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HomeMy WebLinkAboutUS SURVEY 3043 LT 1 OF LT 11 T10N R2E SEC 18U $ Survey 3043 Lot 1 of Lot 11 #075-092-30 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME LEGAL DESCRIPTION LOOAT,ON //¢/2-F /-- :~Z??? I []~EW J~UPGRADE DISTANCE TO: We ~/~z~ ]7~' Dwelling Manufacturer Q ~1 fe]l~.~ DISTANCE TO: No. of lines Length of each llne Top of tile to finish grade Nearest lot line Trench width Length Width Type of crib Crib diameter PERMIT NO. No, of compartments Liquid depth PER T ZCZ Liq u id2a~Y~ g~° n s PERMIT NO. Distance between lines inches Total effective absorption area inches PERMIT NO. Well DISTANCE TO: Foundation DISTANCE TO: lilding foundation Total effective absorption area foundation Nearest lot line Distance to lot line line Septic tank OTHER MATERIALS SOl L TEST RATING INSTALLER 13 (Rev. 3/78) LEGAL · OEF'ARTMENT OF HEAL.TH AND ENVIROI'qMENTAL F:'R~TE~TI~N ~25 - STREET, qNCHORAGE, ~':; 99U0~ 264'"'4720 F:'ERMIT NO: 840926 HOLDING TANK DAI-IE I SSLI!ED: 10/31/84 · ,, I ...... ~1 ,. C/O S 2 S ENG'G HAROLD biEBERT ADI}RESS= oRE 196X EAGLE RIVIER. Al< 99577 CONTACT PHONE: ~94-2.979 L.Ei:a~I~ .... DESCRI.F': ,..LIBLI[,~ ' ~ I,u].(]lC' - xl,. U.o'm ....... :* ~r "r:, .... ~. .. ~ I P: SECT'[ON: 1S i~ TOIxlNS :[ 0 N I-OT SIZE= 100C~() (S9. :'T,, OR LOT': C,R, , ! ~ ...... lC,.. NA RANGE: 2E I cer'Li~y that: fcirt, h by th~ Municipality c',F Anchorage (MOA) anm t. he State of Alaska= 2,, I will inst. all the system in accordance wi'Lb all MOA codes an~ regulations~ and in compliance with the des:i, gn criter)a of 'Lh:i.s pel"mit. 3,, I will adhere Lo all MOA anti Sta'Le of Alasl.::a r's~quil'e)lile~r~'(.~Ns for' the set. back distar'lc:es Fron' any existirmg well, k-~as'l'.ewa'ber disposal ~vs'Lem OD I:)ubl;i.c IF A I_..IFT STAT]:ON IS I,,~)].~J_,._D ];Ix! AN -fi.,~.,., COVE:RED BY MOA LL THEN (1) AN ELECTR~. I='ERMIT AND IIx!SPECTION MUS]" BE OBTAINED; (2) ~S'""BUILTS WILt_ NOT' BE AI:F:R~ZD/¢~,ITIIOUT AN ~[LE(CTRICAL .[NS,:'EC].I.[]tq ,=:l...,:'O,,r, Al,ID (..;,) TIqE. ",:~c:,, c'O BY [,ATL,, , ...................................................... 1 ................ ] 7'-0  MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION ~--825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 o N-sITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT D SCRIPTION LOCATION NO. OFBEDROOMS DISTANCE TO: JWell are8 Dwelling Manufacturer Material IF HOMEMADE: Inside length DISTANCE TO: Well ~--~ / Dwelling Manufacturer Well Foundation DISTANCE TO: No. of lines Length of each line :h of lines Material beneath tile Width Nearest lot line ench width inches NO. LiqL NO, teen lines effective absorption area Length Width Type of crib Crib diameter Well DISTANCE TO: Class Depth Building foundation DISTANCE TO: Depth PERMIT NO, Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line Sewer line Septic tank OTHER REMARKS DATE LEGAL RPPL I CRNT LOCFIT I ON LE DEPFIRTMENT OF HEFILTH AND ENVIRONMEHTFIL PROTECTION c..:, " ' '-- ' - -' '- ,_,=5 L~ ~TEEET, HNcHORMOE., HK. _.~ CHRISTY MIT_,HELL BN 447 GIRDNOOD, GI RDWOO[:, , , ~ Z5800 SQUARE FEET LT. Z~ OIRDWOCD SM. TR, ~042: LOT SIZE TYPE OF _,OIL HB_~uRPTION =,T_,TEM '-' [:,RFIINFIELD HFIXIMLIM NUMBER OF BED, ROOMS '_-':OIL RATING ,;S-.' FT.-'BR)= 400 THE REQUIRED SIZE OF THE SOIL FIBSORPTION SYSTEM IS: [:,EF'TH= ~ LE~'-4GTH= El GF'A'..