HomeMy WebLinkAboutTIMBERLUX #1 BLK B LT 9ATimberkgx #1
Block B
Lot 9A
#018-271-05
~ 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
PHONE [] NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
~' DISTANCE TO: IWell /aa ' IAbs°rpti°n'""/4' .Dwelling 2 g ' PERMIT NO.~2
~, ~ Manufacturer~. No. of compartments2
~ ~ ~ DISTANCE TO: Well/aa ~ Foundation ~O' Nearest lot line/O' PERMIT NO.~ 2
,o. o, ,i.~,2 L~.~t, o, each line Total length of lines.~,___ Trench width~i.ches, v Dis=nce between lines~
~i~Q Top of ,ile,o finish grad~a}~r' ~r~ ~0' Material beneath tile q6 inches Total effective abs
m Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m . Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to lot llne PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
'OTHER
Eo./roctvr fo cover ¢e er
72-013 (Rev. 3/78)
DEPBRTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 "L" STREET, ANCHORAGE., BK. 99501
· 264-4?20
C)~--S [ 'FEZ SEZ[,~EF: F'EF:~-1 I T
PERMIT NO. < 82E~t~8 )
LGT SIZE
1' BEN -.H
~:0~0 SQUARE FEET
MAXIMUM NUMBER OF BE[,Rn]MS = 4
.... IL RBT'ING (SD FT.,."EF.",=
THE REQUIRED =,I~.E OF THE SOIL Hc,_ORF.I_N _,~_,TEH I=,.
[:"EF'T H== 10 L E ~-,~J] T' H ="1....::-~ ._ --=" -'~'-,
[-~ EF'TH=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF B TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GRCIUND AND THE BOTTOM OF THE EXCBYRTION ,::IN FEET::,.
THERE IS NO SET HIDTH FOR TRENCHES.
THE GRAYEL DEPTH IS THE MINIMUM DEPTH OF GRRYEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE E}::CRVRTION ,.'.'IN FEET:.',.
F:E,~-,.L! I F.: E [:, SEF"T I C: TFtf-~--:: :']. I ZE= 12~30
PERMIT RPFLI_.HNT HR--, THE RESPONqIBILfTY TO INFORM THIS DEF'BRTMENT [:,URING
INSTRLLRTION IN_,FEL. TIuN-~ OF RNY HELLS ADJACENT TO THI.S PROF'ERTY ~N[:, THE
.rgJME'ER OF RESIDENCES THAT THE WELL 14ILL SERYE
THE
qF ~,~ ,.%~
E:BCKF ILL I NG OF
DEPRRTMENT WILL
· :-_ ~.-'-:' .-', ][ ~-~ S F" Et2,. T ! ~3 ~-~ S; FIF:E
RNY _,'~=,TEM WITHCLT FZNRL ZN--FEE. TI_N RND
BE _-LIE.3E,..] TO F,..O:,EL, UT_ON.
F-;E ~_;! L~ I RE[:,
APPR ]',.,'R L BY
MINIMUM DISTANCE BETWEEN R HELL AND ANY ON-SITE SEWAGE DISF'OSRL SYSTEM IB
100 FEET FOR R PRIVATE L4ELL OR 150 TO 200 FEET FROM B PUBLIC: HELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FRO.rd B PRIYBTE HELL TO A F'RI',/8TE SEWER LINE IS 2'5 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY RF'PLY SF'ECIFICRTIONS AND CONSTRUCTION DIAGRAMS ARE
R',/AILRBLE TO INSURE PROPER INSTB, LLAT!ON
F'EF:f--1 ][ ]-- E::-::F' ][ ~:~:E"_--] [- E--:L..EI'IE. EF~. S::- t.. :I_L::~- 82:
I BERTIFY THAT
f: I BM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS
FORTH E:Y THE MUNICIPALITY OF ANCHORAGE
2: I HILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES
Z::: I UNDERSTAND TH8T THE ON-SITE SEWER SYSTEM MAY REQUIRE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4. BEDROOMS.
RND WELLS BS SE]'
ENLARGEMENT IF THE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~SOI LS LOG
TEST
PERFORMED FOR: ~ ~P? , / ,_ ?i ) (-' DATE PERFORMED:
LEGAL DESCRIPTION: -'~'r4 / / O /, /
1
2
~-, 3
4
5
6
I, 7
17-
20-
SLOPE SiTE PLAN
ENCOUNTERED? ~ L
O
P
E
IF YES, AT WHAT
DEPTH?
