. M. A • C. Day phone 562-2191 Mailing address 46o W TuzoF RD i_A10 MARK - Agent PRuDEq TIAL FIRST PROC. c% CARY SAILLGo Day phone 274 - iOoo Address 80o A Sr SU(rE 205 Arlcd 99So 1 Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public water + \j 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 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 FLATTOP ` E04 QVC 5 Phone 34�- 13,5"5 - Address 35S Address 14S 30 ECHo ST. �NC�I• �k �q�16 Engineer's signature l Date (5/'319/ 6. DHHS SIGNATURE 31 ...... ......it:........ THEODORE F. MOORE '�••. CE - 3589 Zr `�hofm®o ��er Approved for bedrooms. Disapproved. Conditional approval for Additional Comments ItITIC bedrooms, with the following stipulations: 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) Back MOA k21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L 2 13I'IS-roVV Sip Parcel I.D. �g A. WELL DATA Well type PRWA7E If A, B, or C, attach ADEC letter./ ADEC water system number N-4• Log present (Y/N) y Date completed !3 5 89 _';Driller AL Pi1*4' Total depth 3 SD Cased to BEDROCk ca 14 Casing height y28 f Sanitary seal (Y/N) I Wires properly protected (Y/N) r �e WATER SAMPLE RESULTS: Coliform D Co 1 1(20 M,e Nitrate 1.9 MV1,,e Other bacteria 0 col / 1010 P7 e Date of sample: g���41 Collected by: FLATTOP TfGN SKr B. SEPTIC/HOLDING TANK DATA Date installed 10126/84 Tank size 1250 68 Compartments 2 Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) N High water alarm (Y/N) u.A . Alarm tested (Y/N) N -4 . Date of pumping 8/ 7 / 9/ by A -e SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1107 Fkpm C•o• On adjacent lots >100 r Foundation 22� To property line 6s-, Absorption field 22 Water main/service line ~ 40 Surface water/drainage >100 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE FROM WELL LOG ! AT INSPECTIONQ > Z J 5 J 3/ 5 x 8 9 R<'6/g1 rT1z ,C a Date of test ^ Static water level 26 2S m (A o Well flow • yg g.p.m. < 2 g p �- co to n z Pump level 340 0 � N Q o "' SEPARATION DISTANCES FROM WELL TO: Z Septic/holding tank on lot 110 TO C•o • ; On adjacent lots /p0 Absorption field on lot 10'7' To Go• ; On adjacent lots `? /00, Public sewer main > too' Public sewer manhole/cleanout > 100 r Public sewer service line > JOQ Petroleum tank Nonl.P- ORSERVFD WATER SAMPLE RESULTS: Coliform D Co 1 1(20 M,e Nitrate 1.9 MV1,,e Other bacteria 0 col / 1010 P7 e Date of sample: g���41 Collected by: FLATTOP TfGN SKr B. SEPTIC/HOLDING TANK DATA Date installed 10126/84 Tank size 1250 68 Compartments 2 Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) N High water alarm (Y/N) u.A . Alarm tested (Y/N) N -4 . Date of pumping 8/ 7 / 9/ by A -e SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1107 Fkpm C•o• On adjacent lots >100 r Foundation 22� To property line 6s-, Absorption field 22 Water main/service line ~ 40 Surface water/drainage >100 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed + , Manufacturer Size in gallons Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manhole/Access (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA "Pump off" level at Cycles tested Surface water Date installed —1012(.1 8 Soil rating 110 a 8pRM System type U D Length 701 Width 12 1 Gravel thickness I i Total depth 3.5 " Total absorption area 1240 o Cleanouts present (Y/N) Y Depression over field (Y/N) N Date of adequacy test Results (pass/fail) PASS for Peroxide treatment (past 12 months) (Y/N) WONE KNowM of If yes, give date N A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellonlot 1078 FROM C.o. On adjacent lots y/o0� Propertyline >/O To building foundation z( To existing or abandoned system on lot On adjacent lots > 50' Cutbank NA • Water main/service line '--' 2S" � Surface water > /oo 1 Driveway, parking/vehicle storage area 60, bedrooms Curtain drain 14-A , OUT FAL-L---QF FOUN aA T/oM DR,4r/'l 8 1 Fkom A&s. FiECD• No e;V1 DeNCE of rl ow FRom 1`0vND, DR,+(N E. ENGINEER'S CERTIFICATION l certify that l have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. At A y,� • "' Signaturee� "• Engineer's Name Thwc,,00,Y F. J`�ao �'� " T Date e.....Yi•......e THEOGOkE r. A100RE CE e e• Rtt HAA Fee $ %n Waiver Fee: $ Date of Payment /5 �/ Date of Payment Receipt Number?a 1 �a Y � Receipt Number 72-026 (Rev. 3/91) Back MOA 21 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 l.D.# Q0-ccll` La CA HAA# k\ 1��CCSI 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) 6rir /o w S /.D Location (address or directions) 715-0 05660 Crag k 81K (b) Property owner Srl f f Harz jyWr16 nook Telephone : (home) 31( '213/ Business Se' /- Mailing Address tS0 RccbS'�f Ck- Rd . /}nc.%io i!•k 99,r'/� (c) Lending Institution Gi. S • M°rr"`Qe Telephone yo 3 Y6- 3o3,s' Mailing Address y Gincgae 170al� 6850 d'Mal/.!y Rc( Anc1+!! + *#e �9's-le (d) Real Estate Company and Agent liinc9'GC Aft fAx - J'mn- kr","e, Address Telephone S - (e) Mail the HAA to the following address: (or check here ®, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single -Family ® Number of bedrooms 2_ 3. WATER SUPPLY Individual Well ® Community ❑ Public ❑ 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 ® Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 Firmer %.ecAn;ccd ,Servt4, Telephone 3yS- r3SZS Address 11530 EcAO V Ann Ak 9IS/K Date 1-tccrcA /H /969 ®� (3F A4 i10 :? , ,ap.• ,,,,,.•,"ngineer's Seal r. 100RE Fj s •sato V P� (Y ! } DHHS APPROVAL Approved forL.bedrooms by /f �`"f'`� Date Approved /` Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 7/88) Back Page 2 of 2 o� X 1-0 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) A CHECKLIST - FEBRUARY 1984 343-4744 Well Classificakn Prt r.a.Ee- Legal Description: 401 2? l3res/Ow S/p If A, B, C, D.E.C. Approved (Y/N) N,A Well Log Present (Y/N) _Y Date Completed 10/8 IV d(d&Wwt &AX Yield d. Yg 9r/J0V e afflao 3/ap Vf Total DepthSM Cased to 2Y' Depth of Grouting H.A, Static Water Level .366 r oo 3/9/89 Pump Set At x T ro Casing Height Above Ground 260 Sanitary Seal on Casing (Y/N) r Electrical Wiring in Conduit (Y/N) i Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot 1(o' 10 C.o. ; On Adjoining Lots > [oo To Nearest Edge of Absorption Field on Lot (Of Aw c.o, ; On Adjoining Lots > r00' To Nearest Public Sewer Line N. A. To Nearest Public Sewer Cleanout/Manhole N. X To Nearest Sewer Service Line on Lot > 2S" ' Water Sample Collected by 77 r Pf &0,,� ; Date .'Z461"89 Water Sample Test Results / 4 v.20.+% Comments UAYyrtld ltf by PWl r T� Sver, c*,v 7/8/69 sAcc&et be d. ofd Won wRteb evua*4' 697.gallae y uyh" k « �quaFe �r a � 6 eG(roon, %�tro4�c G _ UvG � KGa c�'Ir//a�erp� u�a/tr' .t�o �C in well, B. SEPTIC/HOLDING TANK DATA Date Installed /O/ 26/®'Y Size� No. of Compartments Standpipes (Y/N) Y Depression over Tank (Y/N) Air -tight Caps (Y/N) 1' Foundation Cleanout (Y/N) 4' N Date Last Pum�d 3/8/89 6",_.cJ�'f Pumping/Maintenance Contact on File (Y/N) M.A. ; for N.A. Holding Tank High -Water Alarm (Y/N) Al -he Temporary Holding Tank Permit (Y/N) N' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water -Supply Well - IIo ficin C.o. To Building Foundation To Property Line 65-' To Disposal Field To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course taa' Comments 72-026 (Rev. 7/88) Front Page 1 of 2 22' 22I C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Type of System Design Date Installed !D / z6 B y Length of Field Tom` Width of Field ��� Depth of Field 3•S Gravel Bed Thickness 0-s-, Square Feet of Absortion Area 1260 StcVndpipes Present (Y/N) Y Depression over Field (Y/N) 11% Date of Last Adequacy Test 3 /8/6'9 Results of Last Adequacy Test A **ale _�G r Y liea[no-vfte SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water -Supply Well fd 7` 4;ym c. a, To Property Line :�t to To Building Foundation Is" To Existing or Abandoned System on Lot No A. ; On Adjoining Lots To Water Main/Service Line 7 To Cutback (if present) Al' 4. To Stream, Pond, Lake, or Major Drainage Course too, To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Nth Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments S6' Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA cgW i n effect on the date of this inspection. F, � OF A ®4 Signed Company F&21t re -Mn i ae! „Servfc Dates b"` 1eOpO"'°••• Engineer's Seal 4 MOA NO. 199 - CIS' P_ .,A oe esmas«eee• eoeo«e eese� r. n-1,ouiZE � 54 — Receipt No. ! i�s Receipt No. Date of Payment �� 5 Waiver Fee: $ _ Amount: $ Date of Payment 72-026 (Rev. 7/88) Beck Page 2 of 2 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 K'46- 196" 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) ". e. R.- LS ffr3 LX_' S /D Location (address or directions) 7 Is -v Ru. b L,• f C h- R-ollt (b) Applicant Name /rGV'y 01 Of It WIJ112mc"3 i0 -c Telephone: Home ` Z 13y Business – Applicant Address 7 t5 O ticcbbi / Gr- RvcxaC (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ® ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution WeS� rl Mbr _ Q _ Telephone Address q 0 W. "%odo r (e) Real Estate Company and Agent_.Cx, r �rw7e P11ve-er- -V – Met Address :30,C -o A S/-. /f -n c60 crcYC A %r °?_4r>j Telephone Mail the HAA to the following address: 14o tat 2. TYPE OF RESIDENCE Single -Family D1 Multi -Family ❑ Other Number of Bedrooms — ly 3. 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. 4. SEWAGE DISPOSAL Onsite ® 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. Page 1 of 2 72-025 (11 84) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 Eta Ak - Techn ccn t Sel-vlc-/ Telephone 31/4 - 116-3 Address 1 H6-30 l'che SA A/ic4o1-crZe /}!r Date 6' /Y /5G OF AtAr 49 A �......................:.*. ./110,Engineer's Seal 00 '. THEODORE F. /JOORE �� f •.• CE - 3589 ��� P� •...•'' !�, AY4P .• 6. DHEP APPROVAL 66) ie Approved for bedrooms by Approved Disapprov d Condition 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) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) DEPT - OF HEALTH & � N► TY OF ANCHORAGE CHECKLIST - FEBRUARY 1984 -DEPT. ENVIRONMENTAL PROTECTION 264-4720 J U N 1 110 Legal Description: A. WELL DATJR /` [ J`I ED Well Classification Priya If A, B, C, D.E.C. Approved (Y/N) NI -4 Well Log Present (Y/N) Y' Date Completed to P49 1811 Yield 3 gt;m Oer ( Total Depth 100 i Cased to ZY VZ Depth of Grouting NIA Static Water Level fit Pump Set At a4k r+ Casing Height Above Ground 26 Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) Y Depression Around Wellhead (Y/N) N Separation Distances from Well: To Septic/Holding Tank on Lot 110, * ; On Adjoining Lots 2" 100 To