HomeMy WebLinkAboutLILAC PARK BLK 2 LT 8 Municipality of AnchoragePage
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: .Sg~,/ql C)I~CP PIDNumber:_d31~-
Name:Wastewater System: ~New D Upgrade
Address: ABSORPTION F~ELD
Phone: No. of Bedrooms:
~ ~ Deep Trench ~ Shallow Trench ~ Bed~ound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION Soil Rating:
Lot: ~ Block: Subdivision:~'~ ~ Depth to pipe botlom from originalgrade: Gravel depth beneath pipe
Township:~.~ R~n~: ~ Sec~:_~ ~ ~ Pill added above~ ~°riginal~l grade: Ft. Gravel length:~o Ft.
WELL:~ New ~ Upgrade Gravel~: ~¢~ Number of lines: Distance belween lines:
Classificatio~ (Private, A,B,C): Total Depth: Cased To: Total absorption area: ~ Pipe material:
Driller: Date prilfed: Static Water Level: Installer:, Date igsta[led:
Pump Set at: Cas'ng Height Above Ground:
~'~'~: /~ ~.~ ~, ~ ,,. ~ ~,. TANK
SEPARATION DISTANCES ~s~ptic ~ Ho~ing ~S.T.E.P.
To Septic Absorption Lifl Holding ~ublic/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~.~ ~
Well ~ J ~ ~?~ ~ ~/~ Material:~ Numberof Compartments:
Surface
Water ~/~ H/A N/~ w/~ ~ LIFT STATION
Lot Size in gallons: Manufacturer:
Line ~O t~ ~O ~ ~¢
"Pump on" level at: "Pump off" level at: High water alarm at:
~o.nd~t~o. / ~ V~ ~ ~ ~¢
Curtain Pump Make & Model
Remarks: BENCH MARK
· ~ %~ ¢~ ~¢.~_ ~ ~. Location and Descriplion~
.I L*~.' /1 0 ,~c~ [I Assumed Elevation:
Department of Health and Human Services approval
Reviewed and approved by'. ~-~% Date'.
72-013 (1/91)MOA 25
Header
ted 8
I I I I I' I/~' Ho/e~ ~ ~o'
442 LF Total
F~
Foundat/on Clean our
o
M/r ~ ~
6 in,
4' Topsoil ~ Non~tot / l:lrlglnol Ground
3' Cover/ / /' Exist, G, ound
I05,4 , ~ ,/ ~ ~ 101,00 ~ "" ~ lO0,Z~ 4' N/n Cover
...... 90,8 __~ ~
o~ Septic ~ 89,3
qO ~ ~4 ~ r~H 5~r~ge Sl~, [lev, I00,00
TOBBEN SPURKLAND P,E,
E03 W 15TH, AVENUE
ANCH, AK, 99501
.<907) P79-.qg~
IlSEPTIC SYSTEM AS BUILT
BATE, Apr/I 29, 199£
SHEET~ 3/3 GRIB~
N
S£ALE~ I' -- 60 Fl,
TFIB3EN SPURKLAN]) P,E, II
;°03 W tSTH, AVENUE II
ANCH, AK, 99501 II
(907> 8~9-$916 I I
L~lr 8, £L~ICK ~, LILAC PARK
SE£TIDN £2 TI£1~ R3W
£R1AN CARR
IISEPTIC SYSTEM AS I~UILT
I DATE, APRIL £9, 1998
I SHEET, 8/3 6RID, 8736
top of casin9
other
· i
L<y,, .zj.> ~ .. -<_, - ....
oePt kte
SECTION OTRS
DIVIDION OF GEOLOGICAL AND GROPNYEICAL SDRVgY$
WATEk WELL RECO~)
! [7],~ / E~ I
WELL OW~rER: %' > . ~ ; .~, '-
~LL Dg~?Jl: DATE OF CO~ON
Depth of ho3.e:
Depth Of caSin~
. .~ ~. ~ ~. . _L~._~__-_~.
ME'fi{OD OF DRILLLNG:
[_-~cablc
{~air
['] Ot he r: ........
USE OF WELL: ~]domest.~c
CASiaG; ~' ' ' '"
Depths of opcn'~ings~ t,
SCREBI'4 TYPE :'"~" .....
Slot/Mesh Size: '-' :':..i
,~ (-, ~ Between and
Volume used: ...... ~--.. ~
GROU'J' TYPE: ~-~... ~
i)epbh: ~rom ..........
