HomeMy WebLinkAboutPROSPECT HEIGHTS #1 BLK 2 LT 19
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
NAME
'T p uETa PHONE ] [] EW
~UPGRADE
MAILING ADDRESS
LEGAL DESCRiPTiON
~. DISTANCE TO,
AbM orpt,?¢~¢a Dwelling~ PERMIT NO.
~ ~ Manufacturer
Liq, capacity in gallons Inside length Width Liquid depth
~ ~ IF HOMEMADE:
~ ~ DISTANCE TO: Well Dweging PERMIT NO,
O ~ ~ Manufacturer
~ -- ~ Material Liquid capacity in gallons
D Well Foundat~ Nearest lot [ine~ e, PERMIT NO,
~ DISTANCE TO:
~ ~ ~ No. of lines ~ Material be;eaWile'~t~t
Length of e~h~ne Total length of li~es Trench width.~ ~ inches Distance betw~
~ ~ Top of tile to finish grade
~ __ ~ Totar effective absorption area
ken0th ~idth De~th ~EBMIT ~0.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTANCE TO: Well Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS '~ ~ /~ ~--
SOIk T~ST
INSTAELER
REMARKS
APPROVED DATE LEGAL
Permit ~ ~(D%~
Applicant
MUNICIPALITY OF ANCHORAGE
Department/~ Health and Environmenta~-?rotection
825 _ Street, Anchorage, AK. ~3501
264-4720
* * * HANDWRITTEN PERMIT * * *
'W~'OR ON-SITE SEWER PERMIT
Location:
Type of Soil Absorption System Is:
Trench: ~ Drainfield: Seepage Be~:
Number of Bedrooms: ,, ~
Maximum
Phone Number:
Lot Size:
Holding Tank:
Soil Rating(sq.ft/br) ~d>~
DEPTH
The Required Size of the Soil Absorption System Is: ·
_ .LENGTH ' GRAVEL DEPTH ~'~' WIDTH'
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.'
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system,~ithout final inspection and approval by this department'
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. ' Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
~Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER ~1~ 1 9 ~ ~_ * * *
I certify that:
(!) I am familiar with 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 codes.
(3) I understand that t~on-site sewer system may require enlargement if
the residence ,i~ rE~m~deled to include more that~ bedrooms.
Signe~: Issued by:
Applica/t ~
Date:
/
swP/o24
GRE/ ER ANCHORAGE AREA BOF'UGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME g.~90.q/~ ~/F$ 2~ MAILING ADDRESS .~,~b/'~_ k~' ¢ PHONE
LOCAT'ON_.Or. . _
SEPTIC TANK:
DISTANCE
FROM WEU
INSIDE LENGTH
LEGAL DESCRIPTION
MANUFACTURER_~,',~'~7 ~_//]5'~c5' MATERIAL
NUMBER OF
COMPARTMENTS
INSIDE WIDTH
LIQUID DEPTH
IIQUID CAPACITY /~¢¢O GALLONS·
SEEPAGE PIT:
DEPTH '~ )
LINING MATERIAL~¢~C ~/~l(~ CRIB SIZE: DIAMETER DEPTH ~) j
DISTANCE FROM: WELL
ADDITIONAL ABSORPTION
NEAREST LOT LINE 20
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) ~W . FT.
WELL:
TYPe
BUILDING
FOUNDATION
CESSPOOL
CONSTRUCTION_ ~. ~',
NEAREST
LOT LINE
NEAREST
SEWER LINE
OTHER SOURCES
DEPTH ~Ot~ DISTANCE FROM:
SEPTIC SEEPAGE
TANK __ SYSTEM
APPROVED
· DISAPPROVED
REMARKS
DISTANCES:
./
PIPE MATERIAL·
LOT SLOPE:_/-~,A '~-
REMARKS: ~'~£:~ ~/oO fy
Form NO. EQ-031
DIAGRAM Of SYS~
DATE
G.A.A.B. ~
6
NAME OF APPLICANT
GREATEr ANCHORAGe Area BorouGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
PERMIT NO.
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
SOIL TEST RESULTS .~----~--/~/~ /~~-// TO BE INSTALLED By .
NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITy WILL BE SUBJECT TO PROSECUTION.
