HomeMy WebLinkAboutSUMMIT ESTATES BLK 2 LT 3-Summit
sta
Block 2
Lot 3
#015-072-16
Municipality of Anchorage
Development Services Department
Building Safety Division
: On-Site Water and Wastewater Program
· ' ' 4700 South Bragaw Street
'P.O. Box 1~o650 Anchorage. AK99510'0~50
-; www.ci.anchorage.~'k.~us ' . .' , ' .
-' ................ " ' (907) 343-7904
CERT. FICATE O~ HEALTH AUTILIORITY AP-PROVAL.
' '' FoRA-~- ~- :-- -~51NGLEI-AMILyY.UWELLING.,.,~: :..-~ ~- ' · , , .- ·
'"" :1 '"' ' '. . 'iJ . ib -. '..
Parcel I.D.'. '0'~5'0~;2 6 ...... ~ #".'. ' - ='.
~ ......-.: .............., ....,~,. ,,, -..:, --...
· ' '" :" .... .--- : .ExpirafionDate:"'-.:~ ~7 ''-'! '
1.' : GENERAL' INFORMATION ''--':-' '.~:?-:. -' '" "'~ "-''::'- .... ' ' ' "
· " Complete legal description ~ 1'6t 3 BlOck 2 Summit Estates ~: ':' ::-'.' ........ ' ~'' --' .... ~ :'*" ":
"~-...'.Locatio, ........... ' (site'- a~d)~ss or ~ il;~0 n S)'-' 5:'/02 E.'97m A~;ehue,';Anchora.qe~'AK '99516 ......
"" : ;d O~b S~,;~-0a'y'~ .... '"
p~ ~jw.() :~... · . ,,.-...--
Currentope o er s L~a ra on · i one 346-1869 -"
5702 E. 97m Avenue~ Anchorage, AK 99516 :-
..--:.,;:-? Mailing addres
..- ~... ~Lendngagenc~
.,. :,. : .- :':..'-j '~
i" ;',~ " : :' ': ~.'-¢ Ma~hng address
.'-' .':' -: Real Estate Agent,
: Mailing Add~ess
Prudential Jack WhitelAlene Palmer Day phone ,563-5500
3201 C Streei, Ste. 200, Anch~)'ra.cle, AK 99503
Unless o~herwise ~eq'uested, HAA will be held by DHHS for pickup. HAA picked up by:
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
Individual Holding tank
Community On-site
[] Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to home ownem. Certificates of Health Authority Approval am
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 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.
5. STATEMENT OF INSPECTION BY ENGINEER ·
As certified by my seal affiX(ed hereto and as of the Validation date shown below, I verity that my investigation
' ': based on procedures outlined in the Health Authority Approval Guidelines for 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 bedroom§ and type of struct,',re indicated herein. I further verity 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 applicable Municipal and
State codes, ordinances,, and regulations, in effect at the time of installation.
Name of Firm ,Pannone En.q. Svc. '~ ' ' ' '"' ~ ....... Phone ' 272-8218
Address P.O. Box *' ' ' ..... "- ' "''~ -'" *, "* ,* .....
E,ngineer's .Printed Name ,Steven R. Pannone, P.E. Date · 712/2001
EngneersComments.~coadoctmga~adc~uacTtcst. lattcmpttopro,adcathoroul~t.m~fio~- : ~m~m. .
~Smcormg nnaIysxs of thc system m nccordaucc with MOA I~D GuidcEnc~ & Rcsu~tjon~. 'I'ne * .,' . ~.~.'~.~. 'OF :Al ~ee.
the and · ', ''
,.test,..~. hondistancc~mca~torc~ly,dcnti~blcfcaturc~. ,l'heo~tion~XirebraU . ** CO..* * /[~**"~
wcl~ aha sc'phc s'ystc~s dcpcnd on the local soil condidon, gr°ux~l v~xtor levels th,at may fluctuate *..- '*r '-' ~ *" · "*. ' ;"*- ~
outsidcth¢controlof~e~va~uatorofthissvstcm .'UIs*wtcmsevca vr,,;z..~.~;.r.,-*,..~..~ ' ~ ..... ~"*~ ......... ~""*'*~"*-~
...... ~. -.,- . . t~l,~ ~'r ......... · "-~' ' ' ~ ' '~' ',~,~,~.X *,~ ',.",
.?uxts do not b,~arantec ~utur~ perform~ or thc ~ nor do thc'y ~anice ~t th~';c'arc no' ' ~, ~;' ................. ~....
