HomeMy WebLinkAboutSOUTHPARK #2 BLK 1 LT 25Municipality of Anchorage Page 1 of 3
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW030127
PID Number: 020.052.25
Name:
Wastewater System: New
Bob Stevens
Address:
7541 Our Own Lane Anch., AK 99516
ABSORPTION FIELD
Phone:
Number of Bedrooms:
Deep Trench
301.1366
Four 4
Sod Rating:
Total Depth from original grade:
LEGAL DESCRIPTION
1.2 GPD/F?
12 Ft.
Block: Lot: Subdivision:
Depth to pipe bottom from onglnal grade:
Gravel depth beneath pipe:
1 25 South ark Bluff No. 2
3 Ft.
8 FL
Township: Range:
Section:
Fill added above onynal pada:
0.1
Gravel Length:
35
Ft.
Ft.
Gravel width:
Numom of lines:
Distance between lines:
Well: Class A Community
4 Ft.
1
I Ft.
Classification (Private, A. B. C):
Total Depth:
Cased to:
oral absorption area:
560
Pipe Material:
ASTM 3034 PVC
Fe
Driver:
Date Drilled:
Static Water Level:
Ff
nstaller;
Red Dog Masonry
to stave :
711812003
Yield:
n.r I
Pump Set at:
Casing Height Above Ground:
r.
TANK
SEPARATION DISTANCES®
Septic ❑ Holding ❑ S.T.E.P. ❑ Other:
To
Septic
Absorption
Lift
Holding
ublictPrivate
Manufacturer:
Anchorage Tank
Y
11250
From
Tank
Field
Station
Tank
Sewer Line
Material:
u ero onpanmen s:
>200'
>200'
NIA
NIA
>25'
Steel
Two (2)
Well
>100,
>100'
NIA
NIA
LIFT STATION — NONE ON LOT
Surface Water
LotUne
>5'
4'
NIA
NIA
Gal.
lvunulacluler.
ump on eve a .
Fumpolt levela .ig
wa er a,arm at.
Foundation
>5'
>10'
NIA
NIA
In.
In.
in.
Pump Make 8 Model
Electrical Inspections performed by:
Curtain Drain
None
Noted
Remarks:
BENCH MARK
See Lot Line Waiver.
Location and scrip on:
Garage Slab
ASSUmd LIeVat,W:
100.0 Ft.
Engineer's Stamp
•• ( �1
,.
Inspections performed by: MEA
Dates: 16t 711812003
;.'49th �to0..'.. .
2nd 711812003
i._ .... ... ............................ ... �
�� �E.
Department of Hea t
and Human Services approval
A 1 MICHAEL ANDERSON .' W r,
0 �'.J NO. CE -4381
�
Date: z 2 0
,'
����fpfD ............. 'P�```•�••
Reviewed and approved by:
44 %FESS'k
(Rev. 101")
Municipality of Anchorage Page 2 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW030127 PID No. 020-052-25
N x757'24-E 170.63'
33' SECTION UNE ESWr.
---------------------------------------------------
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ii Four Bedroom Home
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PLAN AS-BUILT MICHL ...RD*E:::::
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SCALE 1' 30' �j♦ •..
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: SW030127
N `100.45
y U U
1,250
PID No. 020-052-25
N _In
U f SU
PROFILE AS -BUILT -
Scale: I"= 10'
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
December 1, 2003
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Lot 25, Block 1, Southpark Subdivision No. 2
Separation Distance Waiver
Absorption Trench to Lot Line
Dear On Site Services Engineer:
The septic system on Lot 25, Block 1, Southpark Subdivision No. 2 was inadvertently
placed within 4' of the east property line. The lot lines were not clearly marked during
construction and the end of the trench was mistakenly placed within the 10' of the
property line. We are therefore requesting a waiver be granted allowing the trench to
be at 4' from the eastern line. A majority of the new trench will be a minimum of 10'
from the lot line. The subdivision is currently served by a public water system and no
wells are located within 200' of the absorption trench.
Placement of the new absorption trench at the existing location does not impact wells
or adjacent septic systems. We therefore recommend a waiver be issued allowing the
new trench to be constructed at 4' from the east property line.
Sincerely,
Y41tt,l E4a�
Michael E. Anderson, P.E.
