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HomeMy WebLinkAboutTHOMSON LT 6Thomson. Lot 6 #067-041-06 x2.013 lRev. 3178) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE XNEW 3 3 ❑ UPGRADE MAILING ADDRESS _ O LEGAL DESCRIPTION L !o THo mt o 5 LOCATION 2 ^� ,A. / r O NO. OF BEDROOMS O Y DISTANCE TO: Well OO /� Absorption area Dwelling /r PERMIT NO. a. Q Manufacturer /' n�£ n 61- Material No. of compartments W F I ££ a Liq. cgr�city in gallons ,, IF HOMEMADE: I Inside length Width Liquid depth _ dD Y DISTANCE TO: Well d Dwelling PERMIT NO. Z =�FQ- Liquid capacity in gallons Manufacturer 7/ Material = DISTANCE TO: Well / t Foundation I Nearest lot line 0 ." PERMIT NO.B J (`1 WNo. of lines / Length of each li e/f Total length)ines Trench width Distance between lines 1:. ... S inches Top of tile to finish grade i Material beneath the�q t— Total effective absor n/�rea /4f inches Length Width Depth PERMIT NO. W V o F Wd Type of crib rib diameter Crib depth Total effective absorption area w DISTANCE TO: Well Building foundation Nearest lot line J Class Depth Driller Distance to to bne PERMIT NO. J 3 Building loun DISTANCE TO: S w r lie Septic tank Absorption area (s) OTHER OZ PIPE MATERIALS v v� SOIL TEST RATING Ina� Is 1 Jn INSTALLER REMARKS Ul i w OF �•• �.��� .w &W q'I ti� I O. r.. Raised A. at.r •; W / P a ps O D AP V DATE LEGAL$ & E; [; Ax 2 sR8 LAS L 1c.AI E' ' £ ?I EU- C04-2179 2 x2.013 lRev. 3178) MUrJ I C I F..9L I TY OF F=fNCHL.RFiGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 'L' STREET. ANCHORAGE, AY.. 99501 264-4720 W E L L nrJ © O N- S I T E S E W E R P E R M I T PERMIT 140. C 820840 ) APPLICANT JONATHAN V HALL 1550 E.R. RD 99577 263-3403 LOCATION LEGAL L6 THOMSON LOT SIZE 999999 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING CSO FT/BR)= 115 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: OEF?TH= 11 LEFJGTH= 25 (3FZnVEL_ DEPTH= ? THE LENGTH DIMENSION IS THE LENGTH CIN 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 CIN 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 CIN FEET). REQU I REI? SEPTI C -rnNK S I ZE= 1000 GFiLLOFJS 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 <2Z> I FJSPECT I ONS FIRE REQU I REE> BACY.FILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R 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 THE DEPARTMENT WITHIN 30 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. P E R M I T EXPIRES DECEMBER :3%1_. 1 S):a 2 I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS. SIGNED: APPLICANT JONATHAN V HALL ISSUED BY cv U V4. 0 MLIN I C I PtaL I TY QF F3NCI-IQfZI�C�E � DEPfLRTMENT OF HEALTH ANO ewiRONMEwr L PROTECrion 825 'L� STRElEr, ANCHORAGE, M 991081 x abs-4?20 e! T3-�lw Pf7iM 2 T NO.. S 820840 VIPL.ICRKr JONATHAN V HAIJ` JSSLF V R RD 99577 �OCATIOM . .ErJFL LS THOMSON LAT Sim 9"m SOLJRREi FEEY TVPE OF SOIL. ASSORPTICNM SYSTEM IS: TRENCH << - 4AXIMUAM NUMBER OF BOOMS = 3 SOIL. RATING CSQ FT/9R)= LLS 'f THE REQUIRED SIZE OF THE SOIL FlGSORPTIWM SYSTEM IS: t�EPTl-ice 1.1. t_�riit3Ti-1® 25 tC3RI=iV`EL t>EPT"= T 7� i1 4@J@iH-E1iif�lSf(iM-iS-lHE'L81QTft-CZffT!'