HomeMy WebLinkAboutSPRING HILLS ESTATES #1 BLK 1 LT 4 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telei~hone 264-4720
ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT
1
NAME ~HONE
/E~UPGRADE
~ILING ADDRESS
EGAL DESCRIPTION
OCATION
I- ~ Manufacturer Material
iLiq. capacity in gallons Inside length
DISTANC[ TO: ~WeH Dwelling
NO. OF BEDROOMS
PERMIT NO' ~ I"/ O ~O~
No. of compartrnentz~
Liquid depth
PERMIT NO.
Well Building foundation
DISTANCE TO:
Depth Driller
DISTANCE TO:
PERMIT NO.~ ~'fO ~ 06
Distance between lines
Total effective, absorption area
Nearest lot line
Distance to lot ii'~" PERMIT NO.
S0ptic-~-I~ 1 '7-~/ ~
OTHER
PIPE MATERIALS
pvc_ c~
SOIL TEST RATING
/ 'z% ]2 '/J.---
NSTALLER
~'~'.~ (2~/,'m,"/~/ ~-~ f't oq~
REMARKS
_ _
DATE
72-013 (Rev, 3/78)
/..o~-fl 6. I
It~et~
Well Owner
/ tV1 ..W DRILLING, Inc.
P,O. Box 10.378 * 10300 Old Seward Highway '- ~4-258
(907) 349.8§$5
ANCHORAGE, ALASKA 99511
DESIGNS IN WOOD/S~4 }ITH'.
DRILl.lNG LOG
Location (address of: Township, Range, Section, if known; or distance main road
Lot 4 Block 1 b~prin~ tli].ls Addition ill -
Use of Well
Size of casing. 6" Depth of Hole. 202 --feet Cased to__ 201, 30 feet
Static water level_ 175 ft. (~)"i~ (below) land surface. Finish of well (check one) open end
(
Screen ( ); Perforated ( ~ ::),~
Describe screen or perforat on
Well pumping test at 6 gallons pa~ ~) (minute) for-~. --hours with
of drawdown from static 1791~ ~:~ ~
Date of completlo~ ~m8~ 31.198 ~ ~ :~
- ' WELt LOG
pth i
De n feet from : , ~',~,~
ground surface Give detaii8 Of formations penetrated, size of material, color and hardness
0 .TO 2
2 TO__ lid
110 .TO 160
160 TO 180
180 _TO 202
TO
x );
NOIID310~d qVIN:tV~Nt)dlAN:
TO
TO
TO
TO__ __
TO__ __
TO __
TO
~ No's. 814 & 973
,TO_
· 3--CONTRACTOR
DEEPARTMENT OF:' HEAL'I"H AND ENVIROIqMEENTAL F:'ROTEC"FZCIIq
825 L STREET, ANCHORAi]E, AK 9950:L
264-4720
C?INI'-'"'$~3 :]E 'T'EEE: EE~IE!EIb,,~IEE:F;,", ~.~: I,,~IIE::L..IL. F>' IEZ: IF;: th'] :[: 5C
PE::RM I T NO:
DATE ISSUED'.'
840606
07/22~/84
AI::'PL I CANT
ADDRESS:
C[]NTAC]" F'HOIxlE:
DESIGN IN WOOD
'7021 DRIFTWOOD
ANCHORAGE, Al<
:349~':8() 14.
99502
I-.,EGAL DIESCIRIF',~ SLIBDIVISION: SF:'IRIIxlC~ HII-LS EST. ~[1 LOT: 4.
SECTION: :[5 TOWNSI-ItF:': 12N RANGE: 3W
L. OT [31ZIE: 5 mOi~ mQ. F'r. OR ACRES)
IdAX BE])RO[]IqS:
BI...OCK: 1
Listed be].ow are t,l"le optiorl~.~ avail, able 'Lo you ~.n cJesigr~ing your ~ep'Lic
system. Choose 'l',.he opt iorl tha'L best fi'Ls yocu:' [;~'LB,,
DEPTH TO PIF'E B(]"I:'I"OM (I::'"T.
GF(AVIEI... DEF'TH (I=T.
TOTAL DIEPTH (I::'T.)
GF~AVIEI_ WID'I'N (FT.)
GRAVEl_ I_ENE~TH (FT.)
GRAVEL VOI_IJME ~(CU. YDS.
TANK SIZE (GALS)
SOIl_ RATING (SQ.FT.
