HomeMy WebLinkAboutSUNNY VALLEY LT 25
, MUNICIPALITY OF ANCHORAGE
· . Dr,. /RTMENT OF HEALTH AND HUMAN SER. ?ES
· ,. Environmental Health Division
8 5 L Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
Address ~ SEPTIC ABSORPTION
Phone{s) Pe.~t~/8 NO of B om~ WELL
/~ -~9~ ~ ~° 108' /~/
S~g V~7 FOUNDATION
[ownshi", Ran ge, Secdon
~M ~/V~/ ~/~ driveway,AS-B UILT DIAGRAM (Show location of well. sepdc system, property hnes. foundatlOnwater hod,es, etc.)
, ,
TANKS
~ SEPTIC ~ HOLDING
Manufac[ucer
Material NO. of Compadments
TYPE OF SYSTEM
~TRENCH ~ BED ~ W, DRAIN ~OTHER
onginaIDepth to pipe bottom ,¢Omgrade ~ FT Total depth fr]~riglnal grade FT
Fdl added chore original grade Gr~vel depth beneath p~pe
Total absorpt,on area
~ ~ SOFTI Distance between 'tries
Number of I .... Soil rating IPlpe matedal
Installer Date In~t ailed
WELLS
~ PRIVATE ~ OTHER (Identifv)
Classdicahon (A,B,C} Total Depth Cased to
! ,.staliel Dale Instal,ed:
REMARKS:
Scale: J '~ = ~O' ' ENGINE 'S SEAL
Inspectio~%~ed by:
~13 (3/85J
DEF:'ARTMENT ~/' HEALTH AND ENViRONMENTAL.~'~:OTECTION 825 L. ST'REE'I, ANCHORAGE, AK 99501
P'~.~ -- EE; ]E -:F E:: '.~ EZ ~,~,~ E] IF~ F:> EE ~:::~ P"'~ ]:: -~
PEF~'.M I T' IqO:
DATE: !SSL. ED:
AF?L. I CAIq'I',~ F:'AM NICHOLS
ADDRESS: F:'~, 0,, BOX 77409:7.
EAGLE RIVER, AK
CON'fAC'[ F'HONE~ 694-2979
99577
!..EGAI_ DESCRIP:
LLJ, ,_.fzE..
SLBDZVIS:f'ON: SUNNY VALLEY LOT: 25
~: £::~.: I .Ir~..~W. 16 TOWNSHIF': 14N K~.. ,I.~ :.~ :!.W
3. OA (...Q. FT,~ [.ff~ ACRES)
BLJ]CK: NA
i c:eP'LiEy that:
foPth by the Mun:i_cipality c)F AnchoPage (MOA) and the St.a'Lm of A!aska~
2. i will install bhb system in accordance with al! MOA codes ancl Peguiat. ions,
3. I will. ac:iher'e 'Lc, a].l MOA and State of Alasl<a recluir, ementE, for the set. baci::
dist. anc:[as Fi"cHD ally E)xist:i. Fig ~C:~].],~, was'Lewater disposal syst. em op public
s(awerage Esystem (::)1"~ t, lnJs or any adjacent, or r'leaPby lot.
!H' A I-:(FT' ST'ATION IS INST'AL..LED IN AN AREA COVERED BY MOA BLJII...DING CODES,
THEN (1) AN EL.ECTRICAL. PERMI"I' AND INSPECTION MUST BE OBT'AZNED; (2) AS-BUlL. TS
W):LL NOT' BE APPROVED W:[THOUT AN ELECTRICAL. INSPECTZON REF'ORT; AND (3) THE:
ELE:C'TRtCAL WCJRK MUST BE DONE BY A LICENSED ELECTRICIAN.
APPI-I CAIq't"~ ~lq ~:I:C~]I_S
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCR,PT,ON:
Ore
2
8
10
DATE PERF
Township, Range, Section:
SLOPE
13
14
15
16
17
18¸
19-
20-
iEAL)
WAS GROUND WATER y
ENCOUNTERED?
/
IF YES, AT WHAT
P
E
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~ FT AND ~"'~ FT
72-008 (Rev. 4/85)
IN
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
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Lot 25; Sann~ Va~le~ Subdivision
Location (.address or directions)
~,~.~- ¢.,, /~, ~ .
22027 West Lake Drive
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
Stewart Johnson Telephone: (home) 696-3131 Business 348-5178
22027 West Lak~ Drive, Ea_~le River. Alaska 99577
Telephone
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the following address: (or check here,E]( if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Ea~le River Loop Road No. '~4
Eagle River, Alaska 99572'
TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
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.