DEVELOPNENT ME'/'i40I):
Durat ion;
Date Puml~
WATER CHI,]MIS'PRY SAMF'LE
PLEASE MA.T.[, WHI[I'K C:Oi,
DA YS 'J'O :
DGGS
PO .;30X 77-2.12o
EAGLE .RJ__'VER, AK, 9~q'/7
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910170
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:CARR BRIAN L ~ CAROL J
OWNER ADDRESS:12221 LILAC DR
ANCHORAGE, ALASKA 99516
DATE ISSUED: 6/26/91
EXPIRATION DATE: 6/26/92
PARCEL ID:01521132
LEGAL DESCRIPTION: LILAC PARK BLK 2 LT 8
LOT SIZE: 84329 (SQ. FT.)
NUMBER OF BEDROOMS: 5 THIS PERMIT: 5
THIS PERMIT IS FOR THE CONTRUCTION 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 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
SYSTEM WILL NOT BE CONSTRUCTED UNTIL THIS OFFICE HAS
COMPLETED THE REVIEW OF THE THREE COMPARTMENT LIFT STATION
OR AN EXISTING APPROVED LIFT STATION IS SUBSTITUTED FOR THE
PROPOSED LIFT STATI __~
RECEIVED BY: ~ /~'- '~J7~2~(,{~! DATE:
6751 ~J. ~I)t(}i~D E~LVD,
ANC?!ORAGE, ALASKA
(907)
SEPTIC SYSTEM DESIGN
BRIAN CARR
BED
TOTAL LENGTH
TOTAL WIDTH
TOTAL AREA
'TOTAL DEPTH
ROCK DEPTH
COVER
8-~ F'r.
30 F T.
2520 Sg).. FT.
4 F'r.
O. 5 FT.
3.5 F'I'.
SEPTIC TANK 1500 GAL.
500 GAL. PUMPSTATION
TANK ALERT CONTROL PANEL.
MERCURY FLOAT SWITCHES
PUMP ABS.SEVH 4W 40 GAL ~ 20 FT.
SF'ECZFZCAI'IOIqS fOl:~ CSEF"Fi[] S¥Si-F.M INS'i-Al LATION
LEI]' 13 ~I..OCI<i_,='~'., L_[L~-~C F:'ARI'::i SE[]..:'=":'..,_. Tli. 21'q FC:51,,J
1. O FSENERAL
'L h (.:.::~ i.' c? c, i'" ~.:: % ~:e ~ 'L ,=~,. 'L J 'v c? (::,.f: [:. h ~:? (] ,4 r'~ c:,~l.-' ,, T h [~:, ~:~.(:! <:i r- c.~ % % :i s J. :L '::? 0 0 ]] r-~ <::! ~ s
~'.F'I,;/ l/J?:~t¥'~ F:~dICIJ(:)t'.:~(::ieZ' ;"?',;:i ]. 2~. I:::'[ii:]liO?
· !.'.'.(::~ J, rl!~.'~:,:.'~]. ] '!::}ii %: ,r.:lF'(:).j(.)c::t',, 'JJ'~.::, I~CII~it:i'"aC:-JSOF' /w,..l!i~!. l::i(.,:.:'
j:::c.:/ L!~C~ Hum:i. c::i. pal. :i. '!:y (:)'[: Ar~(:::l'~c)r",'~((:l(::, ~ [:)(:q:)a,u'"Lme?l~L (::)'F I h.x, ,'../ ]. i'.h
hh.u'n,",.J"~ Sh'~F'x,':L (::(.'.':.!~..
2,,0 SEPTIC TANK
4.3 E{s[:al:) ]. J ~.1'~ ,xu~ el. [::,vat J. c:~l'~ f::)~:u '~(:::lirm:u" I:: ,, "i'h :i. s BM
a F' I::) :J. i'. F a F' "-.,,'
z~,, :t,':} I::t_u' ri:i. %l'l a c:(::¥:r?' (:~F a:l. :I survl:.~y r'icrt:.~..~!~ to '(:.1'-~:~ Er'~:l:i_ ne~,r ,,
5.0 ]: NSPEi:E:T t ONS
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: LOT i~; B~ ~,.
