HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 2 LT 4ACampb
Height
II
Block 2
Lot 4A
#014-071-51
PERt'lIT N0. (
r,'llJl'-.I T C T P~RL T T"r' OF
DEPARTMENT ~ 'HEALTH RHD EN'¢IRONMENTAL~ .OTECTION
825 ~'L' STREET, ANCHORAGE,
264-4720
I'JELL PERM I T
APPLICANT RICHARD C. .HOPE 2315 E. 72ND 9~507 344-4292
LOCATION E. 67TH
LEGAL *L4R B2 CR~IPBELL HEIGHTS ': LOT SIZE 12000 SOURRE FEET
MINIMUM DISTRNCE'BETHEEN*R HELL~ Rt4D ANY ON-SITE SEHRGE DISPOSAL SYSTEM I~
1BO FEET FOR R PRIVATE HELL OR 15~ TO 2~ FEET FROM R PUBLIC HELL DEPENDING
UPON THE TYPE 0F PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEIqER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE I5 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPRRTME~T WITHIN ~0 DRY5
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY.', SPECIFICATIONS AND CONSTRUCTIOt'~ DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERrd I T EXP I RES DECEMBER 31. 1981
I CERTI~ THAT .~
1: I AM, FAMILIA~ W~TH THE. REOUIREMENT5 FOR ON-SITE SEWER~ ~H~ WELLS 8S 5ET
2: I WILL~~~~~~INS'TR~'''' ~E' SYSTEM~ . ; IN ~CORDRNCE WITH THE. CODES.
.',.~A'I V~ (a
5546
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD, GOI/ERNOR
Telephone;
Addms~:
274-2533
November 20, 1984
Tobben Spurkland, P.E.
203 West 15th Avenue
"C" Suite 203
Anchorage, Alaska 9950!
~.u'l,,llCIP,'"',tIii OF ANCHORAOE
)" Dcl~'( 0~: HEALTH &
[NiVi~.OI,iM~tlTAL p~oIECTION
R£CEI'9£D
SUBJECT:
Waiver Horizontal Separation between Well and F~nhole/
Sewer, Lot 4-A, Block 2, Campbell Heights S/D
(8521-WA-O6g)
Dear Mr. Spurkland:
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the well and manhole to 84 feet and
the well and sewer line to 71 feet on the subject property.
Sincerely,
Bruce'.~ Ertckson
District Engineer
BEE/dd
c
n~
Indicate North
I
bJ
MUnicipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P,O. Box 196650
Anchorage, AK 99507
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.. 014-071-51
1. 'GENERAL INFORMATION
Complete legal description CAMPBELL HEIGHTS BLOCK 2 LOT 4A
Location (site address) 3620 E. 67TH, ANCHORAGE, AK 99516
COSA# (~-D~ \\~(~
Expiration Date:
Current Property owner(s) JANA SIROVA
Mailing address
Lending agency
Mailing address
Real Estate Agent
SHELLY SCHNIEDER
Day phone
Public Water System
Day phone
M .a,.![!,~ ,Add,mss
U~less Otherwise 'reqrJ~sted, COSA will be held by DSD for pickup.
2. ,:i~'UMBE~' OF MS: 3
' .;, ,: '~ x~ , ·
3. TypE :OF WATER sUPPLY:
individual Well []
Individ'u~l'Wa~ter Storage []
Community Class ~ Well [] .
Day phone 229-1500 '
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank
Community On-site.
Public Sewer.
[]
[]
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners, Certificates of On-Site Systems 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 ^ 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 Certificate of On-Site Systems 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 Spurkland Enginneering
Address 203 W. 15th Ave., Ste 202, Anchorage, AK 99501
Engineer's Printed Name Lars Spurkland
bedrooms.
DSD SIGNATURE
~ Approved for
Disapproved.
