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Home My WebLink AboutSCIMITAR #1 BLK 3 LT 9Scimitar' #1 Lot 9 Block 3 #051 - 132-31 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WATER SUPPLY PERMIT Upgrade Date Issued: Feb 03, 2000 Expiration Date: Feb 02, 2001 Permit Number: SW000011 Legal Description: SCIMITAR #1 BLK 3 LT 9 Design Engineer: 0003 S & S Engineering Owner Name: David Gogert Owner Address: PO Box 876383 Wasilla, AK 99687- Parcel ID: 051-132-31 Site Address: 019950 TULWAR DR Lot Size: 40139 SQ. FT, Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage Ail construction must be in accordance with: 1. The attached approved design. 2. Ail 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 (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to Apd115, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing, 5. The following special provisions. ALL CONSTRUCTION AND COMPONENTS USED IN THIS SYSTEM SHALL COMPLY WITH AMC 15.55.070. Received By: Date: ~' ~ t/-O 0 }anoary 27, 2000 ROBERT C. COWAN, P.E. ClWL ENGINEERS (907) 694-297{) FAX (907) 694-121 MUNICIPALITY OF ANCI IORAGE Department of llealth and tloman Services P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 9, Block 3, Scimitar #1 This is to request a water storage permit for the referenced property. The storage tank has become necessary in order to obtain a llealth Author|ty Approval because the well provldes only 0.21 GPM. Thc proposed storage is cxpcctcd to consist ofh~ 220 gallon galvanized tanks aod two 80 gallon pressure tanks {approximately 80 gallons working capacity). This ~dll cxcecd thc 500 gallon rcqulrcmcnt for ! Icalth Authority Approval pnrposcs. If you rcqnirc additional information, please contact us. Sincerely, Robcrt C. Co'aaa,' P. . RCC/skh Enclosu rcs 17034 NORTH EAGLE RNER LOOP · SUITE 204 · EAGLE RNER. ALASKA 99577 9 OAVID R. OAYT'ON, R.L.$. H¢78 BOX 1026 CHUGIAK, ALASKA 99561' Ph. 696-2417 /Z. FQsemeflls 0~' record,o~et thon lhos., s~owfl on the recorded plot .ore nol shown here~ RECORDING DISTRICT, ALASKA .,,,,,,,~o.o~.,~ ["~"°;~:' I'"° · /~a/ CHUGIAK (907) 688-3199 POST OFFICE BOX 874747 - WASILLA, ALASKA 99687 WASlLLA (907} 376-3199 February 25, 1992 Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 Attention: John Smith, P.E. Program Manager, On-site Services As per our conversation on February 25, 1992 please find enclosed the documents that you requested on Lot 9 Block 3 Scimitar Sub.#1. Enclosed is a copy of the log excepted on May 23, 1983. The redrill log dated May 2, 1983 by the Municipality of Anchorage dept of Health and Environmental Protection on-site services. The well that was redrilled and completed on May 2, 1983 a copy of this log is enclosed, was abandon by the following procedure of 1/3 Portland Cement, 1/3 Sand for base, 1/3 Wyoming Bentonite, 15ft. below ground surface to the total depth of 8iOft. or 795 linear ft. of cement. Casing was cut off and a steel metal cap was welded on the ditch was back filled to compliment the surrounding land scaping. The has been our standard procdure for well abandonment for the last 25 years. Also enclosed is a copy of our redrill long dated 9-11-91 showing from 60ft to 370ft the orgnial 60ft. was drilled by Wilson Well Drilling of Anchorage Alaska approximately in April 1975. Mr. Wilson should or may have filed a copy with the Great Anchorage Borough or the Municipality of