COMMENTS
Gross Net Depth to Net
Reading Date Time Time Water Drop
r
{minut.s/inch)
PERCOLATION RATE
// TEST RUN BETWEEN
;'2-008 (6/79)
P~'RMIT N~I SW
/'"/- AS-BUILT
/~ WASTEWATER ABSORPTION SYSTEM
,/" LOTS gA BLOCK B TIMBERLUX. S/D
/
A It
WELL 10,,~ 14.8
WELL
fsXIST'G ]]RAIN FIELD ~ A
~0 SF ~._._._~,
61,6 39,~
~ T1 SEPTIC TANK
5
P,~,'~.. NI} 018-271-05
C~\WorR\gA-]]TLX,BWG
PREPARED FDR:
Bev H~jeng~
4660 Rabbit Creek Road
AnchoPage, AK 99516
(907) 860-3744
PANNONE ENG, SVC
P, 0, BDX 142085
ANCHDRAGE, ALASKA 99514
874-0308, 878-8818 Fa×
DATEm 11-I4-98 ~ AS-BUILT
gCALEi 1'=30'
/
IN SYSTEM
ERLUX S/I)
P,I,B, ND, 018-271-05
PREPARED FDR~
Bev H:jeng:
4660 Rabbi~ Creek Road
Anchorage, AK 99516
(907) 260-3744
PANNDNE ENG, SVC
P, D, BOX 142025
ANCHORAGE, ALASKA 99514
274-0308, 272-8218 F~x
DATE, 11-14-98 I AS-BUILT
SCALE, 1'--30'
I
'Steven R. Pannone, P.E.
Consulting Engineer
P.O. Box 142025
Anchorage, Alaska 99514
(907) 272-8218
SEPTIC SYSTEM ADEOUACY TEST
Legal:
Owner:
Residence:
Lot 9A, Block B Timberlux S/D
Ms. Bev Hejenga
4660 Rabbit Creek Road, Anchorage, AK 99516
Septic System:
(from Municipal records)
Tank Size: 1500 gallons.
Absorption System Size: 95'x8'x3'
Installation Date: 10/82
Absorption System Type: Deep Trench
Absorption Area: 1520 s.f.
Soil Rating: 280 sf/br
Date of Pumping: 11/13/98
Date of Test: li1/14/98
By: Issaac's Pumping Service
Test Procedure: The System was inspected and measured. Tank was found with 4 feet of cover. The
liquid depth was measured to be 12 inches. The drain field was found to have 3 feet of cover and a total
depth of 7.4 feet. The liqu/d in the monitor tube was measured to be 24 inches deep. Water was added from
A+ Home Services Pump Truck. The water levels in the tank and drain-field monitor tube were monitored.
A total of 800 gallons of water was added. During the test the level rose 36 inches in the drain field. No
rise was noted in the tank. The infiltration rate was monitored for 1440 minutes. At the end of this period
the water level in the field returned to the original level. During this period, a total of 800 gallons were
absorbed. By extending the observed infiltration rate, a total absorption rate 800 gallons per day was
derived.
An adequacy test to determine the well's production rate was conducted at the same time the septic system
was tested. The initial static level of the water was found to be 91 feet below the top of the casing, with a
total depth reported to be 176 feet from the owners records. MOA DHHS does not have a well log for this
property. Water was pumped from the well at a rate of 2.5 to 1.8 gallons per minute (GPM) for 1.15 hours.
A total of 150 gallons were pumped from the well with the static water level drawing down to 101 feet
below the top of the well casing. The water quality was also tested for bacteria (Coliform & Other), and
nitrates. Bacteria and Nitrate samples were delivered to CTE Environmental Service test lab for analysis.
