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HomeMy WebLinkAboutUS SURVEY 3043 LT 68C T10N R2E SEC 18/19US Survey 3043 Lot 68C #075-091-07 JR 1 14 193 09:49 TC S`4S ErIGI IZ-EP I rG FPOM T. TJ : i 10'Y ST FA.O,M -eEO P. 01 i 4 Y Tj`r 1201 ISmona St. 7751 5 SIX INCH WATER WELL DRIL.L.CD .---»----+---OUT TO THE DCF'TH OF 80 feet. DRILLED AT THS RATE OF V24.000 PER FOOT, Steel c&s'ing sGetted t0 60 feet. PROPERTY OWNER r.. Paul Suver 338",975 ....� ._ __.. LOCATION OF WELL SITE Lot 68 C US DRILLER Bernie Claus of Fampart Drilling�Warks WELL LOG: 0 6' Peat (qy2 ) material. +6 42' silty gravel. 400 clay. 42 - 59' F4rdpari. A cemented grkvol. (glacial) 59 - 630 ` Silty red -brown stater mat.er:ial.`Vcry_ poor..__ 61 - 76' Cement L -d &gavel. 76 -- 60' Good tater bearitg finegrayel. i 5-E.jp�+ with_watc-r rocover_y back up t0 within 25 feHt of sur faco. Well has bvea paid for in full by •4r. i>a.ul Suver. COST INCLUDES ALL LA13OR AND MATERIAL. FOR COMPLETION OV SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR TF -IE SUM OF ----^---•--- THANK YOU VERY MUCH. 11 1 BERNIE CLAUS OF RAMPART DRILLI `4i71si2KS DATE January _21 1993 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:SW930005 DATE ISSUED: 1/26/93 DESIGN ENGINEER:DUMMY COMPANY EXPIRATION DATE: 1/26/94 OWNER NAME:SUVER REGINA L OWNER ADDRESS:8010 OLDSEWARD HIGHWAY PARCEL ID:07509107 LEGAL DESCRIPTION: US SURVEY 3043 LT 68C LOT SIZE: 14790 (SQ. FT.) NUMBER OF BEDROOMS: 2 THIS PERMIT THIS PERMIT IS FOR THE CONTRUCTION 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 343-4329 OR 343-4681 AFTER BUSINESS HOURS 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: THIS PERMIT IS ON 1/02/93. THE RECEIVED BY: A WELL DRILLED ON THE SUBJECT LOT ISA IN THE FILE. DATE: ( �on I ISSUED BY:� DATE: ,/2 '4_/,f___� w A Of Pa OT IM 7Z.4G N.JS43E N i m p rr 0 � N r H I� :? Fi��f .G1./.✓H f is Gir✓wed I •r I m p rr I� I •r I e m p rr e 9PL4N5 MUNICIPALITY OF ANCHORAGE Development Services Department �� Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 075-091-07 1. GENERAL INFORMATION Complete legal description USS 304E Lt 68C Location (site address) 144 Beirne Street Expiration Date: 3 — Ig `20Z 0 Current property owner(s) Lara Jesic Lawlor and Jacob Hayes Day phone 503-407-7761 Mailing address PO Box 1598 Hood River, Oregon Real estate agent Erin Eker, Ski to Sea Properties Day phone 907-230-7266 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well El Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer Q Waiver request for: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ Sj'Q Date of Payment Receipt Number. COSA # Q Sr 191s9I 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. 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. I acknowledge that On -Site staff may visit the site to verify the information submitted. Name of Firm Restoration Science & Engineering, LLC Phone 907-278-1023 x108 Address 911 West 8th Ave, Suite 100, Anchorage, AK 99501 Engineer's Printed Name Neil Waggoner Date 12/13/19 OF A4QsA� 6. DSD SIGNATURE •49 TH 16 System #1 Approved for 2 bedrooms System #2 Approved for bedrooms NEIL D w ........... • • • • • • • • • •AG. GO•N ER , �. • Disapproved ¢$ �cSj• _ Z 14704 Conditional approval for bedrooms, with the following stipuil tj�r��.-FESS`13 �j F. NVC GccooVA% J J a1 1 R.1 1 By: Original Certificate Date: 2= Lg — 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 Legal Description: USS 3043 LT 68C If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 101993 Total depth 80 ft Cased to 80 ft ❑ Sanitary seal is functioning correctly ❑ Wires are properly protected Casing height (above ground) 16 in. Date of flow test for COSA 11;26119 Static water level at beginning of test 39.1 ft. 