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Home My WebLink AboutBROWN LT 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, ~elephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT .am~ DISTANCES //)'//~/¢,~'/_ t.7,¢~4,,,~/ c/~ J)&'$1,,c,~J5 I,~ I.,u'oo~ ____'~_ TO SEPTIC ABSORPTION WELL ^,,,r..,~FROM ~ ., TANK FIELD ~q~-~o~V J 8~OZ~I ~ LOTUNE ~ ' Z, I E~o~' FOUNOA~ON /~' Z~ ~' Tow~i~ ~, ~ A~BUlLT DIAGRAM l~ow lation TANKS ~ SEPTIC D HOLDING ':~,,, TYPE OF SYSTEM ~. ~, ~; o , ~ TRENC'~~ ~ .ED ~ W. DRA~N ¢'~:.~.,' ......................... :iff ada~ a~ve ong~n~ grade ~a~ ~ptfl ~ealh pt~ I~ / / t Tot~ a~rpt~on area ~ ~te li~ .. Num~ of Im~ rating P,~ marcia ~ ~ / /so so ~ ~o ~ q FY c ~/' I~tall~ Date IffiJlffi , -~ ~ PRIVATE D OTHER (IdenflN) L FI FT REMARKS: ............................ ' DE~. OF HEALTH &' , ..... " -,'~ ~ /,,~ ~o' ':..:.::- ,,_...,% 72-013 (3/85) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT .ame DISTANCES SEPTIC ABSORPTION L~o~ O~SC...~,ON LOT LINE Lot ] Bloc~ ] Subdivision Z, I E~o~ FOUNDATION Township, Range, Section AS-BUILT DIAGRAM (Show location of well, septic system, properly lines, foundation, TANKS ~ SEPTIC ~ HOLDING Manufacturer Capacity in gallons ~aterial No. of Compadments ~ ~ TRENCH ~ BED ~ W. DRAIN ~ OTHER ~,~ Depth to pipe bottom from Total depth from original grade °riginalgrade ~ FT ~ FT :ill added above original grade Gravel depth beneath pipe ~FT ~ FT Gravel length Gravel width Total absorption area Distance ~tween lines ~0 SO FT ~ FT ~umber of lines I Soil rating Pipe material /~ ~ ~ ~ Installer ~ ,i~ ~ -} Date Installed WELLS ~ PRIVATE ~ OTHER {Identify) Classification (A,B,C) Total Depth ~ Cased to FTI FT Installer Date Installed: REMARKS: Health Depa~ment Approval: _ _ Date: 72-013 (3/85) Owr"m.:,i" Name:,: M I Cl...If41ii!] ....BR[)Wiq 3 4 9,,.-8 () 1 4 f:::'arc.:e 1 1 d :: 0 15'--" Lc,'t. t....ega I: Sub d :i. v i s :i. or'~, E'~R~)WN : I.,,o'[.I '2 EIZom.k: - Sect i c'.,n I.,,.ot S:i, ze 49.38~ (sq,, .~"L,, or' aci".e~[~) i'.'la::.( Bedl'.ooms~ ]"his l'.::'el'm:i,t: 4 To'La], [:];,~[:)at::J,'t'.,y~ 4 ! ~i!,:. must h,':?'.'e aL :i, easi~'L ;7 cc)r, pal'~tments,, Dep'Lh to top o~ .septic 'Lank (s) .::: ! ,,-.';':! ;'; .... ; . : "?-' ~.].,:~'l',,iCd'i OvE:r~ 'l:.ai"'ik (s) . must · h:.:.i:, p \,, .~. (..-' ~.,,.'.:,,:'.., w i th :i. n :'.!!iC~ days o ~' we 1 1 c: omp 1 et i on ,, I. N'..::::'! AI..I .... t:;:'tiii:t::~ EI"JG I I',tE::ERE~ AT't'ACHEi:D DES :1: GN ,, NC)T I F:'Y DHHS I;::'R I OR '1'0 EAC;H :t:I".!~:~I::~E:.~; i .I.t)N. 'TF~ENC;H 1S ]"C/ BE ~ .........x ..... : .,Jl" t:,III:.D AND [',L..OSED C)N ]"HE SAME DA'Y, , L,iiqLEE~S t"II~:A"i" i S I:::'RCiV I DED,, T H I S I:::'EI;:(M I '1' ]: S :[ SSLJED FOR THE ::'L~ANIqED 4 BE. DROC~M SI. txlt':il..,t~: FAMILY DWI~!