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Home My WebLink AboutTERI #2 TR D2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPC)SAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MAILING ADDRESS Ma t e .~17/z?¢: ./ Absorption area JNO. OF BEDROOMS PERMIT NO, No, of compartments Inside length Liquid deptb Dwelling PERMIT NO, Manufacturer Material Liquid capacity in gallons Foundation Nearest lot line PERMIT NO . Total length of lines Material beneath tile Length Width Depth Distance etweenlines Total effective abso;o[Iption area PERMIT NO. Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line ,.~ /.- Septic tank /0o__ ~- &Absorption OTHER PiPE MATERIALS SOIL TEST RATING APPROVED DATE LEGAL. 72 013 (Rev, 3~78) DI]~PARTMIENI" f HEALT'H AND EI'~VIF~ONMISIxH'AL DTEI]TION 825 L HFFREE.'71'., ANE:I-I[]F~ADE~ AK 9950 1 F'ERM I"1' NO." 850549 DAI'E l SSUIED ,", 06/,'..~4/85 AF:'F:'I,,. I CANT: I. EE I:~AYMOND ADDRESS." F:'. 0,, BOX AIqCI4ORA~3E, Al< CDNTAC'[' F'HONE: 694-967 1 99577 BL(:]CK: NA Lisi',,ed below are the options available 'LI::} y~]u in designing your' se'ri'., 4 ....... ~"' system. Ch(~ose t. he ~;ption tha'L best fits yC~LU* si{e. DEEP'f'H 'FEI PIPE BOI'T'OM E)I:;:AVEI,. DEPTH (F'F.) T'O]"AI- DEPTH (I.:'T.) ORAVEL WIDTH (F'T.) E')F~AVIB.,., LENGTH (F:'I'.) GI:~AVEL VOLLJME (CU· YD,S. ) TAI~II'".'.' ,SIZE (GAL. S) .SDIL. RA]"INC¢ (SI?.F]'. /BR) (F:T · 4. () 5. (} 45,, 0 ,.~ ], ~ 000 ,, 0 ~ 150 TANK MUST HAVE AT LEA,S'T' "I'NO CDHPAR'FMENT8 cert. i fy that: 1,, I am f'am,il:Lar with 'Lhe requiremen'Ls 3. I F:' A THEI'q WI L.I.. ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN. For orq-.si~'.e sewers and wells as s~?'L forth by 'Lhe Hur~icipality of Ancl'~.or'~ge (MOA) and the ~tat~ oF I ~i],1 in~.a].l 'Lhe system ~n ac:c:'~¢danc~ ~th all MOA ~Qdes and arid in cc~mp].iar'H::e wit. h t. he design cri'Ler~ of this l:?ermi'L. I will adhere¢'Lo all MDA and State al Alaska r'equiremerrLs f(~r the set back dJ.~T, arlEl2~ t'Pl:]lfl ¢ll'ly exist, ir'~g well, w¢istewa'[.el* dispt:3sal sys'i:,em of sewerage syst, em cji] 'l:,h:ls or any ad,jaEerrL or nearby lrJt,, I I.Inders'Lar~d 'Lha'L 'LhJ,~ p~rmi'L is valid fl:3r a maximum o¢ 5 bedr, eoms and ,br'ly erllal'gelilenf. NJ.i]. peql~til"6) an additi(ar'lal permi'L. LIFT STAI'~DI',I IS INS]'Alui. ED IN AN AREA COVERED BY MOA BUII_DtN(3 CDDI;:u (I) AN ELECTR];CAL. PERMIT AND ZNSF'ECTI[IN IdLlfilT BE ODTAZNED~ (2) AS-BUll_TS NOT BE APF'F~OVED N~'I'HDUT AN ELECTI=~ICAL. INSF'ECTION REPORT~ AND (5) THIE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST '/ SOILS LOG [] PERCOLATION TEST DATE PERFORMED: 5 6 7 8 ~.,~rg SLOPE SITE PLAN ,/ 10 42 13- 14- 15- 16- 17~ 18- 19- 20 WAS GROUND WATER /~.~ ~ ENCOUNTERED? IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop TEST RUN BETWEEN FT AND FT DATE: 72-008 (6/79) DRILLING COMPANY DEPTH OF WELL / ~'~' STATIC LEV EL OF WATER FT. I1~ DRAW DOWN FT. Ended. ~J,.t ,cT?p GALS. PER HR KIND OF CASING From Ft. to...,- Ft, From .Ft. l Ft. Flom.~,.,~,~ _Ft, to,..__..~ I.'t.. · ;- ~F~6nl;~Ft. to.~Ft.. From.___ Ft. to__ .FL ~ From~ F~om~ From Ft. to Ft. Ft. · FI. to_____Ft Ft. to Ft. ' ' From___Ft. to__ , From _Ft. h From FI. to__Ft. From ..... Ft. to____Ft.__~ From , _FI. to__ From___.Ft. to__ Fl .... From__Ft. Io~FI. From __FI, lo .... DRILLFRkS NAME " ' ' 8;~5 .I~ti~STREET, RNCHORR0i'-', RK. 264-4;'~'0 : "' PULLEN PO BOX 96~. ' :'" RROR STREET . D TEK-'RI ~.SUDD #? LOT 5XZC 4~I0 ~TWEEN A WELL AND R~ FOR~R PRIVATE ~LLJ OR [FEET FROM R ~IC W~L ~I~ ~ON ~E ~ ~ ~IC ~QUIRED ~D ~ST I~ ~T~ TO T~ ~T~IT WITtlIN 30 ~LET I I~URE P~ER IN~TRLLRI'ION. ~E~PIRE~ ~E:OEHBER IILIRR WITH THE ~QUIREHENT5 !I~T~L TI~ 5',~TEM Itl ~~E WITH TI~ ~ES. ' ~CRNT PULLEN MUNICIPALITY OF ANCHORAGE �Y t„ 1 $ Development Services Departments :T Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Certificate of On -Site Systems Approval Parcel I.D. 050-751-42-000 Expiration Date: 9/2/2023 Legal description TERI #2 TR D2 Site address 3933 HARCA ST Eagle River AK 99577 Current property owner(s) HERNANDEZ ANNA M X The On-site system(s) is/are approved for 3 bedrooms Conditional approval for bedrooms, with the following stipulations: Comments or advisories: By Original Certificate Date: 6/2/2023 This Certificate of On -Site Systems Approval (COSA) is intended to demonstrate the subject system(s) is/are in substantial compliance with municipal code. The Municipality of Anchorage, Development Services Department (DSD) issues COSAs based upon representations provided by an independent professional engineer. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist X Well Flow Advisory Absorption Field Advisory Nitrate Advisory Tank Age Advisory Arsenic Advisory Other COSA Approval June 2022 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 Application 1. GENERAL INFORMATION Parcel I.D. 05075142 Complete legal description TERI #2TR D2 Location (site address) 3933 HARCA ST Current property owner(s) HERNANDEZ 2. ON-SITE SYSTEMS SIZED FOR 3 BEDROOMS Day phone 907-727-4200 3. TYPE OF WATER SUPPLY: ❑■ Private Well ❑ Private Well serving 2 dwelling units ❑ Private Well serving 3+ dwelling units ❑ Community Well or Public ❑ Water Storage 4. TYPE OF WASTEWATER DISPOSAL: ❑■ Private Septic ❑ Private Septic serving 2 dwelling units ❑ Holding Tank ❑ Community Septic or Public Sewer 5. SEPTIC TANK: R Steel ❑ Plastic ❑ Concrete ❑ Fiberglass Age 10 - See advisory if steel older than 20 years 6. ABSORPTION FIELD: ❑ AWWTS ❑ Bed ❑■ Deep Trench ❑ Wide Trench ❑ Seepage Pit Waiver request for: Expedited review requested: ❑ Distance: By applying for this entitlement, this property is subject to inspection by municipal On-site staff to verify the accuracy of the information provided. COSA Fee $ L rJ' Waiver Fee $ Date of Payment S Z b �2 Date of Payment COSA # 'Ob G Waiver # COSA Application—June 2022 COSA Checklist Legal Description: TERI #2TR D2 Parcel ID: 05075142 If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system A. WELL DATA ❑■ Well log is filed with Onsite (or attached) Date drilled 5/28/78 Total depth 173 ft Cased to 1 1 0 ft ❑■ Sanitary seal is functioning correctly Al Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 5/4/22 Static water level at beginning of test 114 ft Comments B. TANK DATA Measured operating fluid level in septic tank 50 Date of pumping ❑ Required maintenance completed, if AWWTS Comments: Steel, 10 yrs D. ABSORPTION FIELD DATA Which system tested (date installed) 6/13/85 ❑■ ALL standpipes present per record drawing Total measured depth from grade 11.5 ft (max) Measured depth to pipe invert from grade 3.5 ft (min) ❑ N/A — pressurized field. ❑■ Per record drawings, field is insulated. ❑■ Monitor tubes go to bottom of effective. If not, state depth into effective ❑ Presoaked required if (Required if house vacant or field not used for more than 30 days prior to date of test) Gallons introduced gallons date Any rejuvenation treatment (past 12 months) If yes, enter date Comments/Deficienci COSA Checklist June 2022 Well production at time of test 8+ gpm Water storage tank volume0 gallons Well disinfected for coliform test? ❑ Yes ❑■ No ❑■ Coliform bacteria is Negative Nitrate mg/L ❑■ Nitrate less than MRL (ND) Arsenic 4.44 ug/L ❑ Arsenic less than MRL (ND) Collected by NRimEng Date 5/5/23 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/4/22 Results g Pass Fluid depth prior to test 0 Water added 450 gal New fluid depth 3 in Elapsed time 30 min Final fluid depth 0 in in Absorption rate 450 gpd FIELD STATUS — POST RECOVERY Effective depth (per record drawings) 96 Effective depth used 0 in Effective