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HomeMy WebLinkAboutSAMPSON ESTATES BLK 4 LT 12ASampson Estates Block 4 Lot 12A #051-811-44 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 Permit Number: OSP151346 Tax Code Number: 05181144000 Work Type: Septic Upgrade Permit Effective Dates: October 27, 2015 to October 26, 2016 Design Engineer: GARNESS ENGINEERING GROUP LTD Subdivision: SAMPSON ESTATES Site Legal Address: SAMPSON ESTATES BLK 4 LT 12A G:1560 Owner/Address: POMEROY GLEN W & KOVAC LINDA R PO BOX 671271 CHUGIAK AK 995671271 Site Mailing Address: 22592 SAMPSON DR, Chugiak Lot Size in Sq Ft: 57217 Total Bedrooms: 4 This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy 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 requires 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 during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: D� revises 4% cwt . t&9d. MUNICIPALITY OF ANCHORAGE Community Development Department Development Services 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. 051- Property owner(s) GLEN POMEROY & LINDA KOVAC Day phone 907-688-5356 Mailing address P.O. BOX 671271, CHUGIAK, AK 99567 Site address 22592 SAMPSON DRIVE, CHUGIAK, AK 99567 Legal description (Sub'd, Block & Lot) SAMPSON ESTATES S/D; BLOCK 4, LOT 12A Legal description (Township, Section & Range) Lot Size Sq.Ft. Number of Bedrooms 3 (4) APPLICATION IS FOR: (® all that apply) Absorption Field Septic Tank Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ APPLICATION IS AN: TYPE OF DEWELLING: Initial ❑ Upgrade Renewal THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR: NONE Single Family (SF) Ei (w/wo ADU) Duplex (D) ❑ Multiple Dwellings ❑ (SF and/or D) Distance' - I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal codes. GARNESS ENGINEERING GROUP, Ltd. (Signature of property owner or authorized agent) Permit/Rush Fees: 51A - Waiver Fees: Date of Payment: (413%/3 Date of Payment: Receipt Number: 009.1 n61 Receipt Number: Permit No. 059 6139 c Waiver No. (Rev. 01/11) GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS October 12, 2015 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Proposed Septic System Upgrade for Sampson Estates S/D; Block 4, Lot 12A To whom it may concern: The existing 3 bedroom house is served by a private well and septic system. The drainfield is in a state of failure and needs to be upgraded. We are proposing that a new septic tank and drainfield be installed. The owners are requesting we design the septic system to handle a 4 bedroom residence for possible expansion of the house. A plastic tank is proposed to be used per the request of the owner. A test hole has been excavated on the property and the proposed drainfield upgrade has been designed within the 30 foot radius of this test hole. Comments regarding the design are summarized as follows: 1. SOILS: See the attached soils log that shows the soil classifications, groundwater monitoring, and the percolation test results. 2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications. 3. SURFACE WATERS: There are no surface water concerns. 4. TOPOGRAPHY: As can be seen on the attached design drawing, the average topography around the proposed drainfield is a 5 to 10% slope running approximately Southeast to Northwest. There are no slopes within 50 feet downhill of the proposed drainfield that is greater than 25%. In short, there are no slope concerns. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your as is -nce. rey. b.rn!tPP.E., M.S. Presi 3701 East Tudor Road, Suite 101 *Anchorage, Alaska 99507-1259 Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com GLENN VIEW ESTATES NORTH; TRACT C SCALE: 1" = 100' / /— / / / / // ' / a/ /0 / / // / / / / / / / / RESERVE / / / DRAINFIELD / / / SITE// / / /7 //// / / / / / / / / - /// / /// / /// GLENN VIEW NORTH S/D; / / LOT 5, BLOCK2,// / /// / / // a / // / / / sG // /// - 11/ /// // /1 /11, /// / /1 /1 PUBLIC WATER C EPTIC ARE PUBLIC WATER / / / / / / L /- /�\\�( 11 / / 7 N\ 1 1 / //\ \ // / / \ \ /'/ /i' / \ \ \. \ \ // '%' / \ /:i, /7\\\ 9'�•~ \-/\\ \ \v`\ \\�. / / / / SAMPSON ESTATES; 1 / / \ \ \1�l; \I \ / / / // BLOCK 4, LOT 10 / / \ \A\ I \\ /// / / P /I/ \ \� A 1 \ / // CP° / 1 \ \���. / \ \ \/ / /, / \ / / \ / \ SAMPSON ESTATES; )/) / \\ // �PTIC\ BLOCK4, LOT11 // /`y` , /// \ \ / AREA // / `' //' \/ \�____ �/ O� /'/ \ / / �/ / / \ \ APPROXIMATE / / O - / / LOCATION OF \\ STORM DRAIN //S- // // //P` OUTFALL //S/ / / // N. // / /<1�/ •41 // / \/�--- --- ----- --- --. / / / \ /// / // CZPTIC j I / / 1 / 'SAMPSON ESTATES; \ / / // BLOCK3, LOT r EXISTING 3 BEDROOM HOUSE (DESIGNED FOR 4 BEDROOMS) QPTIC ARE SAMPSON ESTATES; BLOCK 4, LOT 13A GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS 3701 E. TUDOR ROAD. SUITE 101' ANCHORAGE, AK 00537 • PHONE (007)3378170' FAX (00 ) 338-3318 'NE69ITE: 0 w.00, essen0Ne I0,aoe n PREPARED FOR: GLEN POMEROY & LINDA KOVAC PHONE NUMBER: (907)688-5356 LEGAL DESCRIPTION: SAMPSON ESTATES S/D; BLOCK4, LOT 12A TYPE OF WORK: `SITE PLAN FOR PROPOSED SEPTIC UPGRADE PAGE NUMBER: 1 OF 2 DRAWN BY: J.L.M. DATE: REVISED 10/26/2015 / / 1W SETBACK TO DRAINAGE EASEMENT INSTALL DOUBLE CLEANOUT N•INSTALL FLOW 'N DIRECTOR N N ati N NGF N. • N N DESIGN CRITERIA: NUMBER OF BEDROOMS: 3 GALLONS PER DAY (GPD): 450 PERCOLATION RATE/S: 5.5 MINMNCH PROPOSED APPLICATION RATE: 0.8 GPD/SQ.FT. MINIMUM DRAINFIELD SQ.FT.: 583 DRAINFIELD DESIGN: MAXIMUM DEPTH: 8.5 FEET WIDTH: 5 FEET LENGTH: 60 FEET EFFECTIVE: 4 FEET REDUCTION FACTOR: 0.50 ACTUAL SQ.FT.: 600 APPROXIMATE LOCATION OF \` ` STORM DARIN OUTFALL (PER ''� MOA WETLAND MAPPING)_____ APPING)— _�—/ —". / INSTALL MONITORING TUBE ` NEXT TO SEPTIC TANK AS N. ''\'x REQUIRED BYM.O.A. - ' /. rPROPOSED 1250 GALLON GREER HDPE TANK / 2;". SCALE: 7" = 40" EXISTING DRAINFIELD EXISTING SEPTIC TANK TO BE ABANDONED PER UPC CODE. EXISTING FOUNDATION CLEANOUT • • • NOTE: THE WEST PROPERTY LINE, THE 100 FOOT SETBACK TO THE DRAINAGE EASEMENT (SURFACE WATER) AND THE 100 FOOT WELL RADIUS MUST BE FLAGGED BY A REGISTERED LAND SURVEYOR PRIOR TO ANY CONSTRUCTION. • • • • • GEG, Ltd. HAS A 8 PAGE SPECIFICATION LETTER THAT PERTAINS TO THIS DESIGN. TO OBTAIN A COPY OF THE LETTER CONTACT GEG. BY PROCEEDING FORWARD WITH THIS INSTALLATION, THE ENGINEER, WELL DRILLER, CONTRACTOR AND PROPERTY OWNER AGREE THAT THEY HAVE READ THESE SPECIFICATIONS AND AGREE TO ACCEPT THE TERMS AND CONDITIONS OUTLINED. • 1' GARNES S ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS 3701 E TUDOR ROAD, SUITE 101 • ANGgRTGE. AK 99507 • PHONE(907) 9378179 • FAX I90719383246. WEBSITE:wow.yamexenomeeml9.mm PREPARED FOR: GLEN POMEROY & LINDA KOVAC PHONE NUMBER: (907)688-5356 PAGE NUMBER: 2 OF 2 LEGAL DESCRIPTION: SAMPSON ESTATES S/D; BLOCK 4, LOT 12A DRAWN BY: J.L.M. TYPE OF WORK: DESIGN OF SEPTIC SYSTEM UPGRADE DATE: REVISED 11/10/2015 \ i Y- GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS 3701 E. TUDOR ROAD, SUITE 101 • ANCHORAGE AK 09507 • PHONE pm 3378170 • FPX (00713303240• WEBSITE: vmwgemessengneem9.mm LEGAL DESCRIPTION PERFORMED FOR: DEPTH (feet) 1 2 3 4 5 6 7 8 9 10 12 13 14 15 16 17 18 19 20 so ••••••••i ••y••• ••••••••6 eee ••••••••• nee ••••••••• ••: n 9 lV 0 m [e sm Q Y � N 3 OyJ m Y C �d3 U1 'QR VJ Z < . ¢ w Z W > J w m �n: _ Z Ya m J � a p w _ in a N w i W i Q� F x O m LL O LL W J 02 n 9 lV 0 m [e sm SCJp 6: �d3 U1 �n: p Cr w p w � in vFi w i i i n 9 lV 0 m [e sm O O O O O O O O O O O � w w w w � cF. ri cF. cFz. 0 0 0 0 0 0 0 0 0 0 0 ce a m w ad ce 04 m ce m w w w w w w w w w w w w n 9 lV 0 m [e sm * - -.w.��������� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET� ANCHORAGE, AK 99501 264-4720 ����11..~9 ����F� V-, 9 1'. * TF /^ PERMlT NO: 8o�040 DATE ISSUED: O2/07/86 APPLICANT: S&S ENGINEERING ADDRESS: SRB 196X EAGLE RIVER, AK 99577 CONTACT PHONE: 694-2979 ` LEGAL DESCRIP: SUBDIVISION: SAMPSON EST. LOT: 12BLOCK: 4 SECTION: 3 TOWNSHIP: 151\1 RANGE: 114 LOT SIZE: 40223 (SQ.FT" OR ACRES) I certify thai: ' ` ' 1. I am amiliar with the requirements for on~site sewers and wells as set [orth by the Municipality of Anchorage (MOA) and the State of Alaska~ 2. Iwill install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria othis permit" 3, I will adhere to all MOA and State o� A1aska for the set back distances Yrom any existing well, wastewater disposal system or public seweragesystem on this or any adjaceor nearby lot" SIGNED DATE: � APPLICANT: t S EPiGINEERING ISSUED B DATE: rararasaeaaea:�n'��ea' MUNICIPALITY OF ANCHORAGE p DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ® NEW Fenton Construction Incorporated 563-8236 1:1 UPGRADE MAILING ADDRESS 2085 Campbell Place, Anchorage, AK 99501 LEGAL DESCRIPTION Lot 12, Block 4, Sampson Estates, located within Sec. 3, T15N, R1W, S.M., AK LOCATION NO. OF BEDROOMS Sampson Drive, Peter's Creek three (3) Well Absorption area Dwelling PERMIT NO. UY DISTANCE TO: 106 10 27 840960 H Z Manufacturer Material No. ofcompartments w~ Steel two 2 En Liq. capacity in gallons Inside len th Width Liquid depth 1000 F HOMEMADE: n a Z DISTANCE TO: Well Dwelling PERMIT NO. ®� = z F Manufacturer Material - Liquid capacity in gallons O - Well Foundation Nearest lot line PERMIT NO. W = DISTANCE TO: 125 45 60 840960 LL Z No. of lines Length of each line Total length of lines Trench width Distance between lines _j P z W 1 40 40 24 inches n a Top tile to finish Material beneath tile - Total effective absorption area C< F_ of grade p 3,2 7,9 inches 532 Length Width Depth PERMIT NO. W a Q h Type of crib Crib diameter Crib depth Total effective absorption area wa y Well Building foundation Nearest lot line DISTANCE TO: $ass, Depth Driller Distance to lot line PERMIT NO. � rlvate 10' 840960 W a, Building foundation Sewer line Septic tank Absorption area(s) DISTANCE TO: 46 82 106 125 OTHER L9 1V"VLC(V4A PIPE MATERIALS ew ABS SCHFD 40 and ASTM 2729 SOI L TEST RATI NG 194 sq. ft. per bedroom INSTALLER - Pieratt Excavating REMARKS OV� i P C .aII "o Of t' , �, �r °s tirJ. CE•5n3e � .3 Rv`a �® 10a APP D D TE LEGAL �. rararasaeaaea:�n'��ea' Y'R° 9 POS, r 1 6-650 r `JA P C Y I Z ANCHORAGE, ALASKA 99502-0650 (907) 264-411-1TONY KNOWLES. MAYOR DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Permit #: 840960 January 31, 1985 TO: Permit Applicant SUBJECT: Lot 12 Block 4 Sampson Estates Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1984. Permits are issued on a calendar year basis by authority of Municipal Ordinance, A new permit must be obtained from this Department for any well and/or on-site sewer system not installed by the expiration date. if you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site sewer system, the original as -built inspection report and the yellow copy must be sent to this office for review and approval, and for documentation. If there are any further questions, please call this office at 264-4720. Sincerely, Keith E. Bandt 3upeYvisor P Environmental Engineering Program KEB/ljw enc: Copy of Permit SWP/057 PERMIT NO: DATEISSUED: APPLICANT: A8DRESS: CONTACT PHONE: LEGAL DESCRIP: LOT SIZE: MAX BErMOOMS: / ` ' �x2% L_ �-il'--v ![,::III !I.