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 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 Comments/Deficiencies: COSA Checklist yellow sheet Parcel ID: 075-091-07 Structure served by this system Well production at time of test 6.8 gpm Water storage tank volume gallons Well disinfected for coliform test? ❑ Yes ❑ N ❑ Coliform bacteria is Negative Nitrate 0.395 mg/L ❑ Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by N. Waggoner Date of Sample 11/26/19 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: 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 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 Community Sewer Manhole/Cleanout > 100' ❑ Yes if No ft ✓Q Yes if No ft Neighboring Tank > 100' ❑ Yes if No ft Private Sewer/Septic Line > 25'F,/71 Yes if No ft Absorption Field on Lot > 100' ❑ Yes if No ft Holding Tank > 100' ❑ Yes if No ft Neighboring Absorption Fields > 100' if No ft Animal Containment > 50' ❑ Yes if No ft ❑ Yes if No ft ft If septic tank is under driveway comment below Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' M Yes if No ft ❑ 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 Surface Water > 100' ❑ Yes if No ft Property Line > 5' ❑ Yes if No ft Wells on Adjacent Lots: ❑ Yes Absorption Field > 5' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Main > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Water Service Line > 10' ❑ 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 If absorption field is under driveway comment below Property Line > 10' ❑ Yes if No ft Wells on Adjacent Lots: Water Main > 10' ❑ Yes if No ft Private Wells > 100' ❑ Yes if No ft Water Service Line > 10' ❑ Yes if No ft Community Wells > 200' ❑ Yes if No ft Surface Water > 100' ❑ Yes if No ft F. ENGINEER'S COMMENTS Per MOA Onsite Files, Sewer main is 11 feet northeast of edge of property sewer easement. From as -built well location, sewer main is approximately 80 feet northeast of the well. 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. COSA Checklist yellow sheet OF A.4 4 P" � • «sail d +a«s«a««s«asss.+s aa�yrws.• •«««ds«:♦asrsers•saa« NEIL D WAGGONER cP« « low �'# 4FESSIA.,�. lu_. �. •' � Q � � �� r; ••h �: bpd � ,� 1 �� Y. •�,�LLI { ' � Y NI i�Yi' 7lC.i�jr1 • is*: a '1.'t .�1 m <� a0<` d m .13-l-1tf 91cuuoN ID)JUOO ;o u01#000-1 MoyS yalaiS 4e u01io30-1 aui't DOiAJ@S ,AIH3d0ad NO,, sluawwo:) 133a1S H O z w f— Q U Z SUBDIVISION: �� BLOCK: LOT: lf6 3 i I i I 1 r �l a 1 v S7U6 ou% f i dK�� g fT f I Al N -1 LINE: SIZE MAIN: " TYPE MAIN:_D /,P DEPT AT MAIN: 8' JET CONNECT LOCATION: S7 -a6 owl' i o o ' G O f COMMENTS: oa! fit -r ft S.- o /V H ee- INSPECTED BY: 2)cp DATE: o -,�G -9 � r�'.wm.c,:c�r.�... a:ir jo-7-6--79 SU!5DjN,'jCT(jz,' Ell I Y i 1, T S: 7?j I Municipality of Anchorage Development Services Department Building Safety Division Onsite Water 6 Wastewater Program 4700 South Bragaw SL P.O. Box 196650 Anchorage, AK 99519-6650 www.d.enchorage.ak.us (907)343-7904 �Ae CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 0 7n 6/ 'bq1' b1 HAA# 105WH 1. GENERAL INFORMATION Expiration Date: Complete legal description U.S.S.3043• LOT 68C -1-1014 R2C Srt (8liq Location (site address or directions) BIERNE STREET + GIRDWOOD. AK 99587 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address KELLY HASTINGS Day phone 783-2231 (AGENT) c/o SCOTT KIRK w/ GIRDWOOD REALTY Day phone SCOTT KIRK w/ GIRDWOOD REALTY Day phone P.O. BOX 376 • GIRWOOD, AK 99587 Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 2 .3. TYPE OF WATER SUPPLY: Individual Well 0 Individual Water Storage ❑ Community Class Well ❑ Public Water System ❑ 783-2231 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 served by a single-family on-site wastewater disposal and/or water supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my Investigation, based on procedures outlined In the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system Is(are) safe, functional and adequate for the number of bedrooms and type of structure Indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage riles and from my investigation and Inspection, the on-site watersupply 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 GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179 Address 3701 E. TUDOR ROAD, SUITE 101 a ANCHORAGE. AK 99507 Engineer's Printed Name JEFFREY A. GARNESS, P.E.Date S 0 Engineers Comments: In conducting this evaluation, GEG, Ltd. attempted to provide a thorough, dodgy conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines d Regulations. c Q F Q �C� " ' The reported results described the performance of the • • Si40� system under the conditions encountered at the time of the test, and separation y* distances measured to readily identir lable features. The operational life of all wells and �0���' 4 N septic systems depend on the local soils condition, groundwater levels that may 0 ....:... ..............:... Iluctuate during the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test .. .... .......... ..... results do not guarantee future performance of the system, nor do they guarantee that y A. me QQ there are no hidden defects or encroachments. GEG, Ltd. can therefore not provide any warranty or future estimate of how long the CE 7 53 e �Q 3�S�OS. system will continue to meet the e •. operational requirements of the ADEC or MOA DSD. The content of this report Is for d1' ° the sole benefit of the owner listed above. Any reliance upon or use of thls report by any roresato^oma 400p000� other person orparty is not authorized, nor will it confer any legal right whatsoever. 5. DSD SIGNATURE .__Iz Approved for e� bedrooms. Disapproved. `�kl OF tAN Clj& r r Conditional approval for bedrooms, with the following stioajlons.' v• S �� Qom' ' • • . • • �•w`^ Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Byl ()'A - U \ 1 ` Original Certificate Date: *0 _ (Rw.17101) Municipality of Anchorage Development Services Department Building Safety Division On-SRe Water 8 Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519.66W www.d.anchcrage.ak.us (907)343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST -rlolu Ras nut\,'. Legal Description: U.S.S. 3043: LOT 68C. _ Parcel ID: (Y1r% -CA I -b'f A. WELL DATA Wee type PWATE If A. B, or C provide PWSID# N/A Date completed 1/2/1993 Sanitary seal (Y/N) YES Total depth 80 ft. Cased to 80 ft. FROM WELL LOG Date of test 1/2/1993 Static water level 25 ft. Well Log (YIN) YES Wires property protected (YIN) YES Casing height (above ground) 12+ in. AT INSPECTION 3/3/2005 41 ft. Well production 15 g.p.m. 6.47 g.p.m. WATER SAMPLE RESULTS: �A Coliform Q colonies/100 mi. Nitrate Q24 , mgJL. Other bacteria _-6,cokmies1100 ml. Arsenic: N/A mgJL. Date of sample: 3/3/2005 Collected by: GEG, UD. S. SEPTICIHOLDING TANK DATA Tank TypelMaterfal Tank size gal. Foundation cleanout (YM) C. ABSORPTION FIELD DATA Number of Compartments Pumper PUBLIC SEWER Date installed tank (YIN) _ High water alarm (YIN) Date installed Sod rating (g.p.dJft'or ft'Ibdrm) _ System type Length ft. Width Gravel bbclowrVp'e ft. Total depth ft. Eff. absorption area_ ft' Monitorin bei Depression over field Date of adequacy testRes ss/Fall) For bedrooms Fluid depth in absorption field be _ in. Water added _gal. New depth _in. Elapsed Time: n. Final fluid depth _ in. Absorption rate >= g.p.d. treatment (past 12 mo.) (YM 6 type) If yes, give date 0. uFT STATION Date installed "Pump on" level at _in. E. SEPARATION DISTANCES Size in gallons High water alarm level at Cycles tested Meets alar & circuit requirements? SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot N/A Absorption field on lot N/A Public sewer main 075'+/— Sewer /septic service line 25'+ On adjacent lots 100'+ On adjacent kits 100'+ Public sewer manhole/deanoul 100'+ Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Surface water SEPARATION DISTANCE FROM ABSORPTION FIELb ON LOT TO: Property line Building foundation Water main Water service line Surface water rveemy, parkingtvehide storage Wells on adjacent lots F. COMMENTS 'SEE ATTACHED G. ENGINEER'S CERTIFICATION I certfy that I have determined through field inspections and review of Municipal records that the above systems are in """" ' conformance with MOA HAA guidelines in effect on this date. . ..................... ey A. Gamess: Engineer's Printed Name JEFFREY A. GARNESS 753' Date31'�1Q� �e� HAA Fee a 430 F ��uRu519 Date of Payment 1�-u( Receipt Number C)i41In3j (nw. 1vo1) Waiver Fee E Date of Payment Receipt Number GARNESS ENGINEERING GROUP, Ltd. CONSULTANTS & GENERAL CONTRACTORS March 8, 2005 Municipality of Anchorage Development Service Department Building Safety Division On -Site Water & Wastewater Program P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref: II.A.A. for U.S.S. 3043; Lot 68C. To whom it may concern: On 3/3/2005 we performed a site visit to conduct a well adequacy test for an H.A.A. It was noted that the sewer main runs along the north property line. Since the sewer main is below grade there is no way to physically measure the distance to the well. We obtained the as -built drawings for the sewer main from AWWU. Per the AWWU as-builts and the as -built survey of the well it appears the well is approximately 75 feet from the sewer main. To accurately measure the distance the sewer main would need to be exposed. We request you issue an HAA for this property. If you have 41questions, please contact us at 337-6179. Thank you for your assistance. P.E., M.S. 3701 E. Tudor Road, Suite 101 • Anchorage, AK 99507 Ph: (907) 337-6179' Fax: (907) 338-3246' Website: gamessengineering.com _..- .� ��`io � j p� /may• '91Qi�+%�'! M /M� y tVtp i gC 6. v v' �aM m � wn'an Ne$b O ;gyp %V • •�� b o cs r I gym• ua' �• t[m torn uraeunw r L LOcn w o- ,pi [. .Yr1r n... [. L.p m w. r• cm^� sI 4 Yt M1ew•r• wr IL Ce...r q r!L f..l _1f� }I M SN2lhNAA }O tlatr /.naA ,l �tlb 0 t.GO IMO 0. GI Vw=- ALYESKA COLLECTION SYSTEM PLAN AND PROFILE r rr 4 >32 Municipality of Anchorage �. Department of Health and Human Services j Division of Environmental Services l:,t On -Site Services Section 825 "L' Street Room 502 P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FORA SINGLE FAMILY DWELLING Parcel I.D. 075-091-07 HAA# Expiration Date: 1. GENERAL INFORMATION Complete legal description Lot 68C, US Survey #3043 Location (site address or directions) Current Property owner(s) Mailing address Lending agency Mailing address NHN Beirne Street Leslie Sturm PO Box 931, Girdwood, AK 99587 Day phone Day phone 783-1389 Real Estate Agent Remax/Dave Bauer Day phone 783-2010 Mailing Address PO Box 