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth lo Water All ~11~ ~
Monitoring? .~ Date:
SITE PLAN
\
Reading Date Gross Net Depth to Net
Time Time Water Drop
.~. I.~ I ~: ~ ~- _. I ~/~
'¢.., ;o~ to$ ~° ~'/q
PERCOLATION RATE '~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FI AND ~""'FT
PERFORMED BY: I
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THA,,~T TI"tlS TEST WAS PERFOR~ IN
DATE: /,
/
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION 'rEST
/<., ,' ~ , (~GINEER's:SEAL) ', ',
DATE PERFORMED: .,~ '
LEGAL DESCRIPTION:
8
9
10
11
12
13
14
15
16
17
18
19
2O
LIKA(,.
Township, Range, Section:
SLOPE SITE PLAN
\
WASGROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT 0
DEPTH? p
E
Monitoring7 ~ ~f Date:--!
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
-- (minuteslinch) PERC HOLE DIAMETER __
TEST RUN BETWEEN __ FTAND __ FT
COMMENTS
PERFORMED BY: I CERTIFY THAT THIS TEST WAS PERFeX,lED
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:'"'~""~' """'~~
72-008 (Flev. 4/85)
IN
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:~
(ENGINEER'S SEAL)
8
10
11
12
13
14-
15-
16-
17
18
19--
20--
LIkAC
Township, Range, Section:
SLOPE
WASGROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT '~,~ O
DEPTH? /' p
SITE PLAN
geplh to Water Age~
Monitoring? /~ ,~_, gate:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE __
(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: I
ACCORDANCE WITH ALL STATI: AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE,
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
' {ENGINEER'S SEAL)
DATE PERFORMED:
Township, Range, Section:
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water Alter
Monitoring? Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~ ~-~)_. (minutes/inch) PERC HOLE DIAMETER ¢',;~ /!
TEST RUN BETWEEN ~'~ FT AND .._?--'~ ~
PERFORMED BY: I CERTIF¥~NAT THIS TEST WAS PERFORMED, IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ · C,(~-~-~.,L~-(_~.
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Waler Alter
Monitoring? Date:
SITE PLAN
S
L
O
· P
E
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE .._'-~/-/ (minutes/inch) PERC HOLE DIAMETER
PERFORMED BY: I CERTIFY T?tAT TRIS TEST WA~PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
t0
11
12
13
14
15
16
17
18
19
20
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~,-; ['Z6 "-~"(,~",--~ Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Oeplh to Water Alter
/floniloring? Uate:
SITE PLAN
%
",
%% 2~) ,
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RAMIE ~, L-/ (minutes/inch) PERC HOLE DIAMETER
TESTRU. BETWEE._ ¥ .ANO
COMMENTS
PERFORMED BY: I CERTIFY TI-tAT THIS TEST WAS PERFOBCED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:'N----* .~ /¢ ,..~.~. ~..,/.~UCC~.F/~(.,.,//,,¢,/',/
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~_r ENGII~ECR'S SEAL)
DATE PERFORMEI~i'~ : ~ '
.L/~.../'~c '~/~-~.~,. Township, Range, Section:
SLOPE
WASGROUNDWATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH?
.P
E
Oeplh to Waler Afler
Monitoring? Dale:
SITE PLAN
x,
'%
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE }~,~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN __ FTAND __ FT
PERFORMED BY: I CERTIFY TNAT THIS TEST WAS PERFC)~.M'ED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ,' '-/--'¢'1~/~--4¢'f--~/
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED? .
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth Io Water After
AdonitorinD? Date:
si'rE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
.. ,.,
¢; / I j o '1~
PERCOLATION RATE c,~-~'~_ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN _ .~ FTAND '~ FT
PERFORMED BY: I CERTIFY THA_~.,,T THI TEST WA PERFOR~ME~D
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ '- "~/,,~'~" '~
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Oeplh to Waler Aller
Moniloring? (]ale:
SITE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
~-'/(,'~/ I: 15' __ /fin
PERCOLATION RATE '( I~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN E~ETWEEN _ Z; FT AND :~ ?~-- FT
PERFORMED BY: I CERTIFY THAT THIS TEST WAS PERFOF.~J~D IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: , .'~DC(.,g z .
72-008 (Rev. 4/85) ~/
PERFORMED FOR:
LEGAL DESCRIPTION:
,'--'.. EN'G NEER'SSEAL~ 7,
Township, Range, Section:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG w PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
S
L
IF YES, AT WHAT O
DEPTH?