-::, FU 11-Du���� DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ��yy 825 L STREET, ANCHORAGE, AK 99501 -/ " 264-4720 |H' ����E73 :1 �IE": lt._: uq ��IP-111. "T: T" 840960 11/27/84 FENTON CONSTRUCTION CO. 2085 CAMPBELL PL" ANCHORAGE, AK 99507 563�8236 SUBDIVISION: SAMPSON EST. LOT: 12 BLOCK: 4 SECTION: 3 TOWNSHIP: IS RANGE: 1W 40223 (SO -F-7. OR ACRES) ' 3 Listed below are the options available to you in designing your septic system. Choose the option that best fits ... .... .... .... your site. 7-1117�E.H.: H I-*'..,: F-11 .. ..... ... lot EEL: 13 .... .....^��~�`�� L"'.1 - ID! ii :1'.�� DEPTH TO PIPE BOTTOM (FT.) 4,0 4.0 4.0 GRAVEL DEPTH (FT.) 8,101 0"5 3"5 TOTAL DEPTH (FT.> 12.0 4,5 7^5 GRAVEL WIDTH (FT.) 2.5 21"D 5"O GRAVEL LENGTH (FT,) 37.0 42"0 63^0 GRAVEL VOLUME <CU.YDS.)� 29.2 32"7 46,7 TANK SIZE (GALS) 1�j000.O ** 1000"0 SOIL RATING (SQ^FT./BR) '194 193 194 ** TANK MUSTHAVE AT LEAST TWO COMPARTMENTS --- --- .... .... ..... .�..... �... .... ..... __~~�._� certi�'v that: z" 1 am fam1liar with the requirements -."or on-site sewers and wells as set Forth by the Municipality of Anchorage (MOA) arid the State o", Alaska. 2" I will install the system in accordance with all MOA codes and regulations� and in cornpliance with the design criteria of this perdit^ 3^ I will adhere toall MOA and State of Alaska requirements Afar theset back distances from any existing well: wastewater`disposal system or public sewerage system on this or any adjacent or nearby lat.. 4" I understand that this permit is valid for maximum o1 3 bedrooms and any enlargement will requirean additional permit^ IF A LIFT STATION IS INSTALiED IN AN AREA COVERED By MOA BUILDING CODES, THEN (1) 114 MAMMAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS.BUILTS WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE" ELECTRICAL WORK MUST BE DO ELECTRICIAN^ SIGNEo DATE: ... .... �_^��~�___ APPLICANT: FENT N 1,� ISSUED BY � DATE: ��~^�����^�-~��-�~���`~-~^~~�_- ^ / r ` , ) $I SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG — PERCOLATION TEST PERFORMED FOR: I en l ct r) Cons+y-uc-i i on �n(-, � DATE PERFORMED: I I I20 t2I I B-1 LEGAL DESCRIPTION: l---Ot 11-,. 0If�Cf_��,`'t� I`-(�`i�x.`�7 }--1 F *` SLOPE EvfTrj 1 0,9 z,o sl l� w; lIn arclo rc.� M L redd,s�, 2 3 4 Z2 0 5 6`.:.": 7 c� (o , b S.Ny S�wo }race 4c 'off `yarnC. d`cw�l, h�h� g mnee�a'�fq do -Sea �� o -: � Ste) SI E PLAN I':IoC, ■MERM■■n■■ Date Gross Time Net Time Depth to Water Net Drop ■■■EM,■FI■■MENNOMENNE; 1150'; 99 I I s 9Xc' ; I�, ►1►z.1 1 o 9 3b 8 1a M■■■■■©EN■ 1-30pi ;,50 13/� 'N.■MM■NE(Jl 121 ' 6N v 19 F t ....NMEMENOMMEM. ENME_! rEENNINEEN ENNNNE■M'NE ■■■EMMMM■■ 113 'V1(, ) r MIMENNEEMEMEN t - BA iP 10 WAS GROUND WATER S 3 �� 11 ENCOUNTERED? OL 12 / P IF YES, AT WHAT E �-!•• DEPTH? 13 '6 I v • .•� ; r�z N c� L.lfm 14 15 /.. 16- 0 18 ` °0°° 3`b a � 19 20 C �l" COMMENTS Reading Date Gross Time Net Time Depth to Water Net Drop 1150'; 99 I I s 9Xc' ; I�, ►1►z.1 1 o 9 3b 8 1a 1-30pi ;,50 13/� . 121 ' 6N v 19 F t 13-io :?-a 113 'V1(, ) r Illb 2b t - BA iP 1912 ; 0 -7 1 1 -5 Vl (o v, . Z'0- 5C� s icy '7 PERCOLATION RATE TEST RUN BFeTWEEN 15 i0 (minutes/inch) 1 1 FT AND - ' 2, FT - PERFORMED BY: Phln 5.10L1e ) CERTIFIED BY: 72-008 (6/79) DATE: i/ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 4/�s�cl' 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Wt _6t�t /J� 4?