HomeMy WebLinkAboutTERI #2 TR D2 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPC)SAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAILING ADDRESS
Ma t e .~17/z?¢: ./
Absorption area
JNO. OF BEDROOMS
PERMIT NO,
No, of compartments
Inside length Liquid deptb
Dwelling PERMIT NO,
Manufacturer Material Liquid capacity in gallons
Foundation Nearest lot line PERMIT NO .
Total length of lines
Material beneath tile
Length Width Depth
Distance etweenlines
Total effective abso;o[Iption area
PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Depth Driller Distance to lot line PERMIT NO.
DISTANCE TO: Building foundation Sewer line ,.~ /.- Septic tank /0o__ ~- &Absorption
OTHER
PiPE MATERIALS
SOIL TEST RATING
APPROVED
DATE LEGAL.
72 013 (Rev, 3~78)
DI]~PARTMIENI" f HEALT'H AND EI'~VIF~ONMISIxH'AL DTEI]TION
825 L HFFREE.'71'., ANE:I-I[]F~ADE~ AK 9950 1
F'ERM I"1' NO." 850549
DAI'E l SSUIED ,", 06/,'..~4/85
AF:'F:'I,,. I CANT: I. EE I:~AYMOND
ADDRESS." F:'. 0,, BOX
AIqCI4ORA~3E, Al<
CDNTAC'[' F'HONE: 694-967 1
99577
BL(:]CK: NA
Lisi',,ed below are the options available 'LI::} y~]u in designing your' se'ri'., 4 ....... ~"'
system. Ch(~ose t. he ~;ption tha'L best fits yC~LU* si{e.
DEEP'f'H 'FEI PIPE BOI'T'OM
E)I:;:AVEI,. DEPTH (F'F.)
T'O]"AI- DEPTH (I.:'T.)
ORAVEL WIDTH (F'T.)
E')F~AVIB.,., LENGTH (F:'I'.)
GI:~AVEL VOLLJME (CU· YD,S. )
TAI~II'".'.' ,SIZE (GAL. S)
.SDIL. RA]"INC¢ (SI?.F]'. /BR)
(F:T · 4. ()
5. (}
45,, 0 ,.~
], ~ 000 ,, 0 ~
150
TANK MUST HAVE AT LEA,S'T' "I'NO CDHPAR'FMENT8
cert. i fy that:
1,, I am f'am,il:Lar with 'Lhe requiremen'Ls
3.
I F:' A
THEI'q
WI L.I..
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
For orq-.si~'.e sewers and wells as s~?'L
forth by 'Lhe Hur~icipality of Ancl'~.or'~ge (MOA) and the ~tat~ oF
I ~i],1 in~.a].l 'Lhe system ~n ac:c:'~¢danc~ ~th all MOA ~Qdes and
arid in cc~mp].iar'H::e wit. h t. he design cri'Ler~ of this l:?ermi'L.
I will adhere¢'Lo all MDA and State al Alaska r'equiremerrLs f(~r the set back
dJ.~T, arlEl2~ t'Pl:]lfl ¢ll'ly exist, ir'~g well, w¢istewa'[.el* dispt:3sal sys'i:,em of
sewerage syst, em cji] 'l:,h:ls or any ad,jaEerrL or nearby lrJt,,
I I.Inders'Lar~d 'Lha'L 'LhJ,~ p~rmi'L is valid fl:3r a maximum o¢ 5 bedr, eoms and
,br'ly erllal'gelilenf. NJ.i]. peql~til"6) an additi(ar'lal permi'L.
LIFT STAI'~DI',I IS INS]'Alui. ED IN AN AREA COVERED BY MOA BUII_DtN(3 CDDI;:u
(I) AN ELECTR];CAL. PERMIT AND ZNSF'ECTI[IN IdLlfilT BE ODTAZNED~ (2) AS-BUll_TS
NOT BE APF'F~OVED N~'I'HDUT AN ELECTI=~ICAL. INSF'ECTION REPORT~ AND (5) THIE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
'/ SOILS LOG
[] PERCOLATION
TEST
DATE PERFORMED:
5
6
7
8
~.,~rg
SLOPE
SITE PLAN
,/
10
42
13-
14-
15-
16-
17~
18-
19-
20
WAS GROUND WATER /~.~ ~
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
TEST RUN BETWEEN FT AND FT
DATE:
72-008 (6/79)
DRILLING COMPANY
DEPTH OF WELL
/
~'~' STATIC LEV EL OF WATER FT. I1~
DRAW DOWN FT.
