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HomeMy WebLinkAboutNOLAN LT 55AO'-/d- ?? ,.s-o-' A P-Srmit .~ Location: ~eqal ~escription..:~ ~E~. 3o~ Type of Soil Absorption SyStem Is: Trench: Drainfield: Maximum Number of Bedrooms': Department '~-~ikh-~nd Environmenta~ ?rotection 825 ~ Street, Anchorage, AK. --~950! ' 264-4720 * * * HANDWRITTEN PERMIT * * * ~'3©8~(ELL A~:.:- .... ~~R PERMIT C~ Mailing Address: ~ /~, r~'~~ Phone Nu~er: ~3 -2 ?~ Zo/~g~) ~o.t .Size: seepage Bed: Holding Tank: Soil Rating(sq.ft/br) The Required Size of the Soil. Absorption System Is: DEPTH ~[A-- LENGTH M2//~_ GRAVEL DEPTH ~//~- WIDTH 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). ~J/2~ * * REQUIRED SEPTIC(HOLDING) TANK SIZETM 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 p~ivate 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. .O~her requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * * 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 codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more that 3 bedrooms. Signe~: _..Issued by: /~//~~~~~c: Applicant ~ Date: ~/~3 SWP/024(1/81) ~l:-~-t.~_~: ~ ~..:ai.u~i~l~i. ~ - .:. _--' ~. , p~ivate ~ell o~ 150 to 200 feet f~ a ~bli~ ~tt de~ndtn~ u~ thc ~ '. <:.:.:?':.::- -:-. _; *~-OCAT,O~ o~ WELL -.J WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological LA Geophysicol Surveys DISTANCE AND D~RECTION FROM ROAD INTERSECTIONS Address end Aroo of Well Location Street Top soil Dry gravel Wet gravel Clay Dry gravel Wet gravel water :included ENVIRONME Section [ EC 16. WATER WELL CONTRACTOR'S CERTIFICATION: 0 10 37 40 40 43 43 59 59 70 OF ANCHO ),AGE EiVE - Addross: BOX 143 Davos Rdo GJ.:cdwo od ~ Ak, 99587 5. DATE OF COMPLETIOH 9 .- _}__ - 82 4. WELL DEPTN: (final) 70 6. ~--~Cable tool ~jRotory {~Ori¥~n D A~r g3 a~t,e~ ~ Bored O Otho~: 7. UBE;;~ Oomeetic [~] Public Supply [~ Industry ~] Irrigation ~.~ B~¢hargo ~J Cor,~m~ric~, ~_~ Test Well r~ Olhor: Threaded ? --. ~t. Dopth Woi§ht ~-- lbs./ft. __ Diameter: 6 Length :. ff. and ft. Grovel pocJ~ 9. FIN1SH OF WELL: Type: O-oen Hole I0. STATIC WATER LEVEL: ft. [~J Above or ~-~ Below lend ~urfoce Equipment usod: II. PUMPING LEVEL below lend surface and YIELD _____ft. ofter____hr3, pumping ft. offer hrs. pumping 12.GROUTING Well Grouted: ~.] Yes L~ No h{aterlal: [] Neat Coment ~j Other: I~. PUMP: (if available) HP~-/~ Length of Drop Pipe 60 ft. capocity X~ Subm. ~ Jul ~ Centrifico, Date REMARKS: Bail tested_ at 50 GoPoM~ Magnuson Drilling AA 538~ Add .... :PoO. B~504 Eagle ~iver, _Ak~ 99577 Aufh'~rlzed-~t~'~'~re'sent°live/ ~ oot.:_~_, 6~ 1982 Form OZ-WWR (11/81) Copy Oislribution: WHUi'E-StoIe OGGS, PINK-OriHer, CANARY-Customer POUCH 6-650 ANGHOP, AGE, ALASKA 99502 i)650 (907) 264-4111 DJ[PAR] MEN] OF HF/'\[ [Ir ,,:',Ji) ENVIRONNIEN i'AI I~I~:OTECTION <Permit ~: 820819 ,January 31, 1983 TO: Permit Applicant Subject: Tract55A USS ~ 3044 G.irdwood Small Tracts A permit issued by this department for an individual well and/or on-site sewer system has expired as of December 31, 1982. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log needs to be sent to this department for documentation of the installation date and to close the permit. If a private engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files and documentation. If there are any further questions, please call this office at 264-4720. Sincerel~ Robert C. Pratt, R.S. Acting Program Manager Sewer and Water Program RCP/ljw enc: Copy of Permit SWP/057 PERMIT NO. DEPARTMENT ( HEALTH AND ENVIRONMENTAL ]TECTtON ,.,°~"=~, -'i~-~iSTREET.. ANCHORAGE, ..... AK. '~.9.~-~1 2e';4-4720 PIE~ L F'ERMIT 8208t9 ) APPLICANT LOCATION LEGAL W. & H. NOLAN BOX 14~ GIRDWOOD 9958? MUST BE USED WITH APPROVED SEPTIC SVST USS#3044 GIRDWOOD SMALL TR 558 LOT SIZE 78~-29~9 999999 SQUARE FEET 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 8 COMMUNITY SEWER LINE IS 75 FEET. ' WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'EF-:r-1 I T F:=-~F' I F-:ES E'.EC:Er.IBER _?