HomeMy WebLinkAboutNORTH WOODS BLK 1 LT 10 , Municipality of Anchorage Page I of
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: ~'c,J cJ'=l o I_~=1 PID Number: O~ I -'T&l -71
Name: ~ktG ~ ~A¢~ ~o~ Wastewater System: D New ~Upgrade
Address:
P.o. ~o~ ~7~i ~Nu~ ~ ~ ~ ABSORPTION FIELD
Phone: ~ . H~ No. of B~rooms: D DeepTrench ~ShallowTrench D Bed D Mound D Other
LEGAL DESCRIPTION soi~ Rating: Total Depth from original grade:
Lot: Block: Subdiv~ion: ~Depth to pipe bo~om from original grade: Gravei depth beneath pipe
Township: --IIRange: _ . Section: Filladdedaboveoriginalgrade:oi __ ~,~1 Ft. Gravell~ngth:loO (~ e ~OI~ Ft.
WELL: =,, _ ~ ~c;;' ~ ~Gravel width: ~ j Number of lines: Distancebe~een lin~:
Clarification (Private. A.B.C): Total Depth: ~ Total absorption area: Pipe material: A~
Driller: ~Dri[led: StaticWaterLevek installer: Date installed: by7
M Ft. Ft.
SEPARATION DISTANCES ~ Septic ~ Holding D S.T.E.P.
TO Septic Absorption Lift Holding Public/Private Manufacturer: ~ Capaci~ in gallons:
From Tank Field Station Tank Sewer Lines ¢~ ~l E~ L~TI 6 ~ ~ O O
Number of Compa~ments:
Welb ~oOl~ ZOOI~ ~ ~ ~J~ Materi~]: ~ASTiQ
Su~ace
W~t~r ]O¢~+ )0~+ -- -- -- LIFT STATION
Lot ~,, Size in__ret:
I ~ ~ O I~ ~ ~ ~ "Pump on" level at: ~water alarm at:
Foundation
~O~ ~ pu~ I Electrica, Ins~ctions performed by:
Cu~ain
Drain
Remarks: ~e~ ~E l~u~T~. BENCH MARK
Location and Description: ~,
Depadment of Health and Human Se~ices approval
Reviewed and approved by: ~, ~/~ ~ ~~ Date: ~-~ ~-9~
72-013 (Rev. 9/91) MOA 25
PERM,T NUMBER: AS BUILT DRAWING P 0EL ,0 NUMBER:
SW990139 ' 051-751-71
//
" ,C~k-)TM / ~ // FCO 11.5 29.4
.../~.,, XX~"~C; / . ~",, ST1 25.3 25.1
O'~X ~\x4'v' / ×~, k X ST2 28.1 26.1
.~ ~x / // ~ ~> DBL1 30.8 28.0
~ ~ / // ~ DBL2 31.6 28.7
/ // ~ C01 70.6 59.2
~ // ~ MT1 70.2 60.0
~ ~ /~ ~ C02 71.2 87.1
~ ~ ~ X c03 ~s.~ 78.s
I /~ X e~ X ~ X MT3 86.3 79.5
MT4 96 2 108 5
~ ~ ~ ~~G ~ ~ ~N~ 1300 GALLON · '
~ ~ ~ ~k%~O~~ k ~ "PREMIER P~STIC" FS 5S.2 60.3
5 ~ ~~~ SEPTIC TANK
~ ~ / ~ ~ / X~INSTALLED FLOW
~NG BED (APPROX/ ~ /~/ ~
~~bONED ~ ~ ~/ ~
~AT IT MAY BE ~ C04~T4
CONNECTED AND USED ~
/
~AS~ WATER AND WAS~WA~R CONS~TANTS, INC. o~m~, ~ '
~,o, .~.~ .O~D ~..~ ~., ~0H0~,,
PHONE: (907) ~37-6179/F~: (907) 5~8-$246 ~'' ........