Eli: [",.11 ~[~: IF'dl
4 ,, 0
3 ,, 0
7.0
20.4.
000.0 **
125
** TANI< MU.ST I-lAVE A"F I_I:':AST TWO COI"II::'AF~TMEIq"t'S
Zl.. ()
2.0
6. ()
53.0
24.5
000,, 0 **
125
c:er'tify that:
1,, I am Familiar with the requirements
3.
f'c:)r"[,l"~ by the MLul:[c:ipa].ity of Anclnorag~ (MOA) arid the ,:taLe oF Alaska,,
I will install the system in accordance wi'Lb all MOA codes and regLtlation~,
and il] comp].iance with the design cpitel',ia of this per'mit.
I ~i].l adhere to all MOA ar'~d State of Alaska r'equil*mments for' the set back
d:i. star~c:e~ ¢pom aFly existing well, ~as'Lewa'LeP disposal system or' p,ctb].ic
sewerage system on th:i.s or any adjacent or hE, ar'by loC,
I urldel-star~d tl'la'L this permit is va].ic:l fc:m a maximura oF :3 bedr, ooms and
IF A
]"l-.IEIxt
WILL.
IELEE',TRICAI_ WORI< IdUST BE DEINE BY A I..I[]ENSED.EI..EC"I"RICIAN.
AF'PL. I6:~NT: DESIGN IN WOOD
]:SSUED BY DATE:
LIF'T STATION IS INSTALL. ED IN AN AREA C'OVERED BY I"10¢:~ BLJILDIIq[:J CODES~,
(1) AN ELIECTRICAI,,,. F:'ERId):T Al'ID IIqSPECT]:ON I'IUS]" BE OBTAINEI).~i (2) AS:'"BI.III_..TE"~
I';IOT BE AI""PF,',C]VED WZTHOI. JT AN ELECTRICAl.. IIqSPECTION REPORT~ AND (.'5) THI!':
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264.4720
SOILS LOG .- PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
4L~
4
5
6
8-
SLOPE
SITE PL'AN
10-
11
WAS GROUND WATER
ENCOUNTERED?
13-
IF YES ATWHAT
MUNICIPALITY OF ANCHORAOEDEPTH'?
OEP1, OF HEALTH &
14-
15-
17-
18-
19-
20-
ENVIRONMENTAL PROTECTION
r JUl 2 0 1984
CEIVED
COMMENTS_ 6'o,'1 .-~,,:, '-~,~ "p
72-008 (6/79)
Reading Date Gross Net Depth to Net
Time Time Water Drop
3'~1,1 Ig /;zo3 ,- 6° --
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch)
· .~' ~'"- FT AND ~:~FT
.CERTIFIED BY: [/ [ J' -- DATE:
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Ser~ces Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
015-051-74.
1. GENERAL INFORMATION
Completelegaldescripfion SPRING HILLS ESTATES ~1: LOT 4., BLOCK 1
LocalJon (site address or directions) 4.621 GOLDEN SPRING CIRCLE
Pmpertyowner THgRESA WAGNER Dayphone~
Mailingaddress 9002 MULHOLLAND DRIVE. GLENALLEN. VA 25059
Lending agency Day phone
Mailing address
Agent.
Address
Day phone
Unless othen~vise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well x×
Community well
Public water
NOTE: /f community well system, provide wri~en confirmation from State ADEC a~test-
lng to the legality and status of system.
4. TYPE OF WASTE'WATER DISPOSAL:
Individual on-site xx
Holding Tank
Community on-site
Public sewer
NOTE: /f community wastewater system, provide wrflten confirmation from State ADEC
lng to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21 C~mputer Vem~on
IoNOte: Alaska Water and Wastawate. r Consultants, In.c,. shaft be paid $750.00 at,
r prior to, closing for the engineanng setwces pro~oeo.
5, STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validabon date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-sEe water supply and/or
wastewatar disposal system Is safe, functional and adequate for the number of bedrooms and type of
structure indicated herein. I further verify that based o~/~e inforrnaEon obtained from the Municipality of
Anchorage files and from my invesEgafion and nspe¢~ .¢_n, the on-site water supply and/or wastewatar
disposal system is In compliance with all Municipal amd State codes, ordinances, and regulations in effect
Nnm~. nfFrrn ALASKA W/~ER~& ~// ,TI~/A~CERiCONSULTANTS, INC. Phone (907)337-8179
Engineers Signature ~._~/~ ~.~.~., Date ~////{
system in accordance wflh ADEC and MOA EIH~ ~uide/ines & Regulal~ns. ~ ne reporteo re~u~ c~escn~eo
performance of the system under the condNfons encountered at the tires of the test, and eaparaNon disfances
measured to readily identifiable features. The opereEotml life of all wells and septic systems depend
on the local soils condNfen, ground water levels that may fluctuate during the year, and the water
usage of the family being sen/ed by the system. These conditions are outside the control of
the evaluafer of the system. Satisfactory test results do not guarantee future performance
of the system, nor do they guarantee that there are no hidden defects or encroachments.
AWV/C,, Inc. can therefore not provide any warranty for future estimate of how long the
system will continue to meet the operational requ/remente of the ADEC or MOA DHH$.
The content of this report is for the sole benefit of the owner listed above. Any
reliance upon or usa of this report by any other person or parly is not authorized,
nor will it confer any legal right whatsoever.
6, DHHS SIGNATURE
~ Approved for ~
Disapproved
Conditional approval for
bedrooms
bedrooms, with the following stipulations:
Additional Comments
By: ~/~~/ /~/~/' ~ Date
The Municipality of Anchorage Depart~nent 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 cedain 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 weds.
72-025 (Rev. 1/91) Back MOA f~l Computm' Vemlon
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Envimnmentel 8endces Division
825"L" Street, Pan 502 Anchorage, Naska 99501 (907) 343-4744
Health Authority Approval Checklist
LegalDescription: SPRING HILLS ESTATES f~l; LOT 4, BLOCK 1ParcelI.D.:
A. INELL DATA
Well Type PRIVATE
Log present (Y/N)
Total depth 202'
Sanitary seal (Y/N)
015-051-74
IfA, B, or C, attach ADEC letter. ADEC ~va~er system number
Y Date completed 8/51/84
: CaSed to 201' Casing height (above ground)
YES
Date of test
Static water level
Well pmduc~on 6
WATER SAMPLE RESULTS:
Date of sample: 7/25/2000
2'+
FROM WELL LOG
175'
Nillate
Wires properly protected (Y/N)~, ; / YES
AT INSPECTION
: '. 167'
g.p.m. 5.1 ' , / g~p:m;
Collected by: A.W.W.C., INC.
B. SEPTIC/HOLDING TANK DATA
Date installed 1 o/1/84 Tank size
Foundation clsanout (Y/N) YES
Date of Pumping 12/31/99
loao Number of Compartments 2 Cleanoute [Y/N) YES
Depression (Y/N) NO High water alarm (Y/N) N/A
Pumper ROTOROOTER
C. ABEORPTION FIELD DATA
Date Installed 10/1/84
Length' 3,F
EffeclNe absorption area
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fluid depth 0 [ins) Minutes later:.
Peroxide treatment (past 12 months) (Y/N)
Soil rating (g.p.dJff2 or fl2/Ixlrm) 125 System type BED
Width 17' Gravel thickness below pipe 6" Total depth 5.4'
578 MonitoringTubepresant(y/N) YES Depression over field (Y/N)
8/24/98 Results (Pass/Fail). PASS For 3
~' 0 Immediately alter 484 gal. wa,tm'added (in.): __
0 Absorp~on late = ~450+ GPD
NONE KNOWN If yes, give date
DO,~ o~ 7/~/~
NO
Bedrooms
0
D. UFT STATION ~
Data installed
Manhole/Access (Y/N) /~O~evel at*. ."Pump off' level at* __.
*Datum __
E, SEPARATION DISTANCE8
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 100'+
Absorption field on lot 100'+
Public sewer main N/A
Sewer/septic service line 25'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Pmparty fine 5'+
Water main/service line. 10'+ Surface water/drainage. 100'+
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Pmparbj line 10'+ Building foundation 10'+
Surface water 100'+
Curtain drain NONE KNOWN
F. ENGINEER'S CERTI~I~AT.J~
of Municipal /ecord. le ~lf~ythf~Jb~ systems are in conformance
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhota/cleancut N/A
Lilt station N/A
Absorption field.
.Wells on adjacent loll
5'+
100'+
Watar maln/sewice line
Driveway, parking/vehicle storage area
Wells on adjacent loll
10'+
10'+
Dali of Payment ?,//,/~
~-o2~ (~ev. ~)*
Waiver Fee $.
