HomeMy WebLinkAboutCHUGACH PARK ESTATES BLK 2 LT 14AGREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LEGAL DESCRIPTION
SEPTIC TANK:
DISTANCE /~./ ~-~
FROM WELL
INSIDE LENGTH
MANUFACTURER C/~::'~'" ~' ~ MATERIAL
INSIDE WIDTH LIQUID DEPTH
NUMBER OF <~
~ ~' / COMPARTMENTS
LIQUID CAPACITY /O--~ ~ GALLONS.
SEEPAGE PIT:
NUMBER OF PiTS / DIAMETER ~ OR WIDTH
BUILDING FOUNDATION /~, NEAREST LOT LINE g ~
ADDITIONAL ABSORPTION
LENGTH_~~, DEPTH / ~
DEPTH 7 DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) t~r~ O SQ. FT.
WELL:
TYPE CONSTRUCTION.
BUILDING NEAREST NEAREST
FOUNDATION --, LOT LINE , SEWER LINE
CESSPOOL OTHER SOU RCE5
APPROVED DISAPPROVED REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
, TANK __, SYSTEM
DISTANCES:
INSTALLED BY: /~/~t~/~'/7~
PIPe MATERIAL:C~ 7'
LOT SLOPE:
REMARKS:
Form No. EQ.-031
DIAGRAM OF SYSTEM
APPROVE~- ~
> -.A.A.B.
F'EF.:H I T NFL
FIF'F'L. I C FII'-,IT
L. 0 F: FI T I Fi I'',1
LEGRL
r':,EPFIF.'.THENT OF' HEFIL. TH FIND EI'.,IVIF.'.OI'.,IHEI'.,ITFIL C,F.:OTECTION
25:'1..~..'.~ E. TUE.:,OF.: F.:D.., RI'.,ICHOF. tFtGE, RK. ?..-3507
276-222i
[,..i E_"' [_ l_ a ~-~ [:, a:~ ~..~ -- 5 1[ T E '_"'.-_-; ET' [,-! E f.4.: F' EL". F~.: I"--ii Z "~-
,:: 76292: .':, E.',RTE OF
W ILL.. I Rr,1 E:,W"r'EF.:
L t 4 E: 2 C H U G I R ~::: F' k:: E S"t"
:5 F.: E: ~"'~ ::':: 72 L-q E:, I":H U G I R K
LOT SIZE '.,::' G; ;-.-.-: ~: E'~ L:.;6!t_IFfF..:E FEET
¥"r'F'E OF '_:;DIL RE:'_--.;OF.'.BTION E;"r'STEH I:.--.,' TF.:E:NCH
I"IR::':;!i"ILIH NI_II"IE~ER OF BEB'F-:OOHS = ]:
?,01 L F.:FIT t i'.,tE-i :; '5 ('! F 7' ,.." E: F.: ::, =: t2 ~;
THE F.:ES!U ]: F..:EI) S i ZE F~F THE '~ 3 t L RE:Sf.')F:F'T I Ot'.,l ~?¢':-:-:'T',.-:"~ht I :.-.];, ·
]''HE L. ENG].'H DIMENSION IS THE LENGTH ,::IN FEET:.'-' OF ].'HE TF.:ENC:H OF:
THE DEPTH OF Ft TF..:EI'.,ICH O~: PI.T I~E; THE DIS'f'Fi1`.,~CE E~E'i'i.,.iEE1'.f THE '.:-];UF:F',~,E:E OF '!"H;E
GF.:OUI'.,IE:, FIt'-,tD THE BOTTOP't OF THE E;:.0_-':.:F¢,?FITiOI'.,I ,:::IN FEET::,.
]''HERE IS NO SET !.,.IIDTH FOR: TF-:ENCHES.
THE GF.:FI',,,'EL E:,EF'TH IS THE H INIHUH E:,EPTH OF GF.:FI',,,'EL BE-I'WEEI'.,I THE OU]"FF~LL F'IF'E
FINE:, THE E,'OTTOH OF THE EXF:R',,,'FtT 'r ON ,.'.'IN FEET::,.
