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HomeMy WebLinkAboutSAND LAKE #2 BLK 2 LT 7and Lake #2
Block 2
Lot 7
#011-133-42
Municipality of Anchorage
On -Site Water and Wastewater Program - (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSPI81170 PID Number: 011-133-42
Dwelling: W Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: M New FIR Upgrade
Name:
Craig & Vanessa Hassinger
ABSORPTION FIELD
FE -1 Deep Trench F-1 Shallow Trench R Bed ❑ Mound
Address
8101 Seaview Street Anchorage AK 99502
El Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
3
2.0 GPD/SF
JTotal
10.0 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
6.0 Ft.
Gravel depth beneath pipe
5.0 Ft,
Subdivision Block Lot
Sand Lake No. 2 2 7
Fill added above original grade
0 Ft.
Gravel length
23 Ft.
Township Range Section
Gravel width
3 Ft.
Beds: Number of Lines
Distance between Tines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
230 Ft2
1
Ft.
Well
>100'
>100'
N/A
N/A
>25,
TANK El Septic A S.T.E.P, E] Holding N Other
Manufacturer
FAP Advantex/Orenco
Capacity
1 1,500 Gal.
Surface Water
>100'
>100'
N/A
N/A
Material
Number of compartments
Lot Line
>5'
>10'
N/A
N/A
Fiberglass
2
NA
Foundation
>10'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Cirenco
1500 Gal.
Remarks Existing Septic Tank Decommissioned
Pump on level at
25 in.
Pump off level at
13 in.
High water alarm at
11 in.
in Accordance with MOA Code. Exisitng
Absorption Trench Abandoned in Place.
Pump make and model
PF2005
Electrical Inspections per -formed by
MOA
Installer
PIPE MATERIAL House to tank D3034 drainfield Tankto D3034
Affordable Septic
Drainfield D3034____ CO/MT Q3034
inspector J. Millette
BENCH MARK (Assumed elevation) 100 ft
Inspectes:tion is' 7/09/18 2 nd 7/10/18
da
Location and description
3`d 7/10/18 4th 7/13/18
Garage Slab (Back Door)
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
F A4
qsAw�
Conditional Approval: Date
,q)
49 TH
..................
• Michael E. Anderson
Approve Date
63% 4381-E
0,
i... law
111tipvLalurl mupuli_a- j -! Z.doc
SAND LAKE #2 BLOCK 2 LOT 7
PERMIT # OSP181170 PID # 011-133-42
SEAVIEW STREET
LOT 7
A BEXISTING CLASS C WELL
FCO 21.5 5.2 ,.
MH1 21.3 15.0 \ so'RADIUS
MH2 28.9 24.3
2C01 28.2 25.2 /
2CO2 30.3 26.6 LOT 8
CO1 30.0 13.3 \' LOT 6
MT 44.5 36.0 3-BDRM HOME ..
CO2 44.6 35.8
NEW 1500 GAL.FAP ADVANTEX O 23'LONG x 3'WIDE x 5'EFF.
TREATMENT TANK w/AX-20 POD •• FCO • DEPTH ABSORPTION TRENCH
•
_ ''-01 EXISTING SEPTIC TANK
DECOMMISSIONED ONSITE IN
= ACCORDANCE WITH MOA CODE.
2001 N ,
2CO2 e � 2000 TH FROM MOA FILES
•
PT1
m-ri-0O2 •
•
• I-1
..
• U �� ---- EXISTING ABSORPTION
1982 TH LOCATION ��• • TRENCH
FROM MOA FILES ABANDONED ABSORPTION
"E— / TRENCH
I I
10 ELECTRICAL EASEMENT EXISTING ABSORPTION TRENCH
ABANDONED IN PLACE
illiktGE
EMOINEENI146
NOTE:
....����x\x NO SLOPES>25%WITHIN 50'OR SURFACE WATER WITHIN 100'OF THE LEGEND
.'4. .....L,q����`� PROPOSED SEPTIC SYSTEM CO-CLEANOUT
Am • �)�' tI ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS 2C0 DOUBLE CLEANOUT
/>ft:•�TH /\ .* / FCO-FOUNDATION CLEANOUT
SYSTEMS.EMS. ARE SHOWN.NO CONFLICTS WITH WELLS OR SEPTIC FS-FLOW SPUTTER VALVE
�F • Michael E.Anderson : # 0 30 60 MH-MANHOLE
f+fo.• CE-44381 </ MT-MONITORING TUBE
ms's•• 9 -i-0-* t="1 im um mi NM FEET
11 F��O$- ��� v SV-SEPTIC VENT
�1,'�\"`o\O"- 1"=30' TH-TEST HOLE
SAND LAKE #2 B2 L7
PERMIT # OSP181170 PID # 011-133-42
o = = o
02u_ 2 g N
— , 98.8 — —
AX-20 POD AND
I- - MANHOLES
r____I v
A \ N—
96.0
95.0 -71
1500 GAL
F.A.P.TANK
J /
-.1'.'— 91.0
0
02 98.7 ORIGINAL/FINAL GRADE 0
—, ,miiim,„ L ,
93.7 93.7
DRAINFIELD ROCK
-."------ 88.7 23' 88.7
79.7
O
`— NO GROUNDWATER 6/01/00
J
±
r, ..............
:I k,
41
*•49 TM /, �9*+�/
�f- .l- -,
F : Michael E.Anderson : f
Ns.� PROFILE AS—BUILT 1fc".•.. 4831-E .:`�i
) GE (NO SCALE) `ili(\\\\L. ~
MUNICIPALITY OF ANCHORAGE ~.� !�;q�p‘jl
DEVELOPMENT SERVICES DEPARTMENT /� P�••••• �1,—. •9tI
4700 ELMORE ROAD ANCHORAGE, AK 99519-6650 'iitc.9TH.. . ; .
SOILS LOG AND PERCOLATION TEST •. Michael E.Anderson .' j
��
I+�c�'• 4831-E
LEGAL DESCRIPTION: SAND LAKE #2 B2 L7 �l�\��\"``���
PERFORMED FOR: CRAIG 8, VANESSA HASSINGER ProfessionalEngineersEngineers Stamp:
DATE: 7/07/18 PROJECT No.:
PARCEL ID#: 011-133-42 TECHNICIAN: N. SHAFER
DEPTH PERK TEST 1
(feet)
1 SLOPE SITE PLAN
2
3
4
5 SEE SITE PLAN
6
7
8
9
WAS GROUND WATER ENCOUNTERED? NO S
1 O IF YES(n WHAT DEPTH? - L
DEPTH OF WATER AFTER MONITORING: - 0
1 1 DATE OF MONITORING: -
12 E DEPTH TO
DATE READING GROSS TIME NET TIME WATER NET DROP
13 (MINUTES) (MINUTES) (INCHES) (INCHES)
14 7/07 TEST HOLE PRESOAKED PRIOR TO TESTING:
15 1 13:20 4
2 13:50 30 91- 516
16
3 13:52 4
17 4 14:22 30 8 s 416
18 5 14:24 4
19 6 14:54 30 816 4 Is
20
PERCOLATION RATE: 6.2 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN: 4.5 FT. and 5.5 FT.
COMMENTS:
Note: This lot is served byaClass Ccmnmunity well.
0 "P, *.OElizabeth L. Walatka
AO
8036 - LS
SCALE: 30'
EASEMENTS OFRECORD, OTHER THAN
THOSE SHOWN ONTHE RECORDED
PLAT ARE NOT SHOWN HEREON
UNLESS DTHEF�V|SENOTED.
