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HomeMy WebLinkAboutSERTICH LT 1Aertich Lot 1 A #014-243-04 r E3 L 16 -.. � I U: b4a Alichonage 'Pleil �: rUtilp 891' 9072430742 p.4 beveloprivent Services Department Buiidinq Safety Division 011 -Site Water 4 Wastewater Program 4.700 Ef-nore Poazl, P.C. Boy 196650 r Mark 3�gich Anchorage, A< 995C7 A E T Mayor vP,%fw.rnurq.orU/2.i1sLitq, --- -1 '907) 343 -7904 Pump Installation Log Nell Drilling Permft.Number: Date of Issue: Parcel Identificativii Number: 014-2 q 0 q Legal Deseriptior., Property Owner Name & Ac1dress, Ser 4,'c L11 za,�� , �77-71 Pump Installation Mite: I/ i ;�/71 Pump ltit2k-e Deptb Belo,w Top of Well Casino: &15–feet Pump PY.Tanufacturer's Naive: Pump Model: C Pump Size �� -hp Pitless Adap ter Burial Depth: i fect 11itless Adapter A,,"anuf acturer's Name: Mjn,/*,�.\,%,,%,— Pitless Adapter Installer: Well Disirfected -Upon Completion? N. N-le-thod of Disinfection: Corm-nents:lel/I -,� kf I Funip installer name: V, G Atteatirm: Tha pwi-ip installe- shall pfovide a pump jm,:ttt]1adon log to the DSD Y/A.-i'll 30 k days of pump installation. Municipality of Anchorage Page. I—of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744 On -Site Wastewater Disposal System and/or Well Inspection Report Permit Number: �9&®3 � PID Number: (91 4 —9qt —b :2 Name: VQS�<_0F_ Wastewvter System: *ew ❑ Upgrade Address: S � � ©� tt i Loo -F> � ABSORPTION FIELD Phone: No. of Bedr oms: Deep Trench ❑Shallow Trench ❑Bed C1 Mound O Other LEGAL DESCRIPTION Soil Rating: I, Z Total Depth from original grade: GPD/ Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Ft. Ft. Township: Range: Section: Fill added above original grade: Gravel length: �7 b 0-1 Ft. i Ft. WELL: El New ❑Upgrade Gravel width: Number of lines: Distance between lines: 12— Ft. Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Ft. Ft. Ur SG. Ft. q > a Driller: Date Drilled: Static Water Level: Inpller: n / Date installed: - iQ �L Ft. i'Z Yield: Pump Set at: Casing Height Above Ground: TANK GPM Ft. Ft. SEPARATION DISTANCES V4ptic ❑ Holding ❑ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines /i�"'C% Number of Compartments: Well -Material: to P, SurfaceLIFT Water N STATION Lot Line I_ 46 i -6 `7 Size in gallons- Manufacturer: i 1 "Pump on" level at: "Pump off' level at: High water alarm at: Foundation Alp I Curtain N r t= Pump Make & Model Electrical Inspections performed by: Drain I? It1 BENCH MARK Remarks: �J j /' q,q pool Location and Description: __ Assumed Elevation: may` C;1 W1, OVIL n 01 - 4EAIExtM sH S SEAL lLh Inspections performed by: e < .- Dates: 1St , /ai8 p{ r< 2nd Ll� .�� �.� ev ` Department of HeWanduilian Services approval V � 7aate: Reviewed and approved by: 72-013 (Rev. 9/91) MOA 25 I I I I REPLICEMENI I I a 1 I PRIMARY TRENCH CO TH MT CO BENCH MARK 1 G I 1500 GAL SEPTIC TANK — c I SWINGTIES: I AC 42.5 FT I 1 BC 29 AD 46.5 BD 461 1 I AE 27 O BE 25 I I AF 87.5 I BF 88 I Well 1 IF I 1 :�•'' ♦ 1 1 49th �.................... ........0 1 I �� •. j �♦ C'.T❑ BEN SPURKLN :� Ar No, AV I AV �•''•••.