Data of Payment.
Receipt Number
07-28-00 08:51 FROM-¢TE ENVIRONMENTAL
ZT~ C T&E Environme n,a, Serviceslnc.
551~301 T-978 P.02/03 F-$46
1004054001
AK Water & Was~ewater Consultants lac.
Spnng H~lls Est ~1 L; 4 Blk t
Spring Hills Est#l Lt4 Blk 1
Drinking WaTer
Client PO#
CT&E RELY' Printed Date/Time 07/28/2000 1:28
Client Name Collected l)ate/Tnne 07/25~000 11 25
Project Name/# Received Date/Time 07/25/2000 15:10
Client Sample ID Technical Director Stephen C. Ede
Matrix d B~~ ~
Ordered By Release
PWSID 0
Sampl¢ Remarks-
paramc~cr ResultS PQL UnitS Method L~mi~ Da~ Date Init
NSrcatc-N 0.746 0.500 mg/L I~PA 300.0 10 maX
07125100 SCL
M~ ~=obiolo? Latona=orr
Tolal Cohtbrm
col/tO0mL SMI8 9222B
07125/00 FOT
07-28-00 05:51 FROM-CTE ENVIRONMENTAL 5615301 T-$78 P.03/03 F-646
CT&E Environmental Services Inc.
Laboratop/Division
200 W Potter Or~a
Drinking Water Analysis R~port for Total Coliform Bacteria Anchorage, AK 99818-160~
Tel' (907) 562-2343
yEP.gE SIDE B£~OP..E COI. I. ECTING SAMPL£ Fax~ (907i 581-5301
'~T-B~- COMPLETED BY waLc~ ~urr>* / P I be
~ An~s~s shows [his Wa~er SAM L~
, PUBLICWATERSYSTEMI-D,~ ~] I I I I I
C] pRIYATI[ WATER SYSTEM
Send lavoWe
Q Seatl InvoiCe
Month Day Year
gAMPLE TYPE:
[] Routine Ci Treated Water
Cl Repeat Sample (for routine sample ~ Untreated Water
with lab ref. no,
C~ Special purpose Time Colletted
SAMPLE LOCATION Coll~ By
Unsansfa~:torY
Sample o'~er 30 haum old, respire may
be qnreli~l~
Sample mo ong in ~nsiT; sample should
no~ be o~ 48 h~am aid al examinanoa
m indicate reliable tesu~m, Please s~d
new sample ~a ~ia 4ellve~ m~-
0.,....,.,
an~itnl MathS: ~e Fil~
= MM~G
Analys~
004054
........... ecl1 Fb~ Jun
Client naiad of unsatisfacto~
ehoflea Spo~ wire Fax~a
BACTERIOLOGICAL WATER ANALYSIS RECORD
¢o/~ ~ --
Coloal~dlO0 mi.
COLIFIRM_
_ Coliform/tOO mi
MMO. MIlG ~ Teal Coll~m.
Membrane Fllle~: Dlte~Coont ~
Verification: LTB ~ . BGB
Fecal Coliform Conflrnmtien
Final Membraae IFiI~O~,~JW'~ ~' a"l~f~'~
~~ Memoer of We $1~ OrouplS~iete Generale ~u Samm'ancal
M[JNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
948-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1.
GENERAL INFORMATION
Complete legal description ~.J~?~L~L~Z~. I~, ~'-...~%~Z~ ._<, r
Location (site address or directions) /(~ 2 / ~-~ ~[~ ~/~
Property owner
Mailing address
Lending agency
Mailing address
Day phone ~/- ~¢DO~
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for~ckup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
NOTE:
TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
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 1/91) Fronl MOA ~21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm i-'o ( .z,~¢~ ,~.J ~t/~'7'
Address 15~62~._~ ]¢') ' "-~'- '~- ~'[:)' 1
Engineer's signature
hone_~: ¢~'~-- ~
Date
Approved for bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: '~'-.--"----- 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 DH HS does th is as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Em ployees 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.
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel I.D.
Legal Description: /-~ ~' ~/'¢_ '~¢-/<' //
A. WELL DATA
Well type. ,,¢>/'~/c..,4~ F'~ '~ If A, B, or C, attach Ar)EC letter.
