HomeMy WebLinkAboutSEQUOIA ESTATES BLK 1 LT 13FjN4oLjm
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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: OSP241159
Work Type: SepticTank Upgrade
Tax Code Number: 01715213000
Site Legal Address: SEQUOIA ESTATES BLK 1 LT 13 G:2939
Site Mailing Address: 6800 SEQUOIA CIR, Anchorage
Owner: FORTIER SAMUEL J &
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
t)epartIII lit
6/21/2024
6/21/2025
48991
❑ 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
rReeeived-By: 55 P O r Date:
Issued By: Date: Z Z_
4
MUNICIPALITY OF
..........................
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
ANCHORAGE
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWERIWELL PERMIT APPLICATION
Parcel I.D. 017-152-13
Property owner(s) Dagmar Mikko & Samuel Fortier Day phone
Mailing address 6800 Sequoia Cir, Anchorage, AK 99516
Site address 6800 Sequoia Cir, Anchorage, AK 99516
Legal description (Sub'd., Block & Lot) Sequoia Estates Block 1 Lot 13
Legal description (Township, Range & Section)
Lot Size 48,991 _Sq. Ft. Number of Bedrooms Four(4)
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(Z all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
RX
(w/wo ADU)
Septic Tank
RX
Upgrade RX
Duplex (D)
❑
Holding Tank
R
Renewal R
Multiple Dwellings
❑
Privy
❑
(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.
(Signature of property owner or authorized agent)
Permit/Rush Feesp—afln— Waiver Fees:
Date of Payment:
Receipt Number:
Permit No. 0.�P2"11 ��
Permit App_-'- : - :'-:c -,
Date of Payment:
Receipt Number:
Waiver No.
June 20, 2024
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Sequoia Est B1 L13 – 6800 Sequoia Cir
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, the well 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 4 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
OSP241159, Deb Wockenfuss, 06/21/24
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
1"=40'
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 13
FEET
0 40 80
NOTE:
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
Sequoia Cir
4-BDRM HOME
SEPTIC PLAN
6/20/24
2CO
NEW 1250-GAL SEPTIC
TANK W/ 20" MANWAY
EXISTING 45' LONG X 20' WIDE
BED SYSTEM TO REMAIN IN
SERVICE
DRIVEWAY
EXISTING WELL W/
100' RADIUS
SHED
DECK
DECK
10' UTILITY EASEMENT
GRN.
HSE.
RE
T
A
I
N
I
N
G
W
A
L
L
DECOMMISSION
EXISTING SEPTIC TANK
PER MOA CODE
VERIFY/INSTALL FCO
OR 2CO PRE-TANK
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241159, Deb Wockenfuss, 06/21/24
Y
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES /;
Environmental Health Division (J
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name_ DISTANCES
TO SEPTIC ABSORPTION
Address FROM TANK FIELD WELL
1600 r T���� fid SLre Zz�� /
Phone(s) Permit No. No. of Betlrooms WELL / 3 � / � , f
LOT LINE �
LEGAL DESCRIPTION
Lot Block Subdivision
f3 % 5�= vQra �3� FOUNDATION7c��/ 30 fr 2r
Township, Range, Section
AS -BUILT DIAGRAM (Show location of well, septic system, property lines, foundation,
j I,:zdV P -761"5A 4 .i%9 —/�a ^/ _ O _ cViveway, water bodies, etc.)
TANKS 1111 NII
M SEPTIC ❑ HOLDING
Manufacturer Capacity in gallons
rr�C_korc? c /?SH
Material No. of Compartments
S' 4e
TYPE OF SYSTEM
❑ TRENCH BED ❑ W. DRAIN ❑ OTHER
Depth to pipe bottom from Total depth from original grade
original grade S FT ,s FT
Fill added above original grade Gravel depth beneath pipe I
/=Z FT pry FT
Gravel length Gravel width
LfS FT �C� FT urti
2 I d /t
Total absorption area Distance between lines
Clot) SO FTS FT
Number of lines Soil rating Pipe material
/ /S -O SO FT 54rt.3S- F;-/2 1
as
Installer / /pp _ Date Installed c� C /
/UIe13.0A ISYEOS o/Z� i/ �/
WELLS P �� r
PRIVATE ❑ OTHER (Identifv)
L� fei
Classification (A,B,C) Total Depth Cased to r
ter t 0 '- FT: FT
Installer Date Installed: / r
LL:_4 h . 1�;r
REMARKS: r O
` Scale: NS' ENGINEER'S SEAL
tvt �(�� ;�,r n r D S Inspectio s Performed by:
) id
rt l
Date:
certily that (his inspection was performed accardinp to all
Municipal and State guidelines in elect is date: -
r
Health Department Approval: laDate: 2 27-4a
72-013 (3/85)
Municipality ® Anchorage
( n*w6w,
r Department of Health and Human Services
825 "L" Street
Tom Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
January 8, 1990
Terrance A. & Debora J. Tauschek
1600 East Tudor Road
Suite 201
Anchorage, Alaska 99507
Subject: Lot 13 Block 1 Sequoia Estates S/D
Permit 4890145, PID 4017-152-13
a
The subject permit, issued by this office for a single family
well and/or on-site wastewater system has expired as of December
31, 1989.