HF...Z,-... THIS
E:AF:KFILLING L-iF R1`'4"r' S~'STEf'I WITHOUT F
E:,EF'FIF.:THENT 1.4It_L E:E SUB..TECT TO F'F.:O'.-__:;ECUTIFI1`'L
H i N I HUH [:' I STRNC:E BETWEEN FI WELL AN[." RN"r' ON"-S I 'rE SEWRGE I::.', I :.'.:.;F'OSF4L '_:.;'-r':S'T'EH
"i.6..'~O FEET FOR FI F'RI',,,'FiTE 14E:LI. OR 2E1E~ FEET FOR R F'LIE:L.I.C WEL. L.
WELL LOGS FiRE F.:EL:.'!UIF.'.ED FiN[." ['1LIST E:E RETU~:NE[:, TO THE [:,EF'FiF.:Tt"IENT WITHIN
OF THE WELL COHF'LETION.
SPEC I F' I CFi].' IONS RN[:, CONS]"RUCT I ON [:, I FiGF.:Sf"IS FiF.:E Fi',,,'81 LFiE:L.E TO I NSIJF.':E F'R¢'~F'EF.:
l NSTFiL. LFI].' I ON.
I CERTIF"r' THRT
::L: I FII'"t F'FIMILIRR WITH THE REQUIF.'.EHEN'f'S FOF.: ON-SITE SEF.IERS FIND WELLS RS SET
FOF.:TH B"r' THE HUNICIF'FILIT"r' OF' RNCHORRGE.
':2: I F~ILL I NSTRLL. THE S"r'STEf'I IN FICCOR[:,RNCE [4iTH THE C:ODES.
:::~:: I UNDEF.:STRNE:' THRT THE ON-SITE SEWER S"r'STEH HFI"r' REg!UIRE ENL. FIRGEHENT IF ].'HE
RESIDENCE IS REHO[:'ELE[:' TO I NC:LI..I[:,E HORE "FHFIN ii: E:EDROOHS.
S I GI",IED: ...............................................................................................
F-IF'F'L.. I CFtI'-,tT I.,.I ILL. I Fih'l [:,N'-r'ER
I L:.,SUED 8"r' .......................................................... [:'RTE .........................................
I1`.4~]F'EC].'II3N HIS].'ORY - SEWER I 0 SEWEF.'. 2: E'~
WELL. INSF' E~ ~4E[..L LOG DFiTE E~ DRII...LEF.:
MUNICIPALITY OF ANCHORAGE
DEPL OF HEALTH
ENVIRONMENTAL PROTECTION
APR 'i 1977
RECEIVED
( erlifie Drilling T,
A & L DRILLING COMPANY
OWNER OF LAND (~ ILL /
ADDRESS
LEGAL DESCRIPTION ~-
DATE-Started
PERMIT NUMB~ 76
BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588
Ended
!
DEPTH OF WELL ~ O
STATIC LEVEL OF WATER FT/.
DRAW DOWN FT. ~OO
GALS. PER HR 60
KIND OF CASING ~ ~ ~ tO
KIND OF FORMATION:
From O Ft. to ~ Ft. OOE[qoR .~' From--
From c~ Ft. to [0 Ft. T~..~OR0_ From__
From / 0 Ft. to / (~ Ft. ~L/~ ff~- ~/~ ~d. From__
From t/~ Ft. t° ~o Ft. ~0 ~ ~g~'~ From__
From ~ ~Ft. to ~c'~ Ft. C~<~'~'t~'~'~'o~<' From__
From ¢._~ Ft. to ~ Ft. ~-~,-~d ~_t~&~'t~r.~. From
From_ ~'~) Ft. to q~" Ft..~'/~ ~" From__
From q~" Ft. to t~o Ft. ff/~trig; ~6~d'qt-.ere- From
From ~DO Et to ~ ~-~ F~ ~ ~o< t< $~/J From
From ~qJ Ft. to ~J/ ~. ~[~,~ ~oc,~ From~
From ~lt Ft. to ~ I ~ Ft. a~O eoc ~< ;~F~ ~/ From
From ~ Ft. to *)o Ft. ~~< C,</~O From
From
From ~ )T Ft. to ¢o~ Ft: ~oq ~' ~'*o0 From
From Ft. to Ft From
Ft: to Ft.
Ft. to._ Ft
Ft. to Ft
Ft. to.__.Ft
Ft. to Ft
__.Ft. to__Ft.
Ft. to Ft.
__.Ft. to Ft.
Ft. to__Ft.
Ft. to.__Ft
__Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to Ft.
Ft. to__Ft.
Ft. to Ft.
