HomeMy WebLinkAboutHAMPTON HILLS #1 BLK 2 LT 15
Municipality of Anchorage Page _
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: '~'-~ ~ ¢'~z::2~ fi~ PIDNumber: ~t~
~¢< ~ ~ ~ ~ ~¢.~~ Wastewater System: ~ New _~pgrade
Phone: ~drooms: ~DeepTrench ~ShaHowTrench ~Bed ~Mound ~Other
Total Depth from original gr~:
Lei: I¢ Block: ~ ~ ~n:~ ~Depth tO pipe bOtl°m I,Om Original-de: Gravel depth beneath pipe .
Township: ~ Range: ~ Section: Fill added above original grade: Gravel ~ength:
Gravel width: ~/ Number of lines: ~ Distan~ ~etween lines:
WELL:~ New D Upgrade Ft. _-- I
Cia~cation (Private,:A,S,¢): % q oral Depth: eased To: Total absorption areA: Pipe material:¢~l ~¢ ,
GPM Ft. [ . Ft.
Fron, Tank Field Station lank S ...... Li .... t~
Well I i ~ ~ t ~¢ -- ¢ ¢ Material: ~¢~ Number el Compartments:
Lot ~' %i' ~ Sizein gallons: Manufacturer: ~
Line ~ ~- "Pump on" lev~n~ off" level at: High water alarm :
Foundation [~ / ~ 1
~urtain Pump/Oriel ~Electrical Inspections performed by:
--- BENCH MARK
Remarks: ,
Localion and Description:
= ad, No. 204 /
Department of He%~~ervic
72-013(Rev 9/91) MOA25
Permit No. SW950199 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 995'19-6650 · Telephorle: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: HAMPTON HILLS #1, BLOCK 2, LOT 15 PIDNo.: 01515461
CO1 C02
GRAD~
SCALE 1"
85.1/
77.9'~
/10' T & E ESMT.
UNDER
· 71.9' NO WATER FOUND
C02
DBL CO
IH
4 BDRM
HOUSE
INTEG
B
EPTIC TAN
100' WELL RADIUS
- 40'
72-0]3A(Rev 9/91) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930199
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:CROCKER ROBERT C & SUE ANN
OWNER ADDRESS:7940 MOOSE RUN CIRCLE
ANCHORAGE AK 99507
DATE ISSUED: 7/06/93
EXPIRATION DATE: 7/06/94
PARCEL ID:01513461
LEGAL DESCRIPTION: HAMPTON HILLS #1 BLK
5
2 LT 1
LOT SIZE: 53145 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
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
].5.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
DATE:
DATE:
--Tune 5, 1993--
HEALTHAUTRORITy
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, AK 99519-6650
ROBERT SHAFL--R, P.E.
ROGER SHAFER, P.E
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
REFERENCE: Hampton Hills Subdivision, Block 2, Lot 15
We request you issue a permit to upgrade the septic system
serving the four bedroom house on the referenced property.
An adequacy test was performed on the existing system and the
absorption capacity of the system was found to be inadequate.
A test hole was excavated and ~ percolatJ, on test performed.
The approximate location of the test hole is located on the
attached site plan.
We do not anticipate any adverse effects on neiqhboring
properties by the installation of the proposed septic'system.
If you have any questions, or require additional information
for your review, please contact us.
Sincerel'
SOIL TEST
Shafer, P.E.
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
'lsu
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
1"=40'
SCALE
Z
UPGRADE
0
~J
0
d
U
0
U
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
F~TERIAL SPECIFICATIONS
REFERENCE: Hampton Hills Subdivision #1, Block 2, Lot 15
GENERAL~
4 o
5 6
The scope of this project includes the relocation of the
existing 1500 gallon septic tank outside the 100' private
well radius and installation of a leachfield trench to
serve the four bedroom residence located on the
referenced property°
Construction shall be in accordance with the approved
site plan and design drawings; Municipal permit with any
special provisions or conditions; and all applicable
State and Municipal Wastewater Disposal Regulations.
The contractor shall be responsible for obtaining any
necessary underground utility locates.
Unless specifically agreed otherwise, the property owner
shall be responsible for final grading areas subsequently
depressed from soil settling· On all leachfield mound
systems, the property owner shall be responsible for
ensuring a satisfactory vegetation growth over the
mounded area°
Contractors installing wastewater disposal systems must
be certified by the Municipal Health Department for
system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified septic
tank manufacturer. Construction shall include two 4"
cleanouts for pumping access.
