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Home My WebLink AboutJODIE ESTATES LT 1,.Todi sta Lot I #01§-143-01 .. '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 Permit Number: ~J ~'~'°e~5' PID Number:' o/5 -/¥3, - el Name: ' ~ ~ ~ d~,4 Wastewater System: ~ New ~ Upgrade Address: Phone:~ - ~ ~ No, of Bedrooms:~ ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: Lot: ~ Block: S,bdiv~i~;l~ ~:%!~, ~,* ~ ~Depth to pipe b0tto~ fr0m¢~origi,al¢ grade: Ft. Gravel depth beneath pipe ~ Ft. Township: ~ Range; Sectio~ Fill added above original grade: : Gravel length: WELL: ¢~ ~ ~ ~ New U Upgrade .,~ Gravel width: ~' ¢ Ft. Numberjof lines; Dist~nce~en lines:Ft. Classification (Private, A,B,C): Total Depth: ¢o: Total absorption area: Pipe material: Driller: ~ ~te Drilled: Static Water Level:Ft. Installer:~¢ ~ ~O ~xc~v. Date installed: ~ I Pump Set at: ICasingHeightAboveGround: SEPARATION DISTANCES ~s~,tio u ,o~din~ U S.T.S.,. To Septic Absorption Lift Holding ~ub[ic/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~C~G E ~ ~ WelY /ool~ Ioof~ ~ ~ ~1~ Material: ~%~E~ Number °f C°mpa~ments: Sudace Wat,~ ~o~'+ ~o~+ ~ ~ - LIFT STATION Lot Size in gallons: I Manufacturer: Foundation ~ ~ I ~ j~ ~ ~ "Pump on" level at: I "P~~t: High water alarm at: Cu~ain Pump Mak~Electrical Inspections performed by: Drain ~ ~¢E ~' BENCH MARK Location and Description: Assumed Elevation: Eagle River, Alaska 99577 2nd 4 "7 -~ [¢~ ROBERT C. COWAN Department of Health a:~d H~man ~ervices approval -~-~?.. ..... 72-013 (Rev. 9/91) MOA25 Permit No. SW960045 2 2 Page of 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 LegalDescription: LOT I, JODIE ESTATES SUBDIVISION PtDNoo: 015-143-01 / 1 2C[ AVE. ST1 ST2 ~FINAL GRADt 1250 GAL 8.% ~ LCT 1 / O C02 : 10(.9' ~ C03 = ~0~.9' ~ EXISTINO co~: ~ Dc' ~ 3 BDRM, ~ v ~ s'r~ ~T~ = 85.9' ~ ~ ~%NEW 250 GAL ~ N0 GROUND WATER ~ ov 79.8' B 0.H. ~ z FCO 1[ 26' ~~'~ ST1 1~' 3o' NEW TRENCH C02 5()' 52' ~r, ~¢~:¢--.¢ iXISTING ] RENCHES ~'e ' .... , 72-013 A ([ er. 9/gl) MOA 25 PERFORMED FOR: (~'~'¥' LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST / ~' ¢ ¢), ¢. E ~ r. Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15- 16- 17 18-- 19 2O COMMENTS SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water After MonitorinG? Date: SITE PLAN S L' Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN __ (minutes/inch) PERC HOLE DIAMETER FT AND -- FT & $ EN~INEERIN~ PERFORMED BY: ~¢-~ - CERTIFY THAT TH. JS TEST WAS PERFORMED IN 17034 Eagle River Loop Road No. 204 r -~ / ' ~-"~ '¢ / / ACCORDANCE WlTHI~!~I~'~I~i~i'~.~,GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ // '~" i f ¢1 ~ 72-008 (Rev. 4/85) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREETf ROOM 502 ANCHORAGEs ALASKA 99519-6650 PAGE 1 OF ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW960045 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME~WILDIN GARY I & BETHENE J OWNER ADDRESS:5420 E ll2TH AVE ANCHORAGE, ALASKA 99516 DATE ISSUED: 4/08/96 EXPIRATION DATE~ 4/08/97 PARCEL ID:01514301 LEGAL DESCRIPTION: JODIE ESTATES LT LOT SIZE: 40444 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH~ THE ATTACHED APPROVED DESIGN. 2o 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) . THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY Bo COVERED, SEALED AND HEATED TO PREVENT FREEZING 5~ THE FOLLOWING SPECIAL PROVISIONS~ SPECIAL PROVISIONS RECEIVED BY: ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. March 25, 1996 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE pLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 1, Jodie Estates S/D A Conditional ~eal%h Authority Approval is requested until the system can be upgraded by June 15, 1996. In addition, request you issue a permit to upgrade the septic system serving the existing'~ee bedroom house on the referenced property. A test hole was excavated and percolation test performed. The approximate location of the test hole is located on the attached site plan. At the time of excavation no water was encountered and after seven day ground water monitoring, the monitoring tube was found to be dry. The existing septic system was tested and found to be adequate for approximately two bedrooms. Therefore, with conservative measures, the existing system can function adequately for a short period until the upgrade can be accomplished. A health hazard will not develop as a result of issuing this Health Authority Approval. Attached is the proposed upgrade design. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. There are no protective well radii which encroach upon the property. If you require additional information, please contact us. Si,nc.er,el_y, / Robert C. Cowan, fl.E. RCC/gk Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 1" = 50' SITE PLAN DESIGN k---"'"~ SCALE TOTEM ROAD o o8 8 -- z ROBERT C. COWAN, RE. ROBERTA. SHAFER, P.E. HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAO DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE W/~TEWATER DISPOSAL SYSTEM DESIGN ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 1, Jodie Estates S/D March 25, 1996 GENERAL: 1. The scope of this project includes the installation of a leachfield trench to serve the three bedroom residence located on the referenced property and excavation of the existing 1250 gal septic tank to verify its integrity. If the integrity of the existing septic tank is poor the existing septic tank is to be excavated, pumped, crushed, and abandoned in place and a new 1250 gal septic tank installed. The existing trenches are to be abandoned as such that it may be used in the future. e Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. De Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. ~EPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 1, Jodie Estates S/D March 25, 1996 Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Page Three Lot 1, Jodie Estates S/D March 25~ 1996 Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (nBS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the %200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four Lot 1, Jodie Estates S/D March 25, 1996 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. e The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. 