Ended. ~J,.t ,cT?p GALS. PER HR
KIND OF CASING
From Ft. to...,- Ft,
From
.Ft.
l Ft.
Flom.~,.,~,~ _Ft, to,..__..~ I.'t..
· ;- ~F~6nl;~Ft. to.~Ft..
From.___ Ft. to__
.FL ~ From~
F~om~
From
Ft.
to Ft.
Ft.
· FI. to_____Ft
Ft. to Ft. ' '
From___Ft. to__ ,
From _Ft. h
From FI. to__Ft.
From ..... Ft. to____Ft.__~
From , _FI. to__
From___.Ft. to__ Fl ....
From__Ft. Io~FI.
From __FI, lo ....
DRILLFRkS NAME " ' '
8;~5 .I~ti~STREET, RNCHORR0i'-', RK.
264-4;'~'0 : "'
PULLEN PO BOX 96~. ' :'"
RROR STREET .
D TEK-'RI ~.SUDD #? LOT 5XZC 4~I0
~TWEEN A WELL AND R~
FOR~R PRIVATE ~LLJ OR
[FEET FROM R ~IC W~L ~I~ ~ON ~E ~ ~ ~IC
~QUIRED ~D ~ST I~ ~T~ TO T~ ~T~IT WITtlIN 30
~LET I
I~URE P~ER IN~TRLLRI'ION.
~E~PIRE~ ~E:OEHBER
IILIRR WITH THE ~QUIREHENT5
!I~T~L TI~ 5',~TEM Itl ~~E WITH TI~ ~ES. '
~CRNT PULLEN
MUNICIPALITY OF ANCHORAGE
�Y t„ 1 $
Development Services Departments :T Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 050-751-42-000
Expiration Date: 9/2/2023
Legal description TERI #2 TR D2
Site address 3933 HARCA ST Eagle River AK 99577
Current property owner(s) HERNANDEZ ANNA M
X The On-site system(s) is/are approved for 3 bedrooms
Conditional approval for bedrooms, with the following stipulations:
Comments or advisories:
By Original Certificate Date: 6/2/2023
This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject
system(s) is/are in substantial compliance with municipal code. The Municipality of
Anchorage, Development Services Department (DSD) issues COSAs based upon
representations provided by an independent professional engineer. The Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist X Well Flow Advisory
Absorption Field Advisory Nitrate Advisory
Tank Age Advisory Arsenic Advisory
Other
COSA Approval June 2022
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval Application
1. GENERAL INFORMATION
Parcel I.D. 05075142
Complete legal description TERI #2TR D2
Location (site address) 3933 HARCA ST
Current property owner(s) HERNANDEZ
2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS
Day phone 907-727-4200
3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units
❑ Private Well serving 3+ dwelling units ❑ Community Well or Public
❑ Water Storage
4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units
❑ Holding Tank ❑ Community Septic or Public Sewer
5. SEPTIC TANK: R Steel ❑ Plastic ❑ Concrete ❑ Fiberglass
Age 10 - See advisory if steel older than 20 years
6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit
Waiver request for:
Expedited review requested: ❑
Distance:
By applying for this entitlement, this property is subject to inspection by municipal On-site staff
to verify the accuracy of the information provided.
COSA Fee $ L rJ' Waiver Fee $
Date of Payment S Z b �2 Date of Payment
COSA # 'Ob G Waiver #
COSA Application—June 2022
COSA Checklist
Legal Description: TERI #2TR D2
Parcel ID: 05075142
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system
A. WELL DATA
❑■ Well log is filed with Onsite (or attached)
Date drilled 5/28/78 Total depth 173 ft
Cased to 1 1 0 ft
❑■ Sanitary seal is functioning correctly
Al Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 5/4/22
Static water level at beginning of test 114 ft
Comments
B. TANK DATA
Measured operating fluid level in septic tank 50
Date of pumping
❑ Required maintenance completed, if AWWTS
Comments: Steel, 10 yrs
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/13/85
❑■ ALL standpipes present per record drawing
Total measured depth from grade 11.5 ft (max)
Measured depth to pipe invert from grade 3.5 ft (min)
❑ N/A — pressurized field.
