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HomeMy WebLinkAboutSEQUOIA ESTATES BLK 1 LT 12LC uo Lr.JL &1�6 Dk �) �Mww 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 Wastewater Disposal System Permit Permit Number: OSP231392 Work Type: SepticTank Upgrade Tax Code Number: 01715212000 Site Legal Address: SEQUOIA ESTATES BLK 1 LT 12 G:2939 Site Mailing Address: 6840 SEQUOIA CIR, Anchorage Owner: SINCLAIR DAVID L & CHERYL B Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: f Department 11 /17/2023 11 /16/2024 49626 ❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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 V�_p F-D P-Gc- Date: Issued By: Date: f l 2 3 5 UH CC PA LL TY OF HCH0RD ° GC 0/ � Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON -SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 017-152-12 Property owner(s) David and Cherie Sinclair Day phone 907-891-4161 Mailing address 6840 Sequoia Circle, Anchorage, AK 99516 Site address 6840 Sequoia Circle, Anchorage, AK 99516 Legal description (Sub'd., Block & Lot) Sequoia Estates, Block 1 Lot 12 Legal description (Township, Range & Section) Lot Size 49,626 Sq. Ft. Number of Bedrooms 5 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (® all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑x Septic Tank ❑R Upgrade ❑X (w/wo ADU) Holding Tank ElRenewal ElDuplex (D) El Privy ❑ Multiple Dwellings ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. 1 (Signature of property owner or authorized agent) Permit/Rush Fees:225 Waiver Fees: Date of Payment: i i / / y I �2 �2 Date of Payment: / Receipt Number: Receipt Number: Permit No. _ �5�2 13 �'� Waiver No. PermitApp_::- :_..:c May 30, 2023 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 Subject: Sequoia Estates, Block 1 Lot 12 - Sequoia Circle Septic Tank Replacement Dear On-Site Services Engineer: The owner of the above lot has a septic tank that has reached its end of useful life, so we are submitting this permit application for its replacement. The attached site plan identifies the location of the home as well as the wells and septic location. No conflicts exist between this proposed system and any other wells or septic system, whether on this lot or adjacent lots. We are replacing the septic tank with the same size designed for 5 bedrooms. The new septic tank will be a minimum of 100’ from all wells and surface water. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231392, Curtis Townsend, 11/17/23 10' UTILITY EASEMENT Benjamin Schiller CE 12592REGISTEREDPROFESSION A L E N GINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND SEQUOIA ESTATES, BLOCK 1 LOT 12 FEET 0 50 100 SEQUOIA CIRCLE 5-BDRM HOME SEPTIC PLAN 11/1/23 RETAINING WALL 20' UTILITY EASEMENT DECOMMISSION EXISTING 1,500 GAL STEEL TANK NEW 1,500-GAL SEPTIC TANK EXISTING 200' OF TRENCHES TO REMAIN IN SERVICE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP231392, Curtis Townsend, 11/17/23 SEQUOIA CIRCLE 10' UTILIT EASEMEN Lot 13 I Lot 3 I I I Lot 2 Lot 11 CONCRETE 1.9' ( HOUSE DETAIL Scale: 1 "=40' 2.4 _111- 4 a g 3.2' 5 A' STORY REST )E" F5 2 w� DAYLIGHT w n 1.9' 10.4' S� 2! 