3e The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. Page Five Lot 1, Jodie Estates S/D March 25, 1996 S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Englneering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION:, 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16- 17 18 19 20 COMMENTS DATEPERFORME Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT fL.,L DEPTH? p E Depth to Monitoring? Reading Date Gross Net Depth to Net Time Time Water Drop ~ ~,. ~ ~ ?/~. ~/~' PERCOLATION RATE ~? (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ? FT AND ¢ FT , PERFORMED BY: ~" ~--~- ~ .... "--- ~ ~ ~, --,I, ~/~ f ~1 .............. I ~Ueq ~ ~"'~. ~ ~ 11~, Z~ ~ ~' ~ . · ~ ~ --~H/I~Y/HA/IHIS TEST WAS PERFORMED IN ACCORDANCE WIT~DL~,~m~ GUiDELiNES tN EFFEC~'O~ THiS DATE. DATE: ~Z~/ 72-008 {Rev. 4/85) Municipality of Anchorage Page ~ of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 34.3-4744 On-Site Wastewater__ Disposal System and/or Wei~ inspection Report Permit Number: ~-~ ¢:~ ~;~"~:::~ PID Number: ~::~ [Z~~(:::;') LEGAL DESCRIPTION , Block: Lot . ~ / Township: I Range: WELL: [] New Driller: Yed: From Well Surface Water Lot Line Foundation Curtain Drain Remarks: S u b divis io,~.;.~ ~ Section: [] Upgrade ITotal Depth: [ Cased To: Date Drilled: Ft. Ststic Water Level:Ft' Ft. GPM Pump Set at: J Casing Height Above Ground: Ft.Ft. SEPARATION DISTANCES TO~~Scapllikc AbSF~;~;ion st~itfiton Wastewater System: [] New ~¢.,Upgrade ABSORPTION FIELD ;~Deep Trench [] Shallow Trench [] Bed [] Mound [] Other Soil Rating: ~ ~ GPa/Sq. Ft. Depth to pipe bottom from original,rede: Ft. Fill added above origir~af grade: ~ '~' "~ Gravel ~ ~ Total absorption fn~taller: t Total Depth from original grade:,~ Gravel depth beneath pipe Gravel length: Ft. Number of lines: TBistance between lines-"-'7" P. ipematerial: '~'~tf~:~ ~ Septic [] Holding [] S.T.E.P. Manufacturer: / rCa,ac,t~ ~ ents: L~F% STATION Size in gal~'~er: ~ [ Elect ri--~r f ~Tq-~ by: ~ BENCH [L ° c a t i°~ii ~ ~*'~//.-~_~. f~:;:~L.2~ ~ Assumed Elevation: /,~ S & $ ENGINEERING Inspections performed bw~.~_~ ...... , ....-0etas: 1st '~-/-~ I Eagle River, Alaska ~527 2nd ~¢ ~-R/ D e pa r, m e n t of H e alt/b-a-i~l d ~H/I,i~?/a~ S.~ivic,..e.s a p p r oval Reviewed and approved by: _~-../,,'~/'/,-/~¢ ..~_%~ate: ~-~4/~? 72-013 (1/91) MOA 25 Permit No. ~I~J~p'~O~.~4~) Page ~' of ~' 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/orWell Inspection Report Legal Description: ..JO'[~l~ ~--~1~.1~,,-~ ~ 1 PID No.: ~1~1zl-501 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:SW910250 DESIGN ENGINEER:S & S ENGINEERS OWNER NAME:SCHMALZRIED GEORGE & OWNER ADDRESS:5420 E ll2TH AV ANCHORAGE, AK 99516 DATE ISSUED: 8/26/91 EXPIRATION DATE: 8/26/92 PARCEL ID:01514301 LEGAL DESCRIPTION: JODIE ESTATES LT 1 LOT SIZE: 40444 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD 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 (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: / August 22, 1991 ROBERT SHAFER, P.E. ROGER SHAFER, P,E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot I; Jodie Estates Request you issue a permit to upgrade the septic system serving the referenced property. An adequacy test was performed on the existing system Aught 2, 1991. The results found an unacceptable absorption capacity. A test hole was excavated and a percolation t~st performed in the area of the proposed upgrade. Attached is the proposed upgrade design. The lots in this area are r~ativ~ly large w~th sufficient room for future well and septic upgrades. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic upgrade. If you have any questions or require additional information for your review, please contact us. Sincer~y, ~R~GER~J. SHA~ER,~p. E.~ RJS/gm 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 SCALE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORME[ LEGAL DESCRIPTION: L~I~::Y'~'''~ I C ~C:~1'~t ~ Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 19- 2O COMMENTS SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S YES, AT WHAT nL IF DEPTH? p E Depth to Water Afl~.~.~? ,.! Monitoring? ' l./~7 Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE '~? (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN "7 FT AND ~ FT PERFORMED BY' "'~' ~ .... I.. ~,... , n ~ ~v - CERTI ACCORDANCE WIT~D/~A~C~ GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Tom Fink, Mayor un c pa Amckorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 January 8, 1990 George & Mildred J. Schmalzried 5420 East ll2th Avenue Anchorage, Alaska 99516 Subject: Lot 1 Jodie Estates Subdivision Permit #890163, PID #015-143-01 The subject permit, issued by this office for a sing.le family well and/or on-site wastewater system has expired as of December 31, 1989. Permits are issued on a calendar year basis by authority of the Municipal Code of Regulations. A new permit must be obtained from this office for an well and/or on-site wastewater