HomeMy WebLinkAboutTIMBERLUX #3 BLK F LT 16 Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page 1 of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number:
OSP161233 PID Number: 018-271-82
Dwelling: 0 Single Family (SF) ❑ Duplex(D) ❑ Multiple(SF and/or D) Project: ❑ New I Upgrade
Name: ABSORPTION FIELD
Jordan Anderson
Address ❑ Deep Trench l Shallow Trench ❑ Bed ❑ Mound
1230 Balfour Drive #1 Anchorage, AK 99515 ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
357-9394 3 .6 GPD/SF 8.4 Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision
Block Lot 4.4 Ft. 4 Ft.
Timberlux #3 F 16 Fill added above original grade Gravel length
Township Range Section 3.2 Ft. 75 Ft.
Gravel width Beds.Number of Lines Distance between lines
SEPARATION DISTANCES 5 Ft. Ft.
To Septic Absorption Holding Sewer Total absorption area Number of trenches Dist.between trenches
From
Tank Field Lift Station Tank Line 750 Ft2 1 Ft.
Well >100' >100' >100' NA >25' TANK ❑Septic ®S.T.E.P. ❑Holding ❑Other
Manufacturer Capacity
Surface Water >100' >100' >100' NA I Anchorage Tank 1,250 Gala
Material Number of compartments
Lot Line >5' 4' >5' NA NA Steel Two
Foundation >5' >10' >5' NA LIFT STATION
Manufacturer Capacity
Curtain Drain None Noted i Gal.
Pump on level at Pump off level at High water alarm at
Remarks Flow Diverter Valve Placed.
Existing Trench on Line for Future Use. in. in. in.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank D3034Tank to D3034
Installer drainfield
Denali Excavating Drainfield D3034 CO/MT D3034
Inspector MEA BENCH MARK (Assumed elevation) 100.0 ft
Inspection
1e 8/18/16 2nd 8/22/16 Location and description
dates:
3° 8/23/16 4t Spa Concrete Slab NE Corner.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp
Conditional Approval: Date .••-•" "" ``( ���
•�..,o•''•. �1
I ''•�
-mss 49th °* �%
•r^C MICHAEL E. ANDERSON444:
v".- *•.� No. cE-43&1• i���
fiV7:-.4/...4'4'..
• .• r 4
��.' •• "f►� ,.1.::.4.
Approv-• ... --^^��"� Date -/3/ 'il*....•••
Inspection Report 9-1-12.doc
Municipality of Anchorage Page 2 of 3
DEVEOPMENT SERVICES DEPARTMENT
Permit Number: OSP161233 4700 Elmore Road Anchorage, AK.99519-6655-343-7904 PID No. 018-271-82
Lot 4
\
\
\A 13 \
S1 38.3' 35.0' \ \
S2 45.0' 41.8' \ \
FDV 48.8' 43.7'
C4 94.4' 78.8' \ \
M1 104.9'119.7' \ \
C5 105.0'120.4' \ \
, Lot 16\\ \
Lot 17 ,�h \
' 42,950 s.f. \ \ Lot 5
`y \\ \
,.4v \
40 C5 \� \\
WOODEN FENCE--N
Existin\\\\\\\AbsorTrench 0 \
\ C�\
S22C0 \
\\ 40 FDV C4 \\ �'\
• O 1
\ •
FCO `�\ \\ 0p\
O \� Seiv `b_e \ \\ Lot 6
V . �4 et Se'1-ipe \ 0y \
Nis ,,,„ ,, \ \
£' \, S \led \\c \
CiR \ �� \
C'C£ WELL
\c,""\ \\
\ LPP \
LEGEND N \��� \
MT Monitor Tube ?2. , \
FCO — Foundation Clean Out 12'2 \c_P \
X4.0+rF a1i4� TH — Test Hole <614/ \
.4 , 4\. CO — Clean Out 258• \ \
a,�' P;.''''' " ' �. 2C0 — Double Clean Out 62 \
C?:' t ��j FDV — Flow Divider Valve \ \
fir' 49th i\ .?*�� FSV — Flow Splitter Valve Lot 15 \
TIMBERLUX N0. 3
i6 0A-4-7
LOT 16, BLOCK F \
•70
' MICHAEL E. ANDERSON l a• \
20,351 S.F.
v. NO. CE-4381 , \
. � PLAN AS - BUILT \
�.� , ESSI ..-
.w`.....� SCALE 1' = 40'
Municipality of Anchorage Page 3 of 3
DEVEOPMENT SERVICES DEPARTMENT
4700 Elmore Road Anchorage, AK. 99519-6655- 343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number: OSP161233 PID No. 018-271-82
983
U 0 �Q
Existing Finished
it
1 11.11.1
Ground
—....— .—M;
1,250 Gallon
Septic Tank
93.95 L —_ 93.8
I v
U R I=– 0
- - 100.7 104.5
/Finished Grade 97.5 /
oG
Geotextile Fabric -
93.1
1 Drainfield Rock 93.1
l
89.1
81.0 75'(Trench Length)
Groundwater @ 83.5'
5-21-92
•••-% OF 44 44ii•
17 1 •�
49th )� * *•
� °O
'•111,4(41.4t 4
-� C;MICHAEL E. ANDERSON
PROFILE AS-BUILT
�V✓ .• NO. cE-4381 a
�V�
No Scale ♦'4 R�ws�Im. *-
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT/ON-SITE WATER AND WASTEWATER PROGRAM
4700 ELMORE ROAD, ANCHORAGE, AK 99519-6650
SOILS LOG - PERCOLATION TEST
PROJECT #:
PERFORMED FOR: Ginger Hubbard DATE PERFORMED: 8/23/17
LEGAL DESCRIPTION: Lot 8,Block 3,Denali View
TEST HOLE # 1 SLOPE SITE PLAN
•■ 4
OG/OL
I
2 . a.
