HomeMy WebLinkAboutGREAT DANE PARK LT 2r7t�l I a
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MUNICIPALITY OF ANCHORAGE -,
D; RTMENTOF HEALTH AND HUMAN SEI ;ES -7
Environmental Health Division 0111 2- 7 3 if
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name Be"11,17 JP7 DISTANCES
Address r SEPTIC ABSORPTION WELL
TANK FIELD
4Z-1
Phone(s) Permit No. No. of Bedrooms WELL
e2ool�, I
LEGAL DESCRIPTION LOT LINE 4 Z 3
Lot Block S?udivisrcm
7
7re-40f�','?e FOUNDATION Z 2_
Township, Range, Section
7/ z u AS-BULT DIAGRAM (show location of well, septic System, property lines. foundation,
driveway, water bodies, etc.)
TANKS F—F—F7-7 I I I I _F_T_T__F_T_TK I I
lk� SEPTIC [I HOLDING
Manufacturer
Capacity in gallons
6 V^ e C r
/ �. y --- t)
Material
No� of Compartments
2
TYPE OF SYSTEM
[]TRENCH [I BED [,Y W. DRAIN El OTHER
Depth to pipe bottom from
'I
Total depth from original grade
original grade
/ZO�'4- FT
16
Fill added above original grade
Gravel depth beneath pipe
FT
Wrav-WI'lengilb
Gravel-w—idth
?l FT
—ab.orpton
Fotal area
Distance between lines
�/ SO FTJ
Number of imes
Soil rating
Pipe material
IS -Z, SO FT
PVC
Wnstalle,
Date Installed
&(" -2.7— &S T I
V/V/g, 7.
FT
FT
FT
FT
WELLS
;0 PRIVATE 11 OTHER (Identifv)
Classification (A,8,C) Total Depth Cased to
FT
Installer Date Installed.
REMARKS:
It 11� q C�A
V��/ e
Inspections Performed by:
/'. et -0
I Date.
certify that this inspection was performed according to all
Muflicipal and State guidelines in effect on this date:
Health Department Approval:
Date._02ZA/2
ENGINEER'S SEAL
Ix -
'J/
I
Size of casing---6L'—Depth of Hole---2-4-1----feet
241.15
Cased to eet
Static water level 154 t. below) land surface. Finish of well (check one) open end XXX);
Screen Perforated
Describe screen or perforati
Well pumping test at 2 0 gau4s pei OU@TA minute
for 1 hours with 100% --ft.
of drawdown from static 164el,
'Date of completion 26 Mayij 19 8 7
Ge
WELL LOG
01 Nsr
Depth in feet from & (:�fjo!A
DEPT. pgolf
.ground surface Give-ditails of formations penetratWpo0gfterial, color and hardness
0 0 2 ckup
T
ity,iravel
'J"
in d & fra
35 Vel
�.)To 71
_To___Z4 y grAve� & water,, 1, - 2 gprp,
74 Sl_
9 lty -kr4 el-I',�-,
i
To
130
_9T0__
V-1
__130 TO -160 1-rSilty 4rqy�f
TO 130 Send
—To— 190 Silty r-rayel
2.") 235 W epinf. hardpar.
-To-
z� A
9.41 Water rame 1
A
__L15__T0_
01
—rko—
NVTWA Certifled Contractor
Ceytificat-c lw's. 8 14 913
—TO
a -CONTRACTOR
��who X il 2: '4-, -1. li__. ji. 11 v L_x �- H cs Fi c! FRIM W KH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
`
IFIT 10—M 1: - I- M W M HAd BEE FR: !I _... 2 ����'14f:�
PERMIT NO: 87O014
DATE ISSUED: 01/27/87 '
APPLICANT: BENNY & JACKIE JOY / W.L. PAINTER
ADDRESS: 1507 KEPNER DR.
ANCHORAGE, AK 99504
CONTACT PHONE: 522 1723
`
LEGAL DESCRIP: EDIVISIDN: GREAT ANIEPARK
' ` �| L8T� j`� ` � BLOCK: N/A'
,�CTION: 21 TO��NSHIP: 12N RANGE: 3 W ` '
LOT SIZE: _i� (SQ^ FT ^ OR ACRES)��»f
MAX BEDROO3MS:
Listed below are the options available to you in designing your sepUc
system. Choose the option that best �its your site.
