HomeMy WebLinkAboutMILE HI BLK 5 LT 3
MUNICIPALITY OF ANCHORAGE
'~ DE,,.~_?TMENT OF HEALTH AND HUMAN SER,.,,/ES
, ' ' Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Na,.e DISTANCES
,k-'"Y-,~ -~.( ,z:2c~. ~ ~ SEPTIC ABSORPTION
~ .... TANK FIELD WELL
Phone(s, I peru, it No. "O. Of Bedrooms w~gg
LEGAL DESCRIPTION
'Lot ~ Block.5~ Subdi~ /~- ~' FOUNDATION
Township. Range. Section
AS-BUILT DIAGRAM IShow Iocahon ol well. septic system, property lines, foundation.
TANKS
~ SEPTIC ~ HOLDING
Depth to pipe bo,,om from Total depth from orig,na' grade
Gravel length Gravel width
Tolal absorpho~ area Distance between lines ~,~ /~ ,
Number ol hnes SoiJ rating P~pe material
ms~aHe~ ~ ~-I1~ Date Inslalled
WELLS
~ PBIVATE g OTHE~ (Idenlilv)
ClasslliCahOn (A,B,C) : TOtal Depth Cased to ~ ~ ~-J~
Instaliel Date Installed:
REMARKS:
I~ ~z~ ~~" cedily that Ihis inspection was pedormed according to all
72-013 (3185)
EAGLE RI¥~_~,
ENGINEERING SERVICES INC.
· P.O. Box 773294
· EAGLE RIVER, ALASKA 99577
Phone 694-5195
SHEET NO. '~ OF ' /
CALCULATEDB~ ~.~ :~ BATE -./~,/~
CHECKED BY DATE
SCALE /'d,/;--~,
,~.....,. ir" i?.,..~i~ ........ ~. !i' "~i"' .-...~ 4 ,~....,.: I]~- ~.~-....~..:~.::.
.Ok::.~'"r"u"~.~v~:::.~.~ ~ ~:,"',,.,~¢1 '~ ~" ~'"' ~ .... ~" '~ * ' ~'~ r
.... '? *,..".-'.,.
............... ~"' 0 C
860328
09 i08186
I:::RE:DE:I::;; :!: CK i}UNE? ~M ~ ~
F:'.O,, BOX 770444
EAGL..E R:[VER, Al< 99577
2q. 3- 1466
LO'T S I ZE:
SUtii{D I V I S ! ON: M I L E H I GH L..C] ]": L"~
SIEC T I ON .-". 9 'f'OWNSH !. P: :[.q.N RANGE: :I.W
:I.A (SQ. FT,, OR ACRES)
3
BL.OCK: 5
Lis'Led be:l.c,~?~ ar'e l:.l'"~e options available to you in designing youn sept:Lc
system. Choose the c,p'L:i, on that. best fi'Ls your' site,
DEP]"H ]'0 F:'t F:'E BOT"I'OM (F:"T'.) 4.0 4,, 0 4,, 0
GRAVEL.. DEF:'"FH (I:::'T,,) 7,, 5 (). 5 3.5
TOTAL. DEP]'H (F"t-.) :[ J.,, 5 4.5 7,, 5
E~RAVEL. W]:DTH (FT.) 2.5 :[9,,0 5,,0
GRAVEL.. [...E:NE.~TH (F:T.) 30,, () 55.0 48.0
GRAVE;[.. VOLUME (CU,, YDS,, ) 22~ 3 24.. 7 ;55,, 6
TANK S :[ ZE (GA[...S) 1,00(). 0 ~-¢~' 1,0()0 ,, 0 '~'~(- :[, ()OC). 0 '~"~'
SC)];[... RA'f'ING (SQ. F'T'. iBR) ;[46 :[46 146
-~.-~,~. TANK PlLIST HAVE A'T' L..EAST ]"WE) COMF'ARTMEN"f'S
Z c e r' ',':. J. f' '? t. h a't:.:
1,, i am f'amiliar' t4:[th the r'equir'emer'~,ts f'or' c,n.-..site seweps and ~.~e].is as
fc:,Pth by '?..ha J¥1LU"iiC;J. pa].:J.'ll.y c3f' Anchorage (MOA) and the Stat~? c,f Alaska,,
2. ]: ~,~:LiI.:I.i[~S:'t'r.~::::[:[ the .system ir] accor'danca, Hi'Lb all Hi:}A c:c~des and
and ir'i c::omp].ial'ic~) :,,~J.'Lh thE.:, da, sJ. gl'~ c:PJ. ter'ia c)f this
:2~. :[ Mill. adl"ler'~:ce 'Lo a].]. I"iOA ar'id State (]f' Alaska pequ:i.r'emerrLs fop the sa, t !:::,ack
d:i. staricE, s f'r'c)m ar]y aex:i.s'l:.:i.r'~g w~.:,,].l~, ~as1:.e~a~,tE, P dispc, sa]. syst~am c)p
sewE, r'aga sys'L0?m c)r'~ 'i:.h:i.s oP any acljac:(:.~n'l: on r'i~eau*[]y lot.