Permits are issued on a calendar year basis by authority of the
Municipal Code of Regulations. A new permit must be obtained
from this office for an well and/or on-site wastewater system
not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this office for documentation of the installation and to close
the permit.
If a private engineer inspected the installation of the on-site
wastewater system, the original as -built inspection report
(three-part form) must be sent to this office for review,
approval and documentation.
When applying for a new permit, the fees are: $90.00 for an
on-site wastewater permit; $50.00 for a well permit; $140.00 for
a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
Sincerely,
John Smith, P.E.
Program Manager
On-site Services
JW/ljm:200
enc: Copy of Permit
"Kids Are Our Future"
/
�
MUNICIPALITY OF ANCHORAGE
Department o[ Health & Human Services
825 L Streeta 99501 343�4720
ON -
SITE SEWER & WELL PERMIT
Permit Number: 890145
Date Issued: 08/O2/89 Engineer Designed
Owner Name: TERRENCE A/DEBRA J TAUSCHEK
Owner Address: 1600 EAST TUDOR ROAD SUITE 201
ANCHORAGE, AK 99507
Day Phone:
2 247
Parcel Id:
017�152�13
Minimum total
septic tank
Lot Legal:
Subdivision:
SEQUOIA ESTATES
Lot: 13 Block: 1
feet
Section: 26
Township:
12N Range: 3W
NEW OWNER RO8ER
DALRYMPLE
BOX 19O353
Lot Size
48991
or acres)
Max Bedrooms:
This Permit:
4 Total
Capacity: 4
SEPTIC
TANK:
Minimum total
septic tank
tank
must have
at least 2
compartments.
feet
requires
insulation over tank<s).
capacity: 1,250 gallons" Each septic
Depth to top o� septic tank(s)
WELL: Log must be submitted to Municipality o1orage Department o11 Health
and Human Services within 30 days of well completion,
PERMIT EXPIRES DECEMBER 31, 1989.
NOTIFY DHHS OF INSPECTIONS AT 34 4744 OR 343-4681.
WELL ORILLED IN 1985; LOG ALREADY ON FILE WITH DHHS"
I CERTIFY THAT:
1" I am {amiliar with the requirements for on~site sewers and wells as set
�orth by the Municipality of, Anchorage (MOA> and the State of Alaska,
2, I will install the system in accordance with all MOA codes and reg lations,
and in compliance with the design criteria C.) IF this permit"
3. I will adhere to all NEV and State o� Alaska requ:i. �or the set back
distances �rom any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot,
4. I understand that this permit is valid �or a 0axiMum of 4 bedrooms" I
also understand that the capacity of the total system is 4 bedrooms and
any enlargement will require an additional permit.
(Owner) TERRENCE A/DEBRA(J TAUSCHEK ��
Issued By: DATE:
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LEGEND...
LOT CORNERS
��e\�,''' FOUNDATION I
lw�QF A®t �— DRAINAGE ARROWS
�,..,,.
j A0. jo
91� NOTES F
' I. IT SHALLBE THE RESPONSIBILITY OF THE BUILDER OR OWNER TO VERIFY THAT
°� •°°° °i• •••• '••' ••••� - BUILDING LOCATION SHOWN MEETS ALL: SUBDIVISION COVENANTS AND ZONING
•�{, a*'N ORDINANCES.
"`!� • OOi•.°aH•0. 00.0.•••.•.• 1./ ••
PPPP � e:. IT 19 THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL ELEVATIONS WITH
Andrew F. Potts � RESPECT TO ALL UTILITIES.