Ho|�.FB1�O. pg 25 BE
AS -BUILT NOCORNERS SET THIS DATE
| hereby certify that I have performed a Mortga ee's Inspection
of the following described property: LOT 7, 19LOCK 2.
SAND LAKE SUBDIVISION No. 2
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying
adjacent thereto, that no Improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
Dated at Anchorage, Alaska
this I 6th —day of_JULY .208.
FnEovW^LATKA & ASSOCIATES, Luc.
En
907-248-1666
Sun���
907-248-1666
| |nf /�
| ��`�
|
|
�t 19
.
.
�—
N89055' 13500
/
�|
~
C)
St
0
She
C)
Coo hain link fence
<
17.7 8.3 Septic system
W
1 Story Frame House
|mf 16CD
C14 04 LOT 7
GJ
0
46.0
Z
fence (typ)
,food
--_-
Wire fen:
N89055'00"W 135.00
|
30
Lot o
!
|
Lot 1�
~^ '^
Note: This lot is served byaClass Ccmnmunity well.
0 "P, *.OElizabeth L. Walatka
AO
8036 - LS
SCALE: 30'
EASEMENTS OFRECORD, OTHER THAN
THOSE SHOWN ONTHE RECORDED
PLAT ARE NOT SHOWN HEREON
UNLESS DTHEF�V|SENOTED.
Ho|�.FB1�O. pg 25 BE
AS -BUILT NOCORNERS SET THIS DATE
| hereby certify that I have performed a Mortga ee's Inspection
of the following described property: LOT 7, 19LOCK 2.
SAND LAKE SUBDIVISION No. 2
Anchorage Recording Precinct, Alaska, and that the
improvements situated thereon are within the property lines
and do not overlap or encroach on the property lying
adjacent thereto, that no Improvements on the property lying
adjacent thereto encroach on the premises in question and
that there are no roadways, transmission lines or other
visible easements on said property except as indicated
Dated at Anchorage, Alaska
this I 6th —day of_JULY .208.
FnEovW^LATKA & ASSOCIATES, Luc.
En
907-248-1666
Sun���
907-248-1666
TY OF ANCHORAGE
C----,NJN' v1,rrr _ MUNICIPALI `�""c S'On-Site Water 8 Wastewater Program s° �';;PO Box 196650 4700 Elmore Road .� Anchorage,Alaska 99519-6650 Phone:(907)343 7904 Fax:(907)343-7997
,q http://www.muni.org/onsite
ehartment
On-Site Wastewater Disposal System Permit
Permit Number: OSP181170
Effective Date: 7/2/2018
Work Type: Septic Upgrade Expiration Date: 7/212019
Tax Code Number: 01113342000
Site Legal Address: SAND LAKE #2 BLK 2 LT 7 G:2224
Site Mailing Address: 8101 SEAVIEW ST, Anchorage
Owner: HASSINGER CRAIG &VANESSA J
Lot Size in Sq Ft: 6750
Design Engineer: FORGE ENGINEERING
Total Bedrooms: 3
This permit is for the construction of:
0 Disposal Field 2 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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
Special Provisions: A percolation test shall be completed at time of construction at the location identified on the
site plan. If results require a design change, construction of the system shall stop pending On-site review and
approval of a change order. Please submit stamped and signed results with the inspection report.
Received By: /� Date:
/ t I ir
Issued By: (LlULI-+ Date:
7e18
X61 8 9 ��
MUNICIPALITY OF ANCHORAGE ry v f
Phone: 7 343-79U4 - 3
Community Development Department Fax: -343-7997
Development Services Division ti
On Site Water & Wastewater Program <<a r 6 8 9 c,h
ON-SITE SEWER/WELL PERMIT APPLICATION M
Parcel I.D. 011-133-42
Property owner(s) g
Crai & Vanessa Hassinger Day phone 830-3228
Mailing address 8101 Seaview Street Anchorage, AK 99502
Site address Same
Legal description (Sub'd., Block & Lot) Sand Lake #2, Block 2, Lot 7
Legal description (Township, Range & Section) Three (3)
Lot Size 6,750 Sq. Ft. Number of Bedrooms
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply) Single Family (SF) 0
Absorption Field 0Initial n (w/wo ADU)
Septic Tank n Upgrade El Duplex (D) ❑
Holding Tank ❑ Renewal I I Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
-L-et-EirternaiveffAlas a , _ • - - - - - J.;
Distance:2/10
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
D
(Signature of property owner or authorized agent)
Permit/Rush Fees:
II
il°.4D Waiver Fees: ' 00
I Date of Payment: 1 E q. Date of Payment:
Receipt Number:
Q) q61/D Receipt Number: 02-C172D
QC v l�O 2
Permit No. OSS $1 h 0 Waiver No. S J
Permit App_i-: ._...:c:
GE
ENGINEER 1 N G
PO BOX 240773
ANCHORAGE,AK 99524
522-7773 677-7766(FAX)
July 2, 2018
Municipality of Anchorage
Development Services Dept- On-Site Water& Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Sand Lake#2 Block 2 Lot 7—8101 Seaview Street
Septic System Design and Permit Application
Dear On-Site Services Engineer:
The septic system on the subject lot has failed and must be replaced before a COSA can be issued
for the 3-bedroom home on the property. We are submitting this permit application for the
construction of a new septic system. The attached site plan identifies the location of the home as
well and the existing and proposed septic locations. The property is served by a private well on
the adjacent lot to the north. No conflicts exist between this proposed system and any other well
or septic system,whether on this lot or adjacent lots.
The ground surface on the lot is flat allowing placement of the absorption system in any alignment.
There are no slopes greater than 25%within 50 feet downslope of the absorption system site.Storm
water drainage will not impact this septic system. The new trench will be constructed parallel to
any slope as much as possible.
The well on the adjacent lot is shown. The new system will be a minimum of 50' from all wells
and surface water as allowed in the MOA Code, and more than 5' away from the septic tank. The
existing septic tank on the lot will be decommissioned in accordance with MOA Code. The new
system will be an Advantex Treatment System with an AX-20 Pod due to the limited area available
on the lot and the location of the existing septic system. The absorption trench will be 3' wide by
23' long with a 5' effective depth. The application rate based on the test hole placed in 1982 is
2.0 gpd/sf. We request a condition be added to the permit for the completion of a new percolation
test prior to the construction of the absorption trench.
Please refer to the attached test hole log,plan and profile pages for the septic design. If this design
is followed,there will be no adverse impacts to adjacent properties.
Sincerely, �•���pF
al* 49?H •
Michael E. Anderson,P.E. h
�I •MICHAEL E. ANDERSON . -
Attachments s'•• CE-4381
;�`�.:
SAND LAKE #2 BLOCK 2 LOT 7
_ , _ -
SEAVIEW STREET \\
/
i
LOT
• W
EXISTING PRIVATE ELD
t /
LOT 8 LOT 6
3_BDRM HOME /
i
NEW 1500 GAL.FAP ADVANTEXI''
,J••- FCO 23'LONG x 3'WIDE x 5'EFF.