The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
Ail standpipes on the septic tank shall extend a minimum
of 12 inches above final grade.
Septic tanks installed with less than 4 ft. of cover
shall be insulated.
Page Two
Hampton Hills Subdivision #1, Block 2 Lot 15
June 4, 1993 '
A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the
tank and the leachfield there shall be two adjacent
cleanouts (unless an effluent pumping system exists
within the septic 'tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. from the
tank. The first cleanout, in line, shall be to clean
toward the leachfield. The second cleanout shall be to
clean toward the septic tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
1. Excavate the proposed trench to the dimensions shown on
the design. The bottom of the excavation shall be within
2 inches of level. If the sidewalls of the excavation
become smeared, they must be raked or scratched (ruffed-
up) before gravel (sewer rock) placement.
2. Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
3. A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
Monitor tubes shall be of four (4) inch diameter and
installed approximately in the locations shown on the
design. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This
is equivalent to the effective depth of the gravel as
noted on the design~
Backfill over the final gravel layer must not be less
than twenty-four (24) inches. Insulation must be
installed when the backfill depth is less than thirty-six
(36) inches. The finish grade over the trench must be
mounded to prevent the formation of a depression after
settling.
Page Three
Hampton Hills Subdivision #1, Block 2, Lot 15
June 4~ 1993
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
The following pipe materials are approved for use in
septic system installations in the Municipality of
Anchorage:
Perforated Solid
Cast Iron
ASTM D3034 (DVC)
ASTM FSiO (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi
140N, or equal) must be installed between the final
leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
When sand is being used as a filter material, it's
gradation specifications must conform to AMC 15.65.060D.
Page Four
Hampton Hills Subdivision #1, Block 2, Lot 15
June 4, 1993
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system° These inspections will occur as follows:
The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel° A septic
tank may be set in place, but may not be backfilled
before this inspection.
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
The final inspection is to occur upon final grading
of the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre-
construction meeting will take place on-site.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LE'GA L DESCRIPTION:
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
[ .-,~-~ (E N,,.,(~N £~ ~'~, SEAL)
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
SITE PI_AN
DEPTH?
Del]Ih to Waler._~.~jr..~ . //
t/Ionitorino? ~../¢~-~ . Date:
Reading
Gross I Net
Time I Time
Depth to
Water
Net
Drop
PERCOLATION RATE (~ (minutes/tach) PERC HOLE DIAMETER
,. , ~,., TEST RUN BETWEEN --~ FT AND ~ FT
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI~FECT ON THiS DATE. DATE:
72-008 (Rev, 4/85)
STATE:' OF ALASKA ' ,.,r '.~{.~ .,
of Geolog{cQI 8~ GeopDysical Surveys
orl,,i., Ne. I 0;667
LOCATION OF WELL (Pleaae complete either la, lb or lc.) ~
I~./Borough Subdivision' ' Lot Bob-- -b '' i .... '' , .- .-j~*.u.r.. r~. , · - * : .
- ',?/. ':'~ ".' ~ -.-:"~';',~.'~D , , . .... .,. ,.-.
~C.I~DISTANCE ANk DI'R~CTION FROM ROAD INTERSECTION8
Street Addre~l and Area of Well Lo,allan -.'.':L:' ' ~ :r' .
2. WELL LOG - Feet Below
~,.I ~ k)~.'k ~ ~,,./,L,.~ 0 ~:.. ~..~c~,.',oo, O.o,~,~ ~.~.. ' "~,'"~-
-~J ~ 9,-~ t ~ ' 33'~'''~%'D~,.,"-~?D~.-,~ O.o;. h-
.,, ~ o'~,r..~.~,.'?-
~ t ~ 5~a~ .qt log'." '~ ~'" ...... ~'~"-'~
~ . ~ ~e~ , i 3 7 /J~.:~- ~,. ,u-,~, ~..~ ~-~-.:-':,.;o,,~ '~. s,~u, i,E
, ' '' ' ' r''~'TYP~~tt~ '~" ~''' Da'merit ~ >-":~:;~r,;?S~?' .
.. .. . . .- .. ~: ., ,,~~:~t,' ~ . _ ~,,,~::~;~:-
' -' . - ' ':b':"~ Above ' or "7'~ Belo~ land lurfo~e - .,,,,~?; -,~..-: ,
..... ~, ~:~ - , ~ .,. , ,,%-,..:/, , , ~:,:: ._
. . ;.. r":. :"'~: Equlpme~t ueld: :' '- : ,~ ,'- '-, ~.,.~?~.-,'_ ,.
