HomeMy WebLinkAboutT12N R3W SEC 22 LT 23 W2TI RSW
c. 22
Lot 23 W2
#015-141-24
Permit Number: OSP121168
Tax Code Number: 01514124000
Work Type: Septic
Permit Effective Dates: July 23, 2012
On-Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Upgrade
to July 23, 2013
Design Engineer: PANNONE ENGINEERING SERVICE
Subdivision: T12N R3W SEC 22
Site Legal Address: T12N R3W SEC 22 LT 23 W2 G:2636
Owner/Address: SCHNEIBEL LAWRENCE W & VICKI D
4811 E 112TH AVE ANCHORAGE AK 995161613
Site Mailing Address: 4811 E 112TH AVE, Anchorage
Lot Size in Sq Ft: 109725
Total Bedrooms: 3
This permit is for the construction of:
Y Disposal Field N Septic Tank N Holding Tank N Pdvy N Private Well N 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 wastewater code raquiras inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction dudng freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Previsions: PRIOR TO CONSTRUCTION: Additional percolation tests shall be completed
such that the entire drainfield is within 30 feet of a test.
Date:
Date:
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On-Site Water & Wastewater Program
Mayor Dan Sullivan
Phone: 907-343-7904
Fax: 907-343-7997
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O]~-~lHI- ~.~
Propertyowner(s) ~,~&~ ~ UIc~] ,~Hu¢~ Dayphone
Mailing address _ ~'11
Site address
Legal description (Sub'd,, Block & Lot)
Legal description (Township, Range & Section)
Lot Size J~:
THIS APPLICATION IS FOR:
([~ all that apply)
Absorption Field
Septic Tank
Holding Tank
Privy
Private Well
Water Storage
THIS APPLICATION IS AN:
Initial []
Upgrade ~
Renewal []
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
Permit No. ~PI~
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
G:\Building\On Site\Forms\Client Forms\Permit App_010411.doc (Rev. 1/11 }
Pannone Engineering Services LLC
Steven R. Pannone, Principal
Registered Professional Engineer
E-maih steve~panengak.com
June 27, 2012
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 S. Bragaw Street
P. O. Box 196650
Anchorage, Alaska 99519
Subject:
T12N, R3W, Sec 22, Lot 23, W2
Septic System Permit Upgrade Request
Ladies and Gentlemen:
I am writing to request a permit to construct an upgraded septic system be issued for this property. The
proposed systems will serve an existing 3 bedroom house. Currently the lot is developed. The existing
drain field will be re-used as a reserve. The new drain field will be built just north of the existing field. The
lot is served by a private well. The surrounding developed lots are served by private wells that are located
over 100' from this system.
1. Soils. Test holes were excavated by S&S Engineering in August of 1997, and the ground water
monitored for seven days. Groundwater was not observed after the seven day monitoring period. Bedrock
was not encountered in the test hole. It is my opinion, based on the results of the percolation tests and
overall soils appearance; an application rate of 0.8 gallons/day/square feet should be used for a
conventional waste water system.
Soil Absorption System Design.
a. See Sheet 2 of the design package
3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and the
existing drain field. The proposed drain field upgrade will maintain at least 100 feet from all surface water
and drainage ditches.
4. Topography: The topography in the area generally slopes to the west at approximately 10%-15%
in the area of the proposed drain field.
5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification
that the review is complete and that there are no further comments is received from MoA On-Site
Mailing: P.O. Box 100217, Anchorage, AK 995:].0-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-.821g FAX: {907) 272-~211
Page 2 of 2
Department, the note will be removed and "Issued for Construction" drawings will be issued.
The proposed installation will not affect the future development of the surrounding or existing lots. There
are no wells or septic systems within 100 feet of the proposed septic location.
If you have any questions or concerns, please contact me at 272-8218.
Sincerely,
Steven R. Pannone, P.E.
