HomeMy WebLinkAboutGLENN VIEW ESTATES NORTH BLK 1 LT 17Glenn View
Estates North
Block 1
Lot 17
#051-821-30
Municipality 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.el.anchorage.sk.us (907) 3417904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number. SWO40064 PID Number. 051.821.30
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inell Homes
Wastewater System: New
A�:
1900 W. Northern Lights, Ste. 200 Anch., AK 99517
ABSORPTION FIELD
3 4-5678 " F ' 5°""
5' Wide Trench
LEGAL DESCRIPTION
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Inspections performed by: T. Kimbrough Dates: 10 4129104
'i 49th 00
2n 4129104
Department of Health and Human Services approval
j pn t MICHAEL E. ANDERSON 1 «
•02: % r .
No. CE-4381
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Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Page 3 of 3
Permit No. SWO40064 PID No. 051-821-30
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PROFILE AS -BUILT
MEL E. ANDERSON
No. EE -4381
._ uiviw ..•• c
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 FAX
MEMORANDUM
DATE: April 22, 2005
TO: Jeff Poet
FROM: Mike Anderson, P.E.
SUBJECT: Lot 17, Block 1, Glenn View Estates North Subdivision
Certificate of Health Authority Approval
The absorption trenches on the subject lot were placed in an east/west direction rather
than the north/south direction as designed to accommodate the revised location of the
new house. The lot is very flat and the trench alignment could have been in either
direction and still remain parallel with the contours of the ground. Additional test holes
were placed to verify the soils in the location of the new absorption trenches. These
test hole logs were submitted with the as -built. The additional pipe shown on the
property was a monitor tube for one of the test holes. It has since been removed.
There is no lift station or high water alarm in the septic system on this lot. The Health
Authority Approval Checklist has been corrected.
Please advise if further information is required prior to issuance of the Certificate of
Health Authority Approval.
-\ Municipality of Anchorage
• -- Development Services Department *A1
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 SUBMITTAL COMMENT SHEET
To: Mike Anderson
Legal description: Glen View Estates North Block 1_Lot 17
The attached paperwork has been reviewed and is being returned for the following reasons:
❑ Original signature or stamp missing on
❑ Calculation error in design. _
❑ Additional soils information needed. _
❑ Water monitoring results Inadequate.
® Discrepancy in information submitted. Trenches were not Installed perpendicular to drainaae pattern
❑ Topographic information missing or inadequate.
® Incomplete; missing _Unidentified pipe on property.
® Incomplete; missing High water alarm checked yes on HAA. but no lift station reported
❑ Additional adequacy test information needed.
❑ Water sample unacceptable. _
❑ Measured/proposed distances/dimensions missing. _
❑ Locations of all soils, percolation and water monitoring tests not shown. _
❑ Proposed system too deep for soils information submitted. _
❑ Well log required. _
❑ Omission in narrative. _
❑ Insufficient fill over tank or field._
❑ Other.
Name of reviewer: Jeff
Date: 4/7/2005
Please supply the necessary information and re -submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 SOUTH BRAGAW STREET ANCHORAGE. AK 99519-6650
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION- LOT 17, BLOCK I, GLENN VIEW EST. NORTH
PERFORMED FOR- SPINELL HOMER
DATE: 4/25/2004 PROJECT No -
PARCEL ID#- TECHNICIAN: T.L. KIMBROUGH
DEM EST HOLE #11
(Icet)
1
2
3
4
5 •' '<
•.
6
7
8 :�.....
9 '•
10-...A
11 .
. r.