TREATMENT TANK w/AX-20 POD •• 10'
J— MH DEPTH ABSORPTION TRENCH
FLAT
CO
PROPOSED TH 7 MH Mr
•
2C0
NOTE: 0 •
DECOMMISSION EXISTING 1000 GALLON SEPTIC ••
TANK IN ACCORDANCE WITH MOA CODE. LFLAT7
•
ABANDON EXISTING ABSORPTION TRENCH IN SE
�— EXISTING ABSORPTION
PLACE. 1982 TH LOCATION 0 .. ` EXISTING •
SEPTIC ••�• TRENCH
FROM MOA FILES �� TANK i--- ABANDONED ABSORPTION
TN .
/ TRENCH
I IELECTRICAL EMENT EXISTING ABSORPTION
TRENCH
illiifGE
[NGIN[10.1NG
NOTE:
������� NO SLOPES>25%WITHIN 50'OR SURFACE WATER WITHIN 100'OF THE LEGEND
QF'�`‘il PROPOSED SEPTIC SYSTEM CO—CLEANOUT
A P••• • •.' ��� ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS 2CO DOUBLE CLEANOUT
*:•�7H �••* FCO-FOUNDATION CLEANOUT
.. PROPERTY ARE SHOWN.NO CONFLICTS WITH WELLS OR SEPTIC FS—FLOW SPLITTER VALVE
d SYSTEMS. MH—MANHOLE
Michael E.Anderson :�/ 0 30 60 MT MONITORING TUBE
��T V.•• �E-4381 ��/ FEET SV-SEPTIC VENT
flF• 44 0.-` � TH—TEST HOLE
�AgDPROFESSIc0•� 1°=30'
SAND LAKE SUBDIVISION #2
BLOCK 2, LOT 7
DESIGN FACTORS: SYSTEM REQUIREMENTS:
450 GPD PEAK FLOW 3' WIDE DEEP TRENCH SYSTEM
PERK RATE: 56 MIN/IN 1,500-GAL FAP ADVANTEX TREATMENT TANK
APPLICATION RATE: 2 GPD/SF AX-20 FILTER POD
450 GPD / 2 GPD/SF / 5' DEEP /2 SIDES = 22.5 LF TRENCH REQUIRED (23 LF SPECIFIED)
BOTTOM OF TRENCH: 9' BELOW GRADE
FLOW LINE ELEVATION: 4.0' BELOW GRADE
TOP OF TRENCH: 0.5' ABOVE GRADE
6"
„a g 1VTIIAI111 _ -
IallmI 1E 11 r:
I1I 1*_ J, 111==*1
' 1111-I 1 I Imt:
q11
I�ll�7
I 0,11=
11=11=11-IC*11:11'
= 111IC111=11=1
6"
;,.,..•:::::•;: •;.:i.:• 4" PERFORATED PVC (HOLES DOWN)
t::;::::::�:.:•::::::; __::;9;;
0,.::::::::::::::;.i„:-::::i.,:::::.;':::..:: DRAINFIELD ROCK
P...::::::.:::•:•:%;•;•:%;9:%:::.
P.;.::;::::::.:::::#_9:!;9 :;
I:::::::::::::::.;:::::::::.I:,
5' is :;:::;:
Mike Anderson
From: Claudia Roberts <Claudia_Roberts@chugachelectric.com>
Sent: Wednesday,June 27, 2018 3:34 PM
To: andengr@gci.net
Subject: Sand Lake Sub#2 B2 L7 septic system
Hello Mike:
Chugach has a two (2)General Easements that affect this parcel. Chugach will claim the East Ten Feet(E 10') under the
General Easements for the existing overhead power line located on Lot 7, Block 2, Sand Lake Subdivision No. 2.
Chugach will grant an Encroachment Permit for a shed, deck, structure, septic system,well, etc.,that intrudes the
easement area and does not limit any future Chugach usage.
Atadia
CLAUDIA ROBERTS
Right of Way Agent III
Chugach Electric Association,m Inc.
5601 Electron Drive
P.O. Box 196300
Anchorage,Alaska 99519-6300
(907)762-4646 or fax(907)762-4852
claudia roberts@chugachelectric.com
72-013 (Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
0
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
NAMr
PHONE
ElNEW
r
MAILING ADD SS
0--913)(UPGRADE
f
47 1
f 1 vP
LEGAL DESCRIPTION
#2 1
Loi'l
� � �
LOCATION
NO. OF BEDROOMS
Well i -
Absorption area i
Dwelling
PERM
v Y
DISTANCE T0:
aQ
Manufacturer
Material
No. of comp ments
F
�
- r
i�
N
Liq. caTi ty in ions
IF HOMEMADE:
Inside length
Width
Liquid depth
DISTANCE TO:
Well
Dwelling
PER
_j 0z
❑ Z Q
—
Manufacturer
Material
Liquid c pacity in g Ilons
2 IP-
I
Well i
Foundation d
Nearest lot line.� d
PER
ew
w=
DISTANCE TO:
L
�_
J w zNo.
Z w
~
of lines
Length of each line P
Total length of lines (�
f 7—
f Trench width
inches
Distance betwe n Ines
'
a H
Top finish
Material beneath tile
Total effective absorption area
p
of tile to grade
^���
� inches
11170- '
Length
Width
Depth
PERMIT NO.
Lu
QF
Type of crib
Crib diameter
Crib depth
Total effective absorption
area
as
w
y
Well
Building foundation
Nearest lot line
DISTANCE TO:
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
w
Building foundation
Sewer line
Septic tank
Absorption area(s)
DISTANCE TO:
OTHER
F
PIPE MATERIALS
�VIC,
o
SOI L TEST RATING 11
'3 `
INSTALLER
REMARKS
0
F
I
L-A
5 el
o
f
d
APPROVED
DATE LEGAL
r
72-013 (Rev. 3/78)
C: 1 NO, M Q. 1 C"D MET
DEPHRTMENT,''O HEALTH HID �NY�RONMENTHL/�ROT�CTIGN
825 STREET01
^ 264~472@
/
1,XWE
M KEE W M 1=4 M Fz-
n
PERMIT foO.
( ;�L:`,2Cj499 )
HPPLICHNT
HULTQUIST CONST INC
4767 MARS: DR
]44-911]
LOCHTION
L7 113*2SHND LHKE #2
SIZE
8700 S8UARE FEET
LEGHL
L7 B2 SHND LHKE #2
LOT
TYPE OF SOIL
HBSORPTION SYSTEM IS:
TRENCH
MHXIMUM NUMBER
OF 8E1f7`-R00M5
SOIL RHTING (SQ
THE REQUIRED SIZE OF THE SOIL HB�ORPTION SYSTEM IS:
REA EEL Q -71- Of — 11. up) L, Q BY 171 -f- 1-1 === "YN Q% V ---i F-!! �=� UVO FEE.: L- E> EEEP2 1- k=E-EI-1
THE LENGTH DIMENSION IS THE LENGTH (I04 FEET) OF THE TRENCH OR DRHINFIELD,
THE DEPTH OF H TREWCH OR PIT IS THE DISTHNCE BETWEEN THE -C.:URFHCE OF THE
GROUND HND THE BOTTOM OF THE FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRHVEL DEPTH IS THE MINIMUM DEPTH 8F GRAVEL BETWEEN THE OUTFI�-ILL PIPE
HND THE BOTTOM OF THE EXCHVHTION (IN FEET).
05"FRE: (It U X I " THE! EE'. ��L- P-1�
PERMIT HPPLICHNT HAS THE RESPONSIBILITY 1'8 INFORM THIS E)EPHRTMENT DURING THE
INSTHLLHTION INSPECT�ONS OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE
NUME5ER OF RESIDENCES THHT THE WELL WILL SERVE.