.. P~Np LEVEL below la,d lurfooe and YIELD
. -,:~ff. H-after. -.. , hrl. pumplng~.g,p.m.:'r_ '
~ ., ~ . .:~-;' ' '~ ~ r'ff. ,offer ~' ~ hr~. pumping ' -'
'r .' ~::''~J :1~ PUMp~, ~:. ( ~f ava ab e) ,"HP '.~ '~:: :
_ ' ~ ,.~x:~ngth ~f ~rop Pipe' ~ ~ r fl, capacity ' . .....
I~, WATER W~LL CONTRACTOR'S ~TIFI~IO~: --- '' :, ' ' ' , -' ,, ~,~,t-~,~
This vie[I wol drilled under my jurisdiction and th s report s true to lhe',Aes o~ m knee/ed e ' : '
~% ~ ~ ~ ~ . ny ]~e and be ef -
~ ed ~epresentollve ' · / ' /
...... . '.
Form O2-WWR (11/81) Copy Distribution', WHfTE-~fale DGGS~ PlNK-Drille% CANARY-Cuelomer
tlNIAI LIN G ADDRESS
EGAL DESCRIPTION
L~T
_OCATI~N
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 AN~ WELL INSPECTION REPORT
D3~: Ciu~-e C' eek
iLiq' IF HOMEMADE:
DISTANCE
Absorption area
IInsidelength
DISTANCE TO: ~-~ lA,,/
[ LengthL/~f each line
No. of lines I
Top of tile to finish grade
Length Width
Crib diame~
Well
DISTANCE TO:
Depth
Building foundation
DISTANCE TO:
Foundation
Total lengtl~ of Ii?es
Crib depth
Building foe ndation
Driller
Sewer line
IDwelling
Material
'~fNearest lot line,~
[ Ac}
| Tlench width
I ' ~nches
NS. UFBEDROOMS~--
'Em,T NO. 7
NO, of compartments
Liquid depth
PERMIT NO.
Liquid c a pa ~i~y~r~g*~'~o n s
Distance between lines
Total effective absorption ar.J~
Total effective ab~o~Jtion area
Distance to lot line PERMIT NO. ~
Septic tank Absorption area(s}
OTHER
REMARKS
APPROVED
DATE
LEGAL
L.Z!5 L::;;?. HFiP'IF'Tr.)I'.,I HILLS;
SO :[ L F;i:l::l"l" :1:1",I('3 (5;C! F'T,,"E:F:i ::, :::::
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THE: 15EF'TF! OF' FI '!"Fi:EI'.,ICH (31:;i: PIT I E!; THE E:,ISTF:INCE BETI4EEN THE LE:I...IF;:FI=ICI~ii: O1::: THE
('_:iFi:OUI'.,!E:, FII'.,I[:, THE E',OTTOFI OF THE EF:;CFIVFIT Z[ O1",! ,:: I I'.,I F:'ES;ET ).
THEF?.E ];S !",10 SET 14:[DTH F:'OI:;i: 'T'F?.ENCHE55.
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F:!I",t[:, TH[ii: E',OTTOI'"! OF THE: EF::CFI'v'I:::I"I'ZOi'.,! (:[I'.,I FEi:ET).
F'ERH :I: ']" Fff:'I:::'L :[ CI::I!'.,IT HFI'.:~; THE Fi:ES;t:::'C~I'.,!S ]1 E: i I... I T'9 ~t" 7 '[ I'.,IF ~ I:~:Pt "I'H 1 5.:; DEI:::'FII;UH"!I~:NT I)1...11::..'. :[ 1'.,1(5i THE
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NUI',t!~?,EI~: "!::: I-:..'.E:S :[ DENCE:'_'i!; THFIT TI...IE HEI....L. H :[ L.I~ 5;EF.?,,,'E.