Anchorage. We have no knowledge if this was done. Sincerely, Jay Williams WE SERVE ALL ALASKA 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NOTICE OF A RIGHT TO LIEN PLEASE TAKE NOTE, that JAY WILLIAMS DRILLING CO., P. O. BOX , Chugiak, Alaska advises notice of a ricjht to lien the following property in the_~_~ Recording Distric described Third Judicial District, State of Alaska toVwit: the construction of valuable improvements, namely: namely: water well construction upon the described premises. The ]lame of the owner, or reputed owner thereof is: and the followil]g persons, natural or corporate, claim, or may claim some interest therein: The materials, labor and/or services were furnished to the property at the request of: Be advised that JAY WILLIAMS DRILLING CO, is entitled to record a claim of lien. WARNING: Unless provision has been made for payment of this claim, you may be liable for payment directly to this claimant, notwithstanding the fact that payme~%t has been made to a prime contractor or other party. 19~?ATED, at <~/~.~(~C~ , Alaska, this~/o~ day of ~J JAY WILLIAMS DRILLING CO. By: OWNER STATE OF ALASKA) Ss: THIRD DISTRICT ) Jay Williams, being duly sworn s+atas, I am the owner named in the foregoind notice of a right to lien; I have read sam a~]d k*]ow the contents thereof to be true, a~]d in witness whereof I have hereunto set my and seal. SUBSCRIBED AND S~RN on this ~ay of ].9 / NOTARY PUBLI~NA Aq~IYq~O~ My corem expires: 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 (UPGRADE) PERMIT PERMIT NUMBER:SW920019 DESIGN ENGINEER:DAVID R. ]DAYTON, OWNER NAME:WILLIAMS JAY D & OWNER ADDRESS:PO BOX 874747 WASILLA, AK. 99687 PAGE 1 OF 1 PARCEL ID:05113231 DATE ISSUED: 2/26/92 P.E. EXPIRATION DATE: 2/26/93 LEGAL DESCRIPTION: SCIMITAR #1 BLK 3 LT 9 LOT SIZE: 40139 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION 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 (18AACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: WELL NO 1 WAS DRILLED 8/9/77 TO A TOTAL DEPTH OF 430 FT. AND WAS DEEPENED 5/2/83 TO A TOTAL DEPTH OF 810 FT. THIS WELl. WAS THEN ABANDONED BY PLUGGING WITH CEMENT WITH A STEEL CAPWELDED ON THE TOP OF THE CASING. ON 9/11/91 A REPLACEMENT WELL WAS DRILLED TO A TOTAL DEPTH OF370 FT, AND PERFORATED 75'TO 85' AND 130' TO 136'. THIS PERMIT IS ISSUED FOR THIS REPLACEMENT WELL. DATE: 9 / / /7 AS-BUILT SURVEY LOT 9 BLOCK 3 %C/,~4/T/%~ ~,,~, L/g/z- NOTE: Easements of record,otller than those shown on the recorded plat ,ore not shown hereon, DAVID R. HC78 BOX 1026 CHUGIAK, ALASKA / SUBDIVISION RECORDING DISTRICT, ALASKA FOR: lDRAWING NO. SECTION ,TO'WN SHIP ~ /<3., /.~-~./, DAYTON, R.LS. 9956'7 Ph. 696-2417 FIELD BOOK NO. ~// / v,/ MUNICIPALITY OF ANCHORAGE ilea' and Environmental Protec Fourth Floor West 825 L Street Anchorage, Alaska 9950]· 279-2511, x 224, 225 INSPEC'flON REPORT ON-Sll'E SEWAGE DISPOSAl. $[':P FIC TANK: INSI[M{ LICN[;I'H ~___ _ IP '.MD[ WI[)I Il ~ [ I[)11l[) F)I'PtI'}] ~-- I I()!Jl[) CAPACII'Y [ , ¢ / I FOfAL tENGFtl ~ / Ef-I ECl Ai;SORPl',ON Am;A. ~ . Sc). ~ ~NGI,~ OF EAC,,L,NE ~ ~ SEEPAGE PIT: Log Crib Ril~gs Crib Size: ()IAIvlEFiR . DI:PfH .... QISTANCEF/(OM: WEt_[ lO'iAi El I'[C'flVE Well Distance To: Lot IJ te IO[~ .... PERHIT NO. I IF F 1....I.L. Id["l I LOCRT I ON LEE. iRE DEF'FtR'I-MENT OF HEFIL'FN .... _ 8'25 '", 5TREE'F., PHC. HCRH~E., BK. .... _F~ ~"~ '-- ~:: ,' ) b~.,. 