HomeMy WebLinkAboutHIGHLAND HILLS #1 BLK 1 LT 7 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PITON E - ~"~ EW--- ~
NAME
MAI L~NG ADDRESS
LEGAL DESCRIPTION
/-7
LOCATION
DISTANCE TO:
/¢¢/,/;/¢ /
Manufacturer
IF HOMEMADE: Inside length
Well
DISTANCE TO:
No. of lines Length of each line
Top of tile to finish grade ~
/
Width ~..) /
Crib diameter--.
DISTANCE TO:
Class Depth
Foundation
DISTANCE TO: Building foundation Sewer line
OTHER
Dwelling/(;~
Width
Material
Nearest lot line
Total length of lines
Mjt~al beneath tile
Trench width
inches
inches
;rib d~~ .- Total effective absorptioJ:~ area ../~r~/, /
Driller '- ~ Distance to lot lina PERMIT NO.
NO. OF B...E.3ROOMS
No. of compartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT..NO.
/
Distance between Hnes
Total effective absorption area
PiPE MATERIALS
S()i L T EST RATi N~f~f
REMARKS
MUNICIPALITY OF ANCHORAGE
Department f Health and Environments Protection
825 ~ Street, Anchorage, AK. ~9501
264-4720
}~//~ ~- HANDWRITTEN PERMIT * * *
Permit
#_
Applicant: C ~"' (/ff'
Location:
Legal Description:
Type of Soil Absorption System I~:
Trench: ~ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) -~'/~TA/'
The Required Size of the Soil Absorption System Is:
WELL AND/OR ON-SITE SFWER PERMIT~/f
Phone Number:
The length dimension is the length(in feet) of the trench or drainfield. 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 = /(//~/U 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 31, 1 9 8 3 * * *
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 wil~nstall the system in accordance with codes.
(3) I u~e~s~and ~at the on-site sewer system may require enlargement if
t~/r~c~s remodeled to include more th~-"i3 bedrooms.
S igne~, ~_/~////C/ Issued by':~)~~'~-~-C'~'
SWP/024(1/81)
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:_
LEGAL DESCRIPTION:
SLOPE
DATE PERFORMED:
SITE PLAN
10
11
12
13
14
15
16
17
18
19-
20-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Reading
'z,' C)O F
Net Depth to Net
Time Water Drop
1'0 ~'
1-1
(minutes/inch)
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological 8~ Geophysical Surveys
IDrillingPermH No.
LOCATION OF WELL (Please complete either la, lb or lc.) A.O.L.. NO.
~.IB .... gh Subdivision Lot Block ~'1 I/4qlr~" Sec fi on No. Township N
,dj DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS $. OWNER (
Address:
Street Address end Area of Well Location
2. WELL LOG Feet Below 4. WELL DE
Surface ~ ~ , ~
M~terlol Type Top Bottom
~ Aug
~ Subn'
[]L~ Range w~)ESlMerldi°n
:i,, :'il :: '?
fool -..[~Rolary [] Driven [~ Dug
[]del{ed ~] Bored [] Other
~ Threaded }~ Welded
5. DATE OF COMPLETION
WATER LEVEL: ft. __/ /
ft.
LEVEL below lend surfaco and YIELD
otter hrs. pumping g.p,m.
after hrs. pumping g.p.m.
Well Grouted: LJ Yes [] No
[] Neat Cement [] Other:
(if available) HP
Drop Pipe ft. capacity
[] del [] Centrifical [] Other
perature _____o ~ F [-0 C
~e and belief;
Nurnber
CANARY ~ Cuslomer
Murdcipality of . chorage
'* --,~ DevelopmentSe.~ices Department
On-Site ~ter and *
4700 South Bragaw St.
P.O. Box 1~6650 ~chomge, AK
~.ci.anchorage.ak. us
(907) 343-79~
CERTIFICATE OX HEALTH AUTHORITY APPRO\!AL
FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Ccmplete legal description
r-xpiraticn Date: I t - 2q -' 0_3,
Ld'r -/3 Ri c~c~: 1
Location (site address or direr[one) =o'7;2C) ~ IG 14 L/M',ID
Current Property owner(s) ,~k~d~! H-t[;*~ '~-~,.L_I._.. Day phone ~'q(~- ~ 1~_
Lending agency Day phct~e
Mailing address
R3al Estate Agent
Maiiing Add,ess
Day phone _~_~--cl -. /~, t/7~, ..