2.9' 2 0' 2.4' DECK DE — r — — — I 20' UTILITY I Lot 1 EASEMENT I 2.0'x 15.4' CANT MORTGAGE SURVEY X_ SCALE _ 1" = 50'_ GRID SW 2939 project No. ` 23-427/A1 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone kenOlongsurvey.com �``�� '�•'rq�Professional Land Surveyors jonathonOlangsurvey.corn of AL L trovisOlangsurvey.com I hereby certify that I have surveyed the following described property: LOT 12, BLOCK 1, SEQUOIA ESTATES (PLAT No. 82-375) Anchorage Recording District, Alaska, and that this Mortgage Location Survey is a representation of the conditions that were found on the date the survey was performed. This survey does not constitute a boundary survey and is subject to any inaccuracies that a subsequent boundary survey may disclose. The information contained hereon shall not be used to establish any fence, structure, or other improvements. Dated this the '5_� Day of _ �Jv P � ti��' 7Iz i-I , of Anchorage, Alaska *; 49 TH qo•', KENNETH G LANG Q o. 202J�r kFpP-1 ZAMAW W ►�_ ESS�7NA + P It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963 r MUNICIPALITY OF ANCHORAGE ® DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 325 L Street - Anchorage, Alaska 99501 Telephone 264.4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW C g „ Y "VEW CL)ORLij 14l r4C. ❑ UPGRADE MAILING ADDRESS PO, Box 1>�3i+ AAJC14()''1q&E am 99,5-11 LEGAL DESCRIPTION - Lot J2_ aLK I SEQuatA Es AzA/ R_3W Sc ZG LOCATION NO. OF BEDROOMS 9 SEQ(Joul C lIR LIE Well Absorption arej Dwelling PEF�t I/T, NO . �1-® Uy DISTANCE TO: '� 1s� 1©t t1 �Cl0 a Q Manufacturer Material No. of compartments G� C. w Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth ®0 Well DISTANCE TO: Dwelling PERMIT NO. 02 O -Q ' < Manufacturer Material Liquid capacity in gallons 9 DISTANCE TO: Well ��r Foundation e�CRt Nearest lot line t P MIT NO. Q wg ,� E 7No. of lines Length 0-veacNinv,,_ ' Total length of lines Trench width Distance b t eep lines 18 P z i 50 2s 2CaS,�' i Top finish Material beneath tile Total effective abs�pion area of tile to grade y 0 -� Length Width Depth PERMIT NO. LU � N Type of crib Crib diameter Crib depth Total effective absorption area Lu LU rn Well Building foundation Nearest lot line DISTANCE TO: Cla,Depth Driller Distance to lot line PERMIT NO. J J i Te w Building foundation Sewer line Septic tank . ,' Absorptiq n areas) I S.3' OTHER PIPE MATERIALS CA SOILTESTR�AjTING ✓ - d INSTALLER C Ucic5; RACK1406 EX -0 1 REMARKS JA�SULA'rib&o 'r Al ` .0 J P 9 P0L): p g C-A� 0349 t. S /.3zY�ej TANK A.yia rvUti row Ili Bio 1,v 4?" Jdam 4TC-S7'8 4-o E� C/ APPROVED DATE LEGAL 3`W6-_ /Ph7/94 L ► 2- i -se0wiA KS'rA'res T l zAv See ' G i 72-013 (Rev. 3/78) ; i t � DEPARTMENT•• HEALTH AND ENVIRONMENTAL r .lOTECTION 25 L STREET, ANCHORAGE, AK 99501 264-4720 v ` I T.E: _L_ F=1E=fit*'! i i , PERMIT NO: 840290 GATE ISSUED: : 05/04/84 APPLIi=ANT: CHARLES HACaD'•r NEW WORLD IN ADDRESS:: P 0 BOX 111314 ANCHORAGE, AK 995-11 CONTACT PHONE: 345-3854 LEGAL CYE'=GRIP: _:UEC?IVISION: SEQUOIA ESTATES LOT: 12 BLOCK: I SECTION: 26 TOWNSHIP: 12N RANGE: 3W LOT SIZE': 49626. (SQ. FT. OR ACRES) LOTLOCATION: SEQUOIA CIRCLE MAX BEDROOMS: O LISTED BELOW ' ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. — _ _ _ — — — — — — T'FEE !'blF 1 E F=C:L•t_ C�F_1=M I r•t DEPTH TO PIPE BOTTOM' (FT.) 4.0 4.0 4. 