•''' �� ♦ . ♦' I jtr4)RiFES��i��•••• 1 1 25 1 0 25 50 75 100 125 150 - --SCAL-E �v 50 F -T - - - I I BENCH MAK: BOTTOM SIDING ASSUMED L£VATION: 100.00 FT TOBBEN SPURKLAND P.E. TRACT A 9ERTIC9 SID SEPTIC SYSTEM AS BUILT Z05 W 75TH. AYENUE P691PT Mkl(907) DATE; OUT ZZ1 1996 ANCH. AK. 279-3916 99501 8716 ABBOTT LOOP ROAD SHEET: 2/3 GRID: 2335 SW960332 PID # 014-241-02 SER00T42. DWG CO IE 89.5 SILT BARB. 6 Ft of Septic Standard Trench , 2' Wide 67' L ong 9' Deep 6' Sewer rock 3' Co ver MT CO all ��• PSE....... NLI SCALE : �:� • '•. � 0'. 49th TOPPEN SPURKLAND L rJ No. CE -222s 17 '♦��441.f OFESSLt'.i� ivu JLj9LL BENCH MARK, BOTTOM SIDING SEPTIC SYSTEM SCHEMATIC ASSUMED ELEV. 100.00 TOPPFN SPURKLAND P.E. TRACT A SERTICH 91D SEPTIC SYSTEM AS BUILT EUJ WIDtn Ave 8716 MOT LOOP POQD DATE OCT ZZ, 1996 Anchorage Ak 99501 ROBERT KOSKI SHEET: 5/j GRID2335 SW960332 PID# 014-241-02 SER00T43. DWG j�pj (rfj oy PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 c)-� -(�(.o ANCHORAGE, ALASKA 99519-6650 lc- 1Lc `'lam ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW960332 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:KOSKI ROBERT A & RHONDA SUE OWNER ADDRESS:8716 ABBOTT LOOP RD ANCHORAGE, AK. 99516 PARCEL ID:01424102 LEGAL DESCRIPTION: SERTICH TR A LOT SIZE: 83908 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: DATE ISSUED:10/03/96 EXPIRATION DATE:10/03/97 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: PROPERLY DECOMMISSION EXISTING CESSPOOL. INSTALL FC RECEIVED B ISSUED BY: DATE l e ^ 3 `l � DATE:-` U/ 63A5 T oSPANMD P.E. 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN TRACT A SERTICH S/D ROBERT KOSKI Municipality of Anchorage Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 September 15, 1996 We are submitting an application for the installation of a septic system for this lot. The present installation is an illegal cesspool. This submittal consist of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only septic system are subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following : No Ground Water or Impervious Layer to 15 ft. MUNICIPALITY OF ANCHORAGE Use Standard Trench ENVIRONMENTAL SERVICES Soil Rating. DIVISION 2 min/in = 1.2 gal per sq.ft/day use 0.8 No. of Bedrooms 4 SEP 781996 Required Area per Bedroom: 150/.8 = 187.5 sq - ft. -Total area required: 187.5 x 4= 750 sqft. RECEIVED Bottom of testhole 15 ft Bottom Rock At 9 ft Top Rock At 3 feet Rock Depth 6 feet Total Trench Length 750/12 = 62.5 ft. SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 62.5 FT TOTAL DEPTH 9 FT ROCK DEPTH 6 FT COVER 3 FT SEPTIC TANK 1250 GAL The installation of this septic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Municipality of Anchorage K DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG — PERCOLATION TEST (ENGINEEh'S SEA`I ) C �- PERFORMED FOR: K©SKI 3 1� D BY=— 2:7 _DATE PERkORMED: ' LEGAL DESCRIPTION:_ I P—A(--C 09, SFE2TICH Township, Range, Section: =1 SLOPE SITE PLAN _�AN 1 c S r—rTI-1 2 3- 4 5 c 6 {� r `✓ Q�Yvl-2- 4 J Vd4&( 7 �DS do 11 8 9- 10- 11 10 11 _ 12 13 - _ 14 15 16 �oTT—OU-1- u-t 17- 18- 19- 20- 17181920 COMMENTS COMMENTS WAS GROUND WATER ENCOUNTERED? 