84ap��0. 3514N"ii' ;`•i`�p 3. THIS PLAT REPRESENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
ei]^••• •• �4 �� FROM THE RECORDED PLAT DESCRIBING THAT PARCEL. INSTRUMENTS RECORDED
�rl�°�A••.•���•,:•••�Q� r� ii' tPRIOR TOOR.AFTER THE FILING Of THE RECORDED PLAT ARE NOT SHOWN ON
THIS PLAT.
_4., THE INFORMATION ON THIS PLAT IS FOR THE USE OF LENDING INSTITUTIONS
SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND
PLATTED LOT LINES OR EASEMENTS . THE PLAT ISNOT TO BE USED FOR
POSITION ING'ADDITIONAL STRUCTURES OR FENCED. -
n; v" Or?'O CERTNeIrATION
I HEREBY CCOTIEY THAT I HAVE SURVEYED THE
PROPERTY DESCM1060 ON T416 06AT AND TMS
IMP11)V^16EP. i$ GIYUAYED THEREON ARE LOCATED
ASSHOWN ON THIS PLAT. .
JATe. 0 'CHIS 7 DAY OF ju NP °IpS8'
a—
..
41 01.4 ��.Ar�S .. .......
BEBSE, EPP§ PoTTS
2226 E. 99'f4i AVE:
349-6452 ANCHORAGE, ALA A 99507 349-6454
DRAWN BY, A✓,L.//. SCALE, ./ �"A f0 C% r DWO. N0.
CHK. BY, DATES (-27+•�.$ff IO. BK.+��^,_. '
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EC ALASKA RUIROf1� nTAL COnTROL SRUS, InC.
5
o Engineerinq & Enuironmental Studies
SPECIFICATIONS FOR BED WASTEWATER TREATMENT SYSTEM
LEGAL DESCRIPTIO\:LOT 13,BLOCK 1,SEQUOIA ESTATES SUBDIVISION
1.0 GENERAL
1.1 The Drawings, sheets 1 through 6, shall be part of
this specification.
1.2 All materials and workmanship shall meet the
requirements of the Municipality of Anchorage,
Department of Health & Human Services (DHHS), the
conditions of the permit, and all applicable rules and
regulations currently in effect.
1.3 All excavations and depths are advisory, and are
to be verified or modified in the field by the
Engineer or inspecting agency.
1.4 It is the responsibility of the property owner or
installer to adhere to approved design for the
installation. to maintain the specified separation
distances and to have the appropriate inspections.
1.5 It is the responsibility of -the property owner or
installer to report to the engineer any observed
conditions which would put the system in violation
of state or Municipal regulations.
1.6 If the installation is not inspected by an AECS
engineer, AECS will not be responsible for the
installed system. An engineer at AECS should be
consulted prior to construction, to determine the
number of inspections that will be required and to
explain what these inspections will involve.
2.0 SEPTIC TANK
2.1 If there is an existing septic tank it may be used
if it meets the capacity requirement for the
residence. The structural integrity of the tank
must be verified.
2.2 The septic tank shall be a UPC -approved
two-compartment tank, constructed of 12 gauge
steel with bitumastic coating and set level on
undisturbed soil. if the tank is buried at a
depth of 4 feet or less, it must be _insulated with
an overlying layer of 2 inch burial type
polystyrene rigid board .insulation,
1412 WESL 33Qb Avenue. 0 dnchoQAGE, AIASkA 99503 0 (907) 279-5553
2.3 The septic tank shall be a minimum of 5 feet from
the house foundation, and a minimum of 5 feet from
the absorption area.
2.4 The septic tank and bed shall be a minimum of 100
feet from any private well or body of water, 150
feet from Class "C" wells, and 200 feet from Class
"A" or "B" wells, unless otherwise specified.
Less than the required separation distance must
have prior approval or waiver by DIMS or Alaska
Department of Environmental Conservation (ADEC).
2.5 Piping shall be fitted with a mechanical
watertight calder coupling on the outlet and inlet
of the septic: tank. Piping shall be 4 inch solid
PVC ASTM D-3034 or cast iron, sloped a minimum of
1/4 inch per lineal foot on the inlet side and 1/3
inch per foot on the outlet side. if the piping
is buried at a depth of 4 feet or less, it must be
insulated with an overlying layer of 2 inch burial
type polystyrene rigid board insulation.
2.6 Cleanouts shall be installed as designated and
capped with air -tight rain caps (Jim Caps or
equivalent), and extend a minimum of 1 foot above
ground level.