5:l~ ~. R ........... DEAN ISONS] '" .... J~ .[ CkLE. N L..T. D L,L~) .... " ]: ~'-_~i~lI]' '-dF:' ..... c',,.D LOT SIZE ]:'aF~:~l.::l SQIJF]RE FEET "F't'PE OF . c IL HE_,uF..E I .[LN _,-r_TEH I.:,. TBEN.,H NI...IHLER (]F EEi..RJOH- = '~' I'"lFl:~:: I [.'1LI ~.1 ' ':' '- ~' ' - ', "" "g SOIL RFFrlNG (Sg! FT, bR.- ...... "" ~" - _ ~ -,TEll I ,S: THIE IRIEQIJ:I:RIED b]:ZE CIF' THE :,.IL FIE:SORPTION q'": ' [:, E"'Z F" 1- I'-I === "-'L. ~2~ IL_ E: THE LENGTH DIMENSION IS ]'FIE LEN['iTH (IN FEET) OF THE I'RENCH OR DRRINFIEI...D. TNE DEPTH OF R 'fRIENCN OR PIT IL=..; THE DISTFIt.,ICE BIETI,.IEEN TlflliF.. SURFRCE OF' THE GROUt,,ID FIND THE E:OTTOH OF THE E',:..;CRVFITION (IN FEET],. TNERE IS NO SET WIt}TH FOR TRENCHES. THE r. iRRVEL. [:,Er'TH IS ]'HE f,IINIHUH DEPTH OF GRRVEI... BETWEEN THE OUTFFILI~ PIPE RND ]'HIE BOTTOM OF TlflF.~ E',,.',CFIVFITION ,::IN FEET). ...................................... IF'-'" F:I R I::'I~CI'::RGE PLRNT MR'¢ BE INSTALLED fl'r THE F'ERMITTEE'"S OPTION SUBJECT TO THE FOLLOWING CONDITIONS: :t.. EITHER R CL.RSS I OR ii NSF RPPRO',/ED PLRNT MFI'~ BE IN~TRLLED. 2. R CONTINUOUS blRINTENRNCE FtGREEMENT IS REQUIRED. IF R MRINTENFINCE FIGREEMEN'r ZS NOT KEF'T CURRENT VOU MRY BE REQUIRED TO ENLARGE THE SOIL FIBSORP"f'ZON SYSTEM FIND/OR '¢OU MR'¢ BE SUBJECT TO PROSE:CU"FZON. ........ "lF 11..4 E~ .- 2,." ;:. :~ I,,!1%:,5 F" E: C: "IF ][ LI I'-.I _. Fl F~ IE R E] ~! IU I F-': IE IZ: ,=, ,'" ' r, ,. ,-... f. IIIt- 13FIE:KFIL. LINL':i OF Ftl"4"r' .-:,.r':,lEl'l !.,.IITHOUT FINRL ]'N,:,FE~.I IJN FIN['.' 8PF'ROVFIt. B"r' "" ":' DEF'FIRI"MEI',Fr 14IL.L BE SIJEx:rE:C]" TO PF.']SEZ..TIEN. HINII"ILIM DISTFINCE BETWEEN R I,IEL. L.. AND FINS' ON-SITE SENFIGE DI.SPOE';RL SYSTEM IS ::1..OO FEET FOR R PRIVRTE !fELL OR 200 FEE']" FOR FI PUBLIC WEL. L OTHER REQUIREHENTS MFI'¢ F:IPPL"r'. SF'ECII::ICFtTIONS FIN[) CONSTRUCTION DIFIGRFIMS FIRE FIVRILRBLE TO INSIJRE F'ROPER INSTFtLL. FITION. I CERTIF'¢ TI-IRT ::L: I FIPI FRMILIFIR WITH TNE REQUIREHENTS FOR ON-SITE SEWERS FIN[) I.,.IELLS f:IS SET FORTH B'.r' 'fFIE HUNIE:IPFtLIT"r' OF RNCHORRGE. 2: I HILL INS"rFILL ]'HE S¥STEH IN RCCORDRNCE WITH THE CODES. ~:: I UNDERSTRN[:, THFIT THE ON-SITE SEWER S'-?STEM HFI¥ REL.]LIIRE ENLRRGEMENT If:: THE RESIDENCE IS REMODEL.lED TO INCI..LI[:,E MOF?.E THFIN Zr. BEDROOMS. RP F'Lu. I C FII'.,IT I}EFIN CONST I'JgSUFZE:' ~..~-L-Z~,,LZ%,~--'z-:~----' ......... ---~----~-~ ............... I.~FI'f E_.O .............. /: ........... VZ.' 0 OSE GEO. _CHNICAL 8-DEVEL Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 ~MENT CO. Russe# Oyster 694-2774 Soils 8- Foundations Performed for: Name:. SO[__LL LO._5 ~K~.gF/ ~LJ~ 77¢.:r A/, . Tel. No. Mailing Addt'ess: .... Legal Description: S_oj.1, Characteristics 4/ 15 Earl Ellis 688-2280 Land Development Ground Water Encountered: Yes ....... No~/_,.~ If yes, what depth Proposed Installation= Seepage Pit~ Drain Field_ _ Cor~nents: ......... ~ , WELL DRILL. II 1305 W. 45TH STREET ANCHORAGE, ALASKA 99503 PHONE 272-9343 DRILLING LOG Location (address of: lown.;hq), }~,ange, Section, if known; or <tistance main road ' Size o[ casing._. [,.L _Depth of I4ole ~}% _ feet Cased ~) Static water level_~=~~ ft. (above) ,(below) land surface. Pinish of well (check one) open end ); Screen ( ); Perforated ( ). Describe screen or perforation Well pumping test at_.