HomeMy WebLinkAboutRAVEN WOODS BLK 1 LT 10Onsite File
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The crib is onl--,r sized for 3 bedrooms and may not be
Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION
Permit Number: OSP171069 PID Number: 015-232-06
Dwelling: 0 Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑■ Upgrade
Name:
Daniel & Betty Bergstrom
ABSORPTION FIELD
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
Address
6020 Trappers Trail Rd
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Raven Woods Sub 1 10
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Tk
Field
Lift Station
an
Tank
Line
Ft 2
Ft.
Well
>100'
N/A
N/A
N/A
N/A
TANK A Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
11250 Gal.
Surface Water
>100'
N/A
N/A
N/A
Material
Steel
Number of compartments
Two
Lot Line
>5'
N/A
N/A
N/A
NA
Foundation
>5'
N/A
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Gal.
Curtain Drain
None
Noted
Remarks Septic tank replacement only.
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Crib is only sized for 3 bedrooms and may not
be tested for a COSA.
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank D3034 Tank to
drainfield D3034
Installer
A+ Services
Drainfield CO/MT D3034
Inspector Benjamin Schiller
BENCH MARK (Assumed elevation) 100 ft
Inspection 15` 5/3/2017
Location and description
nd
dates:2
.
Garage slab
3`" 4th
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
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Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
- On -Site -Wastewater Disposal System or Well Inspection Report - - - - - -
Permit Number: OSP171069 PID No.: 015-232-06
RAVEN WOODS SUB, BLOCK 1 LOT 10
95.87
0 2C0
91.87
OG
Finished Grade
1,250 Gallon
Septic Tank 91.17
95.83 91.37
=� OF !4�gslljll
v
*�•A TM
PROFILE AS -BUILT
No Scale
lr+ �Fc • BenCE 12592i11er
May24,2D17 .. •
1 il`F� pROfESS1�Np�.��
tPP.1" MUNICIPALITY OF ANCHORAGE 0-tent
On-Site Water&Wastewater Program 1° Sr,
PO Box 196650 4700 Elmore Road c 4
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax: (907)343-7997 ._
http://www.muni.orglonsite
I)t l.,n i•nrr
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On-Site Wastewater Disposal System Permit
Permit Number: OSP171069 Effective Date: 5/4/2017
Work Type: SepticTank Upgrade Expiration Date: 5/4/2018
Tax Code Number: 01523206000
Site Legal Address: RAVEN WOODS BLK 1 LT 10 G:2738
Site Mailing Address: 6020 TRAPPERS TRAIL RD, Anchorage
Owner: BERGSTROM DANIEL J & BETTY A Lot Size in Sq Ft: 75359
Design Engineer: ANDERSON ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field El Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well LI 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
Special Provisions: The crib is only sized for 3 bedrooms and may not be tested for a COSA. Please state this
on your Inspection Report.
�.
Received By: �- Date: 5 ( I f f 7
Issued By: NCal O-r/ / - Date: _/y/4 7
EN `t G Y 69 8 9 70 �7>
MUNICIPALITY OF ANCHORAGE
. RUSH
MAY p 3 2017
6
Community Development Department Phone: 907-3 .sr--•04
Development Services Division Fax: 907-34 'r' -6 e i 9
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 015-232-06
Property owner(s) Daniel & Betty Bergstrom Day phone
Mailing address 6020 Trappers Trail Rd, Anchorage, AK 99516
Site address 6020 Trappers Trail Rd
Legal description (Sub'd., Block & Lot) Raven Woods Sub. Block 1 Lot 10
Legal description (Township, Range & Section)
Lot Size 75,359 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(LJ all that apply)
Absorption Field n Initial Single Family (SF) [5(1
(w/wo ADU)
Septic Tank X Upgrade I XI
Duplex (D)
Holding Tank ❑ Renewal n Multiple Dwellings
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage n
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Sig ure of ro rty owner or authorized agent)
Permit/Rush Fees: I� Waiver Fees:
Date of Payment: 57c03" Date of Payment:
Receipt Number: r T,3(03Receipt Number:
Permit No. QSP1gl6699 Waiver No.
Permit App__-. ....c
I i
S)
BLOCK 2 LOT 1
I
RAU N WOODS SUB LOT 9\ /
N �
N
N
_ _ EXISTING NOME (4 BEDROOM)
i
Q — — \N
` \ _ f.