�T?HE OR COUNFLv�. i THE DEPTH OF A TRENCH OR PIT IS TDISTFi M BETWEEN THE SURFACE CF THE OROLM FIND THE BOTTOM OF THE tXY"TIOM tI" FEM. it THOW IS NO SET WIDTH FOR TRMTJCHES. THE GRAYS. DEPTH IS THE MINIMUM DEPTH OF QWfrV- BETWEEN THE OUTFAU. PIPE', -� AND THE M3OTTOM OF THE E74CYiVATiam C t" FEET). f2EQ I fx>=M� ILTf=T Z C -r""K S I .ZEA 1+0Ma0 CiALLQ?V 5` 2ERMIT APPLICANT fWa. THE RESPONSIBILITY TO INFORIi THIS DEPARTmeNr DLURINQ THE (NSTALLATIOM INSPECTIONS OF fm miais ADJtioeir TO THIS PROPERTY AND THE n OF RE`SIooces THAT THE NEU- WILL SERVE- - TLJat C � � 2 rlSf}SGT i QNS ARE t2�K�t-.s I f2E0 --! t 3fXX ILIINO OF ANY SYSTEM WITHOUT FINAL INSPECrIOM AND Aivniov T_ BY THIS ?EP'ARTMFIIT DILL BE sumscr TO PROSFECLJTIO"- "t <fftMt!?AM DISTANCE BETWEEN A WELL ANO ANY ON-SITE SEWAW DISPOSAL SYSTEM IS lk "E 180 FET FOR A PRIYATE WELL OR 150 TO 268 FEET FROM A MMIC WELL DEPEMINQ .JPO" THE TYPE OF PLIC WELL- AINiMUIM DISTANCE FROM A PRIVATE NEU. TO A PRIVATE SEWOt LINE IS 25 FEEr.Am.11 TO A COMMUNITY SPWER LINE 15 TS FEET. *X,- LOO" ARE RF{um" AND "isr ec RETURNED TO THE DEPARTMENT WtTHI" 38 DRYS 71F THE WELL. COMPLETICK )Twit REQUIRE mEm'5 ?w svwLY. sPECIFICATI4?ti HNO COMTWXTION DIFKMM MaE rMIL11BLE 70 INSURE INSTALLATION. F''EM;ZM I T C: {F? I FMS DECEMBER 31, 19it2 CERTIFY THAT I FLM FAM LIAR WITH THE Reau mEwws PoR O" SITE sf ims AND WELLS AS SET -QRTH BY THE MJ rGIPAL.tTV OF ANCHOFII9O- .7!- I UILL INSTALL. THE SVSTEIM IN ivX*RDANCE WITH THE Cooc%j wa C-^�IrIFW IrYrl IFlt Un -31M SF'31ER SYSTEM MAY REQUIRE ENAROE71ENT IF THE :CSIDE7XC IS REMODELED TO INCLLRg ?TORE THAN 3 BEDROOMS. I APPLICANT JONATHA" V HALL �! -SS ED RY 17 M r� t SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR:T J�I DATE PERFORMED: LEGAL DESCRIPTION: Is 10/-���/ 1�w� SLOPE SITE PLAN DE ZT ✓D4 VM-Nr"i�� t� I� I 1 2 ;0 O 3 �� Q .o 5 �Q t 6 b {J. 9 � 10 •- 11 a^ 12 13 ,Q 14 � •Q 15 (D• '• 16- 17- 18- 19- 20- PERFORMED s17181920 PERFORMED s s VCL,L, v�-Acjcb b2wez t IIS �16� Saban! A. S%J6 Ha 72-008 (6/79( ' k. M MM Date MIN MEMO■ Net Time Depth to Water Net ' Drop M■M■■M■M■■ E�. ■■rIO::E■w■ ■■110■NM■i ■■MUMM■M1I01 ■■`O■ME■111M ndil+��MQMO■ r, 010 I ■■■N■EMM1:1M M■MEE NSM■■ M■M■■RMNIME MMMMMM\■OE MEMEi111MM■IM Reading Date Gross Time Net Time Depth to Water Net ' Drop r, 010 PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT N FT CERTIFIED ,fipb 43rilling iEu by. DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 6882759 OWNER OF LAND �41 L c. — 4j ,4 44 /-JG'P% ADDRESS / 5-5'J t ,F' . 0(ej LEGAL DESCRIPTION 71/0'Off" ) S'240 Goi DATE • Started � Ended V r PERMIT NUMBER KIND OF FORMATION: From (-) Ft. to-2—Ft. n Qi",f A Ow fV c� From Ft. to 12 Ft. C t /•4 T rZee L From Ft. to IR Ft. 5�4•WJ From / .o Ft. to O Ft. Cl 47 - From %FromC__l_ Ft. to_7�_Ft. lila e� dc .a Y From''_Ft. to—L/—Ft. From Ft. to FL uj ld 7",'Z i2 From Ft. to Ft. From Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. MISCL. INFORMATION: J'j M g 8, .21 / r/ DEPTH OF WELL iJ STATIC LEVEL OF WATER FT. d 9 DRAW DOWN FT GALS. PER HR ./ i uv KIND OF CASING 6 Sti d D From Ft. to Ft. From Ft. to Ft. MUNICIPALITY OF ANCHORAGE From Ft. to Ft. From Ft. to Ft From Ft. to Ft Ft. From Ft. to Ft. U`L 91992 From Ft. to Ft. From Ft. to Ft. L I T n _ „LL LL.. �� LL. V From Ft. to Ft. From Ft. From Ft. to Ft. MUNICIPALITY OF ANCHORAGE From Ft. to Ft. eros r_ ` .T.I s. ENVIF.:,d:.::I..A._ :..O:ECTION From Ft. to Ft. U`L 91992 From Ft. to Ft. From Ft. to