HomeMy WebLinkAboutMILE HI BLK 4 LT 2
'F
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: ~d2G~ PIDNumber:
Name:
,~v~,~,,~o z, ~ ~o~ ~. ~ Wastewater System: ~ New ~ Upgrade
Address:
~ ~ ~ /~., ~- ~,~ ~ ~c~ ABSORPTION FIELD
Phone:
No.
of
D~Urooms: ~Deep Trench r~ Shallow Trench ~ Bed ~ Mound ~ Other
LEGAL DESCRIPTION Soil Rating: Total Depth from original grad~ t
. G GPD/Sq. Ft.
Lot: Block: Subdivision: Peplh to pips bottom from original g~d~: Gravel depth beneath pipe
~ ~ ~/Z~ ~/~ Ft. ~ Ft.
Township: Range: Section: Fill added above original qrade: Gravel length:
WELL: U New ~ Upgrade Gravel width: ~ t Number of lines: Distance between lines:
Ft. Z Ft.
Classification (Private./__~ ~A'B'C): Total Depth: Cased To: Total absorption area:_~ ~ipe material:
Driger: Date Drilled: Static Water Levek Installer: Date installed:
GPMJ Ft.J Ft. TANK
SEPARATION DISTANCES ~s~pti~ ~ Holding ~ S.T.E.P.
To Septic Absorption Lift Holding ~ublic/Private~ ~ ~¢~/M~ufaoturer: __ Capacity in gallons:
From Tank Field Stalion Tank S ..... Lines ~~7~__
~" /~¢ /¢¢ _ ~ ~ M~teria~r~~ NumberofC~artments:
Surface
w~t~r /¢ ¢ /¢~ -- -- -- LIFT STATION
Lot /~ ~t~ ~ Size in ~allons: ~ Manufacturor:~
Line ~ --
/ ~ ~ a~off level at: High water alarm at:
/~ ~ "Pump on" level : ....
Foundation
C,rtainDrain ~j ~ ~~ ~ .ump~el Bectrical Ins,ecbons pedorme~ b~:
Remarks: ~ Ho~ ~o~/o~ BENCH MARK
Location and Description:
Assumed
Elevation:
S l S ENGINE~RIN~ Muniotpah[y of Anchorage ¢ ..... .: ::, . ,
Inspections performed by: ~7oaa ~!e m~,r ~~pn~e/~ ~,-)~,~ ,~ ,,~'~..~..~,..
Reviewed and approved by: ~ ~ Date: / ~ -/-~fl ~"'?' '
72-013 (Rev. 9/91) MOA 25
Permit No. -~W~7;0764 Page 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
of. 2
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: MILE HI, BLOCK 4, LOT 2
PID No.:05020121
CO1 CO
! C03 MT~
SCALE f' = 40'
LOWER
72-013 A (2/91) MOA 25
50'+ ~0'+
CANYON DRIVE
?.8'
87.8~
· 82.8' WATER FOUND 7-19-93
STATE OF ALASKA
DEPARTMENT OF NATURAl. RIE~OUR~ER
DIVISION OF WATER
LOCATION OF WELL WATER WELL RECORD
F- BoI~ouoH 8UiIDIvISlON LOT BLOCK SECt*ION O. TRB ~CT~N TO~IP
............. OS OW
LOCAT~ISK~CH; WE~ O~ER~
DE~TH$ M~SURE~ FflOM:~ca~in~ top ~0r0un~ su~fac~ WE~ DEPTH:
.............. Depth Of h01e:~ft DATE OF COMP~ON
· ,ORIOLE DATA: De~,h D~th of ~sin~;~ft
_.~.tOrH; Typo and Color From
· D~TH TO STATIC WATER
USE OF WELL: ~ dom**tic ~ ir~ioation 0 mo~tor
...... ~ pubtio supply D other , ~ ....