2.7 If a lift station is required it shall be a
combination lift station septic tank per Anchorage
Tank and Welding, Inc. design. Specifications and
design drawings are on file with the municipality
and the engineer.
3.0 SEEPAGE BED
3.1 The gravel for the bed shall be 0.5 to 2.5 inch,
screened rock with less than 3 percent passing the
No. 200 sieve. All substitutes must have prior
DHHS approval,
3.2 The bottom of the excavation shall be level and
raked with the backhoe blade to ensure that the
bottom has not been compacted during excavation.
3.3 Sand, for leveling, shall have a size distribution
which meets the requirements of MOA code
15.65.077.
3.4 The distribution pipe shall be perforated 4 inch
rigid PVC with a minimum crush sL,,ngth of 1500
pounds and shall meet the approval of DIMS for use
as drainfield pipe. All pipes shall be laid
level, and spaced according to the drawings.
3.5 Monitor standpipes shall be placed as shown in the
drawings. They shall be 4 inch rigid PVC ASTM
D-00034, or cast iron. The rection shown with
holes may be either drilled 0.5 inch holes on 6
inch centers on opposing sides of the pipe, or a
section of regular perforated sewer p=ipe may be
clamped to the solid section with a no -hub
coupling or solvent joint. The perforated section
of the monitor tube shall be located in gravel
only. The portion of pipe above the sewer rock
shall be solid.. A rubber raincap (Jim Cap or
equivalent) shall be placed over the top of the
pipe.
3.6 Insulation is required, using burial type
polystyrene rigid board insulation. There shall
be .1 inch of insulation for every foot of soil
less than the required 4 feet of cover, but there
must be at least 24 inches of soil even though
insulation is used. The solid pipe extending from
the septic tank to the drainfield shall also have
a minimum of 4 feet of cover or an equivalent
layer of insulation combined with soil.
3.7 The side slope of the mound shall be slope 1 foot
vertical to 3 feet horizontal.
3.8 The bed shall be planted with a white clover and
red fescue mix, or with Kentucky bluegrass.
4.0 INSPECTIO\S
4.1 This bed will require a minimum of three
inspections. The first inspection will be of the
open excavation, to assure that the system is
installed in the proper soil strata, correct depth
and meet minimum specified design parameters.
4.2 The second inspection will be after placement of
gravel, monitor standpipes, and distribution pipe,
to verify proper installation and position of
pipes prior to bcxckfill.
4.3 The third inspection will be after final backfill
grading and seeding to ensure that adequate soil
cover leas ►peen provioeu over tnc uea,
4.4 The inspection of the septic tank or lift station
installation can be incorporated with any one of
the above listed inspections.
4.5 Tile lift station will require either an MOA
electrical inspection or certification by a
licensed electrician depending on whether the
building code applies to this part of the city.
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
/ 11200, West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) SSIMM
PROM 2 l Inc. cM Mas 01471.
JOB
SHEET NO. OF
CALCULATED BY DATE ?
CHECKED BY DATE
SCALE
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Oma-
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LEGEND .......
LOT CORNERS
;' FOUNDATION i
(\ OF•A� \t DRAINAGE ARROWS
\ V
jem�?:' 9 it NOTES
TH f
s•
' ' I. IT SHALL BE THE RESPONSIBILITY OF THE BUILDER OR OWNER TO VERIFY THAT
P" "•°•` •" •••• •••' ••••� BUILDING LOCATION SHOWN MEETS ALL SUSDIVISICN COVLNANTS AND ZONING
ORDINANCES.
t!R,,, oon..•o.. w• eo...•••..0 u'
''=', $ 2. I7 IS THE RESPONSIBILITY OF THE BUILDER TO VERIFY All tLEYAT1gH3 WITH
Andrew F. PO((
yy1o: • .'� � RESPECT TO ALL UTILITIES, -
91 ��'•• NO.�i�-�Yi' ;"Q'�`~�' - D. THIS PLAT REPRESENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
41t9';��,•n,
'a FROM FROM THE RECORDED PLAT DESCRIBING THAT PARCEL. INSTRUMENTS RECORDED I
n ••.**,••..r••4� • PRIOR TO OR AFTER THE FILING OF THE RECORDED PLAT ARE NOT SHOWN ON
THIS PLAT .,
4. THE INFORMATION ON THIS PLAT IS FOR THE USE CF LENDING INSTITUTIONS
- SPECIFICALLY TO SHOW ANY CONFLICTS BETWLEN EXISTING STRUCTURES AND
' PLATTED LOT LINES OR EASEMENTS , THE PLAT ISNOT TO BE YSED FOR
POSITIONING ADDITIONAL STRUCTURES OR FENCEI. -
I
yVrYOrr 3 CxRTI',eIr4TION
REBY CERTIFY THAT'I HAVE SURVEYED THE /'L O.T .PLA/✓
PERTY DESCRISSO ON T%IIJ 06AT AND TNIE-
'OVEWENf% LIYUAYED THEREON ARE LOCATED
SHOWN ON THIS PLAT. - .. .__. _�O7- j9/
.9 THIS -27 DAYOF UNC' ,19 ��, Sc gcio/A .5r4 7,,5--S
/ t3ES8r, EPPS POTTS
2220 r. 99'tl AVE,
2ir,7349-6452 ANCHORAGE, ALA A 99507 349-6454
DRAWN BY, e4lL,11 SCALE,./: �rDWG. NO.