Nearest Edge of Absorption Field on Lot 10-7 ; On Adjoining Lots > � To Nearest Public Sewer Line N'/4- To Nearest Public Sewer Cleanout/Manhole N, R To Nearest Sewer Service Line on Lot Nrh Water Sample Collected by TF/"r ; Date [5-1 Water Sample Test Results SaI44 trxc/ory — /ta Co lclorm or o �iier berC%Prt k Comments We casing it Scf role bedrecf- B. SEPTIC/HOLDING TANK DATA Date Installed lo(31 181f Size I ZSO!Z tl No. of Compartments 2 Standpipes (Y/N) �' Air -tight Caps (Y/N) �' Foundation Cleanout (Y/N) Y Depression over Tank (Y/N) N Date Last Pumped K13 I Ar Pumping/Maintenance Contract on File (Y/N) N.h• ; for Nth. Holding Tank High -Water Alarm (Y/N) N-4- Temporary Holding Tank Permit (Y/N) N� Separation Distances from Septic/Holding Tank: To Water -Supply Well f To Building Foundation ?Z1 To Property Line �� >F To Disposal Field ZZ I To Water Main/Service Line NSA To Stream, Pond, Lake, or Major Drainage Course ;Z 100` Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 200 C1' / C DA M Type of System Design 13a 0 Date Installed 31 /&y Length of Field 740 0 i 5-5` at A..., C. o, XJ Width of Field !6 1 Depth of Field 3 i it Gravel Bed Thickness 6 Square Feet of Absorption Area l 2GO G� ptrct-blf Standpipes Present (Y/N) Y Depression over Field (Y/N) N Date of Last Adequacy Test &A . Results of Last Adequacy Test A I+• Separation Distance from Absorption Field: To Water -Supply Well /O-7 To Property Line 7 c0 To Building Foundation 221 To Existing or Abandoned System on Lot N, A • ; On Adjoining Lots > 105) To Water Main/Service Line To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course > coo To Driveway, Parking Area, or Vehicle Storage Area S6 Comments D. LIFT STATION NA. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) 'Pump Off' Level at ** Check Permitted Bedroom Rating Against HAA Request ** Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ��� f-_9Z0"X Date 0!5* Company 0-744t* Tedi Se��ua' MOA No. 9,S__0S25Z Receipt No. Date of Payment OF AZ �y� r`•••"'••.*� + Engineer's Seal Amount: $ l y yAN, t ••� �♦ 49 H ' ' .y♦ 0 ...:..................z *••� J.................... Page 2 of 2 0.S ` : 7FIEODORE.0 ® F. MOORE�••. CE - 3589 .'yt 72-026 (11/84) ke, -0 .••^.,� 14;;;T :+:o0 MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date ` �2-9 O:z (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) `7/So (b) Applicants Name &z -z. w�boK Telephone - Home 31K4Z52Business — Applicants Address 7/5o ZNZ8,1,r r P►< (c) Applicant is (check one) Lending Institution ; Owner/r ; Buyer ; Other [� (explain); (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent Address Telephone (f) Mail the HAA to the following address: 2. Type of Residence Single -Family Multi -Family Number of Bedrooms 17' 3. Water Supply - Individual Well 01 Community = Other (describe) Public M 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 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. [Page 1 of 2] 5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I '*,4ftfy that my investigation of this Health Authority Approval shows that the on-site .,ifltt*r supply and/or wastewater disposal system is safe, functional and adequate for *may the number of bedrooms and type of structure indicated herein. I further verify that, y 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 regula- tions in effect on the date of this inspection. Name of Firm l��I' 'epP5 } D6 Telephone 5y5-EIiSj Address -22ZZo 8e;g-h YA9NLrI6��,,�,� Date`'J ^OOOt�l off. n\l .j (ENGINEER SEAL) el; -,^! 