1029, Girdwood, AK 99587 Unless otherwise requested. HAA will be held by DHHS for pickup. HAA picked up by: 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Well Public Water System TYPE OF WASTEWATER DISPOSAL: Q Individual On-site ❑ ❑ Individual Holding Tank ❑ ❑ Community On-site ❑ ❑ Public Sewer .LCI The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates cf Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independen: professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served b% a private or Class C well and may be reissued with new water sample results less than 30 days old. Certificates_ are valid for one year for properties served by Class A or B wells or a public water system. The Municioal&, of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72 025 (Rev 01 ACID 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 Health Authority Approval Guidelines for the Health Authority Approval application show 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. 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. 5 & 5 ENGINEERING Name of Firm 17034 Eagle River Loop Road No. 404 Phone c/ 7 C% Eaulc River, Alaska 99z// Address Engineer's Printed Name Robert C. Cowan Date /0//6/00 6. DHHS SIGNATURE 1/ Approved for oZ bedrooms. Disapproved. Conditional approval for Additional Comments 1% ^�\1 C^..'./MT C. COWAN IF W �ft\(• • J I� \\ bedrooms, with the following stipulations. Attachments: HAA Checklist Maintenance Agreements Septic System Advisory Supplemental Engineer's Report Well Flow Advisory Other 8 : GJ. zeo-� Original Certificate Date: In -/ -C 0 Expiration Dater _ - / £? -(/ Reissue Date: 72029. Rev 0100)* Municipality of Anchorage E C E V • Department of Health and Human Service Division of Environmental Services On -Site Services Section 625 "L" Street Room 502 OCT 1 7 2000 P.O. Box 196650 Anchorage, AK 99519.6650 www.ci.anchorage.ak.us (907) 343-4744 MIUNIWAUT( OF ANCHORAGE GUIRONMM AL SERVICES DMSION HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: 107' G$ C U. S. SU A V e- y 30 'f 3 Parcel I.D.: 07S--09/-- 07 A. WELL DATA Well type PR'JA 7 E If A, B, or C provide PWSID # Well Log Yt l Date completed 11aA3 Sanitary seal Yt S Wires properly protected yt J Total depth 8 O It Cased to JIt Casing height (above ground) ' 2 t in. FROM WELL LOG AT INSPECTION Date of test / �` 3 /* 1 a /d o Static water level It y O It Well production I S g.p.m • 3 f 9•P•m WATER SAMPLE RESULTS: 1-'n �rao 0 y ?Jn -4 4 /�L vM9w G Collform D colonies/100 ml Nitrate ©- S mg/I Other bacteria 0 colonies/100 mi Date of sample: /o "l°� Collected by: s & s ENGINEERING 17034 Eagle Rhar Loop Rad No. 204 B. SEPTIC/HOLDING TANK DATA Pun �— S4wEl� Eagle Ithar, Alask.99S77 Tank Type/Material Date installed Tank size gal Number of Compart Cleanouts Foundation cleanout Depression over tank High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d. or ff2/bdrm) System type Length ft Width Gravel below pipe ft Total depth ft Effective rption area ft2 Monitoring tube Depression over field Date of adequacy t:rption Results (Pass/Fail) For bedrooms Fluid depth in field before test in Water added gal. New depth in. Elaps Ime: min Final fluid depth in Absorption rate >= g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date 72-028 (REV. ot/W D. LIFT STATION Date installed "Pump on" level at Size in gallons Manhol ess--' in "Pump ofP le in High water alarm level at in _ Cycles tested Meets alarm & circuit requirements. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot "r 14 On adjacent lots AJ AA Absorption field on lot N �A- On adjacent lots /V 1A Public sewer main 7 S Public sewer manhole/cleanout /O0 Sewer /septic service line — i Holding tank Al 14 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Property line A on field _ Water main Water service line Surface water Drainage Wells on nt lots SEPARATION DISTANCE FROMPT ION FIELD ON LOT TO: Property line Building foundation Water main Water Servi a Surface water Driveway, parking/vehicle storage Cu n drain Wells on adjacent lots F. COMMENTS G. ENGINEER'S CERTIFICATION �,�........... I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. .. �C d a f cT C . Cp wh, ROOM C. COWAN Engineer's Printed Name •ti CE .8801 Date /o f/ b foo <; HAA Fee $ �fb • ®`� Date of Payment ID -17-000 Receipt Number 72026 (Rw. Otroo)' Waiver Fee $ Date of Payment Receipt Number ,'; gin, _ _ _ : - ►i3 -�D MUNICIPALITY OFANCHORAGE ' 'i ` //•���.!\+\� DEPARTMENT.OF HEALTH & HUMAN SERV16ES �_Divialon of Environmental Services -Cry is M w� - _ On-Site Services Section ----.. _ P.O: Box 198850 Anchorage. Alaska 99519-8650 - t 343-+1744 EOFHEALTHAUTHORITY LJ.�-:,•y.;,."-10ERTIFICAT, - APPROVAL FOR A SINGLE FAMILY DWELLING - Parcel L-6.4 M Dq (-0'1 HAA 0 • 14A gS'0090 :.1. GENERAL [INFORMATION."= Complete legal description Lot 68C; U S. Sunv¢y M3043 Location (site address or directions) KHN Bo inn¢ Stic¢et G•ih.dwood, AK l n B o+iflvf Da hone 263-0739 (w) erty z %Propowner Y P +, . _. Mailing address '-;4820 W. 88th Ave. Anchorage, AK 99502 .: _._.__ R .Lending agency *"' Day phone v Mailing address Agent Day phone r Address 4 s'ro Unless otherwise requested, HAA will be held for pJckupIt e— - 7v _2. NUMBER OF.BEDROOMS V'2 F"rf v .: .._ r :: > t 3. +� TYPE OF WATER SUPPLY _- —rn —Individual well Community well Public a ;;!NOT If community well system, provide written confirmation from- to t ;fir" 1n to the IegalJty and status of system 1 94 4 TYPE OF WASTEWATER DISPOSAL. `;� • p�\� : . Individual on-site, ^ _ L� ..,._._ 7S"•. �-''�', .. " - - '.." y �.. i. SRM ri , 3t ��.: Holding tank - t, v„.. �,' ,. r,c� +.� «a 1l hir . tt tofT cr �s ,i ,. qtr K^:�i• +, - • Community on-site :Public sewer XXX s '' h••r , ��.: �! � [S ZIJh <, ,,-J ,a ,M, Cfs1 nli-/i, '. - ! t_,•7 nP_1 :'sb R`t-. ,r. _:_: L.._F. {•f 1a,� ✓r .�:1.•-.. ._ n, <,..+. _:..� .:,...., y .., :.u..i•• : � r v.. -NOTE: s .lf community wastewatertsystem, provide written confirmation. from State ADEC. , .. _.�,.. „ o- •r<a a u, attesting to file legality and status of system �. v .,rrmeln...vn� ►•mi:MOA at 5. STATEMENT -OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of thevalidation date shown below, l verity that my investigation of this Health Authority Approval application shows that the ort -site water supply^. =• and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms" i and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my Investation and inspection, the on-site water;:; supply and/or wastewater disposal system is in compliance with all Municipal and State codes, 1. ordinances, and regulations in effect on the date of this inspection - Name of Firm Phone. 6g `f —)-9 79 a Tver 17034 Eanlo r 404Address _ ^=e•. -. _ Eagi s Riva — Engineer's signature 4 Date O q ,✓ C , • S� i �j R02ERT C. COI •v ,W CE -8801 & -DHHS SIGNATURE ft l� JF�rc Approved forbedrooms..74 o1 �y6,r.. 4 Disapproved." - ,4,i Conditional approval for =`= 'bedrooms, with. the following stipulations: 7771 tAaditionai N� TV Th a 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 federaland state requiroments. Employees of DHHS do not ,conduct Inspections or analyze data before a certificate is Issued. The Municipality of Anchorige'is*not responsible for errors or omissions in the profasskmal anmeets work: g , ,^,omments + ,4,i .,. 