system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this office for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site wastewater system, the original as-built inspection report (three-part form) must be sent to this office for review, approval and documentation. When applying for a new permit, the fees are: $90.00 for an on-site wastewater permit; $50.00 for a well permit; $140.00 for a combined on-site wastewater and well permit. If you have any questions, please call this office at 343-4744. Sincerely, John Smith, P.E. Program Manager On-site Services JW/ljm:200 enc: Copy of Permit "Kids Are Our Future" Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SEF 825 "L" Street, Anchorage, Alaska 99502~ SOILS LOG -- PERCOLATION LEGAL DESCRfPTION: ~_Q'~- 2 3 4 5 6 7 8 9 ~0 ES-T-~TES Township, Range, SLOPE WASGROUND WATER SITE PLAN 11 12 13 14' 15 16 17 18 19- 20 ENCOUNTERED? IF YES, AT WHAT DEPTH? Oepth ~o Water ~ M0n~ring? [ ir?,F Reading Date Time Net Time Depth to Water - 74 - 'Tf - 7¢ Net Drop ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINE~ I" EFF~C~, // 72~8 (Rev. 4/~) ,/ PERCOLATION RATE ?¢ ~1~ (minutesYinch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT PERFORMED IN - -' ~ 112-. A~TE /' o, __'", O"~- ...... L /,I ,,,, i~, ~ELL/~ / ,' OR SEPT IL SV~TEN ~ /~/' ,/' ,' SEPA~Z IO H CO~ FLICTS /~ ~ous~ NITHI~ ~OO' OF PROP0~ED ~ ~ 4"~ ~PROPOSED BED PIP~ ,,~ 18' ~40~ M · ~10~ " ~ :FaO~ ~,_ ~ . ~4" PEaF PIPE II II 'SEWER. SYSTEM'LOOATION PLAN. ~, :~ :~ ;,¢ ~t~ ~,: ~%~; ~Of · ~ BL~K [ - SUBDIVISION ,~ L- '~ .... :~ ,~',, ~ :1":= 1~' ' I T< ACCURA~ OF L~ATION Or EXISTING D~W~, .... I ~YSTEMS INOICATED IS NOT EXACT. ,.¥[//¢~x~¢5 I .,.~~ ........ NORTH O~KKY K~55 I DIMENSIONS INDICATED HAVE BEEN ' --. ' '.: [~i {~ R~>"~:'~~'":'"%~i~]J:~! N BY SURVEYING TECHNIQUES. ............. 'r"i'> '"'"'"' 'i '"'i"~~"'"' '"'"" '~'"'"' ............. /~,/ c c° ~TEST MOLE 4" ~LI P/ ~ ~ P~OPOSED BED .~LI L& ENVIRONIVIENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME 1PH°NE MAI LING ADDRESS LEGAL DESCRIPTION LOCATION J Well Absorption area Dwellin9 PERMIT NO. ~ Manufacturer ~ ~/~.~,,~ Material ~(]C ~ No, of compartments Liq. capa~ity[~,~in~ons~ IF HOMEMADE: Inside length ~ Width Liquid depth ~ ~ DISTANCE TO: Well DweUing ~ PERMITNO. ~ ~ ~ Manufacturer Material Liquid capacity in gallons DISTANCE TO: Well /~c~'J'Z'~ Foundation]~c,,.~_ ]~ Nearestlotline ~-- PERMITNO. ~'~ ~;~ No. oflines Length ofeachline Total length oflineg ~ Trench width Distancebetw ~ ;~ ~ Top of tile to finish ~rade Material beneath the ~: ~ %' ~'-~-~ ~-~ches Tota) effect)ye absorption area O ~ Length Width ~ Depth PERMIT NO. ~ ~ Type of crib , Crib diameter Crib depth I Total effective absorption area ~ DISTANCE TO: Well Buildin~ foundation Nearest lot line ~ Clas~ ~ ~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: ~uiid[ng foundat(on SQWeF I)ne Septic tank Absorption area(s) OTHER PIPE ~ATERJALS SOIL TEST RATING < g~ -~ .5' ~ APPROVED ?" DATE LEGAL .,/~ F:'ERM i "j" NO: CONTACT PH(:)NE ~ SOLAR F'L,LIS, i'NC :1.:1,.'.i;,'.::,.', E 74]'H ANC'HORAGE, AK 99502. 344-52, .1.4 L..C)]' S ! ZI:::Z: MAX BIE:DROCIMS: sys'Lea'~,, Choose 'Lhe opt.:i.~n that, best DEF'TH TC) F:'IF'E BOT"I"C3M (F"I".) 4. () 4,, 0 4.0 GRAVEl_ DEF:"I]."I (FT' ,, ) 6 ,, 0 0 ,, t5 3. 'T'OTAL DIE:F:'T'I"] (F'"r'~) !0.0 4,, 5 7. GRAVEl,. WIDT'H (FrT',,) 2.5 2;~f:. 0 D,, 0 GRAVEL. LENGTH (FI",,) 50,, 0 41 ,, 0 65,~ 0 GRAVEL. VOLLJME (CU. YDS,, ) 30.0 :5:~;,~ 4 48. TANK S I ZE (GALS) 1, ()00.0 .x..~-? 1,000 ,, 0 '~,.~. :L ~ 000 ,~ 0 SOtL~ I::~A'I"IIqG (SQ. F:'T,, /BR) 2.00 197 200 '~'~' TANK MUST' HAVE AT I_I::A.:~[ 'T'WO COMF:'ARTT'IFi:NTS I cept,:i,f'y that: ]: ~,,':~lfl {'ami].i.~,:.'d~ ~.~i~:.h t,J')~..? P(-~qU~ipt.,~!ifl~ai'~t.r,:'~ ~'C:H" ,.':)rl'~"~sJ.'~::(~i! i~-)~..,,.',(,?p~ For'tl"l by the Mur~:Lc::i. lg~7.~li'LY c:)F Ancl'~or'ag(.:~ (MC)A) and tho State 2,, I will :i. nst, all the sys'Lem in acc:or'danc:e~ u~ith all MOA and :i.n COml:~liance ~gi'~',;h thc) do~.:i, gn c::t"it~::,r'ia o¢ this per'm:i.t. 3. I will adher',:s.~ t.o a],l MCIA and StaLe o~' Ala~;ka s~::.~,~e~age syst.(,:;~m ori '[.l"l:i.~ pi~ al']y adjac(~r'rJ:, or' ncht~r, by any en:l:a~-gement ~x,,:i, ll r'equ:i.r'e: ar'i add:Et, ional portrait.. ]:J:::' A L.T.J::."T S'T'A]"ION IS INSTAI,J,.,,ED :t.'N AN AREA COVIi!!:RED BY I"'iO& BU]:LDING CODES~, WILL. NOT BE APF:'ROVED WtT'HOLJT AN I:]:I...EC:'TT'~IC:AL ]:NSI:::'EC"FICII".I REi:PC)R]"; AND ELEC"FI::~ICAI_ WORK MUST BE DONE BY A LICENEi:E:D L~SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAl. PROTECTION 825 L Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~/PERCO LATION TEST PERFORMED FOR:__ LEGAL DESCRIPTION: · 1 2 3 4 5 6 7 8 9 10 1I 12 13 14 15 16 17 18 19 2O ...i SITE PLAN WAS GROUNDWATER ~, / ENCOUNTERED? , /V_ 0 IF YES, ATWflAT DEPTH? Reading $ L [)ate Gross Tirne / ' 2 lEST RUN f]ETWEEN Net Depth to Net Time Water Drop ~. ?0 05- h) ' aLaSKa ~nqin¢¢rinq $ ~nuironmcnt~l Sluclks CLIENT ADDRESS PERCOLATION TEST BATA SHEET ZIP CODE LEGAL LOCATION ~-~ ? / TOTAL DEPTH OF tiOLE (~o,~-' ft TO ZONE TESTED ft. ~, ~) ft READING ft CLOCK NET TIME DEPTlt TO DATUM FINAL PERCOLATION RATE PERFORMED BY NET DROP __~IRATE (min/in) ]~OX ]~(~9, .~TAR I~?ISTE A ANCHORAGE, ALASKA 99~0~ 734 7ee~ SIX INCH WATER WELL DRILLed AND~,C_ASED OUT TO THe DEPTH OF,, DRILLED AT THE RATE OF ~2g:/]O Per FOOT. PROPERTY OWNER ///2~. $~e~e $~a~o~ 345-34~$ DRILLER Be_~.'/x~ C~u4 o~:_.~. ~./~:~p~ ~),~/.,~. /-~oA./~ '~' WELL LOG: 0 .... 16' SM/aS q~zveZ. 35°~ c2.a~ hgr~e~ 16---68' Coavt~e 68---95' t~w~xtpa~. Co~ o~ g~jddd~g: ~24~00 .m~ ~tX 134 .