TYPE . ~
MINIMUM DISTANCES, RE(;~UIREMENTS
FOUNDATION TO SEPTIC TANK ~ / DIAGRAM OF SYSTEM
FOUNDATION TO SEEPAGE Pit /~ F
SEPTIC TANK TO SEEPAGE PIT WALE
SEPTIC TANK _
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK
DRAIN FIELD
DRAIN FIELD
· SEEPAGE PiT _ ~ / , DRAIN FIELD
SEEPAGE PiT /~ ~ ~
ALSO CONSIDER AREA WEL~-S.
WATER MAIN TO SEPTIC TANK
SEEPAGE PIT .
DRAIN FIELD
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION S FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTID TANK AND SEEPAGE Pit
FITTED With AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION·
CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GRj~/~TER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
'ESCRIBED SYST'M IS IN ACCOR,ANCE WiTH SAiD CODE, ~~ ~~j~
DAT APPLICANT'S SIGNATURE.
"One ~esl is worih a ~housand opinions"
Per{ormed For /'1/0 0~, ~*~ .~'~' ~ bate Per(ormed.
Lenal Qescrintion: Lot t~Block / Subdivision ~~ ~/~
This Form Renorts Soils LJq ~ Perco-l~tion Te~t /
1
2
3
4
5
7
9
10
.neath
Feet
Soil Characteristics
Was Ground Water Encountered?
Yes, At what Depth?
i
Readinq Date Gross Time Net Time Depth to H20 Net DronI
Percolation Rate !linute
o Drain Field
Proposed Installati..on:~ SeenaQe Pit ttom Of Pi
Deoth of Inlet '-~ ~ _ De~th t Oyr/Tremch
CnU?ENTS:~~
T~t P~¢nrm~a ~,, ~'~"~l ~/~'~.-~-- Data Certified B~:
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
.... ' C'I~RTII~IC~E"OF HEALTH AUTHORITY APPROVAL
FOR
A
SINGLE
FAMII'Y
DWELLING
..I~ e~
Parcel.I.D. _C:) I,¢' - c~,¢)/ _
GENERAL INFORMATION
ComPlete legal description LoS
Location (site address or directions)
Current Prdperty owner(s)
Mailing address
Lending agency
' HAA#: .~::>..30 '1'99
'Expiration Date: ' ~' ," ! O - O ~
Day phone
Day phone
Mailing address
2~
Real Estate Agent /~o~= - ~',r ~ Day phone
Mailing Address
Unless otherwise requeMed, 'HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
' IndMdaat-Wetl
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
~ Individuai On-site ~
[] Individual Holding tank []
[] Community On-site []
[] Public Sewer I-"1
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-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. (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
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
e
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 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation, t3'¢~ ~.~,,,~ f' o ~ ¢~/,, ~'~,~'/J-~-~/ . ~S¢c.., //',z.o ~,~.r~-/~',~,'~.
Phone
Name of Firm
Address
Engineer's Printed Name
bedrpoms.. ~
Dat~....4'-'/.~- ! .~, oo y
DSD SIGNATURE
· ~ Approved fo.r.
Disappr~/ed.
Conditional approval for
· -. ...... ..
- -~...~ .~:¢~ ~
bedrooms, with the following stipulations:
Additional Comments
.~-~ .- _ '.~
ON-SiTE
~: WATER AND . ~'~
~ ~ W~TEWATER : .
/JJJJj]))
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
.0~-05-0~ O1
FROU-CT~E ESI, SGS ENV SERVICES
90~5S15~01
.~rinking Water Analysis Repot[ for. Total Coliform Bacteria
~tEAD t~ST~UC'nONS 0N REVERSE[ SIDE BEFORE COLLECTING SAMPLE
MUST BE COMPLETED BY' WATER SUPPLIER
[] FUaLIC WA~ER SYSTEM IO~
~ PRNATE WATER
I~] Send ~e~ults
~:] Send Invoice
T-208 P.01/01 F-?ST
200 W. POTTER DRIVE
ANCHORAGE. ALASKA 99518
Tel: g07,502-2343
Fax: 907-561-5301
SAMPLE COLLECTION:
Transp~d ,
m ~u ay: ~' Sa~ as collector
TO BE COMPLETED BY ~O~TORY
Temp: _ ~
Delive~ Me~od:-
SAMPLE 'I~'PE:
[] Routine
[] Repeat Sample
(refer to lab no,
~ Spactal Purl~sO
I~ Treated Water
[] Untreated Water
Comments:
[] Samite ovr.~ 30 houm old;
F~esults may be unreEal31o
[] 46 Hour Wmve~ Phone
I-l' RUSH SAMPLE
MMO-MUG (P/A) RESULTS:
Analysis Bet]an: f~ [~-"//~. I"/~ - Total Coli,o,m:
Anal~tc __. ~,j~_., E. Cc<i:
Analytical Mothcd:
MEMBRANE FILTER RESULTS:
D;rect Count. ,,~, . Cotonl~/100ml
ISe~t to Client: ]
Phoned F-1 Faxe0 ~
OateJ~lme:
Spoke witn'~ ..............