depth remaining 96 in in E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) Septic Tank/Lift Station on Lot > 100' Community Sewer Manhole/Cleanout > 100' ■0 Yes if No ft ❑■ Yes if No Neighboring Tank > 100' R■ Yes if No ft Private Sewer/Septic Line > 25' *Yes if No Absorption Field on Lot > 100' ❑■ Yes if No ft Holding Tank > 100' ❑■ Yes if No Neighboring Absorption Fields > 100' Animal Containment > 50' ■❑ Yes if No ft ft ft ft ■0 Yes if No ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' W Yes if No ft M Yes if No ft ❑ N/A— Served by Community Well (not on lot) or Public Water From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required) Building Foundations > 10' ■❑ Yes if No ft Surface Water > 100'■❑ Yes if No _ Tank to Property Line > 5'■❑ Yes if No ft Wells on Adjacent Lots: Field to Property Line > 10' ■❑ Yes if No ft Private Wells > 100' ❑■ Yes if No _ Water Main > 10' ❑■ Yes if No ft Community Wells > 200' Fm -]Yes if No_ Water Service Line > 10' ❑■ Yes if No ft If tank or field is under driveway comment below F. ENGINEER'S COMMENTS li ft ft G. CERTIFICATION & STATENJENT 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, indicates that the on-site water supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation, unless noted otherwise. Name of Firm NorthRim Engineering Engineer's Printcd Name Steve Eng COSA Checklist June 2022 Phone 694-7028 Date 3/3/23 +P�� of Al No Ar �I s *: 49 r o �... .. c Steve Eng 0 1 CE -6256 N4 3/3%2 c= 7CL c n9pfs — m S S ~ � oz =m 3w3=oam � acsi•� ra 3• a xq�o-� m ao o o ° =aoomp=' / O_p umztiy m c d5 ago �°.•rvs 0 =ac —m go Lo- *a7rsms 0 Sp o �.ov o o< Rs=� o 1 � = s 0 c a� o� ^°°mem wa =�Nm n .0..R: n ° OU m= p F S ' my o,-` , ;OR c o 2 '" g0 o n no�.o0 0 m m T Sao° V6 m m A 7 7 ° 0 9 n o m y a c om a (J W maom a 0,o = a .� � .: c 06 om s : ��oe m � d m es o� M 100 Oo� a s v w x• 0 oa — 40 0 N N C N N� s N 0 c c x 0 o D __ m ° 0 m RQj �ELf[ tom•- . . 3og�. M afcN / I �F 0 1 � RQj �ELf[ tom•- . . 3og�. M afcN Development Services Department V Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 Parcel I.D. 05075142 Certificate of On -Site Systems Approval Expiration Date: 3 a0 ), a 1. GENERAL INFORMATION Complete legal description TERI #2TR D2 Location (site address) 3933 HARCA ST Current property owner(s) PLEWKA CARSTEN Mailing address Real estate agent 2. TYPE OF DWELLING: Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 317-6302 Day phone 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ED Private Septic ED Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ Waiver request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 550 1 Waiver Fee $ Date of Payment Date of Payment Receipt Number 0087(0 J 6 Receipt Number COSA # (D S C 2,?, 1�2 16 Waiver # 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- pnocedu(6sibutlihedift-thi --GerlifidatcFof __0n-_SRe_ Sysle- -Approval- uidelines fio this -app ication, 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 NorthRim Eng. Address PO Box 770724, Eagle River Engineer's Printed Name -Steve Eng zlffffl•' i Date 4/30/22 lj . . . . . . . 6. DSD SIGNATURE CE=,. System #1 Approved for bedrooms System #2 -Approved _for bedrooms Disapproved Conditional approval for bedrooms, with the following stipulations: V V M 1 GR M 1 14 Lj By: Original Certificate Date: 5 a3/2002 1 / 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 Cbeallst blue sheet COSA Checklist Legal Description: TERI #2TR D2 Parcel ID: 05075142 If more than 1 septic system on lot: COSA Checklist # of Structure served by this system A. WELL DATA ❑■ Well log is filed with Onsite (or attached) Date drilled 5/28/78 Total depth 173 ft Cased to 173 ft ❑■ Sanitary seal is functioning correctly ❑■ Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 5/4/22 Static water