0 S IF YES, AT WHAT L O DEPTH? P E Depth to Water Aller/ Monitoring) -% Dater 416`5 4eading Date Gross Net r, I... Time Time to ater Net Drop /s 9� Pt2L Salk PDepth o� z 3� — [6l 516 44& 3 y 3 3 3 3/�/ PERCOLATION RATE / (minutes/inch) PERC HOLE DIAMYRR 6 B (a 5 G � 3 TEST RUN BETWEEN FT AND _L FT PERFORMED BY: I S I CERTIFY THAT THIS TEST WAS PERFORMED IN +j 1 ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:At-f 72-008 (Rev. 4/85) LOL 87 OF a. E� 49th #0 .:..........1 .......................... 0..... .. % 1 TUBB N SPURKLAND AN �•' ZAF CE -2225 AV ti,G II I 441, I 50 0 50 100 150 200 1 250 300 rRAC r B G EIGTHY EIGHT AVE. G EXISTING IMPROVEMENTS TOBBEN SPURKLAND P.E. TRACT A SERTICII 91D SEPTIC SYSTEM DESIGN ZOO YY 15Th, AYENUE RORIPT koW DATE; Xrf, 0, IM ANCH^ AK.- 99501 8716 ABBOTT LOOP ROAD SHEET: 1/3 GRID: 2335 I I I REPLACEMENT TRENCH I I I G PRIMARY TRENCH 1 0 1 1 G 1 1250 GAL SEPTIC TANK -� I CESSPOOL s I ABANDON! 1 I 1 I 1 i I 1 I Q o 1 1 I Well 1 I F '��'�S�♦i I I O�P��,' �. .• •' 1 ••�' ♦�� 1 AV Ar 49th 1 ° 1 1 00..... �.� T BEN SPURKL D I AV ♦♦C '.• NO. CE -2225. �•' `i ♦♦♦♦����;;OFESS:���i�� 1 i 1 25 1 0 25 50 75 100 125 150 LSCALE;�~=.0E-T.----- ——— — — — — —- -------------- F-—————— I —————————————— PROPOSED IMPROVEMENTS TOBBEN SPURKLAND P.E. TRACT A SRRTICII SID SEPTIC SYSTEM DESIGN zo3 w 15Th, AYLNVL Wrpr Mkl DATE; SEPL 6, WU ANCH. AK. 99501 8716 ABBOTT LOOP ROAD SHEET: 2/3 GRID: 2335 r, Standard Trench - 2' Wide 62.5' Long 9' Deep 6' Sewer rock 3' Co ver SIL T 6 Ft of Se IVU JLHLL SEPTIC SYSTEM SCHEMATIC BL -NCH MARK, FINISH FLOOR ASSUMED ELEV, 100,00 TOPPEN SPURVLAND P.E. TWA OT A sETTICII 91-1 SEPTIC SYSTEM DESIGN rui WMn AveDATE! 8796 ABBOT LOOP ROAD SEPT. 6, 1996 Anchorage Ak 99501 11 ROBERT KOSKI SHEET: 3/3 GRID: 2335 Municipality of Anchorage • Development Services Department Building Safety Division On -Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel 1. D. _Q 1L4- O -q 3 " Dy HAA Expiration Date: 1. GENERAL INFORMATION Complete legal description I /—/y -s a2 i ) C H Location (site address or directions) _ F'i / i ry A boor Loo p �d Current Property owner(s) W 1 VLLY2-166 IJ Day phone Mailing address�-0 Lending agency Day phone Mailing address Real Estate Agent k y ��� g� Day phone _. Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well [V� Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system.. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates' may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the, Health Authority Approval Guidelines for this application, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm d4k_eM CeuyvLLOLVtae Phone °oL Jr?-36illo Address 'J lt Zd 3 a Engineer's Printed Name t e*e K 5. DSD SIGNATURE ✓ Approved for _4S_ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Attachments: HAA Checklist X Maintenance Agreements Septic System AdvisorySupplemental Engineer's Report ,Well Flow Advisory Other By: A A�,_ Q_ Original Certificate Date: it (Rev. 01102) JVIt 1<1111 r, D. LIFT STATION Manhole/Access (Y/N) -"' Date in Size in gaZa__ - �' "Pump on" I at —in "Pump ofHigh water alarm I at !perDatu Cycles teMeets ala circuit requirements? E. SEPARATION DISTANCES a SEPARATION DISTANCES FROM WELL ON LOT TO: - iL On adjacent lots >�o Septic tank/lift station on lot f t' On adjacent lots Absorption field on lot 1 �.. •---_ .