~PE OF WORK:
AS-BUILT OF SEPTIC SYSTEM UPGRADE~ 2'L ~:""~
c.~mo AND BARBARA DOTSON 688-4758
J.L,M. 1 : 40' 2 OF 3 rofess~O
PERUIT NUUBER: iS ])LTII T DtL/k I1NG PARCEL ID NUUBER:
SW990 i 39 ' o§'m -73'm
M~ COl J
Mf~ co~ /
~ ~ / /~.~(~r~NP)
P) ~- ~ -
~ PROM ~IQI~ ~ m~ ~R ~ 7e,l~ (A~)
~OM ~ ~ 6 F~t ~P (~ ~ ~r~ ~),
A~S~ T~ ~D T~S~T~ COnSULTanTS, INC. ~~../
6901 DE~R ROAD SUITE 2B, ~CHO~GE, AK 99504 ~ .. ....
PHONE: (~07) 337-S~79/F~: (~07)
~ORTH WOODS 8~BDIVI~IO~; lOT 10, BLOCK 1,
PROFILE AS-BUILT OF SEPTIC SYSTEM UPGRADE ~.~~....~ .....
BARBARA DOTSON 688-4758
J.L.M. 1 : 40' 5 OF 5 '%%i~rofess~O~
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
¢07) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Jun 15, 1999
Expiration Date: Jun 14, 2000
Permit Number: SW990139
Legal Description: NORTH WOODS BLK 1 LT 10
Design Engineer: 0041 AK Water & Wastewater Consulta
Owner Name: Craig & Barbara Dotson
Owner Address: PO BOX 671571
CHUGIAK , AK 99567-1571
Parcel ID: 051-731-71
Site Address: 022648 NORTHWOODS DR
Lot Size: 35939 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well [] Water Storage
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 ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By:
Issued By:
Date: ~'/',~' (~¢
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road, Suite 2B N Anchorage ~ Alaska 99504
(907) 337-6179 N Fax (907) 338-3246
Consulting Engineers
June3,1999
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Septic Upgrade Design for Lot 10, Block 1, Northwoods Subdivision
To whom it may concern:
The existing 4 bedroom house is served by a private septic system and a community well. The
existing septic system consists of a 1250 gallon septic tank and a bed type drainfield. The
existing bed is surcharged and must be upgraded prior to the sale of the house. Two test holes
were excavated to the southeast of the existing septic system. We propose that a new 1250
gallon septic tank and a drainfield upgrade be installed. Comments regarding the proposed design
are summarized as follows:
1. SOILS: Attached are logs which shows the soil profile, and the percolation test results. The
soils below the organic layers are a SM/ML material to a depth of 12 feet (bottom of both test
holes). No groundwater was encountered during the excavation of the test holes. A percolation
test was performed in TH#l, between the depth of 5.5 feet to 6.0 feet, indicated a percolation rate
of 25 minute/inch. A percolation test was performed in TH#2, between the depth of 5.5 feet to
6.0 feet, indicated a percolation rate of 1.7 minute/inch. It is our opinion that due to the overall
appearance of the soils, a application rate of 0.6 gallons/day/ft2 should be used.
2. TRENCH DESIGN:
a. Percolation Rate: 1.7 & 25 minutes/inch
b. Allowable Application Rate: 0.6 gallons/day/ft2
c. Number of Bedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 1000 ft2
f. Total Depth: 6 feet (max.)
g. Effective Depth: 4 feet
h. Width: 5 feet
i. Reduction Factor: 0.50
i. Minimum Length: 2 ~ 50 feet lon~ (100 feet total length)
j Effective absorption area = 1000 ft~
J. SURFACE WATERS: There are no surface waters within 100 feet of the proposed
upgrade.
4. TOPOGRAPHY: As can be seen on the design there are no slope concerns. The trenches are
to be installed parallel to slope contours.
I am unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact me at 337-6179, or 244-9612. Thank you
for your assistance.
Sincerely, / _ ,/~
z,., M.S.