~.: $3216o00 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO rampart DRILLING WORKS FOr THE SUM OF ~3216.00 THANK YOU VERY MUCH, BERNIE CLAUS OF RAMPART DRILLING WORKS DATE_Oc~ ~.th., 1,,,Q8~ ~ ,~f,~.4~.~ SERVICE CHARGEOF I~% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS. Municipality of Anchorage o Development Services Department On-SiteBUilding Water &Safety Wastewater Division Program ~"~ ~t.ei.anchorago.sk.us FOR A SINGLE F MILY DWELLING Parcel I.D. 015-145-01 t. GENERAL INFORMATION Expiration Date: Complete legatdescription JO01E ESTATES SUBDIVISION; LOT 1 Location (site address or directions) 5420 EAST 112TH "ANCHORAGE. AK Current Property owner(s) SIMON & LESLIE HARRISON Mailing address 5420 EAST 112TH "ANCHORAGE. AK Lending agency Mailing address Real Estate Agent Mailing address Dayphone 346-1076 Day phone BARRY CASSADAY w/ DYNAMIC Dayphone 5111 "C" STREET * ANCHORAGE. AK 99503 244-0514 Unlessotherw~erequeste~ HAA w~beheldbyDSD ~rp~kup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [] Individual On-site [] Individual Water Storage [] Individual Holding tank [] Community Class Well [] Community On-site [] Public Water System [] 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 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system, DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties sewed by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not respcnsible for errors or omissions in the professional engineer's work. Note:Alaska Water and Wastewater Consultants, Inc. shall be paid $1,4.~5 ~-et, or prfor I to closing for the engineering services provided. ' 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I vedty that my investigation, based on procedures outlined in the Health Authodty Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further vedty that based on the information obtained from the Municipality &Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ' ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504 Engineer's Pdnted Name JEFFREY A. GARNESS, P.E. Date 337 -6179 Engineer's Comments: In conducting this evaluation, AKWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results de$c~bed the pedorrnance of the system under the conditions encountered at the time of the test, and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soils condition, groundwater levels that may fluctuate dudng the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there ara no hidden defects or encroachments. AKWWC, Inc. can therefore not provide any warranty or future estimate of how long the system will continue to meet the operational requirements of the ADEC or MOA DSD. The content of this report is for the sole benefit of the owner listed above. Any reliance upon or use of this report by any other person or party is not authorized, nor will it confer any legal #ght whatsoever. 5. DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for __ Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the f~lowing stipulations: ,~'~ _ . WASTEWATE . : Manitenance Agreements Supplemental Engineers Reo~ Other (Rev. Original Certificate Date: Legal Descrlp~on: A. WELL DATA Municipality of Anchorage Development serVices Department BulMIng Safety Division On-Site Water & Wastewater Program 4700 6ou~h Bragaw St, P.O. Box 19~650 Ancflomge. AK 99519-6650 www.cLanchomge.ak.ua (~07) a43-7904 HEALTH AUTHORITY APPROVAL CHECKLIST JODIE ESTATES S/D; LOT 1 Well type I~rVA~ If A, B, or C provide PWSlD~ N,/A Date completed 10/8/1984. Sanitary seal (Y/N) YES Total depth 134 ft. Cased to 40'+ ft. FROM WELL LOG 10/8/1984, 6,5 g.p.m. Parcel ID: 015-145-01 Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 7/10/2002 70 ft. 6.1,3 g.p,m. Nitrate 0.274 mg./L. Other bacteria Date of sample: 7/10/2002 Collected by: YES YES Date of test Static water level Welt production 10 WATER SAMPLE RESULTS: Coliform 0 colonlas/100 mi, .a~senic: N/A mg./g SEPTIC/HOLDING TANK DATA 12+ in. 0 colonies/100 mi. AKWWC, INC. Date installed 6/7/1996 Cleanouta (Y/N) YES High water alarm (Y/N) N/A A+ SERVlCES Tank Type/Material STEEL Tank size 1250 gal. Number of Cempenments 2 Foundation deanout (Y/N) YES Depression over tank (Y/N) NO Date of pumping 7/10/2002 Pumper ABSORPTION FIELD DATA *DIMENSIONS AND FIELD DATA ARE FOR THE 1991 TRENCH Date installed 9/~/1991 Soil rating ~ fl~odrm) 0.6 System type DEEP TRENCH Length Sa, fl. Width 3 fi, Gravel below pipe 7 ft. Totaldepth. is ,ft. Eff. abaorptionarea 756 fi2 Monitodngtuba YES Depmsaionoverfleld NO Date of adequacy test 7/11/2002 Results(Pass/Fail) PASS For 3 bedrooms Fluid dedth in absorption fleld bafore test .t5 in. Water added l O81gal. Elapsed Time: 95,5 min. Final fluid depth 63.5 in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN If yes, give date - *TESTED 1991 TRENCH ONLY. 1996 TRENCH HAD WATER APPROXIMATELY 12" BELOW INVERT New depth 82 in. 4,50+ g.p,d. O. LIFT STATION Dali ins~lled 'Pump on' level at in. Datum E. SEPARATION DISTANCES Size in gallons 'Pump ofP I~,~1 nt __,ir;. Cydes tested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tankaift steUon on lot 100'+ Absoq3tlon field on lot 100'+ Public sewer main N/A Sewer/septic service line 25'+ Holding tank ManholelA~-~-<- (Y/N) High water alarm level at Meets alarm & circuit requirements? On adjacent lets 100'+ On adjacent lots 100'+ Public sewer manhole/cteanout N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON-LOT TO: Building foundation 5'+ Pmbe~/line 5'+ Water main N/A Water service line 10'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Absorption field Surface water 100'+ Building foundation 10'+ Surface water 100'+ Wells on adjacent lots. I00'+ Property line 10'+ Water service line 10'+ Curtain drain NONE KNOWN F. COMMENTS Water main N/A Driveway, paddng/vehicie storage G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the ebove systems em in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Na~e Dali JEFFREY A. GARNESS 10'+ Waiver Fee $ Date of Payment Receipt Number in. · 'JUL-IS-OZ 05:40~ FRC&t-CT&E E~VI]L~:W~I~TAL zTK CT&E Environmental ~ervlc,, Inc. 9075515901 T~854 P.0Z/O3 Fog10 CT&£ Ref. l~ Ordered Dy PWSID 1024170001 Al(. Wafer & Waslewatcr Consult~nr~ Inc. ]odie Es~tes:~t I ~odie ~tes:~t I D~klng Wa~r 0 All Dalec~'rlme~ are Ala~k~ Standard Time Printed Date/Time 07115/2002 Collect'ed Dafo'FIm(t 07/10/2002 14;20 Received Date/Time 07/11/21 ~ 12:55 Te~nlcal Relea.