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HomeMy WebLinkAboutNORTH WOODS BLK 5 LT 3
Municipality of Anchorage Page 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: -~//t/' ~/~0/~,7 PID Number:
Name: J~¢~ ~ ~ ~6~ Wastewater System: O New ~ Upgrade
% ~ En~~ 2~¢¢/~/~ ~ ABSORPTION FIELD
Phone ~ I No of ~edrooms' ~ Shallow Trench ~ Bed ~ Mound ~ Other
L E G A L D E S C R I PT I O N so~, Rating: Total Depth from original~lgrade:
~ 2 GPD/Sq. Ft.
Lot: ~ Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe~
Township: J Range: J Section: Fill added above original grade: Gravel length:
~ Ft. ~/ Ft.
I
I
WELL: % D New g Upg~ Grave~width: ~1 Number of lines: Dislance~tw~nlines:
~ Ft. / ~ Ft.
Driller: ~ate ~dlled: Static Water [e~el: Installer: .
Yield~GP~ j.um.s~,~,: ~,.~gHeightAb°veGr°und:l %. Ft. TANK
SEPARATION DISTANCES ~s~pt~c ~ Holding B S.T.E.P.
From Tank Field Station Tank Sewer Lines .
WeW
Sudace
Lot Size in gallons: Man~ /
C udainDrain ~O '~ ~O ' ¢ _ ~ __ Pum~ J Electricallnspectionspedormed Y~
/ / ~ / / Lo~tion and Description:
Assumed
Elevation:
,,, ENGINEER'S SEAL
Department of Health and Human Se~ices approva, '~;"~:'....p/¢~/....~-
Reviewed and approved by: ~ Date: 7 -~2_ -¢~
72 013 (Rev 9/91) MOA 25
i i
WASTEWATER DISPOSAL SYSTEH
LST
FINISHED GRADE
~" HD INSULATI~N~
laSO GAL
SEPTIC --~z~ -
TANK ~ SCREENED ROCK
T~TAL DEPTH FR~ ORIGINAL GRADE
~CALE' n~ BOTTOM BF TESTHBLE 80,04'
SEPTIC SYSTEM
I a-c~*.$' SFD o o
NB~TBN C~URT
OF
~ ~ ',. 0~-*;~7:~ ~ PREPARED FOR, KND ENGINEERING
· . ~ . ~0441 PTARNIGAN BLVD
~~8slOg[5__ ~ JAMES AND GAlL BAILEY EAGLE RIVER, AK, 99577
~505 NORTON COURT (907)696-6111/Fcx (907)696-81~1
~~ CHUGIAK, AK, 99567 DATE,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW960127
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:BAILEY JAMES H & GAIL L
OWNER ADDRESS:22405 NORTON CT
CHUGIAK, ALASKA 99567
DATE ISSUED: 6/19/96
EXPIRATION DATE: 6/19/97
PARCEL ID:05173103
LEGAL DESCRIPTION:
NORTH WOODS BLK 5 LT
LOT SIZE: 32890 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK 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 (iSAAC80) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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:
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
May 31, 1996
Municipality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 6650
Anchorage, Alaska 99519-6650
Subject: Upgrade Permit - Lot 3, Block 5, North Woods S/D
Gentlemen:
In March we tested the existing sewer system on the above lot and found it to be in failure.
As a result two testholes were excavated for the purpose of upgrading the system.
We found substantially different material in the two holes. Testhole//1 had a percolation
rate of 2.67 minutes per inch, while Testhole #2 had a rate of 40 minutes per inch.
Testhole #1 is situated just north of the fence along the edge of the slope, while the second
testhole is in the grassed yard.
I am requesting a waiver of the slope separation so that a single trench may be installed at
the top of the slope. Although the slope does drop off to the north, we noted also the
presence of a number of small benches which interrupt the severity of the drop. Coupled
with excellent soil conditions along the bank and the location of the existing system that is
similarly located and has shown no indication of seepage along the bank, ! feel that a
design along the bank is superior to a design in tighter soil in the yard. In addition, we will
be able to gravity feed to this trench, thus avoiding the necessity of a lift station.
There are no surface water sources within 100 feet of the proposed installation site, and no
wells within 200 feet. This lot is served by public water. The existing trench and septic
tank will be abandoned in place.
If you have any questions about this application, please call me at 696-6111/FAX 696-8111.