❑■ Per record drawings, field is insulated.
❑■ Monitor tubes go to bottom of effective.
If not, state depth into effective
❑ Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficienci
COSA Checklist June 2022
Well production at time of test 8+ gpm
Water storage tank volume0 gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
❑■ Coliform bacteria is Negative
Nitrate mg/L ❑■ Nitrate less than MRL (ND)
Arsenic 4.44 ug/L ❑ Arsenic less than MRL (ND)
Collected by NRimEng
Date 5/5/23
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 5/4/22
Results g Pass
Fluid depth prior to test 0
Water added 450 gal
New fluid depth 3 in
Elapsed time 30 min
Final fluid depth 0 in
in
Absorption rate 450 gpd
FIELD STATUS — POST RECOVERY
Effective depth (per record drawings) 96
Effective depth used 0 in
Effective depth remaining 96 in
in
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100'
■0 Yes if No ft ❑■ Yes if No
Neighboring Tank > 100' R■ Yes if No ft Private Sewer/Septic Line > 25' *Yes if No
Absorption Field on Lot > 100' ❑■ Yes if No ft Holding Tank > 100' ❑■ Yes if No
Neighboring Absorption Fields > 100' Animal Containment > 50' ■❑ Yes if No
ft
ft
ft
ft
■0 Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' W Yes if No ft M Yes if No ft
❑ N/A— Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
■❑
Yes
if No
ft
Surface Water > 100'■❑
Yes if No _
Tank to Property Line > 5'■❑
Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
■❑
Yes
if No
ft
Private Wells > 100'
❑■ Yes if No _
Water Main > 10'
❑■
Yes
if No
ft
Community Wells > 200'
Fm -]Yes if No_
Water Service Line > 10'
❑■
Yes
if No
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
li
ft
ft
G. CERTIFICATION & STATENJENT 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm NorthRim Engineering
Engineer's Printcd Name Steve Eng
COSA Checklist June 2022
Phone 694-7028
Date 3/3/23
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Development Services Department V
Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D. 05075142
Certificate of On -Site Systems Approval
Expiration Date: 3 a0 ), a
1. GENERAL INFORMATION
Complete legal description TERI #2TR D2
Location (site address) 3933 HARCA ST
Current property owner(s) PLEWKA CARSTEN
Mailing address
Real estate agent
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone 317-6302
Day phone
3. NUMBER OF BEDROOMS:
3
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
ED
Private Septic
ED
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550 1 Waiver Fee $
Date of Payment Date of Payment
Receipt Number 0087(0 J 6 Receipt Number
COSA # (D S C 2,?, 1�2 16 Waiver #
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, based
- - -------------
on- pnocedu(6sibutlihedift-thi --GerlifidatcFof __0n-_SRe_ Sysle- -Approval- uidelines fio this -app ication, 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm NorthRim Eng.
Address PO Box 770724, Eagle River
Engineer's Printed Name -Steve Eng
zlffffl•' i
Date 4/30/22
lj . . . . . . .
6. DSD SIGNATURE
CE=,.
System #1 Approved for bedrooms
System #2 -Approved _for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
V V M 1 GR M 1 14 Lj
By: Original Certificate Date: 5 a3/2002
1 /
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given 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. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Cbeallst blue sheet
COSA Checklist
Legal Description: TERI #2TR D2 Parcel ID: 05075142
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
❑■ Well log is filed with Onsite (or attached)
Date drilled 5/28/78
Total depth 173 ft
Cased to 173 ft
❑■ Sanitary seal is functioning correctly
❑■ Wires are properly protected
Casing height (above ground) 12+ in.
Date of flow test for COSA 5/4/22
Static water level at beginning of test 114 ft.