MISCL. INFORMATION:
DRILLER'S NAME
MUNICIPALITY OF ANCHORAGE
~ ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
' "' '2 ' 82BLStreet-Anchor=,ge, Alaska 99501'
(jl~_-'-~J i::
' ~:~'. R'EQUEsTxFB~bpp:R6V~['dF.INDIVIDUAL WATER AND SEWER FACILITIES . ..
Complete all pa~ on page 1. Incomplete_ r~u~ ~11 n~ ~ proc~. Please allow ten ~0) days for pr~sing. ' ' ' '
DIRECTIONS:
1. PROPERTY OWNER ~ ~ ~ . - . ~. ~ j PHONE
MAILING ADDRESS
751 . ' ..... . ...... . ..... - .
PROPERTY RES DENT (lfdifferent.from ahoy) , x; ~ - . . r ~, : PHONE
~ BUYER . - . : . PHONE ... '.
~MAILING ADDRESS ~ {',.~:" ;' ~ ' - ._ - ' '. ..- ' '~.',: ' ....
" Lo~ & Ne~tletm'" ~9
MAILING ADDRESS
4. REALTOR/AGENT .... · - , . .- ~ .... ~ PHONE
MAILING ADDRESS
5. LEGALDESCRIP~ION ': ' . -~ ~ . ::, ,' ' · T , · -.~-
STREET LOCATION ~' ' :'-._ ;' ' '
K~lb'erg Ro~ ~-- ' -
6. TYPE OF RESIDENCE
:j~ SINGLE FAMILY
.... .-: i--I MULTIPLE FAMILY
NUMBER OF BEDROOMS
I--]. One [] Four Other__
(~]; '"Two t~ Five .
--~ ;;. Three :- I-3 Six .: ~;'-;-;:'; ::-
7. WATER SUPPLY
INDIVIDUAL'
COMMUNITY
[] PUBLIC UTILITY
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.} Depth /+70'
8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE**
[~ PUBLIC UTILITY
**if individual/on-site, give installation date '~$
If system is over two (2} years old a.n adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PRoCESSiNG CAN BE INITIATED,
72-010(3/78)
'"'"--~'HtS S.IDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS
TIME TIME
IDA [rE RECEIVED
TIME
DATE _-,,~. ., _- . .; DATE .~ ., ............ t DATE
DIRECTIONS: ,7 ,~.~'.."~*--"'~' ";'~,~ :~,~J~-,, -- -', · - .. ',
1."TYPE OF RESIDENCE ' '; "'": .... NUMBER OF BEDROOMS
[] SINGLE.FAMILY.
[] MULTIPLE FAMILY'.,'
.-{~:] ONE [~ (-'] OTHER
[] fwo :[]
THREE ~1-3 ..FIVE
Fou · '
R ~ I--] SIX
2. WATER SUPPLY
[] iNDiViDUAL..:.
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM'-
[]INDIVIDUAL/ON -SITE
[~PUBLIC UTILITY ' ; ' ~': -"
Connection Verified : .
[]Septic Tank or E] Holding ~a~k.~'? 'i
give di me nsions: '
TYPE OF TANK .-
-. ,.. :~.. ;~' .':
TOTAL ABSORPTION AREA .- ' 't ': ~.
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
~-01LS RATING
MAN U F ACTU R ~..~
MATERIAL
Septic/Holding Tank IAbsorption Area
Absorption Area to nearest Lot Line .: .,- --. .
5.
COMMENTS
[~APPROVEDFOR - ~ BEDROOMS ...........
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
LEGAL DESCRIPTION
BY (Title)
724)10 (Rev. 3/78)
ASBUILT-NO CORNERS SET THIS DATE.
............... ~.;wA~_n & ASSOCIATES I4~ND SDRv.:ffNG 694-0829
I HEREBY CERTIFY .THAT I HAVE SURVEYED THE SCALE~
FOLLOWING DESCRIBED PROPERTY:
...... OF
AND ~AT NO EN~OAOHMENTS EXIST ~CE~ AS
~.'~.
., ~.' '...
INDICA~D. IT IS THE flES~NSlBILI~ OF THE
OWN~ TO D~ERMINE THE EXISTENCE OF ANY GRID~
E~EMENTS, COVENANTS, OR RESTRICTIONS ,'
VISION PLAT. UNDER NO CIROU~STANOES S~ FD: ff~ '. L$-6918 ."~
~Y DATA H~EON BE USED FOR CONSTRUCTION ~'~ . ~-'. '
OF FENCE LINES, OR FOR E~LISHING ~ND- '~RAWN,
ARY LINES.