Owner/Civil Engineer
Attachments
-Soils Log
-Septic System Design
Mailing: P.O. Box 100217, Anchorage, AK 99510--0217
Physical: 332 East Manor Ave, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
~M -~--~NI ~ J / ,'
DR~A!N FIELD !Pi ,~.
(2LA) 40LF x 2.0 ED x 3.0 TD ~ '~ ~ ,'"
..... TH1997-2
'" ,... (S~S ENGINEERING) ~ III ~_ / .....
", .:, ./ ~ ' ~ R~I~I /SHED/
'~ k : ~ I ~ ,.,lO00g SEPTIC TANK (E)
%~ ' ~ ~ J ~ ~_/~ ~INSTALL BIVERTER VALVE '
:. DRAIN FIELD (E) ~ ~ //' I " / /
"~W~' ~ "'""" ~ DRIVEWAY ' "" ' ' .... ' '/' "
~ELL (E) ....
: L...,,? ...:. .
.,~ .~' -.- ..,
, ' % :1 ',.
, 53' ROADWAY ~SEMENT
."' / : E 112~h AVENUE
FOR CONSTRUCTION P.O. BOX 100217 ANCHORA6E, AK 9~510 ~ ...... ~&~ ~/27/2012
015-141-24
LAWRENCE & VlCKI $CHNEIBEL ~-. CE 814a ..~ 'ERM~T NO.
4a1~ s. ~l~th ,w~u~
PLAN ANCHORAGE, AK 99516 .~(g~ 'Sheet
-~%~ 1 OF 2
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPEOIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON-SITE WASTEWATER DISPOSAL SYSTEMS.
2. ALL WORK SHALL BE IN ACCORDANCE WITH THE ATTACHED SPECIFICATIONS.
3. SCOPE OF WORK: INSTALL NEW SOIL ABSORPTION SYSTEM.
4. GROUNDWATER WAS NOT OBSERVED AS EVIDENCED BY THE SOIL TEST HOLE. IF AN APPARENT WATER TABLE IS
OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 9 FEET BELOW EXISTING GRADE NOTIFY THE ENGINEER
IMMEDIATELY.
RIOID INSULATION
b--5.o ' I' ~o.o I ~.o~ ~-D,~. ROCK
-~7.5 -- SECTION
TANK (E) IRENCH SEE DESIGN
PROFILE
ABBREVIATIONS
DESIGN PARAMETERS LEGEND cu COPPER
REPLACEMENT SEPTIC SYSTEM --W--- WATER LINE/ DIP DUCTILE IRON PIPE
NO. BEDROOM: 3 (450 gpd) WELL RADIUS TH TEST HOLE
TANK SIZE: lODOg (E) FC FOUNDATION CLEAN OUT
PERC RATE = 6 MPI --' $$ NEW SEPTIC T# TANK CLEAN OUT NO.
SOIL RATING: 0.8 GPD/SF C# CLEAN OUT NO.
AREA RQD: 562.B SF
SYS. TYPE: WIDE TRENCH 2.0' E.D. MC/ MONITOR TUBE NO.
RF: 0.7 RJ. RIGID INSULATION
MIN LENGTH: 7B.8 LF DCO DOUBLE CLEAN OUT
DV DIVERTER VALVE
USE: FS FLOW SPLITTER
(2EA) 40LF X 5' WIDE, 2.0' E.D., 3.0' TD BFG BELOW FINISH GRADE
TOTAL AREA: 571 SF OG ORIGINAL GRACE
FG FINISH GRADE
NOTES:
FOR CONSTRUCTION P.O. BOX 100217 ANCHORAGE, AK 99510 ~'~- .~' ..... '~"~.~'~.~--~i 6/27/2o12
PHONE (907) 272-82J8 FAX (907) 272-8211,~.-.',-¢c°~''~'-_ '~;L~'!{ scale
Ct.' ~ ~___ ~.~ ".Ct NTS
.....~,..,2...,~1~,.~,,~:"~... .......... P.I,D. NO
T12N, RSW, Sec22, LOT 25, W2 ~. o15-141-24-
LAWRENCE & VICKI SCHNEIBEL, Steven R, Panno~e~.. CE 8149 ...~_~ PERMB'_ NO.
