HomeMy WebLinkAboutDENALI VIEW BLK 3 LT 3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMEN]'AL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
IP"°NE
NAME
MAILING ADDRESS
ILEGAL DESCRIPTION
LOCATION NO, OF BEDROOMS
~ ~ DISTANCE TO:
~Z Manufacturer ~,~, Material~/ No. ofcompartments ~
~ Liq. capacity in gallons Inside length Width Liquid depth
~ ~ IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ ~ DISTANCE TO:
~_~ N°'° f lines / Length°f each line," ' T°tallength°flines~7 ' Trench w id~ inches D istancebetwe~7~
Top of tile to finish grade ~ Material beneath tile / Total effective absorption area
Length Width Depth ~ PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
," Class~ r. ~/~ ~.Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer tine Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
SOIL TEST RATING
REMARKS
APPROVED . / ~ DATE LEGAL
(Rev. 3/78)
PERMIT NO.
APPLICANT
LOCATION
LEGAL
FILiI"--I I ,] I PAL I T"'r" i-iF RF~CHCI~:RI3E ~,-~, z
DEPARTMENT r'- HEALTH AND ENVIRONMENTAL ~'~'-~ r ~6~~_'~ p~
- - E TE ..T I ON
825 '"L ~TREET.. ANCHORAGE, AK. '~5 i ~ ~, ~
bIELL R[-t[:, ,3~--5 I TE SEbJER F*ERfq I T
BETHRRD CONSTRUCTION
STAR ROUTE R BOX
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[:,EPTH= ::L :-:' LEr-48TH= _---tZ~ G F~: R',,..' E L [)EPTH= 8
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF R 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).
E".EC-!LI I RED. SEPT I C: TASII< S I ZE= :I.L.:~L_-~C'~ ISRLLF~SIS:
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.
TLqO (2> I FJSPECTICIFJS RRE REI2~IJIRE[:.
BACKFILLING OF ANY SYSTEM WITHOUT 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 280 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PER~d I T E:~-~.P I RES DECEMBEr:
I CERTIFY THAT
i: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF' THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
SIGNED:
ISSUED
V4. 0
1"1 I_1 !'-.t I i.~: .'[ F' FI l__ _T. T '-r' , C~.. I': Fa i'--I C: I'--I C,) t;: B '~ E:
r::EPF~RTHENT r"- H£RLTH F~I'-IE:, EI'.,I'v'ZI;'3r.iME_I',ITF~L
S25 "L STF:EE.T., Fir.,Ir':HOI;'.~C'iE, RI.(. ?'_:.
R 1"-4 [:' ~'Z~ f-,l .-- ::~- i' T E :.--3- E--_ 1,1 F.Z F*~: F' F.:~ i~-'.' I"'1 ]2 -I-
::, ,S £/+ i~
:~;.::IPII_.IM HUHE:ER C~F: E:EDF.:OOP1S = ,~
LOT SIZE C/~-O~/ S:OUF~F:E FEET
· ~E F:E'6!UIFiEC, :~I'ZE OF THE SOIL...F~Er~,OPF'TION 3'¢S:1-Er,1 [:5'
/: 5 3 ..,, ....
, i:-~ F" -F t-t -=: L E l'-J tT_i '-T- H .... C:i F-7: Ft' ' ET L_
[:, E.-£ F' -'F F--t .... (~
THE LENGTH [:, I MENS I ON ItT, THE LENGTH (ll'.l FEET:, OF TH[: TREHC:H OR E:,RF~IrIFIEL[:,.
THE DEF"TH OF R TRENC:H 0~? F'IT I':.:-: THE E:,IE;',~NC:E E:ETHEEN THE '.:3URF--~CE L)F THE
GFtOI..IH[:, FtND TH[-_- DOTTOM OF THE E-:,::I-:FI'v'I-~'F]ON (IN FEE'.T>.
THEF:E [*':' HA :SET H[[:,TH FOF.' TF::ENC:HES
THE GRF~',,,'EL DEPTH [~; THE M]N~MLtM DEPTH OF GF.:F-t'v'EL BETHEEN THE CILI'FFPqLL. F'JF'E
FINE:, THE DOTTOrl OF THE E,'.<C:R',/FITIOI'.I (I1'4 FEET;,.