~EL THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFIINFIELD. THE DEPTH OF B TRENCH OR PIT IS THE DISTBNCE BETWEEN THE SURFACE OF THE GROUND fiND THE BOTTOM OF THE EXCBV~TION (IN FEET). THE TFtE~-BC:H [-.! I [:,TH I ~S 8. ~ZlCdEl FEE-F. THE GRB',,,'EL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE' OUTFBLL PIPE AND THE BOTTuM OF TME ENC.~?BTION .IN FEET). RE=,PUN_,IBILIT't TO INFORM THIS DEPFIRTMENT DIIRING THE PERMIT HFFLI_mBNT HFIS THE ' '- - '= ' " IN:TFtLLFITION IN=FEuTIQN_ OF FIN'Y WELLS AD..TFICENT TO THIS F'ROPERTY FIND THE NUMBER OF EEbIDENCE_, THFIT THE WELL NILL SERVE. ~ > I ~'-.~_--'5. F'EF-:T I C~I'-.I-S t-~RE REQU I F-:ED BFICKFILLING OF FINY =,~_,TEM WITHOUT FINt~L IN=,FEL. TI_N FIND FIF'PROYFIL BY THIS [EFHRTMENT WILL BE SUBJECT TO PROSEELTION. MINIMUM DIST~NCE BETWEEN fl WELL FIND RNY ON-SITE SEWAGE DISPOSFIL SYSTEM IS Z00 FEET FOR FI PRIVFITE WELL OR ~50 TO 200 FEET FROM FI PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC NELL. MINIMUM DISTANCE FROM FI PRIVFITE WELL TO ~ PRIVFITE SEWER LINE IS ~5 FEET FIND TO ~ COMMUNITY SEWER LINE IS ?5 FEET, OTHER REQUIREMENTS MFIY FIPPLY. SPECIFIC:FITIONS FIND CONSTRUCTION DIFIGRFIMS ARE FIVFIILBBLE TO INSURE PROPER INSTFILLFITION. F' EF.'J"'I I T E::---:,F" 'r F-:ES E:,EC:,EI'-lBER --~]--.. I CERTIFY THFIT i: I FIM F~MILIFtR WITH THE F..EW. UIEEMENT_, FOR ON-=,ITE =,EWER_ FIND WELLS RS SET FORTH BY THE MLINICIPRLITY OF ANCHORAGE. ~: I WILL INSTALL THE b~=TEM IN RLCORCHNL. E WITH THE CODE=.. ~: I UN[:,ERSTRND THAT THE ON-BITE SEWER =,~=TEM MRV RE~I_IIRE ENL:RRGEMENT IF THE R.E=,I[.EN_.E IS REMODELED TO INCLUDE MORE THRN ~: BEDRuOMS. .S I GNE[:, '. R'~ '- ' ............. ~ ................ ',, ,,, & I SSI_lED E, T__C~_~ ...... ~Z~2-~ ..... L: RTE ............... ',,,'4. 0 111�1111111 111 11011 ` n _ �� 3. :i� >� F. 5J i! '�� �I �..:4 b•3r[777M!,!U4' ,: Development Services Department On -Site Water & Wastewater Section Parcel I.D. 075-092-29 i.itgr Phone: 907-343-7904 Fax: 907-343-7997 Certificate of On -Site Systems Approval 1. GENERAL INFORMATION Expiration Date: 3-10- 2. —f0_ Complete legal description US SURVEY 3043 LOT 11, PART 1 T10N R2E SEC 18 Location (site address) 114 TELEMARK WAY, GIRDWOOD, AK 99587 Current property owner(s) MICHAEL & FAYE MONTOYA Day phone Mailing address Real estate agent 214 VIA PROMESA PASO ROBLES, CA 93446 2. TYPE OF DWELLING: ® Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) Day phone 3. NUMBER OF BEDROOMS: 2 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Private Well ® Private Septic ❑ Water Storage ❑ Holding Tank ❑ Community Well ❑ Community ❑ Public Water System ❑ Public Sewer Waiver request for: Distance: Received by: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ � 10( ccv I D —1 -� Date of Payment (-3 d 21D Receipt Number l COSA # O S C,2O I (0 5 9 Date: Waiver Fee $ Date of Payment Receipt Number 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 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 FIRST WATER CONSULTING Phone 907-350-9566 Address 13030 SUES WAY, ANCHORAGE, AK 99516 Engineer's Printed Name CURTIS HUFFMAN, PE Date 11/25/2020 Comments: This investigation was completed in compliance with MOA guidelines, regulations, and best industry practices / methods. 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, quality of construction (workmanship & materials), the water usage of the family being served by the system and maintenance. 