HomeMy WebLinkAboutANGELA HEIGHTS LT 3Angela Heights
Lot 3
#050-283-39
tit
by
A & L DRILLING COMPANY
BOX 97, EAGLE RIVER, ALASKA 99577 s TELEPHONE 694-2588
OWNER OF LANDo z
ADDRESS
LEGAL DESCRIPTION A
DATE -Started Ended cj
PERMIT NUMBER I'7 197
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DEPTH OF WELL
STATIC LEVEL OF WATER FT.
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MISCL. INFORMATION:
V
DRILLER'S NAME
_'-
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
25 STREET, HC•dCHI;ERAGE:, AK. ._ 0.1..
279-2511
L-A B__.._ F=EE- F—" irl :1 •_r_
LOCATION CH I CKALOON =.T
LEGAL L_:?: MtdGEL..A HGT'w LOT SIZE :1.:. 439 SQUARE FE.E:T.
MINIMUM DIF,"1"h=lNCE BETWEEN H WELL AND ANY ON—SITE SEWAGE DISPOSAL S'r°k TEM I:-=,
100 FEET FOR H PRIVATE WELL OR 200 FEET FOR H PUBLIC WELL.
WELL LOGS ARE REQUIRED AND t'1UST BE RETURNED 1.O THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
INSTALLATION.
°•r ! =A lL__ :r C Fz" wW-1 F," fl`i r-AE� E:-.
I CERTIFY THAT
1: I AN FAMILIAR WITH THE REQUIREMENTS FOR ON—SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL I NVLTH-:Y 'T Et' ll.'ACCORDANCE WITH THE CODES.
Municipality of Anchorage
• Development Services Department 600, 4
Building Safety Division • ,
On -Site Water and Wastewater Program '
4700 South Bragaw St. • • "'
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 050-785-14 HAA #_ bfbg23
Expiration Date: - O - os
-
1. GENERAL INFORMATION
Complete legal description An- da HaIght,q__Lot
Location' (site address or directions) 10n15 rhirkalnnn err et Eagle River, AK
Current Propertyowner(s)_Darren J_ Vanderwtlt Dayphone_Gg4-8077
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested. HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well CK
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Day phone
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 sample results. (Certificates may be reissued for a period of up to one
year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or
a public water system. The Municipality of Anchorage is not responsible for errors or 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, I 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. 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.
AddressName of Firm KND ENGINEERING lnr- Phone (AQ7) ACIS-6111
1 u •.. • • •.
Engineer's577
•. Na u Date 08126105
Engineers Comments:
This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the
condition of the well and septic applies only to the
conditions as of the day tested. The flow and absorption
rates may change due to subsurface conditions that
may not be observed from the surface, changes in
land use, local soil characteristics, groundwater levels
that may fluctuate during the year and the water usage
of the family being served by the system. The operational
life of all well and septic systems are subject to these
various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system.
Therefore, KND can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can KND guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
5. DSD SIGNATURE
Approved for __+_ bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
WA`�R • , -
PRGGRAM • :
By:
g ; �4 /C/ Original Certificate Date:
.�7 0
Municipality of Anchorage
r r
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program • • •�
4700 South Bragaw St.
P.O. Boz 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 345-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Angela Heights. Lot 3 Parcel ID: 050-283-39
A. WELL DATA
Well type Private If A, B, or C provide PWSID #_
Date completed 5/18/1977 Sanitary seal (Y/NI Y_
Total depth 122 ft. Cased to 122 ft.
FROM WELL LOG
Date of test 5/18/77
Static water level 100 ft.
Well production 25 9 -p.m
WATER SAMPLE RESULTS:
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 2'
AT INSPECTION
8/22/05
ft.
8.22 9 -
p.m -Coliform
_Q_colonies/100 ml. Nitrate 2.76 mg./I. Other bacteria 0 colonies/100 ml.
Arsenic: = ma.p. Date of sample: 8/19/05 Collected by: KND Engineering, Inc.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Date installed
Tank size gal. Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N)----Depression over tank (YM) High water alar (Y/N)
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./flz or fefbdr)System type
Length ft. Width ft. Gravel below pipe ft.
Total depth ft. Eft. absorption area ftp Monitoring tube _Depression over field
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test In. Water added_ gal. . New depth in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes, give date .....
D. LIFT STATION — NA
Date installed Size in gallons Manhole/Access (YIN)
'Pump on" level at in. "Pump ofr level at in.High water alarm level at in.