The test results indicated that the water samples contained no bacteria. Nitrate levels results were 0.523
mg/1, well below the I0 mg/l limit allowed by DEC and MOA Regulations. See the attached water analysis
reports. ~*~liim~im/~_~vmi~atq~~,~~.~ 7q
fete. bl~~ ~egl~ff~tffons require a separation distance of 100 feet. A waiver mum b~ ~lm~ined tim,the
~:to aev, ept ff~ redimti0n in distance:
Ms. Bev Hajenga
November 16, 1998
Page 2
TESTS RESULTS: This system meets the code and operational requirements of the Municipality of
Anchorage.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system. The
reported results describe the performance of the system under the conditions encountered at the time of the test, and
separation distances measured to readily identifiable features. The operational life of all wells and septic systems
depend on the local soft condition, ground water levels that may fluctuate during the year, and the water usage of the
family being served bythe system. These conditions are outside the control of the evaluator of this system. All
systems eventually fail and satisfactory test results do not guarantee future performance of the system, nor do they
guarantee that there are no hidden defects or encroaclunents. We can therefore not give any estimate of how long the
system will continue to meet the operational requirements of the State and Municipality of Anchorage.
SRP/C :\WORK\43 - 9 Shorewood.HAA.wpfl
Rick Mystrom,
Mayor
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
P,O, Box 196650 Anchorage, Alaska 99519-6650
http://www.ci.anchorage.ak.us
December 2, 1998
Steven R. Pannone, P.E.
PO Box 142025
Anchorage, Alaska 99514
Subject:
Waiver Request for Lot 9!.Block B Timberlux Subdivision
Waiver Request #WR980096
Parcel ID # 018 271 05
HA980441
Dear Mr. Pannone:
Your request for a waiver of the required 100 feet horizontal separation of a
private well to septic system has been approved. The approved separations are
private well to septic tank and absorption field of 70 and 91 feet respectively.
This waiver approval applies to the existing on-site wastewater disposal system
to private well separation only. Any future upgrade to the on-site wastewater
disposal system will required all separation distances be met or another
approval from this department.
If there are any further concerns or questions regarding this waiver )lease call
our office at 343-4744.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Water Quality Program
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# WR98~096 · PID% 018-271-05
HA% HA980441 Permit
Date Received: November 19, 1998
Legal Description: Lot 9A Block B Timberlux
Engineer: Steven R. Pannong, P.E.
PO BOx 14~025, Anchorage, AlaSka
Applicant: Ben Ha~ enKa'
99514
~aiVer Requested: Private well to Septic tank of 71 feet; ,private well't~ the
absorption field~:91~-feet ~4~A~ t~_u~ ~ ~-~ C.C} ~
1. Geology: Points:
A. Water Table
B, Soil Sorption - ·
C. Permeability
D, Wate~ Table Gradient
E. Horizontal Separation
TOTAL:
Special Conditions:
3. ~Other:
~Waz~er is~ Gmanted. ~ ,~ waive~ is NOT G~an'ted: "
L~st Cond~.%~Ons or Reasons for above. ~..~-. /~D~A/~'~ .. . :.~ ~
By:
Rec ~: 04354'~ 7218
Amount: $ 9..2.0.00
Date Paid: Nov 1'9,~ 1998
I
70' ~ ~ ~
u..~- I
/.8
IZI
Steven R. Pannone, P.E.
Consulting Engineer
P. O. Box 142025
Anchorage, Alaska, 99514
(907) 272-S218
November 18, 1998
Municipality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519
RECEIVED
tgOV '/9 ]998
Municipality ot Anchora9°
DepL Health & Hurn'~n Services
Attn.:
Mr. Jim Cross, P.E.
Subject:
Lot 9A, Block B, Ti~nbertux Subdivision
Septic tank tO well w~tiver
Dear Mr. Cross;
I am writing to request a separation distance waiver between the well and the existing septic tank and drain
field on the above referenced lot. I conducted a Health Authority Investigation on this lot on November 14,
1998. The adequacy investigation report has been submitted to your office for review. During this HAA
investigation, I discovered the well and septic tank are closer than the required 100 feet. The d~tance
calculates out to 71 feet to the 1,500 gallon septic tank and 91 feet to the drain field. Attached is a site plan
showing the adjacent properties, general site topography and approximate location of wells on each lot.
Lot 92 is approximately 1 acre in size. The lot slopes from the southwest, with the southern end dropping
off steeply to an undeveloped forest. The well is situated approximately 12 feet north of the five bedroom
home. The tank and drain field are located south of the house along the top of the steep hill and
approximately 140 feet from the neighboring well to the west. The soil absorption system was installed in
October of 1982.