' See Site Plan
3 . ..•,....
a
4 ,: •: Gravel/Sand
.a : • with Minor Silt
5 r' i� GW/SW
6 • °
7 1 1—I I BOH
^III Bedrock
8
WAS GROUNDWATER
9 — ENCOUNTERED? No S
L
10— IF YES, WHAT DEPTH? Q
DEPTH OF WATERNone P
I — AFTER MONITORING: E
DATE: 8/30/2017
12-
13— ♦♦♦♦'+OF Ai 1* READING DATE GROSS NET DEPTH TO NET
♦ '�� TIME TIME WATER DROP
. �:' �, 1� 1 8/24 8:10/8:20 10 0"/3.5" 3.50"
14— �`:'� 49th . '.*�� 2 8:21/8:31 10 073.5" 3.50"
15— i1 4 3 8:32/8:42 10 073.63" 3.63"
I,o: hal a SON ;W g 4 8:43/8:53 10 0"/3.5" 3.50"
IPA
0"/3.63" 3.63"
+j�%: No. CE-43111 :'z�74 5 8:54/9:04 10
16-- 1♦e"?.."ez,.,?4Y-it.,../k?"k?" 6 9:05/9:15 10 0"/3.63" 3.63"
17- •
♦••�'PRO�w���;••♦
18
PERC RATE: 2.8 MIN./INCH PERC. HOLE DIAMETER: 6"
TEST RUN BETWEEN_ 2.0 FT. AND 3.0 FT.
COMMENTS: Test Hole Pre Soaked Prior To Percolation Test.
TEST PERFORMED BY: MEA I, MICHAEL E. ANDERSON, CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE
WITH ALL STATE AND MUNICIPAL GUIDELINES ON THIS DATE: 8/25/2017
MUNICIPALITY OF ANCHORAGE sooguellilli,
DEVELOPMENT SERVICES DEPARTMENT .',Pel-...9.t.'''••....
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650 Iif I t: .49th �^► '1,*
*•
•♦♦
SOILS LOG - PERCOLATION TEST0 –.1-.- c= �� :;—
1 :MICHAEL E. ANDERSON ii
♦c .
• No. CE-4381 �,
LEGAL DESCRIPTION: LOT 2, MOUNT BALDY ESTATES ..04 ,•:4-9:"375.0"..
' :
PERFORMED FOR: TROY DAVIS HOMES ♦les, -;;w4•�
DATE: 5/11/17 PROJECT No.: Professional Engineers Stamp:PARCEL ID#: TECHNICIAN: M. ANDERSON
DEPTH TEST HOLE 2
(feet)
1 111111111111 OB/OG SLOPE SITE PLAN
2 • a
3 e '•L SILTY GRAVEL
WITH SAND
4 . .O GM
5 p SEE SITE PLAN
SILT/GRAY
6
7 BOH @ 7.5'
8 II11 BEDROCK
9 �I I I=
a • • WAS GROUND WATER ENCOUNTERED? No
10 IF YES @ WHAT DEPTH? S
1 1 _1 I r—___ DEPTH OF WATER AFTER MONITORING:
DATE OF MONITORING:
12 r----=-7111 DEPTH To
13 DATE READING GROSS TIME NET TIME WATER NET DROP
(MINUTES) (MINUTES) (INCHES) (INCHES)
14-
15-
16
17
18
19
20
PERCOLATION RATE: (MIN/INCH) PERC. HOLE DIA. (INCHES)
TEST RUN BETWEEN: FT. and FT.
COMMENTS: TEST HOLE TO VERIFY BEDROCK DEPTH.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 2/14/18
MUNICIPALITY OF ANCHORAGE ..�i��� 1111,'
DEVELOPMENT SERVICES DEPARTMENT ��r4N)`,. .. ""'� y
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650 .� `�. ••
49th . •
SOILS LOG - PERCOLATION TEST $ --I 1
MICHAEL E. ANDERSON T,
LOT 2, MOUNT BALDY ESTATES •✓ No. CE-4381 ' .
LEGAL DESCRIPTION: • �
PERFORMED FOR: TROY DAVIS HOMES . �:.. ". ••'::••
DATE: 5/11/17 PROJECT No.: 1111"s11
PARCEL ID#: TECHNICIAN:
M. ANDERSON Professional Engineers Stamp:
DEPTH TEST HOLE 3
(feet)
1 OB/OG SLOPE SITE PLAN
2 . e
3 .O ••L SILTY GRAVEL
WITH SAND
4 GM
b
•
O • SEE SITE PLAN
5 • SILT/GRAY
6 • • d
7 BOH @ 8'
8O BEDROCK
1-1 11
9 =1 I.1=
F- •
WAS GROUND WATER ENCOUNTERED? NO
I 0 IF YES @WHAT DEPTH?
DEPTH OF WATER ALTER MONITORING:
11 =I I I— DATE OF MONITORING:
12 1=1II DEPTH To
DATE READING GROSS TIME NET TIME WATER NET DROP
13 (MINUTES) (MINUTES) (INCHES) (INCHES)
14-
15
16
17
18
19
20
PERCOLATION RATE: (MIN/INCH) PERC. HOLE DIA. (INCHES)
TEST RUN BETWEEN: FT. and FT.
