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HomeMy WebLinkAboutUS SURVEY 3042 LT 75DOnsite File US Survey 3042 Lot 75D #075-132-79 WELL LOG Date Dri 1 l ed: i Strati c Water Level feet Draw Down t IA feet Type Material Drilled: Gallons Per Minute Total Feet of Casing 0 feet to 61 to �J to rnt`l t�,-�- nV-A nrP,� �ZI to �()� S -D ( to _ to to to to APR 3 0 1996 HEFTY DRILLING Municipality of Anchorage 3540 AKULA DRIVE Dept. Health & Human Services ANCHORAGE, AK 99516 (907) 345-0593 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW960049 DATE ISSUED: 4/16/96 DESIGN ENGINEER:DUMMY COMPANY EXPIRATION DATE: 4/16/97 OWNER NAME:ONSLOW TERRENCE R & JUDITH J OWNER ADDRESS:BOX 744 GIRDWOOD, ALASKA 99587 PARCEL ID:07513279 LEGAL DESCRIPTION: US SURVEY 3042 LT 75D LOT SIZE: 19580 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (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: RECEIVED BY: ISSUED BY: DATE • /50 DATE: 7&- ge «!J\ 7; 44 7- va-,--c,n I )ol— 7,.-y- n 0 n 4,.,oa,/l "1/ In- O -J 0 J.0 LLI 0 11 z. 0-- < > V) ca .� LLI M c o (n 0% c E 0 0 < 01E C z (n x E0 >: LL) 04 3: ! 3 = -i d /go, 0 X li z z La -(j "* s0 v ci 0 0 C'CL 0 C; c z LA- 0 z m 0 (L 0 0 V) 75 d d E 0 :3 (n :2 -8 CD w V) 0 N cr t- 099 0 0 >- un) 44 ton D N to Ln -90 99 (n 0 -j (n _3 00 60 �J -�o -yo EIE 00 co 00 00 C) N 0 0). 4.00 - m o) 05. - 1-0 N Ln 000 0 6� -100. >0 .0 � J(r) f v /Ra C->,> c) O or n it C'7 '0 LC) 0?1 ry N �0 ry LO 00 ao OT OR, -> MM z ORe .0 0 V '9Q C) 1>1> "> ........ Z z 'or Z5 8 IT . .... 00 CL n QD 09161 LL. Cv z Z) 5 D 0 Q- CL CL (X 2 20 0 0 0 Ix 0 0 Z Q CL MUNICIPALITY OF Development Services Department On -Site Water & Wastewater Section Parcel I.D. 075-132-79 ANCHORAGE Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Phone: 907-343-7904 Fax: 907-343-7997 Expiration Date: ()cli 1 to , a d a 0 Complete legal description US SURVEY 3042 LOT 75D Location (site address) 121 Sproat Road Girdwood, AK Current property owner(s) ,Judith Onslow Day phone (907) 242-5982 Mailing address Real estate agent P.O. Box 744, Girdwood, AK 99587 Rebecca Reichlin 2. TYPE OF DWELLING: ❑� Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone (907) 441-8125 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑n Waiver request for: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 2.10 COQ I Q- IC( Date of Payment Receipt Number ORS�l1� COSA # DSC 20 1317 Date: Waiver Fee $ Date of Payment Receipt Number Waiver # Distance: 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. 1 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Forge Engineering Phone (907) 522-7773 Address 1399 W 34th Ave Suite 101, Anchorage, AK 99503 Engineer's Printed Name Michael E. Anderson, P.E. Date 7/9/2020 % 6. DSD SIGNATURE �""°"'' '"°"'th' .. .� ....., System #1 Approved for bedrooms 64ICHAEL E. ANDERSON CE -4381i• `J® System #2 Approved for bedrooms ��p�F;..,e, 7i9i20 ..,.-� Disapproved �0��PRGFFSSO".1 '� Conditional approval for bedrooms, with the following stipulations: 11))})}1 . By: Original Certificate Date: 7 % to �0.�D 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 Checklist blue sheet COSA Checklist yellow sheet COSA Checklist Legal Description: Parcel ID: If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA Well log is filed with Onsite (or attached) Date drilled Total depth ft Cased to ft Sanitary seal is functioning correctly Wires are properly protected Casing height (above ground) in. Date of flow test for COSA Static water level at beginning of test ft. Well production at time of test gpm Water storage tank volume gallons Well disinfected for coliform test? Yes No Coliform bacteria is Negative Nitrate mg/L Nitrate less than MRL (ND) Arsenic ug/L Arsenic less than MRL (ND) Collected by Date of Sample Comments __________________________________________________________________________________ B. TANK DATA Age