The well on lot 9A was drilled sometime in the 1960's, Them is no well log available for the well on this
lot. I found that it is cased to over 40 feet, the static water level was 91feet below ground level, and the
total depth is approximately 176 feet deep (a new well pump was installed in 1984, which was set at 176
feet below the top of the casing.). Well logs for the surrounding lots are also attached. The ground water in
this area typically flows from the north to the south. A well flow test showed the static water lowered
eleven feet while flowing at approximately 1.8 to 2.0 G.P.M Water samples were taken during the HAA
investigation. I am awaiting results of the analysis of the water, and will pass them on to you as soon as I
receive them
Mr. Jim Cross, P.E.
November 18, 1998
Page 2
The soils on Lot 9A were logged to be silty sands and gravels to sandy gravel to a depth of 22 feet. A clay
layer was encountered between 22 and 27 feet below ground. No water was encountered above the clay
layer.
As outlined under 18 AAC 80.020 and 18 AAC 72.021(a), I have calculated the following points:
Distance from sewer system bottom to groundwater 6.0
Soil absorption below sewage system 3.5
Soil permeability below the system 2.0
Water table gradient 6.0
Horizontal separation 2.__0_0
Total Points 19.5
16-25 Almost sure to be free from any form of contamination from household sewage.
In my opinion, this waiver request meets the above criteria for approval and does not constitute risk to
health. I hope the above information will assist you in determining that the waiver should be granted. If
you have any questions or concerns, please contact me at 227-3522 or 272-8218.
Sincerely,
~, P.~.
Civil Engineer
Attachments
C :\WORK\9A-BThnberlux. WVR.wlxl
'~ ~ERMIT Nil,
/
/
?
?
AS-3UILT
//~ASTE~ATER ABSI]RPTIBN SYSTEM
LnTS 9A BLDCK B TIMBERLUX
/
/
~/ELL 10,6 14,8
EXIST°G WELL
(~)
EXIST'G I]R~IN FIELD ~
Citgo
! ~~ / ~ ~,~ EXIST G 1500g
L~ ,~ T1 SEPTIC T~NK
5
Ci\Work\gA-BTLX,~WG
PANNONE ENG. SVC
P. O. BOX 142025
ANCHORAGE, ALASKA 99514
274-0308, 272-8218 F~x
]ATE, 11-14-98 I AS-BUILT
~C~,L,D ;l'=~O'
I
Municipality of Anchorage
On-Site Water and Wastewater Program
(907) 343-7904
Certificate of ,On-Site Systems Approval
/7,'
Parcel i.D. 018-271-05 ... ~ ~: ~ration Date:
1, GENERAL INFORMATION
Complete legal description Timberlux #1, Block B, Lot 9A
Location (site address) 4660 Rabbit Creek Rd.
Current Property owner(s) RMS Residential Properties Day phone
Mailing address
8742 Lucent Blvd. Suite 300 Highlands Ranch, CO 80129 ·
Real Estate Agent
Day phone
2. TYPE OF DWELLING: [] Single Family (w/wo ADU)
[] Duplex
[] Multiple Dwellings (Single Family and/or Duplex)
3, NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class __ Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual []
Holding Tank []
Community []
Public Sewer Ljr~
-..
COSA to be released to the e~
.~r, unless otherwise requested by the engineer,
Date:
Distance:
COSA Fee $
Date of Payment
Receipt Number
COSA #
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
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,
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 vedfy 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 Pannone Engineering Services LLC
Address P.Q. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone
bedrooms
bedrooms
6. DSD SIGNATURE
)--/System #1 Approved for __
System #2 Approved for
Disapproved
Conditional approval for
Phone (907)272-8218
Date 5/31/13
,,.,-. ~ .....
'..,
~a ~..Stev~en R, Ponnone.
bedrooms, with the following stipulations:
By; O~~'/f// ?L~'?~-'-OriginalCertificateDate: f~-'//~ /-~
The M elopment Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon [he representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
ATTACHMENTS:
COSA Checklist
Septic System Advisory
Well Flew Advisory
X
Nitrate Advisory
Arsenic Advisory
Other
COSAbluesheeL[ '- '.., c
If more than 1 septic system is on the lot:
COSA Checklist # ~ of ~
Structure served by this system ~
Certificate of On-Site Systems Approval Checklist
Legal Description: Timberlux #1, Block B, Lot 9A
A. WELL DATA
Well type Private IfA, B, or C provide PWSID #
Date completed Sanitary seal (Y/N) Y
Parcel ID: 018-271-05
Well Log (Y/N) NO
Wires properly protected (Y/N) Y
Total depth ft. Cased to ft.