Phone 279-39!6
Date 12/5/2011
.......
l,
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:, / ~--- // °'O'-///
(Rev. 11/05)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, AK 99519-6650
' www. muni.org/onsite
(907) 343,7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: CA~,s~.t.t. ~a(,.~'r5 ~tK?,, LOT ~A Parcel ID: OIq- O~|- 5 1
A. WELL DATA
Well type
Date completed
Total depth
If A, 'B, or C provide PWSID # ~
Sanitary seal (Y/N) '/
Cased to ft.
FROM WELL LOG
Date of test
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform j~r~3- colonies/100mL Nitrate 0.tS~ mg/L
Arsenic: ~/D .. ug/L date of sample: Itlz~-Itl
B. SEPTIC/HOLDING TANK :DATA [~,~o~;¢ ~g~j~.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
Y
t- in.
Collected by: L/U~$ Spqc~\~,-,~
Tank Type/Material
Tank size --' gal.
Number of Compartments.
Foundation cleanout (Y/N) '"' Depression over tank (Y/N) -----
Date of pumping --" Pumper ----
C. ABSORPTION FIELD DATA
Date installed ~ Soil rating. (g.p.d./ff~ or ~/bdrm)
Length ~ .ft. Width '--"
Total depth ~ ft. Eft. absorptiOn area
ft.
Monitoring tube
Date of adequaCY test ~ Results (Pass/Fail) ---'
Fluid depth in absorption field before test ~ in.
Water added '-' gal.
Elapsed Time: ~ min. Final fluid depth. '- in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) ~
Date installed "---
Cleanouts (Y/N)
High water alarm (y/N) ----
Absorption rate >=
System type "
Gravel below pipe ft.
'--'- Depression over field '--
For ~ bedrooms
New depth 'Tin.
"-' g.p.d.
If yes, give date '-'""
D. LIFT STATION
Date installed
"Pump on" level at ..,,,~n.
Datum
!E. SEPARATION DISTANCES
Size in gallons ,~'"~anhole/Access (Y/N) ~
"Pump off" level at ~in. High water alarm level at .J
in.
Cycles tested?~ Meets alarm & ~ments?
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Animal containment areas
On adjacent lots 10ot't
On adjacent lots [00'-~
Public sewer manhole/cleanout
Holding tank
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation A/IA Property line --" Absorption field
Water main "-' Water service line '"" Surface water
Wells on adjacent lots --'
.F.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
' ~Propertyline /V'I ~, Building foundation' -- Water main
Water Service line ~ Surface water ~
Driveway, parldngNehicle storage
Curtain drain "-" Wells on adjacent lots --
COMMENTS
G. ENGINEER'S CERTIFICATION ~ 4,~,..O..F..A,.~; ;~ t,
~'~,y:.' ..,,.. ~t
I certify that I have determined through field inspections and ~' o~.,' ~ ' ~
review of Municipal records that the above systems are in ~ /..' 49,T~..~ .. ~,
conformance with MOA COSA guidelines in effect on this date ~ '/",' '-ii:=~;~;J~ ',~,~ '" ~
Engineer's Printed Name . ~~~;;LAN[ i~. ~
· Date t'LISl ~1 4,'"~'- [zlsh/ .:~
COSA Fee $ ('-~°t~ Waiver Fee $
Date of Payment
Receipt Number
(Rev. 4/10)
o,~ _~-o ¥ G,
Date of Payment
Receipt Number
SGS Ref.# 1115695001
Client Name Spurkland Engineering Printed Date/Time 12/01/2011 14:03
Project Name/# Water Analysis Collected Date/Time 11/22/2011 11:30
Client Sample ID Cambell Heights Blk 2 Lot 4A Received Date/Time 11/22/2011 11:50
Matrix Drinking Water Technical Director Steohen C. Ede
PWSID 0
Sample Remarks:
Allowable Prep Analysis
Parameter Results LOQ Units Method Container ID Limits Date Date Init
Metals b~ ICP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<10) 11/22/11 11/23/11 NRB
Waters Department
Total Nitrate/Nitrite-N
0.159 0.100 mg/L SM204500NO3-F B (<10) 11/30/11 AYC
Microbiology Laborator~
E. Coli
Total Coliform
Negative 1 100mL SM20 9223B A 11/22/11 DLC
Neeative 1 100mL SM20 9223B A 11/22/11 DLC
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343.7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014-071-51
1.. GENERAL INFORMATION
· Complete legal description Campbell Heights BIk 2 Lot 4A
Location (site address) 3620 E 67th Ave., Anchorage, AK 99507
Current Property owner(s) David J. Adkins
· Mailing addres~
cos^ #
Expiration Date:
Day phone
Lending agency
Mailing address
Real Estate Agent
Mailing Address
3620 E 67th Ave., Anchorage, AK 99507
Jessica Morales / Checkpoint Realty '
Unless otherwise requested, COSA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 03
Day phone
Day phone 907-301-9291
3. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding Tank []
Community On-site [] .