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 •OF� well and septic system. Therefore, any estimate of how long a system will function satisfactory r�Q; for current or future occupants or guarantee that no unseen encroachments, deficiencies or g•' •9 �rJ discrepancies exist can be given by First Water Consulting& FWGS ' *• TH , , • ,•;* r� 6. DSD SIGNATURE �' .... '•'v'~" • Curtis Huffman j System #1 Approved for bedrooms � �Fc�'•, CE 128991 •,��,� pP �� `�TF�•11/z5/2o2o•�c� r System #2 Approved for bedrooms 11lF110 -1 SS10,, Disapproved lllll((l((f((( Conditional approval for bedrooms, with the follow`\cGQYcQX�, y� "s - ON -SITE �� ATE A►ir, m �rn WAST=v'ATER z^ �r RAM c; Original Certificate Date: 12,-10 T Z E) 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 Legal Description: US SURVEY 3043 LOT 11 NE4 T10N R2E SEC 18 Parcel ID: 075-092-29 If more than 1 septic system on lot: COSA Checklist # _of A. WELL DATA ❑ Well log is filed with Onsite (or attached) Date drilled 1977 Total depth *155 ft Cased to *155 ft Structure served by this system _ Water storage tank volume NA gallons Well disinfected for coliform test? ® Yes ❑ No ® Coliform bacteria is Negative Nitrate mg/L ® Nitrate less than MRL (ND) ® Sanitary seal is functioning correctly Arsenic ug/L ® Arsenic less than MRL (ND) ® Wires are properly protected WE Casing height (above ground) 18+ in. Collected by & COLE SULLIVAN Date of flow test for COSA 11/24/2020 Static water level at beginning of test 52 ft. Date of Sample 11/24/2020 & 12/6/2020 Well production at time of test 6.4 gpm Comments *PER PUMP INSTALLATION LOG IN MOA RECORD DOCS. 6. TANK DATA — NA Age`cf,,tank(s) _ years Tank type/material Measured operafhing fluid level in septic tank ❑ Standpipes/foundat &n,�cleanout per record drawing Date of pumping D. ABSORPTION FIELD DATA - NA 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 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 ded gal New Elapsed time ❑ Code -required soil cover over field Final fluid depth in El System presoaked Absorption rate gpd (Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 1 onths) date of test) Gallons introduced gallons If yes, enter date Comments/Deficiencies: F _'_I 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' Community Sewer Manhole/Cleanout > 100' ❑ Yes if No NA ft ® Yes if No Neighboring Tank > 100' ® Yes if No ft Private Sewer/Septic Line > 25' ® Yes if No Absorption Field on Lot > 100' ❑ Yes if No NA ft Holding Tank > 100' ® Yes if No Neighboring Absorption Fields > 100' Animal Containment > 50' ® Yes if No if No ® Yes if No ft Water Service Line >' _ 10` ®Yes Manure/Animal Excreta Storage > 100' ft Community Sewer Main > 75' ®Yes if No ft ® Yes if No ,Rr'om Septic/Holding Tank on Lot to: (Please enter distances if less than required) ft Building F oundations > 10' ® Yes if No ft Surface Water > 100' ® Yes if No _ Property Linene' , ® Yes if No ft Wells on Adjacent Lots: Absorption Field > 5'`V ® Yes if No ft Private Wells > 100' ® Yes if No Water Main > 10' ®Y`tst- if No ft Community Wells > 200' ® Yes if No a Water Service Line > 10' ® Yes if -o,,— ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances { less than required) Building Foundation > 10' ®Yes if No ft f�a,so ption 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 > 101' 111Yes Yes if No ft Water Service Line >' _ 10` ®Yes if No ft Community Wells > 200' 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 ��Q. •' . � � of Municipal records that the above systems are in conformance g.• ,� [¢� with MOA COSA guidelines in effect on this date. ,,® �.