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform Absent colonies/lO0 mL
Arsenic 5.59 ug/L
g.p.m.
Nitrate <MRL mg/L
Date of sample: 4/19/13 & 5/2o/13
Casing height (above ground) 18 in.
AT INSPECTION
5/20/13
63 ft.
5.0+
g.p.m.
Collected by: PES
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Steel/Septic
Tanksize 1500 gal. NumberofCompartments 2
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Date of pumping
Date installed 10/9/82
Cleanouts (Y/N) Y
High water alarm (Y/N) N
5/22/13 Pumper A+ Home Services
C. ABSORPTION FIELD DATA
Date installed 10/9/82 Soil rating (g.p.d./ft2 or ~/bdrm) 280 SF/BR
Length 65 I 30 ft. Width 3 I 3 ft.
Total depth 137 ft. Eft. absorption area 1520 ft2 Monitoring tube Y
Date of adequacy test 5/20/13 Results (Pass/Fail) Pass
Fluid depth in absorption field before test 0 in. Water added 755
Elapsed Time: 190 min. Final fluid depth 0 in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NO
System type Deep Trench
Gravel below pipe 96 ff.
__ Depression over field N
For 5 bedrooms
gal. New depth 6 in.
Absorption rate >= 750+ g.p.d.
If yes, give date
D. LIFT STATION
Date installed
"Pump on' level at __
Datum
in.
Size in gallons
"Pump off' level at in.
Cycles tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
WELL ON LOT TO: ,,~
Septic tank/lift station on lot ~ ~ /
Absorption field on lot ~ q / ~
Public sewer main 75+
Sewer/septic service line 25+
Animal containment areas 100+
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line S-t-
Water main 10+ Water service line 1 O+
Wells on adjacent lots 100+
On adjacent lots 100'~'
On adjacent lots 100+
Public sewer manhole/cleanout 100+
Holding tank 100+
Manure/animal excrete storage areas 100+
Absorption field 5+
Surface water 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+
Water Service line 10+ Surface water 100+
Curtain drain 50+ Wells on adjacent lots 100+
Water main 10+
Driveway, parking/vehicle storage 10't'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I cerfify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Steven R. Pannone
Date 5/'31/13
COSA brown sheet_10-10-12.doc
~ ~ ' I
;
I
ore will, ~e p~pe~ Ilnei and :~
· ere~, ~ot no Impr~emen~ on ~o~
~ *x~ a, ~dl~ ker~,.~ ~-:, ~'~
MUNICIPALITY 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
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) ¢/~(¢(~ ~/~'~%t-c- C_~..e~'C ~p
Property owner
Mailing address
Lending agency
Mailing address
Agent r~, ~(clc
Address
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Fndividual well
NOTE:
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
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.
NameofFirm ~,~¢~ ¢-~Jq. ~'4( Phone
Address '~-m ,~¢ ~c
Engineer's signature~
Date
DHHS SIGNATURE
./~ Approved for
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 DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order tosatisfy 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.
Municipality of Anchorage J~,,~,, ~E C ~ I V E J~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
1998
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 34~-~/4z~;
Municipality of Anchorage
Health Authority Approval Checklist ~)ept. Health & t~ uman Services
Legal Description: [..-~-C~',~b~cb~ -r~,-zL¢~ '~[ Parcel I.D.:
A. WELL DATA
Well type'-'~C~ uJ A-~-L~ IfA, B, orC, attach ADEC letter. ADEC water system number
Log present (Y/N) ~J C~
Total depth U r~c.~o~j ~
Date completed ,.~,'o [~o~.~ L.~
Cased to ~ ¢ ~;~-~ ~--r Casing height (above ground)
Sanitary seal (Y/N)
Wires properly protected (Y/N) "~
((
FROM WELL LOG
AT INSPECTION
Date of test "'"h ~//~'/9 ~
Static water level ~' c( l t
Well production . g.p.m. ~ c~
g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample:
Collected by: ~ - ~- ,'~A-,u,do ~ ~-~
B. SEPTIC/HOLDING TANK DATA
Date installed /c~,/~'7__ Tank size
Foundation cleanout (Y/N) ~
Date of Pumping ///I-~/? ¢
C. ABSORPTION FIELD DATA
Date installed /o./~ ~__
Length ~'~-~ {P-} Width
/.~"c,o Number of Compartments '~ Cleanouts (Y/N). t
Depression (Y/N) /t~
High water alarm (Y/N) /t/(' ,A
Pumper 'z~ AA cc`.