Respectfully submitted,
I~I~]]~ Engineering
Kenneth M. Duffus,~l:gE.
attachments:
On-Site Well and Sewer Application
Wastewater Absorption System Details
Site Plan
WASTEWaTER DISPEISAL SYSYZPI
LOT 3~ BLBCK 5~ NORTH WFIFIDS
0
SEPTIC SYSTEM
25Z
25Z25Z
IOZ
25Z 25Z
SEPTIC SYSTEM
NORTON COURT
PREPARED FOR=
JAMES AND GAlL BAILEY
22505 NORTON COURT
CHUGIAK, AK, 99567
KND ENGINEERING
20441 PTARN~GAN 3LVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fax (907)696-8111
DATE, 5/30/96 DRA'~/ING #
SCALE, Y = 50' 96024-S1
d d
CDNNECT TD 4' SDLID FRDM HDUSE
C,D,
C,D,
C,a, )
]DNNECT TO 4' SOLID FRI~'~ HDUSE
DESIGN DETAILS
WASTEWATER ABSBRPTIBN SYSTEH
LBT 3, ]}LBCK 5, NBRTHWBBDS S/D
FINISHED GRADE
UNCLASSIFIED FILL FROM EXCAVATION
HD INSULATION--.~.~ /FILTER FABRIC
SCREENED RECK
41'
41'
TOTAL DEPTH FRDM DRIGINAL GRADE 5'
NB WATER DESERVED
N,T,
O -1-
cd
DESIGN
1,
3,
4,
5,
DETAILS
3 BDRMS X 150 GPD = 450 GPD,
450 GPD/1,a GPD PER SQ, FT, = 375 SQ,
375 SQ, FT,/5 ', WIDE X ,54 R, F, FrlR 3,5', = 41',,
USE TRENCH 41' L, 5' W, 3,5' GRAVEL,
TOTAL DEPTH DF SYSTEH WILL BE 5,0" BELOW
DRIGINAL GRADE,
2" HD INSULATION TB BE INSTALLED EVER
FIELD AND SEPTIC TANK,
CONTRACTOR TO VERIFY AND INSURE 8X
GRADE FRDM HBUSE,
PREPARED FOR:
JAMES AND GAlL BAILEY
22505 NORTON COURT
CHUGIAK, ALASKA 99567
KND ENGINEERING
80441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-6111/Fox (907)696-8111
DATE, 6-1-96 DRA'%/ING ~
SCALE, NTS 96084-SB
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ,~Z/~ ,
LEGAL DESCRIPTION: Lt~'~ --~ z~- ~' ~. ~:F~.~p~ Township, Range, Section:
1
2
3-
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
'7",/_/~ / SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT ~)
DEPTH? ,/~ p
E
SITE PLAN
~eol~ihtffingW~ter Alter,~/.y Bale: *~
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ .7 /07 ~ ~F~
PERCOLATION RATE~ tminutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ~' ~ FTAND ~' ~ FT
COMMENTS ,~,~
PERFORMED BY: /J~/J///~")~*"-/~/~-('/~c''~'d,//'-/~' , ,,~i:~ l~'~zf4_C/~,~ CERTIFY THAT T, HISTESTWAS
ACCORDANCE WITH ALL S'¢A~E AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: '~/'(4~~:~
72-008 (Rev. 4/85)
PERFORMED IN
ii
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
3
5
9
10
11
12
DATE PER F OR M E%~~~~
Township, Range, Section:
13
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT
DEPT,? X./~ 0
P
E
SITE PLAN
14
15
16
17
18
19
20
COMMENTS
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE /-TL~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ,~, OFT AND ~' '~ FT
ACCORDANCE WITH ALL STA'T~AND MUNIC~AL GUIDELINES tN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED tN
DATE: ,;~/Z~//.?~,
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-06.50
SOILS LOG -- PERCOLATION TEST
1
2
3
4
5
6-
7
8
9
10
11
12
13
14
15
16
17
18
19-
20-
COMMENTS
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water Alter
Monitoring? Date:
SITE PLAN
I
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ ~0 ~ ~ ~'Y'~ 5" ~'''
PERCOLATION RATE (minutes/tach) PERC HOLE DIAMETER ~
TEST RUN BETWEEN ~ FT AND ~ FT
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
LEGA L/Q ESC R I PT..~N
l P,,,H ON E
t~ ~/~//
EW
PGRADE
I Absorpti~ea
Inside length
· .,.~s ~o oo TODAY
17------_
18 -------
20~
DATE
Dwelling~
Width
hes
:hes
'ption
NO. OFB%OOMS
PERMI~NO.
