HomeMy WebLinkAboutEAGLE CREST #1 TR A LT 26(Rev 05/02/18)
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE
WASTEWATER INSPECTION REPORT
Permit Number: OSP 201183
PID Number: 050-303-25
Dwelling: OR Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New M Upgrade
Name
Mark & Susan Udevitz
ABSORPTION FIELD
❑ Deep Trench N Wide Trench El Bed El Mound
Site Address
10265 Crest View Lane
❑ Other
Phone
Number of Bedrooms
Soil Rating
depth from original grade
3
1.2 GPD/SF
JTotal
4.5 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
1.5 Ft.
Gravel depth beneath pipe
3 Ft.
Subdivision
Block Lot
Eagle Crest #1 TrA
26
Fill added above original grade
1 Ft.
Gravel length
2@ 22 Ft.
Township Range Section
Gravel width
5 Ft.
Beds: Number of Lines
NA
Distance between lines
NA Ft.
SEPARATION DISTANCES
ToSeptic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Lift Station
Tank
Line
379.3 Ft2
2
11.7 Ft.
Well
NA
115.6
103.8
NA
25+
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Capacity
Gal.
Surface Water
NA
100+
100+
NA
Material
Number of compartments
Lot Line
NA
10.9
10+
NA
NA
Foundation
NA
10+
10+
NA
LIFT STATION
Manufacturer
Greer
Capacity
1000 Gal.
Remarks
Alarm location
Outside house at point B
Electrical installed by
DRS Electric LLC
PIPE MATERIAL House to tank Tank to 3034
drainfield
Installer
JR's Septic
Drainfield 3034 CO/MT 3034
Inspector Pannone Engineering
BENCH MARK (Assumed elevation) 105 it
Inspection 1m 7/2/2020
7/14/2020
Location and description
ection
3 d
2-d
4th
Bottom of house trim at point B
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
Date
OF
' H
05 Steven R. Pannone
Septic System
Approved
Date 0///-,7
CE 8149 Q�
Note: this approv
does not include well permit requirements.
(Rev 05/02/18)
--moiLnn0-� _ co
U)
6r- o r- x� m<
-6 O C m En p Ln
F, {zC
*z= -0-1D
0 Ln
m O
CQ z
z n
m (
z�m M'r's
O zr
�
O V1
D r
oz
n cm
<n
0
0 0m
0 0E".:
O 05?
U)
z
C)
m
D
m
I+
O
U1
-P
W
N
�
�
N
-.
nn
N
-.
D
<
n
n
W
p�
m
J
m
.tom
W
W
(A
W
W
C4
W
= c7 G7 O m
D V_ N f l J K
O
N
c0
O
W
c'
Cn
Cn
,'�
(,�
D
om
zyo o �vo��
d
LO
�m
nD Lo
o
p
- q0 0-
W
W
-A.
A
-P
"P
CA
U1
m CD 1- O
00
.A
A
J
(0
J
O
W
P
>
D
W
N
P
to
J
W
W
J
N
�7
Fri
z �7
Om
-i N C
O to
mm
K (n D m D (n -0 0 -1 z -
<pm�Om�DOx
z(nc-0m—xmz
�
IC
cn
�
-+
0A0
r c�mT.
D
M
(_n
p
W
p�
�r
CODCDr
-0�pDD>cf) �n
xxi^I
Ocn
r`'Ix
i!'i�Z0zmzm�pcnZ
x
o m
D u1
O
= c7 G7 O m
D V_ N f l J K
ZW
zj
C7
�—
-P m(n
n
z 1 O O
D
c'
��
(DcC
Go
W
m��c���m��D
om
zyo o �vo��
d
LO
�m
nD Lo
o
p
- q0 0-
DJ z
m /
O J � O
CA
m CD 1- O
D
Lr) 0
—
hl>�
!