hiddc~dcfccuor~cr~achmcuts.P""E~c~thcrc£~r~tpr~v~dca~yv~u`rant~or~ut~c~1~ormancc ~ ~%Steven R
nor 8Jvc aay estimate ofhow I. oas the s'~st~m wUl cont~ue to mcct thc__ o,-__ho._ ...~,Gm" b;,l ~;~,i;,-~,~' .......... ,~**~,r*~,~' .-.'~ 5'~'-.-.*...,~. '.;-.¢,. 'r~ .~ ";"*-;"~,.,~
A.D...EC ~ MOA DSD' Thc c°ntc~t °f I~'ds relx)rt Is for thc sole Ixmcfit of thc ow~cr lJstcd above A~v '
6. 'DSD SIGNATURE, . ~t~,~
.: ~ ' Approved for. /../L bedrooms.
·, - Disapproved.
: Conditional approval for- __ bedrooms, with the following stipulations:
X
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory ,
Well Flow Advisory
Maintenance Agreements
Supplemental Engine(~r's Report
'Other
Expiration Date: / 43 - ,/q-o /
Odginal Ce~ficate Date:
Reissue Date:
7 o /
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bregaw Street
P.O. Box 19~50 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type p_
Date completed
Total depth 70
Lot :~ ~lock 2 Summit Estates
If A. B, or C ixovlde PWSIO # ~
Sanitary seal Y
Cased to 70 h
FROht WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform .~--~.~'~"- colonit~/lO0 mi
Date of sample: 6/2912001
B. SEPTIC/HOLDING TANK DATA
It
g.p.m
Collected by:
Parcel I.D.: 015-072-16
Well Log N
Wires propedy protected Y
Casing height (above ground) 12
AT INSPECTION
6/2912001
6.21 'g.p.m
iD.
Other bacteda '~ colonies/lO0 mi
Ppnnone
Tank Type/Material '
Date installed ~ Tank size 12~0 gal
Cleanouts Y~s Foundation cleanout Yes Delxession over tank No
Date of pumping 612912001 - Pumper A+ Home se~icos
C. ABSORPTION FIELD DATA ~ ~3 --.
ume Ins~alled'8t~ff~ Soil rating (g.p.dJft or It/bdm~)
Length 35 & 24 It Win'th 2.fl It
Number of comPartments ~_
High water alarm No
system type Trench
Grovel below pipe {I & 4 It
To*al depth 14 ff Effective absorption area 711:~ f.(2 Monitoring tube Y De~reSsio~ over field N
Date of adequacy test ~1:~/2001 Results (Pass/Fail) Pass For 4, bedrooms
Fluid deplh in abserp~iofl field before test I:)rv in Water added$00 gal. New dep~hDrY in.
Elapsed Time: 0 min Final fluid deplh Dn~ in · Absorption rate >= 600+ g.p,d.
Any rejuvenation treatmer)tr(past 12 mo.) (Y/N & type) NO If yes. give date
(Rev. 11~)
:L D. UFT STATION
Date Installed
· 'Pump on' level at
Datum
Size in gallons
in'Pump off' level at
Cycles tested
E. SEPARATION DISTANCES
SEP^RAT ON DISTA"CES FROM WELL ,O* 'TO:
Manhole/Access
High water alarm level at in
Meets alarm & circuit requirements?
Septic tank/lift station on lot 108'
Absorption field on lot 120'
Public sewer main 100'+'
Sewer/septic service line ;~5'+
On adjacent lots 100'+
On adjacent lots t00'+
Public sewer manhole/cleanout 100'+
Holding tank NI,'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 15' Property line :~4'
Water main ;~lF+ Water service line
Drainage 100'+ Wells on adjacent lots, 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 14' Building foundation, ~+
Water Service line ~'+ Surface water 100'+
Curtain drain lQ0'+ Wells on adjacent lots 100'+
Absorption field t6'
Surface water 100'+
Water main.