No. of com~c~rtments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Distance b e~.~7~l~ e s
Total ef fective labso~tia.~ area
PERMIT NO.
area
PERMIT NO,
Absorption area(s)
PERMIT NO.
APPLICANT PJ&S
LOCATION NORTON CT.
LEGAL LOT ~ BLK 5 NORTHWOOD SUB
DEPARTMENT ~'~ HEALTH ~N[) ENVIRONMENTAL~ ~0TECTION
825
( 8'1020~ )
101 .,.'%{SLAL. ]M ~ 'F_
LOT SIZE
"" t , , - ,-' ,- - -'. ,- ,' ' ,"--'~ '" ',' ' 'b.- '-~oF~ ~ ~'/('.~
MR,.,IMLM NUMBER UF 8EDROUM:, - ~. mOIL RHTING ,_,C. FI,.BR..-
/
' '-~ , - ~ ~' - ,- "' ,,=-,, - ,-,,c ,-.
tHE RE.b._IRED :,I~E uF THE :,OIL NE,_,uRFTIuN :,T_,TEM I:~. ( _ --
THE LENGTH DIMENSION IS 'THE LENGTH <IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF Fi TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF 'THE
GROUND AND THE BOTTOM OF THE E>:;CA'¥'ATION <IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEF'TH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND ]"HE BOTTOM OF THE E',:<CAVRTION ,(IN FEET]:,.
F'ERMI].' APF'LICANT HAS THE '"'="'-.'-' '"' ""
F,E_,FON_-,IBILI] ~. TO INF]F.'M THIS DEPARTMENT DURING THE
INSTALLATION IN_FEL. TI_N...:, OF ANY WELLS ADJRC:ENT TO THIS PROPERTY ANt:, THE
NUMBER OF RE.:,I[:ENL. E=, THAT THE WELL WILl_ _,ER E.
T' ~..,,11 C, ~..::..' .":. ][ P-.~ "::-_ F" E ..... C- T ][ C, P-~ "."~ ;~ IF...: El F-.' E ,]:." LJ I R F [:.
E,A~kFILLIN:~ OF ANY SYSTEM WITHOLIT FINAL IN_,FEL. TION ANt:, APPROVAL BY THI-',
DEPFIRTMENT WIL. L BE SUB.TEC. T TO PROSECUTION.
MINIMLIM DISTANCE BETWEEN R WELL AND RNY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR t50 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELt_.
MINIMLIM DISTANCE FRCIM R PRIVRTE WELL TO A PRIVR'TE SEWER LINE IS 25 FEET FIND
TO A COMMUNITY SEWER LINE IS ~5 FEET.
OTHER REQUIREMENTS MRY RPPL_M. SPECIFICATIONS AND CONSTRUCTION DIRGRFIMS ARE
RVRILABL.E TO INSURE PROPER INSTALLATION.
PF. ZF~."~"I I: T E.-..-.F I ~;:.E::. g~EC:EF-1E:ER :-]':::L.. 1.::~ ....
I CERTIFY THAT
1: I AM FAMILIAR WITFI THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND ].'HAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
V4. 0
PERFORMEOFOR:
LEGAL DESCRIPTION:
SOILS LOG
MUNICIPALITY OF ANCHOR~(~[CiPALiTY OF ANCHOR~E
DEPARTMENT OF HEALTH AND ENVIRONMEN'I'AL ~°6'r~Fc~H &
ENVIRONMENTAL P,~OTECTION
825 L. Street, Anchorage, Alaska 99501 2644720
SOILS LOG- PERCOLATION TESTApR 2 2 1981
PJ&S
PERCOLATION
TEST
Lot 3, Block 5, Northwood Subdivision
1
2
3
4
5
6
7
8
9
lO
11
12
13-
14-
15-
16
17
18
19
20
COMMENTS
Organics and organic silt, dark
top frozen.
Gravelly-sandy-silt, tan to
light brown, moist, stiff,
contains organics.
Silty-gravelly-sand, gray,
dense, moist, rounded
particles to boulder size.
(GM-SM)
SLOPE
SITE PLAN
WAS GROUND WATER NO SL
ENCOUNTERED,?
