HomeMy WebLinkAboutKNIK VIEW BLK 3 LT 4K nID k View
Block 3
Lot 4
#051-031-52
Municipality of Anchorage
Development Services Department =�s
Building Safety Division
On-Sde Water and Wastewater Program, 4700 S. Bragaw Sl.
3
P.O. Box 196650 Anchorage, AK 99519.6650 Page I of
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATERDISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: 51,J 0303VY PID Number: OSl' 03 � —
Nam. s lac Lt r
Wastewater System: ® New ❑ Upgrade
lr
47 /1 A.5'07
ABSORPTION FIELD
Pin, 6 /� 3:2 _'0 9 � NumMr o19•Uropm: / /
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al
D
LEGAL DESCRIPTION
O GPD*,,
Ft.
BiN:X Lot: Supdwron: • v
Depth to pp• pd Nh ft" on9mtl p e'
p,
Glaval d•ph DaMalh pp•'
it
r
Tow+Yup: Range' Somm
fYl added apow orpnY grade'. _!.
GravN Unpm: /�],'
^/ L/Fl.
I� F1.
/
[3 Upgrade
Gra,W with:
11 rcr
plllnaa
I
MWSn tt* � llrlaa
I FI
Well: ❑ New
FI,
Cusphe"tin IPnvals. A. B. CI: 7oW Dapm: Cated to:
i("BLIG FI
Took aotarpapn area. 0I
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DMor Date DNl $ hCW8WLev01.
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INphl Move GrourW.
TANK
GPM
FL
FL
SEPARATION DISTANCES
Q(Septic ❑ Holding ❑ S.T.E.P. ❑ Other.
To
Septicp
Holding
.bll P.11,
PlAsfr c-
•pamr.
I O Gal
From
Tank
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rSee/wer Line
iee” lei
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hl
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R.marnt
BENCH MARK
Lonum and Daamp4pn.
Mwma/d�aaoon. /DD FL
/
ne � � T
En ' mp
OF JJ
i i 5 ENGINEER
17034 Eagle River Loop Road, No. ,r _ f g-03
ates: 1
it,� i Y
•` • w-
Inspections performed by:
�.•
' ,2nd g—� g-03
�. .i. .._.....�....................%
Development Services Department Approval
Development
C f
p h ROBERT C. COWAN ho-
�j��"�` CE -8801
I� Date: y- �f - os
Reviewed and approved by:
and
ley FR,resi0,���r
tRw.IYW,
�vtidoy--
PERMIT NO. SW030384
PAGE 2 OF 3
Municipalit of Anchora e
DEPARTMENT OF HEKTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 •Anchorage, Alaska 99519-6650 • Telephone 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL IN
REPORT
LEGAL LOT 4 BLOCK 3 KNIK VIEW S/D P.I.D. NO. 051-031-52
INLET VISTA
CIRCLE ,
THM2
a
N
H#
/IS
�L KEYBOX
10' TELECOM ELECTRIC,
AND DRAINAGE EASEMENT
11' MIN.-N--,&MT2
CO2 C /
4 HpUSEO
LOT 4
LOT 3
'Y
SCALE: V - 40'
.ERT C. COWAN �C
CE -8801
/
/ Q
THM2
a
N
H#
/IS
�L KEYBOX
10' TELECOM ELECTRIC,
AND DRAINAGE EASEMENT
11' MIN.-N--,&MT2
CO2 C /
4 HpUSEO
LOT 4
LOT 3
'Y
SCALE: V - 40'
.ERT C. COWAN �C
CE -8801
PERMIT No. SW030384
PACE 3 OF 3
Municipalit of Anchorage
DEPARTMENT OF HE4TH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 •Anchorage, Alaska 99519-6650 • Telephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
LECAL LOT 4 BLOCK 3 KNIK VIEW S/D P.I.D. No. 051-031-52
ST1 ST2 98.1'
FINAL GRADE 2" INSULATION
NEW
93 2' 1300 GALLON
POLYETHYLENE 92.9'
SEPTIC TANK
COI=98.1'
CO2=97.0'
FINAL GRADE
11
11 CO1=91.0'
SR CO2=91.0'
MT1=85.4'
MT2=85.6' . N. T. S.