Municipality of Anchorage
Development Services Department
· Building Safety Division
On-Site Water & Wastswater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(90?)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAH]LY [:)WELLING
Parcel I.D. 051-481-51
t. GENERAL INFORMATION
Expiration Date:
Completelegaldescription CHUGACH PARK ESTATES SUBDMSION; LOT 14A, BLOCK 2,
LocalJon (site address or directions) 19209 KULLBERG ROAD * CHUGIAK, AK 99567
Cu~Tent Property owner(s)
Mailing address
Lending ag6ncy
' Mailing address
Real Estate Agent
Mailing address
ERIC sMFrH Day phone.
P.O. BOX 672117 * CHUGIAK~ AK 99567
Day phone.
746-7502
BUTCH JACQUES w/ COLDWELL BANKER Dayphone. 746-1999
10928 EAGLE RIVER ROAD * EAGLE RIVERt AK 99577
Unless otherwfse requested, HAA wfll be held by DSD for pickup.
2. NUMBEROF BEDROOMS: 3
3. 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 Health Authority
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil
engineer registered In the State of Alaska. Certificates of Health Authority Approval ara 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. Ce~ficates 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 pedod 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 cf the validation date shown below, I vedfy 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 bedmems and type of stn~cture indicated herein. I further vedfy that based on the
information obtained from the Municipality of Anchorage tiles and from my investigation and inspection, the
on-site water supp/y 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 690i DEBARR' ROAD. SUITE 2B · ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. CARNESS. P.E.
Date
337-6179
Engineer's Comments:
In conducting this evaluation, AWV/C, Inc. affempted to provide a thorough,
conscien§ous engineering analysis of the system in accon:tance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the perfomtance of the
system under the conditions encountered st the b'me 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 levals 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. AW1/VC, 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
Disapproved.
Conditional approval for __
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Englneer's Reort
Other
Original Certificate Date: /O ' ! I- O ]
Municipality of Anchorage
Development Services Department
On,.Slte Water & W~tewater Plagram
4700 ~oulh 8ragaw 6t.
P.O. Box 196650 Allchotage, A~ g9519-6650
HEALTH AUTHORITY APPROVAL CHECI~LIST
LegalDesctlpl]on: CHUC, ACH PARK ESTATES S/~ LOT 14A~ BLOCK 2, ParcellD:
A. WELL DATA
Well type ~mVAT~
Date completad 9/29/76
Total depth 4OO lt.
Dete oftast
Stall(= water level
Well produclion
WATER 6AMPLE RESULTS:
*CASED TO BEDROCK
If A, B, or C provide PWSID~ N/A
Smamy ~ea (Y/N) YEs
Casedto '40'+ ft.
FROM WELL LOG
9/29/76
210 lt.
1.0 g.p.m.
Detaof~ampla: ~0/I J='J
8EPTIG/NOLDING TANK DATA
Tllnk 'rype/Matallal STEEL
Tank$1ze 1000 gal. Number of Compmtmenta 2
Depmssinn over tank (Y/N) NO
Pumper
*6" SUMP.
Soil rating (g.p.dJ~m~ 125
VV~th 3 fL
Fou~tJon cleanout (Y/N) NO
Deta of pumping 5/o3/01
ABSORPTION FIELD DATA
Data Installed ~ ~/~$ps
051-481-51
YES
well Log (Y/N)
Casing height (above ground)
AT INSPEC~ON
5/3/2OOl
221 lt.
0.72 ,g.p.m.
YES
12+
Other bactarla ._~Lcolonle~/lOO mi.
AWWC~ INC.
Date Installed 11/15/76
Claanouta (Y/N) YES
High water alarm (Y/N) N/A
SANITARY PUMPERS
Total depth 12 It. Eft. abso~ ama 560 ft" Monlturing tube ~
Date of adequacy tast 5/3/Ol Resulta (Pass/Fall) PASS
Water added 451 gal.
Fiulddepthinabso~nllaldbefomtest 0 In.
Elapsed Time: 625 min. Final fluid depth 11
Any m]uvenatJon treatment (past 12 mo.) (Y/N & type)
In. Absorption rate >=
NONE KNOWN
System type TRENCH
Gmvst below pipe 7 fL
Depression over field NO
For 3 bedrooms
Newdep~ 69 In.
45O+ g.p.d.