O
P
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
2 4-10-81 3:26 PM 20 Min. 9 1/2 1/4
3 4-10-81 3:36 PM 30 Min. 9 3/4 1/4
4 4-10-81 3:46 PM 40 Min. 10- 1/4
5 4-10-81 3:56 PM 50 Min. 10 1/4 1/4
6 4-10-81 4:06 PM 60 Min. 10 1/2 1/4
40
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN 3½ FT AND 5, FT
PERFORMED BY: Howard Grey & Assoc., Inc.
CERTIFIED BY:
DATE: April ll, 1981
; I .
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. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone
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 we!! 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~)25 (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 system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm KN~ Eng!neerL-.
2044'1 Ptarmigan Blvd.
Address
~:~. .......
·
Engineer's signature ~'~
DHHS SIGNATURE
/~' Approved for
bedrooms.
Phone
Date ?,//~ ,~
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date 7-.22-¢'£
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 & HUMAN SERVICES
Environmental Services Division
825"L" Street Room 502 · Anchorage, Alaska 99501· (907) 343:4744
Health Authority Approval Checklist
Legal Description: ,~t/,~'~//~/,t~/~ Parcel I.D.:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
If A. h ADEC [~tter. ADE m
Date completed
/ //~a 0un~'
/ Cased to sing height (above gr
Sanitary seal (Y/N)
/
FROM :WELL LOG
./
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Wires properly protected/N)
AT INSPECTION
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Nitrate ~./ Other bacteria ,,-
~cted by: ..//
Foundation cleanout (Y/N)
Date of Pumping ~/~$/~& Pumper
C. ABSORPTION FIELD DATA
Dateiustalled ~t37",~q//~t/a S6ilrating~r~2~d:v..) /.Z ' System~e~
Len~h ~/' Width Gravel thickness below pipe
Effective absomtion area
,
Fluid depth in abso~fio~eld before test (in.); lately ~er gal. ded (in.):
Fluid depth ~// (ins.) Minutes~later: Abso~tion rate = ~ ' "' g:p.d.
:
Peroxide ~e t (past 12 ~nonths) (Y~)
If yes. g~ e
Manhole/Access (Y/N)
High water alarm level at*
LIFT STATION
Date installed / Size in gallons /
"Pump on" level at*
*Datum
Cycles tested /
E, SEPARATION DISTANCES
"Pump off' level at*
,/
Septic/holding tank on lot
Absorption field on lot
Public sewer main
SEPARATION DISTANCES FROM WELL ON LOT TO:
/
/
/
Sewer/septic service line / Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
; On adjacent lots
: On adjacent lots //
Public sewer manhole/cleanout /
/
Building foundation 2E) / '/' Property line /~9 t.p
Absorption field
Wells on adjacent lots
Water main/service line /t9 / + Surface water/drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Fo
/
Building foundation ,~ ~-
Surface water /Dd) / '/'
Curtain drain ~-'t9 (P
ENGINEER'S CERTIFICATION
Water main/service line //t9 ' 4-
Driveway, parking/vehicle storage area /D
Wells on adjacent lots /b/~ Property line
,.~o.~o~. ew , ur nt.;D
' ~,anc ithMOAHAAguiaelinesineffectonthisaate. _~.~.~fq_,,,**,, ~_~,
~gnature ~. ~~ ~, ~ ~ ~
Engiueer's Name /~.,/~~ ~ . ~a~~
. - . . _ ~.. ~.~...~..~.~
// *i ~...-/.,z, .."k~
................................ :- .................................................................. .......
HAAFee $ ~ ~ ~' W~verFee$
Date of Payment
Rev. 8/95 eSS: haa.wk.doc
Date of Payment
Receipt Number
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. #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Propertyowner-~r~ ~ ~/~/~ ~I-/C~ Dayphone
Mailing address ~o~- ~'7 Z~o<~ ~.~-~,~/-~ /~- '~':"t5'~-~?
Lending agency Day phone
Mailing address
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water ~
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:
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front 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 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.
David R. Dayton P.E.
Name of Firm ....... Phone
Address Chuglak, Alaska 99567
/.
DHHS SIGNATURE
/~'" Approved for
/
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Hd.alth 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 ~Y21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: j'-J~'-r.,~x~ ~¢~ Parcel I.D. c>5" I- '7~5)- 0',5
A. Well Data
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
~ ~.,,r.;. If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow .g.p.m.