Unless othem, ise requested, HAA will be held by DSD for pick,p.
2. NUMBER OF BEDROOMS: ~ ,
3. TYPE OF WATER SUPPLY: '
individual
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individua! On-site ~_]
individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues CeCJficates of Health Authcrity
Approval (HAA) based only upon the representations [liven in paragreph 4 by an inde,-enOent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for th=. transfer of
title (except between spouses) for properties served by a single-family on-s~te wastewater disposal and/or wr, ter
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Autl~ority Approval ara
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a pedod of up to one year with valid water samples.)
Certificates are valid for one year for prope, rties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION Ry ENGINEEE
As certified by my seal affixed hereto and as of the validation date shown below, I verif7 that my investigation,
based on procedures outlined in the Health Authority Apploval Guidelines for t,his application, shows that tl~e on-
site water supply and/or wastewater disposal system is(are) safe, functicnal and adequate for the number of
bedrooms and type of structure indicated herein. I further verity that based on the information obta!ned from the
Municipality of Anchorage flies and from my invesdgaficn and inspection, the cn-s~te water supply and/or
wastewater disposal system is(are) in compliance ~,~th al~ applicable Mun~cip.-J end St3t¢ codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm
Address ~ '5 ~ I '~-~ ~ ;2.~
Engineer's Printed Nam, , c,/~Jo.~ ,~ %u~-~-~z~ _ Date '~/7.-.'[./OZ...,.
5. DSD SIGNATURE
~ Approved for '~ bedrooms.
Disapproved.
Conditiona~ approval for' bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~ept~o tank/~ff =station on lot I C~ |
Absorption field on lot ~ ~ c7
Public cewer main
Server/se~¢ Sen~ce line 'T.~ Holding tank f~'
SEPARATION OlSTANCF.~ FROM SEPTIC/HOLDING TANK ON LOT TO:.
Building foundatlon ~/ ProPerly Ilne IO.. ~' Absorption field.
water main f'r/A Water sen~e llne ~ Z surface
Wells on adjacent lots~' i ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT.TO:
Pro,er~,.e I0 f B~,~.g ~o..~o.. H 0 wate~ ma~. N/A
· Wa~.rServlceline "ZO Sur[ace~ater t~'lo 0~mway. parldng/vehide~ge, .. 7;0'
· Cuttalndraln 'P'JIC~ Wells on edjacent lote ~'/1o~
COMMENTS
Waiver Fee $
Date of Payment
Receipt Numl:)er
I ced~fy that I have determined through field Inspections end
mvisw of Municipal records that the above systems ere in
conformance with MOA HAA guidelines in effect on this date.
.,V,F. $
Receipt Numl:)e,
(Rev.
On adjacent lots
On adjacent lots
Public ~ewer manhole/cleenout
G. ENGINEER'S CERTIFICATION
M-nicipality of Anchorage
Development Services Department
Building S~fety Division
Ork.~lte W'a~r & Waste'~mter Program
4700 8ou~ 8ragaw St
P.O. Box 196650 Anchorage, AK gg51g-6650
(g07) 343-?g04
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Date completed ~.~_~'~
Tot~depth ~7~ fL
Date of test
SteUc water level
Well preduc~on
If A, B, or C pra~le PWSID # ~
FROM Wl=l · LOG
fL
g.p.m.
Parcel ID: O 60-'5~'Z-~..Y'
we, Log (y/N) ~/
Wlres pmpedy protected (Y/N)
~ing height (above ground)
AT INSPECTION
Y
in.
WATER SAMPLE RESULTS:
Coliform ._~colonles/ll~P mi.
Arsenic: mg./I.
SEPTIC/HOLDING TANK DATA
Date of ample:
Tank Type/Material S,'
Tank size [OO~ gal.
