HomeMy WebLinkAboutAGATHA FAYE LT 33A ~' · MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264~720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
O Z ~ Menuf~turer Meterlal Liquid capacity in
~ "o.DISTANCE'O:o' lines X ~ength ~li~ . Tots, len~in~ Tre.c~h ,. inches Dis~nce ~t~
~ Length W~dt ~pth PERMIT
< ~ Type of crib Crib diameter b
m Well Building foundation Nearest lot llne
~ DISTANCE TO:
m Building foundatio~ $e~r line Septic tank Absorption area(s)
~ DISTANCE TO:
SOiLTESTRATi ~J~~ ~ C .
INST~R ' /
REM RKS
¢ ,*j 8RD 190X .
I PH. 6~2~7D ' i / /
~UNIC~PAL~TY?~'~t_AN~ORAGE' ~
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
-264-4?20
ON-SITE SEWER & WELL PERMIT
PER~IT NO: 840759
DATE ISSUED: 09107184
APPLICANT:
ADDRESS:
CONTACT PHONE:
RICHARD GILBERT
P 0 BOX 7?2628
EAGLE-~IVER,-AK
6~8-3153
~577
?-DESCRiP= SUBDIVISIO~:-N~ t~ LOT:--))
SECTION: 4 TOWNSHIP:~N RANGE: 1W
LOT SIZE: 1.25A (SQ.FT. OR ACRES)
~0~$: 3
BLCCK:--NA
LISTED ~ELOW ARE THE OPTIONS AVAILABLE TO YOU I~ DESIGNINO YOUR SEPTIC · CHOOSE--THE--OP-T-XON-THAT--~EST--F-ITS-YOUR-SITE.
rO-PIPE-~OTTOM-(RT..) 4.0 6.0-
GRAVEL DEPTH (FT.) 2.0 0.5
TOTAL DEPTH (FT.) 6.0 ~.~
VEL--WIDTH'-(FT,) 2.5 14.0
GRAVEL LENGTH (FT.)
GRAVEL VOLUME (CU.YDS.) 14.9 14.6
SZZE--(GAL~) ~,000.0-** 1,000.0-**
SOIL RATING (SO.FT./~R) 85
dST--HAVE--AT-LEA ST-TWO --COM PA RTM E NT S
Z ~.-¥--T H A T~'
1. X AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOA) AND THE STATE OF ALASKA.
~---[--WZLL--~ALL--T~E-~Y~T£~-IN-ACCORDANCE--WITH-ALL--~OA-CODES_4ND_~EGULATiONS
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PER~IT.
3. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
D~-S~TAN~$--irAC~--A~¥--EX~$TX~G-~ELL,-A~ASTEWATER-DISPOSAL_$YSTEM_OR_PU~LIC :
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT.
4. I U~DEESTAND THAT THIS PER~IT IS VALID FOR A ~AXIMU~ OF ] BEDROOMS AND
ANY--ENL-ARGE~ENT--WILL--~EQUIRE--AN-ADDITIONAL--PE~NIT,
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY HOA BUILDING CODES,
3--A~--ELEC-T-RZCAL--PER~I~--A~D-INSPEC. TION-MUST-~E--OBTAINED;_(~)_AS-BUILTS
WILL NOT BE APPROVED WITHOUT A)i ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK M~S~/BE DONE~J~Y A LICENSED ELECTRICIAN.
_~C~ .............................. DATE: .........
MT4--g.I¢~ARD--GILBERT
MUNICIPALITY OF ANCHORAGE
'n
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 I.~ Street, Anchorage. Alaska 99501 2644720
SOILS LOG - PERCOLATION TEST A,///
PERFORMED FOR:
LEGAL DESCRIPTION:
I
2
3-
5-
6-
7
10
13-
14-
15-
16
17
18
19
20.
