HomeMy WebLinkAboutHILLSIDE PARK PUD LT 11Hill id
Pork
Lot 11
#015-122-40
Municipality of Anchorage
Development Services Department
Building Safety Division .
On-Site Water and Wastewater Program, 4700 S. Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL iNSPECTION REPORT
PID Number:
Wastewater System: [] New [~'"Upgrade
Permit Number: .,~ ~,zO "~ 0 q 0 ~,'
Address:
lo ~..~l '~'.,-~-J.~o ~ ABSORPTION FIELD
Phone Number of B~moms: ~eep Tre~ ~ Shall~ Tren~ ~ Bed ~ Mound
O~her:
Soil Rating: Total D~pth from ~riginal grade:
LEGAL DESCRIPTION i. ~ ~,~,, I0 ~.
Block: Lot; Subdivision: Depth to pi~ boltom from original gra~e: Gravel depth beneath pipe:
Towaship Range: Section; Fill added above ~iginal grade: Gravel Leagtb:
Well: ~ New ~ Upgrade
C~assifi~tion (Private, A, B, C): Total Depth: Cased to: Total ab~tion area: Pipe Material:
Driller: Cate Drilled: Static Water L~I: Installec Date installed
Yield: Pump Set at; Casi.g Height A~ve Grou~: TANK
GPM
Ft.
SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P. ~ Other:
T~ Septic Absorption Lift Hotding PublidPrivate Man~actureE Capacity:
Tank Field Station Tank Sewer Line
Material: Number of Compadments
s~,,~.w.,,, H/A ~//. ~' LIFT STATION
Size: Manufacturer:
BENCH MARK
9
I I Ill III
~ ~ 1~
SCALE: I' = 50 FE
TOBBEN SPURKL,4NO P.E.
203 I~ 15711. ,4¥ENUE
,4NCM. A/(. 99501
(907,) 279-3916
LOT 11 HII, I, SIDE PARK
JO/.IM IVESEVICI-I
10301 TREE TOP LANE
SEPT/C SYSTEV AS 8U/LT
DATE: OCT. 24, 2002
SHEET: 2/3 GRID: 2539
PERMIT #SP/02040£ PID # 015-12£-40 HSPOOl12.BIVG
S~andard Trench~
2' Vide
50' Long
lO' Deep
6.' Sewer rock
3-4' Cover
~"~ .......... r .......... ~'""~
, ...
NO SCALE
3-~' Cover
-' ~ '
~8 '~ ~8 --' --
6, F~ oF Septic
Effective
ND SCALE
TDBBEN SPURKLAND P.E,
~03 W15~h Ave
Anchop~§e Ak 99501
~7~-~
LOT I1 ItlLLSIDE PARK
JOHN WESEVICH
SEPTIC SYSTEM SCHEMATIC
9ATE, OCK 24, 2002
P£RI~IT ~t SW020402 PARCEL ID 1~ 015-122-40 HSPO011 $. OPIG
9
12
Il
[ i/I I/0;~ ~L'; BUILT
~.
CLIENI:.
,LOT
HLL~JDE PARK
_ PL~T
25,t9
MUNIC/PAI_ITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 995~9-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Oct 09, 2002
Expiration Date: Oct 09, 2003
Permit Number: SW020402
Legal Description: HILLSIDE PARK PUD LT 11
Design Engineer: 0007 Tobben Spurkland, PE
Own~-r Name: John Wesevich
Owner Address: 10301 Tree Top Lane
Anchorage, AK 99516-6827
Parcel ID: 015-122-40
Site Address: 010301 TREE TOP LN
Lot Size: 23904 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
~ Disposal Field ~ Septic Tank ~ Holding Tank [~ Privy
Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: ~~ ~¢,~ Date:
Issued By: Date:
Municipality of Anchorage
Development Services Department
Buitding 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
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 0 12~ 12- ¢--~/C~
Permit Number SW O ~ O ~r~ fO_:2
Property owner(s)
Mailing address (I)
Mailing address (2)
Legal description (Lot, Block & Sub'd.) L. O
Legal description (Section, Township & Range)
Lot Size ¢l
THiS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROP~=RTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Zip Code
Number of Bedrooms
[] Well Only []
E~ Water Storage [-~.
Aores~
Jacuzzi'
[] Water Softening Unit
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorize~ agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev, 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
LOT 11 HILLSIDE PARK S/D
JOHN WESEVICH
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
Anchorage, Alaska 99519-6650
September 27, 2002
We are submitting an application for the upgrade of the septic system for this lot. The submittal
consists 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 the septic system is
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 16 ft.
Use Standard Trench
Soil Rating. From Testhole 07/12/02
<1 mln/in = 1.2 gal per sq.~day
No. of Bedrooms 4
Required Area per Bedroom: 150/1.2 = 125 sq.ft.
Total area required: 125 x 4 -- 500 sqft
Testhole depth 16 feet
Bottom Rock At 10 feet
Top Rock At 4 feet
Rock Depth 6 feet
Minimum Trench Length 500 / 12 = 42 ft.