0 GRAVEL DEPTH (FT.) 4. 0.5 y 0 . TOTAL ,DEPTH (FT.:, 8 jN, 4.5 7.0 GRAVEL WIDTH (FT. >, `��" 32.0 5.0 GRFV%;EL LENGTH (FT: :192.0 6,I 0 179.0 a h: GRAVEL GLUME 0C;U. YDS. :? ^" 72.2 116.0 TANS:: SIZE < ALS)' I; 500. 0 1,500.0 -1,500.0 SOIL BATING is SQ. FT: /BR) . Z06 260 306 ** -GRAVEL LENGTH :> 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH) **'TANK MUST HAVE AT LEAST TWO COMPARTMENTS I CERTIFY THAT: 1• I 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.. 2.-1 WILL -INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES: AND REGULATION& AND INCOMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT." �3.. -I WILL 'ADHERE` TO ALL [110A AND STATE OF ALASKA REG!UIREMENTS FOR THE 'SET BACK ANY EXISTING- WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC DISTANCES FROM SEWERAGE SYSTEM ON THIS. OR ANY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 5 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. I F` A LIFT STATION I'S INSTALLED IN AN AREA COVERED BY MOA BUILDING y_ ODE$• THEN (1`' AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED (2) AS—GUILTS WILL -NOT BE APPROVE& WITHOUT FIN ELECTRICAL INSPECTION REPORT: AND (_3) THE ELECTRICAL WORE: MUST BE DONE BY A LICENSED ELECTRICIAN. SIGNED — „ DATE: A-------- --- APPLiCAMT � E'•1-EAPLE i-1AMA,4WW LD INC -.ISSUED BY DATE: /lcc� 29���F�' All 1�U A*C['(2a1i1at �� PO, -16-650 % j x xa ANCHORAGE, ALASKA 99502-0650 (907) 2.64-4111 i y�J>, y,�� •_ TONY KNOWLES_ MA YOH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit #k: 840290 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 12 Block 1 Sequoia Estates Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, l "` v41�1 �5, h E Bandt Sup Keit , pe visor Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 s , SOILS LOG MUNICIPALITY OF ANCHORAGE 8C10 �� G +.e DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION i9 PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99507 264.4720 SOILS LOG — PERCOLATION TEST jj PERFORMED FOR: GARY HAbby DATEPERFORMED: Iii Ar'1 19M LEGAL DESCRIPTION: Gross SEQ UO I i Lai Depth to /a Time Time SLOPE Drop 41'.II T T 41:z o �0 3� r4 H..'7 Y3 brow?N yy `i;y4 - :310 .O '1:" 3 c„ .y1 4P- 6-14Y:5 n� — y© .3b -0 1 y.a! <yz ( I 4 5- f r iitt 1 6 -6-4 W1 f)ome 5an(1 x .V 6 1''x �Ull�df� 7 < 9 10 `i ljjlysravel L016(md 11 84 � browfq WAS GROUND WATER ENCOUNTERED? 12 1 13 14 51617 15- 16- 17 18 19 20 COMMENTS PERFORMED BY: d - .s�Bt 78 (6/79) GM- -JA nJy �rave� W16it" IF YES, AT WHAT DEPTH? I ock l SITE PLAN, a y !� o s L o O P E Ree din Date Gross Net Depth to Net Time Time Water Drop 41'.II 098 41:z o �0 3� r4 H..'7 Y3 5I:97 yy `i;y4 - :310 .O '1:" .y1 N 57 — y© .3b -0 1 y.a! <yz I O 31 Oa PERCOLATION RATE s1'1 - - (minutes/inc ) ..i TEST RU BETWEEN r I/Z' FT AND FT !i . FIED BY: . -.r k DAT WELL LOG Date Drilleds_ � 19 8 Static Water Level 120 feet Draw Down N/A feet Tvpe Material Drilleds 0 feet to Randg rlmg, grnvpt Lot 12 Bik. 1 Sequoia Est. Gallons Per Minute 11 Total Feet of Casing 295 � e � • .4 :A .. NEENOMMENNI �p Ecc* to 120 Dann sandy clay, gravel 1GO feet to 126 Water at 2 gom. 126 feet to 140 Grey clay Hefty Drilling 140 feet to 160 Grey clay, gravel S.R.A. Box 1553 