-.7 - _- - Public sewer main o Public sewer manh ol e/cleanout �~ Sewer /septic service line N e3 c .. Holding tank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO w *+ y 41 rl Building foundation Property line ti 50 Absorption field Water main /q/ oto Water serviceline, Surface water �✓ _._ _ _.__° Wells on adjacent jots N 1taQ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO Property line .Z 5�j Building foundation y Water main A✓ t� Water Curtain drain Service line o�� Surface water Driveway, parkingivehicle storage >S® A/1 � Wells on adjacent lots � F. COMMENTS, G. ENGINEER'S CERTIFICATION® '+ I certify that 1 have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in e#actfon this date om Engineer's Printed Name S N P KI Art`11� it'. Date HAA Fee $ r —�Waiver Fee $ Date of Payment Date of Payment Receipt /� Number "f o% Receipt Number (ReG:`12/01) X •Y1rLT r ruyy il�.R 4uM>n..41 •LOrO ii.R P9o•oo' ',00 s'f.•ij.v Kra G -2R UNDER NO CRCUMSTANCES SHOULD AN A9 -BUILT BE USED: THE SURVEYOR TAKES RESPONSM1= FOR T'NE:, pETµI, FDR O011SIILLIDTIDN pt- FOR IST AdJ9Di0'BDUNDARY, pt FENCE LINES. 7RANSLJNQ. ! CHL.Y'AND'ASSLLLS, FNANCAL UAB671Y 011Y FOR TFIE DOST OF THE SURVEY. LISTED DISTANCES OVER SCALN0.' REPRODUCTION CAUSE ERRORS N -SCALE FOUN � "'TM SURVEY TYPE FKAL SOL ,�-wB,T .. .. `...:.: SYMBOLS RNAL atNltnw[ As lLr • St7 RFBAR . °1•• {[^ }^ ASPHALT P= RAX ... AS-IKLT... saw.. 1wommm O FaUND. REBAR q.{ 0 ' WOOD FENCL ^^O•"e•�'• DDNCREIE . JT PIANS k LO SURVEYS ASSlRED K K N uLTAL FElICE ®WOOD SCE 4 THE RESPONSIBILITY OF THE BUILDER OR OWNER. PRIOR TO ONLY•7HOSL IYPROVO/N!'17 ABOVE GROUND AND N98LC WILL BE J IN[sHF 10N, TO VERIFY PROPOSED BUILD A GRADE RELATVL . SHOWN. FENCES, WE1LS, SEPTID �,y.I�M yDLwAucs, DRIVEWAYS, FlNISNED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE* .LTC,. ARL SHOWN W THEIR APPROKILIATL LOCATON, ONLY. SNOW EXISTENCE OF ANY EASE►IENT3, COVENANTS S RESTRICTION! YAY PARE BN SOME THBR ILNTS OMATE LOO SEEN AND LOCATED. R DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. .ALL DISTANCES ARC RECORD NLZSS OTHERWISE NOTED. JRVEY CERTIFlCAl10N . - . � Prepare I d by ���,�P, �......... •` Robert E. Johns Jr. &Assoc. �•• Mx r r u r i .'• •••''. Professional Larid Surveyors r w r `x.t� •.r.. r. : � }•j µDIORAOFE, 72NJ1SKA NI601 MTION AS-SUo_TloL S Swc . 9 oaS.F.Roe plat F7• Na n w•4'1 xw +FYI~1r11 �•• • •x :.l 1. = 50 1 R „• r:rr. u+.xr..r.. •x •• x.......t DoH SuMy� Drum by Ch•dtW by. R •x x• J4 REJ MLJ MRI-CPAW AT-KXTe® '' 41 —Sx 1r 10 f' .- _ .. G'kb W.O. n.wbBae pp q2335 22-272 Logow ••••... .r .r. B o�••d�+++ LOT 1—A: SEI2TICH SUBDIVISION C.0. A O _ 'b" • _ N O � � Sid � 0 ' o ! _ r, 7AR, 61 fs O ',00 s'f.•ij.v Kra G -2R UNDER NO CRCUMSTANCES SHOULD AN A9 -BUILT BE USED: THE SURVEYOR TAKES RESPONSM1= FOR T'NE:, pETµI, FDR O011SIILLIDTIDN pt- FOR IST AdJ9Di0'BDUNDARY, pt FENCE LINES. 7RANSLJNQ. ! CHL.Y'AND'ASSLLLS, FNANCAL UAB671Y 011Y FOR TFIE DOST OF THE SURVEY. LISTED DISTANCES OVER SCALN0.' REPRODUCTION CAUSE ERRORS N -SCALE FOUN � "'TM SURVEY TYPE FKAL SOL ,�-wB,T .. .. `...:.: SYMBOLS RNAL atNltnw[ As lLr • St7 RFBAR . °1•• {[^ }^ ASPHALT P= RAX ... AS-IKLT... saw.. 1wommm O FaUND. REBAR q.