�i yaj"tCGJ'.��� n2�IY� /l `'` 7C.t�9/�-(i-��CA-3'� Location (address or directions) (b) Applicant Name���'1- Telephone: Home Business /� Applicant Address �6 �J /� (��,N � / /i kl_ (c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ; Buyer ❑ ; Other ❑ (explain); (d) Lending Institution N ' --r 1 Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: 5 P. e 1-nginearing $R13 196X Eagla diver, Alaska 99577 2. TYPE OF RESIDENCE Single -Family 9 Multi -Family ❑ Other Number of Bedrooms -t�3 3. WATER SUPPLY Individual Well Community ❑ ' Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Pagel of 2 72-025 (11!84) 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE 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 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 Telephone 5 & 5 Er;c�inecrtittg Address Date Ea!jfe `?Ivcr, Alaska 9957" F--- �—Z -(- SOF a T o r4 ^•, t.; eco \: +ir. 6. DHEP APPROV Approved for bedrooms by Date Approved Disapproved Conditional Terms of Conditional Approval 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 ANCHOgAGE ^ MUNICIPALITY OF ANCHORAGE (MOA) ENVIRONMENTALEROTECTIO HEALTH AUTHORITY APPROVAL (HAA) H CHECKLIST - FEBRUARY 1984 ' 04w, 264-4720 Legal Description: c.S*A-1 A. WELL DATA Well Classification �2t Vd�t"�� If A, B, C, D.E.C. Approved (Y/N) Well Log Present (OW)- Date Completed i ' Z g "a'f Yield 12C!5 Total Depth/41z Cased to Depth of Grouting 4� Static Water Level !!�/6 Pump Set At /3/4 l! J. - Casing Height Above Ground — Electrical Wiring in Conduit/W Separation Distances from Well Sanitary Seal on CasinedP# — Depression Around Wellhead (NN To Septic/Holding Tank on Lot 0�&e ; On Adjoining Lots % To Nearest Edge of Absorption Field on Lot �UG ; On Adjoining Lots To Nearest Public Sewer Line A_(/ To Nearest Public Sewer Cleanout/Manhole N To Nearest Sewer Service Line on Lot (D•/� Water Sample Collected by 50 S em(' r/407</0/WG ; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed .��-bSize//>U( No. of Compartments Z Standpipes M- Air -tight Caps(ox Foundation Cleanout,6* Depression over Tank4*0 Date Last Pumped lei Pumping/Maintenance Contract on File (Y/N) ; for Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water -Supply Well %- �� To Building Foundation r To Property Line 16 r To Disposal Field j0 To Water4fttnr Service Line 4 `�- To Stream, Pond, Lake, or Major Drainage Course Comments Page 1 of 2 72-026(11/84) f� C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata 9 Li IBR— Type of System Design�1� 43 Date Installed rz—Length of Field Y-0 — Width of Field Z7 Depth of Field i Gravel Bed Thickness '/a 7 Square Feet of Absorption Area �3Z 3 Standpipes PresentON) Depression over Field (Yftigj Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field To Water -Supply Well 1Ub To Property Line L To Building Foundation �O To Existing or Abandoned System on Lot N To Water-Maio/Service Line 516' - To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments — D. LIFT STATION Date Installed - Size in Gallons On Adjoining Lots — .?� To Cutbank (if present) Dimensions Manhole/Access (Y/N) "Pump On" Level at "Pump Off' Level at High Water Alarm Level at Vent (Y/N) Tested for Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. S & S Engineering .2 _ Y � 6SignedSRB 196x Date Company Earle River, Alaska 9957 MOA No. s Receipt No. 3.7U(a q O Date of Payment Amount: $ %�� Page 2 of 2 72-026 (11/84)