x 160 feet to 260 Brown clay, Gravel h boulders Anchorage.Alaska 260 feet to 280 Br. clay, Boulders 99507 280 feet to 294 Grey clay, boulders 2,94 feet to 295 Sand, gravel w/water MUNICIPALITY OF ANCHORAGE • '� DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On -Site Services Section C1fl P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ` Parcel I.D. # n1� ��" N Q HAA # ACAS C\'I 1. GENERAL INFORMATION Complete legal description Lot 12; B.Coeh 1; Sequoia E-6tate,6 Location (site address or directions) 6840 Sequoia Ci4e2e Property owner David 9 CheAyt Sinctatin - Da h n 345-0854 av c heJc �Wg? - Mailing address 6840 Sequoia C.�nete Anehonage A2a3fza 99576 Lending agency Day phone Mailing address Agent Address Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS' 5 3. TYPE OF WATER SUPPLY: Individual well XX Community well Public water 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 XX 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 LpVOW Hoeg 46A 'A8H)969-ZL -�JoM s,aaaulbuo !euolssa}o,id ay} u, suolsslwo ao saoaaa aol alq!suodsaa }ou sl a6saoyouy }o ApledlolunLN aql ponssl sl 91e3l}11.)80 a aao}aq slep azo pue ao suolloodsul }onpuoo }ou op SHHa to saafoldw3'sluawaalnlow ales pus lsaapal uleV90 A}sl}ss o}aapao ul suo!}n}!}sul Bulpual clay}pus sawo10 siessgoand o} �Cselinoo ase sly} saop SHHa ayl's�lsely }o a1s}Say} u! paaa}s!68a aaaul6ua lsuo!ssaload y }uapuadepw ue �(q anoge g ydw5eaed ul uan16 suolleluesaidaa ay} uodn �(luo paseq sa}sollliJa� lenoaddy Allaoylny y}lsaH sanss! (SHHa) soolnaaS uswnH pue ylleOH }o }uawlaedap abeaoyouy to A11113d!olunN ayl :suollelnd!ls 5u!Mollol ay} U1!m 'swooapaq 60'Np\SSwdOyd 9LS'ON qH 'r Hi 7'V` .40. m sluowwoc) leuo!1!ppy aol lenoadde leuo!1!puo0 •panoiddes!Q •swooapaq aol panoaddy 3 nIVNJIS SHHa '9 einleu6!s s,aa9u!6u3 U966 G)IcPIV' ssaippy — tiaZ 'ON peo'a dool .18n18 91fie3 4£OL L — auogd Lw!3 to aweN •uol}oodsui sly} to alep ay} uo 109119 ui suollelnEw pue 'sa0ueu!pao 'sapoo alelS pue led!oluniN Ile yl!M aoue!ldwoo ui si walsAs lesods!p aalemalsern ao/pue Alddns aalenn a1!s-uo ayl 'uo!loedsul pue uo1.le6!1s9nul Aw woal pue sal!} a6eaoyouy to A}!ledlo!unNl ayl woal pou!elgo uo!lewaolul ayl uo paseq 1e141 f\l!aan A9141an1 I -ulaaay poleo!pui ain}onals to ad/\1 pue swooapaq to aagwnu ayl aol alenbape pue leuollounl 'ales sl wa}sAs lesods!p aa1eM91senn ao/pue llddns aalenn al!s-uo 9141 leyl sMoys uo!1eo!ldde lenoaddy Al!aoylny ylleaH s!y1 to u011eb!lsanu1 AW JUL11 Al!aan I wolaq umoys olep uollep!len aql to se pue 019aa14 pax!lle leas Aw Aq pa!1!liao sy 833NION3 A8 N01103dSNl d0 1N3W31`d1S 5 �.. Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L-07 12) &K I �C_ U )A- 'Sk Parcel I.D. A. WELL DATA Well type PIZIUR1EIf A, B, or C, attach ADEC letter. ADEC water system number Log present&N) YES Date completed _? 