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VILLAGE PARKWAY ESTATES #1 LT 2
Village Parkway Estates #1 Lot 2 #020-291-50 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Water System Permit Permit Number: OSP231165 Work Type: Well Initial Tax Code Number: 02029150000 Site Legal Address: VILLAGE PARKWAY ESTATES #1 LT 2 G:3637 Site Mailing Address: 19400 VILLAGES SCENIC PKWY, Anchorage Owner: FERNANDEZ KYMBERLY E Design Engineer: This permit is for the construction of: Effective Date Expiration Date: Lot Size in Sq Ft: Total Bedrooms: cnt De I)aI- tment 6/20/2023 6/19/2024 130757 ❑ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well 2 Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: (SS urs -Fo (^//'fl—k�L- t"/Ct4Date: Y2D 2 Issued By: � Date: _ 3 MUNICIPALITY OF ANCHORAGE Development Services Department Oki Phone: 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 1A4Vk ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. IO2-09 1 S000D Property owner(s) k\j n&6 -e r(c4 (2-e 1, ej&,,_LLtt7 Day phone 90-7 S-25_ 338� 3 Mailing address I LI 4yb 1/i QoL u, Sct n tc 3a, k -w cc -4 C,[ Ay-, 9gsl (a Site address ML�oO I illcLy sGUSiy ,Qa.rk uaq ,A_, . Ak a1cwo cj Legal description (Sub'd., Block & Lot),/ I lQ o,c., Fbrk,wcy-i ES-jr kS # / Lo{- -2— Legal description (Township, Range & Section) Lot Size r '--D-757 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption_ Field ❑ Initial Single Family (SF) ❑ (w/wo ADU) Septic Tank ❑ Upgrade ❑ Duplex (p) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage K "TGln:V- iS nn"*t oLl?erovGd Zoo Ga� Cretc �D«y-�CwIG Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. ignature of -property owner or authorized agent) Permit/Rush Fees: /, Z- S - Date of Payment: Cj Receipt Number: Permit No. S(D Z 3 1 1 Waiver Fees: Date of Payment: Receipt Number: Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc . 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- 41AA-1 /'��,�,AJ 0dC PHONE NEW 11 UPGRADE MAILING ADDRESS /940o 1/// 1'46E sc4-=711C r'kwv LEGAL DESCRIPTION AA/C/-1d1IF 6E=, AA LOCATION V/LL,4Cm�' P/}1cd vvltY i �� A/o. / 8GKW 4., GOT Z NO. OF BEDROOMS 3': DISTANCE TO: Well %/t Absorption area Dwelling 4W /S PERMIT NO. /v` �j (.SCJ z / VY 17Z WF Manufacturer /= Material S�ZZ No. of compartments -� y Liq. capacity in gallons /Z; � IF HOMEMADE: Inside length ��• Width —� Liquid depth �-- ❑ DISTANCE TO: Well Dwelling PERMIT NO. _10Z 02 F Manufacturer Material Liquid capacity in gallons ❑ DISTANCE TO: Well Foundation Nearest lot line F. PERMIT NO. w= /8p, EZ No. of lines a Lang? of ach lin 7 Total length o li ey Trench width �/, Distance between lines �v F?� J Z Z /- /� y inches OC F. Top of tile to finish grade r Material beneath the rr r Total effective absorption afea ❑ l0 2' sf}N'/� �U FikAU inches �jj© Length Width Depth PERMIT NO. w (7 Q F Type of crib Crib diameter Crib depth Total effective absorption area w d W Well Building foundation Nearest lot line DISTANCE TO: J Class Depth 300/ driller AK NL Distance Ato Ire PERMIT NO. ,��� N� 'YY w -� DISTANCE TO: Building f�non Sewer line ^(/� Septic tank, 7 Absorption areas) 2e3rf- OTHER s s f (v 8 PIPE MATERIALS ! 