Driveway, perking/vehicle storage 60'+
F. COI~MEI~TS . ,~ · I
'lmm Pa ¢* ~ ' - i'ni -.' ' n ~-
re~ of M~ ~s ~ ~ ~ sy~ms ~ in ~'"~'~ ....... ~-'~
~ ~ MOA H~ ~l~s
E--in,ds Pd~ Name S~ .... '&'¢~ ~ ¢~- ':~ ~'~
,~ ~n K. Pannone, y.~
vine . ~/~l~( ., : , 'ee~ ...... ~,~-
Date of Payment
Receipt Number
(Rev.
,Waiver Fee $
Date of Payment
Receipt Number
J~-OS-0t 08:18 FRCIi-CTE £NVII~t~VENTAL
Envlronmer~a! ~ervlGo~ Inc.
CT&E
0075615301 T-621 P.0Z/03 F-730
CI'&E Re f,;~ 1013883001 Client PO~
ProJect.~ame/# Lot 3 Bk 2 S~t ~tes ~l~d De,lee ~9~001 I ~:C0
O~t Seraph ID ~ Hoseblb ~elved DatiVe ~9~001 1~:2~
Ma~x ~iag W~cr Technical D~tor ~ep~ C. Edt
O~ered By
Total NJtra~e/~it.-it e
To:al Coli~'onn
3.69 0.500 mB?L £PA. 3CC.O 07,~3/01 SCZ,
0 col/1OOmL SMllr'~.2O (<l)
06/29/01 KAP
) !, M.N,C!.A..T~ Or ANCHORAGE
DEPAR~NT OF HEALTH & ENVIRONMENTAL PRO~I~CTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE ~ NEW
MAILING ADDRESS
LEGAL DESCRIPTION
NO. OF BEDROOMS
~,~,~,o: I~" I~°~°~ ~" ~,~
~ Eiq. capacitg in flallons Iff HOM[MA~[: Inside Ionflth ~idth kiquid dopth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O Z ~ Manufacturer Material Liquid capacity in gallons
O Well Foundation Nearest lot line PERMIT NO.
No. of lines Length of each bne Total length of lines Trench wldtb Distance between lines
Top of tile to finish grade Material beneath tile Total effective absorption area
Length Width Depth PERMIT
~ W Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Dri[[~ Distance to lot line PERMIT
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(si
SOl L TEST RATING
INSTALLER
REMARKS
~ SEP 2 o '..
RECEIVED
App~licant:
LOcation:
Legal Description:
Type of Soil Absorption System Is:
Trench: ~ Drainfield:
Maximum Number of Bedrooms~
~UNICIPALITY OF ANCHORAGE L]~'%
Department~ ' Health and Environmenta] ~rotection
825 ~ Street, Anchorage, ~ .~
264-4720
~ * * * HANDWRITTEN PERMIT * * *
WELL AND/OR ON-SITE SEWER PERMIT
· ~y~K~ Mailing Address L
Phone Nurober: ~ ~"--
~&C~~ Lot Size:
Seepage Bed: __ Holding Tank:
Soil Rating(sq.ft/br) I~~-
The Required Size of the Soil Absorption System Is:'
DEPTH [~2~{ LENGTH ~ . GRAVEL DEPTH ' WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
d~pth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = ~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for-a private well or 150 to 200 feet from a public well depending upon the type
of:public well. Minimum distance from a private well to a private sewer line
is:25 feet and to a community sewer line is 75 feet. Well logs a~e required
andJmust be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I! certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the r~idence is ~emodeled to include more that 3 b~d~ooms.
S~gne~: ~ Issued by:
Applican~ ~ - ~
~ Date: ~'-- ~-- ~ %
SWP/024(1/81)
/
oGREA~.~ANCHORAGE AREA BOR~.~..~,I
Anchorage, Alaska ggB03
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL-S~STEM
LOCATION .
LEGAL DESCRIPTION
PHONE
SEPTIC TANK: .j~
DISTANCE j,. ~ ,~ ~ p,/u-~ ~,.~..~ NUMBER OF
FROM WELL-P MANUFACTURER' 'g' "' '- TERIAL " COMPARTMENTS /
~J
INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY/~''O'~ GALLONS.