Log present (Y/N). ~'
Total depth_ ,~' O cZ-
Sanitary seal (Y/N)
ADEC water system number _ /X//,¢¢2
_ Date completed ,~u¢.... :~/) /'¢/~ Driller /~/'/~'
Cased to_~' ¢ I _Casing height ~¢, t
Wires properly protected (Y/N) Y
FROM WELL I. OG
Date of test
Static wate'r level __-/~.~
Well flow
Pump level
g,p,m.
AT INSPECTION
MUNICIPALITY OF ANCHORAGe.
_ ~)~'~ , / ~/~¢,~:fAL SE RVICES DIVISION
/¢-"5-'/ P ;'~ 2 ,~ 1992
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main __
Public sewer service line
; On adjacent lots /Po /''/'"
; On adjacent lots .,/OO /¢.
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform O Nitrate
Date of sample:
~..4D C,., Other bacteria
Collected by: ~r~....~J,~ ~
B. SEPTIC/HOLDING TANK DATA
Date installed //O//J
Cleanouts (Y/N) ~
High water alarm (Y/N)
Date of pumping
_ Tank size __ /O ¢2 c".'¢ __ Compartments
Foundation cleanout (Y/N) \/ Depression (Y/N)
Alarm tested (Y/N) --
_
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /¢,o ~' On adjacent lots /oo
To property line ~! ~ ;'~ _Absorptionfield_.'~cP/
Surface water/drainage __. ,~_ .~_~
__Foundation__~
Water main/service line
72-028(Rev. 3/91) ~ront MOA2~ ~ ~O~4~,. CONTINUED ON BACK PAGE
C. LIFT STATION
Date i~
Size in gallons
Vent (Y/N) "Pump on"
High water alarm level ~-'Gy Ices tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Surface water
D. ABSORPTION FIELD DATA
Date installed O¢- 7". / . ,/¢/P~" Soil rating /2~5" ~"~¢ ,~_~,,¢?,~,System type
Length ~'~ ~'/' f Width ~ Gravel thickness ~-~ /! Total depth
Total absorption area
Depression over field (Y/N)
Results (pass/fail) '/~"~ '--? '--~'
Peroxide treatme.nt (past 12 months) (Y/N)
Cleanouts present (Y/N).
Date of adequacy test
for
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /O O I~ On adjacent lots ,/~ ~2 / "'/' Property line
To building foundation /7/O / To existing or abandoned system on lot
On adjacent lots__ ,'v'~/,¢4~ Cutbank ~Water main/service line
Surface water __
/5-/¢
Driveway, parking/vehicle storage area 20
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.
Signature ~_
HAA Fee $ ~/'~)
Date of Payment _/¢~
Receipt Number
72-028 (Rev. 3/91 ) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
polarconsult alaska, inc.
ENGINEERS · SURVEYORS o ENERGY CONSULTANTS
DHHS, Environmental Services, On-site Services
P.O. Box 196650
Anchorage, Alaska 99519
Atm:
Re:
Permit Review Officer
Design and Construction Approval for On-site
Sewer System at 4621 Golden Springs Circle,
Anchorage. Lot 4, Block 1, Spring Hills S/D
December 23, 1992
RECEIV[!D
DEC 2 4 1992
IVILI~HCi :mhty of Anchorage
Oept, -teaith & Human Services
Dear Sirs or Madam:
Attached is an application for a renewal of the health authority approval at the above
referenced property. If you have any questions, please give me a call.
Attachments:
Yellow Form
Blue Form
Nitrate & Coliform Analysis Results
$170, Check #4297
1503 WEST 33RD AVENUE · SUITE 310 · ANCHORAGE, ALASKA 99503
PHONE (907) 258-2420 · TELEFAX (907) 258-2419
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # _ ~) \~- ~-,2~ / -- '~l NAA# ~--~c~.¢--y'%,~c~ /
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT 4 t u V, mt.