4811 E. 112th AVENUE fh~z~,~"~-~:~'~.~'~,~' 0SP121168
DESIGN DETAILS ANCHORAGE, AK 99516~f ~.~/42~,"~"*~¢=~ '~c~/~'./~*.*~c~*-¢~.~"~~ Sheet
20F2
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
TEST HOLE 1
SOILS LOG - PERCOLATION TEST
SLOPE
ORGANICS
J�
SILTY GRAVEL
AND SAND
X TH
SILT W/
LITTLE GRAVEL
DATE PERFORMED: 7/23/12
WAS GROUND WATER
ENCOUNTERED? N
IF YES, AT WHAT
DEPTH? -DRY-
DEPTH TO WATER AFTER
MONITORING? -DRY-
DATE: 7/30/12
PLAN
ii
TH-1 --�, SHED
I
1 3BR > HOUSE \
(E)�
SLOPE
TH
X
READING
DATE CLOCK
NETTIME
WATERTIME
LEVEL
READING
NET DROP
1
6/23/12 12:24
—
5.41
—
2
12:29
5 MIN
9.91 (DRY)
5.50
3
12:29
—
5.41
—
4
12:34:30
5.5 MIN
9.91 (DRY)
5.50
5
12:35
--
5.41
--
6
12:40:45
5.75 MIN
9.91 (DRY)
5.50
PEROLATION RATE 1_.0 (min/inch) PERC HOLE DIAMETER 6 inches
TEST RUN BETWEEN 3 FT AND 4 FT
COMMENTS: Test hole excavated by A+ HOME SERVICES. Prec hole was presoaked.
Test run for one hour. Last 3 readings reported
PERFORMED BY: Steven R. Pannone, P.E. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDLINES IN EFFECT ONTHEDATE OF THIS TEST.
NOTES: Date
P ONE L'1Vl.J �.7YC� LLL +��OF/�k���1� 8/7/2012
RECORD DRAWING P.O. BOX 102954 ANCHORAGE, AK 99510 ,W .:k 'qc4
PHONE (907) 272-8218 FAX (907) 272-8211 ®�ij�p ' -7 A Scale
T1 2N, R3W, Sec22, LOT 23, W2
LAWRENCE & VICKI SCHNEIBEL
4811 E. 112th AVENUE
SOILS LOG ANCHORAGE, AK 99516
:49TH NS
.. ,...
"® 015-141-24
Steven R. Pannone /PERMIT N0.
9F CE8149
cOSP121168
s
NF�Aw Sheet
4 OF 4
Municipality of Anchorage Page / of
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 Report
Permit Number: ..5'~V' ~0~o~ PID Number:
Name: Z~/ ~/ ~/~ ~A Wastewater System: ~New B Upgrade
Add,~,: / ~/ ~, ~or/ ABSORPTION FIELD
Phone: 3¢¢-- ¢77 ? IN°'°f"~r°°,s: Q Deep Trench ¢ShallowTrenoh BBed BMound ~Other
LEGAL DESCRIPTION so, Rating:¢. ~ GPD/Sq. Ft. Total Depth from3 original.¢ grade:
% Block: Subdiv~ion: Depth to pipe bosom from original grade: I Gr~vel depth beneath pipe
Township:,~ IRange:~ ¢~ I Section: ~ Fg, added above original grade:. / -- .~ / Ft. ! Gravel ,ength:.~o.: ~TOTd~ Ft.
Number of lines: IDistance be~eenlines:
WELL: ~ New ~ Upgrade Gravelwidth: ~ Ft. ¢I /~ Ft.