NOTE: Attached is a site plan drawing, a design drawing, two soils logs and a 4 page
construction specification letter which are all part of the design package for this septic system.
mo i oO / / /
N E: LL OPERTIES SHOWN E SERVED BY
~¢AL DESCRIP~ON:
~PE OF WORK:
SITE P~N FOR SEPTIC SYSTEM UPGRADE ~¢..~
PREP~ED FOR: PHONE NUMBER=
BARBARA DOTSON 688-4758
\ ~% 'q-',.,,,.. / ~..-"~ ~ % ~PROPOSED 1250 GALLON
EXISTING SEPTIC TANK TO ~ //~°~5 5 ~¢_ X
EXISTING BED TO BE / X~~/[ %/~/
5 5 EXCAVATE ~0 DRAINFIELDS THAT
~ ~ ARE 6 FE~ DEEP (MAXIMUM) BY
~ 5 FE~ WIDE BY 50 FE~ LONG
~ ~CH (100 FE~ TOTAL LENGTH).
~ ADD 4 FE~ OF CLAN, WASHED
ALAS~ WA~R A~ WAS~WA~R CONSULTANTS, INC.
6901 DE~RR ROAD SUrE 2B, ANCHO~gE, AK 99504
PHONE: (907)337-6179/F~: ([907)338-3246
~GAL DESCRIPTION:
NORTHWOODS SUBDIVISION; LOT 10, BLOCK 1,
........ , ......
~PE OF WORK:
DESIGN OF SEPTIC SYSTEM UPGRADE
PREPPED FOR: PHONE NUMBER:
BARBARA DOTSON 688-4758
CRAIG AND
~:~.. I~""~:~.,.~. Is°~:, : ~o. I~:~ o~ ~
ALASKA WATER & WASTEWATER CONSULTANTS, INC.
,~i*ff~5~~ ,"~
,.~,,~E~ TEST HOLE ~ · ........
ORGANICS
GH CL
4-- GC OL
, .~ SW NH
5-- ~ sP CH
/ SH/HL ~ s~ oH "'[x,~,A ~
EXI~INOX X ~ ~ / SEPTIC
SYSTEM ~ ~J~ /
7-- ~EPTH TO DATE
'GROUNDWATER
8-- DRY 5/27/99 ~ ~~/~'-
10.5' 6/5/99
9~
t
TI~E (HINUTES) READING (INCHES)
12~ 5/27/9__.~ - PERO OA~ PRESO~ED FOR 4+ HOURS PRIOR 10 ~.
1 ~ -- 5/27/99 1 3:10
2 ~:40 30 MIN. 4-1~/16" 1-3/16"
14-- ~ ~:41
4 4:11 30 MIN. 4-]/4" 1-1/4"
15~ --
~ 5 4:~3
16 _ _ 6 4:43 30 MIN. 4-1/2" 1-1/2"
17
18
19 PERCOLATION ~TE 2fi (~IN./INCH) P[~C. HOLE DIA. O~ (INCHES)
FT.
20
TES~ RUN aErWEEN ~-~ Er. AN~g,r.O
COMMENTS:
PERFORMED BY A~S~ WATER · WAST~ATER I, , CERTI~ THAT
THIS W~ PERFOS~ED/~N ACCORDANCE WITH ALL STATE A~ ~NIOIP~GUIDELINES IN EFFECT ON TH~S
Q~T[. Q~T[: ~/z/e?
DEPTH TO DATE
GROUNDWATER
DRY 5/27/99
10.5' 6/3/99
I SOIL LOG - PERCOLATION TEST I ,~,,,~.~...x... ,
LEGAL DESCRIPTION: NORTHWOODS SUBDIVISION; LOT 10, BLOCK 1, ' ........................