12-
13-
14-'
21314 "
51617 15-
16-
17]
18
19
A: •
SILTY SANDY GRAVEL
DENSE
GM
—n
D
H
SITE PAN
SEE SITE PLAN k
WAS GROUND WATER ENCOUNTERED? No
IF YES @ WHAT
D[PIFR r FLAT
DEPTH OF WATER AFTER MONTTORINO: 5/I/�L yytCi(
DATE OF MONTTORINO:
BOTTOM OF HOLE
DATE
READING
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
DWATERF
(INCHES)
NET DRO
(INCHES
4/29/04
TEST HOLE PRESOAKED PRIOR TO TESTING:
1
12:23
10.5"
2
12:53
30
8.25"
2.25"
3
12:54
10.5"
4
1:24
30
8.5"
2.0"
5
1:25
9.75"
61:55
30
7.75"
2.0"
PERCOLATION RATE• I�/INCIi) FERC. HOLE DIA. CHES)
TEST RUNBETWEEN:—§—YT. and --§ —FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY VETECH ENGINEERING TECHNICAL SERVICE. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE- 4/5/2005
• MUNICIPALITY OF ANCHORAGE
•
•••g&V*% uaay •
•
DEVELOPMENT SERVICES DEPARTMENT
- •�
P�E"'•••..,
4700 SOUTH BRAGAW STREET ANCHORAGE, AK 99519-6650
Fi• ,'+ �•�.
4/29/0
z 4 th
SOILS LOG - PERCOLATION TEST
1
:�t`IONEI. E AHOCRSGN��:
LEGAL DESCRIPTION' LOT 17 BLOCK I, GLENN VIEW EST. NORTH •/•U• No. a �3s1�/'�:
PERFORMED FOR' SPIN Lt HOMES•••
atat,OESs,�:•.•
DATE: 4/25/2004 PROJECT No
T.L. KIMBROUGH
ProTnsima En Me•z. Stam
PARCEL ID#- TECHNICIAN:
12:41
DEPTH TEST HOLE # 2
7.25"
(fee)
OB/OG SLOPE
SITE PAN
12:42
10.5"
2 y:
3
1:12
4 -n
S
8.0"
5 •� % SILTY SANDY GRAVEL
. r •,
SEE SITE PLAN k
C
is•N DENSE
5
6 GM
•d
7
8
1:43
30
7.25"
9 •.''''•
WAS GROUND WATER ENCOUNTERED? N_
10 '
:, IF YES ® WHAT DEPTii7
A'.4DEPTH OF WATER AFTER MONTTORMG: /1/ L
FLAT
DATE OF MONITORING: W'I
:•
12
y A•'•
13
14—:.,,.:
15 ;.
16 BOTTOM OF HOLE
17
18
19
20
PERCOLATION RATE• 12 (NiNANCH) PERC. HOLE DIA.�INCHES)
TEST RUN BETWEEN:�T. and —L—FT.
COMMENTS: TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY VETECH ENGINEERING TECHNICAL SERVICE. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES
IN EFFECT ON THIS
DATE' 4/5/2005
DATE
READING
GROSS TIM
(MINUTES)
NET TIf-�E
(MINUTES)
WA7ERF
(INCHES)
NST DROP
(INCHES)
4/29/0
TEST HOLE PRESOAKED PRIOR TO TESTING:
1
12:11
10.0"
2
12:41
30.
7.25"
2.75"
3
12:42
10.5"
4
1:12
30
8.0"
2.5"
5
1:13
9.75"
6
1:43
30
7.25"
2.5"
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water d 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: SW040064
Legal Description: dGlennview Estates North Block 1 Lot 17,
Design Engineer: 0014 Anderson Engineering
Owner Name: Spinell Homes, Inc
Owner Address: 1900 W. Northern Lights Blvd., Ste 200
Anchorage . A 99517 -
Ljjz9joq-1z In'
3 Pr"
Date Issued: Apr 19, 2004
Expiration Date: Apr 19, 2005
Parcel ID: 051-821-30
Site Address: 22433 Shadowy Spruce Drive
Lot Size: 0 SO. FT.
Total Bedrooms: 7 S Permit Bedrooms:
This permit is for the construction of:
❑✓ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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.