]: Lti-tdi~el"s'[.ar]c[ 4:..ha'L this pepmit :i.s valid for' a max:i, mum of 3 bedr'ooms arid
arYy en].?:d:'g(.?m'ier'yl:.. ~z.~i}.]. r'eqLtJ, r'e an ac:hJi'k:i, onal
]:f::' A LIF:'I" STA'T'ION IS INSTALL. ED :[lq AN AREA COVE:RED BY MC)A BUILDZNG CODES,
-!'n[:l~, (].2 AN !:..L.E:C]R.t.t..,AL. F'E..RM1F AND !N~:'E. CF].ON MUS-[ BE
WI:! ...... NO',' BE:; APPROVED WITH[)UT A>.I E;LE~TF(:I,:]AL INSPECT'I3b~ REF:'OR','; AND~(3) THiE
AF:'F'L ICAIq'I"~ FRIEDEF?.I CK ~qlE - ~ / /
A'
EAGLE RIVER' ENGINEERING SERVICES
Lou Butera P.E.
P.O. Box 773294
Eagle River, Alaska 99577
Telephone (907) 694-5195
Mr. Steve Morris
Municipality of Anchorage
Civil Engineer/On-Site Services
P.O. Box 196680 Anchorage, Alaska
99519
REF: Lot 3, Block 5, Mile Hi Subdivision
Dear Mr. Morris:
On behalf of my client, Mr. Fred Dure, I have prepared this
application for an onsite well and septic system permit.
There is a home and well located on the lot as shown in the site
plan and the owner has been residing heretsin~e 1981.~ The past method
of waste disposal has been unpermited subsurface dispos~ Th~ attAch-
ed plan calls for upgrade to a permitted septi? tank ~ith leachf%eld.
The site plan shows that the area available for septi~ installation is
limited by setback distance to a cutbank to the south, 100' well
protective distance and excessive slope to the north. Slope angle to
the north is 45%, making this area unsatisfactory from a leaching and
equipment access standpoint. A level pad has been constructed within
the area designated for septic system on the site plan. The only
suitable septic system for the soil conditions on this lot" is. a ~deep
trench system. The design I have calculated calls for 9' of gravel
depth and a length of 24' as detailed in the enclosed specifications.
If there are any questions or if additional information is
requested, please feel free to contact me at 694-5195.
Sincerely,
Leu Butera, P.E.
EAGLE RIVER ENGINEERING SERVICES
P.O. BOX 775294
EAGLE RIVER, ALASKA 99577
694-5195
SPECIFICATIONS FOR ON-SITE SEPTIO SYSTEM
LEGAL: Lot 5,- Block 5 Mile Hi Subdivision
A. GENERAL
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
5. All materials and workmanship shall meet the requirements of ~
the Anchorage Department of Health and State D.E.C.
'4. All soil tests are advisory to the design and are to. be
verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified or
modified in the field by the contractor to meet MOA, D.E.C require-
ments.
6. It is the responsibility of the' owner to obtain all 'necessary
permits or easements and to locate any ad3acent multi-family wells.
7. The excavation is to be exactly in the are shown on the site plan,
any deviation requires engineer approval.