Classification (Private. A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Dri~r: % Date Drilled: StaticWater Level: Installer: Date installed:
-I Pump Set &t:~ Casing Height Above Ground:
TANK
/ 0 G PM Ft.
SEPARATION DISTANCES ~s.,t~c u Ho~di,, ~ S.T.S.~.
TO Septic Absorption Lift Holding ~ublic/Pr[wte Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~C~O ~5(~
WolF' /00 /¢ /O0~ ~ ~ Material: ~¢~ NumberofC°mpa"ment':
Sudace f
Water /0c'~ /~¢'+ ~-- LIFT STATION
Lot Size in gallons: ~r:
Line ¢ g t ~0 /
Cu~ainDrain ~ ~¢~¢ !~.1 ~ .~ P,mpMake&Model.[Electricall~specti°~sped°rmedb~
Remarks: BENCH MARK
Location and Description:
Inspections pedormed by: : &: :t,c:,,-=,,,,, Dates: 1st ,¢
17~4 Eagle Eiver L~p Read Ne. 2~nd
Department of Heahn aha Human Se~ices approval ,~,
Reviewed and approved by: 0¢//~/~. ~Date:
72-013 (Rev. 9191) MOA 25
PERMIT NO swgso05~. PAGE 2 oF 3
MuniEiP~U~ o~ Anchor~e
DEPARTMENT OF HEA~_THAND HUI~AN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. ]]ox 196650 eAnchorage, A{a~k(z 99519-6650mTelepho~e, 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEH AND/OR WELL INSPECTION REPORT
LEGAL W2, OF BLM LOT 25, SEC. 22, T12N, RSW P.I.D. NO. 015--141--24
WEST 1/2
LOT 23 ~' '~-
4LT.
~'~'"'~ '~' C03 DBLI
LOT 22C NEW TRENCHES~-Fo~COJ ~DBL~ EAST 1/2
~ ~C01 /~ST2
~NE~ 1000
'ANK
kOl
PERMIT NO SW980054 PAGE 5 OF ~
Municipo, Li-'c of' Anchor'o, oe
DEPARTMENT OF HEA~THAND HUIWAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,O. Box 196650 ~,~Ancho~'(lge, A~i(lskc~ 99519-665,0 · Te. tephone~. 343-4744
ON-SITE WASTEWATER UISPOSAL ~SYSTEM AND/OR WELL INSPECTION REPORT
LEGAL W2, OF BLM LOT 25, SEC. 22, T12N, RSW P.I.D. NO. 015--141--24
Si>gs.1, S~2
I I/FINAL GRADE
9 1250 GAL ,
A B
FCO 59.0' 2.5'
ST1 51.0' 17.0'
ST2 55.5' 24.0'
DBL1 57.5' 27.0'
DBL2 58.0' 27.5'
C01 56.0' 25.0'
MT1 55.5' 24.0'
C02 25.0' 57.0'
MT2 41.5' 64.0'
C05 49.5' 59.5'
C04 42.0' 65.0'
cot = 95.3'. c03 = 95'
C02 = 94.7 7 ~-C04 = 94.5
FINAL
GRADE-~
· \ CO1 / \ C03
~MT1 COg/ ~1¢1T2 C04
MTI = 89.3' ~ MT2 = 89.4' J
·
NO WATER FOUND
74,9' B.O,H,
NEWBY. CONSTRUCTION 907~458575 P. 02
~O~OU~H SL 'IDIVI610~§LOCK -
LOCATION/SK~TCIt;
· DEPlaNe MEASUREO FkOM;~'uaslng tO;, (~O~uund surf agO
Oepth
From TO
· BOREHOLE DATA;
Materiel Type end Cold
STA?~ OF ALASKA
· PEPARTMENT OF NATUI~AL R~$OURGiE~
DIVfSION OF MININg & WATER MGMT
WATfR W~L~
WELL OWNER:
D~P?H TO STATIC WATER
~.~ . ft below ~ top of ¢~sing
METHOD OF DRILLING; [~veir rotary L~. Gable too]
[~ other
USE OF WELL: ~ domestic ~ irrig~tlon ~ monitor
~ public Supp~.~, other_ - . ......