-:L.. I CERTIFY THAT l: 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. SIGNED: __ APPLICANT W.~ NOLAN .... V4. 0 • � GG QG • Municipality of Anchorage 6 7 8 9 On-Site Water and Wastewater Program )). (907) 343-7904 ,. - SA ETY MAR 012n UM Certificate of On-Site Systems A oval t2Parcel I.D. 075-061-78 Expiratio �- • $ •°'• . 1. GENERAL INFORMATION: Complete legal description Nolan; Lot 55A Location (site address) 110 Glacier Creek Dr.*Girdwood,AK 99587 Current Property owner(s) Sam Daniel Day phone 783-1910 Mailing address 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 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual ❑ Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer WaiverNariance request for:.` �] Distance: � Received by: Date: j/A.PS COSA to be released to the engineer,unless otherwise requested by the engineer. COSA Fee $ 5-.i Waiver Fee $ Date of Payment 3/9-/I7 Date of Payment Receipt Number Cite)9 6166 Receipt Number COSA# O SC I S/Otolo Waiver# 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my sealxed hereto and as of the validation date shown below, I verify that my investigation, based on procedures gained in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-sitaswater supply and/or wastewater disposal system is (are) safe, functional and adequate for the n@Imber of bedrooms i.n#type of structure indicated herein. I further verify that based on the information obtained from the Municipality bf 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: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road,Suite 101-Anchorage,Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: 3 Y(i( e 0 000000�,� In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system OF A j %%1 in accordance with the guidelines and regulations established by the Municipality of Anchorage and ,.• •• industry practices. The reported results describe the condition of the system/s on the date/s of the 0 1� r� o 0 evaluation. Separation distances were measured to readily identifiable features. Hidden defects or * t Il�� ••�00 encroachments may exist that were not identified during the evaluation. The operational life of all wells g and septic systems depend upon a variety of variables, including but not limited to, soil conditions, /••••.••• •••,••• VA groundwater levels (that may fluctuate during the year), quality of construction (materials and 2VA workmanship),and the water usage of the family utilizing the system/s. These conditions can vary,and Q are outside the control of GEG. Satisfactory test results do not guarantee future performance of the Q J:ff :y A. arne-s. system/s;therefore, GEG makes no warranty(express or implied) regarding the future performance of Q� / CE 7 53 the well or septic system. GEG makes no representation whether an alternative well or septic system (i s .Cb0 can be installed on the property in the event either of the current systems fail to perform adequately in (I��o -3.14133.. pr the future. The content of this report is for the sole benefit of the person/party that retained GEG to aofesslon°oo perform the evaluation. Reliance upon the information provided in this report by any other person or ��OOOoo�� party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. #AECC884 6. DSD SIGNATURE , System #1 Approved for `" bedrooms System #2 Approved for bedrooms ���`l OF ANC'y Disapproved QP0 Conditional approval for bedrooms, with the fol j vin i{ Sions�N, • ,. WATER AN WASTEWATER pROGRA --u7'SrR���C� By` 7-eV Original Certificate Date: —2—I 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 Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other • COSA blue sheet 10.10-12.doc If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system Certificate of On-Site Systems Approval Checklist Legal Description: NOLAN; LOT 55A Parcel ID: 075-061-78 A. WELL