Datum Cycles tested Masts alarm 8 circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NA
Absorption field on lot NA
Public sewer main 75'+
Sewer /septic service line 25'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout 100'+
Holding tank 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: NA
Building foundation Property line Absorption
Water main Water service line Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: NA
Property line Building foundation Water main
Water Service line Surface water Driveway, parkingivehide storage
Curtain 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 /n
conformance with MOA HAA guidelines in effect on this date.
Engineers Printed Name Kenneth M. Duffus
Date Qf
HAA Fee $430.00 Waiver Fee $ _
Date of Payment?.�to Date of Payment
Receipt Number Receipt Number.
(Rev. 12/01)
7k l�ef.au
Al.
08-26-05 82:35PM FROM -CUE ESI, SGS ESV SERVICES
—Sal
SGS ReLD
Clieat Name
Project Naae/a
Clicat Sample ID
Macri:
Sample Remarks:
1055338001
KND Engineering
Angela Hts Lot 3
Angela Hts Lot 3
Drinking Water
9075615301 T-831 P.02/04 F-908
AN Date&Mmes are Alaska Standard T')me
trialed Date/Time
0826/2005 11:03
'Collected Date/ITme
08/192005 13:30
Received DatefTime
08/192005 14:11
Technical Director
Stephen G Ede
Hicrobiology Laboratory
Total Coliform 0 col/100m]. SM209222D A (<-I) 09/19/05 TLF
Allowable
Prep
Analysis
Parameter Results PQL Units Method
Comainer 1D Limits
Due
Date Init
Nivate-N 2.76 0.100 mg/l. EPA 353.2
D (<-10)
08/19/05 AZS
Hicrobiology Laboratory
Total Coliform 0 col/100m]. SM209222D A (<-I) 09/19/05 TLF
||
-------A@q---ON ------------
N o ,' E 93.00'
F-14
RwnY
MUNICIPALITY OF ANCHORAGE Z
• DEPARTMENT OF HEALTH & HUMAN SERVICES z
Division of Environmental Services I y/'o f�
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. #050 `j8-3 / HAA # W-2)
1. GENERAL INFORMATION
Complete legal description Lot 3, Angela Heights
Location (site address or directions) 10035 Chickaloon
Property owner Tome& Kim Van Hoose
Mailing address
Day phone
694 -6612, -
Lending agency Day phone
Mailing address
Agent Dynamic/Susan Bickman Day phone 261-7571
Address 3111 C Street Ste 100 Anchorage AK 99503
Unless otherwise requested, HAA will be held for pickup. -
2. NUMBER OF BEDROOMS: 4
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 y
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(Rov.1/91) Front MOAN21
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.
Name of Firm S & 5 ENGINEERING Phone 69 —d'9 Z 9
17034 Eagle River Loop Road No. 204
Address Eagle River Alapka _99577
Engineer's signature Date a 9 9
6. DHHS SIGNATURE
X Approved for r bedrooms.
Disapproved.
Conditional approval for
Additional Comments
0
111TIC
� OF
CE -8801
bedrooms, with the following stipulations:
Date 12-2 7-29
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 courtesyto 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.
72-025 (Rev. Vat) Back MOA n1
Municipality of Anchorage Lr If
1999
DEPARTMENT OF HEALTH & HUMAN SERV SPALITY OFANCHORA
Environmental Services Division ENVIRONMENTAL SERVICES DIVIS
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description: efI-YQ S/D Parcel I.D.:
A. WELL DATA
Well type Pat 114-16- / If A, B, or C, attach ADEC letter. ADEC wafter system number
Log present &q)7L5 Date completed S/le/ ��z
Total depth �Z 2/ / Cased to 40 f Casing height (above ground) f
Sanitary seal ON) Wires properly protectedON) C's
Date of test
Static water level
Well production
FROM WELL LOG
! /ZIN7�
ioo'
2S
WATER SAMPLE RESULTS:
AT INSPECTION
// 9 '
g.p.m. Co , `� (/-I //V g.p.m.
Coliform Nitrate ) . 7G Other bacteria
Date of sample: 12113 / T7 ,-Collected by:
B. SEPTIC/HOLDING TANK DATA FU61 /G
Date installed
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
J
Tank size Number of Compartments Cleanouts (Y/N)
Depression (Y/N) High water alarm (Y/N)
Pumper
nub 5�_W&741
Soil rating (g.p.d./ft2 or ft2/bdrm) System type
Length Width avel thickness below pipe Total depth
Effective absorption area onitoring Tube present (Y/N) Depression over field (Y/N)
Date of adequacy test Results (Pass/Fail) For bedrooms
Fluid depth in absorption f' d before test (in.); Immediately after_ gal. water added (in.):
Fluid depth (ins) Minutes later: Absorption rate = g.p.d.