CASING STICK-UP: ~ lt. Diem: ~in, t~ft
WELL INTAKE OPTING TYPE] ~ open end ~ ~;oenod
--- ,. ~ podorated ~opon
Depths of openinos: _ to ft
G~VEL. PACK
...... ~_.~ Volume used:. . ~ . Depth to top:
.... r~, ~ ...... ~n~ ~ Depth: fr~' ~ ftto fl
Duration; ~ ~
PUMPING L~EL AND YIELD:
~ fLalter ..~ hrspumping ~ epm
PUMP INTAKE OE~H= ft Horse~wer;
WELL DISINFECTED UPON COMPL~ION? ~ YES ~ NO
CONTRACTOR INFORMAT~UN: REMARKS;
~~Sss Name _ /'-- '
~~,..~//~_~_~ ~,../~, ~ PLEASE MAIL WHITE COPY OF LOG TO:
DNRIDIVISION OF WATER
· ~~[rlorized RespreSent~e ~' Date PO BOX 772116
EAGLE RIVER AK 99577-2116
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930264
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:BELTRAN RAYMOND L & IDA Y
OWNER ADDRESS:HC 83 BOX 1611
EAGLE RIVER, AK 99677
PARCEL ID:05020121
PAGE 1 OF
DATE ISSUED: 8/02/93
EXPIRATION DATE: 8/02/94
LEGAL DESCRIPTION: MILE HI BLK 4 LT 2
LOT SIZE: 75358 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AACS0).
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:
DATE
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
July 23, 1993
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAO DESIGN
SOIL_TEST
PERCOLATrON
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
~unicipality of Anchorage
)EPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, AK 99519-6650
~EFERENCE: Mile-Hi Subdivision, Block 4, Lot 2
~e request you issue a permit to drill a well and install a
septic system to serve the proposed four bedroom house on the
~eferenced property.
~wo test holes were excavated and percolation tests performed
)n the property. The approximate location of the test holes
are located on the attached site plan. During excavation
water was found !~2' and 4.5' in test holes ~1 and %2
uespectively. After seven~ day groundwate~r monitorin water
~a.s found at/,, 12' and 4' respectively. "7--,,~'- * -"'-* ',g/ /
/ '~ -'Z/f,3 /'J ~ ~ d
~h~ch can be seen on the attached site plan~ We ~a~
anticipate any adverse effects on neighboring properties by
the installation of the proposed septic system.
If you have any questions, or require additional information
~or your review, please contact us.
~ince~
~" '~ r, P.E.
S/LSU/ su
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
= 50' SITE PLAN
SCALE
-o
\\
\
\ \
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
8
9
11
12
13
14
15-
16
17
18
19,
20-
3
4
5,
DATE PERFORMED:
Township, Range, Section:
SLOPE
SITE PLAN
-/
WAS GROUND WATER
S
AT WHAT ~) '
Dept? t~ Water After/~
Reading Zte Gross Net Depth to Net
Time Time Water Drop
/
PERCOLATION RATE ~/'~ z/i(minutes/inch} PERC HOLE DIAMETER
TEST RUN BETWEEN 2 FTAND, ~ FT /
COMMENTS ~
17034 Eagle River Loop Road
PERFORMED B ~04 I ~ CERTIF
~agle River, Alaska 99577 ./'_,/~-~/ Y THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELIN~/~/~ECT ON THIS DATE· DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
3
4
5
6
7
8
9
10
11
12
13
14
15
16-
17
18
19
/2. o,e
SLOPE
WAS GROUND WATER
SITE PLAN
Reading
Date
Gross
Time
Net
Time
Depth to
Water
7*If*
Net
Drop
PER~,OLATION RATE _ ~(minutes/inch) PERC HOLE DIAMETER ~ ¢
,, , TEST RUN B/ETWEEN .~-------~ FT AND , ~ FT
COMMENTS ~/~( ~¢¢~Z¢~ ~ /0 ~/~ ~¢¢ ~/ ~ .~
P
~le ~Jve *~--~;- .-Z_ - ..... ~ '//~' w CERTIFY THAT THIS TEST was PERFORMED IN
FFECT ON THIS DATE. DATE:
72-~8 (R~v. 4/85)
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PP. ACTICES
and
MATERIAL SPECIFICATIONS
REFERENCE: MILE-HI SUBDIVISION, BLOCK 4, LOT 2
GENERAL:
1.