���.~�~~~~__
A-1 W I- u
DE&ITlV| T[) PlPE B<]TTOM (FT.) 8,0
GRAVEL DEPTH (FT,) 8"0
TOTAL DEPTH (FT.) 16.0
6RAVEL WIDTH (FT.> 2.5
GRAVEL LENGTH (FT.) 29,0
GRAVEL VOLUME (CU.YDS"> 22.9
TANK SIZE (GALS) 1,00O"0 **
SOIL RATING (SQ.FT. MAR) 150
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
�..... ..... ����..... ��������������... .....
�������
I ce�tify that:
1" I am ��miliar with the requirements �or on-site sewers and w/ lls as set
fcorth by Lhe Municipality o' Anchorage (MOA) and the State W Alaska"
2. I will install the system in accordance with all MOA codes and regulations;
arid in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements {or the set back
distances {rom any existing wel1; wastewaLer disposal system or public
sewerage system on this or any adjacent or lot.
4. I understand that this permit is valid {or a bedrooms and
any enlargement will require an additionaI permit,
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK 1110T BE DONE BY A LICENSED ELECTRI(-;IAN"
SlGNE)DATE:
'
�.._���.�_���.__-~~~�~.~__-��~~`---~- ~-�-`~..... ..... ..... ... .... ..... ..... .....
APPLICANT: BENNY & annuh my ml.. PAINTER
ISSUED BY DATE:
W. L. PAINTER GOMPANY
1507 KEPNER DRIVE
ANCHORAGE. ALASKA 99504
(907) 522-1723
WILFRED L. PAINTER,JR., P.E.
22 January 1987
Municipality of Anchorage
Department of Health & Human Services
825 "L" Street
Anchorage, Alaska 99501
Attention: Mr. Dan Bolles
Reference: Lot 2, Great Dane Park Subdivision
Dear Mr. Bolles:
Please find enclosed a site plan indicating the area calculation for the
replacement field.
I believe from our recent conversation that this was the one outstanding
item required for permit issuance.
Very Tru Yours,
enclosure: site drawing 1/22/87
ALASKA ENVIRONMENTAL
CONTROL SERVICr 'INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB C"e.'f
SHEET NO. OF
CALCULATED BY 7"" DATE Xlvme
CHECKED BY DATE
SCALE— loo'
In
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mut 1,�'n ALITY OF ANCHORAGE
Municipality of Anchorage OF HEALTH &
DEPARTMENT OF HEALTH WHL)MAV9tARVP,#§7lCN
825 "L" Street, Anchorage, Alaska 99502-OA50
SOILS LOG — PERCOLAT1W4E4j987
PC F IV FD
(ENGINEER'S SEXL)
PERFORMED FOR: Lo-�-y Ne -,L -s DATE PERFORMED: Mgt I r-6
17--�
LEGAL DESCRIPTION:-6e-v�t D&�- 0, -f -X Township, Range, Section: TI-LIJ93,uS�-, Z,/ e,& 1-9 1
FTE —PIT $_1 SLOPE - SITE PLAN
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
nn
- or.�awcs
TL 9 i Li
rj vi� " 5a "4
(" SOX&I 9� "-
2'jC-'J-Ser -(�Ae
.S O -PI x ";+t, Acr
4
WAS GROUND WATER
ENCOUNTERED? - t�o
S
L
IF YES, AT WHAT 0
DEPTH? P
s4iiL AM -to E
Depth to Water After i
Monitoring? 1b Date: June- 5
4�
'— / 0 0/0 S /.,P es --� (.Lt
PC
Reading Date Gross Net Depth to
Time Time Water
Net
Drop
L-1 PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND — FT
COMMENTS PO-K-Olal)'24 'bt4t WIQ-f f)�f e�jqr,;�7 ed 6e e-�4Ye �el!yf- J-oll-S t-ael-e -7b
PERFORMED BY: J4E(-S Inc. Er e6 0;? If
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN
CERTIFY THAT THIS TEST WAS PERFORMED IN
ON THIS DATE. DATE: 3 j unc, lq?6
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
,. I I �
PERFORMED FOR: DATE PERFORMED: 2— elf6
LEGAL DESCRIPTION: Z)a-13 C Township, Range, Section: :S -c,: 2 2--
�j 7-f
P SLOPE SITE PLAN
F ET oL of-vrv,(-S,
ML -
2 -
3 - samd
4
1Z
5
6
JF
7
8
9- ei t2j
10- WAS GROUND WATER
C,(e am S',-Pzd ENCOUNTERED?