�P � \ -- --- \ //
NEW FOUNDATION CLEANOUT 100' WELL RADIUS
NEW 1250—GAL SEPTIC TANK
100'
// BLOCK 1 LOT 10 \
/_,
EXISTING SEPTIC CRIB (GONG)
J /nx
�/ EXISTING TRENCHES
�v<v , 1LAYOUT UNKNOWN
f
Or- I FCO \ MT LVT 4
S • , CO N� I
►eco I— !- - -
1 EXISTING WELL DIVERTER V LVE \
\ 1\ EXISTING TANK / coMT I LOT 3
\ V / �i
/ 1
LOT 11 \ N i 100' WELL RADIUS
\ / i / 1
\ 1
rP 9t gSsh4 \\\ - - — ,// �/' LOT 2 1
*:49TM /\ •.* /� \\ /�� 11
W � \\ � i % 1
r."••r - i
. Benj•iv in Schiller : / - 1
r0/F<•• •• A 12592 •:`(:if/ \\ � 1
01‘<s
°:••���� \ ,�
NOTE: WELL DATA FOR ADJACENT LOTS IS
t RONN.. NP r V SHOWN. EXISTING RECORDS ARE VERY OLD AND
l\\������! \\ r DO NOT HAVE EXACT INFORMATION. SEPTIC
0 50 100 \ i TANK IS 100' FROM LOT LINES EXCEPT FOR
mi m m m FEET \ %'
'i LOT 9. THAT WELL IS ON THE FAR SIDE OF
"
1 =50' V THE HOUSE, ACCORDING TO RECORDS.
V ''
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
May 3, 2017
Municipality of Anchorage
Development Services Dept- On-Site Water& Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Raven Woods, Block 1 Lot 10
Septic tank replacement permit application
Dear On-Site Services Engineer:
The septic tank on the above lot has failed, requiring a replacement. The existing home is a 4-
bedroom. We are submitting this permit application for the placement of a new septic tank. The
attached site plan identifies the location of the existing home, well and septic system, as well as
the location of the new septic tank. The drainage pattern in general will not be changed by the
construction.
The existing tank was within the 100' well radius, and the original septic system was an
underground absorption crib- according to records, 17' x 17'. At some point, two absorption
trenches were built, although there is no inspection reportand very little information in the file.
The records indicate the trenches total 95', that they have an effective depth of 3', and that they
have sufficient cover over them (total depth 8' and 10'). This appears to match the measurements
we have made in the field. There is only one cleanout for each, on the far ends. There currently is
no foundation cleanout. bispEc-t o .Qx old taw cad% Arlo RI-F#444 C aticrc.Y
Initial excavation revealed that the crib is made of concrete. There is a wye directly after the tank
that diverts effluent between the crib and at least one of the absorption trenches. We suspect
there is another wye which splits the effluent between the two trenches. Until we excavate the
lines we will not know for sure what is happening.
We are placing the new 1250-gal tank outside the well radius, running pipe from a new
foundation cleanout to get enough slope. After the new tank, we will install a double-cleanout,
with a diverter valve. One side will run to the crib, and the other to the newer trenches.
If the system is constructed as designed, it will have no adverse impact:
• On the wells in the area or those to be constructed in the future.
• On existing septic systems in the area or those to be constructed in the future.
• On reserve space, either surface or subsurface, on any lots located in the area.
• On drainage patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Benjamin Schiller, PE (e); 4:
......
•
Neter: .
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~ MUNICIPALITY OF ANCHORAGE
DEI~RTMENT OF HEALTH AND HUMAN SER~S
;- *' Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264~4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
C~,.- ! -J~,,~-, s ~ ,~ - , DISTANCES
~ SEPTIC ABSORPTION
Address gO Zo 7~,-~ 7~./~ ~ TANK FIELD WELL
/
LEGAL DESCRIPTION LOT LINE ~
Lot
I le,o~k /I Isu~"i~'~'o"~'¢~ ~ FOUNDATION ~
Township, Range, Section
~C~ ~ ~ 7 IZ ~ ~ ~ AS-BUILT DIAGRAM IShow Dca on o we , septic system, prope~y lines, foundahon,
driveway, water bodies, etc.)