DISTANCE FROM WELL~)/''~)u FOUNDATION.~',~ ,
NUMBER OF LINES / DISTANCE BETWEEN LINES
ABSORPTION AREA O'""g~ SQ. FT. LENGTH OF EACH LINE
DEPTH
OF
FILTER
/
DEPTH: TOP OF TILE TO FINISH GRADE ~
MATERIAL BENEATH TILE
NEAREST LOT LINE /O'"" '~ TOTALoF LINEsLENGTH'~ ~4'"' /
TRENCH WIDTH \~ IN. TOTAL EFFECTIVE
/ '
WELL:
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST NEAREST SEPTIC
LOT LINE __ SEWER LINE TANK
OTHER SOURCES
DISAPPROVED REMARKS
DEPTH __ DISTANCE FROM:
SEEPAGE
, SYSTEM
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL:
REMARKS: .
Form EQ-032
DIAGRAM OF SYSTEM
GREATER ANCHORAGE ArEA BorouGH
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
INSTALLATION LOCATION ~/~- /~/~ ~:~/~'~/~/ ~'~
FACILITY TO BE SERVED . . ~/d~
FINANCED THROUGH TO BE INSTALLED "Y ~/~/~
SOIL TEST RESULTS /~ ~ ~ ~~ NOTE~ THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
PHONE
SEPTIC TANK, J~
SEEPAGE Pit /~., DRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION ~ FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
3RAM OF SYSTEM
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF CREATE ANCHORAGE AREA OROUGH ORDINANCE NO. 28-G8 AND THAT THE ABOVE
Legal Description: /f'~ / .~ ,f~/~
This form reports: Soils log
GREATER ANCHORAGE AREA BOROUO~'
~_~.~.)artment of Environmental Qu~_~,~
3330 "C" Street
Anchorage, Alaska 99503
SOILS LOG - PEROLATION TEST
Date Performed__?~/~//h.2-
Percolation test
Depth
Feet
2-
3-
4-
5-
7-
8-
9-
Was ground water
encountered?
If yes, at what depth?
Reading Date Gross Time
Net Time
_~epth to Water
Net Drop
Percolation rate minute.
.Proposed installat--T~-~--~b~-ge Pit Drain Field
!)epth of Inlet Depth to bottom of pit or trench
CO,,1,'.!EI'ITS: .......//~-----7'~-'-- __- ~7____ ..............................
EQ-040 (6/74)
[¥1LLIAM A. EGAN, GOVERi~OR
$OUTHCENTRA£ REGIONA£ OFFICE
MACKAY BLDG.
338 DENALI STREET
~arch 21, 1973.
Mr. Carl Jem~ings
P. O. ~' 4984
Anchorage, Alaska 99505
gJTg-ECF: Lot 5, Block 2 --Su~mit Estates
Dear Mr. Jennin~s:
We have reviewed your situation in light of the interpretation of
the 40,000 Sq. Ft. -20,000 Sq. Ft. requirement contained in Section
18 ~AC 72.030 of the Department of Envirorm~ental Conservation Waste
Water Regulations. It is our finding that since you had ox~nership
of the lot on or before February 5, 1973 and that you intend to
construct a private residence for your personal use, that this particu-
lar Section of the Waste Water Regulations is not applicable in your
case.
}ge would however advise you that of course all existing Borough
Regulations are in effect m~d are applicable in all cases except
where State requirements are more stringent.
Yours truly,
yle w. ct
Regional Environment al~ Eng~neer
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. # ~/~--~ 0'~ 1~ HAA#
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency ~4/~ /=eoCero/
Mailing address /-(oo ~ ~r~
Agent C~r~ ~}r~ V'~
Address
Unless othe~ise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
Co ri ~q-e-,~;~r Day phone
Day phone
Day phone
9q5-o~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the iegality and status of system.
TYPE OF WASTEWATER DISPOSAL:
I ndividual on-site
Holding tank
Community on-site
Public sewer
NOTE:
49 / ~,' ,j ,,
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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.
NameofFirm F/~ ~ ~/~ 7'~cA,~ ~'~c, f _~ ~.,' ~,,'r ,,.f Phone ~'f,.C-
Address /~/5'30 ~c-Ao ..q~ /0-mc,~o~'~'J~ ,~r-/~
EngineeCssignature ,~~ ~"~. ~ Date
DHHS SIGNATURE
b'//~Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
/~:' i ;. ,
*.The Mun cfpality 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
...... ' ' The DHHS does this as a courtesyto purchasers of homes
profess~o .n, al engineer registered m the State of Alaska.