PERFORMED FOR: CRAIO AND BARBARA DOTSON ~~~e~:'"'"~
(*eeo ::zS~ ORGANICS TEST HOLE #2 ull~?o" ........... '~
SOIL CLASSIFICATIONS .
o ~ SW HH
SP CH
S~/~L sH o~
EXlSTiNGk X ~ ~ / SEPTIC
SEP~C ~ ~ ~ UPG~DE
BECOHES SC
W/ DEPTH DEPTH TO I DATE
~ ~.~' ~/3/~,
ISmTE PLANI X
,o ( ,,,
12~H:ItN~" 5/27/9_ ,: PER: ~A~._ ~ PRES~E__ ~ FO: ~___+
/
/
6 3:51 8 MIN, 0 ---- 6
7 3'52 ' 6
17 8 4:02 10 MIN. O"
19 PERCOLATION RATE <1.7 (HIN./INCH) ~PERC. HOLE DIA. 6" (INCHES)
20 TEST RUN BETWEEN~5'5/z?/~1'
COMMENTS: PERC HO~ W~ IN A SM ~NSE, OVE~ ~U~ ~O~[]~Ol~ mS A 0.6 ~PLICATION ~.
PERFORMED BYA~ WATER A WAST"ATER '. C--'~~: ' "~' J , CERTI~THAT
~,~s was .~.ro~ ~. ~cco.~.c~ w~ ~.. s~/~ 7~.~u~u.~s
DATE. DATE: g/]/?e
DEPTH TO DATE
GROUNDWATER
DRY 5/27/99
11.5' 6/3/99
NAME
MUNICIPALITY OF ANCHORAGE ~.~ ·
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONE [~EW
~'~ ~:~3 ~" [~] UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
I o z c. oc/ !
LOCATION
DISTANCE TO:
Manufacturer
Liq. in gallons
IF HOMEMADE:
Material
Did t h~7-~'~',
length
INO, OF BEDROOMS
I No. OT~ comp~rtments
Liquid depth
DISTANCE TO: Well ~/~. Dwelling
If/
Manufacturer
Well Foundation
DISTANCE TO:
No. of lines Length
Top of tile to finish grade
Total length of lines
Material beneath tile
PERMIT NO.
Material
Nearestlotline
Trenchwdth
Liquid capacity in gallons
PERMIT NO.
Distance between lines
inches
Total effective absorption area
inches
Length
Type o__ff crib -
DISTANCE TO:
DISTANCE TO:
r Dep~ ¢r
Width Z. O ~ ,~ O ~j'/,.~ ~'
Crib diameter Crib depth
911 Building f~tion Nearest lot line
Distance to lot line
foundation Sewer line Septic tank
OTHER
PIPE MATERIALS
SOILTESTRATING / ~
INSTALLER
REMARKS
DATE LEGAL
'p~on area~
PERMIT NO.
Absorpt on area(s)
E:'EF'~RTI"'IEN"~ ;F HEALTH ~ND EP'4',,,'~ROIqMENT~L~-'F'ROTEC:TZON
825 '"L'" STREET., ANCHORAGE., RK 9950!
264-4728 : ANC:HORRGE 694-2i~:1 : EAGLE RI',/ER
PERMIT NO. 000008
RPF'LZCRNT: TOM MCCORMICK
RDE:,RES5: BOX &267
CHUG Z AK., RK
LEGAL DESCRIPTION - SUBDIVISION: NORTHWOODS Z BLOCK:
TOWNSHIP: ~SN RANGE: 4W SECTION: 04
PHONE: 688-34~4
LOT:
:1.0
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL F.:ATING = ±94 ,:.'SQ. FT. /'BR)
LISTED BELOW ARE THE OPTIANS R',,,'RILABLE TO Yi_-iU IN DESIGNING yI-IUR SEF'TIC:
SYSTEM. CHOOSE THE OPTION THAT BEST FITS YOUR SITE.
E:E[:. [:,E'--=; Z ,_]N
WIDTH = 20.
LENGTH =
TOTAL DEPTH =
GRAVEL DEPTH =
GRAVEL VOLUME =
0
40. 0
5.0
0.5
29. 6
TANK SIZE = i.,250..0
WIDTH = 5. 0
LENGTH = i56. 0
TOTAL DEPTH = 5.0
GRAVEL DEPTH = ' 0.5
GRRVEL VOLLIME = 28.8
TANK SIZE = i, 250.0
~-~ ~ C,E [)~:Rl t~ F
WIDTH = 5. 0
LENGTH = 9t. 0
TOTAL DEPTH = 5.0
GRAVEL DEPTH = 3.0
GRAVEL VOLUME = 58.9
TANK SIZE = i, 250. 0
T'-r"F' 'ir ,-:RI1 ....... [:.ES Z
FT.