~:LI.,.IIxI[~)ONI.,.,Y AND _EX I:::'!RES [IN A I',It~EW PERMI'T' WtI:L,.t .... BE IRI~ZC;!LJiRED AF:'T'ER 'I"HAT' DATI~ :1:1:::' THE~: SYSTEM HAS ['~ "' ' X o' ............ NO"i' .~..,E.t,I I Il~:~l i ., I:: I'~ ~. F'Y 'T' t'"lt'.'::~ ] .' :1.,, I am f'am:i.l:i.a['~ w:i. th tho requir'emen'Ls ~'or' on,...,si'Le sewers ar'id wells as se'l:. f'or'Lh by the Mun:i. cipal:i, ty of Anchc)rag~ (MOA) and the Sta'Le of' 2.. i wi].l :i, nstall 'Lhe s'y'~t, em :Ltl ac::l:::or'dal"'lce with a].l M[](::i cc)c:les and reguia'L:i.c)r'~s~, and :i,r'~ compl',i, ar'tce [~l]:i.'t'..J"j t,,he CJ~/~J,(~Jl"t c::r'~.'LeP:i.a (:)~ 't:.h:i.s per'mi'L,, :]~,,, 1 will a(:Jhel=e 'k.o al, J. MOA al"lc:l State (::).l A].a~ka r. equ:Ll"emer'~ts (ol" the set (:J ;i. ~"" ......... . . .~.,~::~J ~..(.:e~]5 [ I" C)ll'i ~;~,l"i~k.' (~')'( :~, E~'[',, :J, I']C WE') t :I. ,, was'Lewater d i st:)osa ',1. system or'. pub :1 :i. c E~?~w(.~.~l"-a~:j{~)~ ~B'y"~j't:,.ef[i Cil"~ 'Ll'"l~,~i c)f'- (i~i"~z ac:lj;~c:er'YL oP r]ear, by lo'L., t ur'~der, s'Lar~d fha'l:, this per'.m:i.t is raj. id for' a max:i, ml.,~m of' 4 bedr'ooms,, also undersLand that 'Lhe capac:i, ty (~l"u.:~, total system ~,s 4 ~:){~)~c:Jl"~::)l::)~l~ and any c~,"~].ar.c, emei~~ r'.equ:i. Pe ari~:~it:i, orl~]. ,::,errr, i'L ,, .............. ............................................................ ............ (Owner') Mi[,.HAI~::] .... PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN.SERVICES 825 "L" Street, Anct~orage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: .~.r ~-~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTER ED;' IF YES. AT WHAT DEPTH? ~4~mtming? Daze Gross Ne~ I Oeo;h to Ne~ Reading Time Time/ Water Oroo PERCOLATION RATE (m,nute~,nctt) PERC HOLE DIAMETER TEST RUN 8EI~WEEN ~ FT AND . COMMENTS "~Zg/J)/Z'-/O/~/~/-- T'E,,~,"~ 1"/~/4~__ ~ ~0~~ /~E~ ACCOROANCE WIT~ ALL ~ATE AND MUNICIPAL GUIOELIN~S IN ~FECT ON THIS OATE DATE 72~ (R~. ~ THAT. THI.~ TEST WAS PERFORMED IN Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN.SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2O Township. Range, Section: SIT~ ~LAN SLOPE WAS GROUND WATER ENCOU NTER ED ? /k,/O IF YES. AT WHAT DEPTH? It Rla:ling Date Gross Net Deoth to Net Time Time Water Drol~ PERCOLATION RATE (mmutes/mc~) PERC HOLE DIAMETER __ TEST RUN BETWEEN FT AND FT ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE DAT[ / ' 72~ (R~. ~) IN PERFORMED FOR: Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN.SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRII~I'ION: ~.OT ~. I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2O ,~ US~t Townst~ip, Range, Section: '-~ 2 '?