[] Sat!sractory
I--I Unsatisfactory
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
· ' -- FOR A SINGLE FAMILYDWELLING' ' · ",.
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Current Property owner(s)
Mailing address 700 ,Wu./
HAA#.' O~ C) ././L. c~ ~
Expiration Date: ~ ~ {~ - O ~
Lending agency
Mailing address
Real Estate Agent
'. iMailing Address
)2. NUMBER-OF BEDRoOMs:
Day phone
otherwise requested, HAA will be held by DSD for pickup. P l¢ou'~ ~1/ -r~c,z' ~c~ (~,
3. T~P'E 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 [--I
Public Sewer I--I
The Municipality of Anchorage Development Services Depadment (DSD) Issues Cedificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-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 propedies served by a private or Class C well and may be reissued with
new water sample results. (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
Municipality 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(am) 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
NameofFirm /'='l~/",Jo/~ 7~r-'~,~c~! ~'~'~,'~¢~j'
Address 1¥5'"30 Ec.~
Engineer's Printed Name
DSD SIGNATURE
~ ApproVed for,
Disapproved.
Conditional approval for
Phone 3' ?~-- I ~',~-5'
'Date
· bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HM Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: / O '" (_~ - O 3
(Rev. 01/02)
Municipality of Anchorage
Development Services Department'.
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. d. anchorage.ak, us
(9O7) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: , L~ 19.~ /"JIo~'~' '~, p~./~,~z. ,/¢~3' ~ ~., Parcel ID: 0 t~'-091 - Z~"
A. WELL DATA
We~l.type.
Date completed
Total depth ~ ZS' ft.
Date of.test
Static water level
Well production
If A, B, or C provide PVVSID # --., .. Well Log (Y/N) Y'
Sanitary seal (Y/N) ¥ 'r Wires properly protected (Y/N)
Cased to ~ ~ ft. Casing height (above ground)
FROMWELL LOG '. , AT INSPECTION
, 'f3 ft.
I g.p.m, g.p.m.
in.
WATER SAMPLE'RESULTS:
Coliform C:) colonies/lO0 mi.
Arsenic: '-- mg./l.
Nitrate ?.~0_ mg./I.
Date of sample:
Other bacteda
Collected
'~ colonies/lO0 mi.
.~' t~ F/~.,/, '~¢c~
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ~ l,~,,r,r , .
Tank size t oDD gal. Number of Compaftmehts
Foundation cleanout (Y/N) Y Depression over tank (Y/N)
Date of pumping ~ / ?,. ! o~ Pumper
· Date installed "//~ ! "/y
Cleano6ts (Y/N) ~
High water alarm (Y/N) ~. ~
.C..ABSORPTION FIELD DATA
Date installed '7/~ / ~ ¥ Soil rating
Length t ~f
Total depth ~, .., ft.
(g.p.d./~ or~/bdrm) iF'O ca'~l~S~ystem ~pe
ft. Width ~ ff. Gravel below pipe 7
Eft. absorption area 3~ Z ft: Monitoring tube ~'. ~ D'epression over field
(Pass/Fail) ~'o,,~' For ¥ bedrooms
Date of adequacy test ~ / t~ ! 0.3 3 ~.~?ults ~. ~
Fiuid depth in absorpticn field before test ¥3.~n. Water added ~'3~gal. New depth'TR Z. in'.
Final fluid decth '/~ in.
Abscrption rate >= ~0<:~ c.p.d.
E!apsed Time: hfS" min.