��������
BACKFILLING OF HNY SYSTEM NITHOUT FINHL INSPECTION HND APPROVAL BY THI,"S
DEPARTMENT WILL BE SUBJECT TC PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL HND ANY ON-SITE �EWHGE DISPOSHL SYSTIE:M IS
100 FEET FOR H PRIVHTE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FFe.(DM H PRIVATE WELL TC) H PRIVH'M LINE IS 25 FEET HND
TO H COMMUNITY SEWER LIVIE IS 75 FEET.
OTHER REQUIREMENTS MHY APPLY. SPECIFICATIONS HND CONMRUCTION DIAGRAMS AF -`.E
HVHILHBLE TO INSURE PROPER INSTHLLHTION.
VIER7 lot M I W- �M" 'K- 131 NET CI 1=2 to! ED KEE W ���; A'-,
I CERTIFY THHT
U I HM FAMILIAR WITH THE REQUIREMENTS FOR ON --SITE SEWERS HND WELLS AS SET
FORTH BY THE MUNICIPRLITY OF HHCHORHGE.
2 I WILL INSTALL THE SYSTEM IN HCCORDHNCE WITH THE COOPS.
]' I UNDERSTHND THHT THE ON�SITE SEWER S95TEM MHY REQUIRE ENLHRGEMENT IF THE .
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ] BEDIROMS
SIGNED�~__._
HP �CHNT HUL�oUIST CONST IMC /^ /
/
� ^�
'l DHT �m'�/�^ /
SOILS LOG
l01UNiCIPALETY OF ANCHORAGE
DEPARTMENT Ot HEALTH AND ENVWONi0EN TAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264.4720
SCOIL.S LOG — PERCOLATION TEST
PERFORMED FOR: -S�i —
^
k--.r'lteo
DATE PERFORMED:_
INAS GROUNID WATER
LEGAL DESCRIPTION: 1-- 0-t
t
610C K
SLOPE
ENCOUNTERED?
L
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72-008 (G/79)
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of ✓4:! 6 Stl !7, 0 MILS ioro A2, (Or.
LofS 7-11 JA (1Ici6S' Hn I -F24- public water system located
in/7�z =a r�T{ T'C Alaska, submitted in accordance with 18 AAC 80.100
by e _ have been reviewed and are
X approved.
❑ conditionally app oved (see attached �conditions).
'iTTL€4)1�cih r-vE&l —��L1y L�E'Y f
DATE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contract order no. Approved by Date
or descriptive reference)
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the 5k=Lbtc-t Cc( ik:e, 0-0t Ag kC (r— �tJ< 7- l Z- public
water system was completed on -Is- Z71 ti e= Pi M� (date). The system is hereby
gra fed interim appal too erate for 90 days following the completion date. �j —7
4 -Y
J jy 6jY1,i P LI C(1 l� 31 Li 1 h t (' v / �' / �t'rLE DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
f al approval to operate.
/� e c. L `�®'''" �Lv1vu,.YA4T—CI u.Z�t��IM��'O
BY TITLE �— DATE
COSA Checklist yellow sheet
COSA Checklist
Legal Description: Parcel ID:
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
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test?Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) years
Tank type/material
Measured operating fluid level in septic tank
Standpipes/foundation cleanout per record drawing
Date of pumping
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA ______________________
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
Code-required soil cover over field
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Adequacy test date
Results Pass For bedrooms
Fluid depth prior to test in
Water added gal
New depth in
Elapsed time min
Final fluid depth in
Absorption rate gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
Comments/Deficiencies:
Sand Lake #2, Block 2, Lot 7 011-133-42
FORGE ENGINEERING
10/14/20
Class C Well on Lot 6 to the East. Arsenic retested 10/28/20
2
STEP/Advantex/Fiberglass 2
Fiberglass
See Maintenance Report See Maintenance Report
Deep Trench
07/13/20 10/19/20
3
9.3 0
4.5 514
34
1440
0
>450
No
✔
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 if No ft
Neighboring Tank > 100’Yes if No ft
Absorption Field on Lot > 100’Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’Yes if No ft
Holding Tank > 100’Yes if No ft
Animal Containment > 50’Yes if No ft
Manure/Animal Excreta Storage > 100’
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
Property Line > 5’Yes if No ft
Absorption Field > 5’Yes if No ft
Water Main > 10’Yes if No ft
Water Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’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
Property Line > 10’Yes if No ft
Water Main > 10’Yes if No ft
Water Service Line > 10’Yes if No ft
Surface Water > 100’Yes if No ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’Yes if No ft
Community Wells > 200’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.
11/11/20
Community Well adjacent lot.
✔✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
>50
>50
✔
Lot is served by Class C Well on Lot 6 to the East.
• •
Gt 8V
Municipality of Anchorage
On-Site Water and Wastewater Program
i
(907) 343-7904 SAFETY
Certificate of On-Site Systems Approval
Parcel I.D. 011-133-42 Expiration Date: / t " 6:1"-
1.
'1. GENERAL INFORMATION
Complete legal description Sand Lake #2, Block 2, Lot 7
Location (site address) 8101 Seaview Street Anchorage, AK 99502
Current Property owner(s) Craig & Vanessa Hassinger Day phone
Mailing address 8101 Seaview Street Anchorage, AK 99502
Real Estate Agent Carmi Gubser Day phone (907) 830-3228
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 Individual El
Individual Water Storage El Holding Tank El
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: (1&/f J 4. Date: g(q`/
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ Waiver Fee $
Date of Payment 7:3( -i 0 Date of Payment
Receipt Number ( �X/C 03 - Receipt Number
COSA# Q C- I $I 3 7�5� 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 Forge Engineering Phone (907) 522-7773
Address PO Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 8/09/18
r�Q�EOF Ak
••.0 40
d
* 49 TH " *
f i7 r
6. DSD SIGNATURE
System #1 Approved for —3 bedrooms �r . Michael E.Anderson
� �'F • 438 -E. •�`�
System #2 Approved for bedrooms , %TF. �;•-�,� • :.����
lil9FopROFESS\C3 -
•
Disapproved 1\\ ��
Conditional approval for bedrooms, with the following stipulations:
`\ Ui- ,..
•vu„,.
L
ON-SITE G,
WATER AND
o WASTEWATER a-
'77),
'n PROGRAM
cy—nk 11r
Original Certificate Date: 0-c?"-/W
By: J
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 blue sheet r c
. Ifmore than 1septic system iaonthe lot:
CDSAChecklist #o___
Structure served by this system
���D�|����� A{Or�� k�7
Lego|D�achodon� Sand `-=`" ""-` Block ^-' `-"� '
A-WELLOATA
r'lnec r,
01i-1��.�_��
Parcel |D�" ' ' '~'� `'�
Well type If A,B.orCprovide PWS|D# Well Log (YIN)____
Date completed Sanitary seal MYN\Wires properly protected 08N\________
Total depth ft. Cased to Casing height (above ground) ________n.
FROM WELL LOG AT INSPECTION
Date of test
Static water level
ft.
Well production g.pJn.
VVATERSAMPLERE8ULTS:
Coliform Ned oobniee/100mL NitrateND mo0-
Arsenic 55.0 ug/L Date of sample: 7/11/18 Collected by. Forge Engineering
ft.