OD / I�
I> m
w ED
ozo
O �o
/1 D m�
_Z oZ
NOTES:
RECORD DRAWING
I 1 I ITO I
m n>>o:EZ
0 Z --q
�I I I<omr
to W m r
on / I I I 1 W� D �J �z0OLnN
C
<z _ t4 r
�10� Ocn
u C
v ` z0m
p
O u O
i n<, 11 13.I / �� �Nm(7m�
cx,
z O O
�00tnito
D4C7�tNj1�
060'Ln
.p
mo
PANNONE EMG SVC LLC (C.I. 1088) REVISIONS
P.O. BOX 1807 PALLIER, AK 99645 _ `p(E. �F••'4.4gs'I,
PHONE (907) 745-8200 FAX 907) 745-8201 REV 1: 11/5/2020 _'��.. by �,
EAGLE CREST #1 TRA L26
DRAWN MJL MARK & SUSAN UDEVITZ
10265 CREST VIEW LANE
SITE PLAN EAGLE RIVER, AK 99577
p Slaven R. Pannone
CE -8149
8/14/2020
CALE
1 " = 40'
J.D. NO
050-303-25
ERMIT N0.
OSP201183
HEET
2 OF 2
I
\
a
-�
%n
mmI
2 ZI
c < / [fl
n=
=
xxi^I
ro r
N_2
0
z
�1
�—
NVI
noru
<
d
U m
n /
a T
3:
= 3
W
m /
D
D
!
>
D
NOTES:
RECORD DRAWING
I 1 I ITO I
m n>>o:EZ
0 Z --q
�I I I<omr
to W m r
on / I I I 1 W� D �J �z0OLnN
C
<z _ t4 r
�10� Ocn
u C
v ` z0m
p
O u O
i n<, 11 13.I / �� �Nm(7m�
cx,
z O O
�00tnito
D4C7�tNj1�
060'Ln
.p
mo
PANNONE EMG SVC LLC (C.I. 1088) REVISIONS
P.O. BOX 1807 PALLIER, AK 99645 _ `p(E. �F••'4.4gs'I,
PHONE (907) 745-8200 FAX 907) 745-8201 REV 1: 11/5/2020 _'��.. by �,
EAGLE CREST #1 TRA L26
DRAWN MJL MARK & SUSAN UDEVITZ
10265 CREST VIEW LANE
SITE PLAN EAGLE RIVER, AK 99577
p Slaven R. Pannone
CE -8149
8/14/2020
CALE
1 " = 40'
J.D. NO
050-303-25
ERMIT N0.
OSP201183
HEET
2 OF 2
o0
0o c J
00
C/)
t
moi'Zo C
z m co 0 -o
z
��
rn
c�\� S� It
~
SO' 08' 00"E 135.00'
NNO
O
3:' :9t
zzK:-aC,: r--<rn m
V
0
•
i.
r
Nm• Rl: I= i
��1�,��4)t cJ�
_
Ci
O
cn C < r —�
m, � O
;
";. �
:41I r•
%Z: rn�• •moi
0.
O
ra y
O
D
zI-°zom� �7
�'• Cl
i m : CTI: : ^ %
O
z
ommo� 1
a�mzCn
mm
'�
"CO
[ 1`
mi
A• I
''-
.•
O O "
M<U)> m
I
, y '•°
.
z
I
0zmornn >
—I z
24.2'
cn
xz�rm�
C `�°
I
D
-�oC:)>
0 �
c"
I to
0
o
m
Co
D(3)m
o=
=D�zm-�
0
T—
m
24.2'
C
-A r-
g
�%
I cn
24.2'
_-+
O�
p
0
m �
N
( r!