Pump level1
SEPARATION DISTANCES FROM WELL TO: /~///,,~
/
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
ATINSPECTION
MUNICIPALITY OF ANCHORAGE
r-NvmONMENTAL SERVICES DIVISION
OCT 1 9 1993
g.p.m.
RECEIVED
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size I oo4:~ Compartments :~-
Foundation cleanout (Y/N) y DepresSion (Y/N)
/'J/~- Alarm tested (Y/N)
Z,~' /~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /f.,,//~ On adjacent lots ,'~//~/--
To property line ~u ~ Absorption field ~
Surface water/drainage /,~ ~
Foundation ~'
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
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
· Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length ~' .~ ~ Width
Total absorption area ioo~ ,e~z,,.~o.~ Cleanout present (Y/N)
Date of adequacy test I c'i ~ ~ / ~ 25 Results (pass/fail)
Water level in absorption field before test -~ ,~ ~'~
Peroxide treatment (past 12 months) (Y/N) AZ
Soil rating (GPD/Ft2)
Gravel thickness
System type
Total depth
Y' Depression over field (Y/N)
f/~ for ..~
Aftertest .~'~/~/,4~ Z~-~...~
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots /~///,~ Property
line
/O 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 in effe~,.~l?_..~.~,'~of this inspection.
David R. Dayton P.E.
2~10 ~nalar
Chuglak, Alaska
Signature
Engineer's Name
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
D. R. DAYTON, P.E., R.L.S.
~~~ Cbugiak, Alaska 99567
20210 Donalar
696-2417
.October 18, 1993
ADEQUACY TEST
Legal Description: Lot 3, Block 5, Northwoo~s Subdivision
Date of T6s~: October 14, 1993
Septic Tank: 1,000 gallon, 2 compartment, steel tank
.Absorption System: 92' long x 6½'effective depth trench
Soils Rating: 280 sq ft per bedroom
Requirements: 3 Bedroom - 450 qallons per day
Test:
Water was pumped into the absorption trench while measuring
volume, time and water level rise. After pumping was stopped, the
water level drop was measured at timed intervals. ·
The results plotted on a graph of t~me~and gallons absorbed
and extrapolated to 24 hrs.
Results:
The absorption trench is currently functioning adequately for
a 3 bedroom home.
Note:
The trench had 52" of standing water before the test. Afterl.
24 hrs. the water level was ~he same. This amount of standing water
may indicate the system is in its waning years.
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
*: Location (address or directions)
(b) Property owner ~r'~L/
Mailing Address ~'ZC
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address ~/-/dr
Telephone ((''{//~-
Telephone: (home)
. Business
Telephone fl-J/,'~-
(e) Mail the HAA to the following address: (or check here ,~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family'S' Number of bedrooms
WATER SUPPLY (__~w,'t,~_~,, t-~' ~,,'~ i /
Individual Well~ Community ~ Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
SEWAGE DISPOSAL
On-site,,l~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-02S (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto an d as of the validation date shown below, I verify that my investigation of th is
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 of Firm
Address
Date
Engineer's Seal
6. DHHS APPROVAL
Approved for v~ bedrooms by -~.///4-~ ~/~"~ -~ ~ D a t e
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.
72-025 (Rev. 7/88) Back Page 2 of 2
Well Classification ~oz~
Well Log Present (Y/N) __ Date Completed
MUNICIPALITY OF ANCHORAGE (MOA) ~
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Lega Description: /--.04- "~
I~____~B, C, D.E.C. Approved (Y/N) .Y
Yield
Total Depth Cased to
Depth of Grouting
Static Water Level
Pu rn p Set At
Casing Height Above Ground
Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot
; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by
; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DA,]'A
Datelnstalled ~;/~! ~'~'~&ii~e //~C-~r~/ No. of Compartments ,~
StanCpipes (Y/N) ~ Air-tight Caps (Y/N) ~/' Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /~,! Date Last Pumped ~/~'/~?~'
Pumping/Maintenance Contact on File (Y/N) ~J'/~ . ;for
Holding Tank High-Water Alarm (Y/N) ~/~- Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ~ ~(~20 ~
To Property Line ~'f~ ~
To Water Main/Service Line ~-'~ ~ ¢
To Stream, Pond, Lake or Major Drainage Course
Comments
To Building Foundation
To Disposal Field ,~'
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
/zz /?
