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HomeMy WebLinkAboutCONTOUR ACRES #2 LT 4Contou A Lot 4 #017-451-24 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report N.~.:~ ~ ~ ~1 ~ Wastewat~System: ~ New ~ Upgrade Phone: ~_ /~ ~No. of Bedrooms: ~ D Deep Trench ~ Shallow Trench ~ Bed ~ ~ ~ Other LOt: ~ Block: 0 ~ ~[ Subdivision: ~E~ ~'~ Dept~ ,o pipe bottom from original grad,:~ ~vel depth beneath pipe Ft. i Ft. Ft, WELL: ~/~DNew ~ade Oraveldepth: ~ Number of lines: I Distance .tw.. ,in.: Driller: ~ Date Drilled: Static Water Level:Ft. ~er: Date installed: Yle~ GPM I Pump~., at: F,, J Casing Height Above Grou;;: TANK SEPARATION DISTANCES ~.~c ~ .o~ ~ s.~.~... TO Septic Absorption Lift Holding =ublic/Private Manufacturer: ~ Capacity iff gallons: Well /~ ~ ~ ~ ~ Material: ~~/ Number of Compa~ments~ Cu~ain Electrical Location and Description: Inspections pe~ormed by~ Dates: 1st 72-013 (1/91) MOA 25 ..?~' Permit No. Page Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION of P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report PID No.: ENGINEER'S SEAL 72-013 A (2/91) MOA 25 Permit No. Page Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SEFIVlCES DIVISION of P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description: ~/~////'&~f~f //-~4:/'C 5 ~ 7/ ~/ ~ ~'~' PID No.: 72-013 A (2/91) MOA 25 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW910231 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:NELSON GEORGE N OWNER ADDRESS:5501 PENNY CIR ANCHORAGE, AK 99516 DATE ISSUED: 8/06/91 EXPIRATION DATE: 8/06/92 PARCEL ID:01745124 LEGAL DESCRIPTION: CONTOUR ACRES #2 LT 4 LOT SIZE: 94066 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ,,~ _ RECEIVED BY: ~~ DATE' DATE: Permit No. Page Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report PID No.: 72-013 A (2/91) MOA 25 SYSTEM DESIGN GUIDELINES AND NARRATIVE Lot 4, Contour Acres Subdivision, 2nd Addition TANK REPLACEMENT The purpose of this application is to replace a leaking septic tank. Ail materials, construction methods and required inspections to follow MOA rules and regulations. The contractor is responsible for notifying the Engineer and the MOA at least four hours in advance of all inspection needs. Contractor will insure no additions or changes have been made to the location of wells and septic systems on the adjacent lots prior to the time of construction of this system. If any changes to those systems have occurred, the engineer should be immediately contacted for review and possible changes will be made as necessary. The lot is generally flat with a slight 1 - 3% slope to the slope. The installation of the system will have little or no effect on the surface drainage, ground water, or the adjacent systems in the area and will remove the leaking tanks. If a garbage disposal is used the tank should be pumped on an annual basis. The tank shall meet all Municpal and applicable standards for a two compartment steel tank. page 2/2 MUNICIPALITY OF ANCHORAGE Heal and Environmental Protect Fourth Floor West 825 L Street Anchorage, Alaska 99501 279-2511, x 224, 225 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: DISTANCE _ NUMBER OF INSIDE LENGTH INSIDE WIDI'tt ..... L. IQUII} DEPTH _~_ t IOUID CAPACIT ....... GALLONS. = .................................. / ~ TOTAL LENGTH D,ST^NC~ ,':ROM W,:,~ .._/O__¥__EO~,,DAT,O~_¢'~_~ .......... ~^~..*~ ,. O, ~.,N~_ /0 ' ..%_ O~ '.,~E .... ~..~..__/ ..... ~ O~ Lines --' l' --- DISTANCE BE'TWE. EN LINES .._../~._/.~_ ........ fRENCt4 WIL)TtI._~.~IN. TOFAL EFFECTIVE A~SO,,T,ON AREA ..... ~.~ ........... S~. ~. ~ E~T. O~' ~^~,, ~,~ ....... ¢_~--- .................................. / DEPT~t OF FILTE~ SEEPAGE PIT: DIAMETER _____OR WIDTH .... LENGTH. :, DEPTH Log Crib Rings BUILDING FOUNDATION Crib Size: DIAMETER .... L)EPTII ...... DISTANCE FROM: WELL -!OTAL EFFECTIVE NEAREST LOT LINE ..... ABSORPTION AREA (WALL AREA) SQ. Well Class: Depth: Well Distance To: Lot Line Bldg: Sewer Line: Pipe Materials: __~.j~. # of Bedrooms: ~~~ Installer: L{ Remarks: I I';;tl;:'i,:;' i 'i I]I ':1::-1 t i I'll'.j ':iF;Ii '1 H[~:: I. Fi:NI]~ I'H t) :1] MF.'N'E; :[ ["iN .... ..-, t HI"~ ..1:. E:E'T~i,IE]F:I'.J THE: ..-.,L. t~.F H...E C)F:' 't'HE:: t"HI-!:' t::,!i!!:F:"T'H t':1: F! 'rl:~.'.E-I'.~f::H ['11~, F']'T ]~:., THF-.': I:)'1:'" ...... i ...... '"' I"" ...... 1 ........ i]iRi.]Ii..tNi]~ FIN[) ']I"H~] [~111'1"[11',I l'll...ll¥t.,?F: [% Mi'] 'RE]'t L,4'[I':,"t'H F"[]IE' "I"F;.'F'I'.4f][-IF.:..'~:i;. 'i'Hl.::: ['~i~,:'FtViF:! .... I":,t~:F'-t'H :['.F; I'H[~ MTN]'H!.tM DEPI"H F:tt'.,I[) 'lHii:: [::,' i']'t" ][ I]t',I [:]IF" THE] F.~:.:',[:FIVI=I'T' ]] [IN ( :[ N F-E':E':.T ). t"1 ]: N J: i'"IL.ii'"t D :t :!i:;'t'FIN[:[.::: E:,'ETH[.:.:t'i.;.N A HE:t...t.. FIN[) ANY L-.iN-:~ ::l.I;.!ll.:] F'I.:'F'I" F:'I'I[~! Ft F:'I:~?TVFIT'FE b.IF].l.. 1".'11(' ~:'[~ F'I~:[~]T' F'I]t('. FI PI.IBI.. :[ I:: HE.'I..I ..... I]1 ]'Hl-.i:R I:;:, F: I .:! i t '[ [;?[.:]1"t1.~]%1 't]:!'; I"IFi'-P FIF:'PL..'