of tank(s) years Tank type/material Measured operating fluid level in septic tank Standpipes/foundation cleanout per record drawing Date of pumping C. LIFT STATION Required maintenance completed Age of lift station years Lift station material Comments: D. ABSORPTION FIELD DATA ______________________ Which system tested (date installed) ALL standpipes present per record drawing Total measured depth from grade ft (max) Measured depth to pipe invert from grade ft (min) N/A – pressurized field Monitor tubes go to bottom of effective. If not, state depth into effective Code-required soil cover over field System presoaked (Required if vacant for greater than 30 days prior to date of test) Gallons introduced gallons Adequacy test date Results Pass For bedrooms Fluid depth prior to test in Water added gal New depth in Elapsed time min Final fluid depth in Absorption rate gpd Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficiencies: US Survey 3042 Lot 75D 075-132-79 6.8 4/18/95 None 100 100 .508 >18 Forge Engineering 6/29/20 67.7 6/29/20 PUBLIC SEWER PUBLIC SEWER COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100’ Yes if No ft Neighboring Tank > 100’ Yes if No ft Absorption Field on Lot > 100’ Yes if No ft Neighboring Absorption Fields > 100’ Yes if No ft Community Sewer Main > 75’ Yes if No ft Community Sewer Manhole/Cleanout > 100’ Yes if No ft Private Sewer/Septic Line > 25’ Yes if No ft Holding Tank > 100’ Yes if No ft Animal Containment > 50’ Yes if No ft Manure/Animal Excreta Storage > 100’ Yes if No ft From Septic/Holding Tank on Lot to:(Please enter distances if less than required) Building Foundations > 10’ Yes if No ft Property Line > 5’ Yes if No ft Absorption Field > 5’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10’ Yes if No ft Property Line > 10’ Yes if No ft Water Main > 10’ Yes if No ft Water Service Line > 10’ Yes if No ft Surface Water > 100’ Yes if No ft If absorption field is under driveway comment below Wells on Adjacent Lots: Private Wells > 100’ Yes if No ft Community Wells > 200’ Yes if No ft F. ENGINEER’S 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 COSA guidelines in effect on this date. 7/15/20 - Public Sewer - Public Sewer ✔✔ ✔ ✔ ✔ ✔ ✔ ✔✔ The lot is served by the public sewer system. ✔ L\ \ \ \ Lot 76 \ \ \ \ / \ \ 49th\ / Star Surveying \ © Lot 75C I \ \ \ a o W 0 0 20 40 S68 30, ".� ryg18..E US SURVEY FEET 2-Story?`'j2 „ti �$$• House P \ \ Garage \Sae ejd9. {� S tbOck 2p 1,017t \ v . `263• \ 1,OOt 6t 9 \ \' \ \ \S\°`kms ]Lott 7/5,1D a 9 Ro e. p foo W Flagpole Z;' • TH •i•y A. Hurst ••. S-1179 •• A F9'• �111� Of S8104�`��AW �. �IINLr RQ /I \ I -All dimensions shown are grid bearings ground distances; record boundaries are per Plat No. 95-73. -49th Star has conducted a physical survey of the property and all details shown on this Asbuilt Survey are correct. Under no circumstances should any data hereon be used for construction or the establishment of property lines. -It is the owners responsibility to determine the existence of any easements, covenants, or restrictions; no title research performed AS BUILT SURVEY LEGEND 49th Star Surveying LLC 321 Fireoved Drive Lot 75D, 0 Well Anchorage, AK 99508 US Survey No. 3042, Q Comm. Pedestal (907)891-6111 Girdwood, Alaska Jeremy@49thStarSurveying.com Utility Pole W.O. 2026 DATE: 6/30/20 SCALE: 1"=40' A 2020-028979-0 L Recording Dist: 301 - Anchorage A S 7/9/2020 08:01 AM Pages: 1 of 4 K A IIIIIIIIIIIIIIIIIIIIII 1002-19B Grid 5012 EN20011 KZS.UI.ZQ.ILM IT;.kp _ (herein "Chugach"), whose address is P. 0. Box 196300, Anchorage, Alaska 99519 and Judith J. Onslow (herein "Permittee"), whose address is P.O. Box 744, Girdwood, Alaska 99587. 1. Easement. Chugach is the grantee or user of an casement for the construction and maintenance of electrical facilities, as follows: W- !