6 SOI L TEST RATI NG /50 o�%JiC' 11 of tr 6v su r6 ^I t INSTALLER P Ime 17 ow/v&7c REMARKS O Rleo,V-580 AE�VM crF Fi« API -z -X 41 441 41L I-AIVIOSCAOIIIV�� IS fV 0-54/J0 `UA/ E. 5./0 A5A/d/ Z W, 5AP4 IE C. , v i V /A! 6,r y -:5 C40"S TN /59 rH S Ti APPROVED DATE LEGAL 72-013 IRev. 3/78) PERMIT NO: DATE ISSUED: ,��P! 0 -1.1 C,_ -.0. L.- T. -y". ��W, ff-31F� �P �11 V. -II C-3 SnPi, C-�� IE-. DEPARTMENT OF HEALTH AND ENVIP[]NMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-i472O 11,3 IT1,11—En; 1E T �11: 1 .,@if E,: I� �: - �����IL.- F- E`-,, OR", 11 -11, X , F, APPLICAMT: ADDRESS: CONTACT PHONE� LEGAL DESCRIP: LOT S�ZE: 850O21 ENGINEERED DESIGN 01/22/85 ALLFN J. MOOR 6522 IMLACH ANCHORAGE, Au 99502 561-1148 SU8nIVISION: VILL, PW ESTATFS #1 LOT: 2 BLOCI<: N/A SECTION: 15J TOWNSHIP: 11m RANGEP. 3N 13o757 (qg,FT. nR Ar REp> I certi[y t�at: � 1, I am �amiliar wi .h the requirements �or on-site sowers and wells as se+ Iorth hy the Municipality off Anchu,age (MOA) and the State p" Alaska. 2" I will installthe syste�� in accordance with all MgA codes and regula+inns, and incompliance with the design criteria o'Lhis permit^ 3. I wi]l adhere to all MOA :And 9tate o1 41as1 .a requirement.s For the set back distances 1,r1)m any existing well, I'^astewater dispo,Ljal system or publiC- s ewerage system on this or any adjacent or nearby lot, IF A LIFT STATION IS INSTALLED 7N AN AREA COVFRED BY MOA BILDING CODES. THE�1 /�) AN EiECTRI��AL PERMIT AND INSPECTI[lN MUST BF OBTAINED; (2) AS-8UILT�S WILL NOT BE APPROVED uITHn!!T AN ELECTRICAL INSPECTION 9EPOR,T-; AND (3) TME ELF CTRI[�AL WOR BY A LICENSED ELECFIR ICLAN , SIG��D DATF: \ T1 Y�\ -._. x-��u�___-________ ` » \ APPLICANT: ALLEN J. MOOR ISSUED BY ` ^ zue4 CL ~ / u'Art-'? ` PERMIT NO DATE If-".+SUEDN APPLICANT: ,T: CONTACT RHONEi:w L...ECi'.AL JESC:;E IPs I_..OT SIZE: I Pell LJ Ih':II 7C E_ ..@.. F:" .I__ I T 10 :; ,r-...% 1""111 _ "; hi C_:..; .. ;r-, ..._r E__ DEPARTMENT OF HEALTH AND ENVII OI1MENSL.. RROTECCfIOrd L. STREET, ANCHORASE, AK 9950:1. 264-4720 1II �:�._... m:.c•. -v_-' p.:' .r_:•E.c.IL,I'J_Lp _,E_L_b_F= - L__ 840965 ENGINEERED ,u_).r rF.:SIC- 11/28/8/1 : ALLEN J. MOOR (S522 1:111-ACH ANCHORAGE: iii':: 9950 561-1148 SUBDIVISION: VILL. PW ESTATES HI LOTc ;_ SECTION: 15 TOWNSHIP: 11N RANGQ 130757 (SQ.FT. OR ACRES) certify that; 1 1. C am familiar with the r6gLAaPE'.tr2nts for Cin-..sit2 53(3WePS and forth by the Municipality of Anchor=age (MOAK and the Stat$ •_.. 1 wi.l.l. install ....u:. .,y-.tetr in ,.._ccarrl<urt:::r+ with a.l._. INCA c:oca!;a=i and in compliance .with the desa:i.gn criteria of this permit. 3. i will ,_,;;he;,_ to all P;Gr, ::inr.l Si_aL_ of !11<ar>k<, ra_sct_irerllc_u.tra distances from any existing well, wastewater disposal sys'L sewerage system on 't.1'is or any adjacent or nearby lot. N IF dLIFT STATION r S INSTALLED Ih4,rRr1 COVERED tY °r:fUC_ITNG HEN (1) AN ELECTRICAL PERMIT ( i'lND INSPECTION MUST BE OBTAINEI)p (2) WILL NOT }ilii_ APPROVED WITHOUT AN ELECTRYCAL INSPECTION REPORT; AND ELECTRICAL WORK MUST BE BONE BY A LICENSED EI_f_C RICIAI',I:. SIGNED APPL..ICANTg ALLEN 3. MOOR , :isry'.IJE"t7 BY -?2 Gam ---- DATQ E):. TE;; l�/a fes% WATER WELL RECORD r STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological 8 Geophysical Surveys LOCATION OF WELL (Please complete either la, ID or It.) 5. DATE OF COMPLETI N —lL Z 6. ❑Cable tool (KRotary ❑Driven ❑Duff ❑ Auger ❑ Jefted ❑ Bored ❑ Other: 13 c O`1,17, 70 f la. BorougnSjj''bdivi Sion VMill Lot Block Ar klpe-4 y Ib. I/4 qtrs. �1 {7.A rt sA7ALf S. CASING: ❑ Threaded [A Welded di0m.