- 7'"'/SA/ ~ ,~ ~J SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? IF YES. AT WHAT DEPTH? . I t tl I Re~:ling Date Gross Net / Oeot~ to Net Time Time Wate~ Drop ! PERCOLATION RATE __ (mmutes~,nc~) PERC HOLE DIAMETER TEST RUN BE'DWEEN __ Fl' AND FT IN I I I I I 7~ % ~ .' FOUNDATION ~' DRAINAGE ARROWS NOTES: I. IT SHALL BE THE RESPOHSlSlLIT¥ OF THE BUILOER OR OWNER TO VERIFY THAT BUILDING LOCATION SHOWN MEETS ALL SUBDIVISION COVENANTG AND ZONING ORDINANCES. ~:. IT IS THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL ELEVATIONS WITH RESPECT TO ALL UTILITIE$~B DRAINAGE. 3. THiS PLAT REPRESENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN FROM THE RECORDED PLAT DESCRIGING THAT PARCEL. INSTRUMENTS RECOROED PRIOR TO OR AFTER THE FILING OF THE RECOROED PLAT ARE NOT SHOWN ON -- -- d I 30' 30' EURVEYOR'~ CERTIFICATION I HERESY CERTIFY THAT I HAVE SURyEylrO THE PROPERTY D(S(:RIGEO ON THIS PLAT ANO THE IMPROVEMENTS SITUATED THEREON ARI LOCATED AS SHOWN ON THtG PI-AT. . ~ LEGEND 0 LOT FOUNDATION DRAINAGE ARNO NOTES: IT SHALL IE THE RESPONSIBILITY OF THE BUILDER OR OWNER TO VERIFY THAT BUILDINI LOCATION SHOWN MEETS ALL SUIOIVISION COVENANTS AND ZONINg, OROINANDES. , tT IS THE RESPONSIBILITY OP THE BUILDER TO VERIFY ALI. ELEVATIONS WITH RESPECT TO ALL UTI~,ITIEEt & ORAINAGL THIS PLAT REPRESENTS THE PARCEl. OF PROPERTY DESCRIBED IRLOI FROM THE REDOROED PLAT DESCRIBING THAT PARCEL. INSTRUMENTS FRIOR TOON AFTER THE FILING OF THE RECORDED PLAT ARE NOT SHOWN' ON THIS PLAT. THE INFORMATION ON THIS PLAT II FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY CONFLICTS IETWEEN EXISTING STRUCTURES PLATTEO LOT LINES OR EASEMENTS ~ THE P~AT IS NOT TO IE USED FOR ~IITIONINi ADDITIONAL ITRUCTURES OR F~NCE8. '~Z 0 T ~ZAW 2 , 349-6451 DRAWN BY '- /~/') CHK. BY, BE$SE, EPP$ I~ POTTS 2220 E. 88'th. AVE. ANCHORAGE, ALASKA 99507 344-1352 JDW~, '~ '-".'~ '. · WATER WELL RECORD · ;., STATE OF ALASKA '~. ' · · - DEPARTMENT OF NATURAL RESOURES · Division of Geologicol ~ Geophysicol Surveys ": '":'~': !' .-';'/:~' Drilling Permit No. LOCATION OF WELL (PleDGe complete either lo, lb or lc.) ; "' ~'''~ - · A.D.L. No. STANCE FROM ROAD INTERSECTIONS ~ .. '-, ~. OWNER OF WELL: AND DIRECTION ' '[ ';? "' :'J ";: ' addrea,: Designs In Woo, Street Address end Area of Well Locoflon ". ,"~,~ ..... ',' ' ~oho~e ~ WELL LO6 Fief Below ...,. 4, WELL DEPTH: (flnol) 5. DATE OF COMPLETION MQterlol Type Top 80ttom .:J ~; ~ f~:,-~ ~ ~ 0 ~ 6, ~ Cobll tool ~ Rotary ~ Driven ~Dug : TXp~: Dlomefer: '~ Set between ff. ond ff. ,r . ",';. '1 Boekfllllng Grovel pock .... I0, ~TATIC WATER LEVEL: MUNICIP~IT~ ~ AR~, )~':'~ "" ":';'~' ~ Above Or ~ Below Iond ,urfoce Dote _. F~VIR~NME ~T~ PR~E ' '?'r'' ; 1,.~ ;1 II:,PUMPING LEVEL below land ~urfoce and YIELD ' ',": ' '" "- ' Material: 0 Neof Cement 0 Other: ' ]4. REMARKS= ~ ~ , ,~ ..... · 15 Weter Tempereture o ~ F ~ C This well ~as drilled under my )urlsdlcflon ahd this report]l j~:~:{~.:t~.'bilt of m~ knowledge ond be Registered Business Neme ' :..,?'