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. CertJticates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems Approval
are valid for 90 days from the date of issue for properties served by a pdvate or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a pedod 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 Certificate of On-Site Systems 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 Watkins Engineering, Inc. Phone 907-349-1851
Address p.o. Box 110443, Anchorage, AK 99511-0443
Engineer's Printed Name Cindy W. Ellis, P.E. Date :2 ,- ~_..~.-' 0'7
5. DSD SIGNATURE
L,'/' Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the followin~c
Attachments:
COSA Checklist
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
X
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
~ ~ginal Certificate Date: 3 - ,~ - 0-7
Municipality of Anchorage
Development Services Department
8undlng ~ OIv~lon
On-Site Water & Wastewater Program
4700 8ragaw 6treet
P.O. BOX
Anchorage. AK ~g519-6650
www.m~mLorg/onslte
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKMST
Legal De~: Campbell Helght~ BIk 2 Lot 4A
A. WELL, DATA
we, type Pd
Date completecl 7/28/1981
Total dept~ .73
IfA, B, otC provkle PWSID #
Sanitary ~eal (Y/N) Yes
Cased t~ 40+ It.
FROM WELL LOG
?/28/1081
25
WATER ~A,MPLE RESLILT~:
B. SEPTIC/HOLDING TANK DATA
Nl~ate o,t?g n~.
Date of ~aml:)le: 2/6/2007
Date of test
Static water iewl
Well pmduc~on
Number of Compa~lments
Dep _re~__.V~n over tank
Pumper
So# raUnO (O.p.d.~t2 o~ ~red~) ~
Tank 'rype/Matedal N/A
Tank~ize __ gal.
Founcla~m cleanout (Y/N) ~
Date of ~umplng
ABSORPTION FIELD DATA
Date ,mall .N/A
Lengm
It. Wklth It.
Eft. absorpl~n area · Monitoring tube
Results (Pas~/FalI)
Water added
Total depth It.
Date of adequacy test
Fluid depth in ab~ field before test ,in.
Elapsed Tk'dle: ~.min. Final fluid dept~
Any rejuvenation ts'eat~ilent (past 12 mo,) (Y/N & type)
Pamel ID:.. 014-071-61
We#Log(Y/N) Yes
Wires propedy pn~ected (y~q) yes
Casing height (atx~e ground) 12+
AT INSPECTION
35 ff.
7,~ g.p.m.
Other 10acmrm 0
Collected by: Roclo/Tralnor
Date Jnstmled
¢~anoute (Y/N)
High water .mrm (y/N)
colonies/100 mL
Granml below pipe It.
Depression over field
For bedrooms
gal. New depth in.
.in. Absorption rate >- g.p.d.
D. UFT STATION
Date installed N/A
'Pump on' level at __ in.
Datum.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic lank/lift station on lot N/A
Absoq~flon fleM on lot N/A
Public ~ewer main 71'+
Sewer/septic service line 25+
Animal containment =mas 100+
High water
Ueet~ marm & ~:u~t m;u~mer~?
Size in gallons
'Pump off' level at in.
Cycles tested
On -,dj-cent k:~ 200',,
On adj=cent
Public ~wer manhole/c~eanout
Holdi~lg tank 100'+
Manure/anlma! ex~.~te ~torage areas 100'*
Surface water
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation NA Property line
Water main Water service line
Wefts on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Properly line NA Building foundation
Water Service line Surface water
Curtain drain Wells on ,,(ljacent lots
Water ma~n
Recel~ N~er
(Rev.