Any rejuvenation ?,reatment (past 12 mo.) (YIN & type) I~lon~ I,n:,r~oc,.~,n If yes, Give date ~/.~L,
LIFT STATION /~J' ~'
Date installed
"Pump on" level at ~in.
Datum
Size in gallons
"Pump off" level at ~
Cycles tested
in.
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?.
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~5 ta'-eptic" 'nldlift station on 10~ :' ~,~ ~' ' ...... ' ""'
Absorption field on lot
Public sewer main t~. ~'.
'Sewer/septic service line '~ ~.~ ° Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
· 'Oh adjabent lots ' ~, too '
On adjacent lots '~' t~ '
Public sewer manhole/cleanout' ", A/. ~.
Property line I ?,O~ Absorption field ,~" '
Water service line ~, ~O ° ' Surface water ';> I c,o ,
Building foundation ~ ~.
Water main ~fo ~. ' ~'
Wells on adjacent lots ;:~' ~ ~O ~ "
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line '7
Water Service'line
C u ~3i'i~ drain
Building foundation ~V0"' Water main ~J. ~-.
Surface water ~5, 't ~,~o ' D~veway. parldng/vehicle storage
Well~ oh'adjacent lots ~. ~oo '
F. COMMENTS
G. ENGINEE'R'S CERTIFICATION
I ~e~ti~y that I have determined throug~ field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect'o~l 'this date.
Enginee~s'P. rinted Name -/'-~'
Date. ~'/~' / ~'.~ ... ' '" "
' HAA Fee $ 3 ?J~' , ~
Date of Payment
R~'eipt Number
(Rev. 12/01).
Waiver Fee $
Date of Payme,nt
'Receipt Number
'89/0g/2003
23:55
09 EOO3 ~0:00
I
I
I
I
! '
I
425-895-4532
~TEUR~T
PAGE
82
SGS Ref.#
Client Name
Project Name/g
Client Sample ID
Matrix
Sample Remarks:
1035813001
Flattop Technical Srv.
Prosl~ect HeiSts #I
L19, Blk 2
Drinking Water
All Dates/Times are Alaska Standard Time
Printed Date/Time 09/16/2003 7:37
Collected Date/Time 09/10/2003 14:30
Received Date/Time 09/10/2003 16:00
TechnlcalDirector . /Steph~g~C/~de
EP 300.0 - Detectable amount of nitrate in the calibration blank; the concentration of nitrate in the sample is 10X greater.
Allowable Prep Analysis
Parameter Qualifiers Results PQL Units Method Container ID Limits Date Date Init
Waters Department
Nitrate-N
4.50 0.100 mg/L EPA 300.0 B (<=10) 09/12/03
Microbiology Laboratory
Total Coliform
2 OB, No Coli col/100mL SMI8 9222B A (<=1} 09/10/03 KC
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. # O/~'" - O?1-
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner-- ~ '""-'"-''~;~'vt"~%~~ ~%'~c~ Dayphone
Mailing address ~.
~¢~ -~ ~~ Day phone
Lending agency
Mailing address
Agent
Day phone
Address
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
Public sewer
NOTE:
if community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) 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.
Name of Firm %/0~¢-x4 S~ ,-
Address ~..0 "~ ~ /~-¢ ~ ~
Engineer's signature ~
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
Date
bedrooms.
b,edrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72q~25 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health & Human Services
.E^'TH ^UT.Om ¥ ^...OV^' C.ECK',S
LegalDescription: J"Jq/~:~;L ~1'O%~_~'~L ParcolI.D.
A. WELL DATA
Well type li~
Log present (Y/N) ~'/
Total depth /'/~1- 5
Sanitary seal (Y/N) y
If A, B, or C, attach ADEC letter. ADEC water system number ~('/~
Date completed ~/~o/7 t'// Driller
Cased to ~'7/,~- Casing height
FROM WELL LOG
Date of test ~0/7~/
Static water level /'/~'
Well flow
Pump level
Wires properly protected (Y/N)
g.p.m.