{ 0 ' WOOD FENCL ^^O•"e•�'• DDNCREIE . JT PIANS k LO SURVEYS ASSlRED K K N uLTAL FElICE ®WOOD SCE 4 THE RESPONSIBILITY OF THE BUILDER OR OWNER. PRIOR TO ONLY•7HOSL IYPROVO/N!'17 ABOVE GROUND AND N98LC WILL BE J IN[sHF 10N, TO VERIFY PROPOSED BUILD A GRADE RELATVL . SHOWN. FENCES, WE1LS, SEPTID �,y.I�M yDLwAucs, DRIVEWAYS, FlNISNED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE* .LTC,. ARL SHOWN W THEIR APPROKILIATL LOCATON, ONLY. SNOW EXISTENCE OF ANY EASE►IENT3, COVENANTS S RESTRICTION! YAY PARE BN SOME THBR ILNTS OMATE LOO SEEN AND LOCATED. R DO NOT APPEAR ON THE RECORDED SUBDIVISION PLAT. .ALL DISTANCES ARC RECORD NLZSS OTHERWISE NOTED. JRVEY CERTIFlCAl10N . - . � Prepare I d by ���,�P, �......... •` Robert E. Johns Jr. &Assoc. �•• Mx r r u r i .'• •••''. Professional Larid Surveyors r w r `x.t� •.r.. r. : � }•j µDIORAOFE, 72NJ1SKA NI601 MTION AS-SUo_TloL S Swc . 9 oaS.F.Roe plat F7• Na n w•4'1 xw +FYI~1r11 �•• • •x :.l 1. = 50 1 R „• r:rr. u+.xr..r.. •x •• x.......t DoH SuMy� Drum by Ch•dtW by. R •x x• J4 REJ MLJ MRI-CPAW AT-KXTe® '' 41 —Sx 1r 10 f' .- _ .. G'kb W.O. n.wbBae pp q2335 22-272 Logow ••••... .r .r. B o�••d�+++ LOT 1—A: SEI2TICH SUBDIVISION Municipality of Anchorage O !� Development Services Department a ,.'f Building Safety Division On -Site Water and Wastewater Program , 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99579-6650 www.ci.ancharage.sk.us (907)343-7904 • ' CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. OIC— 2jD HAA n L j Expiration Date: 7z C - OA 1. GENERAL INFORMATION Complete legal description t o it AiR /R S c r—T i d H p Location (siteaddress ordirections) 9*716 466,i4 L,op iZaacO Current Property owner(s) V_ _05k i Day phone3 L4q— 7 S 7 Mailing address I O /� b>,c i� I—voP 0Cco`s Lending agency Day phone Mailing address Real Estate Agent V� a� + G re t rt h- 11U Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY:' TYPE OF WASTEWATER DISPOSAL: Individual Well c Individual On-site Individual Water Storage ❑ Individual Holding tank ❑ Community Class Well ❑ Community On-site ❑ Public Water System ❑ Public Sewer ❑ The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the trarsfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible fer errors or omissions in the professional engineers work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this applicaticn, shows that the on- site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm I v16bti., Address go-6Lel, Engineer's Printed Name ! 'T0'rk1Aa 7 2- ! +5 Lit ;4 �Lv 3 Phone 979 -'se, / b 5. DSD SIGNATURE " TaLbmSp°'t`� Approved for bedrooms. ©q da,� wM•..• ROTESSIO Disapproved. ���+avoao _ Conditional approval for bedrooms, with the following stipulations-. nttttlrrrrrrr�ir,,. Additional Comments J=� . ON-SITE di WATERAND ; rn 1NARTFWATFR - _ PROGRAM Attachments: HAA Checklist X Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other By: l�/� ``� �r� ti� Original Certificate Date: 0.2— (R". 2 (R«. 