~'~- SOl L$ LOG
PERCOLATION
TEST
DATE PERFORfl~
FSLOPE SITE PLAN
WASGROUNDWATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
~G,os," ~/'.., D.p,h,o
/R~ te Tim~,~ Time Water Drop
PERCOLATION RATE
PERFORMED BY:
TEST RUN BETWEEN
COMMENTS ///,~/~Ij'/*-~'~,~/,,~'~C- ~-~/~w~- ~C~
72-008 (6/79)
CERTIFIED
......... §'-7'7 } 6 JUL t 6 1984
FT AND
•
• Municipality of Anchorage
_ On-Site Water&Wastewater Program ._
(907)343-7904 6 8 9 10
• 5. E
CERTIFICATE OF ON-SITE SYS SJlx11PPIPOVIAL
6 ti
Parcel I.D. 051-072-77 E3 r;►• •
1. GENERAL INFORMATION
Complete legal description AGATHA FAYE S/D; LOT 33A
Location (site address) 22049 YARNOT AVENUE, CHUGIAK,AK 99567
Current Property owner(s) IAN SMITH Day phone 202-4473
Mailing address 22049 YARNOT AVENUE, CHUGIAK,AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:
• Single Family(w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well I Individual On-site
Individual Water Storage ❑ Individual Holding tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for. N/A Distance: -
Received by: ,U Date: 4 7 F
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee$ CJ 2 ' Waiver Fee$
Date of Payment (D - '979-
2 Date of Payment
Receipt Number 3F Receipt Number
COSA# '(15Gc. 12A2- 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 GARNESS ENGINEERING GROUP,Ltd. Phone 337-6179
Address 3701 E.TUDOR ROAD,SUITE 101 'ANCHORAGE,AK,99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E. Date 6/3/s
Engineer's Comments:
In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system in accordance with the .�����\\ ,
guidelines and regulations established by the Municipality of Anchorage and industry practices.The reported results describe the �� OF 44'
condition of the systems on the date/s of the evaluation.Separation distances were measured to readily identifiable features. ��..4.4t
t��••,. •• •.•�I..
Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic i r\'.. •••. Yom,o
systems depend on a variety of variables including,but not limited to,soil conditions,groundwater levels(that may fluctuate during a �� `..v Y
the year),quality of construction(materials and workmanship),and the water usage of the family utilizing the system/s.These g ,10 * *0
conditions can vary,and are outside the control of GEG.Satisfactory test results do not guarantee future performance of the at
systems;therefore,GEG makes no warranty(express or implied)regarding the future performance of the well or septic system. / 1 ip--'
GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the 0 )�.{... . . %
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: AGATHA FAYE S/D; LOT 33A Parcel ID: 051-072-77
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A Well Log (Y/N) YES
Date completed 9/4/1984 Sanitary seal (Y/N) YES Wires properly protected (Y/N) YES
Total depth 160 ft. Cased to 160 ft. Casing height (above ground) 18+ in.
FROM WELL LOG AT INSPECTION
Date of test 9/4/1984 5/25/2018
Static water level - ft. 132 ft.
Well production 15 g.p,m. 5.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform NEG colonies/100 ml. Nitrate 4.29 mg./L. Collected by: GEG, Ltd.
Arsenic: <5 ug./L. Date of sample: 5/31/2018
B. SEPTIC/HOLDING TANK DATA 4"OF WATER STANDING IN POST TANK CLEANOUTS
Tank Type/Material SEPTIC/STEEL Date installed 1/4/2006
Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout(Y/N) YES Depression over tank(Y/N) NO High water alarm (Y/N) NO
Date of pumping (o f /`I/ l '' Pumper + \ U,- )� il-I "( -
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE
Date installed 1/4/2006 Soil rating 4-p.d./ 3or ft2/bdrm) 1.2 System type 5-WIDE DRAINFIELD
Length 63 ft. Width 5 ft. Gravel below pipe 4 ft.
Total depth *7.8 ft. Eff. absorption area 630 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 5/25/2018 Results (Pass/Fail) PASS For 5 bedrooms
Fluid depth in absorption field before test**5.5/0in. Water added 776 gal. New depth 5.5/0 in.