Date of PWment
Receipt Number
SGS Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
1070476001
Watkins Engineering
Campbell tlLS Block 2 Lot 4A
Campbell IlLs Block 2 Lot 4A
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 02/19/2007 8:25
Collected Date/Time 02/06/2007 14:43
Receh'ed Date/Time 02/06/2007 15:10
Technical Director Stephen C. Erie
PWSID 0
Sample Remarks:
Allowable Prep Analysis
paramet~ Results POL Units Method Con~ain~ ID Limits Date Date Init
~at~ls by ZCP/MS
Arsenic
ND 5.00 ug/L EP200.8 C (<10) 02/14/07 02/15~7 TI(.
Wa~:ers Depa=tment
Total Nitrate/Nitrlte-N
0.179 0.100 mg/L EPA 353~ B (<10) 02/08/07 JDS
k~L crobiolocd~ Laborator~
Total Coliform 0 col/100mL SM20 9222B A (<1) 02/06/07 DPT
r. Lit.
02/0~/2007 NON 15:55 I'[~[/l~ ~'0 (]3961
e6t:OL ZO GO qe.-I
Municipality of Anchorage
Development Services Department
Butldlng Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLanchorage.ak.us
(907) 343-7004
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. (~/~' ~71-
¶. GENERAL INFORMATION
Expirat~on Date:
Complete legal descripflon CAMPBELL HEIGHTS S,/D; LOT 4A, BLOCK 2
Location (site address or diractions) 3602 EAST 67'rH AVE. *ANCHORAGE~ AK 99507
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
MERLYN AND SHERRY PARRET Dayphone 349-7197
3602 EAST 67TH AVE. *ANCHORACE~ AK 99507
Day phone
RICHARD JORDAN W/SUN PROPERTIES Day phone
4130 CRANNOG *ANCHORAGE AK. 99502
229-1755
Unless othetw/se requested, HAA will be held by DSD for p/ckup.
2. NUMBEROF BEDROOMS: 4
3. 'I~PE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WAS i ~-WATER DISPOSAL:
Individual On-site B
Ind[vldual 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 dvil
engineer registered in the State of Alaska. Certficates of Health Authority Approval are required for the fl'ansfer
cf titJe (except between spouses) for propertes 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 vatid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new ware, sample results less than 30 days old. (Certficates may be reissued for a period of
up to one ~,ear with valid water samples.) Certficates are valid for one year for properties served by Class A or B
wells er a public water system. The Municipality of Anchorage Is not responsible for er~ora or omissions in the
professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As cerEfied by my seal affixsd hereto and as of the validation date shown below, I verify that my
invest'gat/on, based on procedures outlined in the Health Authority Approval Guidelines for this applicat/on,
shows that the on-site water supp¥ and/or wastewater disposal system is(are) safe, functional and adsquate
for the number of bedrooms and ~/po of structure indicated herein. I further verify that based on the
information obtained from the Municipalhy of Anchorage files and from my invest/gat/on and Inspec~on, the
on-site water supp¥ and/or wastewatar disposal system is(are) In compliance with all applicable Municipal
and State codes, ordinances, and rsgulattons In effect at the t/me of lnstellat/on.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS. INC. Phone
Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE. AK 99504-
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Date
537-6179
Engineer's Comments:
In conducing this evaluaEon, AWX4~, Inc. attempted to ~ a thorough,
consdenffous engineering analysis of the s),~lem in accordance v,f~h ADEC and MOA
DSD Guldet/nes & Rsgulaffons. The reported ~esu/ts described the pen'ormance of the
sTstem undo'the cendi~ons enceu~ at the time of the test, and separaEon
distances measured to madi~, Iden~fiable fea~uras. The operational ~fe of all wells and
septic systems depend on the Iocal softs condition, gtoundwatsr leve~s that may
fluctuate dudng the y~ar, and the water usage of the family being sea, ed by the system.