Date Installed
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Type of System Design '--~'I~<~--NC ~/
/
Length of Field ~2 ~ ~
Depth of Field ~,Y~ ~
Gravel Bed Thickness ._~-/~'~ ~ ._.~, z//~ ~
Statndpipes Present (Y/N) )/"
Date of Last Adequacy Test ~/~:::~/B?
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ;~ ~
To Building Foundation /O '
Lot
To Water Main/Service Line ~.¢-
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line /~)
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present) /~/,~
Comments
LIFT STATION -- /
D.
Date Installed ~ /~
Size in Gallons '~
"Pump On" Level at ~
High Water Alarm Level at ~
Tested for ~
Meets MOA Electrical Codes
(Y/N) ~
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test,
/
**Check Permi?~ Bedroom//~ating Against HAA Request**
I certify that I//'h,~ ~/(/~ecke~//c'e~ied, or conformed to all MOA and
inspection. /// /,'////Z /
Signed ///./~1 '~// ~ '~
Company /~ ~/~!~-/~ ~
Date ~~
MOA No. ~'~ ~
Receipt No. ~ //~'~ ? /-~;' Receipt No.
Date of Payment '~,~--/,/~r/~, Waiver Fee: $
· _ _ Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
effect on the date of this
Engineer's Seal
DEPT. OF ENVIRONMENTAL CON /
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 316
ANCHORAGE, ALASKA 99503
STEVE COYVPER, GOVERNOR
563-6775
DATE: March 6, 1989
PWSID: 213001
To Whom It May Concern:
According to the records on file in this office, the CHUGIAK
UTILITIES/NORTHWOODS S/D is in compliance with the State of Alaska
Drinking Water Regulations.
sincerely,
VERA E. CRAIG
Environmental ficer
MUNICfPALITY OF ;uNCHORAGE
DMSION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF H"m~LTH AND ENVIRONMENTAL PROTECI'ION
APPLICATION FOR mHEAL~ AIY~HORITY APPROVAL CERTIFICATE
1. General Info~nnation Application Date ..~
<a) Legal Description (include lot, block, subdivision, _~.~icnf township f range)
Location (address or directions)
(b) Applicants Nan..
Applicants Add~ess ~--~
(c) Applicant is (check_o_~) Lending Institution
Buyer ~; Other ~ (explain)~
(d) Lending Institution
Te le phone
Address
(e) Real Estate Co. & Agent
~ of i~esidence
Single-Family.. Multi-Family
Number of ~edrooms ~
Other (describe)
Individual Well ~
Note: If crmarunity ~1! sy~tem¥-nT~st have written confirmation from ~e State
Department of Envirop~ntal Conservation attesting to tl~ legality and s,t. atus.
Is the ~11 adequate fo~ the number of bedroans specified in this HAA~)
4. _Sewage Disposal
Onsite ~ .~ublic ~ Co,,m~nity ~ Holding Tar~k
Is t.he wastewater disposal system adequate fc~ the rnmber of h~-~drocras
[Page 1 of 2]
2-].5-:34
6. DHEP Approval
Approved for ~ ,, _
Approved ~
( ENGINEER SEAL)
Disapproved
Terms of Conditional Approval
%~e Municipality of Anchorage Depa~tarent of Health and Environmental P~otection ~c:
not guarantee the. c~ntinued sat. isfactory performance of the water supply and/c~ ~;
wastewater disl~osal system. ~qis approval indicates that, as of the validaticn d5
shcwn above, based on the data and info~mnatioa furnished by_ an e~3ineer registere.~i
the State of Alaska, tile water supply and wastewater disposal system is safe and f
tional for the number of bedrocm~ and type of structure indicated.
( D~IEP SEAL)
7. Mail t?~ HA~ to the following address:
KB2/d5/s
[Pag~ 2 of 2]
2-15-84
A®
MUNICIPALITY OF ANCHORAGE (MOA)
REALT~ AU~HO~TY APPROVAL (HA_A)
CHECKLIST - FEBRUARY 1984
WSI. T .¥. DATA
Well Classification
Well Log:P~esent .(Y/N) Date C~,~leted
Total ~pbh .. Cased to .