B.SEPTIC/HOLDING TANK DATA
TankTmo/@ateha/ F.A.P./ Fiber Glass
Tank size 1500 e gei Number ofCompartments 9��
Foundation cleanout (//N) V
Date ofpumping
Date installed 7/1q/1A
Cleonouts (YIN) \/
Depression over tank (YIN) W High water alarm (YIN) '
N�� Construction
__ rumpor'' ~ ~^'�~^'
Date installed 7/10/18 Soil rating (o.p,dm2or*u*dnn) 2.0GpD/SF System type Deep Trench
�� �
0 5
L�Q��" ft. Width"'" ft. �u�|b�o��m..M ft.
Total depth 10 ft. Eff.absorption area 230 ft2 Monitoring tube \/ Depression over field N
�VV
Date ofadaquaoytest New Reau|ta(Paaa/Fai|) For ____bedrooms
Fluid depth inabsorption field before test in. Water added_ gal. New depth______in.
Elapsed Time: min. Final fluid depth in. Absorption rate >= g.p.d.
Any rejuvenationtreatment (past 12mo.)(YIN &type) |fyes, give date________�
D. LIFT STATION
4'12444 1500
Date installed — Size in gallons
"Pump on" level at 25 in. "Pump off' level at 13
Datum Top of pump Cage Cycles tested New
in
Manhole/Access (Y/N) Y
High water alarm level at 1 1 in.
Meets alarm & circuit requirements? Y
E. SEPARATION DISTANCES
WELL ON LOT TO:
>50' > 100'
Septic tank/lift station on lot On adjacent lots
Absorption field on lot >50' 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'
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >1 0, Property line >51
Water main >1 0, Water service line >10'
Wells on adjacent lots >50'
ABSORPTION FIELD ON LOT TO:
Property line >1 0, Building foundation >1 0,
Water Service line >10' Surface water >100'
Curtain drain None Noted Wells on adjacent lots >50'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that 1 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 Michael E. Anderson, PE
Date 8/09/18
COSA brown sheet 10-10-12.doc
Absorption field >5
Surface water >100'
Water main > 10'
Driveway, parking/vehicle storage >10'
4�t\\\fit
kl
O�� AC,gsllt
j*. 49 TH .. .
Michael E. Anderson
�,/•. „4381-E .•��`��
�111��PR0.SS &, �'
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT . 907-343-7904
On-Site Water and Wastewater Section Fax: 343-7997
www.muni.org/onsite
Arsenic Advisory
Certificate of On-Site Systems Approval # OSC181378
Subdivision: Sand Lake #2 ,Block, 2 Lot 7
A water sample revealed an arsenic concentration of 55.0 micrograms per liter
(ug/L). The Environmental Protection Agency (EPA) has established a maximum
contaminant level (MCL) of 10.0 ug/L for public drinking water systems. While
private wells are not subject to this regulation, EPA standards are based on existing
health information and can therefore be used to gauge the relative quality of water
from private wells. information on arsenic is available from the On-Site Water and
Wastewater Program website (www.muni.org/onsite) or at 343-7904.
This advisory must be attached to all copies of the subject Certificate of On-Site
Systems Approval.
Mailing Address: P.O.Box 196650*Anchorage,Alaska 99519-6650 *www.muni.org
Municipality of Anchorage ,
Development Services Department -r''`
Building Safety Division `t! +.
On -Site Water and Wastewater Program $ A
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 +
www.ci.anchorage.ak.us ^
(907) 343-7904 �(
Q CERTIFICATE OF HEALTH AUTHORITY APPROVAL�s
FOR A SINGLE FAMILY DWELLING
Parcel l.D. 011 -133 -1151 -
1. GENERAL INFORMATION
HAA # 050 OId
Expiration Date: / O - 29 - O S
Complete legal description Loi I Block 2 Maxt- 11Z
Location (site address or directions) %lot Sexy;eu3
Current Property owner(s) Choi; San1tA5on Day phone 2L43 — 146 --
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
slot Scno(w ,Ane�r AK `nSo2
Day phone
FF5013 Day phone
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 2
3. TYPE OF WATER SUPPLY:
Individual Well ❑
Individual Water Storage ❑
Community Class C Well K
Public Water System ❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank ❑
Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verity that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verity 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
Address
Engineer
5. DSD SI(
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: - D �� Original Certificate Date:_ a g ^ U S
(Rev O1102)
Municipality of Anchorage
Development Services Department •�s•.
Building Safety Division • • , , ,
on -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Loi -1 Slock 2 So—Auks..'-2 Parcel 10: :93 -1/ 2—
A. WELL DATA
Well type oinhKn��Y
Date completed =
Total depth � ft.
Date of test
Static water level
Well production
If A. B, or C provide PWSID # = Well Log (YIN)
Sanitary seal (YIN)=
Cased to — ft.
FROM WELL LOG
ft.
Wires properly protected (YIN) _
Casing height (above ground) — in.
AT INSPECTION
WATER SAMPLE RESULTS: o.to L.S.
Coliform —.0--colonies/100 mi. Nitrate 6+B mg./l.
Arsenic: — mg./l. Date of sample: 15 MS
B. SEPTICIHOLDING TANK DATA
Tank Type/MaterialGtn� S4c{d
Tank size 1000 gal. Number of Compartments 2
ft.
Other bacteria —,�— colonies/100 ml.
Collected by: "_Snurkk00%a
Date installed 6�28�Q2
Cleanouts (YIN)
r�o!{ndation cleari6ut ('iNN) Y Depression over tank (YIN) 14 High water alarm (YIN)
Date of pumping / Pumper � o
C. ABSORPTION FIELD DATA
��Q1"1-
Date installed -4 W4 Soil rating (g.p.d./ftZ or ft2/bdrm), (a System type i%een 1.5
Length �8i ft. Width 3-10 ft. Gravel below pipe ft.
Total depth 19_25 ft. Eff. absorption arealift' Monitoring tube Y Depression over field e� _
Date of adequacy test All to S Results (Pass/Fail) Pass For bedrooms
Fluid depth in absorption field before test -40 in. Water added!ta gal. New depth_g_% % in.
Elapsed Time: {IM min. Final fluid depth kb_ in. Absorption rate >= 1W g•p.d•
Any rejuvenation treatment (past 12 mo.) (YIN & type) Alone, krowe% If yes, give date
D. LIFT STATION
Date installed mons anhole/Access (Y/N)
"Pump on" level a _ in. 'Pump off" level at in. High water alarm level in,
Datu Cycles to Meetsalar circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot --
Absorption field on lot
Public sewer main ._
Sewer /septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout —
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation > lo' Property line > lo' Absorption field to'
Water main _ N,A Water service line 72 S' Surface water 1 too'
Wells on adjacent lots 10014 L.f'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I L.S.
Property line 'r S Building foundation 1101 Water main > 2S'
Water Service line )"LS Surface water 7lee' Driveway, parking/vehicle storage '12S'
Curtain drain N/� A Wells on adjacent lots JOo *
F. COMMENTS
1# M.A...
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 Te66c..
Date '*I%5% ZoaS
HAA Fee $ �-3 0 /7S 9Ur4
Date of Payment —2 ' a % - Q .7
Receipt Number .r 4na
(Rev. 12/01)
Waiver Fee $ _
Date of Payment
Receipt Number,
•'i
6 &+rte
C"M y
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of�us'riciu�.!%1C� Scf /x art1�5ldn7 Z- Islet 2
/ -•+s n / (f f aS �(Y a (VI -1 1 - Fs4- if 4P public water system located
in Ryyae_ •,vu 9;9 y�} �C Alaska, submitted in accordance with 18 AAC 80.100
byw 11 M CJ �e Fd r , r rvs have been reviewed and are
K approved.