__�__.In. royft. Depth Weight ,ft diom.__in. to_ ft. Depth Stickup it. 0 Q _ TYa tOO — It. DISTANCE Ap 11 nrvE$j� FROM ?OAD-1INTERSECTIONS Jq" Street Address and Area of Well Location Drilling Permit No. A.D.L. No. Section No. TownshipN❑ Ranffe E❑ Msrl did. 5 ❑ W❑ 3. OWNER OF WELL: 911en Moor Address: 2. WELL LOG . Material Type Feet Below Surface Top Bottom 4, WELL DEPTH: (final) MoD fl. 5. DATE OF COMPLETI N —lL Z 6. ❑Cable tool (KRotary ❑Driven ❑Duff ❑ Auger ❑ Jefted ❑ Bored ❑ Other: 13 c O`1,17, 70 f 'L. 6 C k. 20 d T. USE: DQDomestic ❑ Public Supply ❑ Industry E] Irrigation ❑ Recharge ❑ Commerical ❑ Test Well ❑ Other: _ rnrk,era0 Ar klpe-4 y Fe 1116e G S. CASING: ❑ Threaded [A Welded di0m.__�__.In. royft. Depth Weight ,ft diom.__in. to_ ft. Depth Stickup it. Q _ TYa tOO 9. FINISH OF WELL: Y TYPe: T)hIPo Dlomder SIof�Mesh Site: Length: Set between fl. and ft. BockfiHing Grave] Pack CLOli-1 Yf ' 10. STATIC WATER LEVEL: 1 8 S ft. ❑Above or C] Below land surface Dote Eduipment used: s / O If. PUMPING LEVEL below land ...fact and YIELD 1t. after _hn. Pumping g.p.m. _11. eller _tent pumping __q.D.m- 12.GROUTING Well Grouted: ❑ Yet W No Material. ❑ Neat Cement C] Other: MUNICIPALITY OF AN FHEALT & 13. PUMP: (If available) HP Length e1 Drop Pips ft. capacity 9 P.m. ❑ Subm. ❑ JN ❑ Cenlriflcal ❑ Other -- 14.REMARKS: i 16. WATER WELL CONTRACTORS CERTIFICATION: 15. Water Temperature This well was dnlltd under my Iu,isdl,lion and this report is true to the best of my knowtedge and beilefp , R". t4s�A..i� f fi�f'tr�k.st. d/J —i37-7 I R¢g. ..'ed sinews Nome Contract License Number —99� iH Signet _&r its. ic' m 02 *WH i:,/bll Dole: d - ere Copy 0,1,bubonWHITE' Stare DIGS, PINK - Driller, CANARY- Customer e F1 IF LJC 0 f�,, 4r, Cd r "2, � �7�y •'�/ Municipality of Anchorage On -Site Water and Wastewater Program (907)343-7904 Certificate of On -Site Systems Approval Parcel I.D. 020-291-50 Expiration Date: `7 it if j 3 1. GENERAL INFORMATION Complete legal description Village Parkway Estates #1, Lot 2 Location (site address) 19400 Villages Scenic Parkway Current Property owner(s) Allen & Phyllis Moor Day phone Mailing address 19400 Villages Scenic Parkway, Anchorage 99516 Real Estate Agent Day phone 2. TYPE OF DWELLING: El Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 3 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ll Individual El Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request Received by: �' ib i ��L �� Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ 0 �2 Waiver Fee $ Date of Payment (P l ?> Date of Payment Receipt Number bi -- q � Receipt Number COSA # 05r, � 9 N 0 11 1 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. Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218 Address P.O. Box 100217, Anchorage Ak. 99510 Engineer's Printed Name Steven R Pannone 6. DSD SIGNATURE System #1 Approved for 3—bedrooms System #2 Approved for bedrooms Disapproved Date 13C9`('G Conditional approval for bedrooms, with the following stipulations: Original Certificate Date: 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 blue sheet f '., c If more than 1 septic system is on the lot: COSA Checklist # of Structure served by this system I Certificate of On -Site Systems Approval Checklist Legal Description: Village Parkway Estates #1, Lot 2 A. WELL DATA Well type Private If A, B, or C provide PWS ID # Date completed 6/8/1985 Sanitary seal (YIN) Y Total depth 300 ft. Cased to 13.5 ft FROM WELL LOG Date of test 6/9/1985 Static water level 185 ft. Well production 0.5 g.p.m. WATER SAMPLE RESULTS: Coliform Neg colonies/100 mL Nitrate 2.30 mg/L Arsenic ND ug/L Date of sample: 1/7/2013 B. SEPTIC/HOLDING TANK DATA Tank Type/Material Septic/ Polyethylene Parcel ID: 020-291-50 Well Log (Y/N) Y Wires properly protected (YIN) Y Casing height (above ground) 18 in. AT INSPECTION 1/7/2013 108 ft. 1.8 g.p.m. Collected by: P.E.S. Date installed 7/23/1999 Tank size 1300 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping 8/29/2012 Pumper A+ Home Services C. ABSORPTION FIELD DATA Date installed 7/23/1999 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 System type Wide Trench Length 120 ft. Width 5 ft. Gravel below pipe 0.5 ft. Total depth 3.0 ft. Eff. absorption area 600 ft2 Monitoring tube Y Depression over field N Date of adequacy test 1/7/2013 Results (Pass/Fail) PASS For 3 bedrooms Fluid depth in absorption field before test 0 in. Water added 479 gal. New depth 0 in. Elapsed Time: 120 min. Final fluid depth 0 in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date D. LIFT STATION Date installed Size in gallons "Pump on" level at in. "Pump off' level at Datum E. SEPARATION DISTANCES WELL ON LOT TO: Cycles tested Septic tank/lift station on lot 100+ Absorption field on lot 100+ Public sewer main 75+ Sewer /septic service line 25+ Animal containment areas 50+ SEPTIC/HOLDING TANK ON LOT TO: Manhole/Access (Y/N) _ in. High water alarm level at Meets alarm & circuit requirements? On adjacent lots 100+ On adjacent lots 100+ Public sewer manhole/cleanout 100+ Holding tank 100+ Manure/animal excrete storage areas 100+ Building foundation 5+ Property line 5+ Water main 10+ Water service line 10+ Wells on adjacent lots 100+ ABSORPTION FIELD ON LOT TO: Property line 10+ Building foundation 10+ Water Service line 10+ Surface water 100+ Curtain drain 50+ Wells on adjacent lots 100+ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that l 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. Engineer's Printed Name Steven R. Pannone Date 13o61 fo COSA brown sheet 10-10-12.doc Absorption field 5+ Surface water 100+ Water main 10+ Driveway, parking/vehicle storage 110+ in. o S Z �D �? o J 0Z o F O LANTECH i N� y�O xQ p ZEn p W' o s 0 000 O u o"o p0. ® W o Z m , C �, -. 09 m o c A N = � 3 n O ; N m w O '1 m N c 3 v r z 0 Z} M o Z. rnZ rn_0 NZ vwZ 0) M WZy� / ON+�� O(nTl / ° < y CA OD S ~ zzi aaa\a%` M / au° p0 f�D -bC X r Z / Oo O0i 13 9 7c :3 p rn z i o. DN nmO `c I— (n a O m C5 m0 W 2 � o / co rt p IV C 0 / r " Mzm / .�N r' o vh O o 00 Cl) o> n M A x c>jl�� !.