~ed By ( Ni~rate-N 0.274 Units Atlowible Pt~'p Analysis Umtt~ I~ale Date 0~00 mg/L F-PA 300.0 (<10) 07/11/o2 Init JDT Hicrob:Lology Laborat. o~'lr To~al Colif'o.n 0 col/I OOmL SMIS 9222B (<1) 07/I 1/02 SBH CT&E Environmental Services Inc. 200 W. Potter Drive ~rinking Water Analysis Report for Total Coliform Bacteria Ancho,ugn. AK 99S18-1605 Tel: (9071 562.2343 READ INSTRUCTIONS ON REFERSE SIDE BEFORE COLLECTING SAMPLE Fa~: 1907) 581-5301 MUST BE COMFLbl ~D BY WATER SUPPLIER [] PRIVATE WATER SYS~ ~M - ~ ~d R~utt~ · · ~ ~tnd I~voic~ Month Day SAMPLE TYPE: O Routine [] O Repeat Sample (for routlnesamp~e wRh lab ret'. no. ) n Special Purpose Time SAMPLE LOCATION Collected Yesr II Treated Water Untreated Water TO BE COMPLLrl'ED BY LABORATORY Pmal~s~s shows this Water SAMPLE to be: ~1~ Satisfactory ~ O Unsatisfactory 0 Sample over 30 hou~ old, ~sults ~y ~ un.liable . O 8~ple t~ long in ~t; sample should ~ot be ov~ou~ old at examination to indigen ~liable tcsulg. Please smd ~ew sample ~ia ~ccial dcIi~ ~1. ~me Recel,ed / ~ Annl~{~ Began / ~ Analytical Method: ~ Membrane Filter MMO-MUG o Number of colnnles/I O0 mi. Lab Ref. No. Result+ Anulyst Sent to A.D.~C. Ruth ~k~ Jura Collecled Date: Time: Client notified of unsaflsfactot7 results.'. t'hened Spoke with Date' _ , Time: Fa~ed Faxed BACTERIOLOGICAL WATER ANALYSIS RECORD bIMO-MUG Ruult: Total C~llform ~ Coil Membrane Filter: Direct Count ~ .. Colonies/100 mi Verification: LTB BCB COL1PIRM Petal Coliform Confirmation Final Membrane Filter Results Reported By~OJ/~ Date Collform/] OD mi ~me t '9~%T r~ ~rm~ql~ uom~v.,,d ~hn :4OS Grouu [$ocl6t& Gbn~ralo de Surveillance) 0i6-d ~O/iO'd I~SB-J. 10~5195~05 /l~l~ ~YlP/~NO~l/Ik'3 ]l'l~dO~::l ~1~:60 ZO-Sl-*h3t Z EAST llPTH AVENUE N 89 56' 19' ~/ 115.05 Z LEGEND SEWER VENT N 89 57' 07' ~/ 13b,O0 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. # 015-143-01 ' 1,' 'GENERAL INFORMATION Complete legal description· HAA Lot l;' J0d~e Estates. HA 960108 Location (site address or directions) Property owner Mailing addreSs 'Lending agency Mailing address.' Gary & Beth Wilden 5420 E. 112t~t Avenue 5420 E. 112th Avenue / Anc~[oca9e, AK Day phone Anchoraqe, AK 995/6 Day phone 346-322& ,," Ager~t Peter .Jarrett/ R~nax Properties 'Address 260'0 Cordova Stre~ Anchorage, Al< * Unless oth'erwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 Day phone 99503 257-0175 TYPE OF WATER SUPPLY: Individual well Community well NOTE: 4. TYPE OF WASTEWATER DISPOSAL: XXX ~ , Public water · If community well system, provide written confirmation from ~tate ADEC attest- lng to the legality and status of system. Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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 structu re indicated herein. I further verify that based o n 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 S & S ENGINEERING Phone Address Engineer's signature 17034 Eagle River Lo<~p Road No. 204 Date -IS SIGNATURE /Approved for Disapproved. Conditional approval for REQUEST YOU RELEASE THE CONDITIONAL H.A.A. AND ISSUE A HEALTH AUTHORITY APPROVAL PLEASE BE ADVISED ALL WORK STATED ON UPGRADE PERMIT ~SW960045 HAS BEEN COMPLETED° bedrooms. bedrooms, with the following stipulations:"": Additional Comments · Date 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. 72~25 {Rev. 1/91) Back MOA #21 u~r~,~-- . e~ices Division Env,ronment? S .... ~ o9501e (907) 825"L" Street, Room 502 e Anchorage, ~'~ ~ Health Authority Approval CheCMist Legal Descnpno ' ~ ~" ; ~' ? ' ':: ~( Parcel I.D.:_ A. WELL DATA ADEC water system number Well type ~,~(D ,,0~- 7 t~ If A, B, or C, attach ADEC letter. Date completed ' ! ;'" Log present ~/N) ¢ .E ~ ~ ] 3~1 / Cased to ) 3 ~7 Total depth _ FROM WELL LOG / Nitrate _ Sanitary seal ~/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform _ Date of sample: 7)- / 2¢ "i Casing height (above ground) Wires properly protected Cc/N) AT iNSPECTION 4.; c C Other bacteria Collected bY: 3 4- f~ ~,,4o . s vnctuo oe XAm DATA "d 6 I ~i / ~ 6~ Tank size W× 4( ¥ Number of Compartments ) Date instmte Foun~tiou cleanout Date of Pumping Cleanouts ~/N)~ High water alarm (Y~ C. ABSORPTION FIELD DATA , i 2 ..... n~ l,. ,, d/fl ~or ft/bdrm) Date installed 6 / ~ [ ~}' (: ~on ran ~/?v. _ ..... .... ' h &~ Tube present~ Len~h ~ 5 W~dt ~ Gravel thic~ess below p~pe ~ ¢' 6: Monitoring Effective abso~tion area ~ For ~e~ooms ...... t~ ~)t /v 4 ~/ Results ~ass~ail) ~ Date ot aoequa~ tc~ - , Fluid depth in agso~fion field before test 0n.); ~ l~e~t~i3 ~er gal. wmer added ....... - _g.p.d. /(inS.) Mim~s-late~{- Abso~tion rate Fluid dep¢ ....... ~ ~ yes, give date Peroxide t~a~t'~ast 12 ~on~s) ¢~ D. LIllE STATION Date instal/ed _ Size in gallons Manhole/Acccss (Y/N) "Pump on" level at* 0 ' High water alarm level at* --~ "Pump iT level at* CyclesIe~ted E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: ]~¢Pti(/ltolding tank ou lot / 0 ¢9 ~ 7: Absorption field on lot / C t> ' '? Public sewer main zv //j Sewer/septic service line S' 0 "'t .; On adjacent lots _; On adjacent lots Public sewer mmfi~ole/cleanout · Lift station SEPARATION DISTANCES FROM/S~'PTI~C/~OLDING TANK ONLOT TO: Building foundation ,~ ......... Properly line · , ) --~-~ Absorption field Water maim'service hne ). a ' ,,. ~ -~ourmce water/dra/nage / , ' c '/ W" ~ ens on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~,. 