¢. C;PI.:Er;: :[ F']: I].':1=11" ]] I:IVF:I ] I F:!l-~lt..li:i: 't"1]:1 [ N':.;i IR[;:' Pf;."I]P[E[~:' '[ N'E-¥1' FII .I i-:IT' :[ GREATER ANCHORAGe ArEa BOrOUgh DEPARTMENT OF' ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-4561 PERMIT NO. SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT INSTALLATION LOCATION FINANCED THROUGH TO BE INSTALLED BY NOTEz THIS PERMIT lB NOT VALID WITHOUT BOIL TEBT COMPLETION DATE ANTICIPATED FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DIBTANCEB, REQUIREMENTB FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE PIT ~0 f /0 · , DRAIN FIELD SEPTIC TANK TO SEEPAGE Pit WALL---- % SEPTIC TANK ,_~ , SEEPAGE PIT . DRAIN FIELD TO NEAREST LOT LINE. WELL TO SEPT,C TANK SEE.AGE P,T cro / I DRAIN FIELD . , ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TAl~K ~6( , SEEPAGE Pit /' DRAIN FIELD TO RIVER, LAKE, STREAM, CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIE. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit FITTED WITH AIRTIGHT REMOVABLE CAPS, GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. DIAGRAM OF BYBTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. ~ FORM NO, E:G-O! 6 ,® GREI' 'R ANCHORAGE AREA BORr SH Depsrtment of EnvironmentsI Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME ~"~91~ ~/'f-~:¢~/.~--~ MAILING ADDRESS LOCAT,ON LEGAL DESCR,PT,ON PHONE SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER INSIDE WIDTH MATE RIAL NUMBER OF COM PA RTM ENTS LIQUID DEPTH LIQUID CAPAC / GALLONS. TILE DRAIN ~~/"/ DISTANCE FROM WELL NUMBER OF LINES. A~3SO RPTION AREA /~.~ / ~ /-4-- FOUNDATION NEAREST LOT LINE TOTAL LENGTH / OF LINES ~'~ DISTANCE BETWEEN LINES /t~ TRENCH WIDTH '~ IN. r~/ ~ SQ. FT. LENGTH OF EACH LINE ,/C~ ~-~' ! TOTAL EFFECTIVE "~'-~ ¢.,¢= 7'~i~,'"~..,4/., /6 / ~/.. /DEPTH OF FILTER DEPTH: TOP OF TILE TO FINISH GRADE /¢ MATERIAL BENEATH TILE~ ~ //W'l~X. ABOVE TILE IN. WELL: TYPE -z'',~'~''/.2/'~;~'~¢--'' CONSTRUCTION b l! ,~'t~.-~g:) DEPTH ,.~ ~0 j DISTANCE FROM: BUILDINGFouNDATiON /O ~ NEAREST ,~..t2/~.. NEAREST SEPTIC / SEEPAGE ,/gk-t2 / __, LOT LINE__, SEWER LINE__, TANK /~ SYSTEM CESSPOOL APPROVED OTHER SOURCES DISAPPROVED REMARKS DISTANCES: INSTALLED BY: ,~r/'~" z-¢ SEWER LINE DEPTH: PIPE MATERIAL: (~,~ ,~7"' ~"~ ~/ LOT SLOPE: ' REMARKS: (.,)'4/Z:~ -~',~/,5'~---r~77~ ~ DIAGRAM OF SY.S~M G.A.A.B. Form LQ-032 GREl r ANCHORAGE AREA bof ~gh ~ .4~E~.~ I T NO.. DEPARTMENT OF ENVIRONMENTAL QUALITY -- 3-330 "C" STREET ANCHORAGE, ALASKA 99503 //~J~~TELEPHON E Z74-456 ! SEWAGE DISPOSAL SYSTEM m APPLICATION AND PER MAILING ADDRESS PHONE LEGAL DESCRIPTION ~" ~ [*'-'// INSTALLATION OF: SEPTIC TANK f/~'-' SEEPAGE PIT - DRAINT~~ OTHER TYPE AND SITE OF FACILITY TO BE SERVED3~~'~ 9/I~ ~ t lq --' ' ' ~~ NOT~ THIS PEEMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED FINAL INSPECTION: DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO BEPTIC TANK ;rr .-X DRAIN FOUNDATION TO SEEPAGE PIT . DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS. SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK , SEEPAGE PIT TO NEAREST LOT LINE. WELLTOSEPT,CTANK /0or DRAIN FIELD /'"2 D WATER MAIN TO SEPTIC TANK SEEPAGE PIT DRAIN FIELD SEPT,C TANK, ' r · - , SEEPAGE PIT , DRAIN FIELD TO RIVER, LAKE. STREAM. CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK A.ND SEEPAGE. PIT GRAVEL BACKFILL < / ~ CONFORM TO BOROUGH RE ULATIONS REGARDING INSTALLATION. LICENSED DESIGNER TYPE I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.~--~ PORM ~ EQ-016 4040 "B" STREET, ANCHORAGE, ALASKA 99503 PHONE: 907-279-2581 August 20, 1975 WO ~17426 Mr. Dave Burlingham Timber Enterprises P.O. Box 3351 Anchorage, AK 99501 Subject: Subsurface Investigation for feasibility On-Site Sewer, Lot 4, Contour Acres #2 Dear Mr0 Burlingham: This letter is an addendum to our letter to you dated July 21, 1975 about the same, above referenced project. As noted in our previous report, the first 11 feet of soil. on the site is quite tight and impermeable being a sandy silt, ML. The material from 11-16 feet is a gravelly silty sand, SM. On August 19, 1975 we inspected the test pit, which you had dug to a depth of 2].. feet adjacent to our previously placed test holeo Our observations of that test pit indicate that this gravelly silty sand extends at least to the 21 foot depth for a total layer thickness of at least 10 feet. No water table was detected in the 21 foot deep test pit. In this 10 feet of gravelly silty sand, the silt content varies considerably from a minimum of about 10% to as high of 30-40% with a layer, at least 3 feet thick, that the silt content is less than 20%. It is our opinion that you can use an assumed absorption area pe~ bedroom of 220 square feet, and that this value %~ou!d be larger than that required if percolation data was actually collected on the site. We hope that this information can be helpful to you. If we can offer any further explanation or help in this matter please do not hesitate to contact us. Very sincerly yours, ALASKA TESTLAB Melvin R. Nichols, C.E. Laboratory Supervisor MRN:rb 4040 "B" STREET, ANCHORAGE, ALASKA 99503 PHONE: 907-279-2581 FOSS DHILLING 1336 Ingra Street ~chorage, ~aska 99501 SIZE OF CA~ING ~ ",,DEPTH OF HOLE~O~To CASED TO o~. D o~ STATIC WATEH LEVEL--PT. YIE~~G~.PER.MIN. WITH ~ o~ o~ow~. FT, PUMP TO BE SET AT o~, ~ .,/~'~.,a77~j · . to _,.,._to Gte/' --_r ANCHORAGE Area BO[ UGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 PERMIT NO, INSTALLATION Of: SEPTIC TANK SEEPAGE PIT DRAIN FIELD OTHER TYPE AND SIZE OF FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS TO BE INSTALLED _~.,. NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST COMPLETION DATE ANTICIPATED ~{, rt~ {,,' ~"'f[~'7('- ~'~'/~',~'{.'