N �O A
m� N
x D >r
z -v-1 G)O
rDO=CSD
r�cnm�
O
O
I
0r00 Dr—I
I
� o�0 �O0)i
24.2'
� � m c., -i >
+ C-)
v
y
o® : ►
m
cn 000
®
NO' 08'
00"W 135.00'
:-
o
Dr"Dm;;oCD
C) —
07';:o ::�E-i
yt—
flC�
—Im <
r' m
U)
o0
0o c J
00
C/)
t
Ul
z
��
rn
c�\� S� It
~
—i
NNO
O
3:' :9t
V
0
i.
r
Nm• Rl: I= i
��1�,��4)t cJ�
_
Ci
O
m
C0
m
:41I r•
%Z: rn�• •moi
0.
ra y
O
i m : CTI: : ^ %
-�°s8 -�`
z
z
[ 1`
m
It
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 470OElmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
Permit Number: OSP201183
Work Type: Septic Upgrade
Tax Code Number: 05030325000
Site Legal Address: EAGLE CREST #1TR ALT 26 G:0855
Site Mailing Address: 1O2R5CRESTV1EVVLN, Eagle River
Owner: UOEV(TZMARK S&SUSAN L
Design Engineer: PANNONEENGINEERING SERVICES
This permit imfor the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft:
Total Bedrooms:
6/24/2021
IZ Disposal Field 2 Septic Tank 0 Holding Tank 0 Privy 13 Private Well 0 Water Storage
All construction shall bminaccordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55
Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC8O)
1 The wastewater code requires inspections during the installation. The engineerDevelopment
Services Department per AMC 15.G5.Provide ootifireUonbycalling (9O7)343-7gO4(24/7).
4� From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall beeither:
o. Opened and Closed onthe same day, or
b. Covered, sealed, and heated boprevent freezing
Special Provisions: Contractor shall retain the double cleanouts downstream the existing septic tank, so that
the line between the two tanks can bocleared ofany blockages.
RecakmdBy:Oaha� �/ / / A,
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 050-303-25
Property owner(s) MARK & SUSAN UDEVITZ Day phone
Mailing address 10265 CREST VIEW LANE, EAGLE RIVER, AK 99577
Site address 10265 CREST VIEW LANE
Legal description (Sub'd., Block & Lot) EAGLE CREST #1 TRA L26")
Legal description (Township, Range & Section)
Lot Size 17,820 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑X
Initial ❑
Single Family (SF)
❑X
(w/wo ADU)
Septic Tank
❑X
Upgrade ❑X
Duplex (D)
❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
fi
I certify that the above information is correct. I further certify that this is '-in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 5�s� qqt, •a5- Waiver Fees: +
Date of Payment: �ll q Date of Payment:
Receipt Number: 6Jr660gG Receipt Number:
Permit No. C� P �G �� Waiver No.
Permit App_-'- : ::..,:c COV I D-19
'570 DISCOUNT APPLIED
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201183, Rebecca Carroll, 06/24/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201183, Rebecca Carroll, 06/24/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201183, Rebecca Carroll, 06/24/20
1: -5 7 —k / =-- , 0—:-- 7 —
132 126—;C -tet: cuv, 5/-3 11
R-A!571C
\j
N
m 70 A9
6'- N
115T
Z7
A
N L
IV
'Z I
1 U 7-14- e!5 A4 7.
10–rL= AC cr,.S5
5 - ACCO -055 -c- f 0 V" X2
0T. 2^7-30 6 A tz_
Ell
8221 DEL STREtl
ANCHORAGE, ALASKA 99502
PHONE 243-4890
5 f3UIZ-7-
F A4
go so
-491" 0
0.
AM
4
LS 5773
-W
NQT U Ecooments not appearing on record subdivision
plat are not ithown unless description of easement Is
provided by client. it Is the respo"IbIlItY Of the Ow1W
or builder, pritor to construction, to verify proposed
building grade relative to finish grade and of) titles
connections, and to determine the existence Of any
easements, tovitnasta, or restrictions which do not
appear on the recorded subdivision Plat.
Eldvations b4sed an aVaurAd dalisla unless otherwise
indicated, and bearings and 415tonjOS are record data.