0 Surface water .~ ~::' o ) Cnrtain drain ,~' ENGINEER'fl CERTIFICATION l certify that l have determined thru field inwecttons and revtew o ?krumc~ in conformance with ~OA HA~ guidelines in effect o ~gnuture /~, ~,: V'// / ~C~X~ .... ' ) - c Waiver Fee $ Date ofPa~ent ~~}.(r, ~eceipt Number ~.('x~_}( , Date of Payment Icy. 8/95 eSS: haa.wk.doc ~~~ Receipt Number Properly Line ~ 0 '(~ W ~./ ~ ater main/service line Driveway, parking/vehicle storage area ,~ C Wells on adjacent lots / 0 0 '"t 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. # E I S- - / ~" ~ -- 1. GENERAL INFORMATION Complete legal description Lot I; Jodie Estazes Location (site address or directions) Property owner Mailing address Lending agency Mailing address 5420 E. lleth Avenue. Anchorage,_ AK Gary & Beth Wi!den Day phone 346-32~6 5420 E. 112th Avenue Anchor(~q~ AK 995~6 Day phone o Agent Peter Jarrett/ Rer;~¢,.;4 Properties Address 2600 Cordova Street Anchoraqe., AK Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual well XX;,C Community well Public water NOTE: Day phone 257-0175 99503 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 NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. XXX 72-025 (Rev. 1/91) Fronl MOA #21 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 S & $ ENGINEERING Phone 17034 Eagle River'Loop Road No. 204 Eagle River~ AlasJ~a 99577 Address Engineer's signature ~/'~ J~/~//~-"-- Date REQUEST YOU ISSUE A CONDITIONAL HEALTH AUTHORITY APPROVAL. SYSTEM TO BE UPGRADED NO LATER THAN 15 JUNE 1996. DHHS SIGNATURE Approved for bedrooms. Disapproved. /~V Conditional approval for J~ bedrooms, with the following stipulations: The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 ~CNW~¢¢uT}ONMENIALSERVlCES DIVISIO Legal I)cscriplion: A. WELl, I)ATA Well lypc. {:'¢'~u'A 1[, l,og present (~/N) Total depth _ 1 ~7> ~ ~ Sanitary seal (~)N) _ Health Authority Approval Checklist -)oOt~- ~'f. ¢/~ Parcel l,P.: IfA, B, or C, attach ADEC letter. ADEC water system number Date complclcd Cased to Casing height (above grotmd) Wires properly protected ,/ FROM WELL LOG AT INSPECTION Date of test ~o Static water level ~.' Well production WATER SAMPLE RESULTS: g.p.m. Colilbrm ~ Nitrate O, /o Other bacteria ~ Dale of sample: '2 ' .2q - qg Collected by: ~A¥ ~ ~ / ..3,~o'y B. SEPTIC/IIOLDING TANK DATA 7/'~ '~ ___ tllllber of Col,lpanlllelltS CleallOtltS (_~.~) ~ l)atc installed ~-, , Tank size Ig 5' o N ' -, *~ Fouodatioo clcanout <~) g Depression (Y~ ~ High water alarm (Y~) ~ ~ C. ABSORIYFION FIELD DATA Datcinstallcd '"1-G-'1~ Soilrating~~rfl:/bdrm) O. Length ./~q '~ '~ % .... Width .> Gravcl thickness below pipe Effective absorption area '-/r:~ (~, ~ Monitoring Tube prescnt{(:~YN) h/ Date of adequacy lest _% .-,5,' -r_~ t5 Results (Pass/Fail) lquid dcptb ill absoft)floe field before test (in.); 'Y' Pc,'oxidc trcatnlcnt (past 12 lnonths) (V/~)) ~ Systeln lypc 'q-~agci4 7 Total dcpth [ 2 t _ _ Depression over field (YJ~) ~ For S' ~(C 'Y' bedrooms fimnediately after ~ gal. water added (in.):, '¢ Absorption rate = ',7~t; ~/' g.p.d. If ycs, give date '~ Do LIFT STATION Date installed High water alarm lcve~ E. SEPARATION DISTANCES Size in gall~- ...... - Manhole/Access (Y/N) "Ptn~e~l at* "Pump off level at* *Datmn SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot joo Public scwer ~nain Sewer/septic service line _; On adjacent lots : On adjacent lots Pnblic sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation ~, Property linc ! D ~P Absorption field ~ . Water mai~ffservicc line lo "P Surface water/drainage J0:O 1'4~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ) o '~ Water main/service line Surfi~cc water i ~ o ~ + Driveway, parking/vehicle storage area ~ o Cu~ain drain ~O~d~ k~cxa~ Wells on adjacent lots I oo V Prope~ line F. ENGINEER'S CERTIFICATION are ] cert!f? that I have determined thru field inspections and review qfMunicipal i,? co,ffbrmance with.~/lOxrd y~ ~uidel~ m ef/aot on this date. Engineer's Nane ~z3 i~ c . k ,;O//.~ c~,. ~ ............................................................................................................... HAAFoo $ ~)D ' d~) WaivcrFce$ ~)}-~ ~" Date of Payment Date of Payment _ RecciptNumber /Z(/-/__&~'',S"'~ ) ReceiptNnmber Rev. 8/95 OSS: haa.wk.doc Zt~ CT&E Environmental Services Inc, Laboratory Analysis Report CT&E Ref.# 960688,4722 Collected Date 02/29/96 Client Sample ID LI JODIE ,SD OS FAUCBTI0688-01 Matrix Drinking Water Technical Director PWSID 0 Released By ~ S,'unple Remarks: QC Attowabte Prep AnaLysis Parameter ResuLts Qua[ PQL Units Method Llmlte Date Date Intt Nitrete-N .I00 U .1 mR/1 ~PA 353o~ NO3 0]/0~/96 03/02/96 200 W, Potter Drive. Anchorage, AK 99518-1605 -- Tol: (907) 562-2.343 Fax: (907) 561-6301 3180 Pager Rood. Fairbanks, AK 99709-5471 -- Tek (907) 474,8656 Fax: (907) 474-9685 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFOI~NIA, FLORIDA, ILLINOIS, MARYLAND. MICHIGAN. MISSOURI. NEW JERSEY, OHIO, WEST VIRGINIA CT&E Environmental Services inc. La bor~m.W' Division Drinkina~ Water Anal,;sis R~port for Total Coliform Bacteria ~ . Anchorage. ~..ID LVSTRUCTIO ¥S O.V ~VERJ~ siDEBEFO~ COLL~CTI3'G SA3[P~E T~;: (~07) r} ~, 5¢,~d Results' G $~nd [n.oice Month Day Year SAM?LE Rou6ne O Treated Water Repeat Sample (for routine sample ~ Un~rea~ed Wa~er ,.hh lab eel no. ) Speci~l Purpose Time Collected SA3LPLE LOCATION C~llect~d By TO SE CoM?LETED BY Ar. ab'iis showa thi~ Wa¢~r SAMPLE ~o b~ UnrZl[e, bi~ C $amp[~ too tong i~. :r~nSk: s~mple S'aOuid ,qo~ be over 48 houei old ~ new s~.mp[¢ via spech[ de[ireO' m~il. Da~¢ Received ~].