COMMENTS: TEST HOLE TO VERIFY BEDROCK DEPTH.
TEST PERFORMED BY ANDERSON ENGINEERING. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON THIS
DATE: 2/14/18
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: ~ t;~'q2..O ~.'7 O( PID Number: C3 1 ~, - ~ l- ~
Name;
Wastewater System: D New ~pgrade
~O( Z~HS~U~ Ct~ ABSORPTION FIELD
Phone:
lNg, or.gems:- ' D Deep Trench ~hallow Trench ~ Bed D Mound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION S°HRating: · ~ GPD/Sq. Ft.
Lob Block: Subdivision: 3epth to pipe bottom from original grade: Gravel depth beneath pipe
WELL: D New ~ Upgrade Gravel d~Dm~ ~ ~ Ft. Number~of gnos:~lDist~nc°
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: ,
Yield:GPMII Pump Set at: Ft.I[ Casing Height Above Ground;Ft. TANK
SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P.
TO Septic Absorption Lift Holding Public/Pr[vat~ Manufacturer: Capacityin gaOleRs:
From Tank Field Station Tank Sewer Lines ~HC~ ,m~ N ~ [ ~
Well [~ [~5 -- -- ~ Material: ~,. -- ' Numberer Co~dments:~
Surface
w.~ ~ ~ ~ ~ - LIFT STATION
LineL°t ~ ~ ~ ~ ~ ~ ~ ~ Size in gallons: J Manufacturer:
I
Foundation ~ ~ -- ~ ~ 'Pump on" level at: I "Pump off" level at: High water alarm at:
CudainDrain _ ~ ~ ~ ~ Pump Make & Model Electrica~ Inspections pedormed by:
Remarks: BENCH MARK
Location and Description:
I Assumed Elevation'
.
2nd
of
Heallh
~e~ar,men, and Human Services approval :r,:~ ~:-_,,,,0;r¢~',
Reviewed and approved by: 4om~ %,,,~ Date: /O/q/q> ~':~" ~
72~)13 (1/91) MOA 25
!
/
_J
/
/
! \
!
/
\
\
TBBBEN SPURKLAND P.E.
203 W 15TH, AVENUE
ANCH, AK, 99501
Lilt ~6 ~LllCK F TIM~£RLUX
SEC, $~, TI~N ~3~
[OH PlA TTENgU£GE£
SEPTIC SYSTEM AS BUILT
DATE, DC~ ~ 1992
SHEET, 2/$ GRID, ~$6
Monitor
Cleon Out
Stondord Trench ~
3' l/ide
75' Lon9
9' Deep
5' Se~er rock
4' Cover
1£50 gal SepYnc tank
Anchorage Tank
98
Miro£! 140
93
5 £t o£ Septic Rock
Cleon Out
Monitor
3
Double Cleon Outs
Foundation Clean out
/ ~ ~ ~ 4' Cove¢ ~
~ ~. INSULATION
1250 gaL septic tank
TBBBEN SPURKLAND P,E,
803 ~15%h Ave
Anchorc§e Ak 99501
LgT 16 Y?LDCK F TIMY?EPLUX #3
SECTION 34 T12N RS1,/
TOM PLA TTENBURGER
T~gM, GARAGE FLEER SLAB
A.9.~IIMF17 FI FV. lbO. DE
SEPTIC SYSTEM AS SUILT
rare, OC~ 8~ 1998
sHE~T, 3/3 ~' 3136
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
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920279
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:PLATTENBERGER THOMAS C &
OWNER ADDRESS:4601 TIMBERLUX CIR
ANCHORAGE, AK 99516
DATE ISSUED: 9/11/92
EXPIRATION DATE: 9/11/93
PARCEL ID:01827182
LEGAL DESCRIPTION: TIMBERLUX #3 BLK F LT 16
1
LOT SIZE: 42689 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
DATE:
DATE:
20~ i~ 15~h. Awnue, Suit~ 20~
ANCHORAGE, ~L~o~,., 99501
(907) 279-~916
SEPTIC SYSTEM DESIGN
16 BLOCE( F TI~4BER_u~ ". ~-:
ROBERT HODGES
SYSTEM CONF:B:~-~:-u~. iON
STANDARD TRENCH
TOTAL LENGTH 75 FT.
TOTAL WIDTH 5 FT.
TOTAL DEPTH ~ FT.
ROCK DEPTH 5 FT.
COVER 4 FT.
SEPTIC TANK VERIFY
OF EXISTING i25 GAL TANK.
