Loading...
HomeMy WebLinkAboutUS SURVEY 3042 LT 75CA 0 t; At, S TA P"TM W. VPW,& • Municipality of Anchorage Page I of 7- 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: S`�,J 9 Lo i 25 PID Number: C-7s 13Z -18 Name: Wastewater System: ❑ New El Upgrade l,c�n �T. Inc.. . Address: ABSORPTION FIELD Phone: (._ 2 -7-7 No. of Bedrooms: ❑ ep Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other LEGAL DESCRIPTION Soil Rating: Total Depth from original grade: GPD/S . Ft. Lot: Block: Subdivision: Depth to pipe bottom from o al grade: Gravel depth beneath pipe S S 5 (cm U21-> Woo Ft. Ft. Township: Range: Section: Fill added above original grade: Gravel length: Ft. Ft. WELL: ® New ❑ Upgrade Gravel width: Numbe flines: Distance between lines: Ft. Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: pr I U A- IlCO Ft. I Op Ft. SQ. Ft. Driller' Date Drilled: -j Static Water Level: Installer: Date installed: G t=-T t j rv(­ '_, ci{o Z (Z) Ft. Yield: I Pump Set at: Casing Height Above Ground: TANK lC] GPM Llr1iL, Ft. I,� Ft. SEPARATION DISTANCES ❑ Septl ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines Well -Material: ( 25 � Number of Compa Surface Water LIFT STATION Lot Size' ons: Manufacturer: Line Foundation "Pump on" level at: "Pu "level at: High water alarm at: Curtain Pump Make i£ Model Electrical Inspections performed by: Drain Remarks: BENCH MARK r r r e_ ev' �\ too` -kt•o ss m�h1.t� Loc nd Description: ( Assumed Elevatio . ENGINEER'S SEAL OF Inspections performed by: 5 �) ►�� ��c�. Dates: 1s i 23 G %��� m°°°° sea °°®�°°°° •°°°°Q09©°°° 2nd%00° oaa��s Kenne4ii ��',�° Department of Health and H an' rvices approval CE 7116 by: I �� v o '9F�P'9DFESS�D�'A Reviewed ' a 03 and a Pp roved Date: 72-013 (Rev. 9/91) MOA 25 a;:: A-C=2U.9' B-C=29.B' AS —BUILT �Y�T�k� DETAILS/SITE PLAN r/`/ ��`���- / SYSTEM ./ / �-/ / LOt 75C, USS 3042 (G|rdwoocl) Pern|t# 3\/960125 PID#075-132-78 SCALE' l^ ~ 50' NOTE' PROPERTY SERVED BY PUBLIC SEVER. PREPARED FUR' HAMANN CONSTRUCTION, INC pu BOX 770617 EAGLE RIVER, AK 99577 KND ENGINEERING 20441 PTARMIGAN 8LVD EAGLE RIVER, AK, 99577 (907)696-6111/Fux (907)696-8111 1HIEFTY DRILLING WoU Water — It's nol maUy bcl(utl 1 1, 3540 AKULA DRIVE TELEPHONE: ANCHORAGE, ALASKA 99516 (907) 345-0593 WELL LOG Date Drilled : --I ��))C) Lp Static Water Level 0_ Feet Draw Do<Nm ;j 1� Feet Type Material Drilled: cl I rd c oC) uct Gallons Per Minute I Total Feet of Casing to to I 0 to O 1 Qnme� �5, ILA- to -70' <151 I i --*BoOlz� 1�p to I o to to to RECEIVED J A,�j '2. 8 190 NEFtY DRILLING 3540 AKULA DRNE N(,uni6pah-oj ,�i AOCI)c:age AN0110RAGE, AK 99516 Dept. Health & Human Servmes (907) 345-0593 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 WELL SYSTEM PERMIT PERMIT NUMBER:SW960125 DATE ISSUED: 6/17/96 DESIGN ENGINEER: EXPIRATION DATE: 6/17/97 OWNER NAME:BRET THOMPSON OWNER ADDRESS:P.O. BOX 391 GIRDWOOD, AK 99587 PARCEL ID:07513278 LEGAL DESCRIPTION: US SURVEY 3042 LT 75C LOT SIZE: 17405 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: WELL 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 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 B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: RECEIVED BY: ISSUED BY: DATE:. DATE: r rum Mcrvitic 1 n a L-rnvu IN"� i nrn w I ,zz.;L 7 _ . t�ln�• 9.ts•So..._-� PJQ,STp,s I i I - St v!S'e-a1- Z1'1•C'o -101o" %", ® ' d o 62 . ��6 f �8a --� tog. 08 s — lvZ.So js.OXB. C 06G� . 44.0 8 0rrtr6e 6 LOT ISC , ��,: .o �• .. cQ�Uy wY • • i ►0� 1'1�4055 i°F�CsV:JOo•'�_ 3.5�® i •D8•0 _o 9�ac�. l r U l `�� 1 hi tot° 52'-23'`t-t 2t1.55 1 10 '1'iat��t••�, � tist.CsG • 6ls5E1•t'6NT'J ' LOT IS -P. on •e 8r�L1t'rtKCy SLAW. ��•'s pRo�os� c,I1,sr�i• '" '�l.i�A. G � 'R'i�pttJ 1►Ci1Lr to t .fp ,.sC� AI.JN. {fJV011. 3 ' 1.� i� N N 4 d� �d iv N• S tD Li`f�STtr ra aSraW�ct Np�►1 i Do •e o PLOT PLAN X. AS BUILT SCALE GRID 5012- Project No. `>(6-125 1731 George Bell Circle a L�a'o 0?2 o Anchorage. Alaska 99515 (907) 345-6476 I Hereby certify that t.have surveyed the following describe property: Lot UC , Block LIS 0>5 •,n) i�r�•°i;t� A Recording'Distriet. Alaska, and'that the improvements situated �' . �' ,lo t#� thereon are within the property lines and do not encroach onto the property ' •_ �; +� adjacent theieto, that no improvements on the property lying adjacent thereto �'� ••; �6 encroach on the surveyed promises and that there are no roadways, transmission ;,'' •'f --' %p lines or other visible easements on said property except as indicated hereon. .0 0 f Dated this the Z'3t=° Day of 19 n.. at Anchorage. Alaska 0 Kenneth o. t.n � It is the responsibility of the owner to determine the existence of any easements. ��,®"••.