__L~ga]lons per (lmm') O}finute) for /','~ _hours with / ~'L ~$,% ..... ft. of drawdown from static level. WELl, LOG Del)th in feet from ground surface Give details of formations penetrated, size of material, color and hardness ..... L2 ...... ' ............ L ......................... · ~--~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF: HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 051-132-31 HAA# HA000031 GENERAL INFORMATION Complete'legal description Lot 9~ Block 3~ Scimitar #1S/D Location(siteaddressordirections) 19950 Tulwar Drive Chugiak, AK 99567 Property owner Mailing address David Gogert Day phonej07-373-0424 PO Box 876383, Wasilla, AK 99687 Lending agency Mailin. g address, Day phone Agent Betty Sullivan/ Address '960 Herman Road~ Wasilla, AK 99654 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: NOTE: Dayphone 907-376-2448 XXX Individual well Community well Public water 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 XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 Address Engineer's signature S & S ENGINEERING I ?.~-~,i ~.agie I(iver Loop Road No. 204 Eagle River, Alas~(a 99577 Phone Date 11/"~./oo = DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for Additional comments bedrooms, with the following stipulations: By: ? 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 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 errom or omissions in the professional engineer's work. RECEIVED Municipality of Anchorage° _ ,. dAN 28 DEPARTMENT OF HEALTH & HUMAN ,.)ERVlrj,~¢~p^uf¥ o~-ANCHOr) Environmental Services Division ~VIRONMENTALSERVICES 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Descr ption: /~)~ ~ ./ A. WELL DATA Well type Log presen4Y.~N)~'/~ Total aepth Sanitaw seal'N) Health Authority Approval Checklist ~/--,~ ~,~ ~'~-,//W'/7~'7~,/ _Parcel I.D.: L"r-~-~-,/ '-/~ ~-~ ! If A, B. or C, attach ADEC letter. AI3EC water system number Date (;ompleted ~'~///~1//¢/ Cased to //,.~2 ' Casing height (above ground) J /-y- FROM WFLL LOG Wires properly protecte(~/N) _ AT INSPECTION Static water level Well 3roductian WATER SAMPLE RESULTS: g.p,m, Coliform Nitrate Date of sample: ,/~,,'..~' ~_ Collected by: S. SEPTIC/HOLDING TANK DATA Date installed ~/Z~/¢~Tank size / ~t/~ Number of Compa,ments __ / Foundation cleanout Y)~) /~/¢~ De ression Y Date of Pumping _~/¢¢ _Pumper C. ABSORPTION~f,,~/,-2FIELD D~T~ Date installed ~.,/',/~-~ / Length ,~'~' // W/idth Other bacteria High water alarm (Y/N) ,A~///,/~- Soil rating (g.p.d./fF or fF/bdrm) ,~-~- ¢ System type Gravel thickness below pipe Total depth Effective absorption area ~_,~2~/:Ill Monitoring Tube present/(~)N~ ¢.~' _ Depression over field (Y.~)~_/~/ ¢. ,¢//. ~ Date of adequacy tes,_ /~//O/¢¢~Results(PasS/Fai,)~¢~ For ¢~%~ bedrooms Fluid depth ir. absorption field/ /before test (in.); ~ Immediately aEer~ gal. water added (in.): ~ Fluid depth (ins) Minutes later:. /~ Absorption rate = g.p.d. Peroxide treatment (past t2 months) (Y/N) _,&{¢/V~- ,~/V~'-//YA/ If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Manhole/Access (Y/N) High water alarm level at*/ / Cycles tested / E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot /D~/-,~ Absorption field on lot /Oco /4- Public sewer main ~/,/,4- Sewer/septic service line ~¢-- ~- ~ On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station /%/ / ~ / SEPARATION DISTANCES FROM SEPTIC/HOLDiNG TANK ON LOTTO: Foundation ~- / '¢- Absorption field -~ Property line -¢'- / Water main/service line /¢-? F Surface water/drainage /~' ~- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line /~) / '~ Building foundation ///7 /_¢__ /~.. Water main/service line Surface water / 0 cO /./- Driveway, parking/vehicle storage area / Curtain drain'/Y'~/',/~ /L~./~-f~J.A/ Wells on adjacent lots /d:~ o /~'- F. ENGINEER'S CERTIFICATION I certify that I have determined fi in conformance with MQA HAA guidelines in effect on this date. Signature ~ ~ ~ .._~.