REPLACE IF LEAKING
INSTALL TANK CLEAN GUT
PUMP BOT~ ~O~PARTMENTS
ABANDON EXiSTiNG TRENCH
INTEGRITY
I...cr[. :1.6 ~3 l oc: f-:: F' ]':[ mber' l ux
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
13-
14-
15-
16-
17
18
19
2O
COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 %" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Ho L.~
ENGINEER'S-sEAI~)':, ,
Township, Range, Section:
SLOPE
WAS GROUND WATER ~- ~
ENCOUNTER ED? I'%4 O
L
IF YES, AT WHAT
DEPTH? pO
E
ilrlOniloring? J ~ Dale:
SITE PLAN
I
N
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch) PERC HOLE DIAMETER ~ I)
FTANO
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
1
2
3
4
5
6
7-
9-
10-
11
13-
14-
15
16
17
18
19
2O
Township, Range, Section: [~1~1 t t~. ~/_.~') ~e...~....~/
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT ~-
DEPTH? . pO
E
Oopth to Water Alter
Monitoring? Dale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE O~O (minutes/inch) PERC HOLE DIAMETER
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
TOB3EN ~PURKLAND P.E,
803 W 15TH, AVENUE
ANCH, AK, 99501
LOT I6 ~LI1CK F TIM~ERLUX
SEC. 34, T1~N RSW
TOM PLATTEN~U£GER
SEPTIC SYSTEM DESIGN
DATE: AUG. $0~ 1992
SHEET, 1/$ GRID, $156
/
/
/
/
AYgANDON EXIST. TRENCH
INSTALL [RENCN
TDBBEN SPURKLAND P,E,
203 W 15TH. AVENUE
ANCH, AK, 99501
LDT 16 BLD£K F TIMBERLUX
SEC, 34, TI2N £3W
[DM PLATTENBURGE~
SEPTIC SYSTEM DESIGN
I)AT£, 4U~. 30, 199£
SHEET~ ~/.? -RID, 3136
Monitor
-I
Clean Out
ND SCALE
Standard french:
3' F/ide
75' Lan9
9' Deep
5' Sewer rock
4' Cover
Cleanouts
3
EXISTING
]250 gal £ept/o tank
.Double Clean Outs
-NSTALL
i,dotlon Cleon out
~ra£! 140
5 Ft oF Septlc Rock
Monitor
4' fopsoll
4' CoveF
1250 got septic tank
Exist, 5round
NO SCALE
TDBBEN SPURKLAND P.E,
203 W15~h Ave
Anchop~ge Ak 99501
LO[ i6 y?L~TCK F [IMY?E£LUX #3
SEC[ION 34 []2N R3W
TOM PLA TTEN£UNOER
SEPTIC SYSTEM DESIGN
~AT~, AU~ 3~ 1992
SHEEZ, 3/3 GRI~, 3136
oGREL jR ANCHORAGE AREA BO[ jGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME /_~//S /~d~ /).-.~'~'~_'~_'.~,.,)~ _ MAILING ADDRESS ~'~S'/ .F. ,~,~"-~/~ ,X~/'F~/'/ PHONE
LOCATION LEGAL DESCRIPTION ,,~.,0~-- /~ /~-~/~lT /2' /-~,,¢~/,~t=[Z,/~,,A,- ,.~-,~
SEPTIC TANK:
DISTANCE
FROM WELL ~'
INSIDE LENGTH
MANUFACTURER (~' 4'~'t~'~
INSIDE WIDTH
. MATERIAL
LIQUID DEPTH
NUMBER OF
__COMPARTMENTS
LIQUID C A PAC I Ty/,,~-~-~ G A L LO N S.
TILE DRAIN FIELD:
DISTANCE FROM WELL ////~:)~'~-- FOUNDATION /~I'~h' _NEAREST LOT LINE
NUMBER OF LINES DISTANCE BETWEEN LINES /Y//~ TRENCH WIDTH
ABSORPTION AREA /'/F~'V SQ. FT. LENGTH OF EACH"LINE
DEPTHr TOP OF TILE TO FINISH GRADE // ~ DEPTH OF FILTER
MATERIAL BENEATH TILE
TOTAL LENGTH /,
OE L,NES
IN. TOTAL EFFECTIVE
?" ^BOVE T,LE
IN.
WELL:
BUILDING
FOUNDATION__
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
NEAREST
SEWER LINE
DEPTH
SEPTIC SEEPAGE
TANK SYSTEM
REMARKS
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL: '~'~5/ ,,~'/,~,~,4"
LOT SLOPE:
REMARKS:
Form EQ-032
DIAGRAM OF SYSTEI~,~. WNF..
DATE
GRl~j../er ANCHORAGe Area B~,~,/UGH
DEPARTMENT OF' ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-456 l
SEWAGE DISPOSAL SYSTE~ -- APPLICATION AND
INSTALLATION OF: SEPTIC TANK / SEEPAGE PIT ., DRAIN FIELD
FINANCED THROUGH TO BE INSTALLED BY
COMPLETION DATE ANTICIPATED d O ~ '~ f'~"~ .~'~.'~ /~/~
FINAL INSPECTION: 24 HOUR NOTICE REGUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL G}UALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION·
~2~-e w~ .s:e~ i'~- .~
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEEPAGE PIT
, DRAIN'FIELD
DRAIN FIELD
· SEEPAGE PIT ~' (~1
ALSO CONSIDER AREA WELLS.
DIAGRAM OF SYSTEM
WATER MAIN TO SEPTIC TANK , SEEPAGE PIT
DRAIN FIELD .
P,T
TO RIVER· LAKE· STREAM,
CAST IRON INTO AND OUT Of SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION S FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM .~S IN ACCORDANCE WITH SAID CODE.
DATE APPLICANT'S SIGNATURE
FORM NO. EQ-016
GRI='ATI(R ANCHORAGE AREA BOROUG[F
DEPARTMENT OF ENVfRONMENTAL QUAI.~TY
3330 "C" Street
ANCHORAGE, ALASKA 99503
Performed For ~! LT/)U~
Legal Descrip~ion~ Lot ~
This Form Reports Soils Log
Case'#
Soil Test Must Be Logged To ~'
Depth
Feet Soil Characteristics
1
1
12~
13~
14--
1]~I-F'I-~E~D~'mN Dated Performed
Block F Subdivision '~M~R[u~
~ Percolation Test
Below Proposed Seepage System
Was Ground Water Encountered?