TANKS !c~ )
Mater~l ~ ~ ~Compa~ment~
TYPE OF SYSTEM
D TRENCH ~ BED ~ W. DRAIN ~ OTHER /
Grave' mengt"¢ ~ FT ~ + FT
/
TotaJabsorp~,on area~j~ SQ F1 Distance between,ines~ ~ ~o ~ FT /'L/
~ PRIVATE ~ OTHER {Identify) --
C,ass,ficat,on (A,B,C, Total Depth FT Casedto ~ ~'~ /
FT /
REMARKS: /
JOt
Scale: ~ ~ E~G~NEER'S SEAL
I ~~ cedify Ihal this inspe~ion was pedormed according Io all
Municipal and Slate guidelines in effect 0n this date: / ['-~ -~ ~
HealthDepa.mentApprova,: ~~~ ~ Date:/~-//
72-013 (3/85)
[ bF It.~_ NO:
DATEi ISSt.lED:
DL:.]::'ARI'HE},i'F'~?' HEAl_TH AND ,_h~ Ii: ...... ~,tl qL~l"'l,( ....... C ].ON
C~2_'L'~ l... S]REEF~
AF'PL I CAIq'T ~
ADDRE SS:
C. ARL :~ .~k~,oC N
.... I, .%1 r.=l* "iF:AIL.
IL.,, ~L,,.AE, E..~, Al'< -~ 9~.Lo
I_EGAL, DESCRIF:': SUBDIVISION: RAVENWOOD LOT: 10
SECT'ION: 24 ]'OWNSHIF;': 12N RANG[:_': 3W
L. LiT SIZE]: !.645A (SQ.FT,, OR ACRES)
MAX BEDF!OOMS r, 4
BLOCk.. 1
system. Choc)se the option that best fits ye, ur site,
DEPI'H TO PIF:'E BEHTEIM d=]''. )
[~iRAVIEL DEF'TH (F'f',
TO'TAi.. L)EPTH (Fl,)
GRAVEL WIB'r]-~ (F:'F.
GRAVE:L L!EI'~G]H (F:] . )
GRAVEL VOLUME (CU.YDS',,)
lANK SIZE (GALS)
SOIL RAI!NG (SQ.F'T'. /BR)
c:]ep'l:, i ~: v that:
J.~ I am ~amiliar wi'th t. he i'equiPement.!s for'
on-.site s:~ewers and wells as set.
,':or't.h by the MunicJ. pality o~' Anchorage (MOA) and the State of' Alasl.:;a.
2. I wilt install 'Lhe system J.n accordance w~'Lh all MOA curies and regu].at, ions,
and in comptiance with the design c~itepia of this pepmit..
3,, I will adhere to all M[)A arid State of Alaska neciuinement, s for the s~t.. back
distanc:es From any existing well, wastewa'Ler disposal system or pub].ic
sewer'age system on t. hi~s or any adjacent op nearby lot.
4,. I under, stand that this permit is valid For a maximum o¢ 4 bedrooms and
any enlargement wi. ll r'equire an add:i, tior~al permit.~
;:,~..,~.~ON IS .~No,ALLE*-, IN AN AREA COVERE:D BY I,.,A BUIL. DING ~"
. ~-,~ BL, IL_ I ~
FHIEN (1) AN ELE~-,R]CA,.. F'ERMI'T AND INSPECTION MUST BE OB]AINEDi (2) ~(::'-) ~ ....
F ....... ' ..... ~ ~'[ ...... ] '
WILL. NOT BE AF:'PROVED WI'THi]LJi AN _.~...E.uTI~IL, AL. [F.o,"c. UII[.N REP[)R-r'~. AND ~._,"~'¢ THE
.o .~..~,lc.i) DA 'FE:
.. ¢~(~ ....................................... ~ .
AF F-t. l~.,?.~bl I ,,
· _./
CLIENT
S~S ENGINEFRS ZNC
~ ANCHORAGE,
] ~REBY CER~ZFY T~T Z ~VE ~VEYED THE FOLLOWZNG DESCRIBED PROPERLY.
ANCH~AGE ~C~ING ~]STRIC3. AK.. A~ T~T THE ]~ROVEMENTS S]TUA3EC 1HEREON ARE
THE PREMISES IN OUESII~ AND T~T THERE ARE N0 RO~WAYS, TRANSMISSION LINES OR
OTHER V]SZBLE ~SENE~S ~ S~ZD ~0PERTY EXCEP~ AS INDICATED HEREON.
D~ED THZS ~ DAY ~ O~. , tg~ ANCHO~GE, &LASKA.
....... ,
PHgPOSED B~.w.NG GRADE RE,AlIVE TO FIN]SH GRADE AND UII~I~Y CONNECTIONS AN5 1O
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
(ENG~SEAL)
LEGAL DESCRIPTION: /~'4~,~c-~ct .~/u~A: /
1
2
3-
4'
5
6
7
8
9
10
11
~of tO
Township, Range, Section: ~ ~-~ T~z,~ ~,
13-
14-
15
16
17
18
19
20-
COMMENTS
SLOPE SITE PLAN
T~ 2-.
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water Alter,5'~d t
Mo~itori~§? ,~r~ Dele:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ,i,~. ~' (minutes/inch) PERC HOLE DIAMETER __
:',~ ~'
TEST RUN BETWEEN FT AND F~
ACCORDANCEWITHALLSTATEANDMUNICIPALOUIDELINESINEPFECT?N~TTH;SDATE. DATE: '~y ~/~- '~
72'008 {Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ~',/l~,~-/e~, ~-V~<,
DATE PERFORMED:
(EN GINE~E~AL)
LEGAL DESCRIPTION: /2,~,v'~,~oo~/ ,~/c~/< / Lcd' /d Township, Range, Section:
1
2
3
4
5
6
7
8'
9-
10-
11
13-
14-
15
16
17
18
19
20-
COMMENTS
SLOPE SiTE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT ~
DEPTH?
Depth Io Water AlterB~,,::~.
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~ ~" (minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~'-'~- FT AND ~ FT
l,~z ? ...... t~ ~ ~ ~' ~.,%/:~__ .
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFE~ON THIS DATE. DATE:
72-008 (Rev. 4/85)
OAAB-HD-I
G~ATER ANCHORAGE AREA BORO]iIi~H
HEALTH DEPARTMENT ~
327 EAGLE ST. ANCHORAGE, ALASKA 99501 239-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION ~/~1~ ~ ~'~/'/~p
SEPTIC TANK:
!
NUMBER
OF
DISTANCE FROM WELL c~ MATERIAL
COMPARTMENTS
LIQUID CAPACIIY ,/,*~ Z~D GALLONS. INSIDE LENGTH INSIDE WIDTH.
LIQUID
DEPTH __
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAl
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER
DISTANCE FROM WELL
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
LENGTH / 7 ~ DEPTH
BUILDING FOUNDATION
so. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
FOUNDATION ., NEAREST L E
DIST TH
~'-'-~ LENGTH OF EACH LINE
TOTAL LENGTH
OF LINES
IN. TOTAL EFFECTIVE
DEPTH: TOR OF TILE TO FINISH GRADE
.DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE
WELL: TYPE ~/~- ~' -~-~'~ DEPTH / ~(~ /
NEAREST / SEPTIC
_OT LINE /~ / SEWER LINE ~-~/~" , TANK
DISTANCE FROM
· BUILDING FOUNDATION. ~// / WATER
SAMPLE /J/~ NEAREST
~'/ ! SEEPAGE OTHER
· SYSTEM //~ /' CESSPOOl ~ SOURCES
DISTANCES:
-7(2 =/~'~ ~
DIAGRAM OF SYSTEM
DATE
APPROVED ,-
T
GffEATE ANCHORAGE AREA( OROUGH
HEALTH DEPARTMENT.
327 Eagle St. Anchorage, Alaska 99501 279-2511
Ne.
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
RESIDENCE ADDRESS ~ LOCATION OF INSTALLATION ~~.~
APPLICATION TO INSTALL: SE~IC TANK~,SEEPAGE PiT. ~ , DRAIN FIELD , OTHER
TO SERVE THE FOLLOWING FACILITY ~~~
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS ~,Jk, ~ ~Y ~), PERMIT TO INSTALL A %'J~-!~.~,.¥~ ~..~,
AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED ~ ~~
. SEPTIC TANK SIZE ~YPE~/~ SEEPAGE AREA ~--00 ~(TYPE C.~, ~
/~ ~ DIAGRA~ OF SYSTEM
DISTANCES:
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.