5. The following special provisions.
EE,,,ej EK s�6l.t++ep Ars,9„I c6 noes 4a scri;c sysrE.-I_
%%e Ne.v Re v,sED DEV7AJ r_4AA,'ES fiRE 'Fon ^ S 6EGZpp„
Nous E. F.VI"Ueet will co-udvof 7 -CS -r NaIE> /VEEP o/uvrlry
eoNf'/n.u,j:on) Of 5EP7.c sysrrt..
Received By:
Date: A I zo t
Issued By -.V Gr_
1 1 ' Date: y I f o
Municipality of Anchorage
• -tel 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
Parcel I.D. nSl " �iZ f 3� Permit Number SW
Property owner(s) Sainelt Homes, Inc. Day phone 3445678
Mailing address (1)1900 W. Northern Lights Blvd., Suite 200 Anchorage, AK 99517
Mailing address (2) Zip Code
Legal description (Lot, Block & Sub'd.) _Lot 17, Block 1, Glennview Estates North Subdivision
Legal description (Section, Township & Range)
Lot Size 40,006 SF Acres/Sq.Ft.
THIS APPLICATION IS FOR:
Number of Bedrooms Three (3)
Sewer Only ® Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jacuzzi ❑
Swimming Pool ❑ Water Softening Unit ❑
Therapy Pool ❑
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.
C-.
(Signature of property owner or authorized agent)
Permit Fees:
Waiver Fees:
Date of Payment: `i Im Date of Payment:
Receipt Number: Receipt Number:
(Rev. 12/00)
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 (FAX)
MEMO
DATE: 4/2712004
TO: Lot 17, Block 1, Glennview Estates North Subdivision
WITH: MoAIOn-Site Water and Wastewater
FROM: Mike Anderson
SUBJECT: Lot 17, Block 1, Glennview Estates North Subdivision
Septic System Permit Number SW040064
The homeowner has upgraded the house proposed for this lot to 5 bedrooms. We
have revised the site plan and design for the septic system accordingly. Additional test
holes will be placed prior to construction to verify the subsurface soil conditions on the
lot. Please modify the permit to allow for a 5 bedroom septic system on this lot.
Please let me know if you have additional questions.
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ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 522-6779 FAX
April 16, 2004
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 17, Block 1, Glennview Estates North Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The owner of Lot 17, Block 1, Glennview Estates North Subdivision intends to construct
a three-bedroom home on the lot. We are therefore requesting a permit be issued for
the construction of a new septic system to serve the new home. The subdivision is
served by a community water system and no conflicts exist with adjacent septic
systems or wells. The attached Site Plan and backup documentation identify the
location and configuration of the proposed septic system and alternate site. Existing
spot elevations and the current drainage pattern are identified on the Site Plan. The
drainage pattem will be maintained after development of this lot is complete.
A test hole placed on the lot during the subdivision phase indicated silt with some gravel
in the area of the absorption trenches. The accepting soils were tested and found to
have percolation rates of 17 minutes per inch. No groundwater was found during
excavation and none was noted during the monitoring period. The test hole is more
than 30' from the alternate site and we are proposing to provide acceptable test hole
data prior to the construction of the new system. Acceptable soils logs and percolation
test data will be provided along the inspection report and certified as -built for the new
system. Our design includes the placement of a new 1,000 -gallon septic tank along
with 2 - 44' long by 5' wide by 4' effective depth absorption trenches to collect and treat
the sewage generated in the house. The bottom of the trench will be 4' below the
surface. The distribution pipe will be 1' below the surface. A flow splitter valve will be
placed to assure even flow of effluent to each trench. A minimum of 3' of cover will be
placed atop the trenches and a minimum of 4' of cover will be placed atop the new
septic tank.
Lot 17, Block 1, Glennview Est. North
April 16, 2004
Page Two
The ground surface on the lot slopes at shallow grades from west to east as shown on
the Site Plan. The absorption trench will be constructed parallel with the slope of the
ground surface as much as possible in conformance with Municipal requirements. The
new septic system will be constructed a minimum of 100' from the well proposed for the
lot and on adjacent lots. It will also be constructed a minimum of 100' from any surface
water in the area.