If Yes, At What Depth?
Reading Date Gross Time Net Time Depth. to H20 Net Drop
_!
I I
Percolation Rate Minute Proposed Installation: Seepage Pit
Depth of Inlet Depth ~o Bottom of
Drain Field
Pit Or Trench
Date Certified BY:
Date:
~1--~V DRILLING, Inc.
p. C~. BOX 4'1224 · 1310C International Airpor[ Road
(907) 274-461l
ANCHORAGE, ALASKA 99509
Well Owner_
DRILLING LOG
Dittbender
.Use of Well
Location (address of: Township, Range, Section, if known; or distance main road
Dom
L16, Blk F, Timberlux Subdiv.
6 ~Dept~ of Hole
20 ft. (~e)
); Perforated (
Size of casing
Static water ]eve]
Screen (
Describe screen or perforation
Well pumping test at 8 gallons per ~ (minute) for
oJ~ drawdown from static level.
Date of completion 23 Aril 1975
41 feet Cased to 40 feet
(below) land surface. Finish of well (check one)
).
None
1 hours with 100 ~
open end (
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
0 TO_ ~ ORganics
TO.
TO.
.TC
TC
TC
TC
TC
T£
TC
TC
.TO
TO
TO
TO
x );
~5
27
35
36
38
6
8
25
27
35
36
38
41
Small Gravel: silty
Medium Gravel: occ cobbs
Small Gravel;
Boulder
silty, occ bouldrs
Silty Gravel
Water Gravel
Boulder
Water Gravel
1--CUSTOMER
6 � 89i0
?o
• IWIN
♦6C wi
• Municipality of Anchora• e
�- - SEP 2 9 2016 -., -,-
On-Site Water and Wastewater Prografh e.l� fD
(907)343-7904 ,\ E TY
b �
9
Certificate of On-Site Systems Appro - 6 a
Parcel I.D. 018-271-82 Expiration Date: 1_ 3 H
1. GENERAL INFORMATION
Complete legal description Timberlux #3, Block F, Lot 16
Location (site address) 4601 Timberlux Circle Anchorage, AK 99516
Current Property owner(s) Jordan Anderson Day phone 223-2200
Mailing address 1230 Balfour Drive #1 Anchorage, AK 99515
Real Estate Agent Day phone
2. TYPE OF DWELLING:
O Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: Three
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Q Individual lx I
Individual Water Storage Holding Tank I l
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 1Waiver Fee $
Date of Payment C1/1301110 Date of Payment
Receipt Number O12. 6 Receipt Number
COSA# Q5cgo<<{53 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.
Name of Firm Anderson Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 9/7/2016
s* .
49TH vi ' 4
6. DSD SIGNATURE •
of: � -
,? %^
System #1 Approved for `; bedrooms / :MICHAEL E. ANDERSON�
(44 of
System #2 Approved for bedrooms ♦%••• CE-4381 •••.
Disapproved p•'.....•p•\.c`'o'
114 ROFESSIO 4a►
Conditional approval for bedrooms, with the following stipulatiorma0m
..— I
By: .... Original Certificate Date: /^ 3 ! CJ
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 blue sheet_C '.- '. 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 #3, Block F, Lot 16 Parcel ID: 018-271-82
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (Y/N) Y
Date completed 4/23/75 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 41 ft. Cased to 40 ft. Casing height(above ground) '12 in.
FROM WELL LOG AT INSPECTION
Date of test 4/23/75 9/7/16
Static water level 20' ft. 22 ft.
Well production 8 g.p.m. 4.1 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mL Nitrate `- St(, mg/L
Arsenic 41.1) ug/L Date of sample: 8/31/16 Collected by: And. Engineering
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 8/8/16
Tank size 1,250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N
Date of pumping New Const. Pumper
C. ABSORPTION FIELD DATA
Date installed 8/22/16 Soil rating (g.p.d./ft2 or ft2/bdrm) .6 GPD/SF System type 5' Wide
Length 75 ft. Width 5 ft. Gravel below pipe 4 ft.
Total depth 11 •6 ft. Eff. absorption area 1 50 ft2 Monitoring tube Y Depression over field N
Date of adequacy test New Const. Results (Pass/Fail) For 3 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.
N
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 >100' On adjacent lots >100'
Absorption field on lot 100' On adjacent lots 100'
Public sewer main '75' Public sewer manhole/cleanout >100'
Sewer/septic service line >25' Holding tank >75'
Animal containment areas >50' Manure/animal excrete storage areas >100'
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 None Noted Wells on adjacent lots >100'
F. COMMENTS
Existing Trench Connected with Flow Diverter Valve.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and _�,`� OF /COIt
review of Municipal records that the above systems are in r► Q41, .••" ••. q 1I
conformance with MOA COSA guidelines in effect on this date. ar f7;.; ;_: -- , • •SI
Michael E. Anderson, P.E. %*.• •491L4 t% •"."7v04
Engineer's Printed Name .�. ` 0
Date 9/9/2016 j ,• .•.... • ..••.... . .
• MICHAEL E. ANDERSON :.
0I✓+f•. CE-p438I ,14.`::''''
, at
diI;oFESSto0-4`
COSA brown sheet 10-10-12.doc
\ Lot 4
\\ \
\ \
Lot 17 �`., Lot 16\ \
��`o* 42,950 s.f. Lot 5
44 14.2'x24.2' GARAGE \
'`�/ w/ CARPORTS \ \
•WOODEN FENCE �/ /
PROTECTIVE RADIUS / tTIc
a�
�� \ \
/ ES �
/ Sy \ .6• *0
.
U.fi A 6 5 9 .9 s \ 18.0'x19.0' SHED
‘''' co* \
'014r
WELL N I `
I / P' 1.4'x12.0' CANT \ \
10.2'x27.9' DECK \ \ Lot 6
\ /
2.0'x22.0' CANT N 2y2.2614,
'
1 STORY RESIDENCE 268.62• \ \
w/ DAYLIGHT BSMT. / \
2.0'x16.0' CANT
------ ,
\ Lot 15 \
10' UTILITY EASEMENTS \ \ \ --- ---- ---
\\\ V.
\\\ \ Lot 7
\ \, \
PLOT PLAN AS BUILT X SCALE 1" = 60' GRID SW 3136 Project No. 16-288/A1
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates , inc . (907) 522-6476 Phone ooOp
(907) 522-4625 Fax opo F q Copp4
Professional Land Surveyors kenOlangsurvey.com oC
jonathanOlangsurvey.com 4'\�•'... .
•�sOp
1 hereby certify that I have surveyed the following described property: Oo�P ,1,....\ '•�O�
LOT 16, BLOCK F, TIMBERLUX SUBDIVISION, ADDITION #3 (PLAT 71-240) (/)... 49TH /� •*��
Anchorage Recording District, Alaska, and that the improvements situated thereon are I 0
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed Q •� •• Q
premises and that there are no roadways, transmission lines or other visible �'�°, KENNETH i :.0 0
�� .
easements on said property except as indicated hereon. Q ,r� l icAtt(s .•' 00f
Dated this the Day of �Eyr�t�u�rs � Li4i4��'F� •.LS— 20 .••' c.
pg
, at Anchorage, Alaska ,o O o
� ,°q'SsioNA000�
It is the responsibility of the owner to determine the existence of any easements, Opppo
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
MUNICIPALIT~ 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
018-271 -82 ~ HAA #
1. GENERAL INFORMATION
Complete legal description
Lot 16; Block F; Timberlux Subdivision #3
Property owner
Mailing address
Lending agency
Location(siteaddressordirections) 4601Timberlux Circle
Anchoraqe, AK
Bruce Hilton/Thomas Plattenberg~yphone
4601 Timberlux Circle Anchorage, AK
344-0986
99516
Day phone
Mailin_g address
Agent
Address
Bonnie Mehner/Prudential Jack White
Day phone
344-0986
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well Xx
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 OFWASTEWATER DISPOSAL:
NOTE:
XX
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.
72-025(Rev. 1/91) Front MOA~2$
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 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 oom
ordinances, and regulations ~ ~¢~?~r ~te of t
Name of Firm ¢' fl~la~ewater Con,
Address
Engineer's signature
)liance with all Municipal and State codes,
ls inspection.
__ Phone ~?--~/7C~
Date
Wastewater C.?n. sultant lnc.' :
6. DHHS SIGNA~-~ ~ ;
~ Approved for ~E~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulatk)ns:
Additional Comments
The Municipality of Anchorage Dbpartment 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.
Legal Description:
A, WELL DATA
Well type PRIVATE
Log present (Y/N)
Total depth 41'
Sanitary seal (Y/N)
Mumcipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICE~iUG 0
Environmental Services Division -'-,
825 L Street, Room 502 · Anchorage, Alaska 99501
cr~w~(uJ~l~NTAL SERVICES, DIVISION
Health Authority Approval Checklist
TIMBERLUX ~5, LOT 16, BK F pa~tcel:l.D.: 018-271-82
IfA, B, or C, attach ADEC letter. ADEC water system number
YES Date completed 4/25/75
Cased to
YES
40' Casing height (above ground) 1'
Wires properly protected (Y/N)
FROM WELL LOG
Date of test 4/25/75
Static water level 20'
Well production 8 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate
Date of sample: 7/23/99
B. SEPTIC/HOLDING TANK DATA
Date installed g/21/~ Tank size
Foundation cleanout (Y/N)
Date of Pumping 7/7/99
ABSORPTION FIELD DATA
Date installed 10/7/92
Length 75" Width
YES
AT INSPECTION
.7/20/99
25'
4.3
g.p.m.
2.57 mg/L Other bacteria 0
Collected by: A.W.W.C., INC.
YES
1000
Depression (Y/N)
Number of Compartments __
NO High water alarm (Y/N)
Pumper ISAACS
2 Cleanouts (Y/N) YES
NO
Soil rating ~or ~/bdrm)
3' Gravel thickness below pipe
Effective absorption area 750 SO FTMonitodng Tube present (Y/N) YES Depression over field (Y/N) __
Date of adequacy test 7/20/99 Results (Pass/Fail) PASS For 3
Fluid depth in absorption field before test (in.);
Fluid depth 46.25 (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
56.5 Immediately after 798gal. water added (in.):
1180 Absorption rate = 450+ g.p.d.
NONE KNOWN If yes, give date -
0.6 System type DEEP TRENCH
Total depth FROM O.G.
NO
bedrooms
57,75
72-026 (Rev. 3/96)*
D. LIFT STATION ~
Date installed Size in gall?~s
Manhole/Access (Y/N) ,,Pum~*~ "Pump off" level at*
High water ~ ~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
100'+
100'+ On adjacent lots
100'+
100'+ On adjacent lots
N/^
N/A Public sewer manhole/cleanout
N/A
25'+ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation __ 5'+ Property line 10'+ Absorption field 5'+
Water main/service line 10'+ Surface water/dra nage. 100'+ Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
10'+
1 0'+ 10'+ Water main/servioe line
Property line Building foundation.