7771 Date ...� 4..L3 Th a 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 federaland state requiroments. Employees of DHHS do not ,conduct Inspections or analyze data before a certificate is Issued. The Municipality of Anchorige'is*not responsible for errors or omissions in the profasskmal anmeets work: g , Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description:/ r r 68 'A,.S, SwzAASParcel I.D. A. Well Data Well type -ri2_IUATE If A, B, or C, attach ADEC letter. ADEC water system number Log presentOtY J) ij5S Date completed I - ? – 93 Driller &imz aiwt,,�, Total depth 60' Cased to g0 Casing height Sanitary seal (Y/N) EC, Wires properly protected&) Ya FROWELL LOG Date of test Static water level Rs' - Well flow 15+ —9 -P.M. Pump levell 010K1 SEPARATION DISTANCES FROM WELL TO: o z Septiciholding tank on lot PJ 4 ; On adjacent lots /oo F Absorption field on lot AA ; On adjacent lots Public sewer main > Public sewer manhole/cleanout Sewer service line Ve, + Petroleum tank (A6rot= ltj c .�, B. WATER SAMPLE RESULTS: Coliform tea -"pp Nitrate�L Other bacteria –19— Date of sample: 1 '4's- 4 1 � A5 Collected by: SA S EMUr F-Rlry,- DATA Date installed t4 Cleanouts(YIN) Tank sae cleanout (Y/N) High water alarm (Y/N) pian Date of pumping umi SEPARATION DISTANCES FROM SE OLDING TANK TO: (YM) Well(s) on lotOn adjacent lots Foundation � To propel Absorption field Water main/service line water/drainage 72-MP93)•Fmnt _ - CONTINUED ON BACK PAGE AT INSPECTION rn -' m v. q6 14 m v �C SEPARATION DISTANCES FROM WELL TO: o z Septiciholding tank on lot PJ 4 ; On adjacent lots /oo F Absorption field on lot AA ; On adjacent lots Public sewer main > Public sewer manhole/cleanout Sewer service line Ve, + Petroleum tank (A6rot= ltj c .�, B. WATER SAMPLE RESULTS: Coliform tea -"pp Nitrate�L Other bacteria –19— Date of sample: 1 '4's- 4 1 � A5 Collected by: SA S EMUr F-Rlry,- DATA Date installed t4 Cleanouts(YIN) Tank sae cleanout (Y/N) High water alarm (Y/N) pian Date of pumping umi SEPARATION DISTANCES FROM SE OLDING TANK TO: (YM) Well(s) on lotOn adjacent lots Foundation � To propel Absorption field Water main/service line water/drainage 72-MP93)•Fmnt _ - CONTINUED ON BACK PAGE &Ueo UFT STATION`'n Date Irisi2N /ed /T Size in Vent (Y/N) High water alarm levet Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: (Y/N) 'Pump off' Level at tested Well on lot On adjacent lots Surface water ABSORPTION FIELD DATA Date Iled N Soil rating (GPD/Ft=) System type Length Total absorption area Date of adequacy Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Gravel thickness Total depth present (Y/N) Depression over field (Y/N) (passlfaii) for Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot On adjacent lots To building foundation yes, give date line To existing or abandoned On adjacent lots Cutbank Water main/service Surface water Driveway, parking/vehMe storage area Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and NAA guidelines in effect Signature 1/Y�°✓' el" ^ Engineer's Name /rdQfA7— C Cov/1,�J Date ! /& 9 r HAA Fee $�-. U Date of Payment /ll2�-p Receipt Number_-lva'lo�Doo�J 72-M (993)' Back of this inspection. nip ROBERT C. COVJAN CE•CCO1 Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH 6 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. # 411`x"c) I 1. GENERAL INFORMATION HAA# 4 Q5'1)(10Q1n Complete legal description r ntr gar- 60 n_c_ 511r rey Ina Location (site address or directions) NHN Bernie Street, Girdwood Property owner _Regina r._ SL1oer (Paul Suver) Day phone 338-1975 Lending agency 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 Day phone: 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. 