DATA Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES Date completed 9/3/82 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES Total depth 70 ft. Cased to 70 ft. Casing height (above ground) 12+ in. FROM WELL LOG AT INSPECTION Date of test 9/3/82 2/16/18 Static water level UNKNOWN ft. 23.1 ft. Well production 50 g.p.m. 5.6+ g.p.m. WATER SAMPLE RESULTS: Coliform Ne9 colonies/100 ml. Nitrate 0.656 mg./L. Collected by: GEG, Ltd. Arsenic: <5 ug./L. Date of sample: 2/16/18 B. SEPTIC/HOLDING TANK DATA PUBLIC SEWER Tank Type/Material Date installed Tank size gal. Number of Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression over tank (Y/N) High water alarm Date of pumping Pumper C. ABSORPTION FIELD DATA Date installed Soil rating (g.p.d./ft2or ft2/bdr • System type Length ft. Width ft. Gravel below pipe ft. Total depth ft. Eff. absorptio . ea ft2 Monitoring tube Depression over field Date of adequacy test Results (Pass/Fail) For bedrooms Fluid depth in absor• '•n field before test in. Water added gal. New depth in. Elapsed T'• e: min. Final fluid depth in. Absorption rate >= g.p.d. y rejuvenation treatment (past 12 mo.) (Y/N &type) 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 .• 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 N/A On adjacent lots 100'+ Absorption field on lot N/A On adjacent lots 100'+ Public sewer main 75'+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 25'+ Holding tank 75'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: PUBLIC SEWER Building foundation Property line Absorption field Water main Water service line Surface water Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIE I : I LOT TO: Property line B • e. • oundation Water main Water service line Surface water Driveway, parking/vehicle storage .in drain Wells on adjacent lots F. COMMENTS ...% •• /44,754,_ G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and +' .. . j • review of Municipal records that the above systems are in '\ / % conformance with MOA COSA guidelines in effect on this date. 0 ; =f• y ---G. •ess; COI Engineer's Printed Name JEFFREY A. GARNESS til'• CE-7 53 -cam alr Date 3/1)/ 8 •�44k'°ROFESS\‘,,\,. 4 LICENSE Illiu""� #AECC884 (Rev. 10/12/12) P\-� \Ws - N • oma. 6��$2C y • • A. .. / LOT 55A ` / •p, 2 Story N221..' 01 558 • 0. House O 6• x' ' k��\\\�� 1'\- 2.2 � AIIII41 of ACq‘k, o . . ANI i*: • A! .•*r 7 ,S ,;/ ere �` .�r. / l N �4r • 4;r6 •',% / IRk 1a°" r 0 ?5 30 kvssro,a���-�% / / \\\�� / / US SURVEY NOTES / FEET \ —All bearings shown are Alaska :ate Plane Zone 4 grid bearings, all distances shown are ground distances in U.S Survey Feet —Lot 55A shown as per Pict No. 82-418, Anchorage Recording District —49th Star has conducted a physical survey of this property as shown on this drawing and that improvements situated thereon are within the property lines and no encroachments exist other than noted —It is the owners responsibility to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plot —Under no circumstances should any data hereon be used for the construction of or for establishment of property lines AS-BUILT SURVEY Legend 49th Star Surveying 321 Fireoved Drive Lot 55A Nolan Subdivision 44 Found Survey Monument Anchorage,AK 99508 891-6111 Girdwood, Alaska • Jeremy@49thStarSurveying.com PLAT NO. 82-418 — Vol Well W.O. 18001 J DATE: 2/28/18 SCALE: 1"--.3C MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # ~',-~ ~-¢~t~ ~. - ~ "~ HAA # ~ ~,~o~(_~¢_~ \ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section, township, range) Lot 55A; Nolan Subdivision Location (address or directions) Mile I. 5 A16,~ha Highway (b) Property owner FHLMC Mailing Address # 35-884601-3C Telephone: (home) Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent JACK WHITE COMPANY ATTN: Georqe McCoy/ Address 3201 C Street Suite I00, Anchorage, Alaska 99577 .... ,~ Telephone 563-5500 (e) Mail the HAA to the following address: (or check here.