.'~ /~ FINAL INSPECTION: 24 HOUR NOTICE REQUIRED· BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. SEPTIC TANK SIZE TYPE SEEPAGE AREA SIZE TYPE MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK FOUNDATION TO SEEPAGE Pit SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK ,SEEPAGE PIt TO NEAREST LOT LINE. WELL TO SEPTIC TANK DRAin FIELD WATER MAIN TO SEPTIC TANK DRAIN FIELD SEPTIC TANK, ., SEEPAGE Pit TO RIVEr, LAKE, STREAM. DRAIN FIELD · DRAIN FIELD SEEPAGE PIT ALSO CONSIDER AREA WELLS. SEEPAGE PIT DRAIN FIELD CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP Of EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETer CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit FITTED WITH AIRTIGHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. LICENSED DESIGNER DIAGRAM OF SYSTEM I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITh said CODE. FORM N EG~-0 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. muni.org/onsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 017-451-24 GENERAL INFORMATION Complete legal description Location (site address) Contour Acres'::~ ~ ~'- UI 5501 Penny Circle Anchorage, AK 99516 COSA# Expiration Date: Current Property owner(s) Lance Lockard Day phone Mailing address 31208 Alvaradao Boulevard, Suite 381 Union City, CA 94587 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, COSA NUMBER OF BEDROOMS: ¢vill be held by DSD for pickup. Four (4) TYPE OF WATER SUPPLY: Individual Well 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 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 vedfy 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 Anderson Engineering Phone 522-7773 Address P.O. Box 240773 Anchorage, AK 99524 Engineer's Printed Name Michael E. Anderson, P.E. DSD SIGNATURE Y Approved for Disapproved. bedrooms. Date 7/22/2011 Conditional approval for bedrooms, with the following stipulations: By: Attachments: COSA Checklist X Septic System Advisory Well Flow Advisory Nitrate Advisory Arsenic Advisory Maintenance Agreements Supplemental Engineer's Report Other ,'~0~~Original Certificate Date: (Rev. 11/05) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Elmore Road P.O. Box 196650 Anchorage, AK 99507 www. muni~orglonsite (907) 343-7904 CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST Legal Description: A. WELL DATA Well type Private Date completed 8/18/75 Total depth 300 f. Contour Acres No. 2, Lot 4 Date of test Static water level 136 Well production 3 WATER SAMPLE RESULTS: Coliform 0 colonies/100 mL Arsenic: N/D ug/I B. SEPTIC/HOLDING TANK DATA Tank Type/Material Sepl~c/Steel Tank size 1,250 gal. Foundation cleanout (Y/N) Y Date of pumping N/A C. ABSORPTION FIELD DATA Parcel ID:. 017-451-24 If A, B, or C provide PWSlD # Sanitary seal (Y/N) Y Cased to -- FROM WELL LOG 8/18/75 203 ff. g.p.m. Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 5/25/11 127.3 ff. 1.1 g.p.m. >18 Nitrate N/D mglL Date of sample: 7/13111 Collected by: M. Anderson 2/19/97 Y N Date installed Number of ComPartments Two Cleanouts (Y/N) Depression over tank (Y/N) N · High water alarm (Y/N) Pumper No Sludge Noted in Tank. Date installed 8/22/75&8/25/77 Soil rating (g.p.d./~ or ~lbdrm) 220 SF/BDRM System type Deep Trench Length 91 ft. Width 3 ft. Total depth 16.5 ff. Eft. absorption area 1,092 ~ Monitoring tube Date of adequacy test 7/13/2011 Results (Pass/Fail) Pass Fluid depth in absorption field before test 35 in. Elapsed Time: 1,440: min. Final fluid depth 24 Any rejuvenation treatment (past 12 mo.) (YiN & type) Gravel below pipe 6-11 Y Depression over field For 4 bedrooms Water added 725 gal. Newdepth 35 in. Absorption rate >= 600 N If yes, give date Y in. in. g.p.d. UFT STATION Date installed uPump on' level at Datum in. E. SEPARATION DI81'ANCE$ Size in gallons 'Pump off' level at Cycles tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot >100. Absorption field on lot >100. Public sewer main N/A Sewer/septic service line >25' Animal containment areas >,50' in. Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? in. On adjacent lots >100' On adjacent lots >1o0. Public sewer manhole/cleanout Holding tank NIA Manure/animal excrete storage areas N/A >100. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation >5' Property line >5' Water main NIA Water service line >1o' Wells on adjacent lots >1o0. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line >1o' Building foundation >10. Water Service line >1o' Curtain drain None Noted >100' COI~IENTS: Absorption field >5' Surface water >100. Surface water >100. Walls on adjacent lots Water main >10' Driveway, parking/vehicle storage >25' 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 Name Mk:ha~ E. Anderson, P.E. Date. 7/22/2011 COSA Fee $ Date of Payment Receipt Number (Rev. 11/05) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage?) Development Services Department Building Safety Division On-Site Water and Wastewater Program ~ P.O. Box 196650 Anchorage, AK g9519-6650 www.ci.anchorag e.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 0 t '7 - /4¢/ - ~ '{ Expiration Date: 1. GENERAL INFORMATION Complete legal description /--6, b ~ Location (site address or directions) 5-5'0 Current Property owner(s) Mailing address Lending agency Mailing address 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System r~,cAc~' {' ~"~,,~'"~ /-~tr~-;i Dayphone ~AE ~ a~ Day phone ~z- Real Estate Agent ~e~ ~too~ Pro~r~l P~Day phone ~9 -7~P Mailing Address qR q/ ~" ~ v v Unless othe~ise requested, H~ will be held by DSD for pickup. NUMBER OF BEDROOMS: ~ ~ ~ ~/~ ~PE OF WASTEWATER DISPOSAL: ~ Individual On-site ~ Individual Holding tank Well ~ Community On-site ~ Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of ~aska. Certificates of Health Authcfity Approval are required for the transfer of title (except between spouses) for properties served by a single family on-site wasteweter 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 less than 30 days old. (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 Municipafity of Anchorage is not responsible for errors or omissions in the professicnal 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, r~'lct Address i~t._c, $0 Engineer's Pdnted Name DSD SIGNATURE Approved for Disapproved. Conditional approval for Phone '~' Date tV'/ bedrooms, ' ,-~ .... bedrooms, with the following stipulations: Additional Comments .._ ,,.<~'~.. _ .. ~_-~ ,~: ON-SITE ~ , WA[ER AND ,rn' - · WASTI~WATFP · ROGRA " ..... · Attachments: HAA Checklist X Septic System Advisory Well Flow Advisory %" Maintenance Agreements Supplemental EnGineer's Report Other Original Certificate Date: Mnnicipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196660 Anchorage, AK 99519-6650 www.cLancho~.ak.us (e0~) 343.7OO4 HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: ~.oP'f: ~'o~""~* A'¢~"~ -:,',','~.~ Paronl ID: 0/'7 A. WELL DATA Well type IPv ~' If A, B, or C provide PWSID # Datecompleted ~/18/ ?~" Sanlt~ryseal (YIN) 1" Total depth ;~¢PO fl. Cased to '~O,3 IL FROM WELL LOG Date of test ~. / t ~ / 75- Static water level I 3' ~' ft. Well production ~ g.p.m. WATER SAMPLE RESULTS: Coliform O colonies/100 mi. Nitrate ~, t~ mg./I. Other bacteria _ Date of sampte: ~' /~/~'2, Collected by: 7~. ~='. B. SEPTIC/HOLDING TANK DATA TankType/Material ~ep/~'c / ,~ Tank size 1 3 ~'o gal. Number of Compartments '~ Foundation cieanout (YIN) Y' Depression over tank (YIN) Date of pumping ~/ITi~0~ Pumper ,A'f' J~f,," C. Ata$ORPT1ON FIELD DATA Up,q,' Date installed ~/~.z/1,5' Soil rating (g.p.d./t~ or ~/bclrm) '2 Length ~'d' ' Total depth I~,~" ft. Date of adequacy test walt (YIN) ¥ W~res properly protected (YIN) Casing height (above ground) AT INSPECTION 6/ 13 ~ ft. ~,9'7 O.p.m. I "~ in. Date installed ~;~// Cleanoute (YIN) High water alarm (YIN) ,,v. ,4. ~.~.,,.,System type T~-~~--~ It. Width ~' ft. Gravel below pipe ~" ~- It Eft. absorption area'/?~ ftz Monitoring tube 'T' Depression over field ~' /0"/0 2. Results (Pass/Fail) P~.r Fluid depth in absorption field before test~7.~'in. Water added'~"~'7 gal. Elapsed Time: I f~ ? min. Final fluid dabth~, ~'m. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) .ft. For ~ bedrooms New depth ~',? in. ~OO g.p.d. J~/gp,q ¢ /,eno ~.-.~ If yes, give date N, O. UFT STATION /v'./t. Date installed 'Pump on" level at in. Datum E. SEPARATION DISTANCES Size in gallons 'Pump off' level at in. Cycles tested Fe SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot Absorption field on lot Public sewer main Sewer/septic se~'~::e line Manhole/Access (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lots On adjacent lots Public sewer manhole/cleanout Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Property line ~'~-' Water service line '~ Absorption field Surface water Building foundation Water main '~, { ~ Wells on adjacent lots "80' Surfacewatar ~> [~o' Dfivew'ay, paddng/vehidestorage ,.f'O' Wells on adJacont lots ~> ~oo' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~(," Building foundation ~ ,~'' Water main Water Service line '~ I(.P ' Curtain drain h,/~' 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 w~th MOA HAA guidelines in effect on this date. Engineer's Printed Name T,4~=~c;~,r'~ ~'./w'oore in0 Date HAA Fee $ Date of Payment ~' / f ¥/~ O Z Receipt Number (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 Water Well Advisory, Health Authority Approval # 020255 During a recent Health Authority Approval on-site inspection and test of the potable water supply well on Block , Lot 4 of Contour Acres #2 subdivision, the well's productivity was determined to be .97 gallons per minute. The minimum well productivity required by this Depaxhnent (AMC 15.55) for a 4-bedroom residence is .41 gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory must be attached to all copies of the subject Health Authority Approval. ./ · ! p ~ h lV )~ .': c~k. . g' hereby certify that Z ~ave su~eye~ the des~lbed ~to~erty~O~ ~ Anchorage Recording Precinct. Alaska. and tl~at improvements situated tl~ereon are svi~in the Ruest~on and that there ~e no roadways, trans~s o3 as tndleat~ ~ercon. Dated at Rnchorage. tl~i~ /~r~ ~3x o~ ~P~E~ . l~,~~ )'RZD %'/ALATI~ & ~SO~IA~ 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 ~ "/ '" HAA# ~ ~--~.