11 S
IF YES, AT WHAT L
0
DEPTH? P
12 - 5,wk9rLA OpAj E
13- Delith to Water After C -le- �
-fv Date:'
Monitoring?
14-
Net
Drop
15-
16-
17 -
18-
19
Reading Date Gross Net Depth to
Time Time Water
Net
Drop
20
PERCOLATION RATE (minutes/inch) PERG HOLE DIAMETER
TEST RUN BETWEEN FT AND - FT
COMMENTS Sc>;l -S� L'a t-A�7k- 6f j!��2 t7'112
a -,lei 6�,,,e—
PERFORMED BY: A�CCS P -K 0 �1- a/ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFEC/OIN THIS DATE. DATE: 3
72-nnR ipp� ww;i
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: La-rry Neo -s DATEPERFORMED:
LEGAL DESCRIPTION: Geiex:f T),L,-7e- Z O'f Township, Range, Section: z t 76/1 jv le3tj- -ra
FD- 7EF—yr �n SLOPE SITE PLAN
0:FLT:
I�L or
2
3
4 G rq
5-
6 V
7 J
8
9 a, S
10- WAS GROUND WATER
a ENCOUNTERED?
11 S
L
IF YES, AT WHAT 0
12- DEPTH? P
54oL S rcl Zo E
13- Depth to Water After c>A j U ne S fic> 12
Monitoring? - Date: wj
14-
0
NEEMENNE
15-
16-
611
MMEMENNEEFA
17-
"MINNEEMNIME
18-
HEINEEMENEE
NEINEENOMEN
19
ENINEENEEMN
MENNERNMEN
REEMEMENIMM
NEEMENNE
611
MMEMENNEEFA
"MINNEEMNIME
HEINEEMENEE
NEINEENOMEN
ENINEENEEMN
Reading Date Gross Net Depth to Net
Time Time Water Drop
20
7- 1 PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
-t#3 TEST RUN BETWEEN FT AND — FT
COMMENTS SQ, ed
PERFORMED BY: A- 67C S' /.,t c Sj— P6 02 V_
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN
1� �n. I.— I '..�
CERTIFY THAT THIS TEST WAS PERFORMED IN
ON THIS DATE. DATE: LAM e
Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 015-273-47-000 Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lot 2,
- - . oreat Dane Park
Locatiom�ife addragSj
Currant.Pro6erty owne
S
Mailing address
ReaVistate Agent
2. TYPE OF 6WELLING:
11101 Great Dane Circle
Joy
110 1 Great Dane Circle,
El Single Family (w/wo ADIJ)
D Duplex
El Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEID.ROOMS: 3
Day phone
Ak 99507
Day phone (907) 360-4884
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual
Fxl
Individual Water Storage
Holding Tank
F1
Community Class Well
Community
0
Public Water System
Public Sewer
M
WaiverNarlance request for.N/A
Received ).7 Date:
COSA to be relips' to the engneer. unless othermse requested by the engineer.
Release to Glen Verplancke or Jon Wagner
COSA Fee$ %Va
Date of Payment
Receipt Number
COSA #
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
S. 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 AEC Phone (907) 315-2805
Address 501 East Heather Way, Wasilla, AK 99654
Engineer's Printed Name Glen Verplancke Date 5/03/2016
6. DSD SIGNATURE
System #1 Approved for �3 bedrooms
System #2 Approved for — bedrooms
Disapproved
Conditional approval for _ bedrooms, with the following stipulations:
J,717�1 Original Certificate Date: E�
1-6
The Municipality bf Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 6 by an independent professional civil engineer registered in the State of Alaska. The Municioalitv
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
COSA blUeSh"Lf - ', C
Nitrate AP0.2
Arse "Vog
;0
Other
If more than I septic system Is on the lot:
COSA Checklist #
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: Lot 2, Block N/A, Great Dane Park Subdivision Parcel ID- 15-273-47-000
A. WELL DATA
Well type Private IfA, B, orC provide PWSID # N/A Well Log (Y/N) Y
Date completed 5-26-1987 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth Z41 ft. Cased to _L41:_ft, Casing height (above ground) 24" in.
FROM WELL LOG AT INSPECTION
Date of test 5-26-1987 4-18-2016
Static water level 154 ft. 132
Well production 20 9 -p -m. 7.5 g.p.m.