8. it is always recommended that a surveyor locate the nearest lot line
position and .the location of any easements.
8. DRAINFIELD
1. The dra%sfield is to follow the natural land contour to maintain
uniform total depth of the trench bottom.
'2. The bottom of the trench shall be level, plus or minus 1.5".
5. The total depth of the trench excavation is not to exceed 10' at
any point.
4. The trehch gravel is to be covered with typar fabric-material. ·
5. Soil or combination of soil and extruded board insulation to a depth
of 4' or equivalent is to be placed over the drainfield.
6. The area over the trench is to be finish graded to prevent pondin~
of surface water runoff.
7. The septic tank and leaohfield must not be closer than lO0~feet to
any existing private well, i50~ to any Class "C" well, or 200 feet
to any community well.
-REOOMMENDED LEAOHFIELD DIMENSIONS
TOTAL DEPTH= 11.5' GRAVEL DEPTH=' 9~ TRENCH LENGTH= 24' TRENOH WIDTH= 50"
~ Bedroom
Septic tank size= 1000 gallon
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
LEGAL DESCRIPTION: ,)---c)"~ ~ ~,/,/-'t" ,.~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20-
CATE PERFORMED:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
L
O
IF YES, AT WHAT
DEPTH? ~z° ~' 5- ~"z' /
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
COMMENTS
Ealle River Engineering Services
PERFORMED BY: ~ 0_ ~e~ 7732~~. CERTIFIED BY:
Ea§le River, AK 99577
694-5195
7' (minutes/inch) = /~'
~ FT AND ~ FT
72-008 (6/79)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Parcel I.D. O~O .- ~o! '-I 7
1. GENERAL INFORMATION
Complete legaldescription'L3; B5; t. lile High Subdivision
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Expiration Date: "~
#1
Location (site address or directions) 21949 Lower Canyon
Current Property owner(s) Fred and Ann Dure Dayphone 227-7121
Mailing address PO Box 770444 Eagle River, AK 99577
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: .3
Day phone
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site
[] Individual Holding tank
[] Community On-site
[] Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of AJaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a singte family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
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 less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Munic!pality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further veri~ that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm
Address
$ & S ENGINEERING
170':,.; :-Ur,- ~-;,'-,
Eagle Rlver~ Alaska 99577
DSD SIGNATURE
Approved for
Disapproved.
bedrooms.
Phone 6 ~ ~ - '3- '~ -7 q
Date ) 3,//e /e /
Conditional approval for .3 bedrooms, with the following stipulations:
$300.00 to be placed in escrow and is not to be released
office ~tves final approval. Seotie ~--~ tn ho p,,~?oa bv June I.
Additional Comments
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
, gg : ON-SITE
._~-. WA~ERAND ·
PROG
~.~ ... ..' ~.~
772)))))
Maintenance Agreements
Supplemental Engineer's Repo~
Other
Original Certificate Date: / .9_ - / / - 0 /
(Rev. IZ~0)
Mnnicipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 8outh Bragew SI.
P.O. Box 196650 Anchorage. AK 99519-6650
www.cLenchomge.ak.ua
(~07) 343-7a)4
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDesc~ptlon: LOT- 3 i~La¢< ,~ I~/t,e, HtCIv Sip #/ ParcellO: 05'0 -,~o/--)7
A. WELL DATA
Well type ~,~var L
Date completed ~/)/7/~r L
Total depth ,.~'00 ft.
If A, B, or C provide PWSlD # --
San~ary seal O/N) ¥~ J
FROM WELL LOG
Dateoftest y /-~ /~' C~
Stalk; water loyal / '~- O It.
Well production /. O g.p.m.
Well Log ~N)
Wires properly protected (~)
Casing height (above ground)
AT INSPECTION
I olo
/33 ft.
O, 3 ~ g.p.m.
in.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi. Nilrate J. ~t ~- mgJL
Date of sample: j! / '~o / o I Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material -.S'~,a 7, c / $7"~..~. c.