Elapsed Time: 0 min. Final fluid depth 5.8/0 in. Absorption rate >= 750+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) NONE KNOWN If yes, give date -
**SOUTH MONITORING TUBE (MT1) /NORTH MONITORING TUBE (MT2)
D. LIFT STATION
Date installed Size in gallons Manhole/A - .. •
"Pump on" level at in. "Pump off' I- - - in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer main 75'+ Public sewer manhole/cleanout 100'+
Sewer/septic service line 25'+ Holding tank 75'+
Animal containment areas 50'+ Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line ***10'+ Surface water 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line **4' Building foundation 10'+ Water main 10'+
Water service line ***10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
**PER WR#05009. ***PER 2006 COSA THAT WAS SIGNED BY THE ENGINEER THAT DID THE SEPTIC INSTALLATION INSPECTIONS.
G. ENGINEER'S CERTIFICATION •.,b .. •.' 1,♦♦♦
•••
1 •
♦
: 41 rd i\ * ♦
I certify that I have determined through field inspections and ; ,� •• cam. ;
review of Municipal records that the above systems are in •
conformance with MOA COSA guidelines in effect on this •• •
date. e fGarneA r
JEFFREY A. GARNESS • 1S
CE-79-53--4•. ��':
Engineer's Printed Name •••/\<<N4),<;....
� �,
Date ' • pp-NO ,,\
LICENSE•,4,1`"S`, -�••
#AECC884
(Rev. 10/12/12)
25 Lot 24 + 8403S f
N39°59'00"E 30!-;.0.0
r.,•-) 1 � 1 1 !'71 r
o; 1` �� • A- .\. SY erj
_
n •
��.°0\ i -N ge9tove y
ai
W (' \) ..l w 39.0u ;� 63.6
N N
U 11 11 1"' Lot 33A N o
:� b t . Ic 16.0 4)-5... eats /Yard light
v CTs O r12.o fi-�.a.3on s t►c'j •
W { 0'Road Reservation • I e `s .� �.
>" I m 0 l3 5.0'to �_ Lot 34A
D T
u_ r' / I �, a • o
/ I to
N `x'39.0 N .•. Asph- C
50.0 - A1S9° • c,
274 /
63 0
o
• 0
o
Lot 33B 0
rn n
05 ai
$ )e ' M ,1Ssiw °a t3 OF = al i1-e Des- Go'f, gall+ MI.. O W
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op
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,� / 3�?��00 }
!
1
46b, -.4 t YARNOT AVE
OF
�Q� • C'14 �, AS-BUILT NO CORNERS SET THIS DATE
° 49th - •7 f i hereby certify that I have performed a Mortgagee's inspection
• �C of the following described property: LOT 33A,
.•• • •• ° ••• AGATHA PAYE SUBDIVISION
00 ..• Rer
• .. •• ••;
IØ r,'.Fred Wal a tka;i / Anchorage Recording District,Alaska,and that the
s�•aa 3255 - S ,'j' improvements situated thereon are within the property lines
� �-r ., ,• y and do not overlap or encroach on the property lying
0 F'-' a ,, , ^ 0 ,...0) .v, adjacent thereto,that no improvements on the property lying
RI o ssiot,At• Com► adjacent thereto encroach on the premises in question and
SCALP: 'In= 50' et%0AN%% that there are no roadways,transmission Anes or other
visible easements on said property except as indicated
hereon.
Dated at Anchorage,Alaska
this 25th day of September,2014.
EASEMENTS OF RECORD, OTHER THAN FRED WALATKA&ASSOCIATES i
THOSE SHOWN ON THE RECORDED PB 1 -8, pg 71-73 Engineers and Surveyors I
! PLAT ARE NOT SHOWN HEREON. Seward BE (807-248-16666)
i
•
• 1
HUNI¢IPALITY
DIVISION OF ~I~01~AL ~TH
DEP~ ~ ~TH ~ E~IR0~ ~0TE~TION
~PLI~ATION ~K ~TH ~HO~I~ ~P~OV~ ~KT~ICA~
%. ~uaral Info~a~ion
(a) Le~al Descrip=~on (include lo=, Block, su~division, sec=ion, ~o~ship, ra~e)
Location (address or
(b) Applicants Name~/r~ ~ ~//~.~ & Telephone - Eome ~- Business
is (check one) Le~i~ Institution ~; ~er/b~lder~;
Applicant
Buyer ~; Other ~ (~plain);
(d) Lending I~$titution
Address
Telephone .~'-~.~- c~ p~o
(e) Real Estate Co. & Agent
Address
Telephone
(f) Hat1 the HAA to the folloving' ~ddress:
TTpe of Residence
gingle-Family'~,
Number of Bedrooms
Hulti-Family~
Other (describe)
~ater Supply
Individual ~ell.~ Community~ Public~-~
Note: If community ~11 system, must have vritten confirmation from the State
Department of Environmental Cowervation attesting to the legality and status.