DATE ~/~/~ APPLICANTS SIG NATU R E'2~ ~,~ D-~-.~
~GREATER ANCHORAGE AREA BOROUGO
' HEALTH DEPARTMENT ~ CASE
~ 327 EAGLE STREET
, ! ANCHORAGE, ALASKA 99501
Performed For ,~/~ ,C~/~/~f ~f//~/n.~ Date Performed
Legal Desc~lpt~on. Lot..~Block...~_.Subd~v~s~on
Thxs Form Reports a. Sozls Log._..___~.--- -Percolatzon TesI
Depth
Feet Soil Characteristics
Was Ground ~ater Encountered?
If Yes, At %~bat Depth~ ~
Reading Gross Time
Proposed Instal~Seepage Pit
Depth Of Inlet
COMMENTS: f~ ~/~6 /~z~
Test Performed By :___/~t~, q ~ , ,
Location Sketch
I ! ! f. I-~ f I t
J l, t ~ t"ii,,I i I
Net Time
Depth To H20
Net Drop
Drain Field
Depth To Bottom Of Pit Or Trench'
Data Certified By: ~
Date:c/
~t~c ~ter le~l~fet ~abo~(~) M ~ce. ~sh of ~
(cheek ~ ~~~, ~ ( ); P~f~t~ ( ).
feet of ~O~ ~ s~tic leal
MUNICIPALITY (P~ ANCHOF. AGE
DEPT. OF HEALTH &
tO
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL-.----/~') (~'") - ~L ~ /
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or ~Jirections)
(b) App(icant Name
'~ Applicant Address
Tele P h o n e: H o me ~'z*~')?¢''-'¢,.¢~'' 3 Business
'Applicant is (check one):'Lending Institution []; Owner/builder,~; Buyer ~; Other r-] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address ~, ?0 / ~)~'~x/'~/
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~'.. Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Wel~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite,~,_ Public [] Community [] Holding Tank []
Note: If com munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status,
Page 1 of 2 72-025 (11184)
ENGINEERING FIRM PROVIDIt~NSPECTIONS, TESTS, FILE SEARCH, D~ AND INFORMATION
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 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 /~¢/4 Telephone "%~4¢/-
Address /?.g./.2:? ~J _~ /2//,¢~ _f~/7~-- z~ /2¢/~'~, /~
DHEP APPROVAL
Approved for
Approved ~( Disapproved
Terms of Conditional Approval
Conditional
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 ANC~GE
ENVIRONMENTAL SERVICES"J~'~;ISI~IJ~INIclPALITY OF ANCHORAGE (MO/g
MAR 1 1987
RECEIVED
WELL DATA
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~c~7-t0 ~ /
Well Classification
Well Log Present~(~N)~
Total Depth /~'
Static Water Level
'~'~/¢~' If A, B, C, D.E.C. Approved (Y/N) ?~,/~
Date Comp?eted /~/'- ¢'~ ¢ Yield
Cased to / ~&' Depth of Grouting ~:F~
Pump Set At
Sanitary Seal on Casing (~Y?N)
Depression Around Wellhead (Y~?
Casing Height Above Ground /' ~' ';
Electrical Wiring in Conduit~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot ~'~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by /4~:¢5
; On Adjoining Lots /~'~"
//¢~ ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Water Sample Test Results
Comments (~") .~Jj~7.,~
B. SEPTIC/HOLDING TANK DATA
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Date Installed
Standpipes~N)
Depression over Tank {Yc~..~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
Size /¢5'~ No. of Compartments /
Air-tight Caps~,~) Foundation Cleanout (Y~.?
Date Last Pumped //~?
X~ ;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field :5~ '~-
Square Feet of Absorption Area ~"/
Depression over Field (Y~
Results of Last Adequacy Test x~,,/,~
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field ~ /
Gravel Bed Thickness -~
Standpipes Presen~N)
Date of Last Adequacy Test ,,~,,/,4
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots /~'
To Cutbank (if present)
Comments
D, LIFT STATION
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
~ Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I h/c~r/ch/e~cked, ~/erified, or conformed to all MOA and
Signed g4/¢/'~ ~ ~ ¢/4.. ~-~ Date
Company ~c~ 5 MOA No. ~'~-
f
BeBeipt No.