* d mom r `�° s m m rr > y o0 cin m Z D W o M n ry ,9'S4 L•9L MO T VR7 4 OX c y ° o CD 7 M UO x - � 9 9 N O � 6'+ � o wo N � LA Q t0 Ln MH IL a� :-nD ® S l0 g m� roQ oa ° °na�s30' 00 Kab�~ 3'rz 4n`� o Rni^£"' viii ooO��q�o 'a- 0* '82 soap,MR Is. FH bu�uaa)S opz1LP ana�� °off � X00 ~ Q ° cn m ' �� o Oluaoc 5a6ni • MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES M 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.# xl�l�-I`ll -.S0 HAA# 1AQc n n2t_�)(n 1. GENERAL INFORMATION Complete legal description 4— Location (site address or directions) I q yo(>y+ l�agtJ� G'3 Property owner II�� nLor Dayphone 3qq— 1/667 Mailing address I/i tbxe).� ' c P-wbai w N5 1,6 Lending agency Mailing address. N� Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well Community well Public water Day phone Day phone NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer 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 LZM Vow HD6e MA ^08) SZO U -Miom sdoombuo !euo!ssajoid ay1 u1 suo!ss!wo ao saoaaa aol a!q!suodsaa jou si 96ejoyouy jo Algediownvq eql ponss, si ajeo!j!jaao a aaojaq elep az(!eue ao suo!joadsui jonpuoo lou op SHHO jo saaAo!dw3 -sluawaa!nbaa olels pue!eaapal u!eljao �s!les olAepio u! suo!lnl!lsu! bu!pua! a!agj pue sowoy jo saeseyoand o4 Asajjnoo ase s!yl scop SHHa o41'eNse!y to alelS ayl u! paaajs!6aj aaau!6ua !euo!ssaload juopuedapu! ue (q anoge 9 ydej6eaed u! u9A!6 suo!lelueseidea aqj uodn A!uo paseq saleo!j!j)ao !enoaddy (j!aoyjny yjieaH sonss! (SHH4) soo!AaaS uewnH pue yj!eeH jo juawlaedep 96ejoyouy jo /j!!ed!o!unn eql OIL,(] :AS •� •n• T iTl1T'1DT'11T KdS 'Z/bul 0'S si uotgpaquaouoo agpaq?N 'AgTlTquq?ns panuT uoo sZ q= •quasaad saquagzu oap aaegy •sapoD Zpdioiunw pup 04Pgg buT a sluawwoO Jeu011!ppy :suo!je!nd!1s bu!mo!!ol ayj y1!m 'swooapaq aoj I'Midde !euoil!puop •panoaddeso •swooapaq aol panoaddy ly 3Hf11VNDIS SHHU '9 eo dyr ,I©� (l.v ne^fJ y y45�u`V`v � Zd 1 z h ajet] aanjeu6!s s,aaau!6u3 £ O ssaappy auoyd wa!3 jo aweNl b •uo!joadsui s!yj jo alep ayj uo joelle ul suo!1e!n6ea pue 'saoueu!pio 'sapoo ajejS pue !ed!o!unw pe y1!m aoue!!dwoo ui s! wets (s !esods!p jolemelsem ao/pue A!ddns aalem al!s-uo ayj'uo!joadsu! pue u0!je6!js9nu! (w woaj pue sa!!j a6ea0youy jo (j!!ed!o!unn ayj woal psu!ejgo uo!jewaolui ayj uo paseq jeyjAj!aaAaayjanj ! •u!ejeq paleo!pul aanjonajslo adAj pue swooapaq jo jegwnu 9y1 aoj ajenbepe pue !euo!lounj'ales s! wets (s !esods!p Jejemalsem Ao/pue A!ddns jejem alis-uo ayl leyj smogs uo!leo!!dde !enoaddy Al!aoylny y1!eaH s!yj jo uo!1e611sanu1 (w jeyj Aj!aaA ! 'mo!aq umoys alep uo!jep!!eA ayj jo se pue olaaay pax!lle !ees lbw (q pa!l!1jeo sy H33NI!DN3 AS NO11O3dSNI dO 1N3W31V1S 'S Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: -�� V+ ItQaRT n PSI - Parcel I.D. CS � I(- 5o A. WELL DATA Well type If A, B, or C, attach ADEC letter. ADEC water system number NA Log present (Y/N) Y Date completed pp '&S, Driller M CIPALIT RAGE Total depth �� Casedto /3` c eeLror Casing height e6l'ONMENTALSERVICESDIVISION Sanitary seal(Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG /35 5 SEPARATION DISTANCES FROM WELL TO Wires properly protected (Y/N) 7 APR 21 W -9 - AT INSPECTION Ll •15-Yz g.p.m. . 