1 y $Y Driller Total depthYES Cased to ��S Casing height �I/Y / Sanitary seal DN) 7 ES Wires properly protected ((ON) YES FROM WELL LOG AT INSPECTION ��i ISy �t� 9 MUNICIPALITY OF ANCHORAGE Date of test l MENTAL SERVICES DIVISION Static water level oma -i-03 i:3 2 S 1992 Well flow g.p.m. S,3 g.p..m. Pump level ��k ay6(fi RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ��d �� ; On adjacent lots Absorption field on lot i o� r 4- ; On adjacent lots 1�0f0 Public sewer main NZA Public sewer manhole/cleanout t`� A Sewer service line �5 r� Petroleum tank N6NE. 6%wh) WATER SAMPLE RESULTS: Coliform d Nitrate �p! �Qr 10 �� Other bacteria Date of sample: i'a 1122- Collected by: S t S Erx,,"zz'atAIr, B. SEPTIC/HOLDING TANK DATA Date installed — IT18`I Tank size 1�)00Gm- Compartments `/'/ Cleanouts (ON) 7 U Foundation cleanout ON) � Depression (Y/6) f High water alarm (Y/N) - WA Alarm tested (Y/N) N A Date of pumping .l l7Z Pumper A4– SEac/LGTS' SEPARATION DISTANCES FROM SEPTIC/ TANK TO: Well(s) on lot (60 k- On adjacent lots 1 + Foundation To property line '60•-Anorptiontield r Water main/service line Surface water/drainage Ju r+ log* 72-026 (Rev..7/91) Front - CONTINUED -ON BACK PAGE C. OF ,STATION Date installe Size in gallons Vent (Y/N)"Pum�Ievel High water alarm level Meets MOA electrical codes (Y Manufacturer Manhole/. SEPARATION,OtSTANCE FROM LIFT STATION TO: M1 D. ABSORPTION FIELD DATA On adjacent lots "Pump off" level at Cycles tested Surface ater Date installed rd/�}ISy Soil rating �6 SFALL System type712> Nc* /��zworc Gi; E;o, 4N, a5.5, as, / Length -.--.--Width 3 Gravel thickness I/ Total depth is 5 Lirjir:s T07f14.. Total absorption area I6LjN AF Cleanouts present (Y)N) Depression over field (Y/6 Yoh Date of adequacy test ;t L( i i2 Results 60/fail) 1 IRkS for S Peroxide treatment (past 12 months) (Y/6 NO-( Kvvowt' If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 100 ,+ On adjacent lots /00 '4 Property line_ To building foundation 0 /4 --To existing or abandoned system on lot SS bedrooms G: On adjacent lots X0'4- Cutbank ALE Water main/service line /U r'L � Surface water MU / Driveway, parking/vehicle storage area . ® /�" Curtain dr( ---tin Aug- 4.1wi✓ 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. S & S ENGINEERING .� dlw-wr °�11 V (3b reo e ° Signature __ I� ri a Y agiver oop Od _ 9, .2.0 4 1U 4 ; Eaglo River, Alaska 9957%, o9aano# 909• ,2,8 o , o Engineer's Name �n,wse cc-o.�ro,e•. e, Date --. v� �,t A noc�:r( J. 'Hna"r:,i o , �n �.rlJ �9a e•euo9nve� \r�5yari HAA Fee $ 1'74� 00 Date of Payment Receipt Number 3 y 8&9 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number 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 6 -.28 - f3 S 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) u s ti s 13 /-Iv.ac c e- r i z 12- it/ P,°ti z G I Location (address or directions) fi e 4 C) s << (b) Applicant Name Rv'? pR"'f s 61' Telephone: Home Business 3 J9 Applicant Address E e' `y0 Sey / e, /Iii4 fas kc- 6 (c) Applicant is (check one): Lending Institution ® ; Owner/builder 01/,Buyer ❑ ; Other ❑ (explain); (d) Lending Institution Address (e) Real Estate Company and Agent — Address Telephone (f) Mail the HAA to the following address: f Y-/ 2. TYPE OF RESIDENCE Single -Family Multi-Fami! ❑ Other Number of Bedrooms 5 Telephone 3. WATER SUPPLY,// Individual Well tit ---'Community El Public 11 I Note: If communitywell system, musthavewritten confirmation from the State Departmentof Environmental Conservation I attesting to the legality and status. 