~ ., Analvdgal 3 ethod: .~ .Membrxa." Fih~r ,~ MX'fO-MUG Number O['COlO~{e$."100 Lab R~r. No Result~ Azml)~t. : .'"" 96.0688 S,:,,~ m .\.L),E,C, ~ O::< ,3/. ~J Ti.t:,: ,Jun Clien r noti fled of un$:~(iSfartOF,.' r~Sul;5: [] BACTERIOLOG[C:%b WATER ,&",'.CLYSIS RECORd) 5t310.M-L'G Retuh: Total Coliform .X(¢mbrane Fihor: Direct Coun¢ Verification: LTB BGB ,,, Fecal Coliform Confirmation Reported B?' - 'i Date E. Coli O Coh)nle~/lO0 all COLIFlP.31 Coli(Orm/IO0 mi S, o/. 9~ ~.,~ /~zr-O ~,, PAST ONE OF TwO. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage. Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # GENERAL INFORMATION Complete legal description Lot I; Jodie Estates Location (site address or directions) 5420 East 112t¢~ Avanua Property owner Mailing address Lending agency Mailing address George. & Mildr&d Sc~alzried Day phone 5420 East 112th Avenue, Anchorage., AlaSka 546-1363 WK b62-2654 Day phone o Agent Carol Kilqore RE/MAX PROPERTIES Address 2600 Cn~dn~m _~,¢. A~o~o~g~; A/c,S~ 9q503 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: XX Individual well Community well NOTE: Day phone 257-0162 Public water If community well system, provide written confirmation from State AD£C attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: XX Public sewer 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 furtherverifythat 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 .... S & S ENGINb-~RIN~ 7034 Eagle Ri,vet Loop Road Phone__ Eagle River, Alaska 99577 Engineer's si~,:lnature Date DHHS SIGNATURE ,~.~. Approved for Disapproved. bedrooms. Condi[ional approval for bedrooms, with the following stipulations: Additional Comments I1 II I The Municipality of/\nchorage 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 DH HS 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 enginee~s work. 72-025 (Rev. 1/91) Back MOA #2J Well type~ if A, B, or C, attach ADEC letter. ADEC water system number com ~etea- ~ Date P \ ..~ Log present ~,1) ~ . ~'~J-~_~___ Casing height- ~ \--2~z3¢ Cased to ' - - Total depth Sanitary seal ¢!~N) ~- /' _ Wires properly protected4:~N) --~ ''~ AT INSPECTION FROM WELL LOG __~ ~-~'~_ I Date of test ~ ~,.0~ I - Static water level ~ ~ ~z2_~ ~', ~, .~t~ g.p.m. Well flow ~ g.p.m. ~ ~ -- Pump level SEPARATION DISTANCES FROM WELL TO: ~ ~ ---------; On adjacent lots \ ~c~>t .A~ Septic/holding tank on lot ~ Absorption field on lot __________~¢;~2~~ ; On adjacent lots ~ I -¢;~-I Jr' ~ Petroleum tank ~'~-- ' Sewer sewice iine WATER SAMPLE RESULTS: Coliform --~ Nitrate Date of sample: ~ ~'~'' .--~_t ~..~"~~ .--. Other bacteria -- Collected by: ~ _~ ~_~---- SEPTIC/HOLDING TANK DATA~ ,/, ~ ~/ ~_~_ ~//l~)~r~ ;"' "Tanksize ~ ~Compartments Date installed ~ ~ ~ Depression~ ~ ,/ -/' F,~undation cleanout~N) -- -~ ~ -- Cleanouts ,[SC/N) ~ 7 ~_~ , High water' alarm (Y/N) ~ _ Alarm tested (Y~_~. Pumper Date of pumping ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: ] Foundahon -- Well(s) on lot ~, ~:>L.~> _On adjacent Iots~ ~ ~:~ I .Water main/service line-- ~ ~'~> -- To prOperty line ~-~:~ I'Jr~ Absorption field ~ .~ Surface water/drainage cONTINUED ON BACK PAGE 72-026 (Rev, 7/91) Front ~. L,-T STATION Date instalie%~ Size in gallons ~-~ Manufacturer ---- ~7~ ~ Manhole/Access (Y/N) Vent (Y/N) ~'~-- ...... "Pump o n'~_~ High water alarm level Meets MOA electrical codes (Y/N) ~~ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA Surface water ate Installed -__ -1-- Z~ _- GI ¢- -.~ I .... ~' ' , Soil rating ~, ~¢ ~F~¢ ~ ...... ~ .... , Length '~t-' .-~ ' ~~~ystem type '-~ ..... Width ~ G ~ t ~- . ~ -~ ravel thickness ~ ~ . / oral abso Dtinn hr,, , ~l[~'"/ -z -~~-/otal depth Depression over field (y~_ ~b~ _ Date of adequacy test__~ Oleanouts present~¢~) ---77~ Peroxide treatment (past 12 months) (y~ ~- for ~ bedrooms _ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~& ~ }-:~I. $. On adjacent lots ~~- To building foundation .~ ~--(~' ?; ..... ~ropertyline~ ~ ~ L: - ' To~xisti~g or abandoned system on lot_ On adjacent lots__ ~% _) l.~ .... Cutbank_ L Surface water ~_ ~f :~,~ ~- Water main/service line_ 0 -~-' ~'¢ ~Z' / --Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all ~QA and HAA goidelines in effect, ~ of this inspection. S & S I:~NGINEERING Signature '~7034 ~' , ....... Engineer's Name ( ' ~f ~ Waiver Fee:$ , of Payment _~,,' ~_-) ~ _~ L~) (_) .--, ,~--~ Date of Payment 4pt Number ...... %'~ -~/~--~ Receipt Number (Rev. 3/91)Back M0^21 CHEMICAL & GEOLOGgCAL t?ABOg ATOJ Y A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX:(907) 561-5301 ANALYSIS REPORT BY SAMPLE £or WORKorder# 36865 Date Report Printed: AUG 5 91 ~ 17:12 Client Sample ID:L1 30DIE ESTATES PWSID ;UA Collected AUG 2 91 @ 13:00 hrs. Received AUG 2 91 @ 16:00 hrs. Preserved with :AS REQUIRED Client Name :S & S ENGINEERING Client Aect :SNSENGP BPO ~ PO ~ NONE RECEIVED Req ~ Ordered By : Analysis Completed :AUG 5 91 Send Reports to: Laboratomy Supervis.