level at beginning of test 114 ft. Comments B. TANK DATA Age of tank(s) 9 years Tank type/material Sptcstl Measured operating fluid level in septic tank 50 ❑■ Standpipes/foundation cleanout per record drawing Date of pumping 6/11/21 D. ABSORPTION FIELD DATA 6/13/85 Which system tested (date installed) same ❑■ ALL standpipes present per record drawing Total measured depth from grade 11.5 ft (max) Measured depth to pipe invert from grade 3.5 ft (min) ❑ N/A — pressurized field ❑■ Monitor tubes go to bottom of effective. If not, state depth into effective Well production at time of test 8+ gpm Water storage tank volume0 gallons Well disinfected for coliform test? ❑ Yes ❑■ No ❑ Coliform bacteria is Negative Nitrate mg/L ❑■ Nitrate less than MRL (ND) Arsenic 4.59 ug/L ❑ Arsenic less than MRL (ND) Collected by NRim Eng. Date of Sample 5/4/22 C. LIFT STATION ❑ Required maintenance completed Age of lift station years Lift station material Comments: Adequacy test date 5/4/22 Results ❑✓ Pass For 3 Fluid depth prior to test 0 Water added 450 gal New depth 3 in Elapsed time 30 min bedrooms in ❑E Code -required soil cover over field Final fluid depth 0 in ❑ System presoaked Absorption rate 450 gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) n0 date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: COSA Checklist yellow sheet E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' Yes Community Sewer Manhole/Cleanout > 100' 0 Yes if No ft 0 Yes if No Neighboring Tank > 100' Yes if No ft Private Sewer/Septic Line > 25' El Yes if No Absorption Field on Lot > 100' Yes if No ft Holding Tank > 100' 0 Yes if No Neighboring Absorption Fields > 100' Yes if No Animal Containment > 50' ❑✓ Yes if No 0 Yes if No ft if No ft If septic tank is under driveway ft ft ft ft Manure/Animal Excreta Storage > 100' Community Sewer Main > 75' El Yes if No ft 0 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. Property Line > 5' Q Yes if No ft Wells on Adjacent Lots: Q Absorption Field > 5' Q Yes if No ft Private Wells > 100' ❑✓ Yes if No. Water Main > 10' ft Yes if No ft Community Wells > 200' ❑✓ Yes if No. Water Service Line > 10' Q 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' Q Yes if No ft Wells on Adjacent Lots: Water Main > 10' Q Yes if No ft Private Wells > 100' 0 Yes if No Water Service Line > 10' Yes if No ft Community Wells > 200' 0 Yes if No Surface Water > 100' Yes if No ft F. ENGINEER'S COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet OF ..:4..TH.. ..: *, Steve CE -6256 *AF ft ft ft ft ft 1 \ S 68'26'01 "E 0 i2 o CaC'9s O es 2� PLOT PLAN AS BUILT X SCALE 1" = 40' GRID SE 704 Project No. 13-226 Lang & Associates, inc. 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Registered Land Surveyors (907) 522-6476 Phone Re oQ000000 g y (907) 522-4625 Fax kenOlangsurvey.com / jonothanOlongsurvey.com OF q QOP�, .. • • • , • I hereby certify that I have surveyed the following described property: TRACT D-2, TERI SUED. ADD. 2 (Plat No. 80-172) 0 * q.gTH 's440•• •• v* Anchorage Recording District, Alaska, and that the improvements situated thereon are �....:........r9 ......:... within the property lines and do not encroach onto the property adjacent thereto, that Q /T J no improvements on the property lying adjacent thereto encroach on the surveyed 0 , • r; • • ... •' premises and that there are no roadways, transmission lines or other visible Q KENNETH G. LA •� easements on said property except as Indicated hereon. Q , Dated this the 8 Da of Num �� 00••'• S-520 Y UM-P�r f at Anchorage, Alaska S •� , •''••50 0 It is the responsibility of the owner to determine the existence of any easements, �O�R�FfSsioNA�oo" covenants, or restrictions which do not appear on the recorded subdivision plat. �40000� "3 V60% NOTE: DRIVEWAY ENCROACHES ONTO TRACT D-1 / / 16.1' IOU / NOTE: DRIVEWAY ENCROACHES ONTO TRACT D-1 / / 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. 