Ft._pt%. L I T n _ „LL LL.. �� LL. V From Ft. to Ft. From Ft. to Ft DRILLER'S NAME ' MUNICIPALITY OF ANCHORAGE • DEPARTMENT OF HEALTH 8 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. # �� - I'�'L1 k - r4t- HAA # V' (1C1-) C' a Sel 1. GENERAL INFORMATION Complete legal description Lot 6; Thomson Subdivision 7043 Clemons Circle Location (site address or directions) Eagle River, AK Property owner Patti Gallagher Day phone 70qg Clemon Circle Eagle River, AK .Mailing address Lending agency Day phone Mailing address Agent 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 2 XXX Day phone 786-3387 99577 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 XXX 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.M (R«.1/91) Fran MOA n1 5. STATEMENT OF INSPECTION BY ENGINEER. As certified by my seal affixed hereto and as of the validation date shown below, l 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 FirmS & S ENGINEERING —11034 gagfe River i oop Read No. 204 Phone �� Y ` `I Address Eagle River, Alaska 99577 Engineer's signature 6. DHHS SIGNATURE _ice/Approved for Disapproved. M Z bedrooms. Conditional approval for Additional Comments 7^ Date //7 /'17 OF qC ++ ?ROBERT G covam I�� j CE-UO104 bedrooms, with the following stipulations: • 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-M 0'• V91) B� MOA M wa*N _..a ,n rnLIIT W ANC}10RAQfi ENVIROty�AEMAI SERVICES D JUN 19 1997 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICESRECE I VE Environmental Services Division 825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744 Health Authority Approval Checklist Legal Description: L—L>T %Ti1pM6o4 S117 Parcel I.D.: A. WELL DATA Well type I .101J Itx)W- If A, B, or C, attach ADEC letter. ADEC water system number Log present ®N) Date completed _J Total depth 80 it Cased to i'0.14- Casing height (above ground) Sanitary seal6il) FROM WELL LOG Date of test Static water level Well production 7S g.p.m. WATER SAMPLE RESULTS: Wires properly protected 04) y(� AT INSPECTION G -i2- 3& SD t9 - P.M Coliform '1'T Nitrate MIZI -14- OtherOther bacteria Date of sample: (o ' o) ' 9 7 Collected by: B. SEPTIGHOLDINO TANK DATA Date Installed R - $ Z Tank size /Oa D Number of Compartments Z Cleanoutsa) Foundation cleanoUf 49�— Depression (YQ0 AJ High water alarm (Y/N) d1A Date of Pumping �i l D Pumper PJM/ 1..( 4 r C. ABSORPTION FIELD DATA Date li>,stalled 8 -3Z _ Soil rating (g.p.d./W or ttYbdrm) ISS System two "fia- Ae' N Length Z $ 1 Width �?. S 1 Gravel thickness below pipe 7 Total depth /a 4t/". Effective absorption area��. Monitoring Tube presen9fDN)- Depression over field (YQ r� Date of adequacy test 6 - /a ' S 7 Result Fail) %H•S For 3 bedrooms Fluid depth in absorption field before test (in.); /o u Immediately after VO gal. water added (in.): • s •� i• Fluid depth _V (ins) Minutes later: /0 OfIg Absorption rate = 467' a.p.d. Percodds treatment (past 12 months) O(ND 4 f yes, give date r, (A'• 72-026 (Rev. 3198)' D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* E. SEPARATION DISTANCES Size in gallons "Pump on" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: off" level at" VES-. yy "1�Y Septic/bolding tank on lot I Dcµwr..ts ea,K%IvT On adjacent lots loo tY Absorption field on lot loo 4 11 % On adjacent lots I b o It Public sewer main S) h Public sewer manhole%leanout 1A Sewer /septic service line 2.:t5 t Lift station Ji 1. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation .5 1 Property line h rA- Absorption field fog } i Water mairdservice line 110 1 Surface water/drainage 1 e a % Wells on adjacent lots I o o ; SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: I o µe "L � r L4 �O.SW �s Property line lo, �uildinClundation - 10 I t Water main/service line 10 + Surface water l 0 0 1f' Driveway, parking/vehicie storage area ys t Curtain drain Wells on adjacent lots ►oo a F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal recd ms are in conformance with MOA HAA guideline in effect on this date. 'C ¢ 9 h '! Signature Engineer's Name ... r COWAN �! Date 7 �i�'.'`. CE -8801 , HAA Fee S q Date of Payment Receipt Number 3 /2 72-M6 (Rev. 3/96)• Waiver Fee $ Date of Payment Receipt Number a -17-1997 1741 ME ESI ANCHORAGE 9075615301 P.04i07 • CTBE Environmental Services Inc. 973082003 Client PO# Printed Date/Time 06/17/97 13:50 Analysis S & S Engineering Collected Date/Time 06/12/97 20:00 :'roj", NIA Received DateTime 06/13/97 16:50 lb l,6 Thntnson SlD Technical Director: Stephen C. Ede ";ntri Drinking Water 10 max Order, i s 0 Released By :11'SL- 06/13/97 RAM T,tat �.. ..: Allowable Prep Analysis Results ►aL units Method limits Date Dote Init 0.966 0.100 mg/L EPA 300.0 10 max 06/13/97 SPM 0 tot/100x1 SM18 92223 06/13/97 RAM T,tat �.. ..: M Alaska Distributor COMPLETE WATER SISTL SSALES a fESVICE Jim Sullivan ARCDELL 688.2510 PUMP Po. Box 197 or SUPEagle River, Alaska 258-2510 99577 745-2510 Fax 688-2543 NWWA CERTIFIED PUMP INSTALLER N 2 8115 Payment due on receipt of Invoice unless other arrangements made. Customer Order No. Phone D eo C pleljQn Name / Address City. Description Price Amount Received In Satisfactory Condition TOTAL • Please pay by Invoice. All account Past Due Will be Charged 1 Va". $25 second billing charge THANK YOU 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 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 6 Thomson Subdivision Location (address or directions) (b) Applicant Name John Hall Telephone: Home 694-3604 Business 786-3403 Applicant Address 7793 Eagle River Road Eagle River Alaska 99577 (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Home Savings 6 Loan Telephone Address Anchorage (e) Real Estate Company and Agent Address Telephone (t) Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Familyff Multi -Family❑ Other Number of Bedrooms two (2) 3. WATER SUPPLY Individual Well Dx7Community ❑ 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 Ekx Public ❑ Community ❑ Holding Tank ❑ Note: 11 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) (-s r^ 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION [d 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 this inspection. Name of Firm Address Date Telephone Engineer's Seal This department has received written confirmation from the engineer in regards to the conditional approval of April 18, 1986. The work has been completed and inspected by the engineer(SSS Engineering) and this propery now meets with MOA codes. DHEP APPROVAL c Approved for two (2) bedrooms b Approved xxxxx Disapproved Conditional _ Terms