Sewage Disposal
Onsite.~. Public ~-~ . Corn.unity ~ Holdin~ Tank ~--~
Note: If community ~ell system, must have vritten coMlmation from the State
Departnent of Enviro~ental Conse~ation attesti~ to the legality aM status.
[Page I of 2]
5. En~ineerin~ Firm Providin~ Inspections~ Tests~ File Search~ Data and Infor~ation
e
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or ~rastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. ! further verify that,
based on the idormation obtained from the Municipality of Anchorage files and from my
investigation and inspection, the om-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.
Telephone
Address
Date
DBEP Approval ~ .~.~
Approved for ..~.~ bedrSoms
Approved ..
Terms of Conditional Approval
CAUTION
TIt~ HU}IICIPALITY OF ANCHORAGE DEPARTHENT OF ~TH ~ E~IRO~ffi~ ~OTECTION
(D~P) ZSS~S ~TH A~HO~I~ ~P~OV~ ~RT~ICA~S BAS~ SO~LY U~N T~ ~PRESE~-
ATIO~ GI~N ~ P~ 5 ABO~ BY ~ ~PE~E~ PROFESSIO~L
IN ~ S~ OF ~S~. ~ ~EP ~ES ~IS ~ A ~TESY TO P~SERS
T~IR ~ING ~TI~IO~ ~ O~ER TO SATISFY
~S. ~O~ES OF DHEP ~ NOT ~UCT INSPECTIO~ OR ~LYZE DATA BEFORE A
CERTIFICATE ~ ISS~D. ~ ~ICIP~I~ OF ~CH0~ ~ ~OT ~SPONSIB~ FOX E~ORS
OR ~ISSIONS LN ~ ~OFESSIO~L ENGI~ER~S ~O~K.
(DH~P SEAL)
ILR4/eJ/D18
[Page 2 of 2]
7 -1
A. ~LL I~TA
MUNICIPALITY OF ANCHORAGE
HF.~/.TH ;~ORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
..RECEIVED
Well Classtftcati(~ ~o~
Well Log l~esent (Y/N)
Total Depth /&o Cased to
Static ~ater Leal .~-,.9. 7 /
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distan~s f=cm W~11:
To Septic/HoldinG Tank (~ Lot
To N~a~st EdGe of Absorption Field on Lot
To Nearest Public Se~r Line
z£ A, S, = C, D.S.C. ~oveU(Y/N) ,~//4
Date Completed ~/4/~ Yield
Pum~ Set At
Depth of GroutinG
Senitary Seal on Casing (Y/N))"
Depression Around Wellhead (Y/N) AY
//9o +
~ O~ ~joining Lots /d~
~ On A~joining Lots
To Nearest Public Sewer
Cleancut/Manhole ,~.~- To Nearest Sewer Servio~ Line on LOt ~ ~ ~
B. SSPrIC/~OLDING TA~( ~a~TA
Date Installed /~ Size. /~'~) No. Cf Compartments ~
Standpipes (Y/N) / A/l~tiGht Caps (Y/N) / Foundation Cleancut (Y/N) ~'
Dei=ession over TamR (Y/N) ~/ Date Last Pumped ~e~u ~-~. ~.~
Pumping/Maintenan~ Conteact on File (Y/N) ~ ; fcc ~/~
Holding Tank High-Water Alarm (Y/N) 2Y~ Tempora~y Holding Tank Permit (Y/N) ~/~
Separation Distances f=(~ Septic/}{olding Ta~k:
To Water-Supply Well
TO Progerty Line /~
To Water Main/Seevine Line
Cc.,,,~nts ,?¢,.,.,.;~- ~ ~4~ O7~
[PaGe 1 of 2]
To Building Foundation
To Disposal Field ~- ~
To Stre~u, Pond, lake, ~ Major DrainaGe
2-15-84
Ce
ABSOI~,z'~.C3N FIELD [I~TA
Soils ~atinG in A~ti(a~ Strata
Date Installed /~z/ S~y~.-.~¢.