1. GENERALINFORMATION Complete legal description Tract D2; Ter± Sub~±vls±on Location (site address or directions) Harca Street Property owner Charles V. Talsky Day phone Mailing address H 4 '~~ka 99577 Lending agency Day phone. Mailing address_ Agent Day phone Address 694-2977 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: lJnless otherwise requested, HAA will be held for pickup. 3 NOTE: Individual well xxx Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWAT["!R DISPOSAL,: NOTE: Individual on-site XXX Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and stafus 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 Address Engineer's signature Phone __ Date DHHS SIGNATURE F., Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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) 8ack MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAl. CHECKLIST Legal Description: / ~/~ ~]::~'~ "~¢-t Parcel I.D, A, WELL DATA Well type ~:::~"~\[ h-''C~-'~ If A, 13, or C, attach ADEC letter. Log present ~'4) ~,] [)ate completed Total depth /'~'~' 'Z-'* Cased to /Jrt' ~ Sanitary seal~'/N) y Date of test Static water level Well flow Pump level FROM WELl. LOG SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line .~,~ t ADEC water system number ~'-'~-~, ¢ '7 fJ Driller Casing height Wires properly protected (~N) AT INSPECTION g.p.m. ~_________________,~, ..~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE[ RESULTS: Coliform (-~ ~ ""J~ ~,,C Nitrate Date of sample: B, SFPTIC/HOLDING TANK DATA Date installed Cleanouts ~ON) ~-/ High water alarm (Y/~)) Date of pumping Collected by: _ Other bacteria $ & $ ENGINEERING 17034 Eagle River Loop Road No, 204 Eagle River, Alaska 99577 Tank size ~,~¢,~, ~..t._ __ Compartments Foundation cleanout ~'~N) ',// Depression (Y~:~ ~'~ . Alarm tested (Y/N) ~-~' /_~ ~. l.~ Pumper ~g--- , SFPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ z:>o ~ ~ On adjacent lots To property line ~ [ ''¢ _Absorption field Surface water/drainage ~ z) ~ Foundation Water main/service line 72-026 (Rev. 7/91} Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at ~vel at High water alarm level Meets MOA elec~"~~Oyc e~ tested SEPARATI~..~.~STANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length ~ ~'' ~ ¢¢ ' Width Total absorption area Depression over field (Y~P~ Results ~/fail) /?,&~ % Peroxide treatment (past 12 months) (Y~ Soil rating t,'~,~::>~ ¢/~¢~'' System type Gravel thickness ¢' ~ Total depth Cleanouts present. TN) Date of adequacy test ~, .- for ("~) "/-/'t/~ ~ bedrooms t/_.~ o ~(~,J If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot To building foundation On adjacent lots Surface water \ O O Curtain drain E. ENGINEER~SCERTIFICATION !!i~~, , I certif? that I have checked, verified, or conformed to all MOA and HAA guidelines in effoct on the date of this in~ection. Signature $ & $ ENGINEERING 17034 Eagle River Loop Rca8 No. 204 Eagle River, Alaska 99577 Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91} Back MO,~ Waiver Fee: $ Date of Payment Receipt Number ,/~.~× CHEMICAL& 6I;~OLOGICAL f~ABO~TORI : JUH 25 92 t 1~:00 with : A? BB~UIB~D Reqt ~ ~ond i~po~t~ to: Sample BOU~IME 8AMPLE COLLgCYED BI: i~AI, I ~e,t, P,rforr~ Soo Bp~olal In{truction~ Abovp U}-Un~vallabl~ ND' Non~ DItPct~ "9me 8ample N~rk, hbow IVIUNICIPAI. ITY OF ANCHORAGE DEPARTMENT O1" HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITI-- SEWER AND WATER FACILITY 264-4720 Application Date GFNERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) TraCt D-2 Teri':; Addn. #2 T14N R1E Sec.33 Location (address or directions) Off mile ll Eagle River Road (b) Applicant NameChuck Talsky Telephone: Home 69li-2977 