WATER SAMPLE RESULTS: C -z C/4 & a 1
Collform _j_oolonles/1 00 mL Nitratel4ftM mg1L
Arsenic 1.7 ug/L Date of sample: 4112/2016 Collected by: Glen Verplancke
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SePtic/SteW' Date installed 5-14-87
Tank size 1,260 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 3-17-16 Pumper A+ Home Services, Inc.
C. ABSORPTION FIELD DATA
Date installed 5-14-87 Soil rating (WlqXVf,4AW ft2/bdrm) 150 System type Trench
Length 50 5 ft Wdth 5 ft. Gravel below pipe 3.5
T 10 ff. absorption area n
ft' Monito Ing tube Yes Depression over field No
D * 0. a a 2016 Results (Pass/Fail) Pass For 3 bedrooms
F101d' abs cptiomfi . e beforetest Dry in. Wateraddod 453 gal. New depth 0 in.
9
t4'
El I a Final fluid depth 0 in. Absorption rate >= 453 g.p-d.
Any n
nt ast 12 mo.) (YIN & type) Unknown If yes, give date N/A
p
D. LIFT STATION
Date Installed NIA Size in gallons NIA Manhole/Access (Y/N) NIA
"Pump on" level at NIA in. "Pump off level at NIA in. High water alarm level at NIA in.
Datum N/A . Cycles tested NIA Meets alarm & circuit requirements? N/A
E. SEPARATION DISTANCES
WELL ON LOT TO:
Septic tank/lift station on lot > 100 FT On adjacent lots >100 FT
Absorption field on lot >1 00 FT On adjacent lots > 100 FT
Public sewer main > 75 FT Public sewer manhole/cleanout > 100 FT
Sewer /sepftic service line >10OFT Holding tank > 100 FT
Animal containment areas > 50 FT Manurelanimal excrete storage areas >100FT
SEPTICIHOLDING TANK ON LOT TO:
Building foundation 8'9" Property line 79 FT Absorption field 5' 10"
Water main >10 FT Water service line > 1 OFT Surface water > 10OFT
Wells on adjacent lots >10OFT
ABSORPTION FIELD ON LOT TO:
Property line 23 FT Building foundation 23'4" Water main > 10 FT
Water Service line >10FT Surface water > 100 FT Driveway, parking/vehide storage > 10 FT
Curtain drain > 50 FT Wells on adjacent lots >100FT
F. COMMENTS
System has an In-line tee rather than a double clean-out between the tank and field.
* Information obtained from MOA date base.
G. ENGINEEITS CERTIFICATION
I certify that I Kave detannified through field inspections �anct
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Glen Verplancke
Date 5/03/2016
COSA canary sheet-2-6-15.doc
V .. it, LOT 3
'k
of
LOT I
20' ......
.. .........
..........
EXIDTIm
.......... mom
LU ..............
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L)
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01
OWE
112th AVENUE
-- — - — - — - — - — - — - — - —
UNDER NO CIRCUMSTANCES SHOULD AN AS -BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES
THE SURVEYORTAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
SURVEY TYPE
SYMBOLS
ILOT= AS-11ULT
nNA. SIRRICTURE a -BUILT
SET REBAR DRAINAGE ASPHALT
7n ;w
PLOT PLAN ... AS-EIRLT ... LOT SURVEY ... TOPOGRAPHY
0 FOUND REBAR IS 0 8 . WOOD FENCE CONCRETE
AS-RIALT ... NO CORNERS SET 0 RECERIFICATION �ILT ... NO CORNERS SET
([gy) ASSUMED ELEV. j( )I I( METAL FENCE WOOD DECK
PLOT PLANS & LOT SURVEYS
NOTE:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO
ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
SHOVON. FENCES. WELLS, SEPTIC CLEANOUTS, SIDEWALKS, DRIVEWAYS,
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE
ETC.. ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICIIONS
MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH 00 NOT APPEAR ON THE RECORDED SUBDIVISION PLAT.
ALL DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
SURVEY CERT11FICATION
Prepared by
PLOT PLAN
OF 4
Robert E. Johns, Jr. & Assoc.
Professional Land Surveyors
AW C�l
AV
1700 Brink Grin.
'-.* 0
ANCHORAGE, ALASKA 99504
Scale,
60'
Rec. Lot S.F.
lice. Plat File No.
As 49th -
FOUNDATION AS-fiUR_T
17:
A-INAR �.f ft
ww 0Wd IN.
i'i ' I Ask- 111I
..... ................................. .....