AT INSPECTION
~UHIC?ALITY r~F ANCHO.~GE
3///0/q~, ENVIkONM£NT/,LSER',IC.~S DIVISION
.,,.,, 1 8 1993
IVE D
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot I 0.5
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ¢
Date of sample: ~i~/o
Nitrate ~ P~, '~('4~ Other bacteria ~
/
Collected by: T.._~
B. SEPTIC/HOLDING TANK DATA
Date installed '7~1/7¥2 %"~/~2,. Tanksize /OOO -t' ~o-~ Compartments ~- '~ /
Cleanouts (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) . ~/
High water alarm (Y/N) )%//'~ Alarm tested (Y/N) /'~'~',~
7
Date of pumping ~'~4.~.~ II ~ I, ~ ~3 Pumper J.,~ o_~. ~' .5
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
Topropertyline .~ ~O
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91) 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 '7/~//~
Length ~ ~ ~ Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail) '~
'~ ~ Gravel thickness ~¢, / Total depth /,,~. /
'~/~;;~ ~ Cleanouts preseqt (Y/N)
~ Date 0f adequacy test ~////o/¢~
for "~ bedrooms
Peroxide treatment (past 12 months) (Y/N) /~/'~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I~ On adjacent lots ) l ¢ Property line
To building foundation To existing or abandoned system on lot
On adjacent lots ~ /¢~:~ Cutbank ~[~X~ Watermain/serviceline
Surface water ~/0 Driveway, Parking/vehicle storage area
Curtain drain J~/C~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on .th_e date of this inspection.
HAA Fees
Date of Payment
Receipt Number c'~-~'~'~?
72-026 (Rev. 3/91) D~ok MOA21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99515 TELEPHONE {907) 562-2343 FAX: (907) 561-5301
Chemlab Re£.# :93.0966-! REPORT of ANALYSIS
Client Sample ID :LI9 B2 PROSPECT HEIGHTS
Matrix : WATER
Client Name :TOBBEN SPURKLAND, P.E. Collected :03/10/93 @ 13:45 h~s.
Ordered By :TOBBEN SP~KLAND Received :03/10/93 @ 14:00 les,
Project Name : WORK Order :63915
ProJect~ : Report Completed :03/11/93
PWSID :UA Technical Director [:~N C. ED~
Released By :.~<~~' ~
Sample
Re~rks:
ROUTINE SAMPLE COLLECTED BY:
QC Allowable Extract Analysis
Parameter Results Oual. Units Method Limits Date Date Init
NITRATE-N 2.36 mg/1 EPA 353.2/300.0 lO 03/11/93 MCE
See Special Instructions Above UA - Unavailable
** See Sample Re~arks Above NA = Not Analyzed
U = Undetected, Reported value ts the practical quantification limit. LT - Less Than
D - Secondary dilution. CT - Greater Than
~
MUNICIPALITY OF ANCHORAGE
DMSION OF ElkKQRONMENTAL HEALTH
DEPARTMENt7 OF HEALTH AND ENVIRONMENTAL PROTECT%ON
APPLICATION FOR HEALTH ALri~HORITY APPROVAL CE~PIFICATE
1o C~neral Infornmtion
Application Date
(a) Le~l~ Descri!otion (include lot, btc~, subdivisicn,.~ecg~ion,.~cwnship, range)
Lo~tion~d~ess o= ~ctions)
(b) Applicants N~ '~/~ ~O~
(c) Applicant is (check one) Lending Institution ~-~; Owner/builder
Buyer ~-~; Other ~ (explain);
(d) ~nding Institutio~ ~ ~~ ~/~,
Te lepho~ ~ -~O/~
2. ~zpe of Residence
Single-Family ~ Multi-Family ~-~
Number of Bedrooms
O~e= (~s~ibe)
3. Water Supply
Individual Well ~ Community ~ Public ~
Note: If c~,~,,'unity ~11 system, must have written confirmation from the State
Department of Environmental Conservation attesting to t}~ legality and status.
Is the ~11 adequate for the number of bedrcons'specified in this HAA (Y/~)
4. ~_,..~ej~ge Disposal
Onsite, ~ Public ~--~ Community ~-~ Holding Ta~k ~
is the wastewater disposal system adequate fc~ the number cf b~droc~s (Y/N)
[Page 1 of 2]
2-15-84
.~P. glneering Firm Providi_~ Inspections, 7bsts, Data and Information
I certify .that I have checked, verified, c~ conforra~d to all MOA HAA Guidelirms in
effect on the date of this inspection.