1, Z l9 S RECEIVED Qeov�^ . g.p.m. a-4 a'- ayo 14 / 30 wt..: v1 Septic/holding tank on lot I 10 fi ; On adjacent lots i7 1(3-� Absorption field on lot �D f ; On adjacent lots Public sewer main 1Y Public sewer manhole/cleanout / Nle Sewer service line Petroleum tank r1 ! d WATER SAMPLE RESULTS: Coliform / Nitrate Other bacteria Date of sampler S L 9 z Collected by:' B. SEPTIC/HOLDING TANK DATA Date installed 7/Tank /8� Tank size !a 5 o Compartments — 1114 Cleanouts (Y/N) 12- Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) N�/� Alarm tested (Y/N) NZZA Date of pumping AA At 't a0.' ,? 9 t: Pumper AdLdLCS SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 1/0 ± On adjacent lots }> f0'0 Foundation N] I% To property line > `'fir% Absorption f laid /72 Water main/service line -,50 Surface water/drainage N110 72-026 (Rev. 7/91) From CONTINUED ON BACK PAGE C. LIFT STATION K// Date installed Manufacturer_ Size in gallons Manhole/Access (Y/N) Vent(Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface water 7 Date installed -1/10 /8-5 Soil rating 150 System type Length 4O Width I Gravel thickness j1 Total depth /7/, ± Total absorption area Cleanouts present (Y/N) N Depression over field (Y/N) O Date of adequacy test Results (pass/fail) ���'� for 3 bedrooms Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 3a0 * On adjacent lots » 100 Property line 10+ To building foundation To existing or abandoned system on lot fXA k On adjacent lots NO e Cutbank 1 ` 0�^ Water main/service line > a-0-0 Surface water N .10 Driveway, parking/vehicle storage area > 50 Curtain drain K10 E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name r Date aft JL HAA Fee $ 1. Date of Payment Receipt Number 72-026 (Rev. 3/91)Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 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 # 52863 Chemlab Ref.# 92.1562 Sample # 1 Matrix: WATER Client Sample ID L2 VILLAGE PARKING EST. Client Name :TOBBEN SPURKLAND, P.E. PWSID UA Client Acct :TOBBENS Collected 6 firs. BPO# PO# :NONE RECEIVED Received : APR 15 92 6 13:30 firs. Req# Preserved with AS REQUIRED Ordered By :TOBBEN Analysis Completed APR 17 92 Laboratory Supervisor STEPHEN C. EDE Released By : (,1At�' evveiv'c Parameter c.—.........vcm36v�CC6o.vcv Results Units NITRATE -N 5.0 mg/l Send Reports to: 1)TOBBEN SPURKLAND, P.E. 2) s--6 MethodAllowable Limits EPA 353.2 SO Sample ROUTINE SAMPLE COLLECTED BY: T.S. Remarks: I =-Tests Performed =====.96CO9 `v6 See Special Instructions........ AboveC6vv-=v UA -Unavailable ND- None Detected See Sample Remarks Above NA- Not Analyzed LT -Less Than, GT -Greater Than ��� aSE3S Member of the SGS Group (Socidtd Generale de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 2644720 Application Date J J_ �'^ 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 1/ fla.,e /a.x... t E:. i,4r, A J,1 di / tot -o I— 2. Location (address or directions) (b) Applicant Name 1418n Mol lj Telephone: Home 3 `/t- 3 3- Business Applicant Address IYF loci (J�7(u� e:,�� °��`��% «c!z A4 j9J—/�l (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder �4uyer ❑ ; Other ❑ (explain); (d) Lending Institution _#��'e Address (e) Real Estate Company and Agent Address Telephone (f) Mail the F¢PP to the follgAving address: TYPE OF RESIDENCE Single-Familylk"Multi-Family ❑ Number of Bedrooms 3 3. WATER SUPPLY Other 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 ISPOSAL 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. 