~'"~ ~-~\~ GENERAL INFORMATION Complete legal description Location (site address or directions) ~5"Ol ?~nn, Z, ~'c~¢ Property owner H F'S I'lobehl, y .~'~c_r % ~-&c~r ~,~/-~ Day phone Mailing address ~ ~c~/ ~" 5'/. ~,~ cAo/-~,~ . A-~ ~J-~,~ Lending agency ~,~ ~toc~,n Day phone Mailing address Agent [~ccrbo~r~ I~sty/ Address ~0! ~/> ~,/~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: Day phone If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NO'I:'E: 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 1~'/¢r/-/-0/¢ ?'~(_.~n/~f Phone Address /V~ZO ZEc.~o ._C/. /~t,~4o,.-,~,~,,~, /+~ ')¢5'/0/' Engineer's signature ~"~ j~. ~/-¢~¢L DHHS SIGNATURE ~ Approved for bedrooms. Disapproved. 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) Back MOA UNIOP,',UW of ANCHO O ENVIroNMENTAL SERVICES DlVtSION of Anchorage SEP 2 5 1997 DEPaRTMEnT OF HEALTH &HUMAN SERVICESRE i Environmental Services Division (~E VE 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription: L~i~ ~ ~¢>~/-o~,," /°,-c~ ~t~'~ ParcelI.D.: {:~ ~'7 A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N). Total depth Date completed Cased to 20 ,?' Casing height (above ground) Sanitary seal (Y/n) 'r' * Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test 8//g'/7~- 2/ /¥ / 97 Static water level 158" ' J3' ~" Well production ,~ g.p.m. I. O g.p.m. WATER SAMPLE RESULTS: Coliform 0 cc, / / (c,c,, ,,~ ,,~ Nitrate Date of sample: 9 / I P/9 7 ~. 8 ,~ ,~e / -~ Other bacteria ,,/ Collected by: i F[~ ~c~ ~, ~/ B. SEPTIC/HOLDING TANK DATA Date installed ~'/~ / ? ! Foundation cleanout (Y/N) Date of Pumping ~/1~/P7 Tank size I ~o'z~ Number of Compartments Y' Depression (Y/N) N High water alarm (Y/N) /V. ,~, Pumper -~",.~ ~,~ ABSORPTION FIELD DATA Date in~Italled &= / ~Z/7~ Soil rating (g.p.d./fF or fF/bdrm) ~.E.~r.~',,.,,,' System type '7-renc/~ Length ~ o~ Width ~' Gravel thickness below pipe E'-//' Total depth ~o Effective absorption area ~E or~ Monitoring Tube present ~/N) ~ Depression over field (Y/N) Date of adequacy test ~ //P 17 ? , Results (Pass/Fail) /'>~cr For Fluid depth in absorption field before test (in.); ~g" Immediately afterlT?v/ gal. water added (in.): Fluid depth I E" (ins) Minutes later: ~ Absorption rate = ;:> o"o~ g.p.d. bedrooms Peroxide treatment (past 12 months) (Y/N) N if yes, give date /V. 72-026 (Rev. 3/96)* D. LIFT STATION ~; Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ioo' Absorption field on lot 1 o '7 ' Public sewer main Sewer/septic service line ~> ~-5"' Size in gallons "Pump on" level at* On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation ~O' Property line ,~',5" Absorption field Water main/service line ;> ~'o' Surface water/drainage ~ !o~,' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line '~J,~' "/' Building foundation Surface water '2' ~c~o' Driveway, parking/vehicle storage area Curtain drain /Vo,~ .50o,,? Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of in conformance with MOA HAA guidelines in effect on this date. Signature ~7"'~.,~.,.~_ .~, ~ Engineer's Name '7"A ~ c.~o*-~ ~'. /~'oo ~ Date ~'{~.~ ,./--t'~ /~¢r- ?,~ /~ 7 "Pump off" level at* Water main/service line are HAA Fee $ ~ O ~ c,_..~ ..o.,**n. Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number Parcel I.D. # 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 GENERAL INFORMATION Complete legal deScription Location (site address or directions) 5'.5'-d~/ f' ¢/~,~,~ C't ;'-c I ¢ Property owner Mailing address Lending agency Mailing address Day phone Agent j~cZ<,~ P,~4/~ Z>/~,,~c ?ro?erh'<r Dayphone ECl-7~'/6" Address ~111 "C'" 51~.j ~C~,,t-~, (oc~,, ,,~,~c,~o~a~¢ ~ ¢9~'-~ ~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~/ 3. TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: 4.' :TYPE OF WASTEWATER DISPOSAL: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. Individual on-site ',:.- - :Holding tankN,r..