(g.p.d./ft~o~ ~_~O Systemtype "[~-['-
Soil rating
~---~ C~) Gravel thickness below pip~e~ ~'&," L'~,~ Total depth
Effective absorption area /~ ~ L~ Monitoring Tube present (Y/N) ~ Depression over field ~)
Date of adequacy test /I/m/~ ~ Results (Pass/Fail)~ For ~ bedrooms
Fluid depth in absorption field before test (in.); ~q Immediately after ~ gal. water added (in.):
Fluid depth [~qD (ins) Minutes later: ~ ~' Absorption rate = ~ g.p.d.
Peroxide treatment (past 12 months) (Y/N)
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pum_~at~
High water alarm level ~ *Datum
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELLON LOT TO:
Septic/holding tank on lot '~* I ~r~,~)~. ~o~r'On adjacent lots
Absorption field on lot ~ I~ ~A~ue,t ~,.~(,.~¢,¢r- On adjacent lots
Public sewer main
Public sewer manhole/cleanout ,~L ~
Sewer/septic service line ~:~
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ ~ ~ Property line <~ ~ Absorption field /
Water main/service line ~-c~ ~ Surface water/drainage ~'//~' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~
Surface water
Curtain drain
F. ENGINEER'S CERTIFICATION
I certify that I have determined t
in conformance;~ ~A~,~ guidelines in effect on this date.
Signatur~~.
Engineer's Name ~'--~J~--~
Date ////~ / ~:~
Building foundation ~ ~ ~ Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots / c,o -r
HAA Fee $ .,~Y-/~- ~
Dateof Payment ~-~ ////7'~ (~
Re ce, p t N u m be r .'/-/f~' ~/(~¢3 ('~7//'ZT//~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
t~~l~'}' DEPARTME~
#1: Time 9:30 a.m.
Date 4-25-77 Monday
Insp Kennedy
MUNICIPALITY OF ANCHORAGF_.~,~
~OF HEALTH AND ENVIRONMEN-~ PROTECTION/v
L Street, Anchorage, Alaska -99501
279-2511, ext. 224 or 225
Date Received: April 22, 1977
#2:
Time #3: Time
Date Date
Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: National Bank of Alaska
Mailing Address: Post Office Box 3-3859 99509 Phone:
Property Owner: John J./Margaret Capossela Phone:
Mailing Address: % Jean Smith, Realtor 277-6013
Legal Description: Lot 9A Block B Timberlux ~1 Subdivision
Single Family Residence: (xk Number of Bedrooms:
Multiple Family Residence: ) Number of Bedrooms:
3
Well System:
Permit #
Construction
Public/Community System: ( ) Individual Well:
Depth of Well 230' Well Log on File
Bacterial Analysis
( )
Sewage Disposal
Permit #
Septic Tank Size
Absorption Area
System: On-site System ~x) Public Utility
Installed 1964 Installer
Manufacturer
Soils Rate Material
( )
Distances: Well to Septic Tank to Absorption Area
to Sewer Line Nearest Lot line Absorption Area
to Nearest Lot Line
Page'T%~o
Department of Health and Environmental Protection
Request for Approval of Individual Sewer and Water Facilities
Legal Description: Lot 9A Block B Timberlux ~1 Subdivision
Affadavit Attached: (i) Letter Attached: ( )
Approved: 7~ Date:
Disapproved i~ .~~ ~ Date:
~epartment Worksheet:
OMUNICIPALIT¥ OF ANCHORAGE
Department of Health and Environmental Protectioh
825 L Street, Anchorage, Alaska 99501
279-2511, ext. 224, 225
~equest for Approval of Individual Sewer and Water Facilities
Property Owner: John J. and Marqaret Caposella
Mailing Address: c/o Jean Smith, Realtor 277-6013
Phone:
Name of Buyer: Stan R. Hajen.qa and Beverly D. Haienga
Mailing Address: 3750 W. 74th~ Anchoraq% Alaska Phone: 243-~825
3. Lending Institution: National Bank of Alaska
Mailing Address:
Realtor/Agent:
Mailing Address:
Legal Description:
Street Location:
P.O. Box 3-3859, Anchora9% Alaska
Jean Smith
Phone: 279-2506
Phone: 277-6013
Lot 9A, Block B, Timberlux S/O #1
M[]e ].10 Rabbit Creek Road, Anchorage, Alaska 99507
Single Family Residence: (X) Number of Bedrooms: 3
Multiple Family Residence: ( ) Number of Bedrooms:
Water Supply: *Individual Well (X) Publi~/Community System
If Individual Well, well depth ~
If Community System, name of system
Sewage Disposal System: On-site System ( ) Public System (
If On-site System, date of installation: 1964
( )
*NOTE: A well log is required on ALL wells drilled since 6/75.