Use 50 ft
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTH 50 FT
TOTAL WIDTH 2 FT
TOTAL DEPTH 10 FT
ROCK DEPTH 6 FT
COVER 4 FT
SEPTIC TANK 1250 GAL
The installation of this septic system will not prevent wells and septic systems from being 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.
~ ~,.~-~ ......... ,?.:-~....,~
SC~LD I' = I00 F~
TOBBEN SPURKLAND P.E.
203 Jg I51'1-L AVENUE
ANCt/. AK. 99501
[907) 279-39I~
LOT 11 HILLSIDE PARK
JOHN IYESEVICH
10301 TREE TOP LANE
SEPT/C SYSTEM DESIGN
DATE: SEPT. 27, 2002
SHEET: 1/3 GRID: 2539
PERMIT # SVO2OXXX PII} # 015-122-40 HSPOOIlLflVG
CONNECT TO D'ISTIN; TRL-NCH%
IEY/ TRD~H \
TOTAl. D~ I0 FT
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
ANCN. AK. 9950~
(907) 279-3916
LOT 11 HIU, SIDE PARK
JOHN Y/ESEV/CH
10501 TREE TOP LdNE
SEPT/£ SYSTEM DES/ON
DATE: SEPT. 27, 2002
SHEET: 2/3 OR/D: 2559
PERMIT #SVO2OXXX PIB # 015-122-40 HSPOOll2.DVG
125fl Qa! Sept;c tank
Trench:
$0' Long
I0' ~eep
6. ~ Se~/er rock
3-4' Cover
NO SCALE
.~.~/~~ Moni'ton
3-4 Cover ~. , . : .-
6. £g o£ Septic Rock
Effedfve
125fl gal sept/c tank
NO SCALE
TOBBEN SPURKLAND P,E.
203 ~15~h Ave
Anchorcge Ak 99501
LOI' II lt71,hgIDE PARK
~OHN ~E$~qCH
SEPTIC SYSTEM SCHEMATIC
])ATE, SEPF. 27, 2002
SHEET, $/5 GRI]), 2539
PERWIT t~t SP/O2OXXX PARCEL ID t~ 015-122-40 HSPOOII3.DWG
=edormed For:
Legal Description:
Municipality of Anchorage
Development Sen/ices Department
Building Safety Division
On-Site Water and Wastewater Program
47'00 South Bragaw St.
P.O. Box 196650 Anchorage. AK @9519-6650
www.cJ.anchoraqe.ak.us
(907) 343-7904
Soils Log - Percolation Test
Slope
ENGINEEB'S S E ~', I.:
Site Plan
15-
16-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT OEPTH?
~,,,, ~ ,,,~.-gL 'Vt -~ Depth to Water After
Monitoring?
Reading Date Gross Time Net Time Depth to Water Nel D-co
PERCOLATION RATE ,~. ~ (m~nute~nch) PERC HOLE DIAMETER
TEST RUN BETWEEN 11~ FT AND ~, FT
~ERFORMED BY % ~ I '"~ ,~ CERTIFY THAT THIS TEST ¥$,.: S
=ER:ORMED ~N ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: (~ I~.,~'~/¢ 7..,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONIVIENTAL ENGINEERING DIVISION
~ 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE EW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Well ~ Absorption area Dwelling PERMIT NO.
DISTANCE TO: ~b ~
~ N Liq. capacity in gallons inside length Liquid depth
/~ ~, IF HOMEMADE:
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation Nearest lot line PERMIT NO.
~ 5 Trench width Distance betwee.
No. oflines ( Length of ea~ li~e , Totallength 1Tsf .3 ¢:nches
= ~~ ~ Top of tile to finish grade Material beneath tile Total effective a~ion area
Length Width Depth PERMIT NO.
~ ~ ~ype of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Clas~ / Depth Dritler Distance to lot line PERMIT NO.
~ DISTANCE TO: ~ Bu~ld~ng foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
, .
SOl L TEST RATING
INSTALLER ~ ~ ~
APPROVED ~ DATE LEGAL
Applicant:
Location:
~.~.~UNICIPALITY OF ANCHORAGE,-.,.
Department(c Health and Environmenta~rotection
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT * * *
V~-L=L=~/OR ON-SITE SEWER PERMIT
':2¢~-, Mailing Address:
Phone Number:
Legal Description: Z ~ ~ ~K LOt Size: ~,~
Type of Soil Absorption System Is:
Trench: L.~ Drainfield: Seepage Bed: Holding Tank
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) ~.~.c~'
DEPTH
The Required Size of the Soil Absorption System Is:
LENGTH ~ ~ . GRAVEL DEPTH z~ WIDTH ,,(30 ,.3'~'7~-
The length dimension is the length(in feet) of the trench or drainfield. The
depth 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 = //~-00 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 are required
and must 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 ~ 1 * * *
I certify that:
(!) 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 requirp:enlargement if
the residence is remodeled to include more that 3 b~ooms.