of Conditional Approval CAUTION F@;FMAIM 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 tending 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) ISI r�, 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 264-4720 Application Date S — f? -6 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, seption, township, range) Location (address or directions) (b) Applicant Name L4 Home 690- 360V Business7e6- 5YO_T Applicant Address 1 / -7 -2 G /- A o - ^� " I (c) Applicant is (check one): Lending Institution ❑ ; Owner/buildey� Buyer ❑ ; Other ❑ (explain); - (d) Lending Institution Address _LG_�; (e) Real Estate Company and Agent Address A� b I^ E Teelleejphone (f) 10 lh HAA to the following address: �& ixd neer ng ,RHa9Ex Eegfo River, Alaska 92577 2. TYPE OF RESIDENCE Single -Family Multi -Family ❑ Other Number of Bedrooms 2 Telephone 3. WATER SUPPLY Individual Well Community ❑ Public ❑ Note: It 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. 72-025(1LBq Page 1 of 2 r n 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation dale 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 this Inspection. Name of Firm S A S Enptneering Telephone 6f//-297 9 ARB 196x Address Date WEtc GAS//VG_ AIUX7- SE' E,t!T�N060 410'CL7x �A45vv/0, m/kov, i/E/NN?r 6�le aAjv 1V66,V r 7a 7D C-41WIA-11 74F 6. DHEPAPPROVAL Approved for ���� bedn Approved _ LE Terms of Conditional Approval t Assu.e cva rt /2 'r 7z;' 43E SGcdu:�E 0 � s Cors► �oG-e 7-�cd CAUTION ,U 6-1- 3'd j4 jvz' , 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 engineers work. Page 2 of 2 72-025 11 1'811 MUNICIPALITY OF ANCHORAGE DEFT. OF HEALTH 3 MUNICIPALITY OF ANCHORAGE (MO.) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) APR 11 CHECKLIST - FEBRUARY 1984 2844720 V F Legal Description: Z"dn7 A. WELL DATA Well Classification 1�(Zt�ln�T� If A. B. C, D.E.C. Approved (Y/N) I 'li(o Well Log Present) Date Completed 8 r 87— Yield Total Depth 60, & N Cased to O ~ Depth of Grouting Static Water Level Z9 Pump Set At UK Casing Height Above Ground Sanitary Seal on Casing q1K) Electrical Wiring in Conduit Depression Around Wellhead (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot I�� r ; On Adjoining Lots I C)C' t 4 - To Nearest Edge of Absorption Field o Lot D1 ~ ; On Adjoining Lots L O c' t r To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot 30 �� Water Sample Collected by S 5 I:F ti 6 / nl q r, e/'tn- ; Date 41 918 6 Water Samplg Test Results Comments W Ww-' Mi AA7 F>? [ 1 1v "�,.�......c wn�wl 1-irf..veyr'_ G.Cow�a.11] rJG�OS fb13lL dI.ePF� TD Ey/Mi�/�-t'� TiEG� 65 r r M B. SEPTIC/HOLDING TANK DATA Date Installed 8 ' Z 6'$''Size tOO'`` No. of Compartments Z VY�Qj Standpipes4Air-tight Caps (AGN) Foundation Cleanout (Y4 Depression over Tank) Date Last Pumped Pumping/Maintenance Contract on File (Y/N)^/d ; for — �f— Holding Tank High -Water Alarm (Y/N) -JN Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: r To Water -Supply Well ( 0 v 10- To Building Foundation _t_ i r To Property Line W w -14- r} To Disposal Field To Water MeirdService Line Course Comments Page 1 of 2 72-026(M84) To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA 1 Soils Rating in Absorption Strata IIS 4I aQ Type of System Design Date Installed 8-7 �"S Z Length of