Tanksize I'O~0 gal, Number of Compartments '~
, Founda. flon deanoot (~q) Vt, -~ Depression over tank (Y~ .',~0
· Date of pumping Ca"/a~r'~/'~L ~t,4A I-'umper ~
C..t~SORPTION ~EI.~ DATA
Length i.t 0 fl. Width 3 ft.
Other bacteria O colonies/100 mi.
S & $ ENGINEERING
17034 Eagle River L(mp Road Ne. 2g4
Eagle River, AlJska ~9577
Date installed
High water alarm (Y/~ ~v 0
Total depth 13 ft. Eft. absorption area '70%0 ~ Monitoring tube Ye J
Date of adequacy test il/'30/0 , Results ~---~Fall)
Fluid depth in absorption field before testi't ' a ' in. Water added-,~''~'Ogal.
Elapsed Time: '~(2 min. Final fluid depth$"a' "in. Absorption rate >=
Any rejuvenation tmatmant (past 12 mo.) (Y/N & type) ~c ~,~.
System type '7'/~ ~,,. ¢ H
Gravel below pipe ¢~ ft.
__ Depression over field
For 3 bedrooms
New depthS. ~ 'i~.
I./5-0 g.p.d.
If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
'Pump on' level at in. 'Pump off" ~larm level at
Datum ~..-------~'-"-~'ycles tested Meets alan~ & cimult requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: /
Septic tank/tiff stet]on on lot / O 0 On adjacent lots ! 0 o
Absorption field on lot / O B ' -t- On adjacent lots ,/0 0
Public sewer main ~,//,~ Public sewer manhole/cleanout ,~/,4'
Sewer/septic service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'- ~- Property line ~' /1/- Absorption field
in*
Water main /~ //t Water service line / 0
Wells on adjacent lots / o 0 ¥
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~' (~,,t,v~t .- Building foundation
Water Service line / o ~' Surface water ! 0 0 ·
Curtain drain /vg,.,~ ~(,,~.~ Wells on adjacant lots JOo
Surface water
Water main ~/,4
Driveway, paddng/vehicle storage O'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have datermlned through field inspections end
review of Municipal reconfa that the above systems are/n
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date ) ;)~//
HAAFee S ~)0~. ~'"
Date of Payment
Receipt Number
(Rev. 12/00)
·
Waiver Fee $
Date of Payment
Receipt Number
IlY'. ' '
ROBERT C. COWAN, RE.
ROBERTA. SHAFER, RE.
December 4, 2001
CML ENGINEERS
(907) 694-2979
FAX (907) 694-1211
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK 99519-6650
REFERENCE: Lot 3; Block 5; Mile Iligh Subdivision #1
Request you issue a Health Authority Approval on the referenced property and
grant a waiver for the separation distance between the east property line and the
leachfield at 2 feet. We do not anticipate any adverse effects to the referenced
property or to adjacent properties.
If you require additional information, please contact us.
Sincerely,
RCC/ts/waivers/dure.doc
17034 NORTH EAGLE RNER LOOP * SUffE204 * EAGLE RIVEI~ ALASKA 99577
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Sitc Water and Wastcwatcr Program
4700 Bragaw Street
P.O. Box 1966~0 Anchorage, AK 99519-6650
www.ci.anchorag¢.ak.us
(907) 343-7904
Waiver Review Worksheet
WRY: WR010100 PID~: 060-201-17 HA~: HA010633 Permit~:
Date Received: 12/10/01
Legal Description:
Engineer:. Bob Cowan P.E.
17034 Eanle River Looo Rd.. Suite
Applicant: Fred & Ann Dure
Waiver Requested: 2 feet from orooerht line to absorotlon field
Criteria: Geology
A. Water Table
B. Soil Sorption
'C. Permeability
D. WaterTable Gradient
E. Horizontal Separation
Points:
Total:
List Conditions or Reasons for above:
Reo~: 13391 Amount: $1t5.00 Date Paid: 12/1012001
Municipality of Anchorage
George P. Wuerch, Mayor
Btdldlug Safc - Division
P.O. Box 19C'C,50 * 4700 S. Bragaw Street
Anchorage, Alaska 90519-6650 · (907) 343-8301
h ttp:/Pa'ww.cl.anchorage.ak.us
12/11/2001
S & S Engineering
17034 Eagle River Loop Road No. 204; Eagle River, Alaska 99577
Subject:
Waiver Request for Mile High Subdivision #1
Waiver Request #WR010633
Parcel ID #050o201-17
HAA# 010633
Block 5 Lot 3
public %lrorks
Dear Engineer:
Your request for a waiver of the required 10 feet horizontal separation from the
on-site wastewater disposal system to property line has been approved. The approved
separation distance is 2.0 feet.
