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HomeMy WebLinkAboutDAFOE BLK 1 LT 2BI)afo lock I Lot 2 015-491 -11 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP241389 Work Type: SepticTank Upgrade Tax Code Number: 01549111000 Site Legal Address: DAFOE BLK 1 LT 2B G:2638 Site Mailing Address: 6550 ROCKRIDGE DR, Anchorage Owner: TSCHOPP CHARLES F & LYDIA M Design Engineer: GARNESS ENGINEERING GROUP LTD This permit is for the construction of: Effective Date Expiration Date Lot Size in Sq Ft: Total Bedrooms: 11/26/2024 11/26/2025 49717 ❑ Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage All construction shall be in accordance with: 1. The attached approved design. 2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80) 3. The wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing -Reeeiu�d-By: �-55,ate Date: Issued By: Date: glo y 61 MUNICIPALITY OF ANCHORAGE Development Services DepartmentPhone. 907-343-7904 On -Site Water & Wastewater Section Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcell.D. 015-491-11 Property owner(s) LYDIA TSCHOPP C/O STEPHANIE WHAN Day phone 425-652-0903 Mailing address 6550 ROCKRIDGE DRIVE, ANCHORAGE, AK Site address 6550 ROCKRIDGE DRIVE, ANCHORAGE, AK Legal description (Sub'd., Block & Lot) DAFOE;BLOCK 1, LOT 213 Legal description (Township, Range & Section) Lot Size Sq. Ft. Number of Bedrooms 5 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (0 all that apply) Absorption Field F-1 Single Family (SF) FX -1 L__.j Septic Tank (w/wo ADU) Upgrade rX_1 Holding Tank 0 Duplex (D) D Renewal ❑ Privy 0 Multiple Dwellings D (SF and/or D) Private Well 0 Water Storage 0 THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 22 Waiver Fees: Date of Payment: Date of Payment: Receipt Number: 2-1 G Receipt Number: Permit No. 05 PZ 5133,1 Waiver No. GAIDevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241389, Deb Wockenfuss, 11/26/24 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241389, Deb Wockenfuss, 11/26/24 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP241389, Deb Wockenfuss, 11/26/24 0 w 0 ui D a Municipality of Anchorage Page [ ,,of "Z.. DEPARTMENT OF HEALTH 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 Rep,oft Permit Number: ~-'~L'd~'70~'~2 PIDNumber: 01~ z~J..""ll I~P_. ~' t'-112-~. -T-%F__2Fiz3,o¢,~.,WastewaterSystem: []'NeoN ~)~Upgrade Name: Address: No. of'~5 ~-"'¢'~ 'Bedrooms: '~-Z~'~-- ~ C ~ E] Deep Tren%f-1 Shallow Trench [] Bed F'I Mound/Other Phone: ~ ~oil Rating: % Total Depttt from ori~ grade: LEGAL DESCRIPTION rap/s,. Ft. /- .... Lot: ~ ~, Block: Subdivksion: Depth to pipe bottom from original g~: Gravel dep~neath pipe · [] New [] Upgrade Gravel width: Classification (Private, A~,.,...........~ Total Depth: C~;;~: Total absorption area.