CLIENT. M OU XJ 7-A I tJ
I= AJ 6; 1 0IJ C- EF
LEGAL D
LOT Z6,, rR A
1-'=A6- L E Cr --7
DATE SCALEFIELD OK.
I
GRID
-711947D P'=30 Id
E. ii
LN
.~ MUNICIPALITY OF ANCHORAGE
· DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street o Anchorage, Alaska 99501 Telephone 264-4720
ON'SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
I ,'vm
~ DISTANCE TO: Well Dwmling PERMIT NO.
OZ' Manufacturer X/4 Meteria, Liquld capecity in ~,,ons
Trenc idth Distance ~t~ lin~
OTHER
PIPE MATERIALS ~.~ ~/~~
APP~OV A~E LE~
72-013
I4Ut~ I C I PAL I T~' OF 8t~CHORBGE
DEPARTMENT OF HEALTH RND ENVIRONMENTRL PROTECTION
825 L STREET, 8NCHORRQE~ RK ~_~501
264-47~0
Ot~--_c. I TE --C. ELSER 6% &SELL PER;~ I T
PERMIT NO:
DRTE ISSUED:
840i36
04?05?84
RPPLIC~NT:
CONTROT PHONE:
LEGRL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
C/O S & S ENG'G.
ERGLE RIVER,
694-2979
SCOTT E~CBV~TING
~9577
SUBDIVISIO~'I: ERGLE CREST
SECTIO,I: ? TOHNSHIP:
17~20 -<SO. FT.. OR RCRES>
LOT; ~6 BLOCK:
RRHGE: IH
LISTED 8ELOH 8RE THE OPTIONS R'¢RILBBLE TO YOU IN DESIOHI~'IG YOUR SEPTIC
SYSTEbl. CHOOSE THE OPTIOH THaT BEST FITS YOUR SITE.
TR fl
~:E[~
DEPTH TO PIPE BOTTOM <FT. ) ~.0 ~
GRRVEL DEPTH (FT.) 0. 5
TOTAL DEPTH (FT.) ~. 5
GRRVEL HIDTH <FT. > l?. 0
GRRVEL LENGTH <FT. ) ~4. 0
GRBVEL VOLUME (CU. ~DS. ) 21. 4
TflNK SIZE (GBLS) 1,0~. ~ ~:*
SOIL RflTI~IG (SO. FT. /BR) 125
~:m DEPTH TO PIPE BOTTOM < ~.5 FT. REQUIRES INSULBTIOH
~:m DEPTH TO PIPE £'.OTTOM < 4. 0 FT. MRY REQUIRE 8 LIFT STRTIOH
~:~ TRNK MU=T HW./E 8T LEAST THO COMP~RTMENT-q
CERTIFY,THflT:
±. I R~'I FRHILIRR HITH THE REQUIREMENTS FOR OH-SITE SEHERS fiHD HEL~S RS SET
FORTH BY THE MUNICIPBLITY OF RNCHORRGE (MOR) RND THE STRTE OF RLRSKR.
2. ' I HILL INSTRLL THE SYSTEM IN RCCORDRNCE HITH RLL MOR CODES 8HD REGULBTIOHS,
8ND IN COMPLIRNCE HITH THE DESIGN CRITERIR OF THIS PERMIT.
5. I HILL RDHERE TO RLL MO~ RND STRTE OF 8LBSKR REOUIREMEHTS FOR THE SET 8RCK
DISTRNCES FROM RN'¢ E>~'ISTIHG HELL, HRSTEHBTER DISPOSRL SYSTEM OR PUBLIC
SEHERRGE SYSTEM ON THIS OR RNY RDJRCENT'OR'NERRBY LOT.
4. I UNDERSTRHD THAT THIS PERMIT IS VRLID FOR 8 MAXIMUM OF ~ BEDROOMS RHD
SHY ENLRRGEMENT HILL REQUIRE RN RDDITIONBL PERMIT.