3/77
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
"C" Street, Anchorage, Alaska 99503 274-4561
Date Received
Time of InspectionS_
DateofInspection_~_~
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
1. Approval requested by:
Mailing Address:
2. Property Owner:
Mailing Address:
3. Legal Description:
4. Location:
5. Type of facility to be inspected
6. Well Data:
A. Type ~
C. Construction~
7. Sewage Disposal System:~(~o.~,~
A.
B. Depth ~0
D. Bacterial Analysis
Installed B. Installer
C. Septic Tank: 1. Size
2. Manufacturer
D. Seepage Pit:
E. Disposal Field:
Distances:
I. AbsorptiOn Area
Total length of lines
2. Material
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
, Absorption area
, Other contamination
, Absorption area
., Sewer Lines
C. Absorptionarea to nearest lot line
EQ-034 (1/74) '
Page 1 of two pages
~Paqe 2~ of two pages - for Approval of Individual pr & Water Faci'lities
Comments
App~q~l ~Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information cpi~tained in this request fo.r a.pproval to be a true a. nd
accurate re. present, ation of. the ~/uUjec]~ sewer and water facilities and these facilities
are operatl no~ saYoi~factorily~. / / /,,' , // , ~
, /, '-.,
o
o
GRE?F[!R ANCHORAGE AREA gOROUGH
Department of Environnmnta] Quality
"C" St., Anchorage, Alaska 99503
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
Type of Inspection: CMRO
Property Owner: ~1
Mai-ling Address:
Name of Buyer:
Mailing Address
Name of Lending Institution:
Mailing Address:
Name of Realtor or Agent:
Mailing Address:
Legal
Location:
Description:
27R-~,561 · .z,.?D,~~
,', f' ·
Phone
Day Phone
Phone
Type of Facility
Water Supply
Type of Supply:
If Individual,
If Individual,
to be inspected: No. Bdrnls.~
Public Utility Individual
number of dwellings presently served
depth of well ~0
Sewage Disposal System
~ Type of System: Public Utility
v If Individual,, date of installation
Individual (on-site) X
EQ-037 (1/74)
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
, .
} -,, Date Received
Time of Inspection
Date of Inspection
~ ~-'h~,?~ ~,,}~ REQUEST FOR APPROVAL OF
~,'~ ~r INDIVIDUAL SEWER & WATER FACILITIES
1. Approval requested
Mailing Address:
Property Owner: ~mm~/J --]-'- (-,(o~-~ Phone:
~1 /1
Mailing Address: ~ /a//~ ~//~rF J'7',~-,0~, - ~(~ ~.)~o~-
Legal Description: /~oT- ~· /~/oe~ ~.. ~'~^/~/. '~',~-'.~T~,/
5. Type of facility to be inspected ~-~ ~0~ No. of bedrooms
6. Well Data:
A. Type y ,ll J
C. Construction
Sewage Disposal System:
A. Installed
B. Depth
D. Bacterial Analysis
B. Installer ~_~-~
~. 2. Manufacturer
C. Septic Tank: 1. Size
D. Seepage Pit: 1. Absorption Area ~ 2. Material
E. Disposal Field: Total length of lines
Distances:
A. Well to: Septic ~anK ~, Absorption area
Nearest lot line '~' , Other contamination
B. Foundation to septic tank ~ ~
C. Absorption area to nearest lot line
/'~)~9 /, Sewer Lines~m '~,
, Absorption area ~ /~z--
EQ-034 (1/74) Page I of two pages
~ .-~age 2 of two pages - Relst for Approval of Individual
& Water Facilities
· Legal Description
Comments
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate re~resentation of the subject sewer and water facilities and these facilities
are oper~i~'~ satisfactoiil,~.
SIGNED "~,~-"4~ 'T~ Date ~',~'~,
EQ-034 (1/74) ~ ~ ~