~~ Pipe mate~ .,,..,~~~ - Static Water Level:Ft. Dat GPM Ft. Ft. SEPARATI 0 N D ISTAN CES ~Septic [] Holding [] S.T.E.P. TO Septic Absorption Lift Holding ~ublic/Private Manu.,facturer: Capacity in gallons: ,WelP/o~'~ % / 3~t~ Materia~¢~ Number of ~a~ments: Surface~~ Water /~ ~ ~00/~ LIFT STATION FOUndation ~ l~ ~ "Pump on" le~~h: " : ' water alarm at: Ou~ainDrain ~{~ ~ ~U°d~' IE'e~trio~"n~P~oti°~sPe'°r~edby:~ BENCH MARK Remarks: ~ ~ Assumed Elevation: .. Inspections pedormed by: ~~ ~-~ Dates: 1st ¢ Depadment of Health and Human Services approval 72-013 (Rev. 9/91) MOA 25 SE~¥!C lANK rOUbLE C/D ~NEV 1562 3ALL3N SE~TIS / EXZ&TING ~EWER EXZSTINE.r/~u HOUSE iNVERT 2F iNLET PREPARE3 7~ CHARLES TSCHEPPS TRE ~ELL iS l~O'+ FRDN THE REPliC ~ TANK L'~5~ABE 2hi .ET ~2~ ~K 1¢ ~IAFO~, ;/ELL PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUNLAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW970236 DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES OWNER NAME:TSCHOPP CHARLES F & OWNER ADDRESS:6550 ROCKRIDGE DR ANCHORAGE, ALASKA 99516 DATE ISSUED: 8/04/97 EXPIRATION DATE: 8/04/98 PARCEL ID:01549111 LEGAL DESCRIPTION: DAFOE BLK 1 LT 2B LOT SIZE: 49717 (SQ. FT.) NUMBER OF BEDROOMS: 5 THIS PERMIT: THIS PERMIT IS FOR THE CONSTRUCTION OF: SEPTIC TANK SYSTEM 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 DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: DATE: ~-~ Al[a k W lter & W, tewater 8471 Brookridge Drive - Anchorage - Alaska 99504 (907) 337-6179 - Fax (907) 338-3246 Consulting Engineers August 4, 1997 Municipality of Anchorage Department of Health & Human Services Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 Ref~ Septic Tank Replacement for Lot 2B, Bk 1, Dafoe S/D. 6550 Rockridge Road. Anchorage, Alaska. To whom it may concern: The existing 5 bedroom house is served by private well and septic system. The existing 1250 & 500 gallon septic tanks were exposed and found to be full of holes. Attached is a 1": 40' scale drawing showing the proposed location for a new 1500 gallon tank. There are no surface waters within 100 feet of the proposed upgrade. I am unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact me at 337-6179, 244-9612, or on my digital pager at 1-800-481-1162. Thank you for your assistance. i S ncerely, ,~ ~, ~ Jeffrey . s, P.E.';'M.S. Owner/ConStant STEMS DN THEM, THE """"""""""""""""""~~LLS ARE ~0~';- SEPTIC ...., AN?,. PREPARE~ 3Y: iNSTALL DOUBLE TF~ D.D DRAiNF~ELD CDNSTRLICTED IN 1974 -- REMOVE EXISTING 5O0 GALLON ~EPTiC TANK AN~ ,,~INSTALL ANEV' ~$C~ ~ALLDN / SEPTIC TANK / EXISTS'NO / / / JET .~iLEANE%' F~OM THE F~UN;B--% A':'2DN C,/D ~UT T~ THE NE'~ TANK, HOUSE ~,,~, 2iqA~LES TSCH~PPS ALASi<A v/ATE~ & WASTEWATER i2ARNESS ISOALE, ~.' = 40' I THE ~ELL Z~ ~% TANK UPGRADE ~ i~ Ig MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME ._~?,. · MAILING ADDRESS .... LEGAL DESCRIPTION LOCATION ¢ ~ , ~ , ~, . /: ~,' -, ~"/ ,." ¢' NO. OF BE~MS Well 'J Absorption area Dwelling PERMIT ~ Z Manufacturer ~, Materi~l ¢- No. of ~mpartments Liq. capacity in gallons Inside length W~¢t~ Liquid d¢~ O~'0 IF HOMEMADE: ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. ~ Well Foundation Nearest lot line ~ No. oflines Length of each li~e ~ Total length oflines~ Trench width Distance bgtween lines ~ Topofdle~o~"sh grade Material beneath die Totaleff~ct~v~ab r~tion Length Width Depth PERMIT NO. ~~ ~h ~o ~rp ~ ~ Type of ccrb / er ~~ ~e Cla~ ~ x Deoth Driller Distance to lot line ~E~MIT~O. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TE~ ~T[~ ~'.' INSTALLE~ . REMARKS ?~ ",~ APPROVED. /~,? ,, -. DATE LEGAL 72-013 ev. 3~78) /., WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ Geophysical Surveys Drilling Permit No. LOCATION OF WELL (Please complete either Io, lb or lc.} A.D.L. No. c. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 5. OWNER OF WELL: Address: Street Address and Area of Well Locntion 2. WELL LOG Feet Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETION Surface ft. Material Type TopBottom .... ... ~ diom. in. to ft. De~th Stickup ft. 9. FINISH OF WELL: Type: .*' ~ .f , Slot/Mesh ~lze: Length Set between ft. and ft. Backfilling Gravel pock I0. STATIC WATER LEVEL: ;~ '" 'Dot, ~c~O~ ~ Abov~ o~"~ ~ Below land eurface 0 ~u~ ..... ..... EAL~k~ ~ ' ' , ~q'e merit used: ~L pRO'[~CT~()~ ' . ENV~RO~4~[[4~fi II PUMPING LEVEL below land surface and YIELD '~VV -- -- ft. after ~ hrs. pumping g.p.m. ~% ' ' Moferi~t: ONe,, Ce.ertl 0 Other: 15. PUMP: (~f ov~iloble) HP Length of Drop Pipe ft. cepecity g.p.m. 14. REMARKS: 16. WATER WE~ CONTRACTOR'S CERTIFICATION: ~5. Woter Temperature __o 0 F 0 C This well ~os drilled under m~ jur[sd[cHom ond this report is true fo the best of my knowledge ond beHef~ R~ist~ed ~siness.,~g~t ~ Contract License Number .....,.- .~i ~ "' ~. ~. ~.,..,., . ,; Signed: .-/~ ''~ ' Dote ', ~ I ..~ /, ,,- ~ ,' A'~ t h~Tz~ d' ~epresentotive ~ : Form OZ-WWR (11/8i~ Copy Distribution: WHITE-State DGGS~ PINK-Driller, CANARY-CustOmer , ,r':,EF'FtRTMENT ~:I..IEFILTH RNr;, EN',,,',IRONMENTFIL ITECTIO['4 .. , 825 "L' bTF. EET RNCHOF..RGE., RE. 99.-°~E ~ ? 264-472¢-'~ ,]u ~-4! -- 2=-; ITE '_-~EI,-IEF-: F'EF-:Pl ][ T PEF.:MIT NFl' ,' :=:AA4~:':.., ', . ./ ....... ¢, ~,~..~ L .~ Pf~-:x~,~L~° RPF'LICRNT CHRRLES F. TSCHOPP SRR BOX 28T RNCHORRGE LOCRTION ROCKR I [:,GE LEGRL E28':;BLOCK 2;'~FOE' S/D' LOT SIZE 60000 S: ..... E FEET ' ~' ~ ~RF.' T'T'F'E OF SOIL RE:SORF'TION SYSTEM IS · TRENCH ['Ii'T,:-::IMUM NLIMBER OF E:E[:,ROOMS = 5 THE REL.]UIRED StZE OF THE SOIL RE:SORF'TION S'¢STEbl IS' [)ES'TH= 2_~--~ LE~4~]TH= S--t 'u]F-:R'-.-'EL g, E F' T H = THE LENGTH [:, I MENS I ON IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF ~ TRENCH OR PIT IS THE D ISTRNCE BETP~EEN THE SURFFICE OF THE GROUND RND THE BOTTOM OF THE EXCFI',,,'RTION (IN FEET.'.". THERE IS NO SET WIDTH FOF.: TRENE:HES. THE GRR',,,'EL DEPTH IS THE MINIMUM DEPTH OF GRR',,,'EL 8ETP~EEN THE OUTFRLL PIPE RND THE BOTTOM OF THE E',:"-,'CFI',,,'RTION (IN FEET). F'ERMIT RPF'LICRNT HRS THE RESF'ONSIE:ILIT'T' TO INFORM THIS DEPRF.:TMENT [:,URIN]i THE INSTFILLFITION INSF'ECTIONS OF RN'T' PELLS R[:,..TRCENT TO THIS F'ROPERT'¢ FIN[:, THE NJMBER OF F.'