V .49th )K' *
MICHAEL E. ANDERSCN
._ No. CE -1781 y
Permit Number: SW030127
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
7A� ►ONS
Z; I T? (.V,
Date Issued: May 14, 2003
Expiration Date: May 13, 2004
Parcel ID: 020-052-25
Legal Descri tion: 'SOUTHPARK #2 SUBDIVISIO.... LO
g p CK 1 LOT 25 a
Le
Design Engineer. 0014 Anderson Engineering
Owner Name: BOB STEPHENS
Owner Address: 4731 SOUTHPARK BLUFF DRIVE
ANCHORAGE, AK 99516 -
Site Address: 4731 SOUTHPARK BLUFF DRIVE
Lot Size: 22729 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
F✓ Disposal Field Z✓ Septic Tank E] Holding Tank E] Privy Private Well E] Water Storage
All construction must 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 engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Ibi Date: Lo,,7
Date: ��
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
ON-SITE SEWERNVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 020.052.25 Permit Number SW O 10 / Z 7
Property owner(s) Bob Stephens Day phone 301.1366
Mailing address (1) 7541 Our Own Lane Anchorage AK 99516
l3
a4in 3/ 9 95-/6
g address (2)4%SOuTI�PI�l41t �uf� DR�v� Zip Code
Legal description (Lot, Block & Sub'd.) Lot 25 Block 1 Southpark Subdivision Addn. No. 2
Legal description (Section, Township & Range)
Lot Size 22,729 Acres/Sq.Ft. Number of Bedrooms Four (4)
THIS APPLICATION IS FOR:
Sewer Only ® Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
�, V-c�
(Signature of property owner or authorized agent)
Permit Fees: 4cD Waiver Fees:
Date of Payment: �;-- Date of Payment:
Receipt Number: Receipt Number:
(Rev. 12/00) Ulu
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 FAX
May 7, 2003
Municipality of Anchorage
Development Services Department
On -Site Wafer and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 25, Block 1, Southpark Subdivision No. 2
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 25, Block 1, Southpark Subdivision No. 2 intends to construct a new
four-bedroom home on the lot. The subdivision is currently served by the Municipal
water system. We are therefore requesting a permit be issued for the construction of a
new septic system to serve the home. The attached Site Plan and backup
documentation identify the location of and configuration of the new septic system and
alternate site and the parameters used in the design. Also identified on the plans are
the test hole locations and the septic systems on the surrounding lots. Drainage arrows
and spot elevations are shown indicating the current drainage patterns. The drainage
patterns will be maintained after construction.
The test holes placed near the location of the proposed absorption trench and alternate
site indicated clean sand with some gravel and varying amounts of silt and percolation
rates approximating 2 to 5 minutes per inch. No ground water was found during
placement of the test holes and none was noted during the monitoring period. We are
therefore proposing to place a 1,250 -gallon septic tank and a 35' long x 3' wide x 8'
effective depth absorption trench. The distribution pipe will be placed 3' below the
existing surface and the total depth will be 11'. Sufficient fill will be placed over the
septic tank and absorption trench to prevent freezing.
The ground surface on the lot slopes as shown on the site plan from north to south at
varying slopes. The back of the lot slopes steeply to Rabbit Creek. The absorption
trench will be constructed at the front of the lot parallel with the slope as much as
possible in conformance with Municipal requirements. All components of the new
Lot 25, Block 1, Southpark No. 2, .
May 7, 2003
Page Two
septic system will be constructed a minimum of 100' from any surface water and 10'
from the water service line on the lot.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future. The subdivision is currently
served by the Municipal water system.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
7I/kjt
Michael E. Anderson, P.E.
Attachments
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No. CE -4381 -
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SCAM 1 low ��A MIGNELE."DERSD,1
No. CF4WSi
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83-213
SOUTHPARK SUBDIVISION, ADDN. NO. 2
LOT 25 BLOCK 1
22.129 S.F.
N
33' SECTION UNE ESMT.
5/8' REDN2 M PER
RELATIVE ELEVATION FROM ASSUMED DATUM 100'
SITE
• 6
I ' I
I I
I I
I I
Four Bedroom Home
I �1
I I
I I
I FlN. FLR.
EL. - 110' 18• 1.250 canon
sr I Se tic Tank
I sa
TH
16.;
A.C. DRUE T'
c 35' Long ■ 3' Wide z S'
a Effective Depth Absorption Trench
N
• Alternate ite
C
0
• TN 1®
10 T. & E. ESW.
�� _.. a•313.T6
O_
SDUSNpPR' D
PLAN
SCALE 1 Is = 30'
LOT 25, BLOCK 1, SOUTHPARK SUBDIVISION NO. 2
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Four Bedroom Home Deep Trench System
Perc. Rate: 4 Min./Inch 1,250 Gallon Septic Tank
Application Rate: 1.2 GPD/SF 8' Drainfield Rock
4 Bedrooms X 150 GPD/1.2 GPD/SF (Application Rate) = 500 SF Absorption Area
500 SF/16 SF/LF = 31.25 LF Trench Length
THEREFORE: Construct a 35' Long x 3' Wide x 8' Effective Depth Absorption Trench.