Foundation cleanout (Y/N) x/
Date of pumping
Number of Comparlments
Depression over tank
Other bacteda .~ colonies/100 mL
Conected by:
Cleanoute (Y/N) ~/
High water alarm (Y/N) ~
C. ABSoRPTIoN FIELD DATA
Date installed C~/~t?/t'~ Soil mfing (g.p.d./fl~ or ~/bdrm) ~
Totaldepth ~.~ ff. Eff. apsarpflonama qbO~ Monltedngtube ;/
Date of adequacy test '~/~.~./e z~ Results (Pass/Fail) '~
Fluid depth in absorption field before test O in. weter added"/~20 gal.
Elapsed Time: ¢~O min. Final fluid depth z~ in. Absorption late >=
Any rejuvenation b'eatment (past 12 mo.) (y/N & [ype) ~
Gravel below pipe 0 o 5 fL
Depression over field
For ~ bedrooms
Now depth ~,/~ in.
V~'O g.p.d.
If yes, give date
READ INSTRUCTION8 ON REVERSE ~iOE BEFORE COU,~C'~k~I SAMPLE
200W. Potter Drive
Anchorage, AK 99~18-1~05
MUST BE COMPLETED BY WATER SUPPLIER
"~ PUBUC WATER SYSTEM
L~Se~d IRed'Its L~ ~end InvOice
Begin:
SAMPLE TYPE:
Lab Re! No.
Re,It' Analyst
/V~ Routine
~ Repeat Sample
(refer to lab no.
~ Special Purpoee
· LocMl~n Celtac1~d ;~,:
Treated Water
Untreated Watm'
Se~t to ADEC: ANC F~K JUN
Date: , T~me: .,
Client notified of un~atlsfactory results:
Coffered: by (Inltlel~:
BAC [r=RIOLO~iCAL WATER ANAYSiS RECORD
I~ MO-MUG Reeutt: Total CoIIfom~
Membrane Rltec [~e~ Count ~
Veflficat~oe: LTB BOB
fln~ Membrane Fal~' I~ul~: ~
~n~:
Coil
COUFO~M
~-~ MamDer Of ~ ~ G~OUp [Sc~clett G~n~mle de ~?~Jr~,~lfim-tce)
Ru~ ~G 02 OL;OSp
Eva Lo,eh
90'7
p.t
CSBUlLT
J ~ H.~P. EBY CERTIFY THAT I HAVE SURVEYED THE
ASSOCIATES LAND S59{Vc-YING 69&-082:.
FOLLOWING DESCRIBED PROPERTY;
AN~ THAT NO ENCROACH~£NTS EX,ST EXCEPT AS
IND!CATF.-D. IT IS THE RESPONSIBILITY OF THE
OWNER TO DL~TSRMIIVE THE EXISTENCE OF' ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APP"AR CH THE RECORDED S~I-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOi.~_D FB~
r-,NY DATA HEREON B_~ USE~ FOR CONSTRUCTION
O? FENCE LINES, OR FOR ESTA~LISHING BOUND-
ARY LINES. DRAWN= .
DATE,
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 HEAl_TH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) /~lt.¢- ~/,~ /./iLA.,'~"h~
Property owner O_CF~? l=~cy_, Dayphone :~c~ ~5~-zb
Mailing address ~"~.o.~oY,. ~1_~-,o:~'/ ~,JILE.~-~'¢' ~ ~K ~b)~l - c.~D.~--
I_ending agency
Mailing address
Agent
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
'rYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
NOTE:
If community well system, provide written confirmation from State ADEC attest-
~ng to th¢ legality and status of system.
TYPE OF WAS'I'EWATER DISPOSAL:
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 #21
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 -~-/'-d..A.)~.~J ~g,/d~o~ ~'-P, ~L~. Phone
Address ~)'O ?;~O~ /q'~o~2.~~ ~,'OOj~ /~ [~,
Engineer's signature-~---~ Date
DHHS SIGNATURE
· ~/ Approved for -~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
'-.:the M~i~cil~lity of A~','~'~0rage Department of Health and Human Services (DHHS) issues Health Authority
-,~,~proval ce"~tificate~.'based only upon the representations (j iven in paragraph 5 above by an independent
p'r0fessional ~'" ;'"
engineer registered in the State of Alaska. The DHHS does this as a courtesyto 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.