.ES I[:,ENCES THRT THE [,ELL HILL SERVE T I..4 E~ ( '-~ ::, I ~-~ :5 F' E C: T I C! ~-4:5 R R E F-: E L----! Iii I F-: E [:, - ' I]', ~ - BFICKFILLING OF FIN'¢ S'¢STEM P.IITHOUT FINRL INSF'ECTION RND HFFF.._,HL THIS [:,EF'FIF.:TMENT HILL E:E SUE:JECT TO PROSECUTION. MINIMUM DISTRNCE BET~4EEN R I.,.IELL RND RN'¢ ON-SITE SB4RGE DISPOSRL S'¢STEM IS iOF.~ FEET FOR R PR I ',,,'RTE HELL OR ±50 TO 200 FEET FROM R PUBLIC 1.4ELL DEPENDING UPON THE Tb'PE OF PUBLIC HELL MINIMUM DISTRNCE FROM Fi PR I ',,,'RTE HELL TO R PRI'¥'RTE SD4ER LINE IS 25 FEET RND TO R COMMUNITY SEHER LINE IS 75 FEET. OTHER REQU I REMENTS MR'T' F~F'PL'¢. SPEC I F I CRT IONS RND CONSTF.'.UCT I ON D I RGRRMS RRE R',,,'RILRBLE TO INSURE PROPER INSTFtLLRTIO[.4. S' E F: ~-1 I T E ::-:: F' I F-: E S [:, E E: E hl E: E F-: .3----': 1 .. 1 9 :B ~.--:'~ I C:ERT!F'T' THRT &: I RM F'Rf'IlLIFIR HITH THE REQUIREMENTS FOR ON-StTE SEHERS RND 1.4ELLS FIS SET FORTH B'T' THE MUNICIPRL!T'T' OF FINCHORRGE. 2: I HILL INSTRL. L THE S'¥'STEM I[.~ RCCOR[:,FINCE PJITH THE CODES. ]:: I UNDERSTRND THFIT THE ON-SITE SEF.IER SYSTEM MR'¢ F.:Eg!UIF.:E ENLFIRGEMENT IF THE RESIDENCE IS REMODELS[:, TO INCLUDE MORE THFIN 5 BEDROOMS. S I GHEE:, ' [:,RTE .... f ~ ~ '~ / V4, ¢ Department of I:nvironmenzal QualiW 3330 C Street Anchorage, Alaska 99§03 LOCATION __ INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING ADDRESS SEPTIC TANK: DISTANCE _~~'~ 5/.~.~,.~ / NUMBER OF FROM WELL MANUFACTURER -? MATERIAL ;~ COMPARTMENTS INSIDE WIDTH INSIDE LENGTH LIQUID DEPTH LIQUID CAPAC TY/~"~--~-~)GALLONS. TILE DRAIN FIELD: .- TOTAL LENGTH] DISTANCE FROM WELL FOUNDATION NEAREST LOT LINE_Z~2~_ .OF LINES / '--3 NUMBER OF LINES 3- DISTANCE BETWEEN LINES --Z~---TRENCH WlDTH~'~'IN. TOTAL EFFECTIVE ABSORPTION AREA ~ ?~"~/~ SL~. FT. LENGTH OF EACH LINE_ [~)~"~? ' /'~,/71.~) DEPTH: TOP OF TILE TO FINISH GRADE ~"~' DEPTH OF FILTER _~ MATERIAL BENEATH TILE ~'~ .IN. ABOVE TILE <~'"'" IN. WELL: BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION_____ LOT LINE____ SEWER LINE__, TANK SYSTEM__. CESSPOOL _ APPROVED OTHER SOURCES DISAPPROVED __ REMAR KS 2~Z_//L~ V/ DISTANCE FROM: DISTANCES: SEWER LINE DEPTH: LOT SLOPE: I DIAGRAM OF SYSTEM Form EQ-032 GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456! SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT PERMIT NO. L:/,.~/~,.~"-I ~ MAILING ADDRESS I NAME OF APPLICANT D> ~ ~ ~ ~,~+ ~'~ ' E INSTALLATION LOCATION '~ , ~ //// INSTALLATION OF: SEPTIC TANK ~ SEEPAGE PIT /' , DRAIN FIELD TYPE AND SIZE Of FACILITY TO BE SERVED FINANCED THROUGH SOIL TEST RESULTS COMPLETION DATE ANTICIPATED PHONE OTHER FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY Will BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREMENTS FOUNDATION tO SEPTIC TANK ~ FOUNDATION TO SEEPAGE Pit '~-~O/-- SEPTIC TANK TO