Comments
B. TANK DATA
Age of tank(s) 9 years
Tank type/material Sptcstl
Measured operating fluid level in septic tank 50
❑■ Standpipes/foundation cleanout per record drawing
Date of pumping 6/11/21
D. ABSORPTION FIELD DATA 6/13/85
Which system tested (date installed) same
❑■ ALL standpipes present per record drawing
Total measured depth from grade 11.5 ft (max)
Measured depth to pipe invert from grade 3.5 ft (min)
❑ N/A — pressurized field
❑■ Monitor tubes go to bottom of effective. If not, state
depth into effective
Well production at time of test 8+ gpm
Water storage tank volume0 gallons
Well disinfected for coliform test? ❑ Yes ❑■ No
❑ Coliform bacteria is Negative
Nitrate mg/L ❑■ Nitrate less than MRL (ND)
Arsenic 4.59 ug/L ❑ Arsenic less than MRL (ND)
Collected by NRim Eng.
Date of Sample 5/4/22
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 5/4/22
Results ❑✓ Pass For 3
Fluid depth prior to test 0
Water added 450 gal
New depth 3 in
Elapsed time 30 min
bedrooms
in
❑E Code -required soil cover over field Final fluid depth 0 in
❑ System presoaked Absorption rate 450 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) n0
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
Yes
Community Sewer Manhole/Cleanout > 100'
0 Yes
if No
ft
0
Yes
if No
Neighboring Tank > 100' Yes
if No
ft
Private Sewer/Septic Line > 25' El
Yes
if No
Absorption Field on Lot > 100' Yes
if No
ft
Holding Tank > 100' 0
Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' ❑✓
Yes
if No
0 Yes
if No
ft
if No
ft
If septic tank is under driveway
ft
ft
ft
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' El Yes if No ft 0 Yes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
Yes
if No
ft
Surface Water > 100'
Yes if No.
Property Line > 5'
Q
Yes
if No
ft
Wells on Adjacent Lots:
Q
Absorption Field > 5'
Q
Yes
if No
ft
Private Wells > 100'
❑✓ Yes if No.
Water Main > 10'
ft
Yes
if No
ft
Community Wells > 200'
❑✓ Yes if No.
Water Service Line > 10'
Q
Yes
if No
ft
If septic tank is under driveway
comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Q
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Q
Yes
if No
ft
Private Wells > 100' 0 Yes if No
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' 0 Yes if No
Surface Water > 100'
Yes
if No
ft
F. ENGINEER'S COMMENTS
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.
COSA Checklist yellow sheet
OF
..:4..TH.. ..: *,
Steve
CE -6256
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PLOT PLAN AS BUILT X SCALE 1" = 40' GRID SE 704 Project No. 13-226
Lang & Associates, inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Registered Land Surveyors (907) 522-6476 Phone
Re oQ000000
g y (907) 522-4625 Fax
kenOlangsurvey.com / jonothanOlongsurvey.com OF q
QOP�, .. • • • , •
I hereby certify that I have surveyed the following described property:
TRACT D-2, TERI SUED. ADD. 2 (Plat No. 80-172) 0 * q.gTH 's440•• •• v*
Anchorage Recording District, Alaska, and that the improvements situated thereon are �....:........r9 ......:...
within the property lines and do not encroach onto the property adjacent thereto, that Q /T J
no improvements on the property lying adjacent thereto encroach on the surveyed 0 , • r; • • ... •'
premises and that there are no roadways, transmission lines or other visible Q KENNETH G. LA •�
easements on said property except as Indicated hereon. Q ,
Dated this the 8 Da of Num �� 00••'• S-520
Y UM-P�r f at Anchorage, Alaska S •� , •''••50 0
It is the responsibility of the owner to determine the existence of any easements, �O�R�FfSsioNA�oo"
covenants, or restrictions which do not appear on the recorded subdivision plat. �40000�
"3
V60%
NOTE: DRIVEWAY ENCROACHES ONTO TRACT D-1 /
/
16.1'
IOU /
NOTE: DRIVEWAY ENCROACHES ONTO TRACT D-1 /
/
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.