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 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, Ive rify that my investigation of th is
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
S & $ ENGINEERING
17034 Eage River Leop Road No. 204
Eagle River, Alaska 99577
Name of Firm
Address
Date
6. DHHS APPROVAL
Approved for '--~
bedrooms by
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. 7188) eack Page 2 of 2
(~M MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA)
PALITY OF ,'~;¢i~LC~i~ST. FEBRUARY 1984
ENTAL SERVICES DIVISIO~13.4744
MAY i i ]990
RECEIVED
Legal Description:
A. WELL DATA
Well ClaSsification ~ ~ ~ ]c_~ i~'"~ N~'! /~
L
Well Log Present (Y/N) ~ Date Completed
Total Depth ~'/"/' Cased to ~(2"f Depth of Grouting
Static Water Level . z.~ --~ ~
Casing Height Above Ground 2 ~--"
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ,/ 0 ,~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line /U/
To Nearest Sewer' Service Line on Lot
Water Sample Collected by
Water Sample Test Results
If A, B, C, D.E.C. Approved (Y/N)
Yield ~. ~/ q~
Pump Set At ~ f~'
S~nitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots / CO
[ / ~ ' ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
~') ~ ~ ~I~.!^IC.~,FHJ~, Date ~'"'-/-'~ - ff~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed -7"~o Size
Standpipes (Y/N) ~
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) iV/~l
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
I oOO~¢~l No. of Compartments ~--
Air-tight Caps (Y/N) L~ Foundation Cleanout (Y/N)
~ Date Last Pumped "~L/~ /-
k.)/~ ;for
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
TO Stream, Pond, Lake or Major Drain~ge
Comments ¢-~0~ 7~1C-. rU ~ ~OC, CI
To Building Foundation
To Disposal Field
Course ~/~ ~
72-026 (Rev. 7/88) Front Page 1 of 2
O. ABSORPTIO. FIr:LD DATA .~
Soils Rating in Absorption Strata [¢:~ ~-- ~/~,;~ Type of System Design
Date Installed -'~ / cC~/o f Length of Field ~--~
Width of Field ~ Depth of Field ~
Gravel Bed Thickness ~
Square Feet of Absortion Area .;2.) ~ .~ ¢' Statndpipes Present (Y/N)
Depression over Field (Y/N) /"J Date of Last Adequacy Test
Results of Last Adequacy Test ~F4 ,~f.~,~¢_."~'~ -- ~ c¢~q/¢-oo/¢~
SEPARATION DISTANCE FROM ABSORPTION FIELD;
To Water-Supply Well
To Building Foundation
/ I ~ I ~- To Property Line
; On Adjoining Lots
To Existing or Abandoned System on
.%o 4--
To Water Main/Service Line / O/¢'
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicl~ Storage Area
Comments
To Cutback (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level ai
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
~ Dimensions
~.~ Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect
inspection.
Signed
Company
Date
MOA No.
~te of this'~
Receipt No.
Date of Payment
Amount: $
/
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET .ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SAMPLE fat Work Ozdet J 21521 Date Report Printed: ~¥ 8 90 @ 14:27
Client Sample ID:L2$ SONNY VALLEY
PW$ID :UA
Collected ~AT 4 90 @ 10:55
Received WY 4 90 @ 16:00
Preserved with :AS REQUIRED
Client Name : S & S ENGR
Client Acct: SNSENGP
P.O.J NONE RECEIVED
Ozdezed By : R. SHAFER
Analysis Completed :~AY 0 90 Send Reports to:
Laboxatoxy Supexv~so;~ :JTEPNEN C. EDE l)S & S ENGR
Released By : ~ ~_.~ ~/ 2)
Special
Instxuct:
Chemlab Ref t: 901226 Lab Smpl ID: 7 Watrix: WATER
Allowable
Paza~eter Tested Result Units Method Limits
NITRATE-N 0.30 rnq/1 EPA 353.2 10
Sample ROUTINE SAMPLE.
Remazks: SAMPLE COLLECTED BY RD$.
1 Tests Pex£ormed See Special Instxuctions Above OA=Unavailablo
ND~ Non~ Detected "See Sample Remarks Above
NA= Not Analyzed LT-Less Than, Gl=Greatex lh~n
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] ,u,,,c wATE, SYSTEM '.D."
~. PRIVATE WATER SYSTEM
Mailing Address
Phone No.
S & S ENGINEERING
17034 Eagle River Loop Road NO., ~J~
Eagle River, Alaska 9957~.