SEEPAGE PIT WALL SEPTIC TANK , SEEPAGE PIT TO NEAREST LOT LINE. WeLL TO SEPTIC TANK DRAIN FIELD /~ DRAIN FIELD , DRAIN FIELD , SEEPAGE PIT , ALSO CONSIDER AREA WELLS. WATER MAIN TO SEPTIC TANK DRAIN FielD. / SEPT,C TAN., , SEEPAGE PIT TO RIVER, LAKE, STREAM. SEEPAGE PIT .,DRAIN FIELD CAST IrON INTO AND OUT OF SEPTIC TANK AND INTO CrIB CROSSING GAP Of EXCAVATION 5 FEET INTO UNDISTURBED SOIL. 4 INCH DIAMETEr CAST irON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE Pit FITTED WITH AIRTigHT REMOVABLE CAPS. GRAVEL BACKFILL CONFORM TO BOROUGH REGUL~TIONS rEGARDING INSTALLATION. OR LICENSED DESIGNER TYPE DIAGRAM OF SYSTEM I CERTIFY THAT i AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAiD CODE. /? DAT~'?-~/-- APPLICANT'S SIGNATUre /~'~'~'?~'--" ~:' ~:':"~- ~" FORM NO. EO-016 GREATER ANCtlOkAGL AIiLA department of Enviro,~ineuLa] 3330 "C" Street Anchorage, Alaska 99503 S()II,S .IX)(i PEROI,ATION TblST This form reports Soils log_._~__ ........ Percolation Dep th Feet 2- 3- 4- 5- 6- 7- 8- 11 - 12- Was ground water encountered? if yes, at wi~at depth? Reading Date Gross Time Net Time b~'~ ...... ~F~,, to Water~ iJre,. Percolation rate minute. .Proposed installation' Seepage Pit Drain Fiche ........................... Depth of Inlet ..... . Depth to'iJ~'~[~-'~,?--pit or trenc]~ ................................ COMMENTS' E(~- 040 (6/74) GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3330 "C" Street ANCHORAGE, ALASKA 99503 ,,.,~' OCT !8 !973 Case # Performed For .T~_ ~QJ~o~_ Dated Performed (~'- c~- Legal Description: Lot ~ Block \ _Subdivision ~'~'~"oe. This Form Reports Soils Log_ 7<* Percolation Test - Soil Test Must Be Logged To 4' Below Proposed Seepage System Soil Characteristics Depth Feet 10-- 11-- 12-- 13-- Was Ground Water Encountered? If Yes, At What Depth? Reading Date Gross Time Net Time Depth to H20 Net Drop Percolation Rate Minute Proposed Installation: Seepage Pit Drain Field Depth of Inlet Depth' to Bottom of Pit Or Trenc~ COMMENTS: ~;~¢ /~ ~,// '~ e'~ vc~__o_.~..~- -- .,, T es t Per for me d B Y /~L~cm _,!__ ,~C>~¢,)/~_~¢¢ D'ate Certified BY: Date ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date _ 1. GENERAL IN. FORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) .," ' Eo,~ation (add~s or directions) ;~'[b) AP'0~ibaht'~me C~L~ '[~~ Telephone: Home Applicant Address ':~ 0 8C K R t DGE (c) Applicsnt is 4check one): Lending Institutioa ~ · Owner/builder~; Buyer ~ ' Other Business (explain); (d) :'Lending In~tituti°n __ Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following Telephone TYPE OF RESIDENCE Single-Familyj~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well,(~' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite~' Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page I of 2 72-025 (11/84) ENGINEERING FIRM PROVIDIN~ISPECTIONS, TESTS, FILE SEARCH, DAt~AND INFORMATION As ce~ified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I