Static Water Level Pump Se~ ~t
Casing F~ight Above Ground / /
Electrical Wiring in Conduit (Y/N)
Separation Distances f~c~ Well:
To Septic/Holding Tank on Lot ~O~
Sanitary Seal on Casing (Y/N)
Dap~ession A~ound Wellhead (Y/N)
; On Adjoining Lots ~0
TO Nearest Edge of Absorption Field on Lot ~ ~/~ ; On Adjoining Lots "~..~D
To Nearest Public Sewer Line To Nearest Public Sewer
Cleanout/Manhole To Nearest Se~r Service Line on Lot
Water Sample Collected By ; Date
Water Sample Test Results
Cc~m~nts
SEPTIC/~ T.~NK DATA
Date Installed ~'-~7~'~/ Size _/~ 6~ No. ~ C~nts L
Standpi~s ~) Ai~-tight Caps ~) Foun~tion Clean~t ~)
~ession o~ Ta~ (Y~ ~te ~st ~? ~--~ --~,
P~ing~inte~n~ ~n~a~ ~ File {Y~) fo~
Holding Ta~ High-Wate~ Ua~ (Y~) ~/~ ~a~y Holdi~ Tank ~t {Y~) /~
Sep~ation Distan~s ~ ~gtic~ Ta~: /
To Water-Supply Well
To Property Line
To Wate~
Course .
TO Building Foundation
To Disposal Field. ~
To Stream, Pond, Lake, c~ Major D~ainage
[Page 1 of 2] 2-].5-84
C. ABSORPTION FIELD E~TA
Soils Rating in Absorption St=ara
Date Installed G--Z~' ~1
Width of Field ~O//
Length of Field ?~/
Depth of Field ? ~ ~
Gravel Bed Thickness ~-~/ /
~ Standpipes P~esent (~N)
Type of System
Square Feet of Absorption A~ea
Results of Last Adequacy Test~-~ 7/
Separation Distance f~om AbsCZption Field:
To Water-Supply Well ~O~(~_- To P~operty Line /~ '/~-
/_f~ Z~ To Existing or Abandoned System cn
To Building ~u/;ation
LOt ; On Adjoining Lots ~D
TO Water Main/Service Line '~ To CUt~ba~(if present)
TO Stream/Pond/Lake/or Major D~ainage Cou=se
To D~ivew~ Parking Area, c~ Vehicle Storage Area
C~%~t~nts '~-~ $~/_C~/i-~ /~.( /~/%~__ d7/~ /~ ·
,
D. LIFT STATION
Date Installed
Size in Gallons
"Pul~On" Level at
High Water AlarmLevel at
Tested fo=
Electrical Codes(Y/N)
C~m~ents
Dimensions
~ Man~le/Access (Y/N)
~ "~a~ Off" Level at
____~_~__~ Vent (Y/N)
PumpinfCRs du~ng Adequacy Test.
Meets MOA
** Check Permitted Bed~ocm Rating Against HAA l%~quest
I certify thatz~.ave checked, verified, o~ conformed to all MOA HAA Guidelines ~n effect
on the date
Date
/
/
[Page 2 of 2]
2-15-84
DEPT. OF ENVIRONMENTAL CONSERVATION
SOUTHCENTRAL REGIONAL OFFICE
437 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
PWS I.D..# Z /~ O0 [
BILL SHEFFIELD, GOVERNOR
Telephone:
Address:
274-2533
To Whom It May Concern:
According to records on file in this office the )/Te~taJ~©~S
W~ter System is in .compliance with the State Drinking
Water Regulations. :
Sincerely,
INSPECT ON APPO NTMENTS DATE RECEIVED
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR__
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION/vlUNICIPAL ~ OF ANCHORAGE
825 L Street - Anchorage, Alaska 99501 DEPT. ©F HEALTH &
ENVIRONMENTAL PROTECTION
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 AU[~ ~, 6 1981
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWERJ~g~.~i~ i: n
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
PROPERTY RESlDEN~I' fl{different from abov-"~) -- PHONE
2. BUYER PHONE
MAILING ADleR ESS
3. LENDING INSTITUTION I PHONE
I
MAILING ADDRESS
4. REALTOR/AGENT I PHONE
I
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
~' SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SUPPLY [] INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
NUMBER OF~BEDROOMS
[] One r- Four [] Other
[] Two [] Five
E~ Three [] Six
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
J~ INDIVIDUAL/ON-SITE** ~'l YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INrTIATED.
72-010 [Rev, 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE r--i OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
~ERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVI DUAL/ON .SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
I--]Septic Tank or [] Holding Tank
Size: If Tank is homemade i SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/Holding Tank IAbsorption Area [Sewer Line [ Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[Z~]~I~PROV ED FOR ..~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)