~..._~ Engineer's Name Date HAAFee $ ~'~ Date of Payment //~/~'~ Receipt Number :~--~-'7"'7 C'/-/27L5) Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* · ~ EOIgErlT O. Cow^il, P.E. IIO~]ERrA. [~II^FEn, P.E. WELl. FLOW TEST DATA CUENT'. ~,'~,'0 ~-~..~-- ' ', CABINO DEPTII: DATE .RII.LINO COMPLE'IED: ~,/~/ DRII.LER: / WIRES IN CONDUIT; , BACTERIA AND NITRATE SAMPLES COLLECTED {daloJ: I'ESTDATA: CIVIL I.~NGINEEI18 (007) 604-2g70 FAX loc?) I]94-1211 SANITARY SEAL: DEPTIITO .- WATER REMARI(8 (FT) I ME~'ER PUMPING CLOCK READING RATE TIME (GAL) (GPM) JZ~ ~4~' WELL CURRENiLY PRODlJDE8 .~'~L FLOW RATE NOT GUARANTEED--SUBSEQUENT VARIATIONS CAN OCCUR. I ?ri34 IlOl'llll EAP~I E [llVl~fl I aDP · 81 III E 21),1, FA(Il ~': IIlVE[I. Al A.qI(A Ilfl.~/1 F:EB-O'7-2000 10:44 S&$ ENGINEERING 90'7 694 1211 CT&:E ~ef.~ 1000378001 Client Name g & $ J~nginecri~g Ctien~ Sample ID L9 B3 ~a~r~ Dr~g Ordered By P~S~ o S~I~p]e R~m~rk~ Client Printed Dste/Time 02/0412000 15:53 Collected DateFl'ime 01/28~000 3:OO Rec~iv~ Dute~itne 01~g~0O0 15:55 0.535 10 r~x 01/28,/00 cot / 100rrn. S~,d8 01/2B/00 ~aP TOTAL P, 03 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. # (~)~\-\ ~'~b~,~\ HAA# ~,~i~°~L~\('') GENERAL INFORMATION Complete legal description Lo Location (site address or directions) Property owner Day phone Mailing address Lending agency Mailing address Agent ~'~¢,¢N'm-'v~ ~ Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual well NOTE: Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site ' Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev, 1191) Fronl MOA ~21 STATEMI'-'NT 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'" -J.-)~,rP ~j~, ~/~'¢~"O/3 ~.~, Phone Address J~-~ -/~ ~)~ JO.S(z)_ . /~'Cf. 4,/A-~ , /~-/¢_ Engineer's signature ,(~-/~zz'~-~//~Z/_/~ DHHS SIGNATURE ~. App~'oved for ' .~- Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The D H HS does this as a courtesy to purchasers of homes and their lending institutions in order te 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 MOACY21 Municipality of Anchorage Deparlment of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: / A, WELL DATA Well type Log present (Y/N) Total depth ~ ' ~_Cased to Sanita~ seal (Y/N) _ If A, B, or C, attach ADEC letter. Cate completed ADEC water system number ~/I / /~ / Driller _~,// c/~/,//~/,~ Casing height Wires properly protected (Y/N) _ FROM WELL LOG Date of test Static water level / A'T INSPECTION ENVI,ONMI:-NTAL SE VIEES DIVISION g.p.m. ¢4? RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/hetdfl~ tank on lot //~ Absorption field on lot /.~'~ Public sewer main Public sewer service line _____~_ .o.,v ¢- ; On adjacent lots /',o~<~ ; On adjacent lots /o o ~/~ Public sewer manhole/cleanout __ Petroleum tank WATER SAMPLE RESULTS: Coliform CD Date of sample: ¢/1~/¢ '¢' Nitrate _ O,/o //.~/¢/ Collected by: Other bacteria El. SEPTIC/HOLDING TANK DATA ,~' Date installed __ ~,/?~3.