1. GENERALINFORMATION
Complete legal description Tract D2; Ter± Sub~±vls±on
Location (site address or directions) Harca Street
Property owner Charles V. Talsky Day phone
Mailing address H 4 '~~ka 99577
Lending agency Day phone.
Mailing address_
Agent Day phone
Address
694-2977
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
lJnless otherwise requested, HAA will be held for pickup.
3
NOTE:
Individual well xxx
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWAT["!R DISPOSAL,:
NOTE:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and stafus 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
Address
Engineer's signature
Phone
__ Date
DHHS SIGNATURE
F., Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) 8ack MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAl. CHECKLIST
Legal Description: / ~/~ ~]::~'~ "~¢-t Parcel I.D,
A, WELL DATA
Well type ~:::~"~\[ h-''C~-'~ If A, 13, or C, attach ADEC letter.
Log present ~'4) ~,] [)ate completed
Total depth /'~'~' 'Z-'* Cased to /Jrt' ~
Sanitary seal~'/N) y
Date of test
Static water level
Well flow
Pump level
FROM WELl. LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line .~,~ t
ADEC water system number
~'-'~-~, ¢ '7 fJ Driller
Casing height
Wires properly protected (~N)
AT INSPECTION
g.p.m. ~_________________,~, ..~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE[ RESULTS:
Coliform (-~ ~ ""J~ ~,,C Nitrate
Date of sample:
B, SFPTIC/HOLDING TANK DATA
Date installed
Cleanouts ~ON) ~-/
High water alarm (Y/~))
Date of pumping
Collected by:
_ Other bacteria
$ & $ ENGINEERING
17034 Eagle River Loop Road No, 204
Eagle River, Alaska 99577
Tank size ~,~¢,~, ~..t._ __ Compartments
Foundation cleanout ~'~N) ',// Depression (Y~:~
~'~ . Alarm tested (Y/N) ~-~'
/_~ ~. l.~ Pumper ~g--- ,
SFPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~ z:>o ~ ~ On adjacent lots
To property line ~ [ ''¢ _Absorption field
Surface water/drainage ~ z) ~
Foundation
Water main/service line
72-026 (Rev. 7/91} Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at ~vel at
High water alarm level
Meets MOA elec~"~~Oyc e~ tested
SEPARATI~..~.~STANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed
Length ~ ~'' ~ ¢¢ '
Width
Total absorption area
Depression over field (Y~P~
Results ~/fail) /?,&~ %
Peroxide treatment (past 12 months) (Y~
Soil rating t,'~,~::>~ ¢/~¢~'' System type
Gravel thickness ¢' ~ Total depth
Cleanouts present. TN)
Date of adequacy test ~, .-
for ("~) "/-/'t/~ ~ bedrooms
t/_.~ o ~(~,J If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot
To building foundation
On adjacent lots
Surface water \ O O
Curtain drain
E. ENGINEER~SCERTIFICATION !!i~~, ,
I certif? that I have checked, verified, or conformed to all MOA and HAA guidelines in effoct on the date of this in~ection.
Signature
$ & $ ENGINEERING
17034 Eagle River Loop Rca8 No. 204
Eagle River, Alaska 99577
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91} Back MO,~
Waiver Fee: $
Date of Payment
Receipt Number
,/~.~× CHEMICAL& 6I;~OLOGICAL f~ABO~TORI
: JUH 25 92 t 1~:00
with : A? BB~UIB~D
Reqt ~
~ond i~po~t~ to:
Sample BOU~IME 8AMPLE COLLgCYED BI: i~AI,
I ~e,t, P,rforr~ Soo Bp~olal In{truction~ Abovp U}-Un~vallabl~
ND' Non~ DItPct~ "9me 8ample N~rk, hbow
IVIUNICIPAI. ITY OF ANCHORAGE
DEPARTMENT O1" HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITI-- SEWER AND WATER FACILITY
264-4720
Application Date
GFNERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
TraCt D-2 Teri':; Addn. #2 T14N R1E Sec.33
Location (address or directions)
Off mile ll Eagle River Road
(b) Applicant NameChuck Talsky Telephone: Home 69li-2977 Business694-2977
Applicant Address SR :LB Box 24:L7 Eagle River, AK 995?7
(c) Applicant is (check one): [_ending Institution [-I; Owner/builder:~l:; Buyer Fl; Other [] (explain);
(d) Lending Institution Home Savings8 & Leal1
Address :L001 E. Benson Anchorages,
(e) Real Estate Company and Agent
Telephone
AK 99503
272-1451
Address
Telephone
(f) Mail the HAA to the following address:
_
TYPE OF RESIDENCE
Single-Family~;~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well [] Community [] Public [-]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite l[~: Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conserw~tion
attesting to the legality and status.