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
_) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
3 I I
4 I I
5l I
Time Collected
Collected .~
TO BE COMPLETED BY LABORATORY
sa SiS show~ this Water SAMPLE to be:
tisfactor~
[] Unsatisfactory
/
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received ./(~ ~
Analytical Method: Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
1
I 715
I
Analyst
~-~.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter:. Direct Count ~
Verification: LTB BGB
Final Membrane Filter Results
Reported By_ ~__~_~c~:~- Date
Time:
Collform/100mi
~--~--~-~
/~m.q-~"~ a.m.
p.m.
TNTC = Too Numberous To Count
OB -- Other Bacteria
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. #_ ["~ ~-b("3 - %~-~J-[ - ~)c~ HAA # ~.~ ~-%,~,c~._.~.~ ~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Sunny Valley Lot 25 T14N, R1W, Sec.16
Location (address or directions)
22027 West Lake Drive,
(b) Property owner H.UoD.
Mailing Address 222 W. 8th Ave.,
~ (c) Lending Institution
Eaqle River, AK 99577
Telephone:(home)
Anchoraqe, AK 99813
Telephone
Business .271 -4342
Mailing Address
(d) Real Estate Company and Agent Associated Brokers
Address 642 W, 36th Ave.. Suite #1. AnchoraGe. AK 99503-5807
Telephone 563-3333
(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 3
3. WATER SUPPLY
Individual Well:4~ Community ID 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 legality and status.
Page 1 of 2
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Well Classification
Well Log Present (Y/N) '/12
Total Depth "~'~ ' Cased to
Static Water Level N 7 /
Casing Height Above Ground
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description:
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line '"~/~'
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
If A, B, C, D.E.C. Approved (Y/N)
Pump Set At ~"~'~"~
Sanitary Seal on Casing (Y/N) Y
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest pUblic Sewer Cleanout/Manhole
..,2.~-/
; Date ?/~/~' ~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ?/~ Size
Standpipes (Y/N) ? Air-tight Caps (Y/N)
Depression over Tank (Y/N) "~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
No. of Compartments
)" Foundation Cleanout (Y/N)
Date Last Pumped 7/~'~
; for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
're Water-Supply Well /~ g
To Property Line '"/~' '
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
Y
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed '2/~'~
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N) "~
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well //,¢ ~
To Building Foundation /¢'~ '
Lot ¢3,, ·
TO Water Main/Service Line ~'/'~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ,~-~
Depth of Field S'
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
.; On Adjoining Lots ,' .7~ t
To Cutback (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guide.
inspection..
Signed
Company ~',,~
Date ,~A',
MOA No.
Eagle River Engineering Services
Eagle River, AK 99577
694,-5195
ect on the date of this
gineer's Seal
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt
Waiver Fee: $
Date of Payment
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
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 25 Sunny Valley Subdivision
Location (address or directions)
(b) Applicant Name Pan Nichols Telephone: Home 694-2290 Business 561-4928
Applicant Address PO Box 774092, Eagle River, Alaska 99577
(c) Applicant is (check one): Lending Institution []; Owner/builder [~Buyer []; Other [] (explain);
ist National BAnk of Anchorag~elephone
(d) Lending Institution
Address EA~le River, Alaska
(e) Real Estate Company and Agent
Address
694-2103
Telephone
(f)
Mail the HAA to the following address:
$ & S Engineering
TYPE OF RESIDENCE
Single-Family [~x Multi-Family [] Other
three(3)
Number of Bedrooms
WATER SUPPLY
Individual Well [~x 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 ~xx Public [] Community r'l Holding Tank n
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 PROVID INSPECTIONS, TESTS, FILE SEARCH, 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 full:her 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 Telephone
Address
Date
Engineer's Seal
This department has received written confirmation from the engineer
regarding the Conditional Approval of April 23, 1986.
The corrections have been accomplished and an inspection has been
completed by the engineer. The subject property meets with Municipal
standards and is now approved.
DHEP APPROVAL s~~_~,~e
Approved for three (3) bedroom
Approved yjr~ Disapproved Conditional
~e~ptember 3, 1986
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 Js not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
ROBERTA. SHAFER
September I, 1986
CIVIL ENGINEER
694-2979
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
ANDREPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
Municipality of Anchorage
Department of Health and Human Services
825 L Street
Anchorage, Alaska 99501
ATTENTION.. Steve Morr~
REFERENCE: Lot 25; Sunny Valley Subdivision
In March 1986 you issued a condition~ Health Authority Approv~ for
the residence located on the referenced property. The conditional approval
req~red the following work to be completed:
A. Place w~ll wires in condu~t.
B. Perform soil tests and obtain a permit to upgrade the septic
system.
C. In~tall new on-si~e septic system.
All the above work has been accomplished under permit #860318 and an
on-site i~pection report is attached.
RequeSt you issue a final HAA for this property.