}~:;~:~ti~:, '-Co~lrect License Number Form O~-WWR (11/81) Copy Distribution: WHITE'~f~fe DGG~ PINK"Driller, ~ANARY'CusfomIr P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0650 (907) 264-41 ! 1 TOADY k'/'vOWI_ES ~,.!A '," C: O DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850246 Lot 2 Brown Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Susan E. 0swalt Program Manager On-site Services SEO/ljw enc: Copy of Permit PER'MIT NO: DATE ISSJEI:):: 05 / ..... / ...... ' · ... ~ .[ ~ (3 ~.J C Ct N'T'A C T' I::' I'"10 I',t [!ii: I....EE'h'::~I .... DESCF;,' I P :: ' L.[] T S I Z E ',: L.E)T L. OCAT.I: ON:: MA X I'.:.qi.::;DRO0t'IS :: ,;:t AMIES M, I:,"tJI',IL. AF:' .'.'.I. :1. 5 :L W '72NI:) AVENLtE; (.-WqCHORA(i:.UE.~ AK 99502 2 Zl. 5 '"" '70 ./::, ':? DEPTH TO F' I PE B(::!"I"'!"(::~!"'I (F'T ,, ) [':.) F:;'. ~::~ V El .... D I..'.]; F:'"I" i...1 ( F'"I" ,, TO'I"A! ....DE]:::'TH (F'T.,) G R A V E L I,,,J .1: D T H (F:'T, (i~F;.'.(..~VEI .... L..EI'4E'YI'H (F::'T.,) GI::;'.AVIE! .... MOI....UME (C.U, YDS,, ) 'I"ANI.::; S :1: ZE ([).'i(.~L..S) .SI:) Il .... I::;.:AT' I I',tG (SC!, !:::T ,, /BF';: ) For'i:..h by 't:.he Mur~:i.,:::::i.F~a].:i.l'..y [:).r-' Anchor'age (MOA) and 'l:..he E; !:. .~:,,, i'.. .,:.:.:.:, ,::>F {.:.~:l....?:'v..'~ka,, 2,, .'I: t,.,~:i. ]. :I. :i.n!s'l.'..al ]. 'l.'..hf.{'. '~.~y~..-.".i'('..6:.!.,'fi :Lr'i a'..'u[:: (::; ,:;::, i" d ,.'..'..'d"~ ,.;::: 6? w:i.'Lh at :t. h'1[;tA ,::::,:::x.i(.:.:..w..~ -:'..'..':nd r,:..?q:!u].a'!:.:i.,:::n'".,~, and :::.!;,, ! v,~:i.].! adh6:r'e t.o all MI:IA and S':a",:.'=; ,'::~¢ A1a..sl-'.:,.?..'~ r,:.:.:.~.,:::lU:i.r'c.:.:..'men'I:..s {c~.r' .Lh,:.i~ .~.~,..~:.~'i:.. ba',.,::::k d:i.s't:.ance,.'i~; t:' r'c'.')/fl .:?:tr'ly g.:..~i.:: J.'..!?[L :i. ng t,,.~c..,.'t. 1 ~, '../,¢a":i~;~,:..,'.;,~-,~a.'l:..rE, r' d :i..i~.~t::)c::,i~ila]. ~i~y-~p.':..,:-::.:.m ,:::ir i::~J{:::,.:t. 1.,:::: '."ilP:')~',$':-:'."." r' .:T~.{~:J 6:, ,ziy'!..~FI.'.. 6::."f¥i cln '[:. l"i :J. '.:iii C} I" .:.'..':~I"! y .:'..':iCl .;j ?;:!C: E.H"i 'I.;. C} i': i"i ,.'.;.:..",~':'-'. 1" J;:) '.../ ]. C)'l& ,, .q.,, I Lu"Ider"~E.'[atrld T..h.._'¢..'d:.. 'Lhi'..s l::.',c.:,r'm:i.'L is ¥.~':~].i(::I .~'oi" .:::i m.:':?.x:!.;¥iLu.'f',. ,'::.',,,'.' 4-l:tE.:,CJi"('::,,.'zh'¥?.;i:i .~':'.'.f"~(:.J any .l;l::: A LIF:"I' ?,.'l"A'l"IEd',l IS IN.STAi_LI.T:;D ]:lxlAB1 P.'F'?.IEA ........ ,' ,'¢ :::,. 't:,,'.., ;[ ' ~ ........ " .... "' "' II h:.l',~(:1)~'..t~,~ iEL..!ii!;L';'T'FtICAI .... I E. :~1 "r' .......... ~!'",ID .1. N,:,.-[':.:.,1 ~.,...1~,! I'.'1~ q"r ;::.~::: [Xg'I"A]:I'",II!i!:D!I ............................ ') AS"-'!:::: "'1 '~"~::: M I 1....I .... I"q[Tl" BE AF:'I:::'Fi'.EIVI'ZD M I 'I"H[)UT r:::',.'l',l lii..';l_r:i~.CTl::i'. I CAI IEI....I!!i:C'I"t::;: :1: CAI .... t/,I ['.t F;: !<: IfiLIST' I'.":dE DONIE E",Y A I.... :I: CIEI',ISIE.f.) IEL. I.Ei.:iTF;.: I C :I: 2i!'",! ,, AF:'F:'L. I CANT':,.'~.., ~....,~','~ c::.