Peroxide
72-026 (Rev. 3/96)*
(past 12 months) (Y/N)
If yes, give date
D. LIFT STATION 201-1G
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at* "Pump off' level at*
High water alarm level at* Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 'Al /A On adjacent lots N /4
Absorption field on lot Af A On adjacent lots Al Z
i
Public sewer main -IS 4- Public sewer manhole/cleanout
Sewer /septic service line d S -) Lift station NI/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Ael,,%UG
Foundation Property line Absorption field
Water main/servic ' e Surface water/drainage Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: 1�2u6z-lC
Property line Building foundation Water main/service line
Surface water Driveway, parking/vehicle storage area
Curtain drain Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certify that 1 have determined thru field inspections and review of Municipal recordsta9t\h�e v,� j3�ems are
in conformance with VqA HA uidelin in effect on this date. ��P;,.•
Signature G 1C✓z*-- Al r,t rfl
A,
I�
Engineer's Name !G 0 B lcc'1 i C. C o w 4
P1 T� RODERT C COWAN f Q
Date j �� 6 / 0� c, ., CE - Esol r
v
HAA Fee $ JQD
Date of Payment /-.I- _
- 79
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
AddG CT&E Environmental Services Inc.
CT&E Ref.#
996656001
Client Name
S & S Engineering
Project Name/#
Lot 3; Angela Hts
Client Sample ID
Lot 3; Angela Hts
Matrix
Drinking Water
Ordered By
PWSID
0
Sample Remarks:
Parameter Results
Client PO#
Printed Date/Time
12/17/1999 15:25
Collected Date/Time
12/13/1999 9:30
Received Date/Time
12/13/1999 11:15
Technical Director
Stephen Ede
ReleasedA/;�yr%
Allowable Prep Analysis
PDL Units Method Limits Date Date Init
WATERS DEPT
Nitrate -N 1.76 0.500 mg/L EPA 300.0
MICRO LAB
Total Coliform 0 cot/100mL SM18 92226
(<10) 12/13/1999 12/13/1999 SCL
12/13/1999 KAP
M
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. # 050-283-39 ,, HAA # AC\:I L4 AD
1. GENERAL INFORMATION
Complete legal description Lot 3; Angela Heights
Location (site address or directions)
10035 Chickaloon Street
Eaqle River, AK
Property owner Larry & Darlene Sivyer Day phone
Mailing address 10035 Chickaloon Eagle River, AK
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well xx
Community well
Public water
696-8178
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
Holding tank
Community on-site
Public sewer XX
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
ODYY)
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 t is inspection.
Name of Firm a -ilsu-A t T& Phone
Address d� Rn/.,'hf=,
Engineer's signature
ALASKA WATER & WASTEWATER CONSULTANTS INC.
IS TO BE PAID $500.00 AT CLOSING FOR
ENGINEERING SERVICES PERFORMED.
6. DHHS SIGNATURE
Approved for ��' I bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
UITIC
_ Date �� 9
�t
.�
a
frey
Garitest "• tv
C 53
C$1
bedrooms, with the following stipulations:
Date
j f � -C�
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.
72-025 (Rev. 1/91) Baek MOA 021
Municipality of Anchorage H1YIRONMEN1'Al. SERVICES DIV
e
DEPARTMENT OF HEALTH & HUMAN SERVICES Nov 19 199
Environmental Services Division
825 L Street, Room 502 - Anchorage, Alaska 99501 - (907) 34ft
Health Authority Approval Checklist
Legal Description: A'+l G e L N 1-1 �j (, µTs !9/p,. LQr� Parcel I.D.: 050 -'25'3 3'1
A. WELL DATA
Well type If A, B, or C, attach ADEC letter. ADEC water system number rJ A
Log present (&N) 11E s Date completed 5 18 -711
Total depth (2 z 1 Cased to 1221 Casing height (above ground) 18 +
Sanitary seal (Y/N) SGS Wires properly protectedON) �£s
FROM WELL LOG AT INSPECTION
Date of test 5/' 8 /7 7 I t/ l f g 8
Static water level I oo' q9
Well production ZS g.p.m. 7.7 g.p.m.