//¢?? _ Tank size __ Cleanouts (Y/N) ~/ High water alarm (Y/N) Date of pumping 7~Cw° E. ,/0 Og-~ Compartments . Foundation cleanout (Y/N) Y~ ~b~'~ Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line_ Surface water/drainage On adjacent lots _Absorption field_. /g) ~'¥~ Foundation ~'~ /V _Water main/service line 72-026 (Rev* 3/91)Front MOA21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at "Pump off" level at High water alarm level Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Soil rating ~'~ '~'~/"~'~- /System type "~ Gravelthickness Totaldepth Date installed Length ~ / __Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) Cleanouts present (Y/N) ~ Date of adequacy test ~//?o for "~ ~ ... If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~- ~' On adjacent lots ~"4~O-/- Property line To building foundation '¢"/ To existing or abandoned system on lot /.+"/'~ ~'~.~ On adjacent lots Cutbank /f-~'~',~- Water main/service line_ Surface water /¢~ ~ Driveway, parking/vehicle storage area ~ Curtain drain /~,,~,~ ' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer,s Name ]~-~A-~, ~> ~. ~ Date ~?.~/~::)/~/'Z-~ HAA Fee $ ,/'~0 ~ Date of Payment ~-.2~o - .9 ~L~ Receipt Number ~-~.~o ~//~/~ 2 72-O26 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number ROBERTC. COWAN, RE. ROBERT A. SHAFER, RE. CLIENT: WELL RECOVERY TEST DATA ROAD DESIGN SOIL'[EST WELL LOCATION ( egal):~ --/.. ~: TESTDATE: I~/Zz/'~f' ' WELL DEPTH]- -- .~.-~" CASING DEPTH: _ ,~ / 4- CIVIL ENGINEERS (907) 894-2879 FAX (997) 694-t2t 1 TESTED BY: . /'"~ D-2._/,..-,~ WELL DRILLER: --.~/ DATEDRILL. ED: c~/ /I/~/I TEST PROCEDURE: M_.ISC DATA: 1) Draw water down to pm'hR. Casing Height: 2) Shut pump off 15-60 min. Sanitary Seal? -record time Wires in Conduit? -record meter reading Grading O.K.? 3) Turn pump on. Drawdown. Pump Depth: 4, Shut pump oil Samples Taken? -record time Date: -record meter reading 5) Calculale gal./min, recovery. T.E~T DATA_,` START TIME: STATIC WATER LEVEL: / ~ / = TRIAL II .UM. II II METER II OFF 4 - ON -- OFF I;{ESULTS: WELL CURRENTLY PRODUCES: O - ~ / FLOW RATE NOT GUARANTEED--SUBSEQUENT VARIATIONS CAN OCCUR. 17034 NOI~TH EAGLE RIVER LOOP · SUITE 2o4 · EAGLE RIVER, ALASKA 99577 D. R. DAYTON, P.E., R.LS. HC788ox 1026 Chugiak, Alaska 99567 (907) WELL FLOW TEST Lot 9 Block 3, Scimitar Subdivision Unit #1 Date of Test: October 23, 1991 & October 26, 1991 Depth of Well: 370' below top of casing Pump Level: 365' Static Water Level: 170' Standards: The Municipality of Anchorage requires a flow of 450 gallons per day for a 3 bedroom home. Test: On Oct. 23, 1991 the well was pumped at varyong rates for 2½ hours, producing 345 gallons, at which time the water level was drawn down to the level of the pump. ( It was not possible to measure drawdown levels as the probes kept contacting water entering the well from the perforations.) On Oct. 26, 1991 the well was pumped at a rate of 2 gallons per minute until the water level was drawn down to the pump. The prod- uction was 357 gallons. The valves were then adjusted until the pump output was equal to the to the flow coming into the well. ( No air was being pumped.) This flow of 1 gallon per monute was continued for 93 minutes for a total of 450 gallons. Results: 450 gallons were withdrawn from the well in slightly over 4 hours. Conclusion: The well meets the Municipality of Anchorage criteria of 450 gallons