• Curtis Huffman. •. A, CE 128991 ��� pROFESSOI� . ft ft ft ft ft ft ft ft DATE SCHEDULED I I TIME INSPECTOR 14 VA SUBDIVISION US SURVEY 3043 BLKILTRRACT LT 77 NE4 INDICATE NORTH 1 _ n L o Lo ✓ L I r -o' J- i -c SIZE MAIN: gii TYPEMAIN: -DIZ DEPTATMAIN: AT PROP, LINE: 4 CONNECT LOCATION: i ��E ?.W �el COMMENTS 55 S C o4+ c i SE Ev si Cic+a a t{ INSPECTED BY: jlq �aI DAT io - i8-9b '.. MUNICIPALITY OF ANCHORAGE C] Repair Existing Service ❑ Main Line Extension WASTEWATER F-1 City Tap CONNECT PERMIT 96 - 751 a I. WATER &WASTEWATER UTILITY DATE OF APPLICATION 10/08/96 3000 ARCTIC BLVD. SCHEDULED COMPLETION DATE 12/31/96 PHONE: (907) 5642762 Main Tap -To Property Line Only BLOCWLOT/TRACT LT 11 NE4 ® SINGLE FAMILY SUBDIVISION Ds SURVEY 3043 D MUTT -DWELLING No.APTS, TION Res sec 1e COMMERCIAL TAXCODE 7509229 GRID 004913 STREETADDRESS Alyeska Highway OWNER MOLLAN PERRY J s Emma D MAILADDRESS OIRDWOOD,AE 99587-0211 AS -BUILT Mt""ADDRESS POST IN -A CONSPICUOUS PLACE AT THE JOB SITE AWWLI INSPECTOR C] Repair Existing Service ❑ Main Line Extension On Property Only F-1 City Tap ® Have Been Levied �y or_ Hydrant On `] y ty 50' or Longer F-1ToBe Levied Lip Main Tap -To Property Line Only comments: - 3 Main Tap & On Property Connect Disconnect '.. R&R - Main Tap Only owner sta OM1 CONNECT SIZE 4 ISSUED BY SAP INSPECTION FEE S 104.00 [DP,(,.- F -1C H PERMIT FEE $ 35.00 CHECKY. - $ INSPECTED BY REIMBURSIBLE - NUMBER DEPOSITS 0.00 TOTALS 139.00 DATE 101111/4 Mt""ADDRESS POST IN -A CONSPICUOUS PLACE AT THE JOB SITE AWWLI INSPECTOR qG E -4 L67A. fst2s i N0!?1H i n Is!P'IH+!I SEVER SERVICE -;NF. SKETCH hl} SHOVr• 1.CCATION : R CONTROL MIANHOLMCI.EANOUT5 3 v po i , PE MAIN. LM5 57t4• /3{ 2S�SAUDLE� G4ND ICY u5�P E.vB.- -7 7-87 \ -0 \ F § �_ o /K- \ q } k » ® `2 / 37 : !m \\ ] ):\2,G>` o» r =. _ e » ( : \ \ / \ \ \ » ! ! , / ) \ 3 «6 )!/� ; : \� \ \ ] _ 2)/o o : m \ [ ( ) \ k \ o --Ico amm o ( ; _ \ �- \� / §#2 § ® 2 ! ) : 2 ( / ( /> % 2c\ § / )/ \\( i ca !;> � �E -\)�■! / .6'j W V C) O sOr J e ,f�%j1*�ai rte• 45` ,/ 8 f `�.� ?v mss$ \ r- Ln/ V) f' ��' r.,' w ul2 / v CX , r .� •sses s oma. /, a rs / r W to N w / {n w n r j ¢ Q CC) / \ o J N // �v Y W `L rrth / Q. O O / Y Z �. W / U) o UJ O(/ :D i / U't W / Q / Q � r •00f�rrH ce Q. 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F- J LL 0 0e � Q goi mo�� I V) cr C> �M Bm gm Q CL --i Ea=lLH7Z0963Q-JZ:JV-8L9b-99a6-9b94abZb :41 w W N z t1 9 'n 'o Li i oo .- i V1 OCO Ct w z Z rn NCL I 1 cV OM a LU M b a L O rn II +n Ct 0) Z J om Q c�> z V), < Do ¢ cp f -z< d cn W Off+`+ J L)(10� o OS (3) U _j 'o. Q O 3 u6ignooa .De: P.£ MUniCi CERTIFICATE OF F< Parcel I.D. D 7,¢"' ~2 2 -' 30 ', Exp;ration Daf~e 1. GENERAL INFORMATION ' Complete legal description Lot'llD, USS 3043~ NE4~ Tf0N~ R~, $18 Zi~' [I) Location (si~e address or directions) Alyeska Hwy, tst Left past Rulein Road,. 2~d hbuse on Rt Currant Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing Address Day phone Day phone. Day phone Unless o ~ ,,rvwse l~queotec': HAA will be held by DHHS £or pickup. HAA picked up by:_ NU~J~BER OF BEDROOMS: 3 r~dividual Well ndividual Water Storage Community Class __ Public Water System Well TYPE OF WASTEWATER DISPOSAL: [] Individual On-site [] [] Individual Holding tank [] [] Commumty On-site [] [] Public Sewer [] The Municipality of Anchorage Department of Health anc Human Services (DHHS) Issues Certificates of Health Authority Approval (HAA) based oMy upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Aiaska Certificates of Health Authority