NO WATER FOUND
B.O.H.
f
_.
ROBERT C COWAY4��Q j
,'11� �fkit�F �.•, te..
A
B
C
FCO
31.0
3.5
—
ST1
42.5
—
37.0
ST2
46.0
—
39.5
TMT
48.0
—
42.0
DBL1
48.5
—
41.5
DBL2
49.5
—
42.0
CO1
67.5
55.5
—
MT1
63.0
49.0
—
0O2
—
35.5
36.0
MT2
—
33.5
35.0
nooEnr c.COwNL P.E.
• nOOEnr A. snnrER CE.
fig CIVILENOINEEtt3
(goy) 694 2979
r rAx(907)694.1211
Uatet •�//y/0%�
IEN.IIINIIIb1Eiv
APPnwue
Mutilcipality,of Anchorage
emnewAmn DEPARTMENT Or HEALTH AND HUMAN SERVICES
moll)(TV13"q 025 L Street
P.O+ Box 196650
Attcltorage/ Alaska 99519-6650
.eEwEnewAgn
emptel A /0 % 4 enc% 3 .� ; l� �%iec✓ S
RErERENCE:
LNWNEEIIEKI e1ElUEe
NulEronle per septic ins ec ions for t e eferettced property were
per on /L�1 and / Prior to submitting
the Ott -site W ewater Ulepos S to at d or W 11 Ittspectiott
wElEegPEolloll Report we are waiting for the c fif'�ttr-T to be
InE1wnst completed.
If we may be of further service please contact us•
sincetteiyt
Robert C: L'owattE P.E.
sa1E1Ee1
StMOCILVAi
tcncoUlroN
IEeI
kclw*CA1 .
egPECigUe
C"51"
WNnwAlt"
tmPneAle•JIEU
EE "I
t 703 11on111 EAGLE ttivEn LOOP + fiUlt E 204 • EAGLE ttivEn. ALASKA 99517
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
Permit Number: SW030394
Legal Description: Knik Yew Block 3 Lot 4
R1I'Zn 10',3ID
C I -Z :36
Date Issued: Sep 17, 2003
Expiration Date: Sep 16, 2004
Parcel ID: 051-031-52
Design Engineer: 0003 S & S Engineering Site Address: Unknown
Owner Name: Ted Schmelzer Lot Size: 63930 SO. FT.
Owner Address: P.O. Box 999 Total Bedrooms: 4 Permit Bedrooms: 4
Naches . WA 98937 -
This permit is for the construction of:
Q Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be In accordance with:
1. The attached approved design.
2. All requirements specked 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
Date: c7/1 ? /0 3
-_�22 Date: 01 % �j
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 SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
I certify that the above information is correct. I further certify that this application is being made for
Single Family Dwelling and is in accordance with applicable M S gall Code
/J _/� / 17034 W* River Loop Road No. 204t t{/'y�7 IP4%1-- We River, Alaska 99577
(Signature of property owner or authorized agent)
Permit Fees:
('*0 0 0 - ° , Waiver Fees:
Date of Payment: I /I3 /0 3 Date of Payment:
Receipt Number: (2,Y 7 If Receipt Number:
(Rev. 12'00)
Permit Number SWO03L94-
¢Propertyowner(s)
Parcel l.D.1���1—SZ
Property owner(s Col `�"'`"�`
'
a' 'n''-'2tfZ phone
O e07C q
q q
N A S W A
Mailing address (1)
q 3
Mailing address (2)
Zip Code
Vf eLJ
Legal description (Lot, Block & Sub'd.)
G
Legal description (Section, Township & Range)
Lot Size 3 Acr /Sq.Ft.