CASI~O STICK-UP; ~ fl, Oiam: ~ In.
WELL INTAKE OP~NINO ~YP~; ~ open eno
~ perfor3ted ~Ope~
D~pths of openings: - to ~ ft
SCREEN TYPE: . Diem: ..... In.
S/or/Mesh Si~e:
GRAVEL PACK TYPE:
Volume used: Depth 1o top:
GROUT TYPE[
Depth'. from It tO -- ft
PUMPIN( LEVEL AND YIELD;
hfs pumpln~
PUMP INTAKE DEPTH: ft Horsepower;
WELL DISINFECTED UPON COMPLETION? ~ YES
OONTRAOTOR INFORMATION: RE.ARKS:
. _ ~/~ p. /~ . ./ LEASE MAIL WHITE COPY OF LOG TO:
"ANCHORAGE AK 99~03.~B35
Phone 1907)259.8639, Fax (907)EB2-138A
PAGE
1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW980054
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:SCHNEIBEL LARRY W & VICKI D
OWNER ADDRESS:1341 WEST 70TH AVENUE
ANCHORAGE, ALASKA 99518
DATE ISSUED: 4/07/98
EXPIRATION DATE: 4/07/99
PARCEL ID:01514124
LEGAL DESCRIPTION:
T12N R3W SEC 22 LT 23 W2
LOT SIZE: 109725 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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:
RECEIVED BY: ~~
DATE:
DATE:
ROBERT C. COWAN, RE.
ROBERTA. SHAFER, RE.
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW~'EST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAl S
MECHANICAL
INSPECIIONS
ONSITE
WASTEWATER
DISPOSALSYSTEM
DESIGN
March 12, 1998
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
MUNICI]?ALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: West 1/2 of BLM Lot 23, Section 22, T12N, R3W, S.M., AK.
Request you issue a permit to drill a well and install a septic system to serve the
proposed three bedroom house on the referenced property.
A test hole was excavated and a percolation test was performed. The approximate
location of the test hole is located on the attached site plan.
At the time of excavation no groundwater was encountered and after seven day
groundwater monitoring, the test hole was found to be dry.
This property has enough area for a future septic upgrade which can be seen on the
attached site plan.
We do not anticipate any adverse effects on neighboring wells, septic systems or
drainage patterns by the installation of the proposed septic system.
There are no points of contamination within the proposed well radius which can be seen
on the attached site plan.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/jlm
Enclosure
17034 NORTH EAGLE RIVER LOOP SUITE 204 · EAGLE RIVER, ALASKA 99577
NOIS30 NV]d 3118 ,OOL = ,,L
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
,'~ "OBERT
DATE PERFORMED;.- .~
Township, Range, Section: t~ J~ ~ ~
4-
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
I
WAS GROUND WATER
ENCOUNTERED? ~ 0
IF YES, AT WHAT ~-
DEPTH? -- pO
E
Monitoring? Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
~j.,l~'~ ,~: ~z/.~:~.~. .- ~ ~,~ ~"/~ ~$' --/,/~"
~ ~/~,~ ~'~.'/~"A" V~"
~.~ - ~,~.,?. ~/s.,
' ~ ~ '- ~ ....
PERCOLATION RATE ~--- (minutes/inch)/PERC HOLE DIAMETER __
TEST RUN BETWEEN ~b~. FT AND ~.~ FT
s.,,..,....,..