72-02~(Rev. 1/91) Back MOA#21
Municipality of Anchorage ~ ~ C [~ IV ~ D ~)
DEPARTMENT OF HEALTH & HUMAN SERVICFS
Environmental Services Division FE~ ] 0 199'~'
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 --
Mumc~pallty ol A mnorage
ChecklisD'ept't Health &HumanSer,4iqes
Health
Authority
Approval
Legal Description:
A, WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Parcel I.D.:
if A, S, or C, attach ADEC letter. ADEC water system number
Date completed q' ~2~1- ~
Cased to /L5 ~ ~'~,'-~-~ Casing height (above ground)
Wires properly protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well production '~..
WATER SAMPLE RESULTS:
Coliform ~ (:~ .... Nitrate
Date of sample: '2- ~ ~ -- ¢ 'riz
B, SEPTIC/HOLDING TANK DATA
Date installed ~(//~¢-~/~ ~ Tank size
Foundation cleanout (Y/N) _
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length Ct,~, t .Width
AT INSPECTION
g.p.m.
O ,.~-,.%- ~ (::)ther bacteria
Collected by: ~. f2_ ,~'~A/d,,'ac),,v,¢'
/OO~ Number of Compartments ~'. Cleanouts (Y/N).
Depression (Y/N) ¢J High water alarm (Y/N)
Pumper
soil rating (g.p.dJft~ o~?~ '~_t.~ _ System type (J~
CT,~ Gravel thickness below pipe ¢2,. ~',-~ _ Total depth
Effective absorption area
Date of adequacy test 'g- ~'~'--
Fluid depth in absorption field before test (in.);
Fluid depth /q~iO (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N) "
72-026 (Rev. 3/96)*
Monitoring Tube present (Y/N). "(' Depression over field (Y/N) .4/
Results (Pass/Fail) q-PA-5_% For_ ~' bedrooms
Immediately after./--/.5~ gal. water added (in.):
Absorption rate = ~,. T- ~,S'd~ g.p.d.
If yes, give date
D. LIFT STATION
Date installed ,q /' / Size in~g~llens~'~_
Manhole/Access (Y/N) ~m~h" level at p off" level
High water alarm I m
Cycl~.~test~~ [ '
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
On adjacent lots
On adjacent lots
Public sewer main /
Sewer/septic service line
Public sewer manhole/cleanout ,/,'V
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation '~(:i ~ Property line Z-~-~~ Absorption field
Water main/service line .5%~c'-~ Surface water/drainage /4'20 t Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line .~. i .'b Building foundation "~2~ '~ Water main/service line '~,.~ /
Sudace water / ¢O '¢' ':~-~' !
Curtain drain /CPo '~
Driveway, parking/vehicle storage area
Wells on adjacent lots / 67o
Signatu~e~~
Engineer's Name
Date '~-'~
I certify that I have determined thru field inspections and review of Municipal rec°rds;(hat the above~yS'~ems are
in conformance with MOA HAA guidelines in effect on this date. .~,
HAA Fee $ -0)~.~,
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
CT&E Environmental Services lac,
Drinking Water Analysis Re. pos' for Total Cotiforrr~ Bacteria =oo w. po.~: Or,,,~
Anchorage. AK 99518-1605
READ [:YSTRUCTIOYS O.'v' REVERSE SIDE BEFORE COLLECTlYG SA.;[PL£' !'eh (907) 562,1342
Fax: (907) 561-5301
--'---' MUST SS
PUBLIC WATER
SA,',,t; ,-E DATE:
Month Day Year
?,outh, e o Treated Water
Repeat Sample (rot. routine sampl.; ca Untreated Water
with lab ret. no. )
Special Purpose ~/~
Time Collected
Collected By
· ~:t~. ~ ~-~
SAMPLE LOCATION
0¢"~-0._c' _%o -'v ¢,-'7¢'
TO BE CO,:v~LE. TED BY LABORATORY
Analysis shows this Water SAMPLE to be:
%D- Satisfactory ,
o UnsatisS'~¢tor?