Add, ess
Signed by
Date__~_
( ENGINEER SEAL)
6. DHEP Approval
Approved for
~/ bedrcoms
/
Disapproved
Appro~
Terms of Conditional Approval
Date ~/~/
Telephone ~7~'- '-~ 9/¢~
The Municipality of Anchorage Department of Health and Envircp~uental .mzotection does
not ~.aaran%~e the continued satisfactory performance of the water supply and/or the
wastewate~ disposal system. This approval indicates that, as of the_ %~alidation date
shc~vn above, k~nsed on the data and information furnished bi an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and func-
tional fo_~ the ninube~ of kedro<~us and type of structure indicated.
( DHEP S .EAL)
7. Mail the HAA to the following address:
~ ~,'~c/e).~- /
KB2/d5/s
[Page 2 of 2]
2-15-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification ~(~/AT~
Well Log Present (Y/N) y
Total Depth_. //..',,~j,~ (~ased to
Static Water Level ~
Casing ~iuht ~ GFound ~n
Elec~ical Wi~inu in ~n~it (Y~)
~p~ation Distan~s ~ ~11:
To ~ptic/~ Ta~ on ~t
MUN (~IPAI. ITY OF ANCHORAO~
DEPT. OF HEALTH &
E_NVIRONMENTAL PROTECTION"
D.~E.C. Approved(Y/N) ~--~,~_~
If A, B, OZr C, '5/,'3-c/7 ~/ Yiel~~
~te ~le~d _ .
~pth of GF~tin~
~ ~t At ~/~ ~
Sanit~y ~al on Casing (~)y
~pFession ~ound ~l~ead (Y~) ~[
; On Adjoining Lots
To ~Nearest Edge of Absorption Field on Lot j"~ )=7'; On Adjoining Lots NOT bi V
TO Nearest Public Sewer Line ~//~ To Nearest Public Sewer
Cleancut/Manhole ~///% To Nearest Sewer Service Line on Lot N//~
WateF Sample Collected By
WateF Smmple Test Results
B. SEPTIC/HOLDING TANK DATA
Date Installed ~//5/,~/~ Size ../OOO '~ i50cL) No. of CQ~3a~tm~nts
Standpipes (Y~) ~' AiF-tight Caps' (Y~) . ~ Foundation Cleanout (Y~) '~'
~p~essi'on o~ Ta~ ~) t'~ ~te ~st P~d '~/t~
~ing~intenan~ ~n~a~'on File (Y~) ~/~ ; fo~
Holding Ta~ High-Wate~ Ala~ (Y~) ~/~ Te~aFy Holdi~ Tank ~t (Y~)
Sep~ation Disbands ~ ~ptic~~Ta~:
To Water-Supply ~11 /~/~ To ~ilding Foundation~ ~'
TO ~rty Li~ ~ O +
'- TO Dis~sal Field
To ~ter Main/~rvi~ Li~~ ~/~ To S~e~, Pond, ~e, ~ ~j~r ~aina~
Cour~
Comments ' ,
[Page 1 of 2]
2-15~84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed (~[~',% i..%.5L
Width of Field '~Ol'
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from AbsorptiOn Field:
TI~pe of System
Length of Field
Depth of Field
Gravel Bed Thickness
~/'O ~ . . Standpir~es Present
Date of last Adequacy Test
To Water-Supply Well
To Building Foundation
Lot ~//~
To Water Main/Service Line
To Stream/Pond/Lake/or Major D~ainage Course
To D~iveway, Parking Area, or Vehicle Storage Area
--~ 0 To Existing Or Abandoned System cn
; On Adjoining Lots ~///~
~'/~k ... To Cutback(if present)
+
.Comments
D. LIFTSTATION
Date Installed
Size in Gallons
"Pump On" Le%gl at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Co~(~r~nts
** Check Permitted Bedroom Rating Against HAA Request
I ~rtify that I have checked, verified, or confor~ed to all YOA HAA Guidelines in effect
ate
on the date of .this inspeGtion.