Flow Line Elevation in Trench to be 3' Below Original Ground Surface. Total Depth to be
11' Below Existing Ground. Maintain 10' Separation From Water Line on Lot. Place 2' of Direct
Bury Insulation and 2' of Fill Over Absorption Trench or Provide Minimum 3' of Cover to
Prevent Freezing. 4' of Cover Over Septic Tank.
Natural
Backfill
2'6"
Geotextile
Fabric
6" 4" Perforated
PVC (Holes Down)
810" I I �— Drainfield Rock
3'
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum 100' Separation From Surface Water or Streams.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF BUILDING SAFETY/ON SITE WATER AND WASTEWATER PROGRAM
4700 BRAGAW STREET, ANCHORAGE, AK 99502-0605
SOILS LOG - PERCOLATION TEST
PROJECT #: M0314
PERFORMED FOR: Bob Stephens DATE PERFORMED: 5/1/03
LEGAL DESCRIPTION: Lot 25 Block 1 Southpark Subdivision No 2
j� TEST HOLE # 1 SLOPE
IIIIIIIIII PT/OG I / I
2
3
4
5 `.
6 ,r..
7
g :.
t
10-1
0 i r
11 .. •yam
12-
13--
14-
15-
4
21315
..
16-
17
6 17
> 10%
1
N
MEDIUM COMPACTED
WELL GRADED SANDS
WITH GRAVELS & LITTLE FINES - SW
WAS GROUNDWATER
ENCOUNTERED? NO
IF YES, WHAT DEPTH?
DEPTH OF WATER None
AFTER MONITORING:
DATE: 5/7/2003
i (:q'
9th
:...:. ...... .......
............
1,,'y WHARE AMXRSCN
. �:, No. a-4781
••• 4
41
0"ROF �S����v
80H
L
0
P
E
SITE PLAN
See Site Plan
N
2-5%
READING DATE
GROSS
TIME
NET
TIME
DEPTH OF
WATER
NET
DROP
Start 5/1/03
5:15
10"
1
5:45
30
1.25"
7.75"
Recharge
5:46
10.25"
2 1
6:16
30
2.S"
7.75"
Recharge
6:17
10"
3
6:47
30
2.375"
7.625'
FERC RATE: 4 MIN./INCH PERC. HOLE DIAMETER: 6"
TEST RUN BETWEEN 4.5 FT. AND S.5 T.
COMMENTS: Test Hole Presoaked Prior to Test.
TEST PERFORMED BY: MIKE ANDERSON I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES ON THIS DATE: 5/7/2003
2
3
4
5
6
7
8
9
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF BUILDING SAFETY/ON SITE WATER AND WASTEWATER PROGRAM
4700 BRAGAW STREET, ANCHORAGE, AK 99502-0605
SOILS LOG - PERCOLATION TEST
PROJECT #: M0314
PERFORMED FOR: Bob Stephens DATE PERFORMED: 5/1/03
LEGAL DESCRIPTION: Lot 25 Block 1 Southpark Subdivision No 2
2 SLOPE SITE PLAN
�
�p TEST HOLE #
IIIIIIIIII PT/OG I / I
10%
NO
10
• .• •:
IF YES, WHAT DEPTH?
DEPTH OF
WATER
4
Start 5/1/03
5:20
"•
DEPTH OF WATER
II
: •+'+�
None
AFTER MONITORING:
30
• �•: ''r: •
DATE: 5/7/2003
Recharge
5:51
MEDIUM COMPACTED
10.25"
WELL GRADED SANDS
"';�;:•;•'
WITH GRAVELS & LITTLE FINES - SW
.r
1.5"
8.75"
Recharge
�.::• •..
WAS GROUNDWATER
-7
ENCOUNTERED?
ENCOUNTERED?
3
6:52
10%
NO
10
• .• •:
IF YES, WHAT DEPTH?
DEPTH OF
WATER
4
Start 5/1/03
5:20
"•
DEPTH OF WATER
II
: •+'+�
None
AFTER MONITORING:
30
• �•: ''r: •
DATE: 5/7/2003
OF
14-
15 .... �
7,�''
•4. ' • • M101AEL L AN"WN ar
: y
*4o -fR0FfSS0*
17 BOH
S
L
0
E
See Site Plan
N
2-5%
READING DATE
GROSS
TIME
NET
TIME
DEPTH OF
WATER
NET
DROP
Start 5/1/03
5:20
10.625"
1
5:50
30
1.75"
8.875"
Recharge
5:51
10.25"
2
6:21
30
1.5"
8.75"
Recharge
6:22
10"
3
6:52
30
1.2S"
8.75"
PERC RATE: 2 MIN./INCH PERC. HOLE DIAMETER: 6"
TEST RUN BETWEEN 4.5 ' FT. AND S.S T.
COMMENTS: Test Hole Presoaked Prior to Test. Same Soil Characteristics as TH 1.