O conditionally app oved (see attached conditions).
1 ht t ,r4� /�rPPv GATE
By 146�
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED CHANGE ORDERS
Change (contact ordw ma Approved by Date
or Murlpt" "'I"MI)
The "APPROVAL TO OPERATE" section must be completed before any water Is made available to
the public.
APPROVAL TO OPERATE ���
The construction of the �u u t., I:,,- L dua e k L �.+f� �% r Z public
water system was completed onl e,- 4-T Nr /Cl r--iL (date). The system is hereby
graotod interim apprgyal to operate for 90 days following the completion date.
` 2
�• �.,.r r...nMN.e milt ( l�, h �l 1 hPrl -/ � /� b
E DATE
As -built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
f al approval to operata.
r LN lilvt'�JUY'ct
BV TITLE �— DATE
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MUNICIPALITY OF ANCHORAGE
• t Department of Health & Human Services y i
DIVISION OF ENVIRONMENTAL SERVICES �=
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel l.D.# r"5S'" 4-z HAA#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lo 7 -1 C3 K 2gz, ► _6L Id 2 S.*. < < x 12 n i E 12 4 1'�/
Location (address or directions)
(b) Property ownerTelephone: (home)
Mailing Address
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
Telephone
(e) Mail the HAA to the following address: (or check here 7!; if hold_ for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single -Family
3. WATER SUPPLY
Business
.I- Ll £3 -45 02 S-
Number of bedrooms
at -
Individual Well 9 Communityx Public ❑
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 ❑ Holding Tank ❑
Note: I community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. vae) 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 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 ���''► �Or/✓lt�c�uOL: Telephone –
Address
Date !lo ✓ /fl 20
�f .rte
n...r 'fir ."• ���
r.
M ly qq.y%e •_�l
i•�� �f4s
6. DHHS APPROVAL
Approved for /U b Date
Approved Disapproved,,, Conditional
Terms of Conditional Approval
lye
CAUTION
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
oranalyze 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. 7/88) Back Page 2 of 2
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984 i
343-4744
Leg"escription: �-
Date Completed
Electrical Wiring in Conduit (Y/N)
Depth of Grouting
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by S ; Date / 't L)
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed 6. 9?— Size I V-0,0 No. of Compartments Z.
Standpipes(Y/N) :1 Air -tight Caps (Y/N)%Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ly Date Last Pumped-7.7,0-
Pumping/Maintenance
umped 7•ZU-
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well I dt� To Building Foundation
To Property Line
'[
To Disposal Field s /
To Water Main/Service Line 7 .GJ
To Stream, Pond, Lake or Major Drainage Course /`f o &4 �—
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata Type of System Design 1zt NcH
Date Installed 6-S Z Length of Field 783
J
Width of Field - 4, Depth of Field �l ✓�
Gravel Bed Thickness 7 J�
Square Feet of Absortion Area //70 Statndpipes Present (Y/N) 3
Depression over Field (Y/N) �Y Date of Last Adequacy Test 7,/60,9
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well I O-ta
To Building Foundation
Lot
To Property Line
; On Adjoining Lots
To Existing or Abandoned System on
/Df,
To Water Main/Service Line >.2 a To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Areay
Comments
D. LIFT STATION L
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N) _
Comments
Dimensions
Manhole/Access (Y/N)
"Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that I have checked, verified, or conformed to all MOA and HI` guidelings in effect on the date of this
inspection.
Signed
r {
V
rA
_
m 6J
Company
�
i 4
(�� Engineer's Seal
�
Date
U ✓
1
MOA No.
ac 6�3 g&�
Receipt No.
Receipt No
s- _ ct d
Date of Payment
Waiver Fee: $
Amount: $ /70Gb
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE
• Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES �`
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # (")t ` - 1 -,- I_I Z HAA# 001 1/-i-, L1'!'�-1
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 7• B2uck 2• Sand Lake #2
Location (address or directions)
8101 Sea View
(b) Property owner H.U.D.037934-203 Telephone: (home) Business
Mailing Address
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent ROGER'S REALTY ATTN: Lyman Meacham
Telephone
344-8492
(e) Mail the HAA to the following address: (or check here df hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERi NG
117034-rGae l Riyv r Loop Road IRin 2414
Eagle River, Alaska 99.577
2. TYPE OF RESIDENCE
Single -Family W Number of bedrooms
3. WATER SUPPLY
Individual Well ❑ Community Public ❑
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 6X 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 (Rev. 7/88) 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 .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
Telephone
5 & 5 ENGINEERING
Address 17034 Eagle River Loop Roar{ No. $
Eagle River, Alaska 99577
Date
WA
Na. 1467-a s s'
6. DHHS APPROVAL
Approved for __bedrooms by Date
Approved �� Disapproved Conditional
Terms of Conditional Approval
CAUTION
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 orderto satisfy certain federal and state requirements. Employees of DHHS do notconduct 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. nae) Back Page 2 of 2
SPG 9�p�
p�G�oO�J� MUNICIPALITY OF ANCHORAGE (MOA)
pF �¢,�� • Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
Jc'`G�Q���,t 343-4744
\�C ` Legal Description: Lot %��c_.=s 2
A. WELL�,A�A
Well Classification LOAAM I A) %u If A, B, C, D.E.C. Approved (Y/N) t -
Well Log Present (Y/N) Date Completed Yield
Total Depth Cased to Depth of Grouting
Static Water Level Pump Set At
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot Z -4 ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ZC90 r+ ; On Adjoining Lots
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
Comments P Li 5 1 N Z 16 15-0
B. SEPTIC/HOLDING TANK DATA
Date Installed ( Size iQco No. of Compartments 2
Standpipes (Y/N) _Air -tight Caps (Y/N) Foundation Cleanout (Y/N) til
Depression over Tank (Y/N) A% Date Last Pumped 't �7 — Z O — 8 y
Pumping/Maintenance Contact on File (Y/N) t'JIyi ; for 6U 1114
Holding Tank High -Water Alarm (Y/N) AJ.16 Temporary Holding Tank Permit (Y/N) NL
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water -Supply Well / od To Building Foundation
To Property Line -
To Water Main/Service Line
To Disposal Field
To Stream, Pond, Lake or Major Drainage Course
Comments 14Dnn.� L)Ac_AAt
72-026 (Rev. 7/88) Front Page.1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata (5 %4r_:j'Type of System Design :7 ) h
Date Installed Length of Field `a
Width of Field Depth of Field (� S
Gravel Bed Thickness S
Square Feet of Absortion Area / 1 :jo Statndpipes Present/N)
Depression over Field (Y/N) tJ Date of Last Adequacy Test
Results of Last Adequacy Test �� +s f✓!C-toer4 - Z 8eo(vo0nn
SEPARATION DISTANCE FROM ABSORPTION FIELD
To Water -Supply Well ( on
To Building Foundation _11,S
To Property Line
To Existing or Abandoned System on
Lot A)/tA ; On Adjoining Lots o
To Water Main/Service Line / tp 7t To Cutback (if present) N%W
To Stream, Pond, Lake, or Major Drainage Course 00 t
i
To Driveway, Parking Area, or Vehicle Storage Area to t
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N) _
"Pump Off' Level at
"Check Permitted Bedroom Rating Against HAA Request"
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effeZt.,6Mtbiey ate of this
inspection.