· P
E
Depth Io Water Alter
MonilorinD? Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~ ~'2 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
PERFORMED
CERTIFY TFIAT THIS TEST WAS PERFORM, L~N
BY:
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS ~&~','4,"~/~ _ ..
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(~N, GINEER'S SEAL)
~ [('/- (L-[)~ Township, Range, Section:
WAS GROUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
S
L
IF YES, AT WHAT O
DEPTH? p
E
Deplh to Water Alter
Monitoring? Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
(~. ir/..~ I1/-,.i~ - ~,'l~).,~.~,
PERCOLATION RATE _7~ '~_ (minutes/inch) PERC HOLE DIAMETER _
TEST RUiN BETWEEN ~_ FT AND ~ / '_ FT
PERFORMED BY: ~ ~ I CERTIFY THA~, IS TEST WAS PERFORMED IN
72-008 (Rev. 4/05)
PERFORMED FOR:
.-~' (ENGINEER'S SEA:L)"~. --
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
I0
11
12
13
14.-
15
16
17
18
19
20
Township, Range, Section:
~"~ ~ I'~., '~.....,~ SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Daplh Io Watar Altar
Monitoring/ Dale:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
I,, iq'"~ I/:~..J'-- 3;, ~- [-~.~,~,-,~.~
'~ ': ~:4 ~ I q//~
PERCOLATION RATE
PERFORMED BY: ~')"~ % I CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: L~.,~/147. ~ ~ / q ~'/
72-008 (Rev. 4/85) ~
III
Parcel I.D. #
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA# ~
GENERAL INFORMATION
Complete legal description - ~,'~
Location (site address or directions)
Property owner _
Mailing address
Lending agency
Mailing address
Day phone
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~'
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to tile legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev, I/91) Front MOA
5.
STATEMENT OF INSPECTION BY ENGINEER
Ascert[fied 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 suppty
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
Address
Phone
Date
Approved for /
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
Date ~////,//~ ~:~'-'
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 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 engineer's work.
72~)25 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription:_koZ~-~;' F~'2 ].-,'~/~cuck ParcelI.D.
A. WELL DATA
Well type ~-~
Log present (Y/N) y
Total depth ¢2.~ '~
Sanitary seal (Y/N) .'~//
If A, B, or C, attach ADEC letter.
Date completed ;7. 5' ~/ Driller
Cased to ,~o~ "7 Casing height
Wires properly protected (Y/N)
g.p.m.
ADEC water system number
/
FROM WELL LOG
Date of test
Static water level
Well flow /
Pump level
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
Septic/holding tank on lot ¢'¢~
; On adjacent lots
~,
o0
~ m
Absorption field on lot / "~O
Public sewer main
Sewer service line
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ¢2~ Nitrate _
/
Date of sample:
~ Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed "7/9/~/
Cleanouts (Y/N) ¢2_
High water alarm (Y/N)
Tank size / ~'~¢-~
Foundation cleanout (Y/N) .~/
Date of pumping
Compartments
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~ c~ ~'" On adjacent lots
To property line leo ~'~ Absorption field
Surface water/drainage _ /"//~
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed [~// Manufacturer
Size in gallons ~z~ Manhole/Access (Y/N)
Vent (Y/N) y "Pump on" level at ~D ~
High water alarm level c¢~) u
Meets MOA electrical codes (Y/N)
/
"Pump off" level at
Cycles tested IN/,,%
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on tot c~76:) On adjacent lots
Surface water
o. A.sO..T,O. F,EL .ATA
Date installed '7/?/q/
Length c~0 Width V'~,~_ ~/c~
Total absorption area ~-~00 ~
Depression over field (Y/N) ~
Results (pass/fail) ~
Peroxide treatment (past 12 months) (Y/N)
Soil rating '~ ~
Gravel thickness ¢tt
Cleanouts present (Y/N)
Date of adequacy test
for ~
If yes, give date
System type ¢"A"/~
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /50
To building foundation
On adjacent lots
Surface water /i//O
Curtain drain
On adjacent lots .'~ / u-o Property line
~'//~ ¢' To existing or abandoned system on lot
Cutbank P'/'~ ~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Engineer's Name ~.,c~,~ ~t¢ ,r[~[¢,~¢,(¢ ~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA21