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HomeMy WebLinkAboutLAKE HILL ACRES #6 BLK C LT 6QD Aount Ro4 &LC C oSv- taaSa Municipality of Anchorage Page I 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: -~ q G, c> ~,~ ~. PID Number: O 51 -- ~ Name: ~ ~ Wastewater System: ~ New ~ Upgrade Address: ~ ~ ~ ~.~. ~*x 7~ ~*~L~ ¢,V~, -~Y ABSORPTION FIELD Phone: ~,o. ofs~rooms: DD~pTrench ~ Shallow Trench ffBed ~Mound ~Other LEGAL DESCRIPTION so, Rating: ~ ~ ~ GPD/Sq. Ft. Total Depth fro~rlginal grade: Subdiv~ion: Depth to pi~ bo~om from original grade: Gravel depth beneath pi e Township:~__ IRange: -- JSection: -- FillaOd~aboveorigina[grado:o.~ -- ' Ft. Gra~,length: ~O ' Ft. 'WELL: Ex, s~,~ew D Upgrade ~elwidth: I~' Numberoflin.; IDistan~.tw.nlines: Classification (Private. A.B.C): Total Depth: ~ Total absorption area: Pipe material: ~%r~ Driller: ~ Date Drilled: Static W~er Le~l: Installer: oate installed: I '~GPM Pump Set at: I Casing Height Above Ground: Ft. Ft. TAN K SEPARATION DISTANCES ~ Septic ~ Holding ~S.T.E.P. TO Septic Ab~rption Lift Holding >ublic/Priva~ Manufacturer: Capac~y in gallons: F~m T..~ ~,~,~ S~..on T..~ S*we~U.~ ~C~OZ~ ~ Th~ I ~ Number of Compa~ments: Sudace wat~ I~o~+ ,.~+ -- -- -- LIFT STATION Lot Size in gallons: ~ Manufacturer: Foundation ~, iq' -- ~ -- 'Pump °n" 'evel't: I "Pump °~'level at: I High water alarm at: ~' ~Z" =ump Make & M~el {El~rica[ Inspections pe~ormed by: Drain O5i Remarks: N ~ ~,~, , ~ ,,~ ~,~. ~,~ BENCH MARK '~ Location and Description: '~ ~ '= A~umed Elevation: S l S ENGINEERING Dates' 1st t'" ......... ~ .... Inspections pedormed by: fT~~o.~ ~nd 'l-t~--'t~ , Depadment of He H ,ces approval '" .... "'" Reviewed and approved ~Date: / '"- 72-013 (Rev. 9/91) MOA 25 Permit'No. SW960173 Page 2 of 2 Municipality of Anchorage 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 LOT 6, BLOCK C, LAKE HILL ACRES S/D //6 Legal Description: 051 -122-52 PID NO ' ALT. TH# B 68.0" 73.5' 76.0' 88.0' 94.5' 114.5' 120.0' ST1 CO 100.0' 250 GAL ~95.7' EW BED 1 50 GAL. S.T.E.P. SYSTEM MT2 01.5' = 101.$' MT4 = 100.9' MTZ L(F 6 3 BDRM HOUSE B MT2 & = 97.4' · 91.4' B.O.I & = 97.4' SCAL~ f' = MT. DE ROBERT C. COWAN CE-8801 72-013 A {Rev. 9/91 ) MOA 25 EAGLE ELECTRIC INCORPORATED Seotember 25, 1996 To: Mr. Gray Re: Lot 6 Block C, Lake Hill Acres Addition #6 This letter is verify that the septic lift station at the above mentioned property has been wired per the National Electrical Code and per the manufacturers design If you have any questions or concerns regarding the above information, please do not hesitate to contact me @ 344-7121. Thank you for your time and consideration. Sincerely, Todd Houston President ELECTRICAL CONTRACTING Construction · Maintenance · Remodels · Code Upgrade · StatewideService. Licensed. Bonded andInsured 7721 SchoonStreet, Suite 1 · Anchorage, Alaska 9953.8-3038 · (907) 344-73.21 · FAX (907) 344-0827 P.O. Box871632 · Wa$ilI~. Alaska 99687-1632 · (907)373-6881 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PERMIT NUMBER:SW960173 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:GRAY BARI OWNER ADDRESS:P.O.BOX 773182 EAGLE RIVER, AK 99577 PAGE 1 OF 1 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT 7 DATE ISSUED: 7/08/96 EXPIRATION DATE: 7/08/97 PARCEL ID:05112252 LEGAL LOT SIZE: 45274 (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 AMD 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAACS0) . 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: ISSUED BY: t f%~2~'-~'~' '~--/ DATE: ROBERT C. COWAN, RE. ROBERT A. SHAFER, P.E. CIVIL ENGINEERS June 6, 1996 (907)694-2979 FAX (907) 694-1211 SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERING STUDIES AND REPORTS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM DEStGN MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 6, Block C, Lake Hill Acres S/D #6 Request you issue a permit to install a leachfield trench to serve the proposed three bedroom house on the referenced property. Two test holes were excavated and percolation tests performed. The approximate location of the test holes are located on the attached site plan. At the time of excavation no water was encountered in the test holes and after seven day ground water monitoring, the monitoring tubes were found to be dry. Due to unusual percolation readings for this area (0.8 gpd/sq.ft), the next rating was used (0.5 gpd/sq.ft.). 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. If you require additional information, please contact us. Sincerely, Robert C. Cowan, P.E. RCC/gk Enclosure r:N~t, rrN. s~Rwc~s OWm~3N JUN 0 ? 1996 RECEIVED 17034 NORTH EAGLE RIVER LOOP . SUITE 204 EAGLE RIVER, ALASKA99577 ,'1" 'F 5O' I 3AI~G G3SOdO~d -.do :~m~ © , N.T.S. IPROFILE DETAIL PERFORMED FOR: LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: Township, Range, Section: 6 7 8 9 10 11- 12- 13- 14- 15- 16- 17- 18- 19- 20- COMMENTS WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Deplh te Waler After Monitoring? /'~ 0 Dote: SLOPE SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop I PERCOLATION RATE ~-.~ (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN /~ FT AND 5 FT PERFORMED BY: ~.~oO,~ L, /~t~u~ I ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES' ' / - 'IN EFFECT ON THIS DATE. DATE: /o //{~ /<~/~ 724)08 (Rev. 4/85) DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 4. 5- 6- 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage .,/.. / '~'~_'.~'-' ',' ~ ~ ROBERT C COWAN DATE P E R F O R M E~." 4:D ~',""'l'~.~' ~ Township, Range, Section: WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth le Waler Alle~' Monitorino? ~ Dale: SLOPE SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop ~'-2~-'/Z I :lO .~ - 1'~.~1~ I: il J I~/,l, IOq t~ J I: ,~ ,, t~ V~'~ ,, I: I~ ~ I~~ PERCOLATION RATE "Z. {minutes/inch) PERC HOLE DIAMETER COMMENTS TEST RUN BETWEEN ~ FT AND ~ FT PERFORMED BY; ,)) ~;~)y L-. ~I~AV_c I /~TC/"/ -- ~ · ~7~/~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ /~ / ~ ~ 72-008 (Rev. 4/85) j Munlclpalily of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19- 20, DATE 'IF YES, ATWHAT ~ .~I I~ DEPTH? pO E Depth Io Waler After M~niloriflD? Dale: Gross Net Depth to Net Reading Date Time Time Water Drop N PERCOLATION RATE (mmutesJinch} PERC HOLE DIAME~'ER TE~T RUN BETWEEN ~FTAND FT COMMENTS PERFORMED BY: ...... ,- ~ Re I,/ / ~-~- CERIIFY THAT THIS T~BT ~NAS PERFORMED IN ^COOROANCE W~'~;E~ai~t~Ni~C~PAL GUIDELiN~EC:T ON THIS D~TE. DATE: ,~/~r /Ir ? 72-~8 {R~v. 41~) LEGAL DESCRIPTION: ~--.-~'~ ~ ~-~ ~/¢¢~1.~ ¢rlt~L.~ownship, Range, Section:"~-~i..~ , ~,~,~ ~ ~ ! 2 3 4- 5- 6- 7- 8- 9- 10 11 13- 14- 15- 16 17 18 19 20 SLOPE WAS GROUND WATER ENCOUNTERED? S f L IF YES. AT WHAT DEPTH? E Deplh to Water Alter Monitodng? Date: SITE'PLAN Gross Net Depth to Net Reading Date Time Time Water Drop · - ~ PERCOLATION RATE . (minutes/inch) PERC HOLE DIAMETER -- TEST RUN BETWEEN - ,~T AND FT . INEERING . ~ - PERFORMED BY: S & S ~NG I , ~ ~~TIFY THAT T~S T~ST WAS PERFORMED IN 72~8 (Rev. 4/~) ~ Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. 051-122-52 '1. Expiration Date: GENERALINFORMA~ON Complete legal description LAKE HILL ACRES ~, BLOCK C, LOT 6 Location (site address or directions) 25037 MT. EKLUTNA DRIVE, CHUGIAK, AK 99567 Current Property owner(s) BARI GRAY Day phone 688-6902 Mailing address PO BOX 773'182, EAGLE RIVER, AK 99577 Lending agency Day phone Mailing address Real Estate Agent Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class Well [] Public Water System [] TYPE OF WASTEVVATERDISPOSAL: IndMdual On-site Individual Holding tank Community On-site Public Sewer The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class ,A ~r B w. ells or a public water system. The Municipality of Anchorage is not responsible for errors or om~sslons m the professional engineer s work. 4. STATEMENTOFINSPECTION~YENGINEER As certified by my sear affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm KND ENGINEERING, INC. Phone f907) 696-6ili Address 20441 Ptarmiqan Blvd,, Eaqle River, AK 99577 Engineer s Pdnted Name Kenneth M. Duffus Date 06/12/03 Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface, changes