//d2C? C) C~ Fa L_ L._ ,':~ 1'-4 :_.:5:
:Pt'lIT RF'F'LIC?~NT HFt_-'_-, THE RESF'OH$IBILIT'¢ TO INFCU;:M 'FHI: DEF'RF.:TMENT [:,UF'It~G FHE
4%T£tLL. RTION INSF'EC:TIC~HS OF []N'¢ HELLS A[:,JF~C:ENT TO THIS: PF:OF'EF.:TY
.tME:ER OF PEt~';IC, Ef'JCE$ THRT THE HEL_L [.liLt...:,EF.\,E.
....... -T~ 1 -.I ~'2~ ,-'. -::.__' ::, ][ I'-1 '_:-~ F' EE C: 'T' I C~ I'-4 .?; F~ F:: [:; [;-: EE l,):.~ L.f I t:;~: [:: IL':,
¢'.PCF'ILL. ING L'iF FIH',' SYSTEM H I"f'HFHJT F'TNFtL ~H%PEC:TIOH FINE:, F~PF'ROVFqI_ E'.Y FHI'L::
:F'RRT'MENT HIL. L E:E L:;UE',,TEC:T TO F'ROSECLIT~[
NIMI_IM [:,IE';TflNCE E:ETHEEI"I PI. HELL AHD RH'-r' OH-CSITE %EHHFJE7 [:,I~';POSFtL ?¢'_:SfEM
tO FEET FOF.: ¢ F'F.:I'v'fl'FE HELL OR: ±50 TO 200 FEET FROM R F'LIE:LIC HELL.
:'O~i THE T'¢F'E OF F'I.IE:LIC;
t. iIMf..If't DICTfqNCE FF:Or"l R PRI',,,'nTE HEL. L f'O F~ F'RI'v'RTEE '5EHEP [..IfiE I':, 2':; F'EE"r
~ F~ C;OP1MUf.~ZT'¢ SEHER LINE I:; 7G FEET.
]...L LOCi5 HRE REQI_~ZRED RN[T:, MI..I%T E:E PETLIRHEE:, TO THE [,EPFd;;TMEHT H I-FHIH 20
THE PiE-I...L COMF'LETI
'HEF: F:ECH.tIF'EHENTS PIF4Y RF'F'L_Y. fi:F'E. CIFIZFtTIFFffI': RNE', C:F~N%TRI..IC:TICIf.I [:,IF4GRAPI'.E:
,'F~IL_RBt_E T'O Jf.J:E:UF:E F'F:OF'ER IN:ZTF~t_L..FITION.
C:EF:T I F'.r' THF!T
I Rr'l F Felt L. l F~F: H! TH THE F:EC!I_II RFEf'IENTS FOR ,:~r4--S I 'rE SEHERS FIH[:, HELLS AS '::E. f'
~F'TH :, THEE I'II.JN I F: I F'FtL I Th" nF' FffJC:HOF::RGE.
I Hit_l_. IN2CTHLL.. THE ?¢S'FEH IH RCCOF'C:'FflHCE HI I'H THE
I UttE',E3;"5'I't:iND THHT THE ON-'BIT'E 21ENER S'T'::%TEM ['IFt'T' F'[EL:H_IIF:E EHL_FtRGEt'IEHT IF: THE
::~[[:,E:NETE I:~ F'EP!CIC, EL. EE:, TO INC:LI..IE',E MI~'[': THFtf.t ];
2204 Cleveland Anchorage, Alaska 99503
~er form~!~' 'For Steve Steenmyer
ri ti [0t 3
teea l',r:: D on:
This ~orm Re~ort$ Soils Loci
Date Performed
6/16/76
Block 3 Subdivision Denali View Estates
Percolation Test yes
nenth
Feet
16
Topsoil
Soil Characteristics
Silty Gravel (GM) wet
Gravelly Silty. Sand (SM)
Sandy Silt with occasional
gravel layers (ML-SM)
Moist
Bottom of Test Hole
Was Ground Water Encountered?
IY Yes, At what Denth?
No
{ I
Readinq Date Gross Time Net Time Depth to H20 Net Dron'
inches inches
6/16/76 0 3b .. 0
} 6/17/76 24 hrs ±~ 132
6/17/76 0 30 0 ,.
6/17/76 l~-0'min b4~ 18
; 6/17/76 210 min b6.75" 2-3/4
I '6/17/76 240 min 59.25 2-1/2
F---- ' ' ~i% ~" ~ ~ ~
Percolation Rate 1"/12 ' Uinute
Prnposed Installation: Seenaoe Pit Drain
Den. th of Inlet Denth To Bottom Of
~nu~ENTS: 17.5 Squ~~~i~ a~ea required per bodro,
--~~ater or bedrock encountered. .