~ Sample over 30 hours old, results may
be unrelit~bte
Sample too long in transit; sample should
not b: over 48 hours old at examination
to indicate relinble results. Please send
new sample via special ct{livery mail,
Time Reeeh'ed
AnalyticnlMethod: ~ Membrane Filter
O ,M,", I O- MUG
Number ofcolo,fies/100 afl,
Rosult*
Analyst
97.0638
.?.\/.-?' \.
nth Fbkx Jun
'l'lmc:
Client notifi.:'d of t ~ sntisfactot7 results:
Phoned Spoke with
Da:,:' Timu:
Fa'u;d
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-,MUG Result: Total Coliferm
Membrane Filter', Direct Cot, at
Verification: LTB BGB
E. Coil
Co{onNs/100 mi
COLIFI R;",I
Fecal Coliform Confirmation
Final Membrane I;ilter Resulta
o:,t¢ '2,/f, q '3 Ti.to
Coliforn:/100 mi
PART ONE OF
FOLLO
'~.,~. ~lb.,~ Member ol the SCS GrOUp (So~i6t6 G~n~rale de SurvuHIo0¢OI
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
CEIVED
NOV 1 2 t99
343-4744 , q
~. Mu J c;pahty of Anchorage
CERTIFICATE OF HEALTH AUTHORITY uept. Health & Human Service.
APPROVAL FOR A SINGLE FAMILY DWELLING
1.
GENERAL INFORMATION
Complete legal description
Lot 7;
Block I; ffighland Hills t11
Location (site address or directions) Hiland Road
Property owner
Mailing address
Bill and Jill Conard
C/O Marston Real Estate
Day phone
248-1717
Lending agency
Mailing address
Day phone
Agent Jeff Smokey/ Marston Real Estate
Address 4105 Turnagain Anchorage, AK 99517
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
individual well XXX
Community well
Public water
NOTE:
Day phone 248-1717
If community well system, provide written confirmation from State AD£C attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Fronl MOA/121
STATEMENT OF INSP,-CTION BY ENGINEER
As certified .by myseal 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 supl~iy
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 inves_ti_gation 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 ~ --~ Phone ~q¢- ~-'~.," ~
Engineers signature /~./) ~ ~
Date ///// /// ¢'-"~
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
1'4o. i,L57. E 4' ,","
bedrooms, with the following stipulations:
Additional Comments
Th(; 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. 1,4:J$) Back MOA ~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
, .EIVED
Legal Description:
Parcel I,D.
A. Well Data
Well type
Log present (Y~)
Total depth -~'F-., / -'
Sanitary seal ~)N) j~--~
-~' /°a~ ~
f,.;. , ,:: ...-,lAy of Anchorage
Dept. t-{~ciith & Human Service.
If A, B, or C, attach ADEC letter. ADEC water system number
Date of test
Static water level
Well flow
Pump level1
Date completed 3 ~
Cased to ~-¢Or'7~-- / :' ~: Casing height
Wires properly protected ~_/~) ~7'~-"-~
AT INSPECTION
:g.p.m. ~_~L,~' g.p.m.
FROM WELL LOG
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout /Oo
SEPARATION DISTANCES FROM WELL TO:
Septic/he~i~J-tank on lot /Or-)
Absorption field on lot /~(.)
Public sewer main ~-
Sewer service line ~' f-/-
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Collected by:
Other bacteria
B. SEPTIC~ TANK DATA
Date installed
CleanoutsON)
High water alarm (Y~_~
Date of pumping
Tank size //'~2~2~ ~//¢/ , Compartments
Foundation cleanout Y~) .c~.-r__~ Depression (Y,~
Alarm tested (Y/N) /'L///~
Pumper [~ OT-O
SEPARATION DISTANCES FROM SEPTIC/HErEEh~-6 TANK TO:
Well(s) on lot /CPO/¢-- On adjacent lots
To properly line /O ('/'~ Absorption field
Surface water/drainage /'~ Cp---
Foundation //~
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION /joAJ~ /°/?_~-~/L~-- ~
Manufacturer ~~
;~' ;~~~ Manhole/~cess (~) ~
Vent(Y/N)~~~~mpoff Levelat ~ ~
~1~ On adjacent lots Sd,ace water ~~
D. ABSORPTION FIELD DATA
Date installed ~,/~ /
Length ':~'~ ' Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft2)
Gravel thickness
Cleanout present~'4) ~'~
System type ~-/~
O,~ ¢ Total depth -~ /
Depression over field (Y~)/C,)~
for '7-/'(~-.~ (~) Bedrooms
After test (~
If yes, give date ,/~/~¥
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~f~ ~
To building foundation
On adjacent lots //~.b
Surface water //~')
Curtain drain
On adjacent lots /¢Z.9.~ ['7c- Property line //~-} (,74-
To existing or abandoned system on lot /(..//,~
Cutbank~(.!/~. Water main/service line Z~ ~
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
Signature S
I ~4~'r~¢e River~oop Road No. 204
Engineer's Name E.-.C!e _".",¢er, A!---~k.- ?957?