~9 :STEPHEN C. EDE 1)S & S ENGINEERING Chemlab Ref ~: 913877 Lab Smpl ID: I Matrix: WATER Allowable Parameter Tested Result Units Method Limits NITRATE-N ND(O.10) mE/1 EPA 353.2 Sample ROUTINE SAMPLE COLLECTED BY: R.D.J. ~emarks: I Tests Performed ' See Special Instructions Above UA=Unavailable ND= None Detected *' See Sample Remarks Above NA= Not Analyzed LT=Less Than, GT=Greater Than Member of the SGS Group (Soci6t6 GgnCrale de Surveillance) 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 J~ PRIVATE WATER SYSTEM Name Mailing Address S & $ ENGINEERING Phone No. 17034 Eagle River LOOp Road No. 204 Eagle River, Alaska 99527 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 4 TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: /~atisfactory [] 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 /x'~ ¢~"~ Analytical Method: Membrane Filter No, of colonies/100 mi. Time Collected Lab Ref. No, Result* Collected _~ / ~ 5'1. 3877~ ~ i t-FI I I-F1 I I--F1 BACTERIOLOGICAL WATER ANALYSIS RECORD Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count (.__,~ Verification: LTB BGB__ Final Membrane Filter Result~_~ . Reported By -Date Time: TNTC -- Too Numberous To Count OB = Other Bacteria Coliform/100 mi Coliform/100 mi ¢-~ -?/ r~-z_~ a.m. PART ONE OF TWO REMAINDER TO FOLLOW MUNICSPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRON~qENTAL PROT~:CTION 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) Location (address or directions) (b) Applicant Name _~[c~p Telephone: Home ~Y5% ¢~¢/¢~ Business ~"-~%;&/¢ Applicant Address _~( ~;~ ~. 7~¢ ¢~ ~c'4.._ ~'" c*~;' ¢ (c) Applicant is (check one): Lending Institution ~; Owner/builder~ Buyer ~; Other ~ (explain); (d) Lending Institution ~I~?~L'¢~ Telephone (e) Real Estate Company and Agent ~/~' Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Singte-Famity,~'" Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well ~ Community b-] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite,~.]/ Public [] Community E] Holding Tank [] Note: If community well system, must have written confirrnation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72~025 (11,84} ENGINEERING FIRIVI PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND ~NFORMATION As certified by my sea~ 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 veri~y tha~ based on the information obtained from the ~unicipality of Anchorage files and from my inves~iga~ion and inspection, ~he on-si~e water supply e~d/or wastewater disposal system is in compliance wJ~h ali ~unicipa~ and S~ete codes, ordinances, and regulations in e~fec~ on ~he date of th~s inspection. Name of Firm ~L~ ~ ~'~ ~: Telephone . ...~ ~" ~d~ Address [~ ~- ~ '5 .~c~ 5_ , ~, A~ ~?~5~c° ';:~_. Approved for ~-L¢_.~_~ bedroomsby ~ ~ Date __ Approved ~, Disapproved ConditionaF~. 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 hames 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. WELL DATA Well Classification [ ~/'~ ('': Well Log Present ~?N) Total Depth f'~'~( _ Cased to Static Water Level ~./-':d' ' Casing Height Above Ground __ Electrical Wiring in Conduit~¢N) Separation Distances from Well: MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: ~ [/ /~// If A, B, C, D.E.C, Approved (Y/N) Date Completed /;¢* ~' ' ~¢ Yield DEP~, OF HEALFII & t~NV RONMENF,'r',L, P;,~OTf. EI'iON ' 985 Water Sample Collected by Water Sample Test Results Comments Depth of Grouting Pump Set At Sanitary Seal on CasingL~N) Depression Around Wellhead (Y/(,_t~ To Septic/Holding Tank on Lot ~_ :. :*, _ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /( -? ' ; On Adjoining Lots - d'~ ~-~ /~'?c~ To Nearest Public Sewer Line .... ~'?~- To Nearest Public Sewer Cleanout/Manhole __ ' To Nearest Sewer Service Line on Lot B. SEPTIC/HOLDING TANK DATA Date Installed _ ~'~- '%L:'- ~Size _ /,? ¢:; (.? No. of Compartments Standpipes(.~N) Air-tight Cap~(;~['''F~ :*(" Foundation Cleanout~(~i~J Depression over Tank (Y/~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ./~:/:/' ; for Holding Tank High-Water Alarm (Y/N) /¢-~"! Temporary Holding Tank Permit Separation Distances from Septic/Holding Tank: ~C~' 't'~,'~';~~ To Water-Supply Well _ '7~'t _ IC~)/.%' ()i;;~ To Building Foundation ~' To Property Line ~-:? /".. ~0 To Disposal Field ~-~' ' TO Water Main/Service Line ~ /"-~ ,.~2':'~- / Course ~;;,. ~- /(?(., r To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84} C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~?" '?~O Width of Field ;¢,(? Square Feet of Absorption Area Depression over Field (Y~i' /, Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well _//'-~ z~_~,~?_ ___ Type of System Design Length of Field .... 'D~/ /, Depth of Field Gravel Bed Thickness e/"" Standpipes Presen~_~})N) Date of Last Adequacy Test To Property Line To Building Foundation , ? ,:2 "¢' To Existing or Abandoned System on Lot ~,-'~_ /~/¢/I .... ; On Adjoining Lots q o Water Main/Service Line ~ ~'~ zed'_~_ ....... To Cutbank (if present) __/~'¢~ To Stream/Pend/kake/or Major Drainage Course ~./F'~ f'~:'~C'; / To Driveway, Parking Area, or Vehicle Storage Area _ ?'~_~-i '~)' Comments .. LIFT STATION Date Installed ..... Dimensions Size in Gallons /~Manhole/Access-C~N) "Pump On" L,,vel at _' ,/~ .//~'"P~~f"Levelat' -- ~ High Water Alarm Level at . _ ~ Vent (Y/N) Tested for ~/ Pumping Cycles during Adequacy Test, Meets MOA Electrical Codes (Y/N) .7~/ Comments ~' ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked verified or conformed to all MOA and HAAguidelinesineffect onthedateofthisins3ection. Signed .... -~. ~ ~':: ~ _ Date _ ~ ~7- ~E2'~ ~'~ ':~ _ Company /"/~r ;~ ~ ,!: MOA No. ~'~'~¢ '''~' ~:_~., '2 Receipt No. Date of Payment Z ~-' ~:2 :~ Amount: $ z~~ Page 2 of 2 /2-026 (1 h84)