Signed
S & S ENGINEERING
Eagle RiverLoop
Road No . 204
Company
Eae Ra;,_orR ,Alaska 99577
y!F r51� JF'3`.1.Yfn�lll . Rl.i (-i
Date
��
Y� ¢,
:,,.J.v,,....
MOA No,
C= 9 — O o
s,.•..f�
4 a�
No I 74i
P
Receipt No. O S — -2- S (
Date of Payment /b _ g 0
Amount: $ 1749,
Receipt No
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE
• -� Department of Health & Human Services p
DIVISION OF ENVIRONMENTAL SERVICES dj
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # i711 - I'� -)-1 HAA # 0 Q2 J2) l `l
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (addressor directions)
5.cgtIA5 J
(b) Propertyowner
Mailing-Address
(c) Lending Institution _
D
Telephone: (home) Business
Telephone
Mailing Address
(d) Real Estate Company and Agent fIAMPW 1%190TiEi
Address
Telephone
(e) Mail the HAA to the following address: (or check hereK if hold for pick up.)
List contact person and day phone number below:
AEcs 161eX 0
2. TYPE OF RESIDENCE
Single-Family'gL Number of bedrooms z-
3. WATER SUPPLY
Individual Well ❑ Communityx Public ❑
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'K Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
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pue led!ownlN !le y}irn aoue!idwoo ui sl wa}sAs lesods!p ja}erna}sEm Jo/pue Alddns as}ern a}is-uo ay}'uo!}oadsu!
pue u0i}e6!}sanu! Aw woa; pue sal!; a6eaoyouy ;o �(}!led!oiuniN ay} woa; pau!L}qo uoi}ewao;u! ay} uo paseq
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S1141 10 uol}L6l}sanuAw }ey} Aj!Jan I molaq umoys a}ep uoi}ep!len 9144 10 puL o}away paxb;ees lw(q pa�ao sy
NOIlVWi!OdNI
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--Z r~ -7x frYNs '7P L –/
A. WELL DATA
Well Classification
II Log Present (Y/N)
Total h Cased to
Static Water
Casing Height Above Gold
Electrical Wiring in Conduit (Y•
0"-X0�
0` bNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
P 343-4744
C�HN
Date Completed
SEPARATION DISTANCES FROM
To Septic/Holding Tank on Lot
Legal Description: L 7 15Z L040E ad-
T/x l fEe /o
Depth of Grouting
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
If A, B/;:Z\ D.E.C. Approved (YY N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wallhonei W/Ml
;On
To Nearest Pu
Z,,
Z`
/9oCS
Date Installed le r,BY Size 1o'tlD No. of Compartments y
Standpipes&N) - Air -tight Caps&N) Foundation Cleanout(Y)N)
Depression over Tank (Y6)Date Last Pumped 7'2'0-,c1 11"Ae-5
Pumping/Maintenance Contact on File (Y/N) WA ; for
Holding Tarek $Ii lat ,Alarm (Y/N) �A Temporary Holding Tank Permit (Y/N) �A
1, „o+e J ram
SEPAR,A.,LAtl9tAN13 SEPTIC/HOLDING TANK:
To W,atupply`(e)Iss' _ °' �� To Building Foundation
Y'4 -°
To Property Line To Disposal Field
To Water Maih/Service Llne
To Str0i.-n;,Pond, Lake or Major Drainage Course �� t
Comments`
72-026 (Rev. 7/88) Front Page 1 Of 2-
7 0 z- sa✓d vt>r�y
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 3/S Type of System Design 77eE�ell
Date Installed —z�-8y Length of Field -7k
Width of Field 3 �'' Depth of Field �� ;5r- 01
'
Gravel Bed Thickness %:!�'
Square Feet of Absortion Area Statndpipes Present (1 N)
Depression over Field (Y, f9V Date of Last Adequacy Test
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
i
To Water -Supply Well /OV To Property Line
To Building Foundation 33 To Existing or Abandoned System on
Lot 4114 ; On Adjoining Lots lD�t
To Water Main/Service Line /o f To Cutback (if present)
i
To Stream, Pond, Lake, or Major Drainage Course /� f
To Driveway, Parking Area, or Vehicle Storage Area X01
Comments
D. LIFT STATION
nstaIled
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"`Check Permitted Bedroom Rating Against HAA Request"
"Pump Off" Level at
Vent(Y/N)
Pumping Cycles during Adequacy Test.
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines i
inspection. �� �
Signed �" � a `
Company ��Gf
Date
MOA No. dZ
Receipt No. c21,3 / / l 7 7
Date of Payment_Z'\�z
Amount: $ 42y . RC1
Receipt No
Waiver Fee: $
Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
wt
or
O•:
the date of this
IF - - .. .•••.R
• ROY C. REID, JR. �• r
'. CE -2251 : 4- i
is Seal
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
264-4720
Application Date
1. ;/GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision section, township, ran e)
Lrs7< 7 i3lec� Z S lee Su/�/, ��Ieil/d, z TIZN 4YW sQe io
Location (address or directions)
(b) Applicant Name � 64t Telephone: Home Business
Applicant Address
(c) Applicant is (check'one): Lendirigr Institution[]; Owner/builder[]; Buyer[]; Other (explain);
(d) Lending Institution ' Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
Onsite
`Public ❑ , CcmmunityJ Holding Tank ❑
�,
ommunityv✓ellsystem rpust have written confirmation from the State Department of Environmental Conservation
I to the gally an stat�sr�
y✓t r C e � � E -. 72-025 (11/84) -
MLfNICIPALTIY OF
CZ
MUNICIPALITY OF ANCHORAGE (MOA) DEPT. OF HEALRA
HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION
CHECKLIST - FEBRUARY 1984 1 4 1986
264-4720
Legal Description: Z 7'
T/Z/Y e4 W
A. WELL DATA
Well Classification e�o_G/i" If A, BQ D.E.C. Approved (Y/N) Y
Well Log Present (Y/N) � Date Completed /Y/A Yield IVA
Total Depth N 1A Casedt AYA Depth of Grouting IVIA
Static Water Level Pump Set At N��
Casing Height Above Ground NI Sanitary Seal on Casing (Y/N) /111A
Electrical Wiring in Conduit (Y/N) NIA Depression Around Wellhead (Y/N) IV
14
Separation Distances from Well:
O N�To Septic/Holding Tank on Lot On Adjoining Lots
7Q `
To Nearest Edge of Absorption Field on Lot MO ; On Adjoining Lots
To Nearest Public Sewer Line NI To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot 11q
Water Sample Collected by L f ly f /1 CG Afc, ; Date
Water Sample Test Results �DccC! C
Comments Gllllil/llG ��/ XDSC
B. SEPTIC/HOLDING TANK DATA
Date Installed Z�2 Size No. of Compartments Z
Standpipes (Y/N) ! Air -tight Caps (Y/N) y Foundation Cleanout (Y/N) y
/
Depression over Tank (Y/N) Date Last Pumped Z1/7/Ts
Pumping/Maintenance Contract on File (Y/N) NI ; for /Y�
Holding Tank High -Water Alarm (Y/N) N A Temporary Holding Tank Permit (Y/N) A
Separation Distances from Septic/Holding Tank:
To Water -Supply Well X00 / e
To Property Line /1 i
To Water Main/Service Line 3874
Course
Comments
Page 1 of 2
72-026(11/84)
i
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Z -or 7 f3LP1CrC Z s6rNDG �rE ? �
T AF !z ¢ W S¢c, /0 '
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata a/gl� Type of System Design
Date Installed Z& Z Length of Field �� >
Width of Field 3 �� r Depth of Field �� r
Square Feet of Absorption Area 1176
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well /00
Gravel Bed Thickness 7!5-
1
15-
Standpipes Present (Y/N)
of Last Adequacy//Test
Y .� �QGI!'b�3LJ (�Ip2LS�
r
To Property Line S
To Building Foundation 3S r To Existing or Abandoned System on
Lot NIA On Adjoining Lots ;>
To Water Main/Service Line r To Cutbank (if present) _A/
To Stream/Pond/Lake/or Major Drainage Course �(}U
To Driveway, Parking Area, or Vehicle Storage Area
Comments 7�f'iWa-51_
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Dimensions
nhole/Access
"Pu Off" Level at
Vent(Y/N)
Tested for Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes
** 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 L476 Date �Z/�
Company 146 /arc. MOA No. BS- aZIf 5� Of aAC,q��g
Receipt No. 3JrJ �$ ••'
•�
Date of Payment bI '� a1� •• oafsit
•+••••" ' �
H
Amount:$ ^ 1` •• �••�♦w e• • S�
Page 2 of 2
72-026 (11/84)
i
C. Reid, Jr. ?w
No. 2251-E
pROFESS����� z
ALASKA ENVIRONMENTAL
CONTROL SERVIC'�`, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
,, G 7 B Z 5��la 4- - 4; � F z
SHEET NO. OF G/
CALCULATED BY .sF 4f//�©S DATE
CHECKED BY DATE
wee
nQonE39c G //A/E
....1.