If yes, glv~ date -
D. LIFT STATION
'Pump on" level at in. "Pump n. Hlgh water a~m level at ~ In.
~ Cycles tested Meets alarm & drcult requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WFI I ON LOT TO:
Septlo tank/lilt ~tation on lot 100'+
Abeerplion field on lot, 100'+
Public eewer maln N/A
Sewer/eeplic eewlce line 25'+
On adjacent lots 10o'+
On adjacent lois 100'+
Publlc eewer manhole/cleeonut
Holdlng tank N/A
N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+
Water main N/A Water een~ce line, 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
F'rope~ llne 10'+
Water eervlce line 1 o'+
Cut, teltl drain NONE KNOWN
F. COMMEHTS
Building foundation 10'+
Surface water 100'+
Wells on adjacent lots 10o'+
Absoq~tlon field. 5'+
Surface water. 100'+
Water main N/A
Driveway. perklng/VeNcie storage 50'+
G. ENGINEERS CERTIFICATION
t certify that I have determined through f/eld ~pec~3es end
review of Municipal mcorrls that fhe above systems are In
conformance ~ MOA HAA guide#nee in effect on ~ds date.
JEfi.~h.'Y A. GARNESS
HN~Fes$
Oate of Payment
Receipt Number
(Rev. ~2./m)
Waiver Fee $
Date of Payment
Receipt Number.
MUNICIPALITY OF ANCHOP~.GE
M E M 0 R A N D U M
WATER W~LL ADVISORY
During a recent Health Authority Approval on-site inspection
and test of the potable water supply well on Lot ~ ~
of CHU / cH ~~R~ubdivislOn' the well's
productivity was ~etermined to be _~ gallgns per minute.
The minimum well productivity required by this Department
'(~!C 15.55) for a ~ bedroom residence is . ~/ gallons
per minute. AlthoUgh the subject well currently exceeds this
minimum requirement, all parties concerned are kdvised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
la~s and gardens may be required.
This advisory mumt be attached %o all copies ~f the subject
Health Authority Approval.
.. Munici ali ,; n
· DevelopmentSerVi es . . .Depart eht ..
. . ' Building Safety Dlvlsk~".
· On-Site Water & WaStewater Program,..,. :, .. . .
,;,~700.~uth. B~'~vSL':_ ____. _,_.. ! ' ' ..: ',";'._ : ' - : . ' ' ."
· . .... ..~ .., '.' iP.0:B~x]96850~ge, AK99~ig-~50:'?,
,...- v~av.~.ar, c~orage.ax.us - ..... ,, .., ..; , .. .... .... -., .
· · ::; :'..'"..(907)343-7904::.,'.: '.: '.:' ,-,..
'.'- -:' CERTIFICATE OE',HEAkTH,- U I OJ It,Y,'AppI O AL.,: .
'- - FOR 'A':SINGLE FAMII.:Y'DWELL lNG '"".'-": ....
-ParcelI.D.., 051--481;'~~'; "" '".' ': ",* ' *:""'.."": ,".'H~L:,'
1...G,E,NERAL'INFORMATION . . ~' :: ' 'rp' . ' ' '' 4 . :' . : :.E. xplretion~Date:- :/O- .'~-- O-I -
-- - ~ - : t.-!, L ". "' . . . , ,., .,. . ,3.~ :, ,.' , . ','L" ' .-, .
Comp!ete.l.egal~escdption : CHUGACH PARK,ESTATES SUBDIVISION;,:LOT.,14~
Loca,Uon ~site address or directions) '.,, ,, 1920§ 'KULLBERG ~ ROAD * i CHUGIAK,~, AK' 99567 ' '
:;" ':,: - ; - -'..'::,. .:. .t-..,-.'.>". ...... -'
, .CurrentPropertyo~,;ner(s) ......... : '" ~:' "'"' '"'"""~' ' :' ' ~' '
"ERI.C'SUm-I.'.. , _.'; ~. -- .,..' Day. phone .- -746-7502
.Mallingaddress___ ~ P.O. BOX' 672117 * CHUGIAK
' , .... ' .
n,g ,- :D yph~ne,. ".' .',-. '
Lend~ agency ..... ' '< ' :- ". ..... ·. a
Mailing acldrass .- · ' ..... ' ' ~.., ~, ,: ..........