2o
3o
e
Se
The scope of this project includes the installation of a
1250 gallon septic tank and a leachfield trench to serve
the proposed four bedroom residence 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:
me
A septic tank is to be constructed by a certified septic
tank manufacturer. Construction shall include two 4"
cleanouts for pumping access.
e
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.
0
Septic tanks installed with less than 4 ft. of cover
shall be insulated.
Page Two
Mile-Hi Subdivision, Block 4, Lot 2
July 23, 1993
Se
Se
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:
e
Se
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.
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.
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
Mile-Hi Subdivision, Block 4, Lot 2
July 23,. 1993
MINIMUM MATERIAL SPECIFICATIONS=
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
e
Se
The following pipe materials are approved for use in
septic system installations in the Municipality of
Anchorage:
Type of Pipe
Cast'Iron
ASTM D3034 (PVC)
ASTM F810 (HDPE)
ASTM D2662 (ABS)
Perforated .Solid
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
Mile-Hi Subdivision, Block 4, Lot 2
July 23, 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:
me
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.
Se
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.
P.',J. X .5650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TO,~Y Y,~]O;VLES.
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 10, 1986
TO: Permit Applicant
Subject: Permit # 850277
Lot 2 Block 4 Mile Hi Subdivision
A permit issued by this Department for an individual well and/or on-site
sewer system has expired as of December 31, 1985.
Permits are issued on a calendar year basis by authority of Municipal
Ordinance. A new permit must be obtained from this Department for any
well and/or on-site sewer system not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to this
Department for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system
the original as-built inspection report(three part form) must be sent to
this office for review and approval,and for documentation.
If there are any further questions, please call this office at 264-4720.
Sincerely,
Susan E. Oswalt
Program Manager
On-site Services
SEO/ljw
eric: Copy of Permit
I
CiTAL,. DEP'T'H (F::"]".)
F:i'.AVEilL t~.J Z DTH (r::'T.
RAVEL LEN~S"r'H (F:'"f'.)
ANK Sii]ZE (GALS)
i~;!]]i.... RAT]CNG (SC.!,, F'T. /BR)
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
P O~L'.'~4-1 6-650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TON'/ KtVOWLE'.~
Permit #: 840256
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 2 Block 4 Mile High Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent
to this Department for documentation of the installation
and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
and the yellow copy must be sent to this office for review
and approval, and for documentation.
If there are any further questions, please call this office
at 264-4720.
Si,ncerely,
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
F'ERMIT NO:
[)RTE: ISSUED:
FIF'PL. I CFINT '
RDE:,RESS:
LEGFIL DES Y F.' I P ·
· TFIHES [:,. F'RICE
F'O E:r','.'_, '~,..
EFiGLE R I 'v'EF_';.,
':"; E;~ 4 -. ;2 ;.2,4. 2
SUBDIVISION: HILE HIGH LO]-: 2 BLOCK': 4
SECTION: 9 TO!.,.INSFtIP: :t4N F.:FfNGE: ±!.,.I
LOT SIZE: :.1... 7'B (SQ. FT. OR FIE:RES>
HFiX BE:[:,ROOMS: 3:
LISTED BELOH FIRE THE OPTZONS'RVFIZLRE:LE TO h.'OU IN DESIGNING YOLtR SEPTIC
SYSTEH. CI...100S.E THE OF'TION THFIT BEST FITS '.dOUR.SITE.
[.:,EPTFI TO PIPE BOTTOM (FT..':,
GRFIVEL DEPTH ,.'.'FT. >
'f'OTRL DEPTH ,.'.' FT.
GRFI'v'EL H I .[:,TH ,:.' Fl".
GRFIVEL L. ENGTH ,.';F"F.
GRRVE[_ VOLUME ,.'.'CU. YDS.
TRNK SIZE ,::GALS::,
SOIL RATING (SEL FF. ,.'"E:R)
4.0 4..0 4.8
5.8 8.5 ~.5
9.0 4.5 7.5
2.5 !9.0 5.0
45.0 ~6.0 49.0
22.9 25. 3
1,000.0-* ±,000.0**: t, 000.0-*
t50 i50
:+::+: FM'-4,'... MUST HFI'v'E FIT LEFIST TFIO COi"IPAF.:TMENTS
I CERTIFY THFI]":'
:.1... I FII"'I FRMII...IFIR HITH THE F:EOU!F.:EMENTS FOR ON-SITE .:,E~.EF..:, RI'-4E:, HELLS FIF; SET
FOF.:TH BY THE MUNICIF'FILITY OF FINE:HORFIGE (MOFI> RNE:, THE STFITE OF FILFtSKFI.
Z-.'.I Pl..ILL iI'-.ISTFILL THE S','STEH I1'.,I FICL-:OF.:DFII'..IE:E L, II'TH FILL HOFI CODES FINE:, F.:EGULFITIL3NS.,
!::tN[:, II".l COI"IPLIFIiqE:E 14!TH THE DESIGN CRITEF.:IFI i-iF THIS .PERMIT.
2.. I HILL RDHEF.:E TO FIL. L i-'lAB FIt'.,I[:, STRTE OF FILFISF'.:FI F.:E(;!UIREMEi'.,ITS FOF.': THE SET BFICK
RNY ENLFIRGEHENT 14ILL F.:ELT.]UIRE FIN FIDD!'FIL-II'-,!RL_ F'EF. ff,IlT.
IF FI LIFT STFFf'IFq(4 IS. IIqL:;]'RL.LE[:, IN FIN FIREFI CO',:'EF. tEC, E:Y ML3R E,JIL£:,tNG CODES.,
THEN ':'±:', AN. ELECTR!F:F!L PE'RHIT FIND IN'=;F'EC"!"I3N MUST BE OBTRINED; (::_'::, FIS-ELIILTS
.t,.ilLL NOT BE F!F'F'F.:O'v'E[:, [,.IITHOUT FIN ELE'_-TRI_-RL INSF'ECTIf]N REF'OF.:T.; AND ,'5:, THE
ELECTF..:ICRL l.,.10~( HUST BE DONE BY Fl LICENSEE:, ELEF:TF::IF:IFII',I.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
SOILS LOG- PERCOLATION TEST
,~ SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
I
2
3
.---.4
5
6
7
8
9
10
11
12
13- '~'-~
14,
15
16
17
18
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
SITE PLAN
~8~ D
WAS GROUND WATER
ENCOUNTERED? y/o
0
P
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
(minutes/inch)
PERCOLATION RATE
TEST RUN BETWEEN FT AND -- FT
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
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
7
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone
?¢J--7 7
Agent. C,/-/'~¢'~;/-~'~ /-/ ~ ,¢/ ~ /c)
Address 312f ~-~, // ~,7-"-~ ~ ~,zF /¢,~//, /Crc,z.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~7z
TYPE OF WATER SUPPLY:
Individual well ~'
Community well
Public water
Day phone.
NOTE:
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. 1/91) Fronl 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 inves~i_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 S & S ENGINEE~EING~-~
17034 Eag~p-I~iYer Lo~ Road No. 204 Phone ~¢'¢z~2
Address Eagle
Engineer's signature ~ ' Date/,Z
/ /
bedrooms.
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for ..
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type ,,/'~/~/4/,~ '~
Log presen(~'q)/~'
Total depth
Sanitary seal (~N)
Date of test
Static water level
Well flow
Pump level1
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller /g//-,/2/
Cased to Casing height /'~
Wires properly protected~q)
FROM WELL LOG
/ ~
SEPARATION DISTANCES FROM WELL TO:
!
Septic/J~"~W~g tank on lot
Absorption field on lot ./0~ t./_
Public sewer main ~
Sewer service line Z.~-
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~) j~iitrate <~. 2..~ ~,~,,~//~ Other bacteria ~
Date
of
sample: /2. ~ by: ........... Lc-- "--'~ ~'~ on,~
B. SEPTIC/I'I~i~I~TANK DATA Eagle
Date installed ~/,~ ;~/~'~
Cleanouts~/N)
High water alarm (Y/N)
Tank size
Foundation cleanout~)/N)
///~ Alarm tested (Y/N)
Date of pumping ~ ~- ~ Pumper
SEPARATION DISTANCES FROM SEPTIC~ TANK TO:
Compartments
Depression (Y/~)
/
Well(s) on lot /'~2~ r'/- On adjacent lots
To property line /~ ~"/"- Absorption field
Surface water/drainage
Foundation /~
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons / ]~Manh°le/Access (Y/N~_ _
Vent (Y/N). ~~~"Pump~/~ off" Level at
High water alarm level
Meets MOA_~(Y/N).
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~"- ~- '~ - ~' ~
Length /2.~ (
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) ~, ~ System type
Width ~. ,,.5'- - ~ ! Gravel thickness ~ ~
' Total depth /7 /
/OO(D Cleanout present ~;~'N)/~'-J' Depression over field (Y~
/~/~ ~ Results (pass/fail) .~'"'~'"~for ~-~--"'"---'--~ Bedrooms
/~ //'~- After test /t//
~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot . //~
TO building foundation
On adjacent lots ~.~
Surface water
/ Z- Property line
On adjacent lots //~:2 7
//~Z ! To existing or abandoned system on lot
Cutbank ~
Water main/service line
/~ ~ ~/- Driveway, parking/vehicle storage area
Curtain drain /~/J E- ,~(~//'20/--OCkJ'
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date. of this inspection.
Signature$&SE
Engineer's Name~
Date Eagle Eiv~, AlasEa ~)~577
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
18:16 CT~= EHU!RONHENTAL LAB SERdICES
COMIVtI RCIAL'I"ESTII G & EI Glt'tIIEERIING CO.
N0.002 ~02
15NVIRONMEHTAL LABORATORY f;ERVlCE~
Chemlab Ref.# :93,6542-1
Client Sample ID :L2 B4
Matrix :WATER
$633 8 STREET
ANCHCRAGE. AK g951~.
TEL ~[,,3,',~ 562-~343
FAy,: ;9~7} 55!-5301
Client Name :S & S ~N~INEERING
Ordered By :UA
Project Name
ProJect~
PWSID :UA
WORK Order :73873
Report Completed :12/09/93
Collected :!2/05/9~ @ 18t00 hfs
Received :~2/06/93 8 16:00 hr's
Technical D£rector:ST~P~EN_~i, EDE .
Sample Remarks: SAMPLE COLLEC~D BY: RAY,
QC Al!owab]e Ext. Anal
Parameter Results Qua! units Me~hod Limits Data n ~
,.~a~e Init
Nitrate-N 0,26 mg/L EPA ~53,2/~00,0 10 12/08 LLH
* See Special Instructions Above UA = Un~vailable
** See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT = b~ss Than
D = Secondary dilution. GT ~ Greater Th~
Et4VIF~ONMENTAL SERVICES IN ~,LASKA. COLORAOO. UTAH= ILLINOIS, OPI!O..,",4ARYLANE', WE-ST V!I:{~3!i-!iA. NEW .;EP..SiJY. SOUTH CA.~OL[NA