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. ·
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription:/-o/'3~ ~ll, c~-/ ~u~,? ~g~. ParcelI.D.
A, Well Data
Well type 17
Log present (Y/N)
Total depth '7~'
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 19"/~- Driller
Cased to ~ '7~ ' Casing height
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
Wires properly protected (Y/N)
g.p.m.
AT INSPECTION
'~ 3. ~)-' ~ ~
~ ~ g.p.m, ri"1 o~~o~
; On adlacont lots ~ ~ oo,
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform o co/ ~./0~ ~,.,.~ Nitrate
Date of sample: ~/'z?19¥.~ ~o/~/?'7'
3./o~n~ {..~. Other bacteria /~,,,~¢ Collected by: ~ F'. /~o~-~
B. SEPTIC/HOLDING TANK DATA
Date installed 5' / '7 ,~'
Cleanouts (Y/N) Y'
High water alarm (Y/N)
Date of pumping
Tank size I '~ .~'0 d-~/ Compartments
Foundation cleanout (Y/N) ¥ Depression (Y/N)
N. A-. Alarm tested (Y/N) hi,
~/~-/ <~ ¥ Pumper A +
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I o ~ '
To property line ~ Y
Surtace water/drainage
On adjacent lots >. loo'
Absorption field I ~'
O0~
Foundation
Water main/service line
72-026 (3/93)* Front
CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LiFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed 5-/75- ~,,,~r~d¢~
,~j
On adjacent lots
~'~'~ Soil rating (GPD/FF)
Manufacturer
Manhole/Acoess (Y/N)
"Pump off" Level at
Cycles tested
Sudace water
72-026 (3/93)* Back
HAA Fee $
Date of Payment
Receipt Number
Cudain 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.
Date 0~
Well on lot I ~d
To building foundation
On adjacent lots '1>
Sudace water '1>
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots > ~ o o ' Properly line /q'
To existing or abandoned system on lot N, A,
Cutbank N.A. Water main/service line "~ '~ 5"
Driveway, parking/vehicle storage area
Waiver Fee $
Date of Payment
Receipt Number
Length 35"~- 8'~' Width ~,5' Gravelthickness ~' ~ ¥' Totaldepth I~'
Total absorption area '7.5- 8 r-J' Cleanout present (Y/N) "~ Depression over field (Y/N)
Date of adequacy test '~ / a.'7 / ? ~' Results (pass/fail) ?~s.~ for
Waterlevelinabsorptionfieldbeforetest 5'9'~a go" Aftertest Cz"a ac"
Peroxide treatment (past 12 months) (Y/N) No,~ ¢ ~,~ o ~,,-, o.r" If yes, give date /',5 ,4.
1-45- o'/~,,-~., Systemtype
CT&E Ref.#
Client Sample
Matrix
ClientName
Ordered By
Project Name
Project#
PWSID
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~,~'~'~'~'JJJ~'~:~'~'Jf~'J~
LABORATORY ANALYSIS REPORT
94.4954-1
L3 BLK2 SUMMITESTATE8 REAP, HOSE BIB
WATER
FLATTOP TECHNICAL SRV
UA
WORK Order 82565
Printed Date 09/30/94 ~ 15:16 hrs.
CollectedDate 09/27/94 ~ 12:00 hrs.
Received Date 09/27/94 ~ 14:00 hrs.
Teclmical Director
STEPHEN C. EDE
Smnple Remarks:
Parameter
ROLryINE SAMPLECOLLECTED BY: T.F. MOORE.
QC
Results Qual Units
Method
Alloxvable Ext, Anal
Lhnits Date Date hilt
Nitrate-N 3.10 mg/L EPA 353.2/300.0 10
09128/94 CMP.
* See Special Instructions Above
** See Sample Remarks Above
U = Under ected, Reported value is the practical quantification limit.
D = Secondary c~lution.