per day for a 3 bedroom home. The well was tested for flow only at this time. No testing for water quality was done. ( No coliform or nitrate tests.) Water tests will be performed and the results submitted separately. MOUNTAIN ENGINEERING 10251 Crestview Eaet · Eagle River, Alaska 99577 Anchorage 907-696-1700 Outside Anchorage 800.478-0t01 CERTIFICATION OF TFSTING Legal Doocrlption : Scimitar Subdivision, Lot 9, Block 3 Street Address : NO House Number, Tulwer Street, Peters (;reek Date Tested Testing Results : June 2.1 ,_1.9..9.0 : PASSED - For 3 Bedroom Residence Testing Procedure : One thousand gallons of water were added through the first standpipe on the drainfield. Original depth et the beginning of the test was 7,7', and within one hour, tho water level had recovered to the original level, CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 [t STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ,',liM,¥Si:; L,,~UL , for ~i~VOiCF, ~ ~ ~ FAX: (907) 561-5301 !.)I)AVi D DMTOlt, 2) ~"~[~-~ Membor of fha SGS Group (Socl~t~ G~Sn6ralo do Surveillance) ~tl: Time Date Insp MUNICIPALITY OF ANCHORAG~ DEPARTM OF HEALTH AND ENVIRONME'~ 825 L Street, Anchorage, AlasKa 264-4720 PROTECTION 99501 Received: December 28, ].977 ~3: Time Date Insp REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES 1. Lending Institution Request: Mailing Address: United Bank Alaska Phone: Property Owner: Dave Deans Contractors Phone: 694.~9387 Mailing Address: Box 115 C'hickaloon Street 99577 3. Legal Description: 4: Single Family Residence: (x) Multiple Family Residence: ( Lot 9 Block 3 Scimitar Subdivision Number of Bedrooms: Three Number of Bedrooms: 5. Well System: Individual We].]. (x) Community/Public S~stem () Permit ,~ ~7~ ~- Depth of Well 430' ~_Well Log on Fi]-e ( )~ Construction ~_~.;%.~, Bacteria[[ Analysis ~~' 6. Sewage Disposal System: On-site System (x) Public Utility ( ) Permit ,~ ~V~,~ Installed 1977 Installer ~_~~ Septic Tank Size /~O~ Manufacturer Absorption Area ~,~/ Soils Rate ~ Material Distances: Well to Septic Tank ~o Absorption Area to Sewer Line Nearest Lot line Absorption Area Nearest Lot Line Page Health and Environmental Protection of Individual Sewer and Water Facilities ~wo Department of Request for Approval Legal Description: Lot 9 Block 3 Scimitar Subdivision Cor~ent s: Affadavit Attached: ( ) Letter Attached: ( Disapproved: Date: Deparnmen~ Worksheet: MUNICIPALITY OF ANCHORAGE Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501 ~equesL for Approval of Individual Sewer and Wate'~'J)ao%lit2es Property Owner: _~a\l~ ~-~Vk~ ~t~-~-3~ClqZb~-_% Mailing Address: ~_/~- Clt-':ZL~h~Lg~b64 ~.'~--~. Phone 2. Name of Buyer: Mailing Address Phone Lending Institution: Mailing Address: Phone: Realtor/Agent: Phone: Mailing Address: Legal Description: Street Location: Single Family Residence: Multiple Family Residence: Water Supply: *Individual Well If Individual Well, well depth _ '~>Z_. If Co~nunity System, name of system Sewage Disposal System: *~n-site System If On-site System, date of installation: (~Number of Bedrooms: ~ ( ) Number of Bedrooms: (~/Public/Co~'nunity System ( ) Public System ( ) *NOTE: A well log is required on ALL wells drilled since 6/75. ** If on-site sewer system is over two(2) years old, an adequacy test is required by this department. A fee of $25.00 must accompany each request hefere processing can be initJ.ated. 3/77