Signe~: ~F~ ~~/> Issued by: Q~>~/~...//( ~y/~[~(~.~_
Ap~ic ant ..... ~'/7/ '~ ~
Date: y/~>- ~?/~ ~
SWP/024(1/81)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
~'----"'~ 6
7
8
9
10
11
13-
14-
15
16
17
18
19
20
COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOl LS LOG
[] PERCOLATION
TEST
/--oAp1
SLOPE
SITE PLAN
2225-E '~'
NE 25~ 19?l - ',,~
, . WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
P
R~ading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND -- FT
PERFORMED BY:
CERTIFIED BY:
Z..OT'
/0
/.OT ~
iV ,S9 o~ IS"E- - ISz. qE, '
SCALE
.IO/ EQ. UTIL.. ESfvINT_
L£GEN
5/8'REBAR SF_T THIS SURVEY
ORAINAGE ARROW
SPOT ELEVATION
0 ~
-Z.' ~
LOT I I
0
•
•-111c:" Municipality of Anchorage °� 6
On-Site Water and Wastewater Program .;ij 11
(907) 343-7904 $ A T.
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 015-122-40 Expiration Date: / /' 13 /
1. GENERAL INFORMATION
Complete legal description HILLSIDE PARK PUD LOT 11
Location (site address) 10301 TREE TOP LANE,ANCHORAGE,AK 99507
Current Property owner(s) CHRIS SCHIMSCHAT &JONDA BINK Day phone
Mailing address 10301 TREE TOP LANE, ANCHORAGE,AK 99507
Real Estate Agent Day phone
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
TYPE OF WASTEWATER DISPOSAL:
4. TYPE OF WATER SUPPLY: Individual
Individual Well ❑ Holding Tank ❑
Individual Water Storage ❑ Community ❑
Community Class A Well ® Public Sewer ❑
Public Water System ❑
WaiverNariance request for: Distance:
Received by: C/.t r7 �, C� e4ki Date: ii/6 //
COSA to be released to the engineer, unless otherviise equested by the engineer.
v
COSA Fee $ Waiver Fee $
Date of Payment f l ll.f j 9 Date of Payment
Receipt Number 6g3M-rb Receipt Number
COSA* 6 a Ur 9' Waiver*
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,
based on procedures outlined in the Certificate of On-Site Systems 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 ARCTERRA CONSULTING, INC. Phone 868-3791
Address 20441 PTARMIGAN BLVD., EAGLE RIVER,AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 11/09/2017
THIS COSA DOCUMENT CANNOT BE USED TO TRANSFER TITLE UNLESS ALL VENDORS(ENGINEERING,SURVEYING,CONTRACTORS,ETC...ASSOCIATED
WITH THIS COSA ARE PAID IN FULL AT OR BEFORE CLOSING. Engineer's Comments: This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested.
The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes inland use,
local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the
system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function
satisfactory for current or future occupants or can ArcTerra guarantee that no unseen ++�
encroachments,deficiencies or discrepancies exist. .S 0
Aar
9TiI ' ` 4
6. DSD SIGNATURE r / IA_�
System #1 Approved for LI bedrooms. . KENNETH ';
System #2 Approved for bedrooms. 4 I
1 y� rGi /I v-
Disapproved. :t• '�
Conditional approval for bedrooms, with the following stipulations:
-s`t of""CH
34"
N op
,S�E�p p. rn
SIV ApFzGRAM
By: ) tvw Original Certificate Date: j 1 "-)5-/ y
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet 10-10-12.doc
If more than 'I septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: HILLSIDE PARK PUD LOT 11 Parcel ID: 015-122-40
A. WELL DATA —CLASS A
Well type A If A, B, or C provide PWSID# 212461 Well Log (Y/N)
Date completed Sanitary seal (Y/N) Y Wires properly protected (YIN)
Total depth ft. Cased to _ ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic: ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC!STEEL Date installed 10/11/2002
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y(Inside) Depression over tank (Y/N) N High water alarm (YIN) N
Date of pumping 1117/2002 Pumper ONE STOP
C. ABSORPTION FIELD DATA
Date installed 10/12/2002 Soil rating (g.p.d./ft2 or ft2/bdrm) 1.2 System type DEEP TRENCH
Length 50 ft. Width 2 ft. Gravel below pipe 6 ft.
Total depth 12.1 ft. (Measured 11/7/17) Eff. absorption area 600 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 11/7/2017 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 17 in. Water added 640 gal. New depth 30 in.
Elapsed Time: 1440 min. Final fluid depth 13 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed Size in gallons _ Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at _ in. High water alarm level at in.
Datum _ Cycles tested Meets alarm &circuit requirements?
E. SEPARATION DISTANCES - PUBLIC WATER
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank _
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 200'+
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ _ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 501+(NONE KNOWN) Wells on adjacent lots 200'+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date. OF AZ4 `1
Engineer's Printed Name KENNETH M. DUFFUS / /7-
Date
Date 111912017 4.• Ti 1 /\
. KENNETH lil F r ,
COSA canary sheet_2-6-15.doc �`� 7 '• w
� Aff
r
.F' r �
k 'trir'6
,� , , '� a"
Municipality of 3 qchorage
Development Services Depa,,!.ment
Building Safe~¢ DMsion
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 AUTHORI-P/APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
!. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2, NUMBER OF BEDROOMS:
Expiration Date:__
Day phone
Day phone
TYPE OF WATER SUPPLY: '
Individua! WeIl
Individual Water Storage
Community Class /~. Well
Public Water System
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 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 sewed 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 sewed 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 emissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my sea! affixed i~ereto and as o? the vaiidation date shown below, ~ verify that my investigation,
based on proceaures outlined in the Health Authority Approval Guidelines for this appiJcation, shows that the
site water supply and/or wastewater disposa! system is(are) safe, functiol]a! and adequate for the number of
bedrooms and ~pe of structure indicate~ herein, I fuAher veri~ that based on the reformation obtained from the
MunicipaiJ~ of Anchorage files and from my investi~Tation ~nd inspection, the on-site water supply and/or
w~stewater dJsposa~ system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of ~nstallafion.