~"'"".::::, M. I)LINL..AP ISSi!.IED BY MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~SOI LS ~OG [] PERCOLATION TEST LEGALDESORIPTION: L~"~+ _~ SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT ~ DEPTH? P E' Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND 5¢ f 5-0, CERT, F,ED BY: FT 72-008 (6/79) PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 DEPT. C / ' MUNICIPALITY OF ANCHORAGE , .,.. o,- ...... -. DEPARTMENT OF HEALTH AND ENVl RONMENTAL PROTECTION TEST Pouch 6-650. Anchorage, Alaska 99502 276-2224 f,:i/~¥'2 SOILS LOG - PERCOLATION TEST i SLOPE SITE PLAN I i ' 10 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? 77! L '--4 ....... ~ ..... i--4--d- ............. ?.--~---t ..... Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN (minutes/inch) FT AND FT · ...... CERTIFIED B , _ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 015-163-59 HAA # 1. GENERAL INFORMATION Complete legal description Brown Subdivision ~ot 2 11540 ~'ail ~ztds Road Location (site address or directions) Property owner David J. and Marcia M. Lafferty Day phone 346-3809 Mailing address 11540 trail Ends Road, Anchorage, AK 99516 Lending agency Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: X Individual well Community well Public water Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: Individual on-site X 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 Env-iror~enCa'l Mar~gement Thc. Phone 907 272-9336 206 E. Fir/~eed L~., f~ 201, Address Engineer's signa Anchorage, AK 99503 bedrooms. DHHS SIGNATURE L/'"' Approved for Date Disapproved. Conditional approval for bedrooms, with the following stipulations: Additiona! Comments ~'~"~~ L~,~~~. Date By:/ , 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#21 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 HAA # GENERAL INFORMATION Complete legal description 'Br~n Subdivsion Lot 2 Location (site address or directions) 11540 Trail Ends Road Property owner David J. and Marcia M. Lafferty Day phone 346-3809 11540 Trail Ends Road, Anchorage, Ak 99516 Mailing address Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickul NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: Individual well X Community well Public water NOTE: If community well system, provide written confirmation from State ,~um~, aauo~- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site X 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 Enviror~ental Hgt. Inc. // Address 206 E. Fireweed/Ln~, ~chor~,//AE 99503 Engineer's >.~ 6. DHHS SIGNATURE Phone 907 272-9336 Date /~ ~: 't, John Earl / / '%~ "~:.,,".. Approved for Disapproved. Gonditional approval for bedrooms. bedrooms, with the following stipulations: Date ~',/Z.L~'//~g/"' 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 I¢21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Brown Subdicison Lot 2 Parcel I.D. A. Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Private If A, B, or C, attach ADEC letter. ADEC water system number Yes Date completed 03/28/88 Driller 75 ft. Cased to 75 ft. Casing height Yes Wires properly protected (Y/N) ~s 3ft. 2in. Date of test Static water level Well flow Pump level1 FROM WELL LOG 03/28/88 47 ft. 6 ft. .g.p.m. 74 ft. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line 101 ft. 109 ft. 150 ft. 150 + ft. AT INSPECTION 06/10/94 53 ft. 6 74 ft. ; On adjacent lots ; On adjacent lots g.p.mt,-3 ~- < - 150 ft. 150 ft. Public sewer manhole/cleanout 150 + ft. Petroleum tank N/A WATER SAMPLE RESULTS: Coliform 0 colonies/100ml Date of sample: 06/13/94 Nitrate 1.2 mg/1 Other bacteria 0 colonies/100ml Collected by: Chad Helgeson B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) Yes High water alarm (Y/N) Date of pumping 12/30/88 No 08/13/93 Tank size 1250 Foundation cleanout(Y/N) Compartments 2 Yes Depression (Y/N) No Alarm tested (Y/N) No Pumper Isaac' s Pumping Service SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 101 ft. To property line 16 ft. Sudace water/drainage 120 On adjacent lots Absorption field ft. 150 + ft. 6 ft. Foundation 19 ft/ Water main/service line 100 + ft. 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ']2/30/85 Length .57 £t. Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Width 600 Cleanout present (Y/N) 06/10/94 Results (pass/fail) 82 inches No Soil rating (GPD/FF) 150sq. ft./bd~m. 5 ft. Gravel thickness 4 ft. Yes Pass System type W. Drain Total depth Depression over field (Y/N) for 4 After test 83 inches If yes, give date No Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 109 ft. To building foundation 29 ft. On adjacent lots 110 ft. Sudace water None Observed On adjacent lots 150 + f~, Property line To existing or abandoned system on lot Cutbank None Water main/service line Driveway, parking/vehicle storage area '16 ft. ft, ft. 1DO fr. + Curtain drain N/A E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conf~rmed to all MOA and HAA guidelines in effect_~Gf this inspection. HAA Fee * ~00' c~ - - Receipt Number ~L~L~'~' ! ~f~ Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING ,3'-- / [¢ ~ - ,&-- c] HAA # ~ ~-¢ O / ~ ~;7 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township range) Location (address or directions) (b) Property owner Mailing Address T. elephone · (home) ~'e$1~' Business (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here ,~"hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family'J~ Number ofbedrooms 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 i-I Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev, 7/88) Page 1 of 2 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 bedro.oms 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 ,~/dDcl~o,,,J ~ u,J Address ~O, '~0~ ~.'jO 773 Date ~/i~.