•®e,e•••e Ste® covenants, 'or restrictions which do not appear on'the recorded subdivision plat. Municipality of Anchorage Development Services Department- ��� Building Safety Division 5 E T Y V On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907)343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 075-132-78 HAA# l)(1p5?1- 1. GENERAL INFORMATION Expiration Date: Complete legal description U.S. SURVEY 3042• LOT 75C Location (site address or directions) NHN SPROAT ROAD * GIRDWOOD AK. 99654 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address ROGER AND SHEILAGH LEPINE Day phone C/O ERIN EKER W/ PRUDENTIAL JACK WHITE IN GIRDWOOD Day phone ERIN EKER W/PRUDENTIAL JACK WHITE Day phone 320-7266 351 WEST PARKS HIGHWAY, SUITE 200 * GIRDWOOD, AK. 99654 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 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 5 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 served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on -site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on -site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm GARNESS ENGINEERING GROUP, Ltd. Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507 Engineer's Printed Name Engineer's Comments: JEFFREY A. GARNESS, P.E. In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance 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 during 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 are no hidden defects or encroachments. GEG, Ltd. 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 right whatsoever. 5. DSD SIGNATURE _Z Approved for L4 bedrooms. Disapproved. Conditional approval for bedrooms, with the fllowing Phone 337-6179 Date 16 2v &(_ its({ttffff(���rri s _ t Attachments: HAA Checklist Septic System Advisory Well Flow Advisory JJJJj� 40 }PhAW'f`�P"` • Manitenance Agreements Supplemental Engineer's Reort Other By: Original Certificate Date: (Rev. 12/01) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: US SURVEY 3042, LOT 75C A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Date completed 7/3/96 Sanitary seal (Y/N) YES Total depth 100 ft. Cased to 100 ft. Parcel ID: 075_-132-78 Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 18+ in. FROM WELL LOG AT INSPECTION Date of test 7/3/96 10/14/2004 Static water level 70 ft. 72 ft. Well production 10 g.p.m. 6.8 g.p.m. WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi. Nitrate4 ,5 mg./L. Other bacteria C-) colonies/100 mi. Date of sample: 10/14/2004 Collected by: G.E.G. Ltd. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed _ Tank size gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) High wate'r2K[ Date of pumping Pumper C. ABSORPTION FIELD DAT>ItU20 Date installed r ftz rm) Length ft. ft. Total depth ft. EfftZ Monitoring tube Date of adequacy testlts (Pass/Fail) (Y/N) System type Gravel below pipe ft. Depression over field For bedrooms Fluid depth in abso ion field before test in. Water added gal. New depth in. Elapsed T' e: min. Final fluid depth in. Absorption rate >= g.p.d. rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/!alarm "Pump on" level at in. "Pump off' in. High watlevel at in. Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main 75'+ Meets alarm & circuit requirements? On adjacent lots N/A On adjacent lots N/A Public sewer manhole/cleanout 100'+ Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER / Building foundation Water main Wells on adjacent lots Property line Water service line SEPARATION DISTANCE FROM ABSORPTION -FIE Property line �uildiingundation Water service li Surface water Absorption field ON LOT TO: Water main Driveway, parking/vehicle storage C i drain Wells on adjacent lots F. COMMENTS ooOF DOQ/ G. ENGINEER'S CERTIFICATION I certify that 1 have determined through field inspections and Q * 49 t!H review of Municipal records that the above systems are in �....... conformance with MOA HAA guidelines in effect on this date. ?r J ffr' y j . Ga ness: Engineer's Printed Name JEFFREY A. GARNESS Q4m9� �1+ E— 953 Date ofess`o�°�vo HAA Fee $ l .