72-0251R•v.1/91) Front MOA021 cc.A l 5. 6. in STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm S & S ENGINEERING Phone 17034 Eagle 9MVer Loop Road No. 204 Address Eagle River, Alaska 99577 Engineer's signature DHHS SIGNATURE Y Approved for 2--. bedrooms. / Disapproved. Conditional approval for I. Additional Comments Date 1-1 4-9 S bedrooms, with the following stipulations: Date /A 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 engineers work. nms (Rw. 1/91) eK■ MOA 821 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: / CST SURVEY _7,U13, Parcel I.D. A. WELL DATA Well type 11SUA-75 If A, B. or C, attach ADEC letter. ADEC water system number AIN _ Logpresent&N) YES Date completed Driller Driller 7 Total depth —Casedto-00 Casing height �2 Sanitary seal &N) � Wires properly protected (VN) Y i FROM WELL LOG Date of test /f Zlq 3 L'�S �f7-boJ WATER SAMPLE RESULTS: / Coliform olL0o 14 L Nitrated O. 10 'M K `A /./ D3 Other bacteria 0� 0,04 Date of sample: J I ll3 Collected by: S SC�-2/N�► SEPTIC/HOLDIN9 TANK DATA C1RJJE17 Date in edTank size Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) D ssion High water alarm (Y/N) Date of pumping — SEPARATION DISTANCES FROM Wells) on lot To property 11 Surta ate 72-026 (Rev. 7/91) Front Alarm tested (Y/N) G TANK adjacent lots field Watermain/service (Y/N) CONTINUED ON BACK PAGE ' 2S5r, S c Static water level Well flow /S+ g.p.m. g.p.m.m z 71`1 g Pump level �w'U o LL TO: SEPARATION DISTANCES FROM•• o IW N rrrI c,+ Septic/holding tank on lot ; On adjacent lots Absorption field on lot Ai ; On adjacent lots Public sewer main �S Public sewer manhole/cleanout Sewer service line 3rJ r fi Petroleum tank NONI= f�/lkXclnl WATER SAMPLE RESULTS: / Coliform olL0o 14 L Nitrated O. 10 'M K `A /./ D3 Other bacteria 0� 0,04 Date of sample: J I ll3 Collected by: S SC�-2/N�► SEPTIC/HOLDIN9 TANK DATA C1RJJE17 Date in edTank size Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) D ssion High water alarm (Y/N) Date of pumping — SEPARATION DISTANCES FROM Wells) on lot To property 11 Surta ate 72-026 (Rev. 7/91) Front Alarm tested (Y/N) G TANK adjacent lots field Watermain/service (Y/N) CONTINUED ON BACK PAGE C. LIFT STATION Date installed A Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pum on" level at . ( P "Pump off" levet at _ D. High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots FIELD DATA T catU.tC Date,installed`K Length i< Total absorption area Depression over field (Y/N) Results (pass/fail) sa,zp, — Cycles tested Surface water Soil rating System type Gravel thickness Total Cleanouts present(Y/N Date of ade cY test for Peroxide treatment (past 12 months) (Y/N) ) SEPARATION DISTANCE FROM ABSORP N FIELD TO: Well on lot To building foundation On adjacent lots-- Surface ots Surface watei Ow ain drain E. ENGINEER'S CERTIFICATION n adjacent lots If yes, give date To existing or abandoned syste on lot Water main/service Driveway, parking/vehicle storage area 1 certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect S & S ENGINEERING i`j,�Q�, Signature »034 Eagle River Loop Road No. 204 ,. .49 Engineer's Name Date i — —`�'� I M , Ro t HAA'Fee $�% r� Waiver Fee: $ Date of Payment� .J� Date of Payment Receipt Number 2 S 3 Receipt Number 72-M (A". "I) Bwk MOA 21 bedrooms ;.40%%`of this inspection. OF 441. %a 1«. .04A«.1.09 ERSHAFER w% No. 215