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)