inspection.
HAA Fee $ ~0~," ¢j'D
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
11/:1.0/93 11:30 E:T~.E ENUIROHHENTAL LAE, SERUICES N0,681 D05
COMMERCIAL TES?ING & ENGINEERING CO.
ENVIRONMENTAl- LABORATORY SERVICES
........ ~*,, REPORT of
Chemlab Eef.~ ,93.5992-3
Client 8ample ID :L7 Bi HIGH~AND HILLS #l
Matrix ,WA~
Clien~ Name :8 & 8 BNGINEF~N~
Ordere~ By ~R, BHAF~
Project Name ~
Pro~ectf =
PWS~D ." UA
.5633 B STREET
ANCHORAGE, AK 99518
TbJt.: (9d7) 56'2,-2843
FAX: (907) 561-530~
WORK Or,er -. 72952
ReFx~rt Col~leted ;!1/10/93
Collected t11/05/93 @ 11:18 hr~
Received : ~1/05/93
Technical Director ~ 8~H~
~ample Remarks: ROUTINE SA~LJ~ COLLECTED ~Y: S.8.
Qc Allowable Ext. Anal
Parameter Results Qual Uni'ts Method Limits Bate rk~te Ini'
Nitrate-N 1.0 m~/L ~PA 353.2/300.0 l0 i J./09 CH'
NOV 1 ?. ~['.'~
Dept, Hearth &uum~- ~
* See Speciel Instruction~ Above UA ~ Unavailable
NA = No~ Analyzed
** 2~ee Sample Remarks Above
U = Undetected¢ Reported value is the practical ~uantification limit. BT ~ be~s Than
D ~ Becon~ary ~tlution. g?" 6~eater Than
G~nCrsle
COMMERCIAL TES.TFING & ENGINEERING CO. AK DIV
CHEMICAL & GEOLOGICAL iABORATOt Y
TELEPHONE (907) 562.2343 5635 B Slre~l
DrJnkir~g Water Analysis Reporl for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER TO BE COMPLETED BY LABORATORY
[] PUBLIC WATER SYSTEM LD.#
~J/-/~PFIIVATE WATER SYSTEM
Mo. Day
SAMPLE TYPE:
[] Check Sample (for routine sample
with lab ref. no. ~
~ Special Purpo~
Year
Treated Wator
Untte~,ted Water
Anelys:s shows th;s Water SAMPLE to be:
,Satisfactory
Unsatisfactory
~ S¢.m,c, ie too long in h~,nsit; sample should
net be over 80 pours old at ex~mlnation
to indicate reliable resdll¢. P~ease send
:~ew sample via s~cia~ dei:ve~ mail.
Date Re~iv~ ) ~ /~
Anal~lcal Method; Membrane Filter
* No. of co:2nies/l¢;3 mL
SAMPLE Time
NO. LOCATION Collaore. d By Lab Re¢l
............... ~ ~ ~ ....
.... /~ ~/l .~ ..... '..-r
Dept. Health & Human 8ervioe~ ~ '
A .D,E,C, ~~ BACTERIOLOGICAL WATER ANALYSIS
READ INSTRUCTIONS
M~brane Filter: O~ro~l Counl
BEFORE Verification: LSB BaB
F,!~-,~I O~lifom] Cenflrm~lion
COLLECTING SAMPLE
Final Membrane~Rer~b, ft~ _~/_,.,.,~__
'rN'rc = Too Numerous To Count
OB = Other Bacteria
D~te
PART ONE DF TWD:
REKIAINDER TO FOLLOW
AnaJys!