IF. R LIFT.STRTIOH IS IHSTflLLED IN RH fiRE8 COVERED BY ~1OR BUILDING CODES,
THEN <l> RN ELECTRICRL PERMIT RND INSPECTION MUST. BE OBTRINED~ <2> RS-BUILTS
HILL'NOT BE 8PPROVED HITHOUT RN ELECTRICRL IHSPECTIOH REPORT~ 8ND <~) THE
ELECTRICRL I,IORK MUST BE DOIIE E:Y R L~CENS.ED ELECTRICIRN.
C/O Su& S ,¢NG'"6. SCOTT E~;Ol.,,~,/.'flTII.IO J,~
RPF'LICRNT:
ISSUED BY
DflTE:
~ ~ r'l SOILS LOG
MUNICIPALITY OF ANCHORAGE
,,, , DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
,,,~ 825 L. Street, Anchorege, Alaska 99501 264-4720
'-- SOILS LOG - PERCOLATION TEST
PERFORMED FOR: ~ (T~/O
LEGAL DESCRIPTION:
PERCOLATION
TEST
1
2
3
4
5-
6-
7-
8
9
10
11
12 --
13-
14-
15
16
17
18
19-
20-
SLOPE SITE PLAN
COMMENTS
,~ SR~ 1.q~X
} PH. 694-2-7~
72-008 (6/79)
/\
> 'l~l
!
ENCOUNTERED? ,
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
7.. z ·
,, .,
PERCOLATION RATE ~' , ~ (~ (minute$/inchl / /('
TEST RUN BETWEEN "-~-- FT AND ~ FT
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, AIsska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
10
14-
15-
16-
17-
18- No. 1457-E
19-
20
COMMENTS
PERFORMED BY:
72*008 (6/79)
[] SOILS LOG
PERCOLATION
TEST
WAS GROUND WATER //~O SL
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
/
.t
/~ ~ {minutes/inch)
PERCOLATION RATE
TEST RUI~.BET~/EEN ~FT AND /FT~
CHUGIAK, ALASKA
688-3199
';RILLING CO.
WE SERVE ALL ALASKA
POST OFFICE BOX 42 - CHUGIAK, ALASKA 99567
KODIAK, ALASKA
4864826
OWNER OF LAND ......D...u. can...~..e..C..!..o...u.d.....g..~'...' .................................
ADDRESS .......... ?'-'v' ?...r. .....
WELL - SITE .....~26...~r~c~;...~,...l~agl.~..C.~e~t..v-..Sutbv-.....~.
DATE - STARTED ................... .4 .-. 2 .6 ,-. . ~[ .4, ...............................................
4-30-84 ·
DATE - ENDED ...........................................................................................
DEPTII OF WELL ........~.Q Q.g..L.., ...............................................................
200' in hole est.
STATIC LEVEL OF WATER FT .................................................................
100% est.
DRAW DOWN FT ........................................................................................
600 est.
GALS. PER IIR ...........................................................................................
6" Sch~ 40 400'
KIND OF CASING ................................................................................
KIND OF FORMATION:
FRO.SI ......... .0.. .......... FT. TO ....... .2.. ............ FT. 0., ,"Z...e..E.h .q ~, ,~...e. I~ .......
2 ,-.. _,., 11 FT Sand & Gravel
FRO.S! ...................... r I. ~u ..........................................................
FROM ......... ~.), ........ FT. TO ....... ~...4....i..... FT. ~.~.~.~....(.~/.~.~.) ........
14 83 ~T Sand & Gravel
FROM ...................... FT. TO ............................................................
FRO.S! ......... ~.3 ........ FT. TO ....... ~).§ .......... FT. D.Q.%I..1, ~ ~.r. ...............
86 FT 167 ~ Hardpan
FROM ....................... TO ............................................................
FRO.S~ ......... L§I..... FT. TO ....... ~5.4 ....... FT.