Surface water __ 100'+ Driveway, parking/vehicle storage area 55'+
100'+
NONE KNOWN Wells on adjacent lots
Curtain drain __
I ce~i~ that I~ ~r~hr~ field inspections a~d review of Municipal re~t~'~
inconform~i~g~elinesineffectonthisdate.
, Y / {/ JEFF GARNESS
Engineer s N~e
are
HAA Fee $
Date of Payment __
Receipt Number
Waiver Fee $
Date of Payment
~,~ Receipt Number
72-026 (Rev. 3/96)*
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
018-271-82 HAA# HA920079
1, GENERAL INFORMATION
Complete legal description Lot 16 Block F Timberlux Subdivision #3
Location (site address or directions) 4601 Timberlux Circle
Property owner Robert Hodge Day phone
Mailing address 6700 Rockridge Anchorage, Alaska 99516
Lending agency
Mailing address
G.M.A.C. % Carol Nesbitt
Day phone
Agent Bonnie
Address
% Jack White Company
Day phone.'762-3110
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: Three (3)
TYPE OF WATER SUPPLY:
Individual well XXXX
NOTE:
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXXXXX
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.
72-025 (Rev, 1/91) F¢on~ MOA ~21
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 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.
Name of Firm Tobben Spurkland, P.E. Phone 279-3916
Address 203 West 15th Avenue ~206, Anchorage, Alaska 99501
Engineer's signature
Date
DHHS SIGNATUFIE
Approv.ed for
· XXkX Disapl~r, oved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments Groundwater encroachmentj lacks a Four (4) foot
separate between the bottom of the leaching field and the water
%able ~ ~ ~//
DateJune 22, 1992
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.
72~025 (Rev. 1/91) Back MOA#21
6751 W,
AN[:H~)RAGE, ALAS~<A 99502-390~
(907) 248-50?5
Di v:i.s:i, c,r'~ of Envi F'onmei-H::al Heal th
Del:)ar'hment o¥ I..l~a:l. tl-~ and ,<Bocia:J. Ser¥ice?s
Ar-~c:hc~rage~ A:la~:ka 99501
Subjec't:: Grcund Water Monitor:i,r'u:]
l....13'h 16,~ B].ock F' 711nberlux
Gentlemen;
Per" the Eoru::Ji'h:J. ohs O-F '{:J'ic:- Ncc, al th ~:,e:r Lz: . (.,a . ;: :i. sst.te:,d -Fc:~r" 't:.h:i. s i c)'I:: ~
March~ 1992.
aW[3~ . - .. ic:t~_ .:¢]. 5 10~'r(.:¢-= ~t. di s'har'rh
~r-om the existing '{french,, ]'he flionitc]F" is ].6''-"9" (:J(::Ff, p,,
518 5121 15127
d r y d r" y d r y :1. 6" .Zi.: 2 5"
6 / 4 6 / 12
21" J. ()"
The relative ground elevations at the M'T: trench CO~ and i:rench
ar'icj tr(.~nc:h st.tgtp ::,,~:J '¢:,, The:? 4.--J. rtcJ] distribution pipe
St..tfllp! 2.5" I::)e:LC:)W
81.5 ar'id 77,, '-~::', .:
'J"l'ls: hiFll'lest water'level observed ~;as :t.25 ~eet below hot'Eom
· hrer'tch. -I"his situation existed .For a ::,eek more or- less.. It may
al so be arc3ued 'hl"la'k the ~a'L:er" observed was ]"ic:i'k gr'~::)Ltl'ii:lt,~a!:.er'
snov~mel'h entering the exc:avabJ, on,, ~Jhatever the or:i.g:i.n c,¢ the
v~at:.E.)r~ its pr[L, sent Yeas short 'LE(::)rm arid dG~::LriJ, t(:~].y r'e:,l<::t'.c:*cl 'hc:) or'icc*
MUNICIPALITY OF ANCHORAG/E'
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 (siteaddressordirections) ~1~01 '~t~¢[~ Cie
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER, OF BEDROOMS: -~ %
TYPE OF WATER SUPPLY:
Individual well ~
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
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 the validation date shown below, I verify tl~at 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.
Name of Firm__ ,~ fl Phone
Address
Engineer's signature
DHHS SIGNATURE
Approved for
bedrooms.
__ ' Disapproved.
Conditional approval for ~ bedrooms, with the following stipulations:
- zz
Additional Comments
By:
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 DH HS 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'. 0//~-'-~'/~Y-/c,c~ ParcelI.D, ~/~--r~-~)/--(?,~
A. WELL DATA
Well type
Log present (Y/N) _---~_'
Total depth
Sanitary seal (Y/N) __
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~-~/~ Driller
Cased to /-/"0 Casing height
Wires properly protected (Y/N) ~
FROM WELL LOG AT INSPECTION
Date of test L//., ~ ~. ,,73~ / . ~/, ~,~
Static water level ~ O ¢-~¢
Well flow ~ g.p.m. '7, _'Z~
Pump level /,~'/) '~'''~'~'l :,~. L//~ ~
SEPARATION DISTANCI=S FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot /
Public sewer main ....