~ if hold for pick up.) List contact person and day phone number below: S & S ENGINEEPJt'~G 17034 Eagle Ri~er Loop Road No. 204 Eagle Rlyer, Ala~ca ~-~ 2. TYPE OF RESIDENCE Single-Family E~X 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 th legality and status. 4. SEWAGE DISPOSAL On-site E;]( 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 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATIOH As certified by my seal affixed hereto and as of the validation date shown below, Iverifythat 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. Telephone .,-~ .~'~/' '~ ~7~' 7 ~'' Name of Firm Address Date S & $ ENGINEER!NG 17034 (~agie River Loop ~.o,~ ~o. 204 Eag!e River, Alaska 99577 6. DHHS APPROVAL Approved for ~ bedrooms by Approved ~/"/~--- Disapproved Terms of Conditional Approval /~/~,~/~ _,~¢-~/ Date Conditional The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated 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 satisfycertain federal and state requirements. Employees of DHHSdo notconductinspections or analyze data before a certificate is issued. The MunicipalityofAnchorageis not responsibleforerrorsoromissions in the professional engineer's work. 72-025 IRev. 7/88) Back Page 2 of 2 A. WELL DATA Well Classification Well Log Present (~/N) "~ Total Depth '"Jo Cased to Static Water Level  MUNICIPALITY OF ANCHORAGE (MOA) Hea[tho~,~ho,rity Approval (HAA) ~VI~ 343-4744 Date Oompleted ~- ~- ~ Yield 1~' Depth of Grouting ~' ~' Pump Set At Casing Height Above Ground ~M ~ Sanitary Seal on Casing~N) Electrical Wiring in Conduit/N) ~ Depression Around Wellhead (Y~ To Septic/Holdin~ Tank on Cot ; On Adjoinin~ ~ots 1o ~eamst fid~o of Absorption Field on lot ~ ; OnAdjoinin~ Cots 1o ~earest Public Sower Une ~ 1o ~earest ~u~l[c Sewer GIoanout/Manhole 1o ~earest Sewer Sorvice Une on Lot Water Sample Collected by ~&% ~~~ ;Date ~--~- Water Sample Test Results ~~¢~ ~ ~~ ~ Comments B. SEP~I,~HOLDING TANK DATA Date Ins~......~ Size No. of Compartments Standpipes (Y/N) ~-~ Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (~~ Date Last Pumped .... Pumping/Maintenance Contact on~~ . ; for Holding Tank High-Water Alarm (Y/N) ~~olding Tank Permit (Y/N) To Building Foundation ~ ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: . _~...~ To Water-Supply Well ~..........~ T° Property Line To Disposal Field To Water Main/Service Line To Stream, P.0nd, Lake'or Major Drainage Course 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Dat~stalled Width ~ ~~o°fl Results of Last Adequacy Test ~ SEPARATION DISTANCE FROM ABSORPT~ To Water-Supply Well _ To Prop-c'ef4.y....~e To Building Foundation To ~bandoned System on Lot ; On Adjoining Lots~ To Water Main/Service Line Cutback {if present) To Stream, Pond, Lake, or Major Drainage Course To Driveway, Par~ngAArea, or Vehicle Storage Ar~a Comments lv~0 h--~---~ I. ~,/"<'~ "'~'- Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test D. LIF(~ STATION Date~ Size in Gallons % "Pump On" Level at ~ High Water Alarm Level at ~ Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) '-'"'""'"'"""~ ~Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in .e~,f,~,4t,~e,r~,~h~e date inspection. $ & S ~NGIN~ErtlNG Signed 17034 Ea~gl,~ ~iv~ Loop ~ ~c. 204 Company Date ~/¢/~ "' Receipt No. '¢-~ , Receipt No. Date of Payment ~¢~/~ '~' ¢~ Waiver Fee: $ Amount: $ /'~¢ '~ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 ~i'this Se~l MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL SERVICES OERT, F,CATE .NSPECT, ON .EALT. AUTHOR,TY*PPROV*' OF ON-SITE SEWER AND WATER FACILITY 264-4744 Application Date 1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Mailing Address Lending Institution Mailing Address (b) Property Owner (d) Real Estate Company and Agent Telephone:Home s? Business Telephone_ Address Telephone (e) Mail the HAA to the followina address: or: Check here [], if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family/~ Number of Bed?ooms WATER SUPPLY Well~ Community[] Public [] Individual Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite [] Publicx 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 I of 2 72-025 fRev 8/86~ Front ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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 ot bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage flies 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. Date ~/ _'~/~' 7 ,,,.,,.,s,,,,,,,,ov,,, Approved for ~- bedrooms by Approved X Disapproved Terms of Conditional Approval Engineer's Seal .,~,k.% % ........ Date Conditional CAUTION 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. Page 2 of 2 72-o25 fRev 8,861 Back MUNI~,~tJ~.,~,QF ANCHORAGE (MOA) ~.~E~,~.~' ~ITY APPROVAL (HAA) ~kL~\C ~p,L$ ~:CKLIST - FEBRUARY 1984 ~O~'~ ~ 264-4744 ~ ~ ~egal Description: WELL DATA *~C Well ~lassification ~ ~/FI b~ ~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) ~ Date Completed Yield Total Depth ~ / Cased to ~ / Depth of Grouting Static Water Level ~ ~ Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: To Septic/Holding Tank on Lot Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) /¢..,/O/1/'~/~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot /f-,/~/¢',~; On Adjoining Lots /L/o/~,~: /J-J ,'Z'///M /f.,~ · To Nearest Public Sewer Line ~/O(~) / To Nearest Public Sewer Cleanout/Manhole I ~--~ (~ ~'~- To Nearest Sewer Service Line on Lot Water Sample Collected by ~.,~- ~~ ;Date ~:~//'/~'~ 7 Water Sample Test Results ~ ~'~~ . Comments Depression over Tank (Y/N) N% Pumping/Maintenance Contract on Fi, I~,,~/N) Holding Tank High-Water Alarm (Y/N)% n Separation Distances from Septic/Holding T%~~ SEPTIC/HOLD~G TANK DATA Date Installed Size No. of Compartments Standpipes (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course Comments To Building Foundation ~:'~ osal Field To Stream, Pond, Lake, or Major Drainage Page I of 2 72-026 fRev 8/861 Front ABSORPTIONXE~ DATA Soils Rating in Absorl~on Strata Type of System Design \ Date Installed ~, Length of Field Width of Field ~% Depth of Field Gravel Bed Thickness Square Feet of Absorption Area \ Standpipes Present (Y/N) Depression over Field (Y/N) '~ Date of Last Adequacy Test Results of Last Adequacy Test ~ Separation Distance from Absorption F To Water-Supply Well To Property Line To Building Foundation ~ To Existing or Abandoned System on Lot ;~n Adjoining Lots To Water Main/Service Line % 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 Size in Gallons "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) "'"~ Pumping Cycles during Adequacy Test. Meets MOA ** 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. S,gnp.~P~/.~*, .--~/~.~ Date ~ /¢ /,c2;¢ Cor~pan~ '.-'~~~-~'H MOA No. / ~'~- O / '2 Receipt No. Date of Payment Amount: Page 2 of 2 72 026 fRev 8 861 Rack · ~O~'/,.-,L. \ '~.. ' FRA/'IE HOUSE "~-' ' ' ~ RECERTIFICATION AS-BUILT ''~" * - ~HE~ A~IMA~ LOCATIONS ONL~ ,, ~ ,he ,.,po-,,m~,,y o, ,he ~.~,d., o, o~~ ~k' ~oun~ . ~ set con~t~ucti~, to ~e,~fy proposed ~ildin~ive 7 ~ r~r -found 0 set i~ exlsle~e of any easements, c~enonts ~ reslrictions ~0S$ Cp~ -found ~t ~ich do ~ a~ear ~ I~ ~e~ded subdiv~i~ plot% alum. cop -found set . ~ENCfl. ~4NK ZNO ,~,,~ ~.~.~,,., .~-~...... '~"~' ~~ ~ LOT 55A, NOLAN SUBDIVISION TRACT B FIRST AD~TION- GIRDY/O00 TOWNsrrE, ALA.t(A SU~IVISK]N Environmentol gr~ineers, Rncho~}e, Rlosko. GIRDWO00 - .,M.YESKA SEWER COI_LECIION~.~ ~=~oF,LE SYSTEM. US SURVEY $044 R ALYESKA ROAD II . ; I , / 56 55 54 A SCALE t"=lO0' NOTE LEGEND FOIJND $/4" DIAM IRON PIPE \ \ x \ \ 5~ \ \ \ \ \ \ \ \ \ \ \ \\ xx38 A x \ ACCEPTANCE OF DEDICA T/ON Oared at Anchorage, Alaska thls~..~day of TAX CERTIFICA CERTIFICATE OE OWNERSHIP and DEDICATION / WADE P. NOLAN HAZE~' J~/_,.~OLAN' EDNA F, 8703 N.E. 12.~[ ST ZONIN( VICINITY MAP SCALE t"= I MILE 2O BENCH MARK INC i26 E. @ AVE. ANCHORAGE~ AK 99501 279--3736