in land use, local soil characteristics, groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, KND can not give any estimate of how long a system will function satisfactory for current or future occupants or can KND guarantee that no unseen encroachments, deficiencies or discrepancies exist. DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: There are nitrates present. It is suggested that periodic testing be erformed p to insure the wells continUed suitability. Current ..... n~trate concentration ~s 5.14mg/1. EPA maximum concentration is tU.U mg/i. More in~o~ation on nitrates is available ~rom t~e Attachments: on-Site Services Program, at 343-7904. ~'.,. . . H~ Checklist X Ma,ntenance Agreements ~, ~OA~- Supplemental Engineer s Repod Septic System Advisory Well Flow Advisory Other Original Certificate Date: (Rev. 01,~2) Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bregaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LAKE HILL ACRES #6, BLOCK C, LOT 6 A. WELL DATA Well type private IfA, B, or C provide PWSID # Date completed UIK Sanitary seal (Y/N)Y__ Total depth 51' ft. Cased to .40+ ft. FROM WELL LOG Date of test U/K Static water level U/K ft. Well production U/K g.p.m WATER SAMPLE RESULTS: Coliform 0 colonies/lO0 mi. Nitrate 5.14 rog.II. Arsenic: N._~A mg./I. Date of sample: 61312003 B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 711911996 Tank size 1250 gal. Number of Compartments 2~ Co Parcel ID: 051-~22-52 Well Log (Y/N) N Wires properly protected (Y/N) Y Casing height (above ground) 3,§' AT INSPECTION 414103 20 ff. 1.33 g.p.m. Other bacteria ~ colonies/lO0 mi. Collected by: KND Eneineerine Cleanouts (Y/N) Y_ Foundation cleanout (Y/N) Y__Depression over tank (Y/N) N High water alarm (Y/N) _Y Date of pumping 4~3~03 Pumper JR'S ABSORPTION FIELD DATA Date installed 7/19/1995 Soil rating (g.p,d./ft2 or ~/bdrm) 0.~5 Length 60 ft. Width 15 ft. Gravel below pipe 0.5 Total depth 3-4 ft. Eft. absorption area 900 ft2 Monitoring tube Y System type PRESSURIZED BED ft. Depression over field N Date of adequacy test 41412003 Results (Pass/Fail). PASS For 3 bedrooms Fluid depth in absorption field before test 0 (DRY) in. Water added 500 gal. New depth 0 (BRY) in. Elapsed Time: L min. Final fluid depth 0 BRY in. Absorption rate >= 450+ g.p.d. Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date LIFT STATION Date installed 7/1911996 Pump on level at 42 in. Size in gallons 1250 Manhole/Access (Y/N) Y Pump off level at 32 in. High water alarm level at 44 in. Datum Bo'FrOM OF TANK SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main 75'+ Sewer/septic service line 25'+ Cycles tested 3 Meets alarm & cimuit requirements? Y On adjacent lots 100'+ On adjacent lots 100'+ Public sewer manhole/cleanout Holding tank 100'+ 100'+ Property line 10'+ Water Service line 10'+ Curtain drain 50'+ COMMENTS SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line t0'+ Surface water 100'+ Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation '10'+ Water main 10'+ Surface water 100'+ Driveway, parking/vehicle storage 25'+ Wells on adjacent lots 100'+ WELL WAS PROBED TO A TOTAL DEPTH OF 51' FROM TOC & CASING WAS VERIFIED TO 40'+. WELL PUMP HAS A RESTRICTER G. ENGINEERS CERTIFICATION I certify that l have determined through field inspections and review of Municipal records that the above systems am ~n constance with MOA H~ gu,'deli~es in effect on th,~ date. Date JUNE 12, 2003 HAA Fee $375.00 Waiver Fee $ Date of Payment JUNE 13, 2003 Receipt Number ~'~70~'-~ ~ ~,, Date of Payment Receipt Number The }ocation of the structure(s) as showr, on this ~ecord drawing-~~Bw~,~,~m~,=~ 9/27/96 AS BUILT 37-31 (as-built) complies w th T~Ue 21 &MC. 5/30/96 PLOT PLAN 36-28 ~: ~' ~~ ,,, DATE FLD. BK. I LOT ~m ~ ~ ~A~LO~ ~ ~ ~ ~ ~rovided by client, It is th~ responsibility of the owner ~ ~ 2 building grade relative to finish grade ~nd utilities . m ~ or builder, prior fo construction, to verify proposed -- ¢¢ ~ I~' ~¢' ~ connections, end fo determine the existence of any ~- 6 ~;1 - Z : - eesements, covenonts, or restrictions which do not ~ ~ ~ appeer on the recorded subdivision plot. ' [56,~ -- ~ i~ Blewdons hosed on ossumed datum unleas otherwise 79. S&S Engineering o m ~ (907)894-2979 4 I o ~ S ~°~0'30"E 270.41' (MEAS) LEG~ DESCRIP~ON N ~lO'30"W ~70.