FT.
FT.
FT.
CLI. YDS.
GALLONS (TWO COMF'RRTMENT TANK)
Z ELF:, [:.ES Z ~2ui~dl
FT.
FT.
FT.
FT.
CU. Y[:,S.
GALLONS (TNO COMPARTMENT TANK)
'--%F'EC: Z RL [:,ES I ,-~ P-.l
R LIFT STATION MAY BE REQUIRED.
I E L [:, [:, E S I "_-~ f-~
FT.
FT.
FT. ~ ~ NOTE ' ' -REQUIRES INSULATION
FT.
CU. YDS.
GALLONS (TWO COMF'RRTMENT TANK)
i CERTIFY THAT:
i. I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SE]'
FORTH BY THE MUNICIPALITY OF ANCHORAGE AND THE STATE OF' RLRSKFI.
:2. I 14ILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES AND HAVE RECEIVED
R COPY OF THE CODE SUMMARY AND [:,IRGRRM ATTACHMENTS WHICH IS PART OF THIS
PERMIT.
3. I UN[:,ERSTRND THAT THE ON-SITE SEWER SYSTEM MAY REQLIIRE ENL. RRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
PERMIT RPPLICRNT HAS THE RESPONSIBILITY TO INFORM PERSONNEL DURING THE
iNSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROF'ERTY AND THE
NUMBER. ,:iF RESIDENCES THRT/~ P.IEL~ILL SEF.:',,,'E.
- LC? / /
.... ,_,_
ZSSUED BY:__ ~. DATE'
O & E EN~'INEERING & DEVEL(~PMENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster Earl Ellis
694-2774 SOIL LOG 688-2280
Performed for: Name: ~'-~"~/~ ~-' ..~/~'/~-~z4 ~3.'r~.~T, TeI. No.~---2-~d
Mailing Address: ~- ~ ' ~0 ~ /~ ~ ~ ~/~f~ ~. ~?~ 7
Legal Description: ~0'~ /~. ~c~ // ~T~O~ ~U~ ~_ , ~/~ .~
Depth (feet)
0
1__
2__
4__
5__
7__
10__ 5'/v/
11__
13__
Soil Characteristics
No ~ If yes, what depth
Drain Field
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit.__
Comments:
PLOT PLAN
PERC. TEST
=/¢~,,'~/'~"~' d~,w/~' l
-- ~.,~, ~
~, ~ ~ E~rl P. Ellis
... .........
Performed by:
Date:
· !: '~ APPLI¢, .NT FILLS OUT UPPER HA[ ONLY
Mailing Address
Buyer
Address Zip Code
Address Zip Code ~'/' ~'
Realty Co. & Agent Phone
Address Zip Code
Street Location
Ty~ o f~R_ esidence
[] Multiple Family No. of Bedrooms
[] Other
Water Supply
[] individual x~/;'"'/ ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
[] Community '~7~ For wells drilled prier to that date, give well depth (attach log if available).
_p..llic Utility /
Sewer Disposal /
[]"-Public Utility / When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED·
Time
Date
Inspector
Date
Inspector
~),~PROVE D BEDROOMS
) DISAPPROVED
) CONDITIONAL ABPROVAL*
BY: ~.
Time
Date
Inspector
Inspector
AUG 2 9 1983
*CONDITIONS OF APPROVAL
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size
72-023 (3/82)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 051 -731 -71 ~/
1. GENERAL INFORMATION
Complete'legal description
Lot 10;
Block 1; North Woods Subdivision
Location (site address or directions)
22648 Northwoods Drive
Chugiak, AK
Property owner
Mailing address
Crai9 & Barbara Dotson
P.O. Box 671571 Chugiak,
Day phone
AK 99567
688-4758
Lending agency
Mailin_g address
Day phone
Agent
Address
Della
Thomas/Prudential Vista
Day phone
688-1808
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
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
NOTE:
xx
Public sewer
If community wastewater sYStem, provide written confirmation from State ADEC
attesting to the legality and status of system.