Approval are reeuired for the transfer of title (except between spouses) on properties served ~y a single family on-site wastewater disposa and/or water supply system. DHHS also ssues HAAs upon request ~o home owners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for oro~erties served by 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 C ass A or B wells or a public water system The Municipality of Anchorage is qo| resBonsible for errors or omissions in the professional engineer's work. (Re'; 11/99) 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto andas o, the va idation date sh~in be oW, Verify tha?~¥ nye,, g~, on ba~ed on pro~ur6~ 6ul ded n the Heal~h.Au~ho~ ~V ~ppr~v~ G~id~ ne~ for this He~I~R/AG~h6~ iV Approv~ applicati0~-shows tha~ the on~s t~ W~t~ sbppl~ and)d~ '~asteWa[e[ disp0~bl s~s~em i~ s'afe, function~ and; adequate'for the hamber.bf bedrGd~s and'tyPe ~f,strb~t0r& }hdi~te8 here n I'fudh~r vetf~ t~at ba~ed on the information obtain~d from the Mbnicipafity'of;A~Chora~files and from my nve~tigat oA and inspect 0n the site water supply'and/or wastewater d'~s~o~al system is in~cbmpl~an~ With a appli~b ~Mun ~ pal and State codes, ordinan~s, a~d regulations in e~ect at the time of. installation.,: ." ' Name of Firm Pannone Enq;'SvC. ' ' ' · ~''' '~ ~ , ~ ' · ' Phon~ 272~8218 Address P.O. BOx ~02954, Anch, AK 99510 Engineer's Pdnt~ Name steven R. Pannone, P.E. ' -:' Date . 3/~2/200t Engineers Comments: ~ ~dUC~g a~ adequacy test, ~ attempt to provide a ~o~u~ co~J~uo~ ' ' ' ~a - ~g~fing analysis of~e ~-stem b a~ordance ~5~ MOA D~S Guidelines & Re~latio~.' The _..~. ~/~ _ O~ ?~ repo~ res~lB describe ~e ~ffo~ of~ system ~der fl~e ~n~ti0n~ en~er~ at ~dtme of ~e ' test, ~d sep~a~on ~st~ces m~as~ed to r~dily id*nt'fia~le fea~s. ~h* oper~a/ional life of a I w* ls ~d ~ ~'% ~' ' 1 s~tic sysWnu depend on ~e i~M soil mn~tio~ ~o~d water l~,e s thai:may fl~ ctuat~ d~n~ the ~ ca~ ~ )~ ff ~ ~ 7 and the water usage of~e hn~y being sen~ by ~e ~'stem. Thee ~.di~io~ are outs/de ~e ~ol Cf ~ ' ff ~ 9 TH ~ k Ihe cvaluator of this ~,stem. All ~'s~ms even~a~y fad mid safishcto~, test resulB do noVeuar~t~ ~'"'~'"~ ................ '"a'""~ fu~e pe~o~an~ of the syste~ nor do they gu~m~t~ thru there ~e'no hidden def~t~ or ~ncroaclm~dn~ PES can lhercforenot pro[,ide mw wa~ty for fature peffommn~ m;~ve anv,es~ateofhm, t~nethe ' s)stem wdl conbnue lo m~t the operat ona reqmrements office ADEC or MOA DHHS The content of ~) ' ,- : dnsrepo~ s for the sole benefit offlm mmer mtedabove ~yre anceuponor~seofthsre~o~bx am' ~% ~ - .- -' otherpersonorpartyisnotau~orz~nor~51 tmnferafi,lc,al~ htwhats~ver- ' - ~ ~ *42~?'..~[OX~'~ 6. DHHS SIGNATURE ' ' ~ Approved for ~ bedrooms, t~' ~'~ OF ~ Conditional approval for eedrooms, with the following st puling' ON-SITE WATER AND · WASTEWATER Additional Comments Attachments, HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Expiration Date: ~, - / ~z'-_ 0 I (Rev. ~ 1 ~9) Original Cedificate Date: p:.elssue Da,e: :g- Legal Description: A. WELL DATA Well type PRIVATE Date completed __ Total depth UNKNOWN LS :dcipaiity ot Anchorage Department of Health and Human Services Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw Street P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak, us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Lot 11D USS 3043, NE4, TION, R2E~ S18 IfA, B, or C provide PWSID # __ Sanitary seal YES Cased to 40+ ft FROM WELL LOG Parcel I.D,: ft g.p.m Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform 0 colonies/100 mi Date of sample: 3/4/2001 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Date installed Cleanouts Date of pumping o 7 C-- o q3.