UA = Unavailable
NA = Not Analyzed
LT= Less Than
GT= Greater Than
5633 B Street, Anchorage, AK 99518-1600 ~ Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
10/0Gx94
¢
CT&E ENVIRONMEHTAL LAB SERVICES ~ 90?5451555
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENTAL LAmORATORy SERVICES
Drinking Water Analysis Report for 'Total Coliform Bacteria
READ INSTRUCTIOP[$ ON REk'ERSE SIDE BEFORE COLLECTING SAMPLE
MUST BE COlvIPLETED BY WATER SUPPLIER
El PIJBLICWATERSYSTEMI. D.# L I I I [ II
fl $gndRe~ulls El ,¢;end.rnualce
Month Day Year
SAIv~PLE TYPE:
I~ Routine cl Treated Water
I~ Repeat Sample (for routine sample 0 Untreated Water
with lab ref. no. )
· 0 SpeclalPurpose
LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to
Satisfactory
Umadffacior/
Sample over 30 hours old, results may
be unreliable
O Sainple too long in 'aa.n$it; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via special delivery fin',iL
a,e ReeeiYed /o-.s
F
/haalytleal Method: I~embrane F/her
0 MMO-MUG
* Number ofcolonie,/I00 ml.
Lab Rcf. No. Result* Ana!yst
.%ne to A.D.E,C. ~ Fbks Jun
Faxcd
Client notified of unsatisfactory results:
l~honcd SpOke with Faxed
BACTERIOLOGICAL WATER ANALYSIS RECORD
N[MO.MUGResult: Total Collie*tm ~,, E. CMl
Membrane Filter: Direct Count
Verification: LTB ..... BGB ~- COLIFIKM
Fecal Coliform Conllmation
Final Membrane Filter l~esul/~ , . ColiforrMlO0
Colonies/l 0~3 all
MUNICIPALITY Of ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services section
P.O. Box 196650 AnchoragelAlaska 99519-6650
343-4744
Parcel I.D, #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site add'tess or directions) 57OZ. E
Property owner E~-[ J
Mailing.address . P.o.
Lehdihg agency'
Mailid'g ~ "
Day phone
Day phone
Agent
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: d '~
TYPE OF WATER SUPPLY:
Individual well -Y'
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
- 5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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 ~nd/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
NameofFirm A.$.C,G,£,~.
Address .'3ol ~H-,,~.~i~,; P~lo~t,_/~l~e.~g~,,/~l~S/~
EngineeCs signature (~/~¢4~/['%-
Phone $'[ ¢f- ~/'¢~
q55~,5- ,3o,3.S
DHHS SIGNATURE
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72~)25 (Rev, 1/91) Bsck MOA#21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type
Log present (Y~)
Totaldepth ~
Sanitary seal (~N)
If A, B, or C, attach ADEC letter. ADEC water system number --
Date completed ~,~ ~.~,>-~.~ Driller u~ )~,~
Cased to '~ Casing height !
Wires properly protected ~,./~) ~c~
Date of test
Static water level
Well flow
pump level
FROM WELL LOG
AT INSPECTION
SEPARATION DISTANCES FROM WELL TO:
/
Septic/holding tank on lot ) ~ c~
Absorption field on lot j ?~o
Public sewer main I°°'¢
Sewer service line Ir-poe
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank ~ o o P
WATER SAMPLE RESULTS:
Coliform 4'2 K
Date of sample:
Nitrate
Other bacteria
Collected by:
Tank size
Foundation cleanout Y~)
B. SEPTIC/HOLDING TANK DATA
Date installed r~/Z ~z/ 7.c3
Cleanouts ~)'N) Y¢-~
High w~te.r.,alarm (Y~[.~ /~J~ . , .:
,¥/ /
Date of~ um lng' 3 ,~.- ...... Pumper
SEPAR,~TION DisT~ANCES FROM,~EPTIC/HOLDING TANK TO:
· " On adjacent lots I (~ o~'
Well(s) on lot ,l.o 5 f
Topropertyline''''': ;~o-~''''*~ Absorptionfield / (' '
Surface water/drainage ~g>o~'
Compartments
Depression (Y~)
Alarm tested (Y/N)
Foundation
Water main/service line
72-026 (Rev. 7/91) Front coNTINUED ON BACK PAGE
C. LIFT STATION iX.J,
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed t~,~'A~lol~
Length .G ~ / Width
Total absorption area ?£~-
Depression over field (Y/~.~
Results (pass/fail)
Soil rating /Z-5 ~'~ /'~¢~ System type
Gravel thickness (.' Total depth
Cleanouts present ~N)
Date of adequacy test ¢'/-,5//¢'
for ~'(
Peroxide treatment (past 12 months) (Y/~ ,L)¢
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~ 'Z o
To building foundation
On adjacent lots Zo'
Surface water / ~o ~'
Curtain drain ~P0 ¢-
On adjacent lots ~od'4, Property line
To existing or abandoned system on lot
Cutbank / ~o'~' Water main/service line
Driveway, parking/vehicle storage area 5
E. ENGINEER'S CERTIFICATION
I certify that I have checked, vedfied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
HAA Fee $ ~/70'¢'~
Date of Payment L~.~/p ~c~-~....