* ~'--- :., , ;'.?':'::,~ ,, :. ,. Community on:site NOTE: Public sewer If community wasteWater system, provide written confirmation from State ADEC attesting tO the iegalitY 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 regulationsin effect on the date of this inspeCtion. ~ NameofFirm I~/~/-/o/~ 7-~cb,~/(~! _~.',,;¢~-,' ~' Phone Address. /"/5-3 r_J ~ c Aa "~'J'D ,,zY,',c A om,~/~ · /f./..c ,,,/ j' Engineer's signature ~-~ ~ ~ Date /='~& DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments The MunicJ-~ality of A, 6chorage Department of Health and Human Sewices:'(DHHS) issues Health Authority Approval Certi!icateS based only upon the representations given in paragraph 5 above by an independent professIonal engineer rag mtered ,n the State of Alaska. The DHHS does this as a courtesy to purchasers of homes andthe!rJending 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 professiOnaJ'engineer's work. 72.O25(Rev. 1/91) Back MOAiI21 MUNiCiPALITY OF ANCHOI~GI~ ENVIRONMENTAL,SERViCES DIVISION FEB 2 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES R E (~ E, Environmental Services Division .... 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744 Health Authority Approval Checklist LegalDescription: L~ ¥. (O~o~r ~¢r'~' ~ '2 A. WELL DATA Parcel I.D.: ~ ~ 7 ~./,~c' I 2 y . Well type F~, Log present Total depth Sanitary seal (Y/~ Y Date completed Cased to 'E O3" If A, B, or C, attach ADEC letter. ADEC water system number Casing height (above ground) I' Wires properly protected (Y/N) Y' FROM WELL LOG AT INSPECTION Dateoftest ~/ t~. /75' Static water level 1 3' 0" ' Well production .... ~ g.p.m. , , I. O g.p.m. WATER SAMPLE RESULTS: Coliform ~ ~ol /to~o~ ..~ Nitrate /...Ct~ ~o~,~ t' ~ Otherbactefia No~e rep.~hee~, Date of sample: '~ [ I ? / ~ 7 Collected by: /~'/o/'/o/~ 'f'ec}~ -(' ~" C . . B. SEPTIC/HOLDING TANK DATA Date installed 8 / I / ~ I Foundation cleanout (Y/N) Tank size ! 2 fO~ Number of Compartments ~r Cleanouts (Y/N), ,Y' ¥ Depression (Y/N) N High water alarm (Y/N) At, A, DateofPumping '~/Ip/~ 7. Pumper C. ABSORPTION FIELD DATA ur.¢ ,.aate,~ ~/ z.c / 77 Dit~ installed ~ / ~ ~ ! 7~C bo or~ Wid~ Effective abso~fion ~ 7~ 2 oe~ Mo~tofing Tube present~ Depression over field Soilrating (g.p.d./fl:orfl~/bdrm) '~ Z o ~ SystemtYpe '7",'ef c.~ Oravel thickness below pipe 6"- ~1' Totaldepth 1~'o~'0~ Date of adequacy test ~ !: ? ! ~ 7 Results (Pass/Fall) ffo~ For '~ bedrooms Fluid depth in absorption fleld before test (in.); q[" Inunediatelyaiterl7."$~'gaL wateradded (in.): q~' ~,~,lot~, ol&? I'. Fluid depth lO" (ins.) Minutes later: ~0' Absorption rate = '~, ~00 g.p.d. Peroxide treatment (past 12 months) (Y/N) N Ifyes, give date D. LIFt STATION hi. /~. Date installed Manhole/Access (Y/N) High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100' Absorption field on lot I 0 ~t ' Public sewer main b/- A, Sewer/septic service line Size in gallons "Pump on" level at* "Pump off" level at* ; On adjacent lots '~ too ~ ; On adjacent lots '~ I oo ' Public sewer manhole/cleanout N.d. Lffi station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~ O' Property line ~- ~' Absorption field Water main/service line _~ I o' Surface water/drainage '~, I co ' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~ J" Surface water > t oo' Driveway, parking/vehicle storage area Curtaindrain N~o,',~' See~ Wellsonadjacentlots ~, too' ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance with MOA HAA guidelines in effect on this date. Engineer's Name '7'~,o~:~-e~ ~.. tWooe-~ Date .~l,r~o.,~,y ~ 19q7 Property Line ¥ O' Water main/sentice line are HAA Fee $ Date of Payment Receipt Number Rev. 8/95 OSS: haa.wk.d0c Waiver Fee $ Date of Payment Receipt Number 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 1. GENERAL INFORI~ATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA# [,et 4; Con~ou~ Ac~es Su~v~s~on Location (site address or directions) 5501 Penny Lane, Anchorage, Alaska Property'owner HOMEQUITY Mailing address ':>' '~ Day phone NOTE: · 2." "NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well Community well Public .water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. , '~'""- TYPE OF WASTEWATER DISPOSAL: .L:E>? :. i:!,- xxx ~--.:. ~;~,.. , , Individual on-site ..... ,,z. : .... ......~.~.:,.,.,.:._:~,~ ...~-: .. ::,L~,,:.::~,i~ -:%:.::ff.:/':~.::'~T':'~'~. -~OlQIng tan ', ~ _ . ., . . .: .. :':: ~-','~',.~- .: ': -'r:.~-,'e{~i~<~:i[~'~;.:~t t,[~',:'.:t:, ~ :!- -~;,./' '. ,' ':' '. ,.., ~ '-' :...-tt~.,:,:~: "'t ~: :, ~ -:~"~-~'- it'.'.t~ '--;: · .. ~ ' ~'~- .-.; ' .:-:~ ~:.. ,:,:~t:_''~ ~-.. -. , &~<h~;f.~% :r'~ '- ',: ~t??:'-,;~,~ ".: NOTE' :" If community Wastewater system;provide written confirmation from State ~lity and status of system. --.:-... :,,,;.c,:.~::t,..:.;,.:~¢;.." · ~ ..:.Lending a~gency ':'. ,' '" Day phone ..,,:v:: ... ";.~..... ~ . i~, · - ~" ..... ':": ,, ,: ,~,'"': :-' ,' ' ; address" ; Agent ~ackie Dahl/DYN~IC REAr.T¥ Day pho.n'.e~: !279,76 ::::!::.:!!'!;Address 501 ~est. Norl:hern Lights BouZevard, ~chora~e/ · . :~ Unles~ otherwise requested, HAA will be held for pickup. STATEMENT OF INSPECTION BY ENGINEER ~, As certified bY my seal affixed hereto ~nd 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 ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm' $ & $ ;NGINEERING 17034 Eagle Ri~er Loop Road Ne. 204 Address .-__,_ at .... bln;ka 99577 'Engineer's signature Phone ":~,, ;'; ':" Approyed for "" · .... bedrooms. ' '" .':' ........ DisaPprOved. ';", "' ;~: '' ' ' 'with'th 0wng St lat ~'~;, ,:Conditional approval fOr bedrooms, e foil i ipu iOns: Additional Comments The Municipality of Anchorage Department Of Fiealth and Human Services 'iDl-:lHS)'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 requirement$~'Erhployees of DHHS do not · "conduct jnspections or analyze data before a ~certificate is.issued.,,~Tho .Municipality ~of Anchorage is not '~'":':, '::' responsible for errors or omissions in the professional engineer's ( Municipality of Anchorage ~i~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~:~1~4:~ ~"C:~~ ~~ Parcel I.D. O / '~'-- A. WELL DATA Well type '~~. . If A, B, or C, attach ADEC letter. ADEC water system number Log present ~:~)/N) ~ Date completed ~;;~-~1 ~-~:-~ Driller Total depth ~I , Cased to ~ Casing height \'2~ Sanitary seal ({~N) ~'~ Wires properly protected~N) "~ FROM WELL LOG AT INSPECTION Date of test ~--~1 ~-~ ''}~ Static water level \'"~' Well flow ~ g.p.m. Pump level ~-~5' SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I d__.,~,'~ ; On adjacent lots Absorption field on lot I ~::~;~ t 4r- ; On adjacent lots Public sewer main ,/~J T_2,/~ Public sewer manhole/cleanout Sewer service line ,~.~. I~ Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: '~ d ~'~ Other bacteria Collected by: ~ ~ ~ ~ B. SEPTIC/HOLDING TANK DATA ~/~_.~/~ ~ Cleanouts~/N) ~ F~n~ion cloanout ~N) High water alarm (Y/N) Date of pumping . ~ [~ Compartments Depression Alarm tested (Y/N) Pumper SEPARATION DISTANCES iF:ROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage 72-026 (Rev. 7/91) Front On adjacent lots ! ~ I-Ir- Foundation Absorption field CONTINUED ON BACK PAGE C. LIF'I~~ON Date installe~'--. Size in gallons Vent (Y/N) ' Pum~ High water alarm level ~'~'"C~L~ted Meets MOA electrical codes (Y/N) ~ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water Manufacturer Manhole/Access (Y/N) "Pump off" level at D. ABSORPTION FIELD DATA Date installed ~ ~/~ ~/"/ Length ~:::~ I Width Total absorption area Depression over field (Y/~ Results (([~/fail) Peroxide treatment (past 12 months) (Y~ Soil rating ~-'Z~D::~"~/~ System type Gravel thickness~ (oI I ~ I - Total depth Cleanouts present (:~N) Date of adequacy test ~'- ~ for bedrooms If yes, give date "-'--' To building foundation On adjacent lots ,~2-~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot {''''~--~ 1 Jr' On adjacent lots {"~l~;Jr'' Property line Ic::~ ~ 'L' To existing or abandoned system on lot Cutbank .~)/~1~ Water main/service line Surface water Curtain drain Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in ef~_l~l~te of this inspection. '::.%. , Signature :, ~ ~a~., .J.v:r L=c Engineer's Name ~gle ~iver, Alaska 995~ Date [~~ HAA Fee $ l'71~ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number 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. # ("~\'--'[- ~-\,Z~_\ -~.~L~ HAA# ~q/ ~'~{~ 1. GENERAL INFORMATION (Musl be completed prior to submittal) (a) Legal Description (include lOt, block, subdivision, section, township, range) (b) Location (address or directions) 5501 Penny Circle Property owner Mailing Address Geor.qe ~ Cqnthia Ne,.son Telephone :.(home) 345-7131 .Busin:eAs 279:7611 P. O. Box I0-583 Anchorage, Ak. 99511 (c) Lending Institution Telephone Mailing Address (d) (e) Real Estate Company and Agent JACK WHITE COMPANY ATTN: Barbara Parker Mike Lewis PPH/Homeq~ity , frying, Tex,as . # Anchorage, A~as~a 99503 Address3201 C Str¢~ 100 Telephone 563-5500 :- 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 E~ Number of bedrooms 4"'* 3. 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 th legality and status. ' 4. SEWAGE DISPOSAL On-site [~3( 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 th. 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 Telephone Eagle River, Alaska 9957~ Date ' 6. DHHS APPROVAL Approved for Z~, 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. 7/88) Back Page 2 of 2 A. WELL DATA Well Classification Mun!cipalitY of Anchorage Dept, Health & Human Services I Well Log Present (Y/N) ~ Date Completed / ! Total Depth~ Cased to ~ Depth of Grouting .. MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) C E IV~- ~KLIST ' FEBRUARY 1984 343-4744 Legal Description: If A, B, C, D.E.C. Approved (Y/N) 8-/~ ~ '-~ ~- Yield !. ~-- ~.~. Static Water Level ! ~ ~-- Casing Height Above Ground 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 Pump Set At (._) Sanitary Seal on Casing (Y/N) , Depression Around Wellhead (Y/N) ; On Adjoining Lots ( ~ -(" / [ L"') O ~ ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole I Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~SizeL~.~P~ No. of Compartments ! ~,.,~c. ~ Standpipes (Y/N) ('1 Air-tight Caps (Y/N) ~1 Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~ Date Last Pumped "~ ~ ~- - ~ U / / Pumping/Maintenance Contact on File (Y/N)/ A')/I~A ; for ~/I.,~ Holding Tank High-Water Alarm (Y/N) ~I!A ' ~[Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: I To Water-Supply Well ,/ ~_/2. ~ To Property Line ! ~ ~ '# ! To Water Main/Service Line [ ~ "~ To Stream, Pond, Lake or Major Drainage Course Comments ~~'t~ '~5o~,oe-~_ .