~ 30 Well Log _N_ Wires properly protected YES Casing height (above ground) 18 in. AT iNSPECTiON 3/3i200t 53 ft 4.7 g.p.m Nitrate 0,Su mg/I Other bacteria 0 colonies/lO0 mi Collected by: Steven R. Pannone, P.E. Public Sewer System Tank size Foundation cieanout Pumper C. ABSORPTION FIELD DATA gal Number of Compartments __ Depression over tank __ High water alarm __ Date installed Length __ ft Total depth __ ft Date of adequacy test __ Soil rating (g.p.d./ft2 or ft2/bdrm) __ Width ft Effective absorption area ft2 Results (Pass/Fail) __ Fluid depth in absorption field before test __ in Elapsed Time: __ min Final fluid depth Any rejuvenation treatment (past 12 mo.) (Y/N & type) (Rev. 11/99) System type Gravel below pipe ft Monitoring tube __ Depression over field __ For bedrooms Water added gal. New depth in. in Absorption rate >= __ g.p.d If yes, give date r~ ~ ~ffT ~TATION Date installed "Pump on" level at __ Datum Size in gallons in"Pump ofF' level at Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septi~tank/liff station on lot n/a Absorption field on lot Public sewer main 100+ Sewer/septic service line 50' in High water alarm level at __ in Meets alarm & circuit requirements? On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ SFPARATION DISTANCES FROM SEPTIC/HOLDINC~ TANK ON I C)T TO: Building foundation NIA Water main Drainage Properly line __ Water service line Wells on adjacent Iofs SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Water Service line Curtain drain F. COMMENTS Building foundation Surface water Wells on adjacent lots 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. Engineer's Printed Name Steven R. Pannone, P.E. Date 3-12-01 Absorption field Surface water Water main Driveway, parking/vehicle storage Date of Payment Receipt Number (Rev, 11/99) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEbJ~TH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Legal pescription (include lot, block, subdivision, section, township, range) Location (address or direction~)~. Applicants Address ~0 ~ ~ ~:~ Telephone Zm?3- ~'~ - Business (C) Applicant is (check one) Lending Institution ~ ; Owner/'-~m~rz~ ; - Buyer ~ ; Other ~ <explain); . (d) Lending Institution ~ ~Y F O' Telephone Telephone (f) Mail the HAA to the following address: Type of Residence Single-Family~ Number of Bedrooms Multi-Family / Other describe) 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, S.~wage Disposal Onsite ~-~ 'Public ~-~ Community ~-~ Holding Tank .~.~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. Engineering Firm Providing Inspections~ Tests~ File Search, Data and Information As certified by my seal affixed hereto ~nd as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that, based on the information obtained from the Municipality df 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 regula- tions in effect on the date of this inspection. Name of Firm Telephone Date F, ~, ..... ": ..... ~_~,~ ..' ~ ~,~ ~ (~o~E~ s~) ~~~~ ?' ' .~ .. '" ~. ~=oval ~ ~Y~$?,,. ..' .  _ ,~ ~h~- n" c¥~'~' ~ - Approved ~ Disapproved ~ Condition~ ~ Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPAR~I~ENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN THE STATE OF ALASKA. THE DHEP DOES ~HIS AS A COURTESY TO PURCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPL'OYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] . 