Real Estate Agent BU'i'CH ~JacdtJes'~'w/'COi:'DWEl:L-'. BAN'K£1~ D~y phone '" 746-; 1999
Mallingaddress 10928" EAGLE RIVER' ROAD *.EAOLE':RIVER~ AK,,9~577 -' ·
Unles~ othe~. ]se requested, HAA wi~lbo held by DSD forplckup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
3
TYPE OF WASTE'WATER DISPOSAL:
Indivldual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HA.&) based only upon the repmsenta%ns given In paragraph 5 by an Independent professional civil
engineer registered In the State of Naska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties sewed 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 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 sewed by Class A or B
wells er a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the
professlonal engineer's work.
Note: ~. aska Water and Wastewater Consultants, Inc. shall be paid. $00.00 at, or pdor
I
' 4. STATEMENT OF INSPECTION BY ENGINEER. -'.
As cerUfied by my seal affixed hereto and as of the'valida~ date shown below, I t/erify that my
' Ir~esb'ga~ion, base~l o~'prbcedur~ outlih~d in the H~alth ,~uthorityApproval Guidelines for this applica~on,, '
shows that the on-site'w~ter supp~/ and/<~'wsstgwater disposal system Is(are) safe, functional and adequate
for the number of bedrooms and O/pe'of structure I~dicated herein. I further ve#[y that based on the
Information obtained from the Municipality of Anchdrage tiles and from my invastigation and Inspection, the,
on-site water ~upply ~n~°r wastewatgr disposal system Is(are) In compliance wfth all applicable Municipal
and State codes, ordinances, and ,n~ju/ations ~n~ effect, at ~.e time of installatlon.
NameofFirm · ,~,LASKA WATER &: WASTEWATER CONSULTANTS, INC. ' Phone 337-6179
'"' '"" .... '
Address' 6901 DEB,ARE ROAD.' SUITE, 2B *. ANCHORA(;E. AK 99504.
Engineer's Printed. Name JEFFREY A. CARNE~S~ P.E. Date
Engineer'sc0mm~ta:'*" * ':* * ' ~ ·
In conducting this evaluation, AWWC, Inc. attempted to provide a gh~oug ,
conscientious englnesdng ana~sis of the system In aco~dance with ADEC and MOA
DSD Guidelines & Regutations. The reported rasu~ described the pedo/mance of the
system under the condi#ons an~ountered at the time of the test, and seperatk~n
. distances measured to readily Identifiable features. The opera~onallife of all wells and
septic systems depend o~ the Iocal sot~s condiuon, groundwater fe~is that may..
~1uc~uate du#ng the year, and ~e v;ater ~es~e of the fem~ being sewed by the system.
· These conditions are outside the central of the eValuat~ of the ~'ystem. Satisfactog'teet
results do not guarantee future perfecnance of the ~tem, nor do they guarantse that
there are no hidden defecte or encroachments. AWWC, Inc. can therefem not i:~ovldo
' ' any warraniy er fulure estimate of howlong the system will conE~ue to meet the
operational requirements of the ADEC or MOA DSD. The content of this repo~ Is for
the sole benefit of the owner tisted above. Any reliance upon or use of this repe~ by any
other person or par~ Is not authorfzed, nor will it confer any legal right whatsoever.
DSD SIGNATURE
Approved for
Disapproved.
"~ bedrooms.
Conditional approval for
e P"
,.~,-' ON-SITE
~: WATER AND
bedrooms..4~h ~ho ~"~1"" sti~ulations: [ :- WASTEWATER
............. ~ ' ~ ; PROGRAM
-... ...
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manltenance Agreements
Supplemental Engineeffs Reort
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
On-S~e Water & Wmtewatet Program
4700 ~ Bm{paw ~L
P.O, BOX 196650.NIchlxage, AK 99519-6650
~ Da.~dptlon:
A. WELL DATA
Well type PRIVATI~
Data completed 9/29/76
TotaJ depth 400 fL
Date of test
Static water level
Weft preduct~
HEALTH AUTHORITY APPROVAL CHECKLIST
CHUOACH PARK ESTATES S/D; LOT 14~BLOCK 2, Parcel ID: *CASED TO BEDROCK
flA. B, or C provide PWSlD# N/A
8antiaP/~eal (Y/N) YES
FROM WELL LOG
9/29/76
210 .fL
1.0 g.p.m.
WATER SAMPLE RESULTS:
Collfmm 0 colonies/1 O0 mi.