PERFORMED BY: '~'~,.~-~ =.&~,= ~iver Lump Ruaa No. ~ / . CERTIFY THAT THI TEST WAS PERFORMED IN
ACCORDANCE WlT~e[~,~e~L GUIDELINES I, EFFECT ON THIS DATE. DATE: ~ ~/~/~ 7
72-oo8 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~ ¢/~ ~ ~ Township, Range, Section: ~la ~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Water After
Monitoring? /'g/'c ~' Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~' -~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ ET AND ~/ ET
S & $ ENGINEERING i ~ CERTIFY THATJTHIS TEST WAS PERFORMED IN
PERFORMED BY: 17034 Eagle River Loop Road No. 204 ~/1(~ /~/ 7
~'\.ACCORDANCE WITH A~h~r-e/~'~i~i~[~SUIDELINES IN EFFECT ON THIS DATE· DATE:
\, 72-008 (Rev. 4/85)
!,/.UN CIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O, Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
W2t of BLM Lot 23, Sec. 22, T12N, R3W
Location (site address or directions)
Property owner
Mailing address
Lending agenby
Mailing address
Agent
Address
Larry Schneibel
Day phone
1~41 W. 70th Ave., Anchorage, AK 99518
Day phone
349-4779
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well ×xx
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ~
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to. the legality and status of system.
72~)25 (Rev. 1/91) Front MOA#21
5. 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 of this Health Authority Approval application 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 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 in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
EngineeCs signature
17034 Eagle River Loop Road No. 204
/ U/-I ¢.-
Date_
DHHS SIGNATURE
Approved for -FH R£E
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS 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.
72-025 (Rev, 1/91) Back MOA #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIC~c~u-~
Environmental Se~ices Division .
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
/..0725., 5EC,22./ ' ParcelI.D.:
A. WELL DATA
Well type
Log present(~/N)
Total depth
If A, B, or C, attach ADEC letter. ADEC water system number
Sanitary seal
Date completed
Cased to /~.e ~
Casing height (above ground)
Wires properly protected (~N) ¥
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform O
Date of sample:
FROM WELL LOG
/~ g.p.m.
SEPTIC/HOLDING TANK DATA
Date installed
Foundation cleanout (Y/N)
Date of Pum, pi~ '~ fi/>
ABSORpTL.ON F ELD DATA
,
Date installed
AT INSPECTION
Nitrate ~' ! Other bacteria
$ & S ENGINEERING
Collected by: 1~0a4 ~.agle River Loop Aoad N~. 204
Eagle River, Alaska 99577
Tank size./~.~ ~'/~& Number of Compartments.
~--~' Depression(y/N) W High water alarm (Y/N)' ,/~,~
Pumper
Soil rating~orff~/bdrm)' ,~- S" System type
Length ¢ 4¢'
~ Width . Gravel thickness below pipe ~ / Total depth -.-¢ /
Effective absorption area ~.~ (; ~/~ Monitoring Tube present ~/N)_ ¢~ Depression overfield (Y/~ ,~
Date of adequacy tbSt /c///~ -~r~.~ Results(Pass/Fail) ~/"~ For -~ bedrooms
~'-R, ui~test (in.);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
Immediately after gal. water added (in.):
.g.p.d.
-T-S_TA_ T Lo-
Date installed ~~"~----~_
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
Size in gallons
~ "Pump off" level at*
*Datum ~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public Sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation
Property line -~/ Absorption field <~ /
Water main/service line. /~ (¢' Surface water/drainage ,,/00/d- Wells on adjacent lots ,/'~-2c5 /-P'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ¢ ~ / Building foundation // / Water main/service line //<¢~/-/-
Surface water /('~2/-/- Driveway, parking/vehicle storage area
Curtain drain /~/~/~" ,,¢"A/~/v/ Wells on adjacent lots ,/~.20 ~/-
F. ENGINEER'S CERTIFICATION .~;-.":~, ...... .,
I certify that l have determined thru field inspections and review of MuniciPal reo.~-tC, af~l~e~ystems are
HAA Fee $ ~(~(:~ ~¢-~O
Date of Payment ¢7~// /c¢'o
Rece ptNumber OqOZ7 .)
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*