RECORD
Oollform/lO0 mi
__ Coliform/lO0 mi
Property Owuer
Mailing Address
Buyer
Address
APPLI-\'NT FILLS OUT UPPER HAP ~ ONLY
Phone
Zip Code
Lending Institution
Realty Co. & Agent
Zip Code
Address Zip (;ode
Legal Description
Street Location
Phone
~?~ /w>; /
Typ~e.,~Residence
~ Single Family
[] Multiple Family No. of Bedrooms
~ Other
Water Supply
[~l~ividnal
[] Community
[] Public Utility
Sewer Disposal
LTr'"'lndivid ual
[] Public Utility
g Holding Tank
ATTACH WELL LOG. A well tog is required for all wells drilled since June 1975.
For wells drilled prior to that date, give well depth (allach log if available).
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Date
inspector
Time
Date
Inspector
Time
Date
Inspector
Time
Inspeclo/~
Field Notes:
~)) APPROVED BEDROOMS
) DISAPPROVED
) CONDITIONAL. APPROVAL'
'CONDITIONS OF APPROVAL
Soils Rating
3
Date Sewer Installed
72 023 (3182)
Well To Absorption Area
J Well to Tank /'
Well Log Received ~..~,~_.
Septic Tank Size
ROBERTA. SHAFER
ADEQUACY TEST
WATER AND SEWER INSPECTION
WELL INSPECTIONS AND
FLOW TEST
SITE PLAN,<;
ROAD DESIGN
SOIL TEST
ON SITE WASTE WATER
DISPOSAL SYSTEM DESIGN
EXCAVATION WORK
January 5, 1984
CIVIL ENGINEER
694-2979
Carl Disotel
Star Route 9385
Eagl_ River, Alaska
Dear Mr. Disotel,
99577
REFERENCE: Lot 7~ Bloc]( 1~ Highland Hills Subdivision
Dear Sir:
A well and septic inspection was performed on the system located
on the referenced property° All the cleanouts on the septic system
were visible and equipped with adequate seals, g~e well casing
was found to be equipped with an adequate sanitary seal and the
wires from the pump were in conduit. The ground around the well
casing is adequately sloped away from the well. At the time
of this inspection a water sample was taken from the hose bib
on the side of the house and submitted to Chemical and Geological
Laboratories of Alaska for coliform bacteria analysis. The results
of this test were satisfactory.
If we may be of further service, please do not hesitate to contact
S ins e r :~y.~/? /~7/~
cc: Municipality of Anchorage
Department of Health and Environmental Protection
SRB 196X EAGLE RIVER, ALASKA 99577
HEMICAL & GcOLOGICAL LABORATORIES OF ALASKA, INC~
TELEPHONE (907) 562-2343 ANCHORAGE INDtJSTRIAL CENTER
5633 B Slreet
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
I
I
I
f----l~"l
-- II] (') See h on back
(-"~WATE~' SYSTEM:
~ ~ , i.D. .
_ I¢~tt._
City
SAMPLE DATE:
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
~ with lab ref, no.
.~Spoclal Purposo
State Z p Code.
Mo. Day Ye~,r
[] Treated Water
,~.Unt reared Water
SAMPLENO.
4 I
Collected
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
J~Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not 'be over 48 hours old at examination to '
indicate reliable results. Please send new
sample via special delivery mail.
Date Received _
Time Received - '-
Analytical Method:
[] Fermentation Tube
,~lembrane Filter
Lab Ref. No. Result* Analyst
t] I-FI
II L-FI
REAl) INSTRUCTIC)NS
BEFORE
COLLECTING SAM PLE
06-]220 (b)
Rev. 197~1
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date Collect od
r)ate Received
24 Hours
Confirmatory
EMIt.
Multiple Tube Reportl
M~mbrane FIIter~ Direct Count
Verlftcatlom I.TIt
Report~;t Ity /~~ Date
Tlrne~
Time Received -- p,m, Lab, No,
Broth 24 hourl~---- Itroth 48 hourl~ ,
Colt fo rm./30Oi~l
Coil f o rrn/'~ 01~311