FRO.Si ......... .2...5...4...... FT. TO ....... .2.27.. ....... FT..q.l:. a.y... 5...~ r..a...v..e.,~
FROM ......... 2.7.~..... FT. TO ....... 3.3.0 ....... FT. S~nd.-..wa.t e~: .......
FROM 330 wr Tn 371 ~T Blue Clay.
FROM ......... 3-7.1,..-.. FT. TO ....... 3S9 ....... FT. ¢l.a¥.,~...Gr.m~e.1
C a
FRO.SI ......... ~.~.9...... FT. TO ...... A.Q..O. ....... FT. ,...%..,y. ........................
FROM ....................... FT. TO ....................... FT ..................................
FROM ....................... FT. TO ........................ FT .................................
FRO.S! ....................... FT. TO ........................ FT .................................
FRO.SI ....................... FT. TO ........................ FT .................................
FROM ....................... FT. TO ........................ FT .................................
FROM ....................... FT. TO .............. ~ ......... FT .................................
FROM ...................... FT. TO ........................ FT .................................
FRO.',, ....................... FT. TO ............. = :~;i.~,L~g~.~ .~ .......................
FROM ....................... FT. TO ........................ ~F'~'t{~.-,~.6--~% .~ ...........
FROM ....................... FT. TO ....................... FT ................ ,~- 1~._9 .....
·
FROM ....................... FT TO .................
.D
MISCL. INFORMATION: Puop should be set at 280'-well perforated at 290'.
No warranty or no warranties implied.
Dennis Williams
DRIII FR~ N~MF
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Servtces
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LOT 26; TRACT "A"; Ect~.e. C~.e.6t Su. bd. Zv.i.6Zon
Location (address or directions)
10265 Cr~t FZe~
(bi Property owner
(c)
tq~,d~,.~-C,~,~&. Tel.ephone: (home~ Business
Mailing Address
Lending Institution N~th~.~ [~n~.~ Telephone
Mailing Address
(d)
Real Estate Company and Agent ~!~e?~' n~ F,~'~ ~;,,~ A:h'.? 4.d~y [~xn. .' '
Address I&600 Ce.~.~Ze~d ~u~. ~. ~201 E~g~ ~Zv~. A~. 99577 .: '~;
Telephone 694-4~00 ~'
Mail the HAA to the following address: (or check hereX[Zl, If hold fo[ p!ck up.)
List contact person and day phone number below:
S & S ENGINEERING
17034 [r~¢ R~v;~ L;.;p
~le River, Alaska 995~
2. TYPE OF RESIDENCE
Single-Family E;~(X Number of bedrooms
3. WATER SUPPLY
Individual Well [3;X Community CI Public
Note: If community well system,, must have written confirmation from the State Department of Environmental
~Conservation att~stingto thleg'~litY and status. " ' ' ' ' ' ' ' " '
4. SEWAGE DISPOSAL
On-site [k Public I'1 Community i"1 Holding Tank I"1
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ' -
AS certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation ~f thi[ ·
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional end adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address
Date
$ & $ ENGINEERIt~G
17034 Eagle. River Loop Road No. 204
Eagle River, Alasl(a YY'~'~'
Telephone
6. DHHS ApPROV~ _
Approved for ~ bedrooms b .
Approved ~ Disapproved Conditional
Terms of conditional Approval '/~ ~-~ ,'"'"="~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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.
BaCk Page 2 of 2
· ° ' ,~,o~'..~;~ MUNICIPALITY OF ANCHORAGE (MOA)
~ ~.'~ ~.50'1~'~ Health Authority Approval (HAA)
· - ' .~.~ O~..,t',C'~ ~,~: ~'~1~] "CHECKLIST - FEBRUARY 1984 ~
~t4,,m . ~t~ . ~ Legal Descri :ion: ~. ~
A. WELL D/t~,.C '' ' r ' '
V~ell Clas"sifica~ion I t~::;~ J ~:O~1--- "~ If'A, B, C, D.E.C. Approved (Y/N) I,~/~,
ption: ~
Well Log Pre.se_nt,~N) ~D'ateCompleted ~-"~ ~>~" f Yield· ,~,'~..~'~1'~-~ ~
Total Dept~ Cased to''~'''c~'- Depth of Grouting . .