WATER SAMPLE RESULTS:
Coliform "-6"' Nitrate - m R /L Other bacteria
Date of. sample: I I /I 1 Z121 Collected by: A • LjW • C- L
B. SEPTICIHOLDING TANK DATA <f0Mr4V►J►T'Y Z
Date inst Iled Tank size Number of Compartments Cleanouts (Y/N)
Foundation cleanout (Y/N) De High water alarm (Y/N)
Date of - Pumper
C. ABSORPTION FIELD DATA G0vArvl vN 1-ry r, --
Date installed Soil rating (g.p.d./W or ft2/bdrm) System type
Length Width Gravel thickness below pipe Total de
Effective absorption area nitoring Tube present (Y/N) De on over field (Y/N)
Date of adequacy test Results (Pa it For bedrooms
Fluid depth in absorption field before
Fluid depth
--- Immediately
later: Absorption rate =
gal. water added (in.):
treatment (past 12 months) (Y/N) If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION N /
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cyc c
E. SEPARATION DISTANCES
on"
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons
"Pump off" level at*
Septic/holding tank on lot Co m rA Ja -r,( Scw � On adjacent lots
Absorption field on lot 14Idw 1-,y —5;e weK- On adjacent lots I 0 �\ fi
Public sewer main -7S + Public sewer manhole/cleanout 100 1 t
Sewer /septic service line 251 f Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
line
Ipfater_ ' rvice line Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property ine Building foundation
Surface water
F. ENGINEER'S CERTIFICATION
1 certify that I
in conforman
Signature
Engineer's Name
Wells on
loos +
GamMvrl,T'f Sf+WEr—
I-�nt lots
Water main/service line
inspections and review of Municipa
as in effect on this date.
A. 1�,,6as
storage area
Date / /! 9 ri$ qB � e�oF'.• AW
.....
0
HAA Fee $ 3 Waiver Fee $
Date of Payment L1 �� Z�p Date of Payment
Receipt Number iG�/ ( �'. Receipt Number
72-026 (Rev. 3/96)*
are
NOV-18-98 16:18 FROM-CTE ENVIRONMENTAL
AALCT&E Environmental Services Inc.
-.a 10 --womm-
5616301 T-703 P.02/03 F-827
CT& -E Rof.# 986670001 Client Pi )#
Client Name AK Warer & WaMwater Catlsaltan[s Inc Printed 1late/Time 11/18/98 16:05
Projea Nance/9 Angela Height:s SYD 1-13 Colleatet, Date/Time 11/11:98 1040
Clean Sample LD Oursidc Hose Bib Received J)ace/'.!'time 11/12/98 13 20
Matrix Artnking Water Technical -Direr_-t®ra Stephen C. Ede
Ordered BY
FWS111 0 Released By AJ n„ 1 r A
Sampl � mark%
a.Glo"401e Prep Anaiy3is
ParamssLer ReswlTS Pay unles Method 3Imits pate pale leis
Tors[ Coliform 0 Col1100ML SM18 92224 11/12198 RMV
N;sra'ra-N 1.29 0.100 mg/� TPA 300.0 1C 110x ?^/12198 11112/9a GCP
RECEIVED
Nov 19, 19(f3
MUrtiUPailty u1 fdia G(Ioragq
Dept. Health R Human Services
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. # 0 -';C - QQ S" lc I
1. GENERAL INFORMATION
0
Complete legal description Lot 3; Angela Heights Subdivision
Location (site address or directions) 10035 Chickaloon, Eagle River, Alaska
Property owner nay,; t9 srPwarr Day phone 694-2316
Mailing address 10035 Chickaloon, Eagle River, Alaska 99577
Lending agency
Day phone
Mailing address
Agent Don McKenzie/DON MCKENZIE REAL ESTATE Day phone
695-9035
Address 13135 Old Glen Highway, Suite 100, Eagle River, Alaska 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 4
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
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.
Name of Firm - .. S ENGINEERING Phone
Address 17034 Eagle River Loop Road No. 204
River, Alaska 995,717
Engineer's signature
Date
w► OF. 44 11
0••�e+i#p•e/N• a •e4
ROGE J S AFER
.e No. 821
��� 9F� eee•• ti ee•e••�0,��a��
6. DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
By:
Conditional approval for
Additional Comments
2—
bedrooms, with the following stipulations:
NUTlr
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Int 3 , C' � I * Parcel I.D.