If the system is constructed in accordance with our design the following statements
apply:
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.
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,
Michael E. Anderson, P.E.
Attachments
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MICHAEL E. ANDERSON
No. CE -4391 y
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LOT 17, BLOCK 1, GLENNVIEW
ESTATES NORTH SUBDIVISION
DESIGN FACTORS: SYSTEM REQUIREMENTS:
Three Bedroom House 5' Wide Trench System
Perc. Rate: 17 Min.Anch 1,000 Gallon Septic Tank
Application Rate: .6 GPD/SF 3' Drainfield Rock
3 Bedrooms X 150 GPD/.6 GPD/SF (Application Rate) = 750 SF Absorption Area
750 SF/5 SF *.58 (Red. Factor) = 87 LF Trench Length
THEREFORE: Construct Two 44' Long x 5' Wide x 3' Effective Depth Absorption Trenches.
Flow Line Elevation in Trench to be 1' Below Original Ground Surface. Total Depth to be
5' Below Existing Ground. Provide 4' Cover Over Septic Tank and 3' Cover Over
Absorption Trench. Provide Flow Splitter Valve to Assure Even Flow to Each Trench.
Natural
Backfill
Geotextite
6" Fabric
6" 4" Perforated
PVC (Holes Down)
37 Drainfield Rock
5'
TYPICAL 5' WIDE TRENCH SECTION
(NO SCALE)
NOTE: Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater. i
Minimum 10' Separation From Water Services in the Area.
Minimum 100' Separation From Surface Water or Streams:
re
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
Ww .ci.anchorao ae k.vs
(907) 343-7904
Soils Log - Percolation Test
/
LSF,,��NGINEFR
Performed For:
G L E N V I i�
vU
N �'RT N Date Performed:
Legal Description:
Lo i:J
'dK
Township, Range, Section:
0
1.
2-
3-
4
5-
6.
7
8-
9-
10
11-
13-
14.
15-
16-
17
18-
20 -
COMMENTS
SATjb-j 5,L:,--
ML
1LjML
Saat!Ay 5:14
w/rata •
"a,z'N Ml_
DOT TOM of
140LEE'
WAS GROUND WATER
ENCOUNTERED?
- 1
a
Gross Time
--.LAI
S
IF YES. AT WHAT DEPTH?
t
Depth to Water After
Monitoring?
D
F
St}�
E
Date:J
2V�OZ
Reading
Date
Gross Time
Net Time
Depth to Water
Net Drop
FlI_t_
E
St}�
-3�
1)tz O2:
z: 4s
—
,i:l-
3
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a
pERrfx anrw Reye
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TEST RUN BETWEEN 3 FT AND�L _FT
PERFORMED BY:
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. THATDATE. T (Ii WA
PERFORMED
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 17, BLOCK 1, GLENNVIEW ESTATES NORTH SUBDIVISION
GENERAL:
The scope of this project includes the procurement and placement of a new
1,000 -gallon septic tank at the location shown on the Site Plan. Work also
includes the construction of 2 new 44' long X 5' wide X 3' effective depth
absorption trench at the location also shown on the Site Plan. The
distribution line in the trench will be placed at V below the existing ground
surface. Total depth of the trenches will be 4' below the existing ground
surface. A flow diverter valve must be placed to insure even flow to each
trench. The new septic tank and absorption trench must be placed a
minimum of 10' from the water service on this and adjacent lots. In addition,
a separation distance of 100' must be maintained between the septic tank
and absorption trench and any surface water.
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. The Contractor must also verify the location of wells in the
area and assure that the separation distances are met.
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
A new 1,000 -gallon septic tank must be procured from an approved source
and installed at the location shown.
2. A septic tank is to be constructed by a certified septic tank manufacturer.
Construction shall include two 4" cleanouts for pumping access.
Lot 17, Block 1, Glennview Est. North
April 16, 2004
Page 2 of 3
3. The septic tank shall be sufficiently bedded to prevent settling or shifting of
the tank.