Pump Set At Ot~..~o '"'"'
Sanitary Seal on Casing~N)' ~/
Depression Around Wellhead (Y/~)
Static Water Level ~-~'l'
Casing Height Above Ground'
Electrical Wiring in Conduit~N)
SEPARATION DISTANCES FROM WELL!
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field.oq Lot
To Nearest Public Sewer L,ine
To Nearest Sewer Service Line on Lot
! j
,.
Water Sample Collected by d'"" ;~ ~ ~'"'~'~'
Water Sample Test Results
Comments
Nearest Public Sewer
; Date
' ; On Adjoining Lots ~C:~:~ I 'J'' ~
'""-:,' On Adjoining Lots ' --'-'
B. SEPTIC/HOLDING TANK D~T..A ' '
Date Installed ~ ' I"~'E~"~ize \'[:x:>o '/''
No. of Compartments
St. andpipes<:[:~'N) ~ ""' Air-tight Caps ~/N) ~ Foundation Cleanou~N)
Depression over Tank (Y,~ ~ '-- I~ate Last Pumped ~ ~- ~
· Pumping/Maintenance C?ntact.on File (Y/N) ~// /J , for --
Holding Tank High-Water Alarm (Y/N) / ,~' T~porary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply v~eli ' -'-,
· To Property Line
',3~0 ~ater' Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments k}~--~, ~'--~.~=:.~
~-o~ (,~,. ~,.) F,o., Page 1 .of 2
C. ABSORPTION FIELD DATA /
Soils Rating in Absorption Strata "~<~:>'7 ~1~
Date Installed "~ ~' \~ - ~/
~idth of Field~ ' ~,~' ~
TyPe of System
Design
Length of Field
Depth of Field "~
.. .
,~.. -: - ,, .i'Gravel Bed Thickness
Square Feet of Absortion Area ~kg:,l:~ Statndpipes Preser~N) y : '
Depression ?ver Field (Y,~:) I'~ Date of Last ,~dequacy Test
Results of' Last Adequacy Test '~. c~.~-~' L...g- "~"F-~('2 .
SEPARATION DISTANCE FROM ABSO~RPTIO~N FIELD: :
To Water-Supply Well [ ~ To Property Line ~, ~ "' '
To Building Foundation' ' ~t'~='l ~' ~ To Existing or. Abandoned System on
Lot ' {'"~ / ; On A~djoinin~ Lots ' ,~ I ,'
To Water l~lain/Service Ltne . ~ ~ i .~. To Cutback (if I~resent) r~
To Stream, Pond, Lake, or Major Drainage Course
TO DrivewaY, ~Pa~rking Area, or Vehicle Storage Area
Comments I'~CY~ · '""'["~_. ~---~-~-~,~tc.- , t ~~
LIFTSTAT'ON, I"~./~ ' ~ .
· Q~_l.n. sta~lled_.. . ,. , , . ' Dimensions
S'Fze~ ' '* ' ' '
"Pump On" Level et
High Water Alarm Level at
_ Tested for
Meets MOA Electrical Codes (Y/N)
Comments
' Man~ole/,~c~ess (Y~N)
"Pump Off" Level at
Vent (Y/N)
~ ~ycles during Adequacy Test.