6. DHEP Approval Approved for 4 bedrooms By /kc -e-4-4' Approved Disapproved Conditional Terms of Conditional Approval CAUTION `SF�C n0 O ODO O , � J f 14. ._' — THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. 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. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNJCIPALIi f OF ANCHORAG- DEPT. OF HEALTH R< FNVIROWAL''tVTNL FR'C i LC T IOi J OCT 3 0 1984 MUNICIPALITY OF ANCHORAGE (MOA) % HEALTH AUTHORITY APPROVAL ( HAA)- E ED s..".._. CHECKLIST - FEBRUARY 1984 A. WELL DATA Legal Description: ,L2 �RiSToW SI�Usrv, Well ClassificationSAM If A, B, Cr C, D.E.C. Approved(Y ) o Well Log Present (Y/N) Date Completed /a g Yie Total Depth /bn Cased to 29y,_ r, - Depth of Grouting Static Water Level Pump Set At 4L Casing Height Above Ground ,3` Sanitary Seal on Casing (YM) Electrical Wiring in Conduit (Y/N) i Depression Around Wellhead Separation Distances from Well: To Septic/Holding Tank on Lot / 001- ; On Adjoining Lots /-bo'` To Nearest Edge of Absorption Field on Lot /oot- ; On Adjoining Lots N A To Nearest Public Sewer Line To Nearest Public Sewer Cleancut/Manhole x,11+ To Nearest Sewer Service Line on Lot /6o't Water Sample Collected -By ? .,J, ; Date Water Sample Test Results �4; �S�Ac� o �4' r Comments WEZL I _r, 6 B. SEPTIC/HOLDING TANK DATA Date Installed is 8 Size /2 5a No. of Compartments Standpipes (Y/N) y Air -tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N) /1/ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) N ; for Holding Tank High -Water Alarm (YM) Temporary Holding.Tank Permit (Y/N) -- Separation Distances from Septic/Holding Tank: To Water -Supply Well /obi- To Building Foundatibn 20 To Property Line fie. t To Disposal Field zo / To Water Main/Serviee Line N To Stream, Pond, Lake, cr Major Drainage Course V4 Comments ,9 S-A TL tf,O . 'old -0- -0- C-5 (C) (Page 1 of 21 �U " �� ')� �(g� 2-1 5 84 C ABSORPTION FIELD DATA /�c` Soils Rating in Absorption Strata fType of System Design s6n Date Installed i o Length of Field '70 � Width of Field /B ' Depth of Field � 11 Gravel Bed Thickness Square Feet of Absorption Area- Standpipes Present (XM) y Depression over Field (Y/N) N Date of Last Adequacy Zbst Results of Last Adequacy lbst Separation Distance frau Abscrption Field: To Water -Supply Wall 16 To Property Line /0 To Building Foundation }o ' To Existing or Abandoned System cn Lot /v�,+ : On Adjoining Lots A,,44 To Water Main/Service Line ti .4 To Cutbank(if present)'` To Stream/Pond/Lake/cr Major Drainage Course A�,IA To Driveway, Parking Area, or Vehicle Stcrage Area A11 A Catments S .45-�3uiL► DD -"'L iPT S �i Tena . Date Installed Dimensions Size in Gallons Manhole/Access (YM) "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(YM) Canwnts "Pump Off" Level at Vent (YM) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroan Rating Against HAA Request ** I certify that I have checked, verified, cr eonfcrmed to all -MOA HAA on the date of th's i pection. Signed Date ia sa d CatQany MOA No. KBl /d5/s (Page 2 of 21 in effect 0 x Dale . Me No. 2055- o 2-15-84 SOF °A44%11� A AA int; Dole R. �Ilerrell t4o. 2055-E Location: BESSE, EPPS & POTTS 2220 EAST 88 AVENUE ANCHORAGE, AK 99507 (907) 349-6451 WATER WELL TEST Date: o Subdivision: Slo Lo Lot: 2 Block: Client's Name: JAL WL--,',i7RQondC Address: 7/50 7�,t,ka ;[: 6,0r,<. p2b, Tester: Initial Reading on Meter: NOTES: 440w G/ -,S c4L Production Rate: _5,e GPM 24 -Hour Capacity — Gallons