Page 1 of 2
ENGINEERING FIRM PROVIDING ..~SPECTIONS, TESTS, FILE SEARCH, DA1
As certified by my seal affixed hereto and ss o! the validation date shown below, I verify that my investigation of this ~lealth
Authority Approval shows that the on-site wster supply and/or wastewater disposal system is safe, functional end 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, tire omsite 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 ol Firm EABLE R!VE[LF. EBJ~LE~.~IN(~ S_;RVICEF _____ Telephone
EAGLE RIVER, AK 99577
Address
Date .//,//~/':~Y'- 694 -.~L95
Engineer's Seal
Approved ,or~~¢'~ ~¢ (~-~e~d roo ~~';;~/~/_/~/.
.....
Approved ~ Disapprove~
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (I:)HEP) issues Health Authority
Approval ce~'tificates 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 o! DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible lor errors or omissions in the
professional engineer's work.
Page 2 of 2
72 025 (i 1/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
/~UNICIPAUTY OF ANCHORAGE
D~P% OF HEALTH &
I~NVIIIgNMENTAL PROTECTION
NOV 06
Well ClassJficetion /~'"8 / ~'.4 /-,,~ If A, B. C. D.E,C. Approved (Y/N)
Well Log Present [Y/N] /v Date Gert pleted .5--/~ y Yield
Total Depth / :~ '~' ' Cased
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separaeon Distances from Well:
To Septic/Holding Tank on Lo1 __
Depth of Grouting
Pump Set Al
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead [Y/N1
Y
: On Adjoining Lots
To Nearest Eege el AbsoretJon Field on _et / ? ~-/ /"'/'i 6n Aajo~mng Lots /
To Nearest Public Sewer Line .¢.,'¢o.'~4 To Nearest Public Sewer
Cleanout/Manhole /'z~¢,~.~. To Nearest Sewer Service Line on LOt
Water Sarr Die Collected by _ '~:'~'~ ~ .-~¢~,,r.-.t /~?,w$/.~¢~.~.~ )ate _
Water Sam ~le Test Results .~'~ 7'/.x ,~, ¢ /7~U~
Comments
3 SEPTI C/HOLDING TANK DATA
Date nstal ed ~//'¢ S-
Standpipes (Y/N) _ ff
Depression over Tank (Y/N)
Pumping¢ Maintenance Contract on File [Y/N)
Holding Tank High-Water Alarm (Y/N)
Separabon Distances from Septic/Holding Tank:
To Water-Supply We /~.3 '
To Property Line ,~-o '
To Water Main/Service Line /o
Course
Size /¢¢,o ~'~',~ / No, of Compartments
Air"tight Caps (Y/N} _ .J/ :oundation Cleanout (Y/N)
Date Last Pumped
: for .4.//.-4-
Temporary Holding Tank Permit (Y/N)
re Building Foundation / / '
To Disposal Field
To Streaff Pond, Lake or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
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
¢¢
Type of System Design
Length of Field ~'~- ?
Depth of Field ~' /
Gravel Bed Thickness ¢~' /
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line ~'~/~9"
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line ,~'4:~
To Existing or Abandoned System on
; On Adjoining Lots z'Z2~,~. ~
To Cutbank (if present)
Comments
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ? ~-----~ Date '/" d),~/;Y %
Company /~-~,~ "~, ~ MOA No. ~'
Date of Payment I I- ~, - ~,~
Amount: $ (,~¢~ Engineer's Seal
Page 2 of 2
72 026 (11/84)
Eagle River Englneodng Services
~ 0, Box 773294
Eagle Rlvec AK 99577
694-5195