KB1/d5/s
[Page 2 of 2]
2-15-84
Propert,~'OWner
Mailing Address
APPL?'--~IT FILLS OUT UPPER HAl." "ONLY
AOc (
Zip Code
Phone
~ 7Y~-~/oo
Buyer
Address Zip Code
Lending Institution Phone
Address Zip Code
Realty Co. & Agent
Address
Legal Description
Street Looatio~
Type of Residence
~ingle Pamily
'El Multiple Family No. of Bedrooms
[] Other
Phone
Water Supply
'"[~ Community
[] Public Utility
Sewer Disposal
pndividual
ublic Utility
[] Holding Tank
ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
For wells drilled prior t? that date, give well depth (attach Icg if available).
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE iNITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field
I'1
Notes:
~'¥~)'~ MUNICIPALITY OF ANCHORAGE
DEPT OF I~ '!-T~I ,~.
ENVtRONM,2NiA- i ,..O, ECTiON
fiCA' 1 5 1982
REC.E!_VED
( t~L ) APPROVED BEDROOM8
*CONDITIONS
OF
APPROVAL
( L+-DISAPPROVED
) CONDITIONAL APPROVAL~
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
~'~ ~-~..~L_ Well to Tank ~ Septic Tank Size /'~)~(-~
72-023 (3/82)
D.~TE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF i~
825 L Street- Anchorage, Alaska 99501 ENVIRONMENTAL: :';~'CTtOH
ENVIRONMENTAL SANITATION DIVISION ~j~',~ ~. ~[
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1, PROPERTY OWNER I~ PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER ' '/~ "~ PHONE
MAILING ADDRESS /////[/
3. LENDING INSTITUTION [ PHONE
MAILING ADDRESS
4. REALTOR/AGENT
/~ ~'/~,/~ J PHONE
MAILING ADDRESS j~'/~'~
5. LEGAL DE{;CRIPTION
STREET LOCATIOW
6. TYPE OF RESIDENCE
NUMBER OF~B ED~R~S
/~ SINGLE FAMILY [] One ,~ Four [] Other
[] Two "1 I' Five
I~'~ ~/.z~.~ [~ree E~ Six
'"'Z~*~ACH WELL LOG. A well log is required for all wells drilled ·
MULTIPLE FAMILY
7. WATER SUPPLY
~ INDIVIDUAL~
'~ COMMUNITY
[] PUBLIC UTI LITY
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** /~' 7~(~ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(Rev. 6/79) (/,_~ ~%]~O -- /'x~'~'O~'-
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received //-~'.- 7'/
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
.INDIVIDUAL SEWER & WATER FACILITIES
.,,.:,~ ~ FOR
1. Approval requested by:
Mailing Address:
2. Property Owner:
Phone:
Mailing Address:
3. Legal Description: ~z~m-~v- /?
4. Location: ~'7~
5. Type of facility to be inspected
6.
Well Data:
No. of bedrooms
Be
A. Type B. Depth
C. Construction D. Bacterial Analysis
Sewage Disposal System:
A. Installed ~/~/?~ B. Installer
C. Septic Tank:
D. Seepage Pit:
E. Disposal Field:
Distances:
A. Well to: Septic tank
Nearest lot line
B. Foundation to septic tank
1. Size 2. Manufacturer
1. Absorption Area 2. Material
Total length of lines
, Absorption area
, Other contamination
, Absorption area
, Sewer Lines __
C. Absorption area to nearest lot line
E0-034 (1/74/ Paa~ 1 nf twn n~mmc
Page 2 o~ two pages Re
Legal Description
,t for Approval of Individual ·
~r & Water Facilities
Comments
Approved, ~/~ Disapproved Date/~/Y~/?~/
~roval~Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED
Date
EQ-034 (1/74)
GREATER ANCHORAGE AREA BOROUGH_.
Department of Environmental Quality
3330 "C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
1. Type of Inspection: CMRO
2. Property Owner: .~.
Mai-lin9 Address:
3. Name of Buyer:
Mailing Address:
4. Name of Lending Institution:
Mailing Address:
5. Name of Realtor or.Agent:
Mailing Address:
VA FHA CONV ~,/
Z~/~ Day Phone. ~-~7--Y~ ~
Day Phone
Phone
Phone
Legal Description:
Location: ,
7. Type of Facility. to be inspected:
8. Water Supply
Type of Supply: Public Utility
go
No. Bdrms. ~
Individual
If Individual, number of dwellings presently served
If Individual, depth of well ~
Sewage Disposal System ~
Type of System: Public Utility
If Individual, date of installation
Individual
(on-site)
EQ-037 !}/74)