ON SITE
WASTEWATER
DISPOSALSYSTEM
DESIGN SRB 196X EAGLE RIVER, ALASKA 99577
(~,/' 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
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
/
Location (address or directions)
(b) Applicant Name /~'~ /~C/~O/~F Telephone:Home ~ .~'~-qO Business
(c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain); __
(d) Lending Institution/.¢ 'r/¢//¢..( ZC.,~p~U-~ a~-/~///,~/~ Telephone
Address_ ~ ~ ¢¢~
(e) Real Estate Company and Agent ~ ~ ¢ ~ ~
Address
Telephone
(f) ~¢[ail the HAA to the following address:
SRB 196x
E~% ~iwr, alaska
TYPE OF RESIDENCE
Single-Family/~ Multi-Family []
Number of Bedrooms. ~
Other
WATER SUPPLY
Well~ Community [] Public []
Individual
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.
72-025 (I 1/84)
Page 1 of 2
5. ' EN, GINEERING FIRM PROVIDI~INSPECTIONS, TESTS, FILE SEARCH, DA'-~CA AND INFORMATION
As certified by my ;eal 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 suppry 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 Telephone
Address
Date
2.
DHEP APPROVAL
Approved for ~
bedrooms
Approved Disapproved Conditional
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-o25 f~/84~
MUNICIPALITY OF ANCHORAGE (MO~
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal ¢..~7/~°n:
ENVIRONMENTAL PROTECTION
APR 4
RECEIVED
WELL DATA
Well Classification ~?/'~'4¢~' ~--~
Well Log Present (YN~
Total Depth / ~' 0 / Cased to '/-/~ / ~
Static Water Level .4./~- i
Casing Height Above Ground
Electrical Wiring in Conduit (Y~Np
Separation Distances from Well:
To-Sef~ Tank on Lot
I~A, B, C, D.E.C. Approved (Y/N)
Date Completed ~/b~[z~ /'~r/~'~~- Yield
Depth of Grouting
Pump Set At
/~ //~' Sanitary Seal on Casing~/,kr~
Depression Around Wellhead~¢'~
J O~'.'.'~
To Nearest Edge of ¢¢~¢~¢~on,Lot 14:~z~ ~ ; On Adjoining Lots
To Nearest Public Sewer Line . To Nearest Public Sewer
Cleanout/Manhole
Water Sample Collected by S~ ~ ~-~',J,~ t,J. ~-P___~-J,'~ G ; Date '~/~
Water Sample Test Results
Comments 2~
B. SEPTIC/HOLDING TANK DATA
Date Installed Size No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File(Y/N) /, /,.. / ~/.~_r ~ ;for
Holding Tank High-Water Alarm (Y/N) A~ ~T~.~ary,/~ Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank: . ~ ~
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot __
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments //-~¢- ,~r¢.
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
//~ ~/°f~/~''Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
/]vldhole/Acc~ss (Y/N)
/ / /~r~Off'Levelat
/t,/ // / ' Vent(Y/N)
! Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to ell MOA and HAA guidelines in effect on the date of this inspection.
Signed $ & ~ I~gh~aeHl~l Date
Companyi~.,!,~ c,! .'. ' MOA No.
Receipt No. ~"2.'?~ ~, '-%
Date of Payment /'/-!
Amount: $ (~
Page 2 of 2
72 028 (11/84}
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAINEXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
ANDREPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MEgHANICAL
INSPECTIONS
ROBERT A. SHAFER
Aprll 19, 1986
MUNICIPALITY
DEPT. OF H~' ,l!,-; ~694-29Z9
ENVIRONMENfAL ~ ,',¥i ~( N
RECEIVED
Municipality of Anchorage
Department of Health and Human Services
825 L Street
Anchorage, Alaska 99501
ATTENTION:
REFERENCE:
Susan 0swalt
Lot 25; Sunny Valley Subdivision; Health Authority Approval
application dated March 26, 1986
The residence is located on a lot that is approximately three acres
in size. Soi~ in the immediate area of this property have been rated
as GM and a percolation rate of between 50 and 60 min/in. The water
table in this area is sporadic, however, water cannot be anticipated
to prec6ude a mound system.
It is our opinion that this lot has sufficient area to meet ~ll reserved
requirements and that soils will be found suitable for on-site wastewat~
disposal system. Soil tests will be performed and an on-site wastewater
disposal system designed to serve this property as soon as the frost
comes out of the ground, anticipated to be on or about May 15, 1986.
If we,m,,~a~be of further service, please contact us.
, /
Sinc~rel¢,
R~ERT A. SHAFER, P.E.
Ns/ss
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN SRB 196X EAGLE RIVER, ALASKA 99577