fudher 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 in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm ~ E~ ~,- Telephone ~/~ ate DHEP APPROVAL Approved for ~ bedrooms by Approved ,./'~ Disapproved Terms of Conditional Approval Conditional Date ~¢7~' //~/ CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. Page 2 of 2 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: [~ L. Z A. WELL DATA Well Classification i N~0j(,,/l DL/~/-- If A, B, C, D.E.C. Approved (Y/N) Well Log Present CN)/ Date Completed Y/~---~'/~'~' Yield Total Depth | ,~'/'1/ Cased to I'~ ' Static Water Level 8~, C//~ Casing Height Above Ground ~ i-~ / Electrical Wiring in Conduit 8/N) Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Depth of Grouting Pump Set At Sanitary Seal on Casing (~N) Depression Around Wellhead (Y/(~ Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments .¢1( iOER ' On Adjoining Lots Adjoining Lots /~/7~/~ To Nearest Public Sewer To Nearest Sewer Service Line on Lot / ~ p/vl ¢- B. SEPTIC/HOLDING TANK DATA Date Installed Standpipes ~)/N) Air-tight Caps (~N) Depression over Tank (Y~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: TO Water-Supply Well ilO' - 125 ' To Property Line ~10 / T,© Water Main/Service Line Course r ~ ~ 0 ..... Comments Foundation Cleanout ~)/N) Date Last Pumped ~/ll'J¢~ ~ 'for ' ///~ Temporary Holding Tank Permit (Y/N) To Building Foundation 150-~ :i 62; ! To Disposal Field ~--~ To Stream, Pond, Lake, or Major Drainage Page- t of 2 :" 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date , nstalled/¢O/7C/ Width of Field -- Square Feet of Absorption Area Depression over Field (Y~) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well J To Building Foundation I,~ '.~ / Main/Service Line To Water To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~(' 0~0~,0~ 'i"IED i/VT~ Type of System Design Length of Field /~3; ,_~'.~ / Depth of Field o°~[O / Gravel Bed Thickness ~' ~2o~ ¢ 5~ '"'' Standpipes Present (~/N) Date of Last Adequacy Test .s fi T~ ~ Fh C 'rO ,q y TTf EA/C ff To Property Line To Existing or Abandoned System on · On Adjoining Lots ~0/ 7~ To Cutbank (if present) N/~ 100 D. LIFT STATION Date Installed Dimensions Size in Gallons Manhole/A~ "Pump On" Level at /,~ "Pg~:~C~Off" Level at High Water Alarm Level at l~,/' t/~......""/ (Y/N) Tested for I ~ / Vent Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ~ ' ** Check Permitted Bedroom Rating Against HAA Request ** I certify thaU haxe, c~ecke, d,.verifi~d, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed q,PJ/~J[M Date / I-l- ..- Receipt NO. Date of Payment Amount: $ ~0 Page 2 of 2 ALASKA ENVIRONMENTAL CONTROL SERVI i, INC. ! 200 West 33rd Ave Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEET NO. CALCULATED BY CHECKED BY SOA~E I% 30' /~! OA FOP_. J TI~ OF DATE $EPTI¢ TA~K 101 / 7'1 f 12q ' ............. ............ ~' ....... ; ......... : ~ \ :: ' , ieee'"