~ To Building Foundation To Disposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~ ~- z -75`- Width of Field ~ Z~ ~ Type of System Design ~ ~ Depth of Field / Gravel Bed Thickness Square Feet of Absortion Area ~( O ~ ~ ~ Statndpipes Present (Y/N) Depression over Field (Y/N) ~ Date of Last Adequacy Test Results of Last Adequacy Test ~ ~ 5~ ~ ~u ~ ,> ~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot ~-~ / I^ To Water Main/Service Line [ O(~ -f- To Property Line ( © ' ~ To Existing or Abandoned System on ; On Adjoining Lots [ 0 / f'- To Cutback (if present) _~-'0 ./c- f To Stream, Pond, Lake, or Major Drainage Course ,/ To Driveway, Parking Area, or Vehicle Storage Area D. LIFT STATION Date Installed ~ Dimensions Size in Gallons "~ Manhole/Access (Y/N) "Pump On" Level at "~ "Pump Off" Level at High Water Alarm Level at '~. ~ Vent (Y/N) _ / /~ ~'-\ Pumping Cycles during Adequacy Tested for Test. Meets MOA Electrical Codes (Y/N) Comments "~ , **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines .i.n effect on the date of this inspection. .~ ~, ,~,~ /,~,~ '~. Signed S & S ENGINEERING Company 17034 E,,~J~ RN-~;' Lc~.~ .".;~ No. 2J/4/ Receipt No. ~;;~d'~3 Receipt No. J/ Date of Payment /' ~// ~:::~'/ Waiver Fee: $ Amount: $ ('<~ ~' Date of Payment 72-026 (Rev, 7/88) Back Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 56.33 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I,D. #92-0040440 ¸:rO ANALYSIS REPORT BY SAff~PLE for Work Order g 31430 Dete Report Printed: JAN 22 9]. ~ 13:06 el:Lent 5ample ID:L4 CONTOUR ACRES #2 Client Name PWSID :UA Client Acct Collected JAN 18 91 @ 14:00 hrs. BPO # Received JAN 18 91 ~ 15:55 hzs. Req ~ Preserved with :AS REQUIRZD Ordered By ENGINEERING SNSENGP PO ~ NONE RECEIVED Analyuis Completed :JAN 21 91 Send R~ports to: Laboratoxy ~upe~vJ. soz :STEPHEN C, EDE 1)$ ~ ~ ENGINEERING ~e~essed By : / / Chemlab Ref 8:910210 Lab Smpl iD: 1 Matrix: WATER Allowable Parameter Iested Result Unlt8 Method Limit~ NITRATE-N 0.88 mg/1 EPA 353.2 10 Sample ROUTINE SAMPLE COLLECTED BY: RDJ Remarks: Tests Perfoxmed ' See Special Instxuctions Above UA-Unavailable None Detected ** See Sample Remazks Above Not hnalyzed I,T-Less Than, GT-Gzeatez Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. - 43 5633 B Street TELEPHONE (907) 562 23 Anchorage, Alaska 99518 ~ Drinking Water Analysis Report for Total Coliform Bacteria ~ TO BE COMPLETED BY LABORATORY TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.# PRIVATE WATER SYSTEM Phone No. Name S & $ ENGINEERING -- .,,,~res-~iU;~4 Eagle River Loop Road No. 204 Mailing ,,u~ Eagle River, Alaska 99577 Analysis shows this Water SAMPLE to be: Uantisfact°ry satisfactory [] 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 mall. state Date Received SAMPLE DATE: [~ ~-~ ~' Time Received -- - Mo. Day Year Analytical Method: Membrane Filter SAMPLE TYPE: ..Routine Check Sample (for routine sample with lab ref. no. [] Special Purpose zip Code .) [] Treated Water ~ [] Untreated Water SAMPLE NO. LOCATION * No. of coloniesll00 mi. Time Collected Lab Ref. No. Result* Analyst Collected ~ BACTERIOLOGICAL WATER ANALYSIS RECORD READ iNSTRUCTIONS_ BEFORE COLLECTING SAMPLE_ Membrane Filter. Direct Count ~ _Coliform/100 mi BGB. Verification: LTB_ ColitormtlO0 mi Final Membrane Filter Results ~ Reported By ~ate Time: ~ a.m. p.m. TNTC = Too Numberous To count OB = Other Bacteria PART ONE OF TWO REMAINDER TO FOLLOW MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 9'9501 279-2511, ext. 224, 225 REQUEST FOR APPROVAL OF INDIVIDUAL SEWER and WATER FACILITIES 1. Type of Inspection: VA FHA_ 2. Property Owner: David L. Burlingham Mailing Address: P.O. Box 33-51 Day Phone: 3. Name of Buyer: George N. Nelson ____ Mailing Address: c/o British Petroleum Day Phone: CONV__ZZ.T~____ 349-1922 265 7421 4. Name of Lending Institution:. Mailing Address: P.0. 5. Name of Realtor or Agent: Mailing Address: 6. Legal Description: T,ot 4, National Bank of Alaska Box 3-3859 Area, Inc. Phone: 279-2506 X43 Shirley Jones Contour Acres #2 Phone:== ~78.-,2.57.5 Location: Birch/Huffman Type of Facility robe Inspected:__ Ri~K SFR Water Supply Type of Supply: Public Utility If Individual, number of dwellings presently served If Individual, depth of well Sewage Disposal System Type of System: Public Utility If Individual, date of installation 8/75 No. Bdrms .... 4, rlndividual. XZX Individual (on-site) 72-003(3/76) August 16, 1977 National Bank of;flasks % Shirley Jones Post Office Box 3-3859 Anchorage, Al&ska 99509 SubJect~ Lot 4 Contour Acres 92 Suk~ivision On August 16, 1977, this depar~e~tma~e an ins~eotion of the subject individual on-A,ts sewer and water facilities. A search of our records indicate that the orig~al on-site sewer system was designea and approv~ by this fnI~975, for a three(3) bedroom s~ngle family dwelling and your &pproval uquest is for & four(4) If there ara any further questions, please contact this office at 279-2511, extension 224 or 225. Sincerely, Cory Willis, Sanitarian