Location (address or directions)
(b) Property owner %--'--~_i;.~. ',=. r _ ,v'-:: ,. _~Telephone:
Mailing Address ~ ~/
(c) Lending Institution _dN~MD~ ~ Telephone
Mailing Address L)l'q F-._NO'-,,',J iq,
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here [~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms _._~--~'~' ~
3. WATER SUPPLY
Individual Well/bi~ Community [] Public []
Note: Jf community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site,/'~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status,
72-025 (Rev. 7/88) Page 1 of 2
Address
Date
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ' .,,
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
funct ona .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. ~_,C¢_.JAI. INL i, ASSEX~, I N~,¢--.. Telephone
Engineer's Seal
6. DHHS APPROVAL ~ /~
Approved for %.__ bedrooms b~'~?~;~-~ Date
Approved _,/'~' Disappro(;d _ C0/ndit;ona,
Terms of Conditional Approval /J'~.----------------(~'~.~-'-
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7;88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~
Well Log Present (Y/N) Y Date Completed AOL~ ~lI
Total Depth ~.O~CaAed to '?~o[ Depth of Grouting
Static Water Level __~_~ Pump Set At O~to¢
Casing Height Above Ground _4 ~ Sanitary Seal ce Casing (Y/N) _
Electrical Wiring in Conduit (Y/N) _ "~ Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot lOC~ "~¢ .... ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot I~0' '~' ; On Adjoining Lots
To Nearest Public Sewer Line ---]~-I ~ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~'2~¢.~_ ¢.~=~W 11,4 ;Date "~/ ~0{
Water Sample Test Results w--¥~_ .? ¢'; 7
Comments
IfA, B, C, D.E.C. Approved (Y/N) _
YieJd ~'~ ~:~z¢,~.
B. SEPTIC/HOLDING TANK DATA
Date InstalledJ~_l !~4 .Size
Standpipes (Y/N) "~
Depression over Tank (Y/N)
JaOO" No, of Compartments ,2.-
Air-tight Caps (Y/N) Y Foundation C~e~.an. ogt (Y/N)
~'~ Date Last Pumped .tCc~.~LS'g~
Pumping/Maintenance Contact on File (Y/N) I~'~¢,¢e,~ (~EL,~htAIK! ; for
Holding Tank High-Water Alarm (Y/N) _ ~'"J'l ~ Temporary Holding Tank Permit (Y/N) ~'~/~ _
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well I'DO _~' To Building Foundation '~'~-"
To Disposal Field ~C-:~'t-
To Property Line__ ~'J ~
To Water Main/Service Line --~1
To Stream, Pond, Lake or Major Drainage Course
Comments ~ I~_,0, .~,
72 028 (Rev 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed _
Width of Field
[] I I ~ ~f~ Type of System Design -rfzr~40~
!
_ Length of Fierd
Depth of Field
Gravel Bed Thickness
Square Feet of Absortion Area _~/~'~ ~ Statndpipes Present (Y/N)
Depression over Field (Y/N) ~ Date of Last Adequacy Test
Results of Last Adequacy Test ~'~_',J~(-~" "~' ..(g ~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots _ tO0 "~
To Cutback (if present) _ ~/
To Water-Supply Well
To Building Foundation 40 ~
Lot NJ I
To Water Main/Service Line ~l
To Stream, Pond, Lake, or Major Drainage Course
To Dr veway, Park ng Area, or Veh c e Storage Area
Comments ~,~ ~, t4 .~i::~'d A,I"t I) M
Dimensions _
Size in Gallons ~"~,~__~ Manhole/Access (Y/N)
"Pump On" Level at __ ,,~.M ~--~,, "Pu~mp Off" Level at
High Water Alarm Level at /"~//'~" ~./("~ ~ ~'--~ Vent (Y/N)
Tested for __ __ ~~ing Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
/
**Check Permitte/c~edroom ~ting Against HAA Request** .
I certify that I ~¢/~/c~eckeC_~mi~d, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection. /////~,/// ,~
Signed ~,~-%, ~ ~
Date ' ~/~//~/~ ,gineor's Seal
MOA NO. ~f
Receipt No.
Date of Payment
Amount: $
72-028 (Rev 7/88) Back
Receipt
Waiver Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~\ ~Y"~ -
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Properly Owner ~//~ Telephone: Homo ~-/5
Mailing Address ~ ~/~ ~4 ~c~
(b)
(c)
(d)
Lending Institution
Mailing Address _
Real I~st~te Company and Agent
Address ~ _ ·
Telephone
TelePhone '~'- 0"5-7/
(e)
Mail the HAA to the'followine address: or: Check here E~, if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family,[~
Number of Bedrooms ~-~
WATER SUPPLY
Individual Wel[~ Community [] 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 ~ Idolding Tank
Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 trey 8/861 From
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NOI&VWMO~NI ON~ VIVO 'HDU~3S 3~lJ 'SISg& 'SNOI&O~dSNI 9NIOIAO~d ~lJ 9NI~3NIgNg
-g
WELL DATA
MUNiCIPALiTY OF ANCItORAGE
ENVIRONMENTAL SERVICES DIVISION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) APR :!. 41987
CHECKLIST- FEBRUARY 1984
264-4744
Legal Description: , ~..*.,~' .~ R.~//~,,~C' ~'.~jVED
Well Classification
Well Log Present (Y/N) _/t/'
If A, B, C, D.E.C,. Approved (Y/N) /?/'~
Date Completed ~¢:"'~/- .~ Yield ,-~"5~¢'.z~¢/-~ (~,~_
_ Depth of Grouting /v/~
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
Total Depth ~'~¢ ~- / Cased
Static Water Level /,¢';.'~".J~ ~'~.//¢_~m,
Casing Height Above Ground ~"¢¢
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot _~"~'¢
To Nearest Edge of Absorption Field on Lot ~--/~" '''~__; On Adjoining Lots ./¢,~
To Nearest Public Sewer Line ./¢~/.4~ To Nearest Public Sewer
Cleanout/Manhole ~ To Nearest Sewer Service Line on Lot
Water Sample Collected by ~-'"~ ~'-~'~ ; Date :¢¢C_,./.~
Water Sampte Test,esults / _
Comments
SEPTIC/HOLDING TANK DATA
Date Installed./~ ~¢/~' Size ~ No. of Compartments ~
Standpipes (Y/N) _/Y/ __ Air-tight Caps (Y/N) --./'// Foundation Cleanout (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) '--'
Separation Distances from Septic/Flolding Tank:
To Water-Supply Well -'""~ ¢
To Property Line
To Water Main/Service Line
Course __ :
Comments ' '
Date Last Pumped '~¢/¢/-
____ ;for
Temporary Holding Tank Permit {Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page '1 of 2
72 026 IRev 81861 Cro~t ,
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ."'~ L- ¢' / ~ ,¢¢'/~
Width of Field ~"/'~ / ~"
Square Feet of Absorption Area
Depression over Field (Y/N) /%'/
Results of Last Adequacy Test _
Separation Distance from Absorption Field:
To Water-Supply Well ~ ¢ '''"~
To Building Foundation
LOt
To Water Main/Service Line .
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field S "~ /,.¢/'¢~'/f,~1~
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots _..-"'¢'¢' '~
To Cutbank (if present)
Comments
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
Page 2 of 2
72-026 fRev 0/861 B~ck
I certify that I i~¢ve che.Qk~d, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed~/~ ~/~ Date
Company .~/.,/L<'.~ ~/./I'. MOA No. ~ ¢~-
Receipt No. t ~ ~ - OO %%~
Date of Payment .L~ - ~ ~_~, ~;., ..... ,
A.
Amount: $ ~ O0.0(b ~ ~.' ~r's
'.*
&~'/ VAN
¢~ ¢~.". CE~22¢
BEVAN ENGINF:ERING
Approved Well & Septic En§ineers
P.O, Box 112852
Anchorage, Al( 99511
(907) 522-1383
(907
258-0584
MUNICIPALITY OF ANCHORAG[~
ENVIRONMENTAL SERVICES DIVISION
APR 1 4 1987
RECEIVED
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH ~
DEPAAITMENT OF ~ALTH ~D E~IRO~;NTAL PROTECTION
APPLICATION FOR ~ALTH AUTHORITY APPROV~ CERTIFICATE
1. G~neral Info.etlon Application Date
(a) L~gal Description (include lot, block, subdivision, section, tow~ship, rang~)~
(b) Applicants Name l~:~:~ ,,.' /7:~0 Telephone - Home
Applicant
Lending
O~er/builder -;
(c) is (check one) Institution ~ ;
(e) Real Estat~ Co. & Agent ~_:~,~...
Address
Telephone
(f)
Mail the HAA to the following address:
=--' _
2. T~_e of Residence
Single-Famlly]~ Multi-Family
Number of Bedrooms
Other (describe)
w_!a t e_3_r SU_~3AZ-
Individual Well
Commuaity
Note: If community well system, must have ~:itten confirmation from the State
Department of Emvironmental Conservation attesting to the legality and statue.
4. S__ewag~e Dis_p_9~al
Onsite~ Publio :~
Community
Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and ~tatus.
[Page 1 of 2]
Engineering Firm Providin~_!Zn~ections Tt__~_~ File Search, Data and Informatio.__~n
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 shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and typ~ of structure indicated herein. I further verify that,
based on the info~ation obtained from the ~nicipality of ~chorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance ~th all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this ~inspection.
DHEP Approw~l ~
Approved for _~5~ bedrooms
Approved _~c~ Disapproved
Terms of Conditional Approval
-/
CAUTION
TIiE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF t{EALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 AEOVE BY A~N INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PI~tCHASERS OF ~tOMES AND
THEIR IgNDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE Pd~QUIRE-
MENTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE bIUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEth)
RR4/ej/D18
[Page 2 of 2]
7 -19
MUNICIPALITY OF ANCHORAGE
DI~PT, OF HEALTH
ENVIRONMENTAL PROTECTION
WELL DATA
Well Classification
Well l~x/l P~esent ..(.Y/N)
Tota 1 Depth ~ o '.~j . _ Cased to
Static Wate~ I~vel / 7~
Casing Height Above Gr. ound
E].ecra~ical Wiring in Conduit (Y/N)
Separation Distanaes f~cm Well:
To Septic/Holding Tank on Lot /~0'/~
Pump Set At
Depth of Grouting.
Sanitary Seal on Casing (Y__/N.)..
Depression Azound Wellhead (Y/N)
; On Adjoining Lots
To Nea=esn Edge of Abso=ption Field on Lot.. /OC)~ .; C~ Adjoining ]Lots
Cle anout/Manhole /[~ ~
. To ~est ~ ~v:L~ Li~ on ~t.
Wate~ Sable Collected By ,~ ~ ; ~te .... '
Wate~ S~le Test ~sults , ~/~.~ ~
C~nts
B. SEPTIC/HOLDING TANK ~I~TA
Date Installed O~7,
Standpipes (Y/N) ~/
Depression ove~ Tank (Y/N) /~ Date Last Pureed ~- ~,I,W
Pumging/Maintenanoe Contract on File (Y/N) -- ; for ~
Holding Tank High-Water Ala~n (__Y/N) ~-~ Temporary Holding Tank ]~ermit (Y/N)
Separation Distanoes f~e Septic/Holding Tank:
/
To Water-Supply Well . /~.O~_ . To Building Foundation ~?
[Page 1 of 2]
~)~Size _. (~DO c~.~z, No. of Campa~tmsnts ?-
Air-tight Caps (__Y/N) t"_ Foundation Clsanout (_Y/N)/
To Disposal Eield. ~D~-
--i-To Stream, Pond, Lake, c~ Major D~ainage
2-15-84
Ce
ABSORPTION FIELD ~ATA
Soils Rating in Absorption Strata
Date Installed,
Width of Field ! 7 /
Square Feet of Absorption A~ea ~7~
Depression over Field (Y/N) /~/
Results of Last Adequac~y Test --
Separation Distance f~c~ Absorption Field:
To Water-Supply W~ll /~.>c>'~ To P~o~erty Line
/~':~ )'/~/~/F/~.Type of System Design
/Length of Field ,~ r'.
~p~ of Field ~ /
Stan~i~s ~e~nt (~)
To Building Foundation ~d~
LOt ~//~ ; On Adjoining Lots
To Water Main/Service Line /<,//~ TO Cutbank(if pre,sent)
To Stream/Pond/Lake/c~ Major D~ainage Course
To D~iveway, Parkirg A~ea, c~ Vehicle Sto~age A~ea
Cc~ents
TO Existing or Abandoned System cn
Date Installed
Size in Gallons
"Pump .On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at ~
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Maets MOA
** Check Permitted Bedroom Rating AGainst HAA Request
I certify that I have checked, verified, c~ conformed to all MOA HAA Guidelines in effect
the date of thi~ ins~ction.
/
KB1/d5/s
[Page 2 of 2]
MOA No.
I~ tion:
BF23SE, ~q~PS &
2220 EAST 88 AVENUE
ANCHORAGE, AK 99507
(907) 349-6451
WA~'ER V~LL
Client's Na~e:
Address
Initial Reading. c~ Meter:
GALLONS GALIZ~S
TIME GPM ~ VOLUME TC~AL VOLUME
Production Rate: ,,'~,~,~ GPM 24-Hour Capacity "~ Gatlo~s