HomeMy WebLinkAboutALPINE WOODS BLK 6 LT 10 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENI'AL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE__ ~'~17 ~i~, NEW
MAILING ADDRESS
LEGAL D~SCRIPTION
OCA ,O. ur
~ ~ Manufacturer Material ~o. of como~rtments
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
~ ~ IF HOMEMADE:
Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
Q Well ~ ~ ~ Foundation Nearest lot line PER~T NO,
~ · DISTANCE TO: ~ ~ T ~ ~0~0~ ~1
~ Z ~ No. of lines Length Of ~ach line Total length of lines Trench width Distance between lines
~ ~ Top of tile to finish grade Material beneath tile
Q H '
Length Width Depth P ER
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class ~i C Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
A~.ROWD DAT. ..GA. VI" I
72-013 (Rev. 3/78) /"/O~-# ~'~--~7'
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fi;I.IE:[.':'IVISION: £4LPINE 1.4OODS
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Permit ~
Applicant:
Location:
Legal Description:
Type of Soil~bsorption System Is:
Trench: /~ Drainfield:
Maximum Number of Bedrooms:
MUNICIPALITY OF ANCHORAGE
Department ~f Health and Environmental ~rotection
825 Street, Anchorage, AK. 3501
264-4720
* * * HANDWRITTEN PERMIT * * *
WELL AND/OR ON-SITE SEWER PERMIT
Mailing Address:
Phone Number:
Lot Size:
Seepage Bed: Holding Tank:
Soil Rating (sq. ft/br)
The Required Size of the Soil Absorption System Is:'
DEPTH ~' ~ LENGTH ~7. o / GRAVEL DEPTH ~'~ WIDTH =~- T /
The length dimension is the length(in feet) of the trench or drain~ield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~o GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion~
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER ~1, 1 9 8-,q.-* * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
Signe~: Issued by:
Applicant Date:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG ~,/~.~
[] PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
lO
11
12
13
:14
1:5.
t6 ·
17
18
19~,
20
COMMENTS ~ ~' "~
PERFORMED BY:
SLOPE
SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? ~J ~ L
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
CERTIFIED BY:
72-008 (6/79)
PUgUIS
MUNICIPALITY OF ANCHORAGE
0, ar
Development Services Department 4 Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-234-51
1. GENERAL INFORMATION
Complete legal description ALPINE WOODS BLOCK 6, LOT 10
Expiration Date: j 22 - 2- C9 2L)
Location (site address) 6500 DOWNEY FINCH DRIVE, ANCHORAGE, AK 99516
Current property owner(s) CHARLIE & JENNIFER GRAY Day phone
Mailing address
Real estate agent
6500 DOWNEY FINCH DRIVE ANCHORAGE, AK 99516
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑
Private Septic
Water Storage
❑
Holding Tank
❑
Community Well A
®
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ �'j� n Waiver Fee $
Date of Payment 11A31.-Wao Date of Payment
Receipt Number *205903 Receipt Number
COSA # ®c5C-o61Q1$ 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 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY, ANCHORAGE, AK 99516
Engineer's Printed Name CURTIS HUFFMAN, PE Date 1/22/2020
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. 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, 1
local soil characteristics, groundwater levels that may fluctuate during the year, quality of ��\0•' • • • • • ' • .1. ` j
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. 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 *; TM •.* I
well and septic system. Therefore, any estimate of how long a system will function satisfactory .. . .... .. • • • • • • •
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting & FIBS • • • • • • • • • • • • • • • • •
`� Curtis Huffman
6. DSD SIGNATURE �+ 9 •. CE 128991 .•
.
1/22/2020. .'R
System #1 Approved for bedrooms �� F'�FOp • •' • • • A��AWAw
ROFESSION,`+,
System #2 Approved for bedrooms \�\ ESSO
Disapproved
Conditional approval for bedrooms, with the following stipulations:
�,\1111 T'V
o W
M
J ,`
`�d�fl!►it111��1\
y: V`ti— Original Certificate Date: ^ Ro 2-0
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
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.
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
Legal Description: ALPINE WOODS BLOCK 6 LOT 10 Parcel ID: 015-234-51
If more than 1 septic system on lot: COSA Checklist # _of
A. WELL DATA — CLASS A #213598
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to _ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Comments
B. TANK DATA
Age of tank(s) 3 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 48"
® Standpipes/foundation cleanout per record drawing
Date of pumping 10/22/2019
D. ABSORPTION FIELD DATA
Which system tested (date installed) 7/14/2016
® ALL standpipes present per record drawing
Total measured depth from grade 12.8 ft (max)
Measured depth to pipe invert from grade 3.8 ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
Structure served by this system _
Well production at time of test gpm
Water storage tank volume_ gallons
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform bacteria is Negative
Nitrate mg/L E]Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by_
Date of Sample
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 1/21/2020
Results )N Pass For 4 bedrooms
Fluid depth prior to test 40 in
Water added 820 gal
New depth 59 in
Elapsed time 1430 min
® Code -required soil cover over field Final fluid depth 35 in
F-1 System presoaked Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) N
date of test) If yes, enter date
Gallons introduced _gallons FW�C
Comments/Deficiencies:.,
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes
if No
Community Sewer Manhole/Cleanout > 100'
® Yes
if No
ft
® Yes
if No
Neighboring Tank > 100' ® Yes
if No
ft
Private Sewer/Septic Line > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Water Service Line > 10'
® Yes
Animal Containment > 50' ® Yes
if No
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ®Yes
if No
ft
® Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
® Yes
if No
ft
Surface Water > 100' ® Yes if No _
Property Line > 5'
® Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes
if No
ft
Private Wells > 100' ® Yes if No
Water Main > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Water Service Line > 10'
® Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
® Yes if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes if No
ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
® Yes if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify 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.
;0111- �H
r - *.
. .... ...o
Curtis Huffman /
CE 128991
F,0 O... ONP���.�
ft
ft
ft
ft
ft
ft
ft
ft
• Municipality of Anchorage
`� - On-Site Water and Wastewater Program
(907) 343-7904 E SEP-. 8'20?1,4 glpoitikz.
Certificate of On-Site Systems Approval
r!i 9�
Parcel I.D. 015-234-51 Expiration Date: 7-11-1
1. GENERAL INFORMATION
Complete legal description Alpine Woods Block 6 Lot 10
Location (site address) 6500 Downey Finch Drive
Current Property owner(s) Katherine O'Grady Day phone
Mailing address 3328 Morgan Loop Anchorage, AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System Public Sewer ❑
WaiverNariance request for: Distance:
Ai N
Received b OA Lig ..!�1�.1ila� /i Date: ! D12 j
COSA to be released to the engineer,unless otherwise requested he engineer.
COSA Fee $ VP15t)+S Waiver Fee $
Date of Payment 61I 0I Date of Payment
Receipt Number 06o10009I.7 Receipt Number
COSA# Obr O-Itki3 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 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.
In conducting an adequacy test, I attempt to provide a thorough, conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.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 soil
condition, ground water levels that may fluctuate during the year,and the water usage of the family being served by the 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 encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 9/27/2017
' A`� ,k
oei\Q
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6. DSD SIGNATURE " '
System #1 Approved for t bedrooms •SIeven . l`aannnoone • jel
System #2 Approved for bedrooms CE-8149 r`
Disapproved �t �4FESS40NP
Conditional approval for bedrooms, with the following stipulations:
�•�,4 ti�tirrrrr�
jpty_S1TE 01 .
Wp,TERAND o^
PROGRA
WASTEWA
M T
A'�FNT SERV ,
�c
Original Certificate Date: t ^ (
7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the 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.
7. ATTACHMENTS:
•
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA bL.e sheet_E
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: Alpine Woods Block 6 Lot 10 Parcel ID 015-234-51
A. WELL DATA
Well type Public If A, B, or C provide PWSID# Well Log (Y/N)
Date completed Sanitary seal (YIN) Wires properly protected (YIN)
Total depth ft Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/MaterialeptlC/steel Date installed 7114/2016
Tank size 1250gal Number of Compartments 2 Cleanouts (YIN) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (YIN) N/A
Date of pumping NEW Pumper N/A
C. ABSORPTION FIELD DATA
Date installed 7/14/2016 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.6 GPD/SF System type Deep Trench
Length 56 ft. Width 2.5 ft. Gravel below pipe 9 ft.
Total depth 12 ft. Eff. absorption area 1 008 ft` Monitoring tube Y Depression over field N
Date of adequacy test NEW Results (Pass/Fail) For 4 bedrooms
Fluid depth in absorption field before test in Water added gal. New depth in.
Elapsed Time min. Final fluid depth in. Absorption rate >= g p d
Any rejuvenation treatment (past 12 mo.) (Y/N & type) If yes. give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at in. "Pump off' level at in. High water alarm level at in.
Datum Cycles tested Meets alarm& circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 10+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
G. ENGINEER'S CERTIFICATION _s`OF AkI I
I certify that I have determined through field inspections and •
rf faP 4 .1 v��
review of Municipal records that the above systems are in fir; ,,• 1H-I %\ ••*T0
conformance with MOA COSA guidelines in effect on this date. /-•- E
Engineer's Printed Name Steven Pannone 1-•.�}even . 'anno -
Date 9/27/2017 *'•90'4CE-8149 ii
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V SHANE A.HOLT
NO CORNERS SET-HIS DATE
4LS 6914�p'DFess,on v3=.5?