Receipt Number ~"~ ~'c/.z¢
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
NORTHERN TESTING LABORATORIES, INC.
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 907-456-3116
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
~/PRIVATE WATER SYSTEM
NAME
SAMPLE DATE:
SAMPLE TYPE:
~'Routine
[] Special Purpose
'3 .2.:~ ¢i~ Phone '~d~-% ~/~'
Mo. Day Year
Purchase Order No.
[] Treated Water
J~x Untreated Water
[] Check Sample (for original contaminated
~ample with lab reference no.
Sample ~me
No. Location Collected
2
3
4
5
6
7
8
9
10
Signature of Representative
Collected by Laboratory Ref, No.
FOR LABORATORY USE ONLY
CASH CHARGE PREPAID TRANSMITIAL SPECIAL INSTRUCTIONS MAIL
1 HOLD FOR
PICKUP
/
TO BE COMPLETED BY LABORATORY
Received at: ~Anch. [] Fbks.
Date Received
Time Received
Next Sample Due '-
COMMENTS:
SATISFACTORY (~
UNSATISFACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
'E ~D TIME A~ALZYED 3/26/92 16:30
}iE-~ P~E FILTER
Direct Verification Final
Count LSB BGB Result*
f Total Colifor~,Co~nies per jO0 mis.
R e~o rt~a ~y
Date
Time
NORTHI R T ST NG LABORATOtRt $,
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-3125
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378 · FAX 274-9645
Arctic Slope Consulting Group
301 Danner Avenue, Suite 200
Anchorage AK 99518
Attn:
Report Date: 03/30/92
Date Arrived: 03/26/92
Date sampled: '03/26/92
Time Sampled:
Collected By:
Our Lab ~: Al16691
Location/Project:
Your Sample ID: A
Sample Matrix: Water
Comments:
MDL = Method Detection
Limit
Flag Definitions
B = Below Regulatory Min.
H = Above Regulatory Max.
E = Below Detection Limit
Estimated Value
Date
Method Parameter Units Result Flag MDL Analyzed
EPA 353.3 Nitrate-N mg/1 1.8 0.1 03/27/92
RECV'D
Reported By: William E. Buchan
Organic Chemistry Supervisor
WELL LOG
LOCATION:
Lot:
Block:
Client's Name: e,~,..l
Address:
TESTER:
Initial Reading on Meier:
DRAW TIME GPM GALLONS GALLONS FIELD MONITOR METER
DOWN VOLUME TOTAL LEVEL READING
7" I ',q~' Z,O 73/ 31 ;! */' /o ~ 3& 7~
1'~"' 2_;lo 2.~q -(ed ~/ Z~,' {_,,~ 37
NOTES:
5'oZ. ~'/~o0
Production Rate: ~ GPM 24-Hour Capacity ~ Gallons
HOME SEBUICES, INC.
1B9 POE
INVOICE # 6236
DATE I DEBCRIPTION AMOUNT
~,-o E. 9?th $ 90 00
04-03-92 Pump Septic: At .,/.. I ......
Fil~ ~acor,:t~: Non~ ....
I .... T~AL
3~9-5~48 ' ' "' REMARKS
I
~ PROSL~ AREA--OALL FOR~ORE INFOH~ATION
~ NEED~ ~ B~ DON~ AGAIN IN ~ ~ON~H~
i
~ Good Shape ~Sludge buildup on Bottom ~ Floater on top
Jim cap missing or ~Cut standpipe to 1' Above ground D Needs Septlctrlne
~ needs replacing