Date Sur.yed:
04/30/16
Dram b
REJ
Chocked b
JMK
i.0
W, ROBERT E. JOHNS, JR.
Dote Drawn:
Grld:
W.O.
4121—S
'#'0'
05/03/16
2635
16-115
FINAL STRUCTURE AS -BUILT
E.
t. A o\
Legal Description:
L swim � &.1 UmA I
.........
Lot 2
fes.lond6i
GREAT DANE PARK
MUNICIPALITY OF ANCHORAGE C13 73 7
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 -cr 7
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
/-07- X Xiva 111�4 6'201�-r A4& ;P/W -71-2.Al Z3AJ
Location (address or directions)
(b) -Applicant Name ::ro Telephone: Home Business
Applicant Address 15-o7 IWAJEA
(c) Applicant is (check one): Lending Institution Owner/builderx,- Buyer ;Other (explain);
(d) Len�ing Institution
one
4. SEWAGE DISPOSAL
0 ')K
nsite - Public Community[] HoldingTank[l
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)
5. ENGINEERING FIRM PROVIDIN 4SPECTIONS, 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
forth e 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 A-Ee-5 Telephone
Address 4� Y,30� /44`- -.%W,;72- 3 Ala. 1�e �,gze'?
Date /a—&
.6*WQ % viq V4
4t Of L 4
*Go* too
00
to 4 9TH
CE- 2
6. DHEP APPROVAL
-..4
Approved for 7124,& 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 ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
J", '3 CHECKLIST - FEBRUARY 1984
'3 264-4744
Legal
Description:
A. WELL
J0
Well Classification If A, B, C, D.E.C. Approved (Y/N) A11A
Well Log PresentON) Date omplete 5-.--z& --el Yield
Total Depth .7-111 Cased to Depth of Grouting W'At —
Static Water Level — Pump Set At A11A
I
Casing Height Above Ground Sanitary Seal on Casingoy N)
Electrical Wiring in ConduittA Depression Around Wellhead (Y&
Separation Distances from Well: I
To Septic/Holding Tank on Lot 7,7,1 On Adjoining Lots
To Nearest Edge of Absorption Field on Lot 7,34.4, ; On Adjoining Lots
To Nearest Public Sewer Line A11A To Nearest Public Sewer
Cleanout/Man hole — J11A - To Nearest Sewer Service Line on Lot
Water Sample Collected by 1-koe-1 A ; Date 7 -Z -5__'r7
Water Sample Test Results AAT- _/' -&- All 01/
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed Size / 7- 5; �-' No. of Compartments ?_
Standpipes ON) Air -tight Caps 09N) Foundation Cleanout N)
Depression over Tank (Yo Date Last Pumped 19,44
Pumping/Maintenance Contract on File (Y/N) for
Holding Tank High -Water Alarm (Y/N) WA4--- Temporary Holding Tank Permit (Y/N)
I
Separation Distances from Septic/Holding Tank:
To Water -Supply Well 7N To Building Foundation
To Property Line A� 7
To Wat er Main/Service Line-�
Course
Comments
Page 1 of 2
72-026 (Rev 8/86) Front
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
/ z, 6,eoler ?/W
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
.51, /
Type of System Design
Length of Field
De th of Field!
F
Gravel Bed Thickness
Square Feet of Absorption Area 47 Standpipes Present(ON)
Depression over Field (Yo Date of Last Adequacy Test
Results of Last Adequacy Test A�_h
Separation Distance from Absorption Field:
To Water -Supply Well To Property Line
�4
To Building Foundation 2-2-- To Existing or Abandoned System on
Lot On Adjoining Lots
To Water Main/Service Line To Cutbank (if present) "JIA
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
_1"7� �talled
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments —
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
** Check Permitted Bedroom Rating Against HAA Request **
Vent (Y/N)
Cycles during Adequacy Test. Meets MOA
I certify that I hav he ��ed, v�rified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed
Date
Company MOA No. e-1
A"
j
Receipt No. m
Date of Payment ko—
\CC-, C_,C)
Amount: $
LE
C. REID, JR.
E-2251
PlUfUSSIV
Page 2 of 2
72-026 (Rev 8!86) BaCk
& GEOLOGICAL LABORATORIES OF ALASKI, INC
633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
LABORATORIES FEDERAL TAX ID # 92-0040440
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