Test Performed Bv /~.~,,, ']~,:~=~.Z~ Data Certified
cx..?~-O
WATEB WELL LOG
FOSS DRILLING ASSOCIATED
909 CHUGACH DR. #3?
A~CHORAGE, ALASKA 99503
WELL OWNER Frank Oo Beth~rd USE OF WELL
WELL LOCATION Lot 3, Block ~ Denali View Subdivision
Domestic
SIZE OF CASING 6"
STATIC WATER LEVEL
REMARKS
DEPTH OF HOLE 47
8 FT. Go Po Mo
FT. CASED TO 16 FT.
8 WITH 36 FT. OF DRAWDOWN.
DATE COMPLETED 11/26/80
PUMP TO BE SET AT 46'
0 to 10
1__9_Oto 2o
,~ to 47
47 to
to
Alluvium: brown color~ medium hardness
Bedrock: ~re~ and hard
Bedrock: grey and hard~ with water
Interbedded Sand: brown~ with water
to
__to ,
to
tO
___to.,
tO
tO
to
to
__tO ....
to
to
tO
MUNICiPALiTY OF ANCHORAGE
D[?T. (i)[~ i~ ,I J lJ ~
ENVIRONMENIM- ; ' i'[tCl'lON
,.:AN 1 ,.% ~'""'
RECEIVED
'to
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
GENERAL INFORMATION
Complete'legal description
Location (site address or direCtions)
ProPerty owner
Mailing address
Day phone
Lending agency
Day phone
Mailing address
Agent P~,.,~.82,~ L?oJ
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ~ ~
J
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.
4. 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
a~testing to the legality and status of system.
72-025 (Rev. 1/91) Front MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
Sm
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,
Phone ~2.7 ~'_ '5'] ! ~
ordinances, and regulations in effect on the date of this inspection.
Name of Firm )-'"-o ~6 ~ ~ ~ u ? ~c L~. ~ ~- [~-
Address ~_o '5 ~5/ / ~-~ ~,,~.o~5
EngineeCs signature ~ ~
T/~/~-F'~'bed rooms.
DHHS SIGNATURE
/,//' Approved for
Date o
Disapproved.
,Conditional approval for
bedrooms, 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.
72-025(Rev. 1/91) Back MOA#21
RECEIVED
Municipality of Anchorage dUN 1 6 1999
DEPARTMENT Of HEALTH & HUMAN SEP~i~.I~ OF ANCHOEAGE
Environmental Services Division ENVIRONMENTAI.$EEVICES DIVISiO
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744
Health Authority Approval Checklist
Legal Description:
A, WELL DATA
Well type ~-~
Log present (Y/N)
Total depth
Sanitary seal (WN)
Date completed
Cased to / ~:~
FROM WELL LOG
If A, B, or C, attach ADEC letter. ADEC water system number
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Date of test
Static water level
Well production
g.p.m.
,Y
7
g.p.m.
WATER SAMPLE RESULTS:
Colifo'rm ~ Nitrate
Date of. sample: (~/~/~ ~/
B. SEPTIC/HOLDING TANK DATA
Date installed it/~.,/~,O Tank size
Foundation cleanout (Y/N)
Date of Pumping ~/~/~ ~
C. ABSORPTION FIELD DATA
Date installed *}/~-/~
Length ~' 7 ~ Width
Effective absorption area ,~"~' 7..-
Date of adequacy test ~/~9 / ~'q
Fluid depth in absorption field before test (in.);
Fluid depth 7~o (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Collected by:
Other bacteria
2.5.
I~,..?~ Number of Compartments .~. Cleanouts (Y/N) .
Depression (Y/N) {'",~,~ High water alarm (Y/N) ~" ~
Pumper ~0 r'~t 1~
Soil rating (g.p.d./ft2 or fte/bdrm)
Gravel thickness below pipe
Monitoring Tube present (Y/N) y
Results (Pass/Fail)
I 7~ System type /~.4..z~ c ~
Total depth I~ ~ ~
, Depression over field (Y/N) ~ !
For__ -'~ .bedrooms
Immediately after J~',,~,gal. water added (in.): <~ C~
Absorption rate = ~' ~7/~'~ ~:) q.p.d.
If yes, give date
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~ 3~ Property line 2,.C~' Absorption field /~
Water main/service line ~e~-~~. Surface water/drainage .>'~/~;:) Wells on adjacent lots
52.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~' I ~) Building foundation ,~) Water main/service line