72-025 11/84) Page 1 of 2 5.' 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 Healy 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. Name of Firm A C__C S Telephone S-6 Address 12-00 kJ- `S 7,,L Date e r- 7 ' S 6. DHEP APPROVAL Approved for Approved 0 A4 eooe0000e � i t ee oo t. 00 �,•�h C. Reid, . 2251-E 4�� adrooms by Disap oved Cond><nal Terms of Conditional Approval CAUTION Date Seal [Z --T -ZS7 The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates 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 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 file prolessional engineer's work. 'r fagodcfl F� 4ri4.:p:ga5 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA) UEC O 3 CHECKLIST - FEBRUARY 1984 �i V 264-4720 R E E �s'JE'^) Legal Description: �` r( use %�a ICwnYci L_t_ 1-3- A. A. WELL DATA i Well Classification W,11es6'� If A, B, C, D.E.C. Approved (Y/N) - ILI Well Log Present ON) Date Completed 6" " 8 S Yield lZ 6Yr Total Depth 3 00 Cased to /3 !z Depth of Grouting Static Water Level / & 5 Pump Set At Casing Height Above Ground / a Sanitary Seal on Casing 6?N) _ Electrical Wiring in Conduit) Depression Around Wellhead (Y16 Separation Distances from Well: To Septic/Holding Tank on Lot / / ! ; On Adjoining Lots 6 To Nearest Edge of Absorption Field on Lot 30 On Adjoining Lots f 7 - To To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by � Date Water Sample Test Results �"Ffitl - Comments B. SEPTIC/HOLDING TANK DATA Date Installed 7-10-63- Size /Z5y No. of Compartments Standpipes ON) /,.r— Air -tight Caps/ 1) Foundation Cleanout)) Depression over Tank (Y16( 1 Date Last Pumped Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) — Separation Distances from Septic/Holding Tank: To Water -Supply Well //( To Building Foundatior To Property Line Zs77 76 To Disposal Field — To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course GT jo 0 100 /00 /S !7;?- Comments Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata < SO �7' `� Type of System Design 6 "Date Installed -fz'- b S Length of Field z�0 Width of Field Depth of Field 3 Gravel Bed Thickness 6 f e 7�w PI Square Feet of Absorption Area 6 S (D Standpipes Present ) Depression over Field (Y/6�)-)Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water -Supply Well 380 "+ To Property Line To Building Foundation Lot 18-0 + To Water Main/Service Line C 7 / d To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments IFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N Commen On Adjoining Lots -1- To F To Existing or Abandoned System on (- T SO To Cutbank (if present) C7- /o0 — Dimensions Manhole/Access(Y/N) — 'Pump QW -Level ** Check Permitted Bedroom Rating Against HAA Request ** _- Yent (Y/N) Pumping Cy le I,�uring Adequacy Test, Meets MOA I certify that I_bave checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed �' Date u 5^ Company Lck MOA No. S%ry--a!4 Receipt No. �o Date of Payment Amount: $ qb Page 2 of 2 72-026 (11/84)