~ (REC) / I REBAR REBAR LOT 6, BLOCK C, LAKE HILL ACRES SUBDIVISION SIXTH ADDITION 5 PLAT NO. SCALE GRID 71-60 1"-40' NW 156~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVlOES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # © 5--,' - I~-)- ~ -~-.-%- HAA# ~ ~c~L~ -¢-2'L\LtL¢ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone ¢'~:'~ .- d~' >- Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. 3 NOTE: Individual well X; Community well Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: X 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. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of th~ 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 disposat system is safe, functional and adequate for the number of bedrooms and type of structure nd cated herein. I fu~her verifythat 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. S & $ ENGINEERING Name of Firm J~'0;~R. ~.agJe EJver Loop ~oa~ No. 204 Address Eagle River, Alaska 99577 Engineer's signature -~/']~ Phone Date SIGNATURE ~ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date / ~,///~g//~/ 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 courtesyto 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 engineeCs work. MUNiCipALITY OF ANCHOr. AGE ENVIRONMENTAL'SERVICES DI¥1,SlON of Anchorage OCT 1 0 1996,¢~i~ Municipality DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division R ~; C E J V E ~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: L.o r ~.~ CL,~( ¢- C~ L.A~.~¢ Ni~.~. A. WELL DATA Parcel I.D.: Well type ~;.~ ,; ~,1~c- Log present (Y~ /v ,, Date completed Total depth u / ~ Cased to '" / i~ Sanitary seal (.~/N) Ye ) If A, B, or C, attach ADEC letter. ADEC water system number Casing height (above ground) Wires properly protected t0~/N) FROM WELL LOG Date of test ~J t ~( Static water level AT INSPECTION Well production g.p.m. ~'~ g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: /o/// J~I~ROLDING TANK DATA Nitrate /7/· ~ ¢ ~,~//-.~ Other bacteria ~-~ - Collected by: ZZ~66 e~selV ',~e~,!~l el6e=.! ~ 'ON pJov ~1 ~-~i~ ~i~=; ~=0Zt ONIU~NIO~ S · S Date installed '? ~ i ~-'t f.,- Tank size ~ Z ~ ¢ Number of Compartments '~ Cleanouts ~N)__ Foundation cleanout (~/N) ¥~ S Depression (Y~) ~,:. High water alarm (~1) Date of Pumping ¢~-- ~ Pumper C. ABSORPTION FIELD DATA Date installed -7- i~ - Length (o C,' Width Effective absorption area Date of adequacy test Soil rating (g.p.d.tft2 or f¢/bdrm) O, 5- System type Gravel thickness below pipe O. t¢ Total depth Monitoring Tube present ~N) '~.s Depression ever field (Y~ Results (Pass/Fail) -- For -~ bedrooms Fluid depth in absorption field before test (in.); '~ Immediately after ~ gal. water added (in.): Fluid depth ~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Absorption rate = If yes, give date .g.p.d. 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access ~/N) High water alarm level at* Cycles tested ~7 - ICl - ~ (= Size in gallons ~,~ ~' "Pump on" level at* ~'~'~ *Datum "Pump off" level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: i~olding 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,~-~-~'~HOLDING TANK ON LOT TO: Foundation 'Z~ ~ Property line ~ ~ I~_ Absorption field Water main/service line j'o i.~. Surface water/drainage ~eet 'J' Wells on adjacent lots i SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ~ ~ ~ Building foundation i ~ Water main/service line Surface water Curtain drain Driveway, parkingA/ehicle storage area Wells on adjacent lots F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal re ms are in conformance with MOA l-lAA ~luidelines in effect on this date. , ~ ~'~' ,~.'",:~.,r~2~ S gnature ~-~/'~'f-~J~'~ ~ Engineer'~ ~ ~: ~ Date ~ ~ .. .., ~ ~. ?. ',; ,. -. ........... %, ~ HAA Fee $. Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number