These condl~on$ am outside the conb'ot of the eyaluator of the system. Sa#sfactcwy test
results do not guarantee futura performance of the system, nor do they gum'anten that
there are no hidden def,'ts or encroachments. AWWC, Inc. can themfc~'e not provide
any warranty or futura estimate of how long the system v~ll continue to meet the
operational requirements of the ADEC or MOA DSD. The contant of this report Is for
the sde benefit of the owner listed above. Any raliance upon er use of thls t%eert by any
other person or party is not authork~ed, n~ tw~ It conf~ any legal right wha~eysr.
5. *DSD SIGNATURE
~ Approved for /..?L bedrooms.
Disapproved.
CondiUonal approval for __
bedrooms. ~th the fllowtng stipulations:
WA'I'EP, AND
PROGRAM
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
O,her
Odginal Certificate Date:
Municipality of Anchorage
Development Services Department
Or~8~ W~t~r & W~stew~t~r Program
A. WELL, DATA
We~ lype I'FWA~
~,~ ~omp~ted
HEALTH AUTHORITY APPROVAL CHECKLIST
c~;u. Ha~TS S/Oi LOT 4~ ~CK 2 P..I ID: 0 1 ~1-0 71-..,~"1
If A, B, or 0 provide PWStI~/: N/A Wen i..og (Y/N) YES
1981 6ardtmy eeal ('Y'/N) YE:$ Wires ixopedy ~,~,cted ('Y/N) YES
Totaldeplh 73 lt. Casedto 40'+ ~. Casinghelght(abovegtound) 12+ In.
FROMWI=t i LOG AT INSPEOTION
Oate of te~t 1981 8/e/oi.
~'~ water level 20 It, 35
Well ixoductJon 25 g.p.m. 7.5 g.p.m.
WATER 6AMPLE RESULTS:
C,a~,ofw'nple: e/e/el Conected by:. ),wwc, ,~c.
e. m,'n ou)xxe TANK DA'fA
Tank size ,, g~l. Number of Compartments Cinanm~ (Y/N)_~
C. ABSORPTION FIELD DATA . . ~
Totlddepth lt. Eff,~ama fi' Idonltodngtube Oepreasinnoverfleld
Oate of adequacy test _.,/ Re~ult~ ~e~) __ For bedmon~
Ruld depth ~ ab~x~ fletd before test In. Water added gal. New depth In.
~//.~: rain. Final I1t.dd deplh In. AMmT)aon rate >~
,~z11) rejuvenation b'eabllent (past 12 mo.) (Y/N & type) If yes, give dete
D. UFT ~TATION
F_ SEPARATION DISTANCES
SEPARATION DIb'FANCE~ FROM ~ r ON LOT T~,
~p~O tall~/~ ~lt~o~ oll lot N/A
AJ~o~oll ~ld oll lot N/A
Publlo cower main 5o'+
~r/~el~o ~e~ III1~. "'UNK
On ao'Jamnt
On adJamnt lots N/A
Publlo ~ew~r manhole/cleanout 50~+
Holding tank N/A
SEPARATION OIS'rANCE.~ FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Pmpe.y line
Water main Water ~erv~ce ~
We~ ~n ad]acent lots
SEPARATION O~TANOG FROM ABSORPTION ~__~3N'I33T T~.
Pmpe~ line Bu~dl~.~ Wa~e~ maln_.__~
F.
.~"~ * ~O SEPARATION DISTANCE REQUIRED UNTIL 1982.
O. ENGINEER'8 CERTIFICATION
have deMrm/ned ~mugh f~/d ~apec~ons and
mvfew o~ Munlclpal mco~s ~at ~e ebove ey~ems em ln
~ MOA I'IAA g~ldellnes~ effecton ~d~date.
JEFFREY A. GARNESS
HAA Fee $ SC P.