Name of Firm ' ~ ~' b~ ~ ~ v,' ~, ~_~ ~- ~ Phone _ ~ ~- ~ J ~
Address ~%'~ t~ ¢~
Engineer's Pdnted Name %~Lr~~ _ Date_
DSD SIGNATURE
Approved for _~_.~_ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev.
Original Certificate Date:
· ~resPmP:edy pmte~ted;(Y/N~) . .
,., '.'{.',..: .'; '. ~ ' '4. :~ : ~, ..". ' . -~ ........
· "~'.:~- :.'.. ... ca~?~o.~..:~:~.:: .. · .'. c~~' (~eg~?" .,~ ,~.
:. ¥....~:. :......:......~:..;.:~}:.: · .
.~. .... .. ~..
...... · ~.:~:;.~'~ ~:~:~.'.~.=h: .':... ~:..~ "?. : ............. . '?:..;.
-:~'.'.', .. .,. .g:p;m..<.~:..,:.. :...- .-,....~ ~:.'::.. .g~p;m:
ii~..'J'O .~.
Date ]~st~ '
:..'A~Y I {past'.12mo ):.(WN:&'~p-)-'.
" ~' 'lf:yes,'give date
Datum
in :gallons
Pump off' level at
Cycles tested
· " ... ~elelAccess (Y/N)
i..~ '.~!gh water, a,arm ,eve, at
*" "~eets a'larm & 'circuit requirementsl
in.
Absorption.field on lot ,
Public sewer main Pbblic sewer manhole/cleanout
Sewer/septic service' line. Holding tank
SEPARATION DISTANCES' FROM SEPTIC/HOLDING.TANK' ON:EOTTO:
Building foundation Absorption field
Water main ,~.
Wells on adjacent 'lots
F:
Water Service.line z¢'~. '/" Surface water I~/0
Curtain drain 1,4./o Wells on adjacent lots,'.
COMMENTS
of Municipal records that the above systems are in
· conformance with MOA. HAA guidelines in effect.on'this date,
Engineer's Pdnted Name "I ¢~/ ~ ~'~ ~ r~ ~
Date
HAA Fee $ ~"~,~' ~
:Date of Paymeqt
(Rev. 12/01 )
·
Water main ~.¢ .~
Driveway, paFking/gehicle 'storage
,. Waiver Fee $
Date;of Payment
Receipt Number.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 1], Hillside Park
Location (site address or directions)
10301 Tree Top Lane
Property owner David~ Szumigala/Ellen Daley
'Mailing address ..
Day phone
457-5005
Lending agency
Mailin. g address '
Agent t~rn~ ×./Bonnie Gorrell
Address 2600 Cordova, Suite 100,
Day phone
Day phone
Anchorage, AK 99503
244-4146
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual Well
Community well xxx
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
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 $ & S ENGINEERING Phone
17034 Eagle River Loop Road No. 204
Address Eagle River, Alaska 99577
Engineer's signature --')~ '/~¢z,¢¢' ~- ~'~'-- Date
DHHS SIGNATURE
[,'/ Approved for '7'~/ r~ _F ~
Disapproved.
Conditional approval for
bedrooms.
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 DHHS does this as a courtesy to pumhasers 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-O25(Rev. 1/91) Back MOAI~21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVI~v~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription: ~e ~-- Ii Hl~-~.~',~)~ P~£/~ P~O ParcelI.D.:
A. WELL DATA
Welltype Cb~;~ /} IfA, B, orC, attach ADEC letter. ADEC water system number ~1 ~ ¥(~ f
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RES~~'~
Coliform
D o~at~sample:
Date completed ~
Cased to __ Casing h~d've ~r~u~d)
__ W~rly prot;cted (Y/N)
FROM WELLLOG ~ AT INSPECTION ·
g.p.m.
Nitrate Other bacteria
g.p.m.
Collected by:
C=
SEPTIC/HOLDING TANK DATA
Date installed ~ o / ~ / ~ i Tank size
Foundation: cleari6~t (¢'/~ · ~v,,,
Date of pumping i0/'3 J ~
ABSORPTION FIELD DATA
Date installed i e /. / ~ (
Length ~ 6 ~ Width
/ cO <3 Number of Compartments '~ Cleanouts~J'N).__
Depression (Y/(~ /u c~ High water alarm (Y~. ~ 0
Pumper
Soil rating (g.p.d./~ o~
Effective absorption area
Date of adequacy test !
y~'$
~- 5- System type
Gravel thickness below pipe z./ · Total depth
Monitoring Tube prosent~i~/N) l/~j' Depression over field (Y~ '~ 0 .
Results ~...~/Fail) ?/~ $ ~' For
~3
Immediately after $'11 gal. water added (in.):
z~-0 -/ .g.p.d.
Fluid depth in absorption field before test (in.);
Fluid depth ~ 3 %_ (ins) Minutes later: 2_ o Absorption rate =
Peroxide treatment (past 12 months) (Y/N) /~ ~ '¢ ( '~ '~ ~'"' If yes, give date
72-026 (Rev. 3/96)*
.bedrooms
DJ
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycl~~'~
Size in gallons ~
"Pump off" level at*
*Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main /
Seine
On adjace nt_~.OJs--~~
~nt lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~/-f- Property line 5- /-~-- Absorption field
Water main/service line /0 ~-F~ Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I 0 y- Io
Property line Building foundation
Surface water
Curtain drain
Wells on adjacent lots
~00 ¢
Water main/service line
Driveway, parking/vehicle storage area / o -/-
Wells on adjacent lots ~ o o '
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and
in conformance~wi~.~O~2 guidelin.es in effect on this date.
Signature /j/u~-~,-f (....--~ ~
Engineer's Name //~ ~ z; ~,~ 7- C~ ~ ~ ,. # ~
jo /5- /
Date
are
HAA Fee $
Date of Payme-nt ../z~/~---/
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
1. GENERAL INFORMATION
Complete legal description
Lot 111 Hillside Park
Location (site address or directions)
Property owner
Mailing address
Rowland Burno
10301 Tree Top Lane
Anchoraqe, AK
C/O RESS Day phone
8200 Humboldt Ave. S Suite 204 Minneapolis, MN 55431
Lending agency
Mailing address
Day phone
Agent Ken McKean/ Remax Properties
Address
Day phone 276-2761
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF 'BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
xxx
Public water
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
NOTE:
xxx
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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.
$ & s ENGINEERING
Name of Firm l?n~.~ I=n_~le River Loop Road No. 204 Phone ~
Eagle River, Alaslca 99577
Address ., .! ,
EngineeCs signature .Y~',~/ .~.- ~'-~,'~-~--- Date
Approved for -?-;~E::~_ _ 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 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.
~UN~C~^UTY OF ~C~O~,g~
~NVi~O~N'~^~' S~VtC~S ~)~WSION
Municipality of Anchorage OCT ~ 1 ~~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division R ~ C E 1 ~
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
A. WELL DATA
Health Authority Approval Checklist
Well type 4; ~-,~ ~ ,* /i If A, B, or C,'attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed .~"'" ....
Total depth Cased to Cas~ t (~above ground)
Sanitary seal (Y/N) ___ Wi~doperly protected (Y/N)
FROM WELL LOG ~ AT INSPECTION
Date of test
Static water level
Well production . g.p.m.
WATER SAMPLE RE,~L~:
Coliform J Nitrate Other bacteria
g.p.m.
Date of sample:
S~P_T--~_IC HOLDING TANK DATA
Date installed ! ~ / ~ / ~' ( Tank size
Collected by:
Number of Compartments ~ Cleanouts~'/N) y~ ~
Foundation,cleanout (Y/I~ ~' ~ Depression (Y/~))
Date of Pumping ,0//~/~ Pumper
ABSORPTION FIELD DATA
Dam installed /0 /~ ( ~1
Length'; ~ 6 Width
Effectiveabsorption area '~%¢
Date of adeq.acy test I 0 /~/* c
Fluid depth in absorption field before test (in.);
Fluid depth '~ ~ '~ (ins) Minutes later:
High water alarm (Y/~ ~v ~
Soil rating (g.p.d./fF or~ (~ S-' System type 'F ~'~'-
.3 Gravel thickness below pipe ~/ Total depth
Monitoring Tube present (~)/N). Y¥- 3* Depression over field (Y~___~ ~ O
Results (Pass/Fail) ?'~' $ -$ For ~ bedrooms
Immediately after 5"1 t gal. water added (in.):. ~ 5- ~/~"
Peroxide treatment (past 12 months) (Y/N) ~,,o ~ ~
Absorption rate = ~ .~-O -P g.p.d.
~¢'~¢'~"~ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons ..-~-~
Manhole/Access (Y/N) ~mp off" level at*
High water alarm level at* _ ....--- *Datum
E. SEPARATION DISTANCES /v/A - (_,~,~,~y t~/~.rE,~,_
F.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
On adjacent lots
Public sewer manhole/cleanout
Se~ Lift station
SEPARATION DISTANCES FROM/~HOLDING TANK ON LOT TO:
Foundation ~' I ~'- Property line 5' ~--~ Abs0~ption field ~'
Water main/service tine Jo '~ Surface water/drainage Jo~ ~ Wells on adjacent lots
o '+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line / o
Surface water
Curtain drain /v ~.v ~
'/'- Building foundation / (> :-'r- Water main/service line J 0 --~
! o o -+- Driveway, parking/vehicle storage area I
~,-~ 0 ~ ~/ Wells on adjacent lots ;~ o o
ENGINEER'S CERTIFICATION
c OF
. ,
I ce~i~ that I have determined thru field inspections and review of Municipal recor~~E~.~ are
in conformance with MOA A gui~lines in effect on this dam.
Signatur~~
Engineers" Name ~ '~ .
Date ) o / [ ~ /
HAA Fee $ ~-~ ~ ~'/-~
Date of Payment /~
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
Parcel I.D. #
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
HAA #
1. GENERAL INFORMATION
Complete legal description LoT II
~iLLSIDg PARK
Location (site address or directions)
Property owner J.~Ro'~ ~ ELI~-A%E'TH
Mailing address SA M E
~c~. A~
$"r~v~ N£ Day phone
Lending agency
Mailing address
5(0o E, 3~ T~ SUITE I~ ,
Agent JANET
Address ~830
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
NOTE:
Day phone
ANCHoNAC-g
Day phone
9o"'-0 'T
Community well
Public water
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
If communify wastewater sysfem, provide written confirmation from State ADEC
attesting to the legality and status of system.
NOTE:
72-025 (Rev, 1/91) Front MOA #21
o
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 FLATTOP -FECH £t/C~ Phone
Address l¢r53o ECHo ST , A~cH. ~ ~S
Engineer's signature ~~ ~ ~ Date
Approved for -'~
Disapproved.
Conditional approval for
~ h THEODORE ~, A~OORE
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The 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-O25 (Rev. 1/91) Back MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT
A. Well Data
Well type CLASS "A"
Log present (WN)
Total depth
Sanitary seal (Y/N)
Il., ~{ILLSI~)E PA/~K Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
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
g.p.m.
AT INSPECTION
.g.p.m.,~
; On adjacent lots
; On adjacent lots
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
B. SEPTIC/HOLDING TANK DATA
Public sewer manhole/cleanout
Petroleum tank
Collected by:
Date installed 10/%~ Tank size
Cleanouts (Y/N) ¥ Foundation cleanout (Y/N)
High water alarm (Y/N) N
Date of pumping ,~ / ! ,~ 1' ~2 ~_ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot N./~.
To property line ~' 3o
Surface water/drainage
On adjacent lots
Absorption field
I0O'
Other bacteria
G,-", z_ Compartments ~--
N Depression (Y/N)
Alarm tested (Y/N) N,~.
Foundation 17 F~
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed Io/~/
Length 3 (~ ~
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Width
Soil rating (GPD/Ft2) J. ~ System type
Gravel thickness N- Total depth
Cleanout present (Y/N) ¥ Depression over field (Y/N)
Results (pass/fail) 1~A$$ for
~ ~ '~ After test 3 ~'"
NONE K'IV0t,/i~ If yes, give date N,/~
N
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~, ~, On adjacent lots N.~, Property line ~ 3o
To building foundation 28 ¢ To existing or abandoned system on lot N
On adjacent lots >- ~/o' Cutbank N.A. Water main/service line
Surface water :> ~o~' Driveway, parking/vehicle storage area 12 '
Curtain drain N~i~ oBSE~VEb
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature ,~7"~
Engineer's Name
Date A czk~¢, ~.~¢/-
HAA Fee $ /
Date of Payment
Receipt Number
eff~e~,~j~¢~. ~ ¥of this inspection.
$~ ~¢¥ · CE. 3589 *'" >~ ~
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
WALTER J. HICKEL, GOVERNOR
DEPT. OF ENVIRON MENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
August 10, 1993
(907) 349-7755
Mr. Ted Moore
FlatTop Technical
SUBJECT: Lot 11, Hillside Park (10301 Tree Top Lane) & P.U.D.
Class "A" Public Water System, PWSlD 212461
Dear Mr. Moore:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on July 9, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on July 9, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample results were submitted to the
Department on December 2, 1992. This does meet the provisions of 18
AAC 80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on November 12, 1991. Based on
analysis of the previous VOC samples results have been satisfactory. This
does meet the provisions of 18 AAC 80.200(a), State Drinking Water
Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the specified legal description
noted above only.
August10,1993
Page 2
Ifyou have any questions onthe aboveinformation, piease do nothesitateto oontaotthis
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
ML/pf
MUNICIPALITY OF ANCHORAGE
DEPARTMENT dP HEALT. & NUMAN SERWCES ~ / -~-- /2 2 ¢~
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, bloc'k, subdivision, section, township, range)
L o c at ij~ I¢ ~'a~ ~[e s~¢~ ~.~e..c. tio n s)
(b) ~0~ O~~'~ Telephone: Home Business
Telephone ~ ~
(e) Mail the HAA to the followin~ address: or: Check here ~ hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family 1~
Number of Bedrooms "~
3. WATER SUPPLY
Individual Well [] Community~[, Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite'~[, 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.