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALT~ AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 · DEPT. OF HEALTII & E;~VIRONMEN'£AL NOV 5 1984 RECEIVED Legal Description:.//~7~// Total ~p~ / ~ ~ ~d to /%~ ' ~pth of ~outing Static Wate~ ~1 u~ f~ ) ~ ~t At 0{ ~ ~ Casing ~ight ~ Gr~nd ~ ~ ¢ /' ' Saintly ~al o~ Casin~ Elec~zcal Wirln In ~n~i (~ ~pression ~ound ~l~ea~~ ~p~ation Dista~s ~ ~ 7~ To ~olding Ta~ ~ ~t ~ c~ ' , ; ~ ~joining Lots ~. To ~a~st ~ of ~so~ti0n Field ~n ~t ~/~ ~ ~ Adjoining ~ts To ~est ~blic ~= Line ~/~ To ~est ~blic ~r To ~est ~ ~t slean~ a ~ ~ ~¢~ ~/; ~te wate~ s~ y . - wabe~ s~le ~st ~sults ~ r/~¢ C~ents Be [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA SoilsPating in Absorption Strata Date Installed Width of Field Square Feet oE Absorption A~ea Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes P~esent (Y/N) Depression over Field (Y/N) Date of Last Adequacy Test __ Results of Last Adequacy Test . I / Separation Distance frcarl ADso~Pt[on~d~//~' ' To Water-Supply Wall /To~o~erty Line To Building Foundation ~ To Existing or Abandoned System cn Lot ; On Adjoining Lots To Water Main/Service Line To Cutbank(if present) To Stream/Pond/Lake/c~ Major Drainage Ccu~se To Driveway, Parking Area, ~Vehicle Sto~age A~ea Cc~m~nts D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water AlarmLevel at Tested for Electrical Codes(Y/N) Din~nsions /~ Manhole/Access (Y/N) Vent (Y/N) Pumpin~Cyc'les 'du~lng Adequacy Test. M~ets MOA Conments ** Check Permitted Bed~comRating Against HAA Request I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this inspection. KB1/dS/s MOA No. [PaGe 2 of 2] ~' DATE RECEIVED : ~'° INSPECTION APPOINTMENTS TIME TIME TIME outside tap DATE DATE DATE 9-25-81 Friday INSPECTOR INSPECTOR INSPECTOR Pratt /V~UNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTJL~IRONMENTAL PEOTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION S~P 2 J. 1981 Telephone 264-4720 ~R~F~ ~ i~ ~SD REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEW I DIRECTIONS: Complete all parts o~ page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTYOWNER I PHONE Dave/Arlene GermannJ 783-2356 MAILING ADDRESS % 1577 C Street ~103 99503 PROPERTY RESIDENT {If different from above) PHONE 2. BUYER PHONE Harold Herbert 783-2254 MAILING ADDRESS BOX 356 Girdwood 99587 3. LENDING INSTITUTION PHONE First National Bank of Anchorage 265-3745 MAI LING ADDR ESS Box 3-128 99501 4. REALTOR/AGENT PHONE Randy Wagner 276- 4501 MAI LING ADDRESS 1577 C Street ~103 99503 5. LEGAL DESCRIPTION USS ,~3043 Portion of Lot 11 STREET LOCATION Alyeska Highway 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS :~ One [] Four [] Other ~: SINGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six 7. WATER SUPPLY :~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled ' [] COMMUNITY since June 1975. For wells drilled prior to that date, give well [~ PUBLIC UTI LITY depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM :~ INDIVIDUAL/ON-SITE** HOLDING TANK YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) ~ ~,~ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] iNDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] iNDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or E~]Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS [Z~]~'~-PP R OV E D FOR / BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY / 72-O10 (Rev. 6/79)