01/C2) Municipality of Anchorage ° && Development Services Department `° y Building Safety Division . Onsite Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519650 www.ci.anchorage.ak.us (907)343-79W HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Trac I A 5ERTIC4l S/d Parcel ID: 0 1 -d4* O A. WELL DATA well type If A, B, or C provide PWSID # ~�A Well Log (YIN) 1� Date completed L4_6'9'4 Sanitary seal (YIN) wires properly protected (YIN) Total depth yl ft. Cased to 4ye—fL Casing height (above ground) ..1in. FROM WELL LOG AT INSPECTION Date of test a 41 D 2 Static water level ft. ft. Well production g.p.m. �% g.p,m, WATER SAMPLE RESULTS: Coliform oolonies/100 ml. Nitrate 9" mg./i. Other bacteria Wj>_ colonies/100 ml. Arsenic: T✓ mg./I. Date of sample:t1�"101- Collected by: {., Sp✓rtc1 B. SEPTICIHOLDING TANK DATA f Tank Type/Material GREEK $ f r E 1 Date installed b+ htl9 b Tank size ISco gal. Number of Compartments a Cleanouts (YIN) i Foundation cleanout /it 7L—Depression over tank (YIN) High water alarm (YIN) N Date of pumping 1 t 1►u l0 Z Pumper A+ C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d.lft= or 4bd L i System type Deg 1-Cnc I Length ft. Widthof ft. Gravel below pipe ft. Total depth ft. Eff. absorption area ftz Monitoring tube _Y_ Depression over field Date of adequacy test 11- 4-O 1 Results (Pass/Fail) For I bedrooms Fluid depth in absorption field before test _U in. Water added,L ogal. New depth'Q in. Elapsed Time:Wv min. Final fluid depth JL&ln. Any rejuvenation treatment (past 12 mo.) (YIN & type) i Absorption rate >= (o" N o If yes, give date g.p.d. / D. UFT STATION Date installed ize in gallons Manhole/ ss (Y/N) "Pump on" leve;7/Cycles Pump off" level at _ in. HI star alarm level at in. Datum tested Meets alarm 8 cacuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 109 On adjacent lots i /V Q Absorption field on lot 11'4 On adjacent lots > 1&-0 Public sewer main % a5 Public sewer manhole/cleanout N/A Sewer /septic service line >01 5 Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: r Building foundation aq Property line 15 Absorption field !D k Water main )"16 Water service line >,75' Surface water A//D Wells on adjacent lots > too SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line 35 Building foundation Water main Ab*--> .2 � )18 Water Service line > A' Surface water /V/O Driveway, parking/vehicie storage a5 Curtain drain µ l Q Wells on adjacent lots ,;;P !D -O F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. V T•��= a c: Y. Engineer's Printed Name25 C ff` e ur !amj G lB�r�b° DateaFp a^•c;� HAA Fee $ 3 7.7 Waiver Fee $ jt ((a I Date Payment Date of Payment D 1 of Receipt Number Receipt Number (Rev. 12/01) MUNICIPALITY OF ANCHORAGE IiL "' • DEPARTMENT OF HEALTH 1£ HUMAN SERVICES AEML Division of Environmental Services On -Site Services Section Gme P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.D.# 010 —G2L11-02- HAA# 1. GENERAL INFORMATION Complete legal description TRACT A G 2 S t L kf Location (site address or directions) a -7 1(' A, tloo 4 Z' Property owner V_07� V�[ _P_ 08t=--2-1 Day phone Mailing. address 9-71b A66o7ef P—o�` Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. 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 legality and status of system. . 