72*O25(Rev. 1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal sy~q~i~ il~/i~j~l~iance with all Municipal and State codes,
ordinances, and regulations ineffect on the date ol
tCCa~ewater Consutl
Name of Firm
Address
Engineer's signature
:his inspection.
~ 3~--- Phone
Alaska Water & :' . -
__l~tewater Cpnsultan~(s, ti"1¢,. ,~' ".
~. ~ PAID .~ J~o~ ~ '~ ~' .'
~r to, closing for ~ ;
/ Approved for F¢ U~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with th-e following stipulations:
Additional Comments
By:
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 courtesyto purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-O2~(Rev. lf91) Back MOA~I
Municipality-of Anchorage dUN 2
DEPARTMENT OF HEALTH & HUMAN SERVICES 'OFANCH~
Environmental Services Division MUNICIPALITY
825 L Street, Room 502. Anchorage, Alaska 99501. (gc/:~V§~-,~U/T~sERv'cEs
Legal Description: ~o¢.-r~
A. WELL DATA
Well type ~U t~ t~t r..__
Health Authority Approval Checklist
-~',/~ Lo~' JO Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEc water system number
Log~) Date completed ~
Total depth ~ Cased to ~ht (above ground)
Sanitary seal (Y/N) ~'~-._....--'"'""'"'~Wires properly protected (Y/N)_
Date of test ~PE/ ..~TION
Wel~productior~ g.p.m. ~
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample:
B. SEPTIC/I=t~=~-u~G TANK DATA
Date installed
Foundat,ion"cleanout (~N)
Date ,°~ Pumping
C. ABSORPTION FIELD DATA
"
Date installed
Collected by:
Tank size 1 ;.~Oc~ Number of Compartments ~-- Clean0uts (~TN) "~/~-r
"~ -~ Depression (Y/t~ no High water alarm (Y/~). ~.~o
Pumper ~
Soil rating ~o~) ~, (~ System type
Length Jool~Z 6J -S'ol~ Width ~ I Gravel thickness below pipe
Effective absorption area /o00[~7 Monitoring Tube present~/N)'/'z-S
Date of adequacy test t'~-~'J Results (Pass/Fail) ~
~ I
Total depth ~'~r----7'C
__ Depression over field (Y/~) /,J o
For L~ bedrooms
Fluid depth in absorption field before test (in.); ~ Immediately after ----gat. water added (in.): '
Fluid depth ~ (ins) Minutes later: -- Absorption rate = - ~ .g.p.d.
Peroxide treatment (past 12 months) (Y/N)
If yes, give date
72-026 (Rev. 3/96)*
LIFT STATION
Date installed Size in gallo.~s./
Manhol~')--"------.~.~ "Pump off" level at*
High water alarm lev?_l..~ "L)atum ~---~--_._
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septi~ank on lot On adjacent lots
Absorption field on lot
lots
~ cleanout
Public sewer main .----- ~
Sew~e_~Je~ervice line Lift station ~
SEPARATION DISTANCES FROM SEPTIC/I-I~EERt'~ TANK ON LOTTO:
Foundation ~ -F Property line .~1 -I- Absorption field
Water main/service line I Ol'ff Surface water/drainage Jc~~+ Wells on adjacent lots
I
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line J o~+._
Surface water
Curtain drain
Building foundation I ol-I-' Water main/service line I E) I_p
Driveway, parking/vehicle storage area ~/-~
~-,r,~,.~t~ Wells on adjacent lots 2~I t
ENGINEER'S CERTIFICATION ~///
I certify that l ~t~in~p lie/d inspections and reviewof Municipa/r~~~~re
in conform?e wi~;~u~elines in effect on this date.
HAA Fee $ ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*