CHK. BY, DATE, 6^27 9). BK..5 '
i
Municipality of Anchorage 49 •
006
6 90
DEPARTMENT OF HEALTH & HUMAN SERVICES'
825 "L" Street, Anchorage, Alaska 99502-0650 •••
SOILS LOG — PERCOLATION TEST i,'.
1j, 4
I�e�
PERFORMED FOR: e -r (J2 IY y M A DATE PERF
LEGAL DESCRIPTION: / /3 2 / Jre�uorc� Z,4 -les Township, Range, Section: T,�'
DEPTHSLOPE
OP�2nr� La��,-,
1
2
Sze
3 CA?^ Poore
5
6
7
8 60/,� GM /
9-
10-
11 1011
12
13-
14-
15-
16-
17
314151617
18-
19-
20-
WAS
81920
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Water After _, i_ I
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.sti e17< ro'�C4
%EER'S SEAL)
t
REID, JRAt
2251 : r
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SITE PLAN
I I PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
COMMENTS
jU�1�J�PNl2.,%� / t r ZiH r! �� per CT 7/S re'%0r/
PERFORMED BY: 2. ' I-- CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
ALASKA ENVIRONMENTAL CONTROL SERVICES, INC.
f
1200 WEST 88RD AVENUE, SUITE B
ANCHORAGE, ALASKA 99508
(907)561-5040
SUPPLEMENTAL SOILS INFORMATION
8UEDIVI8I0N ,%
�5>>, f LOT ALOC3
DEPTH
0ry21'Ic
DEPTH
DEPTH
DEPTH
�7%e
(FEET)
(FEET)
(FEET)
1
r
1
1
1
2
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2
2-
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3-'
3
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3
3
4
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9
9
9
9-
10-
10
10
10
11
11
11
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11
12
12
12
12
13
13
13
13-
14-
14
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85-195
M -W DRILLING, Inc.
P.O. Box 10.378 • 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner
Terry Tauschek Use of Well Domestic
Location (address of: Township, Range, Section, if known; or distance main road
L11- BI- V'T 11niA
Size of casing 6 T)epth of Hole 112 feet Cased to 112 feet
Static water level AA ft. (g}�1SY�.. (below) land surface. Finish of well (check one) open end ( X ) ;
Screen ( ); Perforated
Describe screen or perforation None
Well pumping test at 8 gallons per 0=) (minute) for -1 --hours with II0
L
of drawdown from static level W2II W/1", S►ti%f $�!� NW%} SEyy
Date of completion
7/22/85 SEG 26, T /a N, R 3 yv S M
N 2 — 06 I 055'�' z
WELL LOG H/ 28- •!� 9 �f r,"OS.