� Waiver Fee $ ` Date of Payment 1 \ l 1 CA Date of Payment Receipt Number r� ��'� %/�' Receipt Number (Rev. 12/00)V� Municipality of Anchorage 4S� Development Services DepartmentBuilding Safety Division T Y n On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 J� CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 075-132-78 1. GENERAL INFORMATION Complete legal description Location (site address or directions) SURVEY 3042. LOT 75C NHN SPROAT ROAD HAA# 14 A- o 16 &,-)- ! Expiration Date: 3 — / 0 — 0 2 Current Property owner(s) JOHN McINTYRE Day phone Mailing address Lending agency Mailing address Real Estate Agent Mailing address C/O DAVE BAUER WITH REMAX PROPERTIES IN GIRDWOOD DAVE BAUER Q REMAX PROPERTIES P.O. BOX 1029, GIRDWOOD, AK 99587 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Day phone Day phone 783-2010 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 5 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 served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $800.00 at, or prior 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 verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on -site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. l further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on -site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Address 6901 DEBARR ROAD, SUITE 28 * ANCHORAGE, AK 99504 Engineer's Printed Name Engineer's Comments: JEFFREY A. GARNESS, P.E. in conducting this evaluation, AWWC, Inc. attempted to provide a thorough, conscientious engineering analysis of the system in accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results described the performance 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 during 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 are no hidden defects or encroachments. AWWC, 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 right whatsoever. 5. DSD SIGNATURE V Approved for `T bedrooms. Disapproved. Phone 337-6179 Date i13 J ff e A Go ess.• Q E-751 4���'°�ofession°moo r��itt�,;;lrr,<,-r; Conditional approval for bedrooms, with the fllowing stipulations: �0 q OF .``� �`�, " ° �.s�' •ice ON-SITEANI ° r WASTEWATER t ( ` Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Manitenance Agreements Supplemental Engineer's Reort Other BY / - Original Certificate Date: (Rev. 12/00) Municipality of Anchorage ' Development Services Department Building Safety Division On -Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: US SURVEY 3042, LOT 75C A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N A Date completed 7/3/96 Sanitary seal (Y/N) YES Total depth 100 ft. Cased to 100 ft. FROM WELL LOG Parcel ID: 075-132-78 Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION Date of test 7/3/96 1 1 /27/2001 Static water level 70 ft. 72 ft. Well roduction 10 g6.4+ .p.m. g•p•m. YES YES 18+ in. P WATER SAMPLE RESULTS: Coliform colonies/100 mi. Nitrate(), mg./L. Other bacteria colonies/100 mi. Date of sample: 1 1 /27/2001 Collected by: AWWC, INC. B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) High water rm (Y/N) Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft or ft2 rm) Length ft. Width ft. Total depth ft. Eff. absorp ' area ftZ Monitoring tube _ Date of adequacy test Results (Pass/Fail) System type Gravel below pipe ft. Depression over field For bedrooms Fluid de th in abso Ion field before test in. Water added gal. New depth in. P Elapsed Ti e: min. Final fluid depth in. Absorption rate >= g•p•d• rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date D. LIFT STATION Date installed "Pump on" level at in E. SEPARATION DISTANCES Size in gallons "Pump off' Cycles tested_ n Manhole/Ac High water alarm level at in. Meets alarm & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A On adjacent lots N/A Absorption field on lot N/A On adjacent lots N/A Public sewer main 75'+ Public sewer manhole/cleanout Sewer /septic service line 25'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Water service line Su water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPT IELD ON LOT TO: Property line uilding foundation Water main Water service li Surface water Driveway, parking/vehicle storage drain F. COMMENTS G. ENGINEER'S CERTIFICATION Wells on adjacent lots o OF .f o 1 certify that 1 have determined through field inspections and * 4� •H review of Municipal records that the above systems are in ... ! E � Ii ( ........ ' .... conformance with MOA HAA guidelines in effect on this date. a •, .J fry A. Garness: • Engineer's Printed Na e JEFFREY A. GARNESS QO 9,s —7953 Date f / L v� lea 0 Profession o ��00000d� HAA Fee $ wee • Waiver Fee $ Date of Payment %z�/D� Date of Payment Receipt Number j � l Receipt Number (Rev. 12/00) 100'+ 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. # 075-1 32-78 HAA #-��1k 1. GENERAL INFORMATION Complete legal description Lot 75C; U.S. Survey 3042 Location (site address or directions) NHN Sproat Rd. Girdwood, Alaska Property owner Cendant Relocation. Day phone Mailing address _ C/0 Jack White Real Estate Attn: George McCoy Lending agency Day phone Mailing address Agent George McCoy Jack White Real Estate Day phone Address 3201 "C" Street Suite 200 Anchorage, AK Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 4 `' " 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. Individual on -site Holding tank Community on -site Public sewer XX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-02S (Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on -site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on -site water supply and/or wastewater disposal_system is in compliance with all Municipal and State codes, ordinances, ANOA#Tn�ff �fit ie d of this inspection. Consultants, ce Name of Firm " Hts a Phone ?3 7-61 79 Address Engineer's signature Date OF ,qI ALASAK WATER & WASTEWATER CONSULTANTS, INC °'°°°° °°• ° IS TO BE PAID $800.00 AT CLOSING FOR •. ENGINEERING SERVICES PERFORMED.T 3 • •°°� .see•• % Je rey . Garq ... 953 e 6. DHHS SIGNATURE 4`%°PRO.FEW���® Approved for E0 UR bedrooms. Disapproved. Conditional approval for Additional Comments 0 bedrooms, with the following stipulations: Date '7-/0 - `7 S 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 orderto 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. v L ✓ e Municipality of Anchorage i 1998 DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division ,'-AUNICIMLITY OF ANCHORAG C�lirl5 825 L Street, Room 502 • Anchorage, Alaska 99501 (90'7'N943 '4744-rq Health Authority Approval Checklist Legal Description: LA 5 2v0"2- 1.0-r 7SC Parcel I.D.: —7 A. WELL DATA Well type PVT—. If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Date completed 712 Total depth /GAD Cased to /b o p Casing height (above ground) Sanitary seal (Y/N) Wires properly protected (Y/N) FRO79, WELL LOG AT INSPECTION Date of test 3 7,Z cj 8 Static water level %O / 9• �S �� G Well production g.p.m. 6 4� 77 -E- g.p.m. WATER SAMPLE RESU ITS: Coliform Nitrate l Other bacteria a Date of sample: 8�ZZ/� Collected by: /�c W V J C r2:7/ at e; oG Cr _ .4'4PG: 7v B.'SF`TIC/HOLDING TANK DATA Date inst d Foundation cleano Y/N) _ Date of Pumping C. ABSORPTION FIELD DATA Date installed Length Width Effective absorption area Tank size Number of Compartments Cleanouts (Y/N) Depression (Y/N) Pumper High water alarm (Y/N) Soil ratin p.d./ft2 or ft2/bdrm) System type Gravel `kness below pipe Total depth Monitoring Tube presbQtt (Y/N) Depression over field (Y/N) Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.): Fluid depth (ins) Minutes later: Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* D. LIFT.STATION Date installed Manhole/Access (Y/N) High water alarm E. SEPARATION DISTANCES mp on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: n gallons "Pump off" level at* Septic/holding tank on lot �J! On adjacent lots 'Ali Absorption field on lot On adjacent lots /v /)e;r Public sewer main �S f-f Public sewer manhole/cleanout q1A I oo / AJ'A Sewer /septic service line Lift station 2 � t SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation Property line Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELlD-6 Property line _ Surface water Curtai+Tdrain F. ENGINEER'S CERTIFICATION I certify that I in conforman Bw ldiiTq—foundation LOT TO: Absorption on adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots inspections and review of Municipal ?s in effect on this date. Signature v' Engineer's Name Date v c% HAA Fee $ 3 0 0,o c) Date of Payment �/ l / l Receipt Number & cyc' 3 C Waiver Fee $ Date of Payment Receipt Number ° - � a o ° a° oov..