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 area 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.
Lot 17, Block 1, Glennview Est. North
April 16, 2004
Page 3 of 3
MATERIAL SPECIFICATIONS:
Septic tanks must be constructed by a Municipally approved septic tank
manufacturer.
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, Femco, 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.
JQci�� �My
Municipality of Anchorage
-Y Development Services Department
e
Building Safety Division
Onsite Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.enchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. 51.821.30 HAA# (150131
Expiration Date: % .5"
1. GENERAL INFORMATION
Complete legal description Lot 17, Block 1, Glenn View Estates North Subdivision
Location (site address or directions) 22433 Shadowy Spruce Drive
Current Property owner(s) Soinell Homes, Inc. Day phone 3445678
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
1900 Northern Lights Blvd. Anchorage, AK 99517
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
Five 5
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
❑
Individual On-site
19
❑
Individual Holding tank
❑
❑
Community On-site
®
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 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 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 Anderson Engineering Phone 522•TT73
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 4152005
RUI
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5. DSD SIGNATURE •i:' *,."No a-.�
_,Z Approved for r bedrooms. �ee�ej,,"
Disapproved.
Conditional approval for
bedrooms, with the fo`owing stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: _4 04& �.C�, �Original Certificate Date:—
(Pe .12IW)
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 198850 Anchorage, AK 995196650
www.ci.anctwrage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal - • I • ,•1 17, Block 1. Glenn View Esiates \ • [11 •moi. • ,Al-fiD 1
A. WELL DATA
Well type _ If A, B, or C provide PWSID � _ Well Log (Y/N)
Date completed _ Sanitary seal (YIN) _ Wires property protected (YIN)
Total depth R Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Static water level R R
Well production 9.p -m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mi. Nitrate mg.A. Other bacteria oolontes/100 ml.
Date of sample: Collected by:
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SeWdSteel Date Installed 4011M
Tank size 1.500 gal. Number of Compartments I Cieanouts (YM) Y
Foundation cleanout (YM)1I Depression over tank (Y/N) ff High water alarm (YM) : p
Data of pumping Pumper New Construction
C. ABSORPTION FIELD DATA
Data installed 4012M Soil rating (g.p.d he or fe/bdnn) .S GPDf$F System type S WIde Shallow Trench
Length 152 ft Width S R Gravel below pipe 3 R
Total depth 6-8 R Eff. absorption area x.310 R= Monitoring tube Y Depression over field tq
Date of adequacy test Results (Pass/Fall) For _ bedrooms
Fluid depth in absorption field before test _ in. Water added_ gal. New depth_ in.
Elapsed Time: _ min. Final fluid depth _ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & type) N If yes, give date
D. UFT STATION
Data installed
'Pump on' level at _ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
'Pump off" level at_ in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO
Manhole/Access (Y/N)
High water alarm level at in.
Meats alarm 8 circuit requirements?
Septic tankHift station on lot WA On adjacent lots WA
Absorption field on lot WA On adjacent kits WA
Public sewer main WA Public sewer menhole/cleanout WA
Sewer /septic service line WA Holding tank WA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >T Property line>
.1 Absorption field >S
Water main >10' Water service line >10' Surface water XIV
Wells on adjacent kris >200'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line >17 Building foundation >10' Water main >10'
Water Service line >10' Surface water >100' Driveway. part ingNehide storage >S
Curtain drain None Noted Wells on adjacent kris moa
F. COMMENTS
G. ENGINEER'S CERTIFICATION����p1;� ^�.••• e
,
I certily that I have determined through field inspedhns and Cu ; �
review of Municipal records that the above systems are inr 49th
conformance with MOA HAA guidelines in effect on this date. &�
t ; rmuri c wmcamr
Engineer's Printed Name Michael E Anderson. P.E. Vim;' ; No. a-4=
`
Data 115!2003......
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Date of Payment
Receipt Number
(rev. 1200)
Waiver Fee $ _
Data of Payment
Receipt Number
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