Receipt Number ~o~-I~
Waiver Fee $
Oate of Payment
Receipt Number
- MUNICIPALITY OF ANCHORAGE
DIVISION OF EliVIRONMENTAL HEALTH
DEPARTMI~NT OF ~EALTH AND ENVIROI~(ENTAL PROTECTION
APFLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
(a) Legal Description (include. lo~, block.~ subdtvis~Qu, ~ect~on, to.ship, range)
Location faddress or direcCio~s)
(C) Applicant is (check one) Lending Institution ~-~
Buyer ~--~; Other ~--~ (explain);
(d) Lending Institution ~ ~,, ~_"~-X~,' ~¢;.~, Telephone
Ad~'d~s s
(f) Hat1 =he ~ ~o =he Iollo~ ~dr~ss=
Business
2. Type of Residence
Stugle-Family[~
Number of Bedrooms
Hultl-Fa~:Lly ~'~
Other (describe)
~ater Supply
Individual Well ~ Communtt-f ~-~ Public
Note: H community well system, must ~ve ~i~en co~i~a~iou froa ~he S~a~e
Depa~Cmeu~ of Enviro~en~ Co~e~a~ion aCCesCi~ to the legality a~ status.
Se~te Disposal
No=e: If cmni:y ~11 system, must ~ve wi~:en co~t~a~ion from the S=a~e
Depar=aen= of Enviro=en:al go~e~ation a~esii~ {o ~he legality a~ sCa=us.
[Pase I of 2]
En~ineerin~ Firm Providln~ Ins~ections~ Tests~ File Search~ Data and Infor~ation
As certified by my seal affixed hereto and as of the v~ltdation date sho~n below,
verify ~M~ my inves~iga~ion of ~his Re~h ~hori~ Approval sho~ ~a~ ~he o~sl~e
water aupply aM/or ~s~ewater disposal sys=em is safe~ fuc:iond a~ ~eq~=e for
=he =bet of bedro~s aM ~pe of s=~c=ure i~lca:d herein.. I fur=her verify
based on ~he i~o~ion ob~ain~ from ~he ~nicipali~y of ~chorage files
lnvestiga~ion ~ inspection~ the o~site ~ter supply a~/or ~s~evater dis~sal
ayste~ Is in c~pliance ~th ~1 ~nici~l a~ ~tate c~es~ ordinances, a~ reg~a-
tio~ tn effect on the da~e of this ins~c~ion.
Address
DREP Approval
Approved for'~rC~} bedrooms
Approved %~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
TEE }DJRICIPALITY OF A}ICH01~GE ~PAR~EN~ OF ~TH ~ E~IRO~ ~OTECTION
(DHEP) ISSL~S ~TH ~HORI~ ~PROV~ ~RT~ICATES B~ SO~LY U~N ~ ~RESEh~-
ATIONS ~N ~ P~ 5 ~0~ BY ~ ~PE~E~ ~0FES~IO~L ENGI~ER ~GIS~
IN ~'~ S~ OF ~S~. ~ ~EP ~ES ~ ~ A ~SY TO P~SEKS
T~IR ~ING ~TI~IO~ ~ O~ER TO SATISFY
~S. ~O~ES OF ~EP ~ NOT ~UCT INSPECTIO~ O~ ~AL~E ~TA ~EFORE A
CERTIFICA~ ~ ~S~D. ~ ~ICIP~I~ OF ~NCHO~ ~ NOT ~SPONSIB~ FO~ ~ORS
0R ~IS510~ LN ~ ~OFESSIO~L ENGInEerS ~0~.