Q�Opp�po4 I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
SURVEY CRJLRLO ST
LAURA HALVFRSO.N@ OF THE FOLLOWING DESCRIBED PROPERTY
Rs'AAA CPR6PFRTFS LOT 10, BLOCK 6, ALPINE WOODS SUB.
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS.AND IS
NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES,IMPROVEMENTS.OR FENCELINES EXIST OTHER THAN NOTED.
EASEMENTS OF RECORD.OTHER THAN THOSE APPEARING ON THE RECORD PLAT ARE NOT SHOWN DATED AT ANCHORAGE,ALASKA THIS _13TH DAY OF
HEREON(UNLESS INDICATED) SEPTEMBER , 2017.
NOTE. FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE —
PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS
HOLT LAND SURVEYING
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
9309 GROVER DRIVE
A NCHORAGE,AK 99507
13686, FB 184-20 345-5513
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
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
7~1 (? '~f;?/~/ Telephone: Home "~'- ~q'~-' Business ~.¢,_-~'- ~-/',--.~ '~'
Applicant
Name
/
Applicant is (check one): Lending Institution [] · Owner/builder~l~; Buyer [] · Other [] (explain);
(d) Lending Institution /~.c,~]%R~ /"i(/-FL./~C .~,~,~/'tY~ Telephone
Address
(e) Real Estate Company and Agent '--'- /I, ~,,.-/~:~~ 'o'-'--
Address
Telephone
(f)
Mail the HAA to the following address:
Number of Bedrooms
Other
WATER SUPPLY ~///p
Individual Well [] Communit ublic []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
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.
Page 1 of 2
72-025 (11/84)
ENGINEERING FIRM PROVIDIN~ JSPECTIONS, TESTS, FILE SEARCH, DA', 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 /~,~--"-~-' .~- ,Z~'-'~ (' Telephone . 5~'/~ _S'"c?
DHEP APPROVA~L ~
Approved for bedrooms by /j
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 (11/04)
WELL DATA
DEPT. OF HEALTH &
B~VlIKa~NTN. ~ROTECTION
MUNICIPALITY OF ANCHORAGE (MOAj
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984 0C'~: 264-4720
Legal Description:
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Welt:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Man hole
Water Sample Collected by
Water Sample Test Results
Comments
Date Com
If A, B, C, D.E.C. Approved~(Y//N)
Yield
of Grouting
Pump Set At
;nitary Seal on Casing (Y/N)
De Around Wellhead (Y/N)
; On Adjoin
To Nearest Public
To Nearest Sewer Service
; Date __
Lots
Lot
B. SEPTIC/HOLDING TANK DATA
Date Installed 7-~'~)-'-'~¢-~ Size /~,'~'¢' No. of Compartments
Standpipes~N) :' Air-tight Caps(~N) Foundation Cleanout'~N)
Depression over Tank (Y~ Date Last Pumped
/CA.
Pumping/Maintenance Contract on File (Y/N) ; for
Holding Tank High-Water Alarm (Y/N) /~///~ Temporary Holding Tank Permit (Y/N)
//6
Separation Distances from Septic/Holding/Tank:
To Water-Supply Well ~'-~ _,~
To Property Line
To Water Main/Service Line
Course /OO
Comments ~ ~'~'~' ~-~:~/
To Building Foundation
To Disposal Field ~'.--~-
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABsoRPTioN FIELD DATA
Soils Rating in Absorption Strata
Width of Field
Square Feet of Absorption Area
Depression over Field (Y(~)
Results of Last Adequacy Test
Type of System Design
Length of Field ~--~
Depth of Field
Gravel Bed Thickness ,~'
Standpipes Present
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
!
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
/
To Property Line 1/~'-
To Existing or Abandoned System on
/
; On Adjoining Lots ~
To Cutban~k (if present)
Comments
D. LIFT STATION
Date Installed Dimensions //
Size in Gallons Manhole/A~)
"Pump On" Level at ~ "Pun:kedDff" 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 havre ch~ed, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~ Date //f¢--,-~- ~ ~
Company ~'~' ~-~ ~' MOA No. ~---0--~ cC/
Receipt No. ~-~q
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
~.~ te ~ ·e ~" ,
~_.,~ ~, *%~F 2'~ Engineers Seal
~ ~ ~ ~. Reid~ Jr, ~
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA g9501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
MUNICIPALITY OF ANCHORAGE
DEPT. OF
RECEIVED
To Whom it May Concern:
~~s on file in this office the
Water System is in compliance with the Stale Drinking
/
Water Regulations
Sincerely,
0.~
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