Number of Bedrooms
THIS APPLICATION IS FOR:
❑
Sewer Only
1A
Well Only
Storage ❑
Sewer and Well
❑
Water
Sewer Upgrade
❑
THIS PROPERTY CONTAINS:
El
Hot Tub
El
Unit El
Swimming Pool
❑
Water Softening
Therapy Pool
❑
I certify that the above information is correct. I further certify that this application is being made for
Single Family Dwelling and is in accordance with applicable M S gall Code
/J _/� / 17034 W* River Loop Road No. 204t t{/'y�7 IP4%1-- We River, Alaska 99577
(Signature of property owner or authorized agent)
Permit Fees:
('*0 0 0 - ° , Waiver Fees:
Date of Payment: I /I3 /0 3 Date of Payment:
Receipt Number: (2,Y 7 If Receipt Number:
(Rev. 12'00)
ROBERT C. COWAN, P.E.
ROBERT A. SHAFER P.E.
CML ENGINEERS
(907)694-2979
FAX(907)694.1211
August 26, 2003
IFALTNAUNgISTY
MUNICIPALITY OF ANCHORAGE
APF'RWALs
Development Services Department
P.O. Box 196650
Anchorage, AK 99519
SEWER & WATER
MAN E%TENSIOFG
REFERENCE: Lot 4, Block 3, Knik View Subdivision
SEWER& WATER
.,it
It is requested that you issue a permto install a septic system to serve the propose
ACTION
four bedroom dwelling on the referenced property.
Two test holes were excavated and percolation tests performed. The approximate locations
ANE 1AlEs
of the test holes are located on the attached site plan. At the time of excavation (8/13/03),
011Ts
ANDRDREPOPTS
no water was found. After seven days of monitoring, ground water was not found.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
WELLINSPECTION
areas or drainage patterns by the installation of the proposed septic system. The
SFLOWTEST
construction of this system will not prevent any future development on any of the adjacent
properties.
SITE PLANS
If you require additional information, please contact us.
Sincerely,
ROAD DESIGN
912. �Robert
C. Cowan, P.E.
SOCTEST
RCC/bjj
Enclosure
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
WSPECTIONS
ONSITE
WASTEWATER
DISPOSALSVSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RMER. ALASKA 99577
1" = 40'
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Municipality of Anchorage
r f
Development Services Department
5
Butldng Safety Division
r' L
D
On -Site Water and Wastewater Program
., f
M1tonitaingl
J
4700 South Bragaw SL
,
P.O. Box 196650 Anchorage. AK 99519-6650
www d ance c_ hora�k.us
ti C
"7) 3417904
+,
4
Soils Log - Percolation Test
Performed For. ✓
W Ehi
Date Performed:
/�,
r" �_
Lesal Description: LnT 4 t� Lo c K 3 n 1 K '-
Depth
(Feet)
i- o
2-
3. '0
4- 0
5- . .
7- 0
6-
O
O_
y O
10-
11-
12- . Q
13-
14- "
15-
c'
16
Nz�De gas,T
17-
19-
20-
,:p...> ................
ROBERT G COWAN
CE -8801
- ....
A'r'.
Sile Plan
ViASGROLMVIATER
A10
ENC=f-ZFZD?
5
IFYES.ATMATDEPTI"
r' L
D
G M Deplhlo Plater Aher
E
M1tonitaingl
J
Dater
PERca+ncrl P.,1Tr
TEST PUM E_Wr u l
AND & FT
I /(!"1�'7 z 41,4— CERTIFY THAT THIS TEST l
PERFORMED BY: IT AL '9-/A)/o3-
PEP.FOR?.1ED IN ACC DANCE WITH P.!! STATE AAD>.:Ur:1CIPAL GUIDELINES IN EFFECT ON THIS DATE. OAT:
Municipality of Anchorage
Development Services Department -
Butldmg Safety Didsicn
Sit Water andwastewdterProgram t
and On- e .•
4700 South Bragaw SL C COWAN
P.O. Box 1966`0 Anchorage, AK 99519-6650 Tec, . CE , 88D1
waw dww d ate— ,lf'~�' • .. , .•!
(co7) 343-7004
soils Log - Percolation Test
Date Peda ned:
Performed For. I!2 �L�'��L• ,/fit a /t �w
Legal Description: L.�oJ— �L,_ - II T'l V
Depth
0ge- fNl L S
2-°!.o F!w
3•
4- e ,
13- ' O
14-
15-
16.