Depth in feet from
nrnnnd �„rface Give detaiIs of formations penetrated, size of material, color and hardness
n TO 9
2 TO 3
3 To 26
26 TO 39
39 TO 81
81 TO 97
97 TO 103
103 TO 106
106 TO 112
TO
TO
TO
-0rganic MUNICIPALITY OF ANCHORAOR
DEPT. OF HEALTH
SiltyGravel ENVIRON ENTAL PROTECTION
A
lli �� U 1 u , 16 u "'=re -No's 814 R 473
L {}STF
CC: pGGS Y96
CC; Muni of /%C11 0"i F— '
3 — CONTRACTOR
MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLINff, G ,
Parcel I.D. # O 1 `T / SZ 13 HAA # I`1 1 Aef ` 0 Jr
1. GENERAL INFORMATION
Complete legal description Lor /3� $Goin 1, S (roublA Cs AT -CS
Location (site address or directions)
Property owner Day phone
Mailing address
Lending agency Day phone
Mailing address
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm 1-1D.0 R -so rJ6)5TZ,1rJ G Phone
Address- PO. Ijo�- 2-40773 A jCh}oR:AGC, Aid- 995z_q
Engineer's signature —�f Date
a° A
. .. - .. D•m• mae gave °DO➢0° •e•r
- — Michaol E. Anderson
6. DHHa SIGNATURE o� s'.• 4381-E
Approved for bedrooms. �$Qr;�pr,or=sslo������
_ Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Municipality of Anchorage
Department of Health and Human Services 44
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lo,�- 1-3
6U ucl S`zouo/A Cs:-4TM- Parc eII.D. 017/5 Z-1
A. Well Data
Well type P/20A7--67
If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
l
Date completed 7Z- Z- lav Driller !-I Ls m5 %/ZI
LU rJ 6
Total depth 0Z I
Cased to //Z- Casing height
Sanitary seal (Y/N)
Z
y Wires properly protected (Y/N) w o
FROM WELL LOG AT INSPECTION
o
Date of test
7 LZ_166 1016 ��'`�
U V
<
.
°r 75 °
0 ¢
LU
water leve
Well flow_
g.p.m. 1117 P.M.g.
z
C, LU
Pump levell
0r.ft4,PJ0uJA1 0,4 K. 4 0 VJ A(
i;7*
,„
SEPARATION DISTANCES
FROM WELL TO:
Septic/holding tank on lot
'%/00 ; On adjacent lots woo /
Absorption field on lot
/ 00, ; On adjacent lots 3'/00 /
Public sewer main
CtiS Public sewer manhole/cleanout /✓�° L�5
Sewer service line
> /®� Petroleum tank
WATER SAMPLE RESULTS:
0
/-z' I n��1� Other bacteria
0
Coliform
Nitrate
Date of sample: 9
/z9 ( 9 q Collected by: A• /—ImL41-4
B. SEPTIC/HOLDING TANK DATA
Date installed 6/2. l// 69 Tank size /, Z15' 0 6,4 L . Compartments _b
Cleanouts (Y/N) y -Foundation cleanout (Y/N) Depression (Y/N)
High water alarm (Y/N) N Alarm tested (Y/N) /``)A
Date of pumping /0//l I q`. Pumper 0" 14c 00A4A1.4 Is RUPAP146
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /00 ° On adjacent lots Foundation
1 f /
To FrvPertr ttnv --120 A4svrption field 2S Water main/service line > 59Pi
Surface water/drainage
72-026(3M)•Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed ® s Manufacturer
Size in gallons_ Manho
Vent(Y/N)
High water alarm level
"Pump on" level
Meets MOA electrical codes (Y
SEPARATION DISTAD E FROM LIFT STATION TO:
On adjacent lots
D. ABSORPTION FIELD DATA
"Pump off" Level at
Cycles tested
Surface water
Date installed / v`> Soil rating (GPD/Ft2) X50 F L �b System type .
Length LL- I _Width ! ZO I Gravel thickness w S _Total depth
Y Depression over field (Y/N)
('AS -S for
Total absorption area
W Fr77 Z,
Cleanout present (Y/N)
Date of adequacy test 101519 `/ Results (pass/fail)
Water level in abso tion field before test !
rp _. test J
Peroxide treatment (past 12 months) (Y/N) N If yes, give date Al/ A
/JO Tl --:,7 Gtt• A-rJ O U T's Af-JD rA v "tTo /L-
SEPARATION
USEPARATION DISTANCE FROM ABSORPTION FIELD TO: -7 AA2, FW so- c/i I7'4
Well on lot O D On adjacent lots Property line
S rJ
I `l
Bedrooms
To building foundation
On adjacent lots— 75 _Cutbank //0 Water main/service line 7� t
Surface water _ > f S D _ Driveway, parking/vehicle storage area
77�
G70,
To existing or abandoned system on lot
"it) a)6'
Curtain drain __— /NJ 0 &1 [�g7-
E. ENGINEER'S CERTIFICATION
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature ("!-
Adial
Engineers Name I t u4A—ct
Date r z� �� �� 01,
HAA Fee $ . _� 0 ' Waiver Fee $
Date of Payment " Zb' C( Date of Payment _
Receipt Number 155 Receipt Number
72-026 (3/93)' Back