Business694-2977 Applicant Address SR :LB Box 24:L7 Eagle River, AK 995?7 (c) Applicant is (check one): [_ending Institution [-I; Owner/builder:~l:; Buyer Fl; Other [] (explain); (d) Lending Institution Home Savings8 & Leal1 Address :L001 E. Benson Anchorages, (e) Real Estate Company and Agent Telephone AK 99503 272-1451 Address Telephone (f) Mail the HAA to the following address: _ TYPE OF RESIDENCE Single-Family~;~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Well [] Community [] Public [-] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite l[~: Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conserw~tion attesting to the legality and status. Page 1 of 2 ENGINEERING FIRM PROVIDING ..~SPECTIONS, TESTS, FILE SEARCH, DA1 As certified by my seal affixed hereto and ss o! the validation date shown below, I verify that my investigation of this ~lealth Authority Approval shows that the on-site wster supply and/or wastewater disposal system is safe, functional end 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, tire omsite 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 ol Firm EABLE R!VE[LF. EBJ~LE~.~IN(~ S_;RVICEF _____ Telephone EAGLE RIVER, AK 99577 Address Date .//,//~/':~Y'- 694 -.~L95 Engineer's Seal Approved ,or~~¢'~ ~¢ (~-~e~d roo ~~';;~/~/_/~/. ..... Approved ~ Disapprove~ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (I:)HEP) issues Health Authority Approval ce~'tificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees o! DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible lor errors or omissions in the professional engineer's work. Page 2 of 2 72 025 (i 1/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: /~UNICIPAUTY OF ANCHORAGE D~P% OF HEALTH & I~NVIIIgNMENTAL PROTECTION NOV 06 Well ClassJficetion /~'"8 / ~'.4 /-,,~ If A, B. C. D.E,C. Approved (Y/N) Well Log Present [Y/N] /v Date Gert pleted .5--/~ y Yield Total Depth / :~ '~' ' Cased Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separaeon Distances from Well: To Septic/Holding Tank on Lo1 __ Depth of Grouting Pump Set Al Sanitary Seal on Casing (Y/N) Depression Around Wellhead [Y/N1 Y : On Adjoining Lots To Nearest Eege el AbsoretJon Field on _et / ? ~-/ /"'/'i 6n Aajo~mng Lots / To Nearest Public Sewer Line .¢.,'¢o.'~4 To Nearest Public Sewer Cleanout/Manhole /'z~¢,~.~. To Nearest Sewer Service Line on LOt Water Sarr Die Collected by _ '~:'~'~ ~ .-~¢~,,r.-.t /~?,w$/.~¢~.~.~ )ate _ Water Sam ~le Test Results .~'~ 7'/.x ,~, ¢ /7~U~ Comments 3 SEPTI C/HOLDING TANK DATA Date nstal ed ~//'¢ S- Standpipes (Y/N) _ ff Depression over Tank (Y/N) Pumping¢ Maintenance Contract on File [Y/N) Holding Tank High-Water Alarm (Y/N) Separabon Distances from Septic/Holding Tank: To Water-Supply We /~.3 ' To Property Line ,~-o ' To Water Main/Service Line /o Course Size /¢¢,o ~'~',~ / No, of Compartments Air"tight Caps (Y/N} _ .J/ :oundation Cleanout (Y/N) Date Last Pumped : for .4.//.-4- Temporary Holding Tank Permit (Y/N) re Building Foundation / / ' To Disposal Field To Streaff Pond, Lake or Major Drainage Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Width of Field ~ / Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ¢¢ Type of System Design Length of Field ~'~- ? Depth of Field ~' / Gravel Bed Thickness ¢~' / Standpipes Present (Y/N) Date of Last Adequacy Test To Water Main/Service Line ~'~/~9" To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line ,~'4:~ To Existing or Abandoned System on ; On Adjoining Lots z'Z2~,~. ~ To Cutbank (if present) Comments Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ? ~-----~ Date '/" d),~/;Y % Company /~-~,~ "~, ~ MOA No. ~' Date of Payment I I- ~, - ~,~ Amount: $ (,~¢~ Engineer's Seal Page 2 of 2 72 026 (11/84) Eagle River Englneodng Services ~ 0, Box 773294 Eagle Rlvec AK 99577 694-5195