Width of Field .~ w
Ty~e of System P~sign
length of Field z/~c '
D~pth of Field ~-- '
C~avel Bed Thickness / '
~ Feet of Absorption A~e& ~5-£ ~ Standpipes l~esent (Y/N)
Del~essic~ o~ Field (Y/N) ~.,~ Date of Last i~bquacy Test
~esults of last Adequacy ~st /u~
Se~aration Distancs f~cm Absc~ption Field:
To Watez--Supply Wsll /~ ~ To P=o~ert¥ Li~ ~ ~-'
To Building Foundation ~' To Existing o~ Abandoned System cn
Lot ~ - ; On ~dJoinin~ Lots
To ~ate= Maimj~e=vice Line /~ ' ~- To Cutbank(if p=esent)
To St~e~/Pond/Lake/c~ Majo= ~ainaGs Ccu=se
To D~i%~way, Pa=kin~ A=ea, c~ Vehim~- St(xaGs Az~a
De
Date Installed
Sizs in Gallons
"P~,~ On" Level at
High ~ater Alarm Level at
Tested for
Electrical Codes(Y/N)
Co~,=nts
** Check Permitted Bedroom Ratin~ ;~3ainst HAA ~equsst **
I ce=tify that I have checked, ~rified, ~ oonfc~m~d to all MOA HAA Guidelines in effect
on the date of this inspection.
[P .age 2 of 2]
2-15-84
MUNICI~ALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. it
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOt $$ '~; 'A.~ath~ F~q~ Subdivision
Location (address or directions)
NHI4 Y~not Av¢~
(b) Property owner A.H.F.¢. # 58548
Mailing Address
Telephone: (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent ,70¢~. 0]h~:¢ CornDctn_~ ATTN: L_~nd~
Address I09~8 J~q.g.~R. RZv~.~ Roa~
Telephone 694-5500
(e) Mail the HAA to the following address: (or check here Ji~ if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 Eaole River Loop
Ea~lle River, Alaska 99577
2. TYPE OF RESIDENCE
Number of bedrooms
Single-Family EX
3. WATER SUPPLY
Individual Well I~[
Community CI Public I-1
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [~ Public [] Community I-I 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 and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional 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, 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
~, & $ ENGINEERING Telephone
17034 Eagle River Loop Road No. 204
Tn_ale River, Alaska 99577
Date
6. DHHS APPROVAL
Approved for L~' bedrooms by
Approved ~ Disapproved
Terms of Conditio.~l Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to 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.
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stria
Square Feet of Ab$ortion Area
Depression over Field (Y~
Results of Last Adequacy Test
· To Wat'er-Suppl~, Well
Type of System Design
Length of Field ,¢/~t
Depth of Field ~'
Gravel Bed Thickness r'!
' ' ~. ~'' ~5 ~' Statndpipes Present~TN)
~ Date of Last Adequacy Test
SEPARATION DI'STANCE FROM ABSORPTION F'IELD: t
/t,:~.~" ' To Property
To Building Foundation'l ' ~:~ I~ ": To Existing or Abandoned System on
; On Adjoining Lots ~ I.~..
Lot t,I /~ ',4--
To Water Main/Service Line ! c> To Cutback (if present)
To Stream, Pond, Leke. or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ,~.-~/.~"'T'I~::=I'~ ~3''Z~--'~'~/-~'~ ~ ea,4-.-~ ~~-~.