Sewer service line J"'///~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
o
WATER SAMPLE RESULTS:
Coliform ¢ Nitrate
Date of sample: h~'~,-~ ¢ / ,¢ ¢¢¢--
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
ate installed 7'/¢ 7
Cleanouts (Y/N) __ [
High water alarm (Y/N)
Date of pumping ___ ,
Tank size /~--,_'~' 0 Compartments /
__ Foundation cleanout (Y/N) J Depression (Y/N)
Alarm tested (Y/N) 'Jk///3~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot J () ,~'% On adjacent lots
To property line ~-¢,J t~
'_-' 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
Size in gallons
Manufacturer
Manhole/Access (Y/N)
Vent (Y/N)
"Pump on" level at
"Pump off" level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 7" / ~/.. ~7,.~ ·
Length ~.~ Width ,.~
Total absorption area //
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating
System type 7"¢~¢~¢C/¢'
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
If yes, give date
Total depth
bedrooms
Well on lot .~ /.2-¢.)
TO building foundation
On adjacent lots ~> '¢¢
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots ~ /~-O Propertyline
To existing or abandoned system on lot
Cutbank 'i%///~, Water main/service line
Surface water
Curtain drain
Driveway, parking/vehicle storage area ~ ~-O
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect:on ~,h~e.~ate of this inspection.
Signature
Engineer's
Date
HAAFee$ /Th
Date of Payment
Reoeipt.umber
Waiver Fee: $
Date of Payment
Receipt Number
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~EPT. OF HEALTH~
82~ L Street- Anchorage, Alaska 99501 ENVIRONMENTAL p~;Or~C~ION
ENVIRONMENTAL ENGINEERING DIVISION JAN 2 2 19791
Telephone 264-4720 ...... ]
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing.
1. PROPERTY OWNER
Wilbur Dittbrender
PHONE
688-3319
MAI LING ADDRESS
Star Route 2 Box 412 99577
PROPERTY RESIDENT (If different from above)
2. BUYER
Robert C./La Verne K.
MAILING ADDRESS
Hodge
PHONE
PHONE
344-7015
Star Route A Box 294 99507
3, LENDING INSTITUTION
National Bank of Alaska
MAI LING ADDR ESS
Pouch 7-025 99510
4. REALTOR/AGENT
Lee Chronister % Totem Realty
PHONE
276-1132
MAILING ADDRESS
724 East 15th Avenue 99501
PHONE
J 272-0571
5. LEGAL DESCRIPTION
Lot 16 Block F Timberlux #3 Subdivision
STREET LOCATION
Timberlux Circle
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One ~ Four [] Other
×[~ SINGLE FAMILY
[] Two [] Five
[] MULTIPLE FAMILY [] Three [] 8ix
7. WATER SUPPLY
{~ INDIVIDUAL* * ATTACH WELL LO(~. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if avairable.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** **If individual/on-site, give instarlation date Approx. 1.975
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTILITY
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
72~)10(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME ----' TIME TIME
DATE -- DATE DATE
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS;
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY EZ] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO ~ FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
~ INDIVI DUAL DEPTH OF WELL
[] COMMUNITY DATE DRILLED
[] PUBLIC UTI LITY /~ ~.~.~ ~
Connection Verified LOG RECEIVED
'ERMIT NUMBER
3. SEWAGE DISPOSAL SYSTEM
~INDIVIDUAL/ON -SITE DATE INSTALLED
~PUBLIC UTILITY ~
Connection Verified ~. INSTALLER
~Septic Tank or ~ Holdin9 Tank P., RR~
Size:~ If Tank is homemad& SOILS RATING
give dimensions: (~ ~~
TYPE OF TANK MANUFACTURER
TOTAL ABSO"PTION A. EA MATE.IA~
4. DISTANCE~ ~eptic/Holdin0Tank Absorption Area Sewer Line ~N~rest Lo~ Line
WELL TO: ~ I ~ ~ ~
Absorption Area to nearest Lot Line
5, COMMENT~
~APPROVED FOR ~ BEDROOMS
~ CONDITIONAL APPROVAL (letter must accompany certificate)
~ DISAPPROVED
DATE ~ BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
l__~ MUNICIPALITY OF ANCNORAGt~
Department of Health and Environmental Protection 825 L Street, Anchorage, Alaska 99501
~quest for Approval of Individual Sewer and Water Facilities
Property Owner:
Mailing Address:
Name of Buyer:
Mailing Address:
Wilbur Dit tbrender
ST. Rt. #2, Box 412, Eagle River, AK. Phone: 688-3319
Robert C. Hodge & LaVerne K. Hodge
St. Rt. A, Box 294, Anchorage~ AK. Phone: 344-7015
· ' n' National Bank of Alaska
Lending Instztut~o ·
Mailing Address: Pouch 7-025, Anchorage~ Alaska
Phone: 276-1132
Realtor/Agent:
Mailing Address:
Lee Chronister/Totem Realty (CONTACT FOR ACCESS)
724 E. 15th, Anchorage, Alaska Phone:272-0571
Legal Description:
Street Location:
Lot 16, Blcok F, Timberlux #3
000 Timberlux Circle, Anchorage, Alaska
Single Family Residence: ~ Number of Bedrooms: 4
Multiple Family Residence: ( ) Number of Bedrooms:
Water Supply: *Individual Well (X) Public/Community System
If Individual Well, well depth approximately 60 feet
If Community System, name of system
Sewage Disposal System: *~n-site System ~ Public System ( )
If On-site System, date of installation: unknown, but house was built mn
1973~.
*NOTE:
A well log is required on ALL wells drilled since 6/75.
** If on-site sewer system is over two(2) years old, an adequacy
%est is required by hhis department.
A fee of $25.00 must accompany each request before processing
3/77
can be initiated.