-• inthatcertain written instrument recordoc-fonth-e-YT-day ot- September 11,1, I'Look 2830, Pages 21 and 22, on file in the office of the District Recorder, Anchorage Keeording District, Third Judicial District, Seward Meridian, Alaska, Dedicated by the plat of the subdivision known as Lots 75A, 75B, 75C, and 75D, U.S. Survey No. 3042, according to Plat Number 95-73, recorded on the 12th day of September 1995, on file in the office of the District Recorder, Anchorage Recording District, Third Judicial District, Seward Meridian, Alaska, (herein "Easement") which pertains to the following described real property: The West Twenty Feet (W20') of Lot Seventy-five "D" (75D), U.S. Survey 3042, described in that certain written instrument recorded on the 5"' day of September 1995, at Book 2840, Pages 21 and 22, on file in the office of the District Recorder, Anchorage Recording District, Third Judicial District, Seward Meridian, Alaska. ["ermittee acknowledges the validity of the Easement. Permittee warrants and represents th— Permittee is the owner of the fee simple interest in the land subject to the Easement and t following deseribed real property to which the Easement is aqjacent: i Lot Seventy-five "D" (75D), U.S. Survey 3042, according to PlatNumber 95-73, recorded on the 12t" day of September 1995, on file in the office of the District Recorder, Anchorage Recording District, Third Judicial District, Seward Meridian, Alaska, (herein "Parcel") 01 Encroachment Permit - Page I ofm eRecorded Document 2. Encroachment. Permittee has constructed or purchased the following improvements *n or within the real property subject to said Easement: A well that encroaches approximately Three Feet (3') into the east side of said Easement along the west property line, for a distance of approximately One Foot (l'); the owner would be required to provide locates of the well if there is future work done in the easement, and Chugach would not be liable for any damage done during future work within the easement, (herein "Encroachment") 3. Permit. Chugach hereby authorizes Permittee to continue the existence of t Encroachment in its existing location subject to the covenants set forth in this permit. I 4. Indemnification. Permittee shall indemnify and hold Chugach harmless from any claims for personal injury, property damage or other loss arising in any way from the continuation of the Encroachment. 061; =003s a R M 6. No Interest in Real Estate Acquired. Permittee hereby acknowledges that t Encroachment and any additions thereto, even if in violation of this permit, has not and shall not real property. Without in any way limiting the foregoing, Permittee acknowledges that t h Encroachment is not adverse to any interest of Chugach and its continuation is entirely wit t It permission of Chugach for purposes of the common law doctrine of adverse possession. This pe creates no interest in the real property subject to the easement. 7. Modification of Utilily Facilities. If the electric utility facilities located within t Easement are upgraded, added to, replaced or reconstructed, Permittee shall pay that portion of Chugach's total costs for such modification which is reasonably attributable to accommodating preserving the Encroachment. If such payment is not made within thirty (30) days of writt demand for same, Chugach may terminate this permit in accordance with paragraph 9, below. I 8. Covenants Runnina with the Land. The obligations of the Pennittee arising from thM 1�.eirmit shall be covenants running with the land which shall burden the Parcel and the PermitteeT interest in the land subject to the Easement and shall benefit the Easement. I 9. Termination. Chugach may terminate this permit after the giving of thirty (30) days written notice of such termination if: 2 of 4 eRecorded Document 2020-028979-0 a. The Encroachment is enlarged, increased or extended within the real property affected by the Easement. b. The Encroachment is damaged by any means to an extent of more than thirty percent (30%) of its replacement cost at the time of destruction. C. Permittee fails to make the payment described in paragraph 7, above. 10. Term. This permit shall, if not sooner terminated by Chugach, expire forty (40) years from the date hereof. 11. Entire Agreement. This written permit constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all other prior or contemporaneous agreements, oral or written, between the parties. No modifications, amendments, deletions, additions or alterations of the permit shall be effective unless in writing and signed by all of the parties hereto. CHH II ELECTRIC ASSOCIATION, INC. By: Shelly Schmitt nior Manager Date: Encroachment Permit - Page 3 of 4 3of4 eRecorded Document 2020-028979-0 STATE OF ALASKA ) ) ss: THIRD JUDICIAL DISTRICT ) The foregoing instrument was acknowledged before me this AZ day of , 2020, by Judith J. Onslow. I NOTARN PUBLIC!" . cP ��//rl9rF•t1 F STATE OF ALASKA ss: THIRD JUDICIAL DISTRICT r' Notary' -Public in nd for the State of Alaska My commission expires: 01- n/ -ZZ The foregoing instrument was acknowledged before me this day of 2020, by ���c of se enior Manager, Distribution Engineering of hugach Electric Association, Inc., an Alaska corporation, on behalf of the corporation. 3J0,. •.ticQA ' NOTARY ' PYLIC AFTER RECORDING RETURN TO: Chugach Electric Association, Inc. P.O. Box 196300 Anchorage, Alaska 99519-6300 x.6"1 �W-Y.4�'J�:j •/ LL{l�.S�''�� Notary Public'in and for the State of Alaska My commission expires: D�-0 1-l2 Encroachment Permit - Page 4 of 4 4of4 eRecorded Document 2020-028979-0 Cataska C-0*1K, N*-1kTPOW's. gw" IN144* W5.17 oft V* W Te*wrA%o=",& us twMJ044M tt, �o�m 124 N~ Rd, Goomsm "I 3ka m *M��rdm ft *&*-,n rimded vt Forge Erwm=v- -41904 4*ft=XW4W-)I- OWWVQ` ftft W, W," M4 "WT4W, W4 h6� ft t"MWM to T* MrU,AJ3414 czMmsww�'s Aweby asut& ft-& Ww W" IWAUM w 01W &,6 et--JrA& ~—ft of Me At -me r4mboriall M T'A AW�M f)VW *"IW* W", 400 Ott 0 94 "" Of 0�400V� by'"A0, Y�A* 104* "0 4POW 0 yl:x* *Aam**-f" *4 wtqtf�- loft Ma*sn *VO*Am I Ak"*a Comr�- � wO * *,*ol hwr-Oms, now wa-4 ftw"� ke wry *vroqft V, V"y * wy a W-w*ftw 0-1 a ",WA co "� %f onwor, wt 74)7f AUSkM dNn2oMd Cr WSr7fW M 3 fMM, d, M VnMaCrWj V* bC �Wand ar no OOM to AbOA UW&;Aa~ bl AM sks Czff wmYwateM tr qwaW WXWVLCM Mms&UbM by M 0, pw4go* wk-ts, pool stw*" *% t* M�Oovw god- mmftmd F tn )vom TO ro-,-vWm,@4 Pm oo wo w. po,*-#o AWO kvm fi-* Am@ aM "mrwm of" Pqmlwv-AW, -kwm CaTaxnadars it Uldu Pa M"Mn ra moom " mumar dmn3W- ama msLA d Aw-mM Fs_ f,*Py. fow�o"#4 ram 0* cwd SEW 52 GC%s 853RIM AtIn.- Vol, � I - P I ope U33MMEEMMEM Su-N,'ecl to ycoo agreermnt, �o if ovvnno� ft cc.-enp" w set jorm bietw, CvC I Cofmnkolcabon Cor -o has r* dbKx-,bort to the cr ". woM orocroachrg into tt* Ta A."OWA Wj Lol 7-50' 121 SpO&I R 'OM so 12, GCI W-041120 -OWG-22, This knw, of wn -ctiec6m in no way precWes GC I Cornu nicatim Cxnp,ftom %*' Uwand enl of aTrf os it tray hm wiltmany podim of ft ulifity ear h'.-ntaf 4 04' M r4m-of-way. inom - "n ' vowriw 0 ac(. -.ss for seA",, its f4o�31' 1A"any 4otWaj a- exV Oifq% rN, WW AW� V oVrifV any 6 re.qLPA-d twsftctiwn. repair or, rown-9fucton *4 rzomftto aicovmrodatt or -Mothev emrowhmems shall be vad by the propoity tmoner. Ely s4rWv below, you aTt-- io WemrAy and hdd GC4 Commxvicaikom cofp harnlwss, now arO tpr�w--T, bv ax iy Omage, co M- --my rise, jOw–Wing pe -- rea=mbiea, mxney's (Acms), kabbws and injury, to way pers-m w- pr I o=v vwV as a re,%wift, of the ofvvooc�m— n%l-,, Pwase m44ato your owwanw by Soov "- tiourov ft"S lot"er addfesL5 -bOow -Manapr'St'. ReU $Peron�m,Cwjml ReV muricabon C*.P 5161 Foirbwks St AnChovotg-C AK 99503 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. "5 & S ENGINEERING Name of Firm 17034 Eagle River Loo- p Road No 204 Phone ('G] `� _ X OI -79 Eagle River, Alaska 99577 Address Engineer's signature - Date f f i 7 �J .............. • • a. ass �.. b'tl»s.s..� fit'" S ROBERT C. COWAN '4 r , 6. DHHS SIGNATURE�� S J� %CE - 8801S, Approved for � bedrooms. C`��;*` •`-_ ��" '"-�.� Disapproved. Conditional approval for bedrooms, with the following stipulations: 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. # 4 ZE ` / 3 2 — %9' HAA # HSA ?1; 0._20 1. GENERAL INFORMATION Complete legal description Lot 75D; U.S. Survey 3042 Location (site address or directions) Monarch Mine Rd. Girdwood, AK Property owner Terry Onslow Day phone 783-2855 (w) Mailing address P.O. Box 744 Girdwood, AK 99587 Lending agency Day phone Mailing address Agent Day phone Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well xxx 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 XXX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 .p 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. l 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 & S ENGINEERING Name of Firm ver oop Roado. 204 Phone Address Eagle River, Alaska 99577 Engineer's signature 6. DHHS SIGNATURE 0 Approved for bedrooms. Disapproved. 6-1y-ag-79 Date i 3 / �� OF �� .....r,.. ROBERT C. COWAN a �� c CE -8801 s� Conditional approval for bedrooms, with the following stipulations: Additional Comments %t 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-M (Rev. 1/91) Back MOA #21 MUNICINAUFY OF AN010MGE ENVIRONMENTAL SERVICES DIVISI Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICESN" 03 1996 1 Environmental Services Division] 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907)ANEW E 0 Health Authority Approval Checklist Legal Description: 4077 751 ; U-!57 5c !/� j Parcel I.D.: A. WELL DATA Well type PK k If A, B, or C, attach ADEC letter. ADEC water system number Log present L?/N) Date completed Total depth 1061 Cased to h Casing height (above ground) /z t Sanitary seal _6)N) Wires properly protected Y/ ) FROM WELL LOG AT'INSPECTION Date of test LZA (,yrnLL r Static water level hlP Well production O g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform G Nitrate 0-_ G� .2 Other bacteria i Date of sample: 1/- 27- Collected by: C- zz1y tj)ll „lw -, B. SEPTIC/HOLDING TANK DATA / u�3L�c sEwf_-� sYs716p-c Date installed Tank size Wit— Number of Compartments �A Cleanouts 1 / ) �- Foundation cleanout (�N) Depression (Yo High water alarm (Y/N) Date of Pumping Pumper Nlf4 C. ABSORPTION FIELD DATA Date installed Length Width �J/A _ Soil rating (g.p.d./ft2 or ft2/bdrm) System type Gravel thickness below pipe Total depth Effective absorption area Monitoring Tube present (Y/N) Depression over field (Y/N) Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.):. Fluid depth (ins) Minutes later: Absorption rate = g.p.d. Peroxide treatment (past 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION P/A 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* Septic/holding tank on lot ljrA On adjacent lots �J//� Absorption field on lot On adjacent lots fi Public sewer main Public sewer manhole/cleanout &0 4 - Sewer Sewer /septic service line %d %z F0W4,4Tn,,J CO Lift station /-S114 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: )k//4 Foundation Property line Water main/service line Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain F. ENGINEER'S CERTIFICATION Building foundation Absorption field Wells on adjacent lots 1-1114 Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots CDP 1 certify that I have determined thru field inspections and review of Municipal recoralst�,t�-e,, b $yet s are in conformance with MOA HAA 'd lines in effect on this date. a` � Signature Engineer's Name �'� a %<<�; .. C4�c...r✓ �,f•x,. g !s •� ROPER7 C. co"VA,:J t v Date HAA Fee $ 0 6r) , lF-07 Date of Payment 2 Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number