P~oe 1 r~f 9 72-025 fRev 8186~ Front
':~Jo~ s,JeeU!0U@
leUO!S$@JoJd Gq), u! suo!ss!Luo Jo ~JOJJi~I JoJ @lq!suodsaJ ~,ou s! abe~oq3uv jo X~!led!o!unlAI eqj. 'penss! s! eleo!j!lJao e eJo~eq
e~ep ezXteue Jo suo!loedsu! lonpuoo lou op SHHQ ~o seeXold~U3 '$~UeLUeJ!nb@J ele~,s pue IeJepej u!eHao/t~s!3es ol Jap Jo
u! suo!ln),!lsu! bu!puel J!eqi pue seuJoq jo sJaseqoJnd o~ XseHnoo e se s!q~ seop SHHQ eq/'e~Sel¥ ,~o eleiS eq~, u! peJ@),s!§eJ
Jeeu!bue leuo!ssajoJd ~,uepuedepu! ue/tq e^oq~ S qde~SeJed u! ue^!~ suo!~,e),uesaJdeJ eq~, uodn XlUO peseq seleo!j!~eo
le^oJdd~' X~!Joq~n¥ q),leeH senss! (SHHQ) seo!^JeS UeLUnH puc q~leeH ~o ~U@LU~Jed@Q ebeJoqou¥ jo /4!led!o!un~ eql
NOI.I. nVO
leAoJddV IeUO!l!puo~) jo suJJel
leUO!]!puoo p@Ao]ddes!C] ~ pe^oJddV
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
WELL DATA
Well Classification ~¢¢//¢ I~) B, C, D.E.C. Approved(~)N)
esent (Y/N) Date Completed Yield
Cased to __ Depth of Grouting --
Pump Set At --
Casing Height A'bo!'~.~__ Sanitary Seal on Casing (Y/N)
~0ndui~ (:~f/N)~'"'~_ Depression Around Wellhead (Y/N)
Separatio'n Distances. f¢(~m Well:
To Septic/Holding Tank On Lot ' ~ ; On Adjoining Lots
To Nearest Ed~l~ ~:~f~,Ab~'~r,~ion Fi~ld,'on Lot
To Nearest P'ublic~$~wer'Lin~ "':';
Cleanofit/M"~nhole" ,,.,'-', .;
· .' i: .;~'::
Water Sample Collected by'
Water Sample Test Results
Comments
T~N~~ewerining Lots
To Nearest Sewer Servic'b'e,.Li~n~on Lot
;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes ~)N)
Depression over Tank (Y(~}
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
Size /,¢¢r~ No. of Compartments
Air-tight Caps N) Foundation Cleanout
Date Last Pumped
~/,~ ;for ~/~
Temporary Holding Tank Permit (Y/N) '~//'~
To Water-Supply Well
To Proper,ty~i ,n,e
To Water Ma~n/Ser~C.¢ L~ne '/~ ·
Course
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
G tS-ommen- ~"
Page 1 of 2
ABSORPTION FIELD DATA
MUNICIPALITY OF ANCHORAOE
ENVIRONMENTAL SERVICES DIVISION
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ~'~
To Building Foundation ~
Lot /J/~l
!
To Water Main/Service LiDe /O
To Stream/Pond/Lake/or Mgjor Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Desig~n
Length of Field ~'~'
Depth of Field ~
Gravel Bed Thickness ¢ i
Standpipes Present GN)
Date of Last Adequacy Test
1988
RECE/VED
To Property Line
TO Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) ,'~/,~
Comments
D. LIFT STATION
'"~,lnstaHed
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
-~- ~uui~ping.__C~ycles~ during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I~ke.d, ~e,rified, or conformed to all MOA and HAA guidelines in effect on tl~e date of this inspection.
Signed Date ~"'~'~{
Compan MOA.o.
Amount: $ /~. ~
Page 2 of 2
72-026 (11/84)
ANCHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: August 11, 1988
PWSID: 212461
To Uhom It May Concern:
According to the records on ?ile in this o¢?ice, the HILLSIDE
PARK SUBDIVISION Water System is in compliance with the State o¢
Alaska Drinking Water Regulations.
MPL:pkk
Sincerely,
Michael P. Lewis
Environmental Engineer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4726
Application Date
GENERAL INFORMATION
(a) Legal DescTiption (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Nam~
Applicant At, dress ,/'~
(c) Applicant is (cheCk one): Lending Institution FI; Owner/builder/~; Buyer []; Other [] (explain);
(d) Lending Institution . Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Famil~ Multi-Family []
Number of Bedrooms 3
Other
WATER SUPPLY
Individual Well [] Community,E~ Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite~ 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.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVI[~-'"'~ INSPECTIONS, TESTS, FILE SEARCH, '~%~A AND INFORMATION
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 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 th~ion.
Name of Firm-- '"'¢/.~-~-;~- ~'~,~ ~ "~/~ Telephone
Engineer's ,Seal
DHEP APPROVAL
~ -/~ ~-~,
-/-/.,,,.e-c- bedrooms by ~ ''~' ')~-'~ Date
Approved for
Approved ~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
264-4720
ko,al Descdpt,om ~
WELL DATA
Well Classification ~-¢¢~¢x¢¢'/'/~ '//'~ If A, B. C, D.E.C. Approve(~)
Well Log Present (Y/N) '---- Date Completed Yield
Total Depth ~-- Cased to ~ Depth of Grouting --
Static Water Level '~-"' Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
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
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed,,'/~/ -/'/-'¢'*J Size J~'-~-¢¢~ No. of Compartments ~
Standpipes~14) Air-tight Caps.) Foundation Cleanout (Y(~')
Depression over Tank (Y(~ ... Date Last Pumped J~'
Pumping/Maintenance Contract on File (y/N)./ ~ ~.d~//A ;for ~¢~'"///~ ./
Holding Tank High-Water Alarm (Y/N) ~/'/'~ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank: t .