Date of ~ample: ~
SEPTIC/NOLDING TANK DATA
wen Log (Y~)
Wh'es ~operty rx'otacted (Y/N)
Ca,~ng belOht (above ground).
AT INSPECTION
5/3/2oo~
221 It.
0.72 g.p.m.
Olber bacteria
AWWC~ INC.
Tank Type/Malarial
Tank Size lOOO gal.
Foundation cleanout (Y/N) NO
Date of pumptng 5/o3/ol
ABSORPTION FIELD DATA
Date Instafled
Length 40 fL
STEEL
Number of Comparlmenta 2
Dapresslon over tank (Y/N) NO
Pumper
*6" SUMP.
Soil rating (g.p.d./lt=on:~ 125
~ 3 fL
051-481 $C -
YES
YES
12+ .In.
11/15/76
Date Installed
Qeanouta (Y/N) ~
High watar alarm (Y/N) N/A
SANITARY PUMPERS
Abeorption ~a~ >-
Totaldeplh 12 ft. Eff. ab~orptionerea 560 fl" Monltoring tube eYES
Data of adequacy teat 5/3/01 Results(Pass/Fall) PASS
Fluid depth In absorption field before test 0 In. Water added 451 gal.
Elapsed Time: 625 mire Final fluid deplh 11 in.
Any reJmmnation tteatmont (past 12 rno.) (Y/N & type) NONE KNOWN
8ystam type TRENCH
Grovel below pipe 7 ft.
Depression over field NO
For 3 bedrooms
Newdepth 69 In.
450+ g.p.d.
ff yea. give data -
D. UFT STATION
Date Instalied Size In Gallons ~
"Pump on" level at .in. "Pum n. Hlgh water alarm level at In.
~ Cycle~ tested Meets alarm & drcult requirements?
Septic tank/lift steUon on lot
Absorption field on lot.
Public ~ewer main
Sewer/se~c ~ervlce line
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
10o'+
100'+
N/^
25'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building founclaUon 5'+ Property line 5'+
Water main N/A Water service line. 10'+
Wells on adjacent lots lOO%
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Water eendce line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
Bulidlng foundation 10'+
Surface water 100'+
Wells on adjacent lete 100'+
On adjacent lots. 10o'+
On adjacent lots. 10o'+
Public sewer manhole/cleanout
Holding tank N/A
O. ENGINEER'S CERTIFICATION
Al~orpt~on field 5%
Surface water. 10o'+
I certify that I have determined through field InspecUone end
review of Municipal reconfs that the above ey~tern~ are/n
conformance wtth MOA HAA guidelines In effect on this date.
Water main N/A
Driveway, paddng/vehlcle storage 50%
Engineer8 .dnt/ed N~m,
Date ~0/
JEFFREY A. GARNESS
Date of Payment
Receipt Number
p~,. ~o)
Waiver Fee $
Date of Payment.
Recelpt Number.
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
WATER WELL ADVISORY
During a recent Health Authority Approval on-site inspect%on
and test of the potable water supply well on Lot ~ ~ ~&7~.. .
Hlook _Q. of CHUC / CH / ubdivzs on, the well's
productivity was ~etermined to be ~7,~m gallgns per minute.
The minimum well productivity required by this Department
'(~C 15.55) for a ~ bedroom residence is . ~; 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 ~f the subject
Health Authority Approval.
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 AUI'HORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
051-481-09 HAA # l~ ,~l/'~0 5~:~ I
1. GENERAL INFORMATION
Complete legal description
C3zuqach Pa~k Estates ~ot 14, Block 2
Location (site address or directions)
19209 Kulberg, Chugiak
Property owner Dazzl & Cynthia Fattens
Mailing address 19~13q T4~ll.~-r-~: Ch~-i~i~: aK
Lending agency N/A
Day phone 688-9279
Day phone
Mailing address
Agent Virginia Kohlfie~:~/Re/Nax of Eagle PJ.~/phone 694-4200
Address 16600 Centerfield D~ive, Eagle River, ~ 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
X
NOTE:
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site ×
Holding tank
Community on-site
Public sewer
If community well system, provide written confirmation from State ADEC attest-
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 MOAI21
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 inves_ti_gation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
Name of Firm Eagle River Engineering Services
Address P.O. Box 773294, Eagle River, Ak
Engineer's signature ~
ordinances, and regulationsin effect onthe date ofthisinspection.
Phone
99577
694-5195
Date
DHHS SIGNATURE
Approved for
Disapproved.
bedrooms.