A. WELL DATA
Well type'If A, B, or C, attach ADEC letter. ADEC water system number //
Log presentLVN) Date completed 1 g "17 Driller �W s VI�
t�
Total depth 1Z2
Cased to
`ZZ Casing height
H
12 4—
Sanitary sealaWN)
Wires properly protected&UN)
W �
FROM
WELL LOG
AT INSPECTION
Date of test
�!'1�
1 0— 1�1— `�2'
o�
u W m
LJ...t
Static water level
Z
o
Well flow
9 -P.M. t0
g•P•1 V.
Pump level
�'�
U��
i
z o ->
1W
SEPARATION DISTANCES FROM WELL TO:
LU
W
Septic/holding tank on lot
a>Jt✓
; On adjacent lots
o�
Absorption field on lot
If ooh
; On adjacent lots
�e,
Public sewer main C'
Public sewer manhole/cleanout
15-0 4—
Sewer service line 1105
i
4--
Petroleum tank N ol•��
WATER RAMPI F RESULTS:
Coliform
Date of sample
Nitrate ,2 X7_ Other bacteria -
�� Collected by:
B. SEPTIC/HOLDING TANK DATA
Date inst led
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
_ Tank size Compartments
Foundation cleanout (Y/N)
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK
Wel I(s) on lot
To property line
Surface water/drainage
72-026 (Rev. 7/91) Front
On adjacent lots
Fou
Absorption field Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed .
Size in gallons
Vent (Y/N) —
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
installed
Cycles tested
Length Width
Total absorption a
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating
—Gravel thickness
Surface water
System type —
Total depth
Cleanouts present (Y/N) _
Date of adequacy test
for
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot On adjacent lots
To building foundation
On adjacent lots
Surface water
Curtain drain
Cutbank
If yes, give date
line
To existing or abandoned system on 1a
Water main/service line
Driveway, parking/vehicle storage area
bedrooms
E. ENGINEER'S CERTIFICATION
1 certify that ! have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
OF 4,(41#
1
S & S ENGINEERING �
Signature 17034 Eagle River Loop Road No. 204
,, uu t°
3 a @xFeA�Al9
"tanO
Engineers Name
c'
y �✓2,�.� Z � � s �., °� � n. Vie!
Date ,' k r4 SHNFER o �
No. 215
HAA Fee $ 1 -70 • Waiver Fee: $ —
Date of Payment 10/ 1-3 ` Date of Payment
Receipt Number 7y r�� Receipt Number
72-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE # 59588
Chemlab Ref.# 92.5696 Sample # 1 Matrix: WATER
Client Sample ID L3 ANGELA HTS.
PWSID UA
Collected : OCT 13 92 @ 09:20 hrs.
Received OCT 13 92 @ 14:50 hrs.
Preserved with AS REQUIRED
Analysis Completed OCT 14 92
Laboratory Sup vi or T PHEN C. EDE
Released By : G N'^J
Client Name :S & S ENGINEERING
Client Acct :SNSENGP
BPO#
Req#
Ordered By
Send Reports to:
1)S & S ENGINEERING
2)
PO# :NONE RECEIVED
....................................................................................................................................
Parameter
Results Units
Method
Allowable Limits
------------------------------------------------------------------------------------------------------------------------------------
NITRATE-N
1.2 mg/l
EPA 353.2/300.0
10
Sample ROUTINE SAMPLE COLLECTED BY: R.J.S.
Remarks:
....................................................................................................................................
1 Tests Performed See Special Instructions Above UA -Unavailable
ND- None Detected "` See Sample Remarks Above
NA- Not Analyzed LT -Less Than, GT -Greater Than
Ash SGS Member of the SGS Group (Socidtd G6n6rale de Surveillance)
MUNICIPALITY OF ANCHORAGk.- MUNICIPALITY OF ANC,)- K)PAGE
Department of Health and Environmental Prot(ENt-APRENIA1,
825 L Street, Anchorage, Alaska 99501 1 ECTION
279-2511, ext. 224, 225 AJ G ( 91?7
_�2equest for Approval of Individual Sewer and Water
R 11 V L
1. Property Owner:
Mailing Address: Phone:
2.
Name of Buyer:
Mailing Address: / Phone:
3. Lending Institution:
Mailing Address:
4. Realtor/Agent:
Mailing Address:
5. Legal Description:
Street Location:
_fe 16 .19
Phone:
Phone:
6. Single Family Residence: Number of Bedrooms:
Multiple Family Residence: Number of Bedrooms:
7. Water Supply: *Individual Well Public/Community System
If Individual Well, well depth 1a3
If Community System, name of system
8. Sewage Disposal System: On-site System Public System kr)
If On-site System, date of installation:
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77