*'Check Permitted _B.e._dro~3m Rating Against HAA Request"
I certify that I have checked, Verified, or conformed to all MOA ,and HAA guidelines in effect on the date of this
inspection. "
Signed ,5 & ,I, ~.N~.,~riF. F. AiNG
Date .... . ,,
MOA No. -- . , ,
-ReceiptNo.- ./&~ ~P ~.~ ~ : ReceiptNo. -
Date of P~y~ent / ~/~ ~ , '" ~' Waiver Fee~$
Amo;nt:$ ' '/,~ ~'~ ~ ~'" Date;f Payment' '
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name~"..'.~/~'-.'>~/ //~ ~'~'~"~.~Telephone: Home ~'-,.5'~,.~ Business
Applicant Address / 7 ~ ~ ~¢~. ~- /~ ~' ~ ~J' ~ ~
(c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain);
(d) Lend,rig Institution~4 ~/;f/~.~_¢~:
Address ~"' ~-
(e) Real Estate Company and Agent
Address
Telephone
Tetephone ,~ ~ ~_
(f) .~a~the HAA to the following address:
TYPE OF RESIDENCE
Single-Family/[~. Multi-Family
Number of Bedrooms.
Other
WATER SUPPLY
Individual Well~ Community [] Public r"l
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite~'~ Public [] Community [] Holding Tank []
Note: If cern'reunify well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72~25 ( I t,84)
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION · "~
As ~ertified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name ~f Firm Telephone
Date ' ~, - .....
6. DHEP APPROVAl. b~~ [~C.~'
Approved for ~ bedrooms ~'~'~' * ~ · ~ ¢~ ¢ .ate
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 $ 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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
J~UNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIROI',LMENTAL PROTECTION
APR 16
264-4720
Legal.Description:
WELL DATA
Well Log Present~/N'r" Date Completed ~/"""~-~ ~ Yield
Total Depth .~ ~ / Cased to ~'{} · ~
Static Water Level ~ d ·
Casing Height Above Ground
Electrical Wiring in Conduit
Separation Distances from Well:
To Septic/Holding Tank on Lot
Depth of Grouting
Pump Set At ~
Sanitary Seal on Casing~..~/N')
Depression Around Wellhead.(..¥~
/Od / ~'' ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /~ · ~ ; On Adjoining Lots fO4) ·
To Nearest Public Sewer Line ~~'To Nearest Public Sewer
Cleanout/Manhole ~'//·/~' To Nearest Sewer Service Line on Lot
Water Sample Collected by ~'/~ ~'~&~;,~v~'~",~.~'~,~ ; Date ~f/'"/~""~
Water Sample Test Results
Comments
B. SEPTIC/HOLDiNG TANK DATA
Date Installed ?~''/7'''g ~'Size
Standpipes ~)1~ Air-tight Cap~l~b~)'
Depression over Tank..~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) "~/~"'
Separation Distances from Septic/Holding Tank:
No. of Compartments
F~undation Cleanout~/N.~'
Date Last Pumped
Temporary Holding Tank Permit (Y/N) Y~'~"~
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation ,~ ·
To Disposal Field ,,'~ /
To Stream, Pond, Lake, or Major Drainage
· .Comments
Page 1 of 2
72-026(11/84)
I,.
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Width of Field ~ d
Square Feet of Absorption Area
Depression over Field (,~Y./~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /4~)<3 "''~
To Building Foundation ~1, t./J
Lot .X.//,',-
To Water Main/Service Line
Length of Field ~
Depth of Field ~
Gravel Bed Thickness ~
Standpipes Present ~/1~
Dat oyL t Adequacy Test
To Existing or Abandon~ System on
; On Adjoining Lots ~O ~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
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
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA. and HAA~ guidelines in effect on the date of this inspection
Signed ~'& ~ I~l~ll~l~e~ ~,.~ Dale ~/~/~ '
Company,~ ~V~ A!~R~ ~ MOA No. ,
P~. ~2~7a -" '
ReceiptNo. ~ ..... ~GG/~
Date of Payment ~- J ~ '~0 ~
Amount: $
Page 2 of 2
?2-026 (t 1,84~