Date of Payment ~/~ f~ ~
Amount: $ ~/~ ¢ ' ~
Page 2 of 2
72-026 (11/84)
HAA guidelines in effect on the date of this inspection,
d***.""' ~h~ ~eaT'~
7127 OLD SEWARD HIGHBS~¥'
ANCHORAGE, ALASKA 99518
(907)344-8551
LABORATORY I.D.
BACTERIOLOGICAL WATER ANALYSIS
TO BE COMPLETED BY WATER SUPPLIER
DATE COLLECTED TIME COLLECTED TYPE
MONTH~ .~ ?-(~-DAY YEAR~ ~? /~.</(~) (~P~ [] PUBLIC. INDIVIDUAL
I.D. NO. (PUBLIC SYSTEMS/ CIRCLE
I I I ~ I _ I I
NAME OF SYSTEM
SYSTEM ADDRESS
CITY
TELEPHONE NUI1BER -
SPATE ~P CODE
LOCATION WHERE SAMPLE WAS COLLECTED
COLLECTED BY: (SIGNATURE)
TYpE OF SAMPLE
(CHECK ONLY ONE THIS COLUMN)
~-~DRINKING WATEB
~/CHECK TREATMENT
[] RAW SOURCE WATER
[] blEW COHSTRUCTION OR REPAIRS
[] OTHER(Specify)
~CHLDRINATED
[]]FILTERED
~UNTRpaTEO OR OTHE2
IS TltIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAHPIE?
[]] YES ~NO
FOR LAB USE ONLY
RESUBMIT SAHPLE
Sample rejected because!
CHECK ONE OR MORE
Sample too long in transit.
Sample should not be over 30 hours.
Sample received too late in week
Not in proper container
Leaked out
Insufficient information provided,
Please read instructions on form.
Other (Specif~)
RECEIVED FROM /4F~ S~/,9~/
RECEIVED BY
DATE ~..~-c~-~'~/ TIME
ANALYTICAL METHOD:
~bqEblBRANE FILTER
~ FERHEtII'~TlflN TUBE
Date & Time Started
PREVIOUS COLLECTION DATE
Da~ & Time Completed~2-?~_~?
ANALYSIS REQUESTED (IF OTHER TliAN TOTAL COLIFURH)
SEND REPORT TO:(PRINT FUlL NPJ~E,ADDRESS AriD ZIP CODE
CITY /TLTUTC/ STATF //~ ZiP
LABORATORY R~SULTS
Analyst ~ _~;~}__~.L/L.~:i
~] Other Bacteria ~'
~ Test unsuitable becauso:
[] Confluent Growth
~ TNTC
SATISFACTORY L~NSATISFACTORY []
BACTERIOLOGICAL WATER ANALYSIS RECORD
FOR LAB USE ONlY
TOTAL COLIFORMS
FECAL COLIFORMS
OTHER
Memi, rame Filter: Direct Count
Verification: LTB
Final MemBrane Filter Result}
Reported By
Col i form/!QOml
BGB
Coliform/lOOml
Date
Time A.M.
P.M.
READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONP~NTAL PROTECTION
APPLICATION FOR ttEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date /~-~6~ ~ __
(a) Legal Description (include lot, block, subdivision, section, township, range)
/,'-.T IO ~ & ~>o,~ooe~
Location (address or directions)
(b) Applicants Name
~¥~'-27Mz-
Telephone - Home Busineso
Applicants Address ~0%0 T~PPE~i ~'~C /~c~o~,~.~ ~ ~F~J--
(c) Applicant is (check one) Lending Institution ~__~ ; Owner/~mri-l-dlSr ~ ;
Buyer ~--~ ; Other ~--U (explain);
Address
(e) Real Estate Co. & Agent
Address
(f>
Telephone
Mail the HAA to the following address:
2. ~ype of Residence
Single-Family,,~--~
Number o.f Bedrooms
3. Water Supply
Individual Well ~
Multi-Famity~--~
Other (describe)
Community ~[j i Public ~--~
Note: If community well system, must have written confirmation from the State
Department of Envirormental Conservation attesting to the legality and status.