To Water-Supply Welt /' ~',¢ ~-¢~, ~/
To Property Line .--~--,~'/'
To Water Main/Service Line ~ ~''~ ~
Course xf'/~/~6¥~
Comments -%'~/'~-~ ~//']~'-'~ %-_Z=-~,~z/~ .~'~.¢/~.~ .-¢/_.. ~..~.~,~"..~,.~
To Building Foundation
To Disposal Field ,.~..¢
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~-5~'- --~;~'/~,p.,~a~,,~' Type of System Design
Da~e Installed /x~ --//_~.~/ -"/ Length of Field
Width of Field ~-~-~ //
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Test
Depth of Field
Gravel Bed Thickness
Standpipes Present ~N)
Date of Last Adequacy Test
,/
Separation Distance from Absorption Field: i~..
To Water-Supply Well _-/"~.-~'-~¢~----f~/Y '// ¢-~
To Building Foundation
To Property Line
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments _.~-~'/--~ ,~ g'//-- '-~'/P ~
LIFT STATION .~
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Date Installed
Dimensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that,~/~ .,/I have checke~t, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~_/.//~"~ ./~'~'~'~'~'~ Date ,~ --~---' --~
Comp~:~ ~:~/' ~ MOA NO. .
Receipt No. ~'~ ~
Date of Payment ~" ~-~ '~
Amount: $ ~ Engineer's Seal
Page 2 of 2
72-026 (11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA g9501
BILL SHEFFIELD, GOVERNOR
Tele,ohone:
Address:
274-2533
Pws I.n.
To Whom it May Concern:
According to records on file in this office the
Water Regulations
Water System is in compliance with the State Drinking
Sincerely,
CONSTRUCTION! AND OPERATION CERTIFICATE
A ASKA DEPARTMENT ENWRONME.TAL CONSERVAnON
APPROVAL TO CONSTRUCT
Plans for the construction of
public water system located
Alaska, submitted in accordance with 18 AAC 80.100
t,O 'Yl ,'~ ~ ¢ J~_~(~ have been reviewed and are
~, approved.
./~ [] conditionally approved Jsee attached conditions).
eY ~ TITLE ~ '
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Chun'ge (contract oraer no. Approved by Date
or ~escriptive reference)
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the ~l/l/~l:'f~ ~OY' j~' Pu ~ Jl'~- 1'0~ Jl public
water system was completed on /~ ~-~41~ ./~ 7 q (date). The system is hereby
granted interim approval to operate for 90 days following the cpmpletion date.
BY TITLE DATE
As-built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
final approval to ope_rate. ~
.... ~,: ~.. ,,~P~ ~ ,:
BY ~ITLE -- DATE
2220 EAS~
/LNCHCXZAc~.~ AK 99507
(907) 349-6451
WkT~R ~,L TF.5'T
Initial Reading c~ Meter:
INVOICE ,,,_~,
EWER AND DRAIN
P.O. BOX 4-2841 PHONE 345-2513
Job Address
CLEANING SERVICE
ANCHORAGE, ALASKA 99509
ROTOR ROOTER SERVICE CALL
STEAM THAWING HRS.
TRiP C~'ARG~%~ HRS.
PLUMBING REPAIR CHARGE
MATERIALS
PLEASE PAY FR(.//I THIS INVO CE
TOTAL FOOTAGE CLEANED OR THAWED '/*' ',
PROBABLE CAUSE OF STC PPAGE -]-:-' ~ ?~" /
BLADES USED
LINE CLEANED ':
[] JOB NOT GUARANTEED FOR FOLLOWING REASON
WORK ACCEPTED BY
BESSE, EPPS & POTTS
ENGINEERING, PLANNING, SURVEYING
2220 £, 88th Ave. / Anchorage, Alaska 99507 / Telephone 907-349-64§ I
TO:
LETTER OF TRANSMITTAL
ATTENTION:
SUB~IECT:
OUR .IOB NO.
Transmitted herewith is/are the following:
CC:
BESSE, EPPS & POTTS
"Providing a quality personalized service to those building Alas#a 's future"
Time ~' Time ~e
Date Date Date
Inspector Inspector Inspector
Comments Conditional Approval
Date Sewer Installed , ~ ~ Permit No. Septic Tank Size
~ ~ { Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
~ ~ Well to Tank
APPLICANT FIL~S OUT LOWER HALF ONLY
Address
Lendinglnstitution )~ ~.~. b..')o~rht~ ~' ~o~F~ Phone
Realty Co. & Agent "rO~ ~ '~'~ '~ ~hono
Address
Legal Description ~.-O~' ~ ~ ~., ~
Street Location ~ ~O~ O~ C ~OO~
Type~f Residence
~ Single Family
~ Multiple Family No, of Bedrooms
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A well log is required for all wells drilled since June
~Community 1975. For wells drilled prior to that date~ give well depth (attach log if
~ Public Utility available.}
Sew~ Disposal
~lndividual Year Individual Installed:
~ Public Utility When Connected to Public UtilityL
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.