I- L�
PFOVA.2C41..� 1.: 000 Fpm 0147
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
264-4720
Application Date
1. GENERAL INFORMATION
2.
(a) Legal Description (include lot, block, subdivision, section, township, range)
v,— /�ocK �js,d �� /fie 71,
Location (address or directions)
(b) Applicant Name I` �� / ®` Telephone: Homee� Business
Applicant Address
(c) Applicant is (check one): Lending Institution ❑ ; ne builder PC, Buyer ❑ ; Other ❑ (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) pAail tha HAA to tha fnllnwina address:
TYPE OF RESIDENCE
Single -Family K Multi -Family ❑
Number of Bedrooms
3. WATER SUPPLY
Other
r
�
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 Public ❑ Community ❑ Holding Tank ❑
Note: ff community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (11/84)
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 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 Telephone
Address
Date
ee®°Y eao xnnn••o Kn sa °a0��
L y C. Reid,
0
2251•E a
FESS4IPC��
6. DHEP APPROVAL
ft
Approved for ,--6E �' bedrooms by �" `� `� �6 f�%`��`C— Date
X
Approved Disapproved Conditional
Terms of ,Conditional Approval
CAUTION
Engineer's Seal
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 the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH & MUNICIPALITY OF ANCHORAGE (MOA)
ENVIRONMENTAL PROTECTION HEALTH AUTHORITY APPROVAL (HAA)
! CHECKLIST - FEBRUARY 1964
U L i 8 264-4720
RE C E I V E® Legal Description: Bi-ecg a Sa�rLc/ �& fin 4*7-
A. WELL DATA
Well Classification 06ultmvl y 1 Tt If A, B/C,JD.E.C. Approved&,
Well Log Present (Y/N) VIADate Completed ��IVIA- Yield
Total Depth 1J(A Cased to r' Depth of Grouting
Static Water Level �� Pump Set At Nr`
Casing Height Above Ground Sanitary Seal on Casing (Y/N)
IUTA
�� u1
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot /fin / O ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /©O ; On Adjoining Lots w ,f'
To Nearest Public Sewer Line ii To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot N�
Water Sample Collected by ni �� ra4P e4Adtd ; Date w/7+
Water Sample Test Results _ )J 1A_
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed2c� c�o2 Size /000 No. of Compartments
Standpipes (Y N) Air -tight CapsYfi�V) Foundation Cleanoutg N)
%f' Depression over Tank (Y/jN),� Date Last Pumped / J� -iI s
Pumping/Maintenance Clonntract on File (Y/N) for All 111 -7 -
Holding
11 -7 -Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) ✓V n
Separation Distances from Septic/Holding Tank:
To Water -Supply Well ��D� To Building Foundation
To Property Line I- M- To Disposal Field �6
i
To Water Main/Service Line 4- g To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
v�
72-026(11/84)
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hv�checked, v rifled, or co formed to all M A an HAA guidelines in effect on the date of this inspection.
Signed Date �3
Company C MOA No. �'j
OF
Receipt No.e
�1 9J o
Date of Payment `'�� •�°° ` M•
Amount: $
H•• •• e e q •° s0 �°¢
.p
e QZ
Ler C. Reid, Jr. a ��
i� °°•• o. 2251-E- eeL 60
Page 2 of 2 �Q�F9�;0B••ee°,ee..pB,E �e
c
72-026 (11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strat f Type of System Design���
Date Installed dig
Length of Field $�
1.
Width of Field J
Depth of Field �� S
Gravel Bed Thickness,S
Square Feet of Absorption Area %� D't
Standpipes Present � N)
Depression over Field (Yf 4) 1)
Date of Last Adequacy Test
Results of Last Adequacy TTest✓�� �� GDS
t3��f On m^
Separation Distance from Absorption Field:
d, To Water -Supply Well MID 7 J(--
To Property Line h r
To Building Foundation 3S/
To Existing or Abandoned System on
Lot
On Adjoining Lots 4' r9-0
To Water Main/Service Line + 35
To Cutbank (if present) ��r`fi
To Stream/Pond/Lake/or Major Drainage Course
`i -I OUB
To Driveway, Parking Area, or Vehicle Storage Area
Comments I t�PLv;wt2{
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons
Manhole/Access (YY
"Pump On" Level at
l "Pilm ff" Level at
High Water Alarm Level at
Vent (Y/N)
Tested for
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hv�checked, v rifled, or co formed to all M A an HAA guidelines in effect on the date of this inspection.
Signed Date �3
Company C MOA No. �'j
OF
Receipt No.e
�1 9J o
Date of Payment `'�� •�°° ` M•
Amount: $
H•• •• e e q •° s0 �°¢
.p
e QZ
Ler C. Reid, Jr. a ��
i� °°•• o. 2251-E- eeL 60
Page 2 of 2 �Q�F9�;0B••ee°,ee..pB,E �e
c
72-026 (11/84)
Time Time
.e
Date
Date
Date
Inspector
Inspector
Inspector
Comments _
t/4-&W-10�Q
Conditional Approval
Q f9 f.4- I C
0�f
Date Sewer Installed
Permit No.
Septic Tank Size
Holding Tank Size
Soils Rating
Well To Absorption Area
Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner a 1� P,3
Phone
Mailing Address 11761 1 �U[7 Vi.^ !' j5ti7
Molt
Buyer
Address
Lending Institution
Phone
Address
v
Realty Co. &Agent RPOTN Pry er
Phone
Address 9301
Legal Description 7v✓r
Street Location✓I U
TypeResidence
&f
i5 Single Family
j
❑ Multiple Family No. of Bedrooms
❑ Other
Water Supply
J7 Individual
ATTACH WELL LOG. A well log is required for all wells drillsd since June
�9 Community
1975. For wells drilled prior to that date, give well depth (attach log if
❑ Public Utility
available.
Sewage Disposal
ICI Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.