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: it community wastewater System, provide written confirmation rrom ware avec attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 - - 1 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm �bb C >7 S 0 y- —1 Ix vJ F— Phone a -7q -Sq � Address %_0 3 Engineer's signature 6. DHHS SIGNATURE Approved for bedrooms. Disapproved. Conditional approval for Additional Comments 0 WTIC Date I zl, q jo bedrooms, with the following stipulations: Date /2 ?Z The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rov. "1) Back MOA #21 '3 aslf v... f a lr bedrooms, with the following stipulations: Date /2 ?Z The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rov. "1) Back MOA #21 MUNICIPALITY OF ANCHUkA'" ENVIRONMENTAL SERVICES DIVISION Municipality of Anchorage DEC 0 6 "' 0 DEPARTMENT OF HEALTH & HUMAN SERVICES R E C E I V - Environmental Services Division - 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: I c %It !Se r C L-, Parcel I.D.: A. WELL DATA Well type P� If A, B, or C, attach ADEC letter. ADEC water system number "A - Log present (Y/N) Date completed ?6 0 /S Total depth Cased to '> z}(9I Casing height (above ground) 02 Sanitary seal (Y/N) Date of test Static water level Well production a FROM WELL LOG Wires properly protected (Y/N) AT INSPECTION "4Z7 g.p.m. J� 7`al g. P.M. WATER SAMPLE RESULTS: Coliform Nitrate v� L Other bacteria � 1 Date of sample: I f���l b Collected by: d B. SEPTIC/HOLDING TANK DATA 1� /J Date installed �Kb Tank size/ 5 �`crr Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) y Depression (Y/N) N High water alarm (Y/N) �- 1 Date of Pumping N14 A)-' Pumper >/ C. ABSORPTION FIELD DATA Date installed I l / 9L- Soil rating (g.p.d./ft2 orttYbdic) • 2 System type I e- t Length l0 7 ! Width _ �� Gravel thickness below pipe / r Total depth Z l� Effective absorption area &10 Monitoring Tube present (Y/N)--�—/ Depression over field (Y/N) Date of adequacy test I Y tiW' Results (Pass/Fail) LI/ Fory bedrooms Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.): _ Fluid aupth (ins) Minutes later: L-/ Absorption rate = 9.p -d. Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* `X If yes, give date r/ D. LIFT STATION J'�-t 0 i,i 1^= Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: "Pump off" level at* r 1 Septic/holding tank on lot 1 D(j On adjacent lots 5 /o-t�2 Absorption field on lot / /7 On adjacent lots -,>/&-O ! / Public sewer main r `! 0 bt 4e_ Public sewer manhole/cleanout c �J -e— Sewer r ,, J Sewer /septic service line i 6°25 Lift station G`! n u SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: / / / Foundation a29 Property line 415 Absorption field _1_51> / 1 Water main/service line Surface water/drainage Non -f- Wells on adjacent lots / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line _ 3 Surface water Curtain drain _ No Vt e_ F. ENGINEER'S CERTIFICATION Building foundation /8 r Water main/service line Driveway, parking/vehicle storage area r t Wells on adjacent lots I 0-U I certify that 1 have determined thru field inspections and review of Municipal records that the.ab&Je systems are in conformance with MOA HAA guidelines in effect on this date. Signature _ Engineer's Name—La . b "t Date c "i t g q b HAA Fee $ �00,0.6 Date of Payment Receipt Number o(✓��� (� b 6� 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number