TEST PERFORMED BY: MIKE ANDERSON I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES ON THIS DATE: 5/7/2003
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 25, BLOCK 1, SOUTHPARK SUBDIVISION ADDN. NO. 2
GENERAL:
1. The scope of this project includes the procurement and placement of a
new 1,250 -gallon tank at the location shown on the site plan. Work
also includes the construction of a new absorption trench 35' long by 3'
wide by 8' effective depth also at the location shown on the Site Plan.
The total depth of the trench will be 11' below existing ground and the
distribution pipe will be placed at 3' below the surface. All components
of the new absorption trench and septic tank must be constructed a
minimum of 100' from any surface water or 10' from the water service
line on the lot. A minimum of 4' of cover is required over the septic
tank and 3' over the absorption trench. In lieu of cover 2" of direct bury
insulation and 2' of cover may be placed.
2. Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
3. The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
4. Unless specifically agreed otherwise, the contractor shall be
responsible for.final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
prior approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. A new 1,250 -gallon septic tank must be procured from a certified
septic tank manufacturer if the existing tank is found to be defective.
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
Lot 25, Block 1, Southpark No. 2
May 7, 2003
Page 2 of 3
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
6. A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
5. Contractor shall verify the septic tank and drainfield are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
6. Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
8. A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall verify this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
Lot 25, Block 1, Southpark No. 2
May 7, 2003
Page 3 of 3
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabric, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as -built of the completed system.
Municipality of Anchorage
Development Services Department =• o
Building Safety Division
."Otis
o
On -Site Water and Wastewater Program S„ E,.
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 �T
www.cf.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 20.052.25 HAA# keF 30
Expiration Date: /Z & /oy
1. GENERAL INFORMATION
Complete legal description Lot 25 Block 1 Southwark Subdivision No. 2
Location (site address or directions) 4731 Southpark Bluff Drive
Current Property owner(s) Bob Stevens Day phone 301.1366
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
7541 Our Own Lane Anchorage AK 99516
Unless otherwise requested, HAA will be held by DSD for pickup.
Day phone
Day phone
2. NUMBER OF BEDROOMS:
Four 4
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class A Well
®
Community On-site
❑
Public Water System
❑
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 5 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 less than 30 days old. (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, I verify that my investigation,
based on procedures outlined in the Health Authority App -oval 3uidelines 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 Anderson Engineering Phone 522.7773
Address _P.O. Box 240773 Anchorage AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date . 12/3/2003
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date: (z z to
(Rev. 12M)
Municipality of Anchorage
• � Development Services Department
% Building Safety Division ` ' w
3 [T
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.ahchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 25 Block J. So uthpark Subdivision No. 2 Parcel ID: 020.052.25
A. WELL DATA
Well type If A. B, or C provide PWSID # _ Well Log (Y/N)
Date completed _ Sanitary seal (Y/N) Wires properly protected (Y/N)
Totaf depth' ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production 9-P.M. 9•P•m•
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate mg./I. Other bacteria colonies/100 ml.
Date of sample: Collected by:
B. SEPTICIHOLDING TANK DATA
Date installed 711812003
Tank Type/Material Septic/Steel
Tank size 1.250gal. Number of Compartments 2 Cleanouts (Y/N) Y
I,
Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) N
Date of pumping Pumper New Construction
C. ABSORPTION FIELD DATA
Date Installed 711812003 Soil rating (g.p.d./ft? or fe/bdrm)1.2 GPDISF - System type Deep Trench
I
Length 35' ft. Width 4 ft. Gravel below pipe 8 ft.
Total depth 12 ft. Eff. absorption area 560 fl? Monitoring tube Y Depression over field N
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorption field before test in. Water added_ gal. New depth_ in.
I ,
Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g•p.d.
Any ,rejuvenation treatment (past 12 mo.) (YIN & type) N 'if yes, give date
X
D. LIFT STATION
Date installed
"Pump on" level at _ in
Datum
Size in gallons
"Pump off' level at _ in.
Cycles tested
Manhole/Access (Y/N) _
High water alarm level at
Meets alarm & circuit requirements?
n
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot NIA On adjacent lots NIA
Absorption field on lot NIA On adjacent lots NIA
Public sewer main NIA Public sewer manhole/cleanout NIA
Sewer /septic service line NIA Holding tank NIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5' Absorption field >5'
Water main >10' Water service line >10' Surface water 2100'
Wells on adjacent lots >200'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 4' Building foundation >10' Water main >10'
Water Service line >10' Surface water >100' Driveway, parking/vehicle storage >5'
Curtain drain None Noted Wells on adjacent lots >200'
F. 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 HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P.E.
Date 12/11/2003
HAA Fee $,+�A�^-
Date of Payment
Receipt Number
(Rev. 12/00)
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Waiver Fee $ /S D
Date of Payment / Z• — 0,3
Receipt Number
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