This waiver approval applies to the existing on-sitewastewaterdisposal system to
property line separation only. Any future upgrade to the on-site wastewater disposal
system will require all separation distances be met or another approval from this
department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
_ Jeffrey W. Poet
Engineering Technician
On-Site Water & Wastewater Program
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.¢i.anchorage.ak.us
(907) 343-7904
Water Well Advisory
Health Authority Approval # 010633
During a recent Health Authority Approval on-site inspection and test of the
potable water supply well on Block 5, Lot 3 of Mile High subdivision, the
well's productivity was determined to be 0.32 gallons per minute. The
minimum well productivity required by this Depa~'tment (AMC 15.55) for a
3-bedroom residence is 0.31 gallons per minute. Although the subject well
currently exceeds this minimum requirement, all parties concerned are
advised that the production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering lawns and
gardens may be required.
This advisory must be attached to all copies of the subject Health Authority
Approval.
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVal FOR A SINGLE FAMILY DWELLING
Location (site address or directions)
· ~:i/'Pr6pbrty owner V,~.d
' ~Mailing'address ' P.O. Bo~ 770444
"'!':. Lending agency
· : .-.:.:. Mailihg address ·..;:.:.:....-
21949 Lower Canyon Driv~
· Ea,ql¢ Riv~r~ AK
Day phone
Eagl~ River,. AK 99577
274-3038
Day phone
~A-en;'~, ~' '-'- Day phone
. . · Address - ~. -~.-... _ - .... ~ . - . . ....... -i: .
.... - -_ ..:: 3, %:~PE OF WATER SUPPLY~:,~,.~- ~_ ~?: ,::~.:::..~ ...... ~. _~_-~ ............... ~.~.~., ...:
:;'-'~'"';;~ ~;~'~:~;~.{~;.~.~.~:,';~:'~,:~':.~;.~;~-.' Ind'iv~d~al well ~;~.~::~:~:-;~' .::[.--:~ '- ;' ~ ......... : ....... :::" - .... i- ..... ~::
:'~ :- '.?¥?%:{':T"~ · ?:--:':~:'}'~:: ...... '.r,.~:--. ; ..... I':- :" ~-' ::* .'''-':_%X--' ': :'~ ?.~ ' -. 7':- ' . . '.','/: .. .:
: "' ":_;:~/:.' ;- ":: ..-L- Public water "-'- :~: -- :'" -":'-';
..... ~';'?".';1- ":'L'~ .....-.' '. ' -. : .... - ......'-----; '"' '-: -. ' ' ....... ; .............. ......
NOTE: , If communi~ well system, provide wri~en confi~ation from State ADEC a~est-
--, , lng to the legali~ and status of'system.. ,.. _ ~ ).)/,,..~ ,.
4. ~PE OF WASTEWATER DISPOSAL: ' .. . ,/;? .'"
............. ,. ,. ........... Indw~dual on s te ......., ...... .............. , ,- , r
.... ' : -- ¢ - :' ' '-) ~'~ ?=1 ' '
.... _ .....Holding tank :.~ ..~ ,_:~..:..: : .....~. ,~ :~,.:,~, .,.};/~. .,'
:~ ' - ---~-" ': .......CommUni~ on-site' -;: '..-?::' '- .... ~ ....':: >~ '~'% ',, '" ..~,,'
· - - - ...... ": ":- -'"-.'" .... - '-'"' ::,-::- - -.,' - ' ., .2,,
Public sewer , - ... ,..
..... -,' .-. ::-,1~ .:.:' .......... . .... ,
NOTE: If communi~ wasmwater sysmm, Rrovide wfi~en confirmation fro~'State ADEC
a~esting to the legali~ and status of system.