Conditional approval for bedrooms,
with the following stipulations:
Additional Comments
.'~ ,' ii- t,'..,' ~'
'%~T~e ~nio[~li~ of ~nChorage Oe~m~nt of Nsalth and Human ~i~ (DHH8) i~u~ Heal~ Authofi~
.~ppro~al ~ifi~t~ ~ only upon th~ repr~n~tions 9i~en in paragraph 5 abo~e by an inde~ndent
p[0t~i~gal eng~[ ~,ster~ ,n the State of Al~ka. The OH H8 d~ th~s as a ooua~ to puroh~ of hom~
anti thel( !~n~i,g~ in~itutions in order to ~tis~ oe~in f~eml and ~ate ~ui~men~. Employ~ of OHH8 do not
conduot irish/ions or anal~e da~ ~fo~ a ~eaifi~t~ is i~u~. The Muni~ipali~ of Anohomge is not
~s~nsible for er~ or omi~ions in th~ prof~ional ~ngin~Fs wo~.
724325(Rev. 1/91) Back MOA~r'zl
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number /~///)
Date completed ~?/'7/_~ Driller ~ ~' /
Cased to Z~.~// Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
~,
/ g.p.m. O- ~ g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/t'~di~g tank on lot //0~, '
Absorption field on lot ///~ ~ ~
Public sewer main /'///~
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout ~//~z~
Petroleum tank
WATER SAMPLE RESULTS:
Coliform '~ Nitrate
Date of sample:
Collected by:
Other bacteria
B. SEPTIC~G TANK DATA
Date installed ///
Cleanouts (Y/N) Y~',O ~ ~)
High water alarm (Y/N)
Date of pumping
Tank size ]i~0~ Compartments
Foundation cleanout (Y/N) /~/~ Depression (Y/N)
/Y'//~ Alarm tested (Y/N) /'/,/~
/~/~ g//~' ~/ Pumper
SEPARATION DISTANCES FROM SEPTIC/~G TANK TO:
Well(s) on lot
To' property line
Surface water/drainage
On adjacent lots ~/D~)/ Foundation
Absorption field z~ / Water ma~./service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level _.-~"~ycles tested
Meets MOA electrical codes (Y/N) ~J
SEPARATION DISTANC.~FRO~ LIFT STATION TO:
On adjacent lots
D. ABSORPTION FIELD DATA
Manufacturer ~
Manhol~A~_,o~
...----'~Pump off" Level at
Surface water
installed ///
Date
Length _/-¢~
Total absorption area
Soil rating
System type ~'/~£/v'r'././
Total depth / ~ /
Depression over field (Y/N) /V~D
for '-~ Bedrooms
Width
5uo¢'
Date of adequacy test _/D/Z"/?~?
Water level in absorption field before test
Peroxide treatment (past 12 months) (y/N)
Cleanout present (y/N)
Results (pass/fail)
Gravel thickness
After test /
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ./~ ~
To building foundation
On adjacent lots 7~30
Surface water
/5
On adjacent lots ;/-'?D~') / Property line
~ To existing or abandoned system on lot
Cutbank /~//~ Water mairdservice line
Driveway, parking/vehicle storage area ~
Curtain drain .,A//,4
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect O.q the date of this inspection.
Signature _ - ~' '":~~,;'. ~
n,,n s.ame a-
HAA Fee $ ~tSlO - dZ::) Waiver Fee $
Date of Payment //-/- ~,z//__ Date of Payment
Receipt Number (,/_./4--,~ ~'7/~/-/-~ ) Receipt Number
72-026 (3/93)* Back
State of Alaska - Department of Natural Resources
Division of Parks and Outdoor Recreation
Chugach State Park
Special Park Use Permit
11 AAC~8.010
Permittee
Name/Organization:
5 9 6 6 ) aov i '~ ]~:/4
Permit # ~' .0 7 ~
Contact nam e/phone:
Address:
Phones:
Location of Authorized Activity (attach map if necessary):
Description of Authorized Activity:
Permit tern: or-n-.~,~- ~% I~%ffto ~:~.~e,.,r~,~' ~.-m-g~- o,.~.~..s .
The permittee agrees to abide by the terms and conditions of this permit,
including any attached stipulations, and will confine their activities to
those described herein.
Petm~?tee
Corporate Secretary & Seal
(if applicable)
Issuing Official
Title
Date