�•� &J.Vfrf-79A. Garnek 53 pROFESSO 47 are 72-026 (Rev. 3/96)* MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES F ; Division of Environmental Services �Rp, CIAy On -Site Services Section Fiy� pF P.O. Box 196650 Anchorage, �4��F l' C g Alaska 99519-6650 343-4744 �y�cesZV CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # __ a7Jr - / 32 7n HAA # i�a�'11CC 1. GENERAL INFORMATION Complete legal description Zor" a5/ L/.SS 30�% �Girciu�ooa�� Location (site address or directions) 1V111V <Sor�a Property owner a614 Day phone _ 69K,277� Mailing address _�D /5o %70 ,1,/7 E��e ,d�,� Ae 9�;57 7 Lending agency Day phone Mailing address Agent • Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: ZrI 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 furtherverify 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 KND Engineers Phone X441 Ptarmigan Blvd Address E44 Engineer's signature Date 7 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for 44 640 Kenneth M. Duf u w 'o CE 7116 . bedrooms, with the following stipulations: MUNICIPALITY OF ANCHOtAr • Municipality of Anchorage ENVIRONMENTAL SERVICES D DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division FEB 1 ine ; 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 CEIV Im / Health Authority Approval Checklist Legal Description: .for 75G 4�5=S / i� 2D1-2- Parcel I.D.: G7$ - 132 - 7,9 A. WELL DATA J Well type 1�2 - If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) _ I Date completed h, YW Total depth _ I DO Cased to / o D Casing height (above ground) 1, : / Sanitary seal (Y/N) I Wires properly protected (Y/N) 1 FROM WELL LOG AT INSPECTION Date of test Static water level 70 Well production g.p.m. 9•P•m. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: _ /�zO��T 7 Collected by: /� / Eh e�� B. SEPTIC/HOLDING TANK DATA Date installed Tank size N er of Compartments Foundation cleanout (Y/N) Depression (Y/N) Date of Pumping Pumper C. ABSORPTION FIELD DATA Date installed Length Effective absorption area Date of adequacy test Soil rating (g.p.d./ft2 or ft2/bdrm) dth Gravel thickness below pipe Fluid depth in absorption field before% Fluid depth (ins) Minutes I Monitoring Tube present (Y/N) _ Results (Pass/Fail) (in.); Immediately after. Peroxide treatment (past 12 months) (Y/N) Cleanouts (Y/N) h water alarm (Y/N) System type Total depth _ Dep ssion over field (Y/N) For Absorption rate = If yes, give date gal. water'edded (in.): M. 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in Ilons Y/N () ..Pump Manhole/Access on" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Wyk Absorption field on lot IVA Public sewer main 2 s On adjacent lots On adjacent lots "Pump off" level at* 1A A Public sewer manhole/cleanout Sewer /septic service line 25 "r- Lift station . 1A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation Property line Absorption field_ Water main/service 0Surface water/drainag Wells on adjacent lots SEPARATION DISTANCE OM ABSORPTION FIELD ON L TTO: Property line Building foundation Water main/service line Surface water Driveway, parking/v�icle storage area Curtain drain Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records ,9t ms are ��� in conformance with MOA HAA guidelines in effect on this date. Signature firr,, �'°`y �T<<e?�i"1''` e N p, Engineer's Name s D�i Date / 9 7 Kera-;1 ;. L.0 q�% o C 7115 s�^F HAA Fee $ = 4 _ Waiver Fee $ — Date of Payment �2 f Date of Payment Receipt Number �� `� / Receipt Number 72-026 (Rev. 3/96)* nca_� �nnn•a octr-i Inn Fib .TaWU TTT_T'T L y C G Y O tl C C y pp SS C i N y u Q Y LL,, � � G U q G •i QQ y 'e ocaC W ; Q osuES ).0 �itE zY u r W LLJ °e a b`ya1S 0160 At a Zt Wav �'N► co �jW o Qu lj GO u <� W$ C L W J �~ W }- W >LL n� t� �D U//�� ti� J / aw � h B'� Ln v w I W Lac z t _t I tz tn S X rn S 4 rq ui O �Q a N,n Q� • �O ' 0,4� J N U i1 N e M `�Q d Q�: cJ oD04ftN n Q ..•� as � z J 44�ooq�c� � z o m z 0 utdw a�u•••.. �dttu�ntcaar.wn>r� wden.lQ ktr�b0-d3S TP ! 700 / / na vvi OG" 7T TXTJ i>n /PT /AT