1 I 4. SEWAGE DISPOSAL Onsi Q4 roic ❑ Community L H010ing Tann L ✓ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. �z-ozs (+1184) Page 1 of 2 rt � 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 /f res Telephone Address Iwa /}z _V A1as� �157�3 Date 6. DHEP APPRO AL Approved for t �� edroo Approved Disal Terms of Conditional Approval CAUTION Engineers Sea! Date 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 en9lneer re9i5i9req in Ing olgiv vt Hlormi, Tne wriv;r p9tr5 Imp ov a wwrivoy t0 pvrGhabers of homes and their lendin8 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 forerrors or omissions in the professional engineer's work. Page 2 of 2 A. WELL DATA MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & 3 -ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA) �pC HEALTH AUTHORITY APPROVAL (HAA) U L 1 iJ CHECKLIST - FEBRUARY 1984 264-4720 RECEIVED Legal Description: 12- vo, X C -'S r /zn/ °'J 3b Well Classification domes,4''c If A, B, C, D..Approved (Y/N) N A F� g Present Date Completed own field �/ �' ; y� Dt Dep h a H -5 r Cased to y+- Depth of Grouting C"'n knc ) St tic ater Level r— Pump Set At Casing Height Above Ground Sanitary Seal on Casing! 1) Electrical Wiring in Conduit aN) Depression Around Wellhead (Y Separation Distances from Well: To Septic/Holding Tank on Lot /33 ; On Adjoining Lots /vo /dO /-4. To Nearest Edge of Absorption Field on Lot �On Adjoining Lots To Nearest Public Sewer Line /1/1,4 To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA tVA Arr To Nearest Sewer Service Line on Lot nrh ;Date 6-26-%S� Date Installed /V .- 17 - B`f Size c;; No. of Compartments ;7— Air -tight Caps l) Foundation Cleanout!/N) Standpipes�1) Depression over Tank (Y29— Pumping/Maintenance Contract on File (Y/N) Holding Tank High -Water Alarm (Y/N) Al Separation Distances from Septic/Holding Tank: To Water -Supply Well /'33 To Property Line R� To Water Main/Service Line /c' y Course Comments ✓ Page 1 of 2 72-026(11/84) Date Last Pumped for N� Temporary Holding Tank Permit (Y/N) To Building Foundation/C7 } To Disposal Field 17-5- 72-026(11/84) 7'S -44 To Stream, Pond, Lake, or Major Drainage C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata_. 3U 6 pfL�'uS* �f Type of System Design Date Installed f t Length of Field 2-0 , Width of Field 3Depth of Field Gravel Bed Thickness H Try - W Square Feet of Absorption Area —. 16Y t7' Standpipes Present/9q) Depression over Field (Y162—Date of Last Adequacy Test Results of Last Adequacy Test /y�f Separation Distance from Absorption Field To Water -Supply Well ! �� c.3 To Property Line 6-- !� To Building Foundation Z%' :�^ To Existing or Abandoned System on Lot To Water Main/Service Line On Adjoining Lots 3 O f � ` To Cuk (if present) IVA i.f To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area3�y11 a74n 4"M e Comments D. LIFT STATION Date In Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level atv( Pumping Cycles during Adequacy Test. Meets MOA ** Check P tted Bedroom Rating Against HAA Request ** \ rtify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed �' /-/' ` _"_' Date 6- Company 14Ee 5 lnW-. MOA No. e4r Receipt No. ''t 1 D��O�Got ,°°°°�° a,o°�i'�V i/.q. Date of Payment V Amount: $ Page 2 of 2 72-026 (11/84) Ler y C. P.eid, Jr. t a � °COOS e. 215 ll1'h`