S__~e D~z~al
Onsite~.~ Public~ Community ! ! Holding
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
En__~jgineerin$ Firm Providing Inspecti~o.~s~ Tests~ Pile Search~ Data and Information
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 shows that the on-site
water supply and/or ~astewater 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 w~stewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Telephone
Name of Firm
Address ~CYD
Date ! 5-
~,,proval
Approved for ~)~/~!~ bedrooms
Approved ~ _ Disapproved
(ENGINEER SEAL)
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPAR~fENT OF t~ALTH AND ENVIRONMENTAL PROTECTIOi
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES ~ASED SOIZLY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY ,~N INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. TH]3 DHEP DOES ~{IS AS A COURTESY TO YURCKASERS OF HOMES
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERA~ J~D S%%TE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ~{ALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF AYCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAl, ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/Di8
[Page 2 of 2]
7-19-84
A. WELL DATA
MUNICIPALITY OF kNCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
MUNICIPALI?Y OF ;,NCHORAG]
S£R 2 0
RECEIVED
Well Classification '& ~D
Well Log P~esent ~N)
Total Depth ~ 'gQ ' Cased to
Static Water Level ~14,11
Casing Height Above Ground
Electrical Wiring in Conduit ~N)
Sepacation Distances f~c~n Well:
To Septic/Holding TarJ< on Lot ¥ ~O,f' ~
To Nearest Edge of Absorption Field on Lot{-
To Nearest Public Sewer Line A)
C leanout/Manhole
Water Sample Collected By ~
Wate~ Sample Test Results
Date Completed 4~ ~//~/~g Yield
il /..-'
I ~/' Depth of ~rouczng
~ ~t At
Sanit~y ~al on Casing ~)
~p~ession ~nd ~l~ead (Y~
; On Adjoining Lots ~/~o'
; On Adjoining Lots ~r/~o'
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~-&'
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~0-~-~ Size I%~O No. of Compartments
Standpipes ~>N) ~.~$ Air-tight Caps ~) ~ Fcundation Cleanout (Y~
~p~essi~ o~ Ta~ (~ ~ ~te ~st P~d
P~ing~intenan~ Con~act ~ File (Y~)~ ; for
Holding Ta~ High-Wate~ Ala~ (Y~) ~ ~ra~y Holdi~ Tank Pe~it (Y~)
Sep~ation Distan~s ~ ~ptic~olding Tank:
To Wate~Supply ~11 ~ ~,~ ~ To ~ilding Foun~tion
To ~o~rty Li~w~ /DQ To Dis~sal Field
To ~ter Mai~Se~vi~ Line ~e To S~e~, Pond, ~e, ~ Major ~aina~
Co~ ~ I~
[Page 1 o~ 2]
Receipt ~
Date Paid:
Amount: ~[.~
2-15-84
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata~-; Z S-- B~/~fg_-
Date Installed 4~ /g~- ~ -(~
Width of Field ~z IQ;
Square Feet of Absorption A~ea ~Y
Depression OVer Field (Y~)'J /oo
Type of System Design
Length of Field Y-/7 '
Depth of Field ~/
Gravel Bed Thickr~ss
~1~ Standpipes Present ~/N)
Date of Last Adequacy Test
Results of Last Adequacy Test ~/
Separation Distance frown Absorption Field:
To ~Water-Supply Well ~-~ /~0.~' To Property Line~..~'
To Building Foundation ~ ~Z.
Lot ~ ; ~ ~joining ~ts~
To Water Main/~rvi~ Line ~ To ~t~(if pre~nt)
To Stre~ond~ke/~ Major ~aina~ C~se
To ~iveway, Parking ~ea, ~ Vehicle Storage ~ea ~5-
D. LIFT STATION
Date Inst~]~l~d ~ ~/~'
Size in Gallcns~'~
"Pump On." Level at~
High Water Alarm Level at~-~
Tested for
Electrical Codes(Y/N)
Cor~r~nts
Di.n~nsions
Manhole/Access (Y/N)
"Pump Off" Leve~ at
Vent (Y/N)
~p~cles duuzing Adequacy Test.
** Check Permitted Bedroc~a Rating Agair~t HAA Request'~*~ ·
Yeets ~DA
I certify that I have checked, verified, o~' confor-~ed to all MOA ~i~A Guidelines in effect
on the date of this inspection.
Company ~ ~
KB1/d5/s
[Page 2 of 2]
--lo-84