D. LIFT STATION .
Date Ins"Pa~/~d ~
Size in Gallons-'~~
"Pump on" Level
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access ('Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request'*
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
inspection.
Signed
Company
Date
MOA No.
17034 Eagle River Loop Road No. 204
Receipt No. ,~.~ 0/,~:~ ~/'c~ /Ch
Date of Payment 7 ~ --~' ~
Amount: $ / ,~ ¢~ '" (-') ¢'~
72-02~ (Rev.
· Receipt No.'
Waiver Fee: $
Date of Payment
Page 2 of 2
· ~,G~
O~/~ ~$tO't4UNICIPALITY OF ANCHORAGE (MOA)
'' C': '~,~J~'O?.A~T{~~ Health Authority Approval (.~)
.~:~O~t~'~ ~/ ' CHECKLIST- FEBRUARY 1984 ~ ' :
t~'" . ~ * : 343-4744 ', ** ,
A. WELLDATA ' ~' : * " '" ~ :'
Well Classification I If A, B, C, D.E.C. Approved (Y/N)
Date Completed
Well Log Presen~N)..~ v ' .,, ' ,
Total Depth / ~' Cased to
Static Water Level
Casing Height Above GroUnd' j I,,,.j,_.
Electrical Wiring in ConduitS'/,! ~
SEPARATION DISTANCES FROM WELI~:
To Septic/Holding Tank on Lot ;[ ~
Pu~np .Set At
Sanitary Seal on Casingd::3:~) :, y
Depression Around Wellhead (Y~])
; On Adj6ining Lots
To Near~st Edge of Absorption Fiel t ' ' / ~' '"; On Adjoining Lots
To Nearest Public Sewer Line ~/~- To Near~st Public Sewer Cleanout/Manhole
To Nearest Sewer Sen/ice Line on Lot ~ ~" '/(' '
Water Sample Collected by ~ ~ /'] /~; Date
.. Water Sample Test Resul.ts . · ' ---
Comments .-
B. SEPTIC/~ TANK DAT,,~ ..... . -' "i
Datelnstalled ~:~/~"%~z~~/" /~';~"~ No. of Compartments '~2.,.
Standpjp, es~N) ' ' "7 Air-tigh~ps ~/N) ~ Foundation CleanoutE,.~N)
Depression overTank (Y/~[~) "' '
/,j/~Date ~.ast Pumped
Pumping/Maintenance Contact on File (Y/N) Z ; for
Holding Taqk High:Wa;er Afarm (Y/N)' ~/-'& Temporary Holding Tank Permit (Y/N) ' /,,I/~
SEPARAT Ol~l'D STANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply We //~ !
... :' . .~. , . , , !.~ TO Building Foundation
~ To P, roperty ,Line "' / O TO Disposal Field "' ~
* . .... ' t I)/_ :.
· To Water Main/Sen/ice Line / ~
TO StJ'eam; pond, I.)ake or Major Drainage Course / ~ ,1"~'
~(,~,. 7/~) ~ Page I of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
~¥$I$ R~O~ ~¥ ~91PI. E for York Order ! 25046
Date Report ~rlnted: JUL 2 90 9 lt:3~
Client Sa~le ID:L33I}
P~SID
Collected ~ 25 90 9 13:~ hrs.
Received J~t 26 90 9 13:00 hrs.
['reserved vtth :L~ R~I~ED
Client Na~e:
Client Acct
Req !
~nalysts Ccepleted :J~ 27 90
Special
Instruct:
Send Reports to:
1)$ & $ []GIN£1~I~
2)
C~e~lab Ret 1:902080 [ab ~1 ID: I Hatrix: WAne
AIIovable
Para~ter Tested Remit Units Method Limits
NII'P~I~-N 1.3 acyl ~A 353.2 10
Sample ROUTIN~ .~tPLE.
Re~arks: ~LE COLLECTED BY RILl.
Tents Retfor~ed
None 0erected
Not Rnalyzed
See Special Instructions Rbove
See ~le Reaarks Above
L?=[zssThan, bT=Greater 11~an
0R~Jnavallable