STATEMENT OF INSPECTION BY ENGINEER .. i~
As certified b~ 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 structu re indicated herein. ~ 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.
'Phone
', · The M~ni'ciDalitv of A~c~horage Department of Health and Human Services (DHHS) issues Health Authority
. ~,L'Approval!Certificates- based only upon the representations g,ven ~n paragraph 5 above by an ,ndependent
-:, prof~mona .entg?,t.~r r~steredmthe StateofAIsska-TheDHHSdoesth~sasacourte~yto purchasera°f h°mes
"a~d th'~i~lendi~g inaiitution~ in order to ~ati~ht ¢~rtain federal and state requirements, fim~loy~ of D~H$ do not'
conduct inspections or~analyz~ da~a bafora a certificate i~ issued. The Municipality of Anchorage i~ not
re~pon~ibie for ~rrom or omission~ in the professional engih~r'~ work. ~' :.. '-'":::.':, !
72-025 (Rev. 1/91) Back MOA ~1 . .
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription:~c:r¢~ ~ ~' ~'~.-~'-~,~s[~lParcelI-D- (-~-O
A, Well Data
Well type ~~.~if A, B, or C, attach ADEC letter. ADEC water system number
Log presenti~N) ~ Date completed ~/~ 7 ~ ,~ c,, Driller
Totaldepth ,>-~o ' Casedto ,~/ ' ~. Casing height
Sanitary seal (~N) '-( Wires properly protected (~N)
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
FROM WELL LOG
Septic/holding tank on lot /o o /
Absorption field on lot /;z ~ )
Public sewer main ~'/,,~
Sewer service line .-~'-
g.p.m. ~
; On adjacent lots
; On adjacent 10ts /~ / '/'
./
Public sewer manho e/cleanout '~/~
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample: ,S'--~
B. SEPTIC/HOLDING TANK DATA
Date nstalledI· .. ~ ~ - ~ '&''' ~
CleanouiS' ~N) ,-/
/
High water alarm (Y~}
Date of pumping
Collected by:
Tank size
Foundation cleanout ~N)
Other bacteria ~-~
$ 8, S ENGINEERING
Eagle River, AlasEa 99577
Compartments
Depression
Ala. rm tested (Y/N)
Pumper ~.,,<~-L:~-r-~¢,,~ ~P~ ~t { ~r.~/-~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /o ~ / On adjacent lots /~
To property line /o ~ 4- Absorption field ~ 5/ ~'
Surface w~ter/drainage /o c~
72-026
Foundation
Water main/service line
~--~. ~-rS 5-~--,~c.-t-~.-¢._ ~-e--~%~_ ~ONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
,Manufacturer
Vent (Y/N) "Pump on" level at
High water alarm level ~ ~
Meets MOA electrical codes (Y/N)
D. ABSORPTION FIELD DATA
Manhole/Access (Y/N) _
Soil rating (GPD/FF)
Gravel thickness
Cleanout present(~)
Result~il) .,,
~" After test
/,~,J~ /~,~/~/W If yes, give date
Date installed ~ ~ ~ ~,
Length /7/,> t Width
Total absorption area 7.~o
Date of adequacy test
~'-hI4:~ ?5--
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO'
Surface water
System type
Total depth
Depression over field (Y/~D
for -~ Bedrooms
Date of Payment
Receipt Number
72-026 (~)* ~ck
Waiver Fee $
Date of Payment
Receipt Number
I cer#fy that l have checked, verified, or conformed to all MOA and HAA guidelin'es ~~~.is inspection.
Signature
'
~ CD~-, ........... .~ ', .':'
~_~.f?,C ; £ ,j ~..'.','.
H~ Fee $.
E. ENGINEER'S cERTIFICATION
Well on lot { ~.~ / On adjacent lots {~ ~ t ~' Property line
To building foundation ~.~ / To existing or abandoned system on lot
On adjacent lots -~c~ ~ ''~ Cutbank ~-~. ' '/
.Water main/service line
Surface water /~a / ~
Driveway, parking/vehicle storage area
Curtain drain /~o~J~.~ //_,~ ~.,/