(DHE~ SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHOPJTY APF~0VAL (HAA)
CFF-fKLIST - FEBRUARY 1984
NOV 2 0 1994
RECEIVED
Legal Description:
Date C~,ple ted
Pu~p Set At
Well Classification ~ ~,
Well Log Present (Y/N) y
Total Depth 7~ Cased to
Static Water Level ~-O
Casing Height Above Ground
Electrical Wiring in Conduit .(Y/N)
Separation Distances frcm Well:
To Septlc/Holdir~ Tar]~ c~ Lot
If A, B, cr C, D.E.C. Approved(Y/N)
7/~ &./~/ Yield ~
Depth of Grcuti~g
Sanitary Seal cn Casing (Y/N)
Depressicn Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Se~r Line
Cleanout/Manhole ~/ To Nearest Sewer Service Line on Lot
Water Sample Collected By .,1_ ~ !~ '~' . .; Date
Water Sample Test Besults ~ ' ~-~
; On Adjoining Lots
; On Adjoining Lots
TO Nea~esL Public Sewer
B. SEI::TIC/HOLDING TANK DATA
Date Installed Size No. cf Co,~artn~nts
Standpipes (Y/N) Ai~-tight Caps (Y/N) Fcundaticn Cleanout (Y/N)
Depression o%~r Tank (Y/N) Date Last Pumped
Pumpir~/Mainte~nce Contract on File (Y/N) ;fcr
Holding Ta~k High-water Alarm (Y/N) Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/~oldinG Ta~R:
To Water-Supply Well
To Prcgerty Line
To Water Mair%/Service Line
Course
Cu.'~e. nts
To Building Fcundaticn
To Disposal Field
To Stream, Pond, Lake, cr Major Drai?mge
[Page 1 of 2]
Receipt # ,~ ,~/O /
Date Paid:
Amount: '
2-15-84
C. A~SORPTIO~ FIEID DATA
-PULL/d-
Soils Ratir~ in Absorption Strata
Date Ir~talled
width of Field
Square Feet of Absorption Area
DAp~ession over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Wall.
To Building Foundation.
Lot
To Water Main/Service Line
To Property Lir~
To Existing or Aha~.doned System on
; On ~djoining Lots
To Cutback(if preset, t)
To Stream/Pond/Lake/c~ Majo~ D~ai~ge Course
To Driveway, Parking Area, (x Vehicle Stc~age Area
D. LIFT STATION
Date I ~.~ talled
Size in Gallons
~'Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Ma~ole/Access (Y/N)
"Pump Off" Level at
%~nt (Y/N)
~umping Cycles c~ing Adequacy Test.
C~ents
** Oneck Permitted Bedroom Rating AGainst HAA Bequest **
I certify that I have checked, verified, c~ conf~,,ad to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed ~
Company ~
KB1/d5/s
Moa No. q roolI
[Page 2 of 2]
2-15-84
.,, D~ ,;'RECEIVED
INSPECTION APPOINTMENTS
TIME TIME I'IME ·
~NSPECTOR INSPECTOR ~N,~EC'~t~ -~[
MUNICIPALITY OF ~CHORAGE ~N~CIPALt~ ~ AN~0RA~
O[PT OF H~ALTH &
~EPA~E~ O~ ~LT~ ~
D WS O.
REQU~T FOR ~PROVAL OF INDIVIDUAL WATER ~D S~~
DIRECTIOn: Co~lete aH ~ort pe~ 1. I~ r~ wil~ ~ ~. ~e~ ~low ten (I0) ~ys for pr~ing.
2. BUYER PHONE
3. LENDING I~TITU~ON I PHONE
~ R~LTO~AQENT I PHONE
I
MAI LING ADDRE~
~ SINGLE FAMILY
i--~ MULTIPLE FAMILY
~ 7, WATER SUI~LY
INDIVIDUAL'
COMMUNITY
[] PUBLIC UTI LITY
~. SEWAOE DISPO~,AL SY~'EM
~ INDIVIDUAL/ON-SITE**
~. PUBLIC UTILITY
I--I One [~] Four
[] Two [] Five
[~. Three [] Six
[] Other
* ATFACH WELL LOG. A well log is required for all wells drilled
since June 1975. For welts drilled prior to that date, give well
depth (attach 1o~ if available.)
.YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72Ot0 (Rev.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
ONE I~ THREE I'-1 FIVE r-i OTHER
[]
SINGLE
FAMILY
[~] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMI~ER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[~ PUBLIC UTILITY . : '
Connection Verified LOG RECEIVED
~. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: ,ic,.o,d)ng T..k ^..
Absorption Area to neer~t Lot Line
5. COMMENTS
[] CONDITIONAL APPROVAL (letter must eccompany certificate)
[] DISAPPROVED
72.010 (Rev. 6/79)