~/~ ~ Engineer's Seal 6. DHHS APPROVAL Approved for ~(~/-) bedrooms by Approved X Disapproved Conditional Terms of Conditional Approval *f;T' I I Iff ~ 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 Well Classification Well Log Present (Y/N) MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: ,z:;',E'/¢//rg. If A, B, C, D.E.C. Approved (Y/N) Date Completed 3//~--g~? Yield ¢ ~,~,w Total Depth 7.5' Cased to ?..5" Depth of Grouting /,/o Static Water Level /'/?' Pump Set At Casing Height Above Ground /?" Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduit (Y/N) )/ Depression Around Wellhead (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots /~¢ ' ; On Adjoining Lots / 'Y'? ' To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by ~4./. N~¢ -P'"A I:>c> ~ El Water Sample Test Results %~T~5~Acr~ ~'~ Comments ~*,iELL, 15 ~,E~....I ,47/ 4: ¢"' ,~ To Nearest Public Sewer Cleanout/Manhole /~/~/~'"$ B. SEPTIC/HOLDING TANK DATA Date Installed /Z- ~o-E8 Size Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) Air-tight Caps (Y/N) ~J No. of Compartments k~ Foundation Cleanout (Y/N) Date Last Pumped IJ~ ~Et~q ; for Temporary Holding Tank Permit (Y/N) /t///~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well To Property Line To Water Main/Service Line /05 ' 85' To Stream, Pond, Lake or Major Drainage Course Comments To Building Foundation To Disposal Field !57 ~-.0~ 5TIE. UCT' I 0 ~J 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /Z - $~- ~8 Width of Field 15o Type of System Design Length of Field ~, o' Depth of Field ~ Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Gravel Bed Thickness ~ ' Statndpipes Present (Y/N) Date of Last Adequacy Test Y SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot klO~E o~ LoT To Water Main/Service Line c~ ~, To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments AE55oR. p'T-io~J ~'/E~_D /S /dEtJ~ To Property Line /~ To Existing or Abandoned System on , ~-..-' · On Adjoining Lots '7 To Cutback (if present) /,./o~./£ /c~4¢,5~'~7' ATION Date I~ Dimensions ,Size in Gallons -""-~~ Manhole/Access (Y/N) 'Pump On" Level at '"'--..~ "Pump Off" Level at High Water Alarm Level at ~ Vent (Y/N) _ Tested for ~~ Pumping Cycles during Adequacy Test, Meets MOA Electrical Codes (Y/N) Comments -"'"'"~ _.........~ **Check Permitted Bedroom Rating Against HAA Request** M A "r'~ I certify that I have checked, verified, or conformed to all 0 an~;[~"'.4~t~tgu~l~_~ _~% in effect on the date of this inspection. , ~~ ~ ~ .,....~.~.~ Signed ~ ~ ~" Company ~~$O~ ~x~~ ~* ~9TM ~ .~.~ ~, .,~,e,,~.;*~.l"~'~'**"~"~ ~'~ ate Sea, MOA No. C~--~-OZ~ ~'%%~ ...... ~' ~.a~,~o~ _ ~ ~', 4381 ' E Receipt No. 0 ~-- ~//O ~ Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back / 7D. oc) Waiver Fee: $ Date of Payment Page 2 of 2