E~:!:~!:::~:::!:::' :[ [...l_ i[ l'.,ll:Z~i OF FIl",t"r' 5¥STE:I"'I H]:'I'HOIJ"f F'iNI:::IL. :[I"I'~F:'FJ'2T]Z':'~I'.,~ FIi",IE:, I:::IF::'F:'I:~'"L'v'FIL 1_:.:':.' 'TH_TS
[)I~LF'FII:;:THE!",IT I,!]:I...L. DE: 'ZSI..IEL.:rECT TO F'ROSEC:LIT:I' 3H
i'"I!I",!]:I"IUH D:[STFII",IC:E Ei:E:TI,IIL~:EI",I FI HIZI..,.L FII",I[)fflN"? OI",!""SJLTE 'L:;EHREiE: D ISI:::'I:'.'~5;F:IL. S'T'S'T'IEI'"I .,T,S
:[.OI;!!] I::'E!:EVT' FCIf;i: !::1 F'F?. 7[ 'v'F:ITE HELl... OF.'r ::!.UO TO ;~OO I:::EET F:l~tOt"l F~ F:'I...IEi~L. :1: C: I.,-!ELL E:'E!:I:::'EI",![::, i l",l(:ii
LIt::'OI"4 'T'Hl:ii: 'T'T'F'E OF PUE',L :[ C Hff:LL..
I"1:!: N :[ ,HI...II'1 E:' ]: STFtI",IC:E F'F:OH ffl F:'¢;i: :[ ",,'I':ITE!: NELL TO FI
TO I:q CC~HHLII',ItT"r' SE!,IEF: LII',IE !':5 7:'!5 FEET.
HE:L.L LOG::.5 FIF:E I:;i:EL:.iU!F;'.EZ:, FIND HIJS, T 13E F;'::ETI...IRNE[:, TO THE: [."EF'FIF;:THENT H:ETH]:t",t U:O DI:::I'T%::;
r)F THE: HELL. CC)HF'L. ETI
OTHE:~;: I:;'.E~E:P.J I F:ff;I'"IE[I",!TS; I'"ll::l"~" F:II::'I:::'LV. SPEC Z[ F'
FI'v'I:::I]:LF:IE~I..E "1"O II",!5;LIF;'.E PI;:OI::'Ei? IN:i~;TFIL. L!:::IT:[OI",!.
:I: C:EFUF:[F'V THf:!T
::1..: J: FIN F:F:IH:!:I...:tLFIFi: HITH THE Fi:E:L.-.!LI]:FiEHEHTS FOFi: Oi",I-S]:TE '_:i;EI,.IE:F~tS!; FIN[::' HE~L.L..5; F~i; SE:T
FOFT'f'H E',h" Tl'"ff.~: HLIN i C: !' F'FIL :[ 'iW OF Flt',ICI"tOt?FIGE.
2.'.': :[ !-,.I :1: LL ]: NSTFIL. L THE Sh"S'I"I:~:H ]: ~-,I F:K::CO[~:[::,FII'.,!Cii: H ]: TH THE
::~i:: 3: L.INDEFi'.5;TI:%![) T!--II::I~E ON-...:il; ]: TE :i:i;E'HE[~: 5;'9S'T[.~ H I"t :: 'r' Fi E I~:!LI ]: I::~E'!: EI",ILFI[;~:GE:H[~:NT ]: I:::' THE
F;?.E:t!i!;I[::'I'!:NCE r: :~; FEf~L l:.~l:::,,,)::r,,er~.i:-h,l~rEi Hr"F;'E THI::II'.~ ~ E[::'~,I;~'-"I','I
'f'::;'::; I:::'[" ................... '"'";'77" ........................... z ................. ~']' ........................................................................................................ 'v'4.
IVlUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVlRONIVIENTALPROTECTION
825 L, Street, Anchorago, Alaska 99501 264-4720
SOILS LOG .- PERCOLATION TEST
[-] PERCOLAI ION
TEST
SLOPE
SFYL: PLAN
5
6
7
'I 0
12
13
14
15
16
17
18
19
20
WAS GROUNDWATL=R
ENCOUN'I-ER ED?
IF YES, AT WHAT
DEPTH?
['leading Date
PERCOLATION RATE
TEST RUN BETWEEN
/
PERFORMED BY: V_.~.~_~(~ ,~ ~
/'2.008 (6~79)
Gross
Time
Net
Time
Depth to
Water
Net
Drop
/ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~/SOI LS LOG -4
[] PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:._.~_
LEGAL DESCRIPTION:
DEPTH
7-
2-
3-
4-
7~
O-
/
PERFORMED BY: '~ ~.-~ '~--"'>"/
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE SITE PLAN
0
P
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN F'r AND FT
CERTIFIED BY: ' U DATE:~'---/ ~'~/
72-008 (6/79)
¥.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HFALTH & 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
Parcet I.D.~t t(~\ ,/-)- \."~\--~r~ HAA#
1. GENERAL INFORMATION
Complete legal description
Lot 15; Block 21 Hampton Hills Subdivi~io~ ¢ \
Location (site address or directions) 7741 M~CZur¢. CZ,~.~,.~¢¢., A,e.~.e4~g~,.
Property owner Rob6rt and SuAnn~ Crocker
Mailing address
Day phone
Lending agency
Mailing address
Day phone
Agent Day phone
Unless otherwise requested, HAA will be held for pickup.
Charl~n~ McLean / 2001 R~ty 276-2001
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
XXX
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. U91) Front MOA #21
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'sepoo e}e~S pue led!o!un~ lie q~!~ eoue!ld~Oo u! s! ~e~s~s lesods!p ]e~e~e~se~ ]o/pue Xlddns
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Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal DescrJption:.~Jc.~rq"'r2-C~-c-J ~-, t~c.-~ ~¢'~c;?J Parcel I.D.
A. Well Data
typ~¢'J~ If A, B, or C, attach ADEC letter. ADEC water system number
Well
Log present) ~ Date completed ¢~
/
Total depth [~--~ !
Sanitaryso (~./)
FROM WELL LOG
Date of test
Static water level I J "~- /
Well flow "~'~'+-' ~'t m?~
Pump level1 ~ .
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot I I I /
Absorption field on lot I~---~ /
Public sewer main ~-/
Sewer service line
Cased to ~ Casing height
Wires properly protecte (~
AT INSPECTION
g.p.m.
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
(_¢,'~/~ g.p.r~.U(~ 1 2 199;~
RECEIVED
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample: ¢/L~,/R '¢7_>
B. SEPTIC/HOLDING TANK DATA
Date installed ¢)- l~- ~ [
Nitrate '~-
Collected by:
Other bacteria
Tank size
Compartments
Cleanout~N) "'-7'/ Fou ndation cleano,~N) "'7
High water alarm (Y~( l*--J Alarm rested (Y/N)
Date of pumping z_.~./..~.~.)/~ Pumper
SEPARATION DISTANCES FROM SEPTIC~TANK TO:
Well(s) on lot
To property line
Surface water/drainage
_On adjacent lots
Absorption field
Foundation ID
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical
SEPARATION DIS...T-A'~CE FROM LIFT STATION TO:
Well.~~ On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length ~¢'~'~ ¢
Total absorption area
Date of adequacy test
Manufacturer~~
Manh~e/Access (Y/N)
"Pump on" level~ "Pump off" Level at
~ Cycles tested
Surface water
System type '~:~¢6 ~'T~
Total depth
Depression over field (Y~)
for ~ Bedrooms
Soil rating (GPD/Ft
Width Gravel thickness
· Results (pass/fa~)
Water level in absorption field before test ~_/./~- After test
Peroxide treatment (past 12 months) (Yt~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot_
To building foundation
On adjacent lots
Surface water
Curtain drain
If yes, give date
adjacent lots _ [~¢¢ Property line
To existing or abandoned system on lot
Cutbank ~.~/~_~_ Water main/service line
Driveway, parking/vehicle storage area
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines/n effect on the date of this inspection.
Signature _
Engineer's Name, ~, ~:¢a~,'..~'= · '
HAA Fee $ ,,/
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
CT&E ENU!RONHENTAL LAB SERUICES '
COMIV ERCIAL'TES'rlNG ENGINEERING CO.
ENVIRONMENTAL LA~OFIATORY BERVICE$ .') ~.~i':~- .:.~
........... .: · REPORT of ANALYSIS
Chemlab Ref'.~ :93,3935-3
Client San, pie ID :B2 L15 HAH~'N HILLS
Matrix
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 567-2343
FAX' (907) 561-530~
Client Name :S & ,S ENGIN~:J~R[NG WORK Orde~ :69246 ·
Ordered By :R. S}{AFI5~t Report Completed :='08/~1/93
Project Name : Collected !f08/06/93 @ 08:00
ProJect~$ ; Received .,:08/06/93 @ 16:00
Technic~] DirectoT~STEPHEN,C. EDE
PW&ID :UA Released By !.
Sample Remarks: ROUTINE SAtiPLE COLLECTED BY~ J.K,B.
QC Allowable Ext, Anal
Para~eter Resul%5 Qual [)nits Method [,itMts Date Date In~
-- ~Nltrate~N 2.37 mg/L EPA 353.2/300.0 10 08/10
* Bee Special Instructions AboVe ~ :.'.~UA : Unavail~le .
see':Sa ~ ' :-,' : · ' - : ~:~:~: - ":; n ,:"
U"= Undetected' Re~rted value is. the practical quant~fication