Field ZS , Width of FieldN r Depth of Field Gravel Bed Thickness Square Feet of Absorption Area 3 �� Standpipes Present 6414' ri Depression over Field (FAQ Date of Last Adequacy Test Results of Last Adequacy Test .SA-J-_I.S et1,U/ Separation Distance from Absorption Field: To Water -Supply Well f D O f To Building Foundation Lot To Property Line /o / ot To Existing or Abandoned System on On Adjoining Lots 3b k r To Water Main/Service Line ZS"f To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments Check Permitted Bedroom Rating Against HAA Request •• I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed S 3 S Engirmwing Date - Company i;;;Z, _Skyy —MOA No. 85'Gls Receipt No. 2a c? 34 Date of Payment *//'V+ Amount: $ _ (,5-0-6 rMA A. SMIs Nw 14974 Page 2 of 2 72-026 (11,84) si j:.uy►1t- AAS & F•I'<f RivfN A� S.� HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER& WATER INSPECTION ENGINEERING STUDIES ANDREPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSALSYSTEM DESIGN May 18, 1986 Muni.cipatity o6 Anchoaage Department o6 HeaCth and Human Seavices 825 L Street Anchorage, Atasha 99501 ATTENTION: Susan Oswatt MUNICIPALITY 01,ANCHORAGE CEPT. OF HALTH 8 ENVIRONMENTAL PROTECTION MAY 191980 RECEIVED ROBERTA. SHAFER CIVIL ENGINEER 694-2979 REFERENCE: Lot 6; Thomson Subdivision; Health Authotity Appnova.t apptication dated Aptit 5, 1986 The xe6e><enced Health Authoaity Appnovat waa conditionat and nequiaed the weft cAaing to be extended appnoximatety 12 inches to provide minimum height abcve g)Lcuad. The g.ound needed to be stoped amy 6¢om the weft to etiminate a depaeasion. On May 18, 1986 the went was n.einapeeted and it was bound that the welt casing does extend a minimum o6 12 inches above the ground and the ground has been stoped adequatety to etiminate the deprte6sion. Request you issue a 6inat appnovat. . SHAFER, P.E. SRB 196X EAGLE RIVER, ALASKA 99577 UUP��PER��HA!�ONLY APPLKf NT FILLS OUT UPPER Property Owner JM/,/ V- 7A • i/ (GW//A�'/ CIG grft��v Phone [j (y Mailing Address Zip Code Time Buyer t^�//^* Address P 6r�� V' "\I Lending Institution / fn vwvp/ - rya�r� C �-a"1 "7 � Phone zi/ Address `�4 ¢�. ip Code95� S� Realty Co. R Agent . Phone Address Zip Code Date Legal Description God '� Street Location 3Rb Type of Residence -11� Single Family Bedrooms O Multiple Family No. of 0 Other Water Supply 'q 1 Individual LV}x,r (�� n �Jnc �LOC�i ATTACH WELL IOG. A well log Is required for all wells drilled since June 1975. log If available). ' O Community -� For wells trilled prior to that date. give well depth (attach ❑ Public Utility Inspector Inspector Sewer Disposal 'IcIndividual Year Individual Installed: 0 Public Utility When Connected to Public Utility: ❑ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Ad et2 n rzon rvan Time Time —� l� �- Time. G t t/J U Cl c Time r Date Date Date Date �s _� c - l , Inspector Inspector Inspector Inspector 1 7 I Field Notes: " (Qr �! MUNICIPALITY OF ANCHORAGE DceT Ce 1`T;f A 6 ENVIR-%1.:9t..A_ ;..O.ECTION G c C 9 1932 RECEIVED. ( APPROVED BEDROOMS- 2 v 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPR VA -e� DATE eq BY: Solis Rating Date Sewer Installed Well To Absorption Area 'E/ 00 Well Log Received Septic Tank Size Q CIO 8— g L Well to Tank -boo rzon rvan