18 -
COMMENTS
Y:ASCROi=V1ATER
^ ��
ESCCtrrEFPDT
, �/ s
IF YES, ATWr'Ai DEPTH?
r L
O
D,p161owate1ARef P
FtonllolingT
E
A�LJ
V
Da'e:
Rearing Dale
Gross Time
FG CO-471C"PATE
TEST FUH SSnr=EN
PERFORMED BY: :e;4
PEP.FOP,?,IED IN ACCOICE WITH AIL 5TAT_ A`.D L:U?IICP,
t✓
M
NelTime Depth to Water MetD(cP
n
-;;t 01 1 2 1 r
/I el
/� •� N
6%_�) FERC FUE DI:,I.t_TER
AND__6_FT
IJ' ?VI,— CERTIFY THAT THIS TEST 4`!A�
IN EFFECT ON THIS DATE. DATE: fi as /O
S FL
FtOBERT C. COWAN. P.E.
ROBERTA. SHAFER. P.E.
CML ENGINEERS
(907)694-2979
FAX(907)694.1211
ONSITE WASTEWATER DISPOSAL SYSTEM
TNMnNonn
APPM MALS
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
$EWER & WATER
MANEXTENSIO S
REFERENCE: Lot 4, Block 3, Knik View Subdivision
August 26, 2003
$EWER& WATER
NSPECTIM
GENERAL:
]. The scope of this project includes the installation of a 1300 gallon HDPE
septic tank and a new trench to serve the proposed four bedroom residence
ENGINEERNOSTUpES
ANCREPaRs
located on the referenced property.
be in accordance with the approved site plan and design
2. Construction shall
drawings, Municipal permit with any special provisions or conditions, and all
WELL*SPECT"
&FLOW TEST
applicable State and Municipal Wastewater Disposal Regulations.
3. The contractor shall be responsible for obtaining any necessary underground
SITEPLANS
utility locates.
4. Unless specifically agreed otherwise, the property owner shall be responsible
for final grading areas subsequently depressed from soil settling.
AWCESIGN
5. Contractors installing wastewater disposal systems must be certified by the
Municipal Health Department for system installations. Owners installing their
TEST
own systems must also receive prior approval from the Municipal Health
SOIL
Department.
SEPTIC TANK INSTALLATION:
TEST
1. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
STRLCTLgM&
NSPECTWNS
2. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
ONSITE
WASTEWATER
DISPOSAL SYSTEM
DESIM
17034 NORTH EAGLE RIVER LOOP • SUITE 204 • EAGLE RIVER ALASKA 99577
Page 2
Lot 4, Block 3, Knik View Subdivision
August26,2003
3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade.
4. Septic tanks installed with less than 4 ft. of cover shall be insulated.
5. A foundation cleanout shall be installed one to four feet from the building foundation. In
the line between the tank and the leachfield there shall be two adjacent cleanouts (unless
an effluent pumping system exists within the septic tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line,
shall be to clean toward the leachfield. The second cleanout shall be to clean toward the
septic tank.
6. Final grading over the septic tank shall be such that a positive slope exists away from the
septic tank.
ABSORPTION TRENCIUDRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed -up) before gravel (sewer rock)
placement.
2. Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
4. Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion
of the monitoring tube extending through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is equivalent to the effective depth of
the gravel as noted on the design.
5. Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The
finish grade over the trench must be mounded to prevent the formation of a depression
after settling.
Page 3
Lot 4, Block 3, Knik Vlew Subdivision
August20,2003
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Tvne of Pine Perforated Solid
Cast Iron
Yes
Yes
ASTM D3034 (PVC)
Yes
Yes
ASTM F810 (HDPE)
Yes
No
ASTM D2662 (ABS)
Yes
Yes
Use of a type of pipe other than listed above must be approved by the inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or
equal).
5. A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
6. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
7. When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever requirement applies.
Page 4
Lot 4, Block 3, Knik View Subdivision
August26,2003
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the installation of the
wastewater disposal system. These inspections will occur as follows:
1. The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
2. The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer
is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre -
construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or
control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these specifications
and plans and in accordance with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be
the owner's representative and will inspect the work as stated above to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor to
cavy out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
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 RTIFICATE OF HEALTH AUTHORITY APPROiU&S
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-031-52
1. GENERAL INFORMATION
HAA # n -b122
Expiration Date: !I - 4 - D 6
Complete legal description Ln' 4 Bi ock Irn x V 7 Py snoni
aaw:+
Location (site address or directions) tFti14 T n I P r V i A t A c 1 r_
J -
J -
CurrentPropertyowner(s) Steve Quigley Dayphone 632-8970
Mailing address 9237
Autumn Ridge
Cir. Anchorage AK 99507
Lending agency
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
4
3, TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
U
Individual Water Storage
❑
Individual Holding tank
•❑
Community Class 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 4 by an independent professional civ it
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 seat affixed hereto and as of the validation date shown below, I verify 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 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
Address 17034
S S S Engineering
N. Eagle River Lp Ste. 204 Eakle
- Phone 694-2979
River, AK 99577
Engineer's Printed Name Robert C Coven Dp.ee-..+//r to S-
5. DSD SIGNATURE f yf i ROBERT C. COWAN
O CE -8801
.� Approved for _ bedrooms. Eo
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X Maintenance Agreements
Supplemental Engineer's Report
Other
(Re, Dim)
Original Certificate Date: 0 -6 -
Municipality of Anchorage
• Development Services Department
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: �T r 8LOe r- 3 Karr K /mow S/� Parcel Ib: 051-051-6;Z
dKtl�
A. WELL DATA
Well type _ If A, B, or C provide PWSID #Well Log ffil)
Date completed _ Sanitaryseal Y/ ) __ Wires properly protected (Y/N)
Total depth ft. ased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
i
Date of test
Static water level
t
Well production g.p.m. g.p.m.
I
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate mg.A. Other_bacteri colonies/100 ml.
Arsenic: a e of sample:
B. SEPTIC/HOLDING TANK DATA
TankType/Material Sri MC ifPrLE
Tank size 15M_ gal. Number of Compartments
Collected by:
Date installed 9 I I % Los
Cleanouts((VN) -16S
Foundation cleanout (?1N)` L Depression over lank (Y!Q) L22 High water alarm (Y/N) /01`1
Date of pumping Ntu-_'> 3YST&k) Pumper tz> lot -
C. ABSORPTION FIELD DATA
Date installed 113 b Soil rating (g.p.d./ftZ or ftZ/bdrm) Lo g System type AF -SP TREKXtA
Length '74 1 ft. Width at ft. Gravel below pipe G-9' ft.
Total depth ft. Eff. absorption area ON ft Monitoring tube YM Depression over field kn
Date of adequacy testN� TE-veN Results (Pass/Fail) aft -
Fluid depth in absorption field before test OA -in. Water added OA- gal.
Elapsed Time: Ph- min. Final fluid depth ADPr in. Absorption rate >=
For ' bedrooms
New depth NW in.
NR g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) AW+ If yes, give date A7 Y1
D. LIFT STATION
Date installed r Size in gallons
'Pump on' level at _ in. Pump offJevel at— in.
Datum Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
tr 5 r
Building foundation � Property line �J 3 Absorption field +
Water main (U1 t' Water service line 10 ,+- Surface water 100'+
Wells on adjacent lots 1 d -
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 16' Building foundation a� 1 Water main
Water Service line (Ot F Surface water l t� Ir Driveway, parking/vehicle storage
Curtain drain hxN $4AfeWO-) Wells on adjacent lots ICc> (t
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that 1 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.
Engineers Printed Name R 0QE4r C. Ca,,i.t'-,
Date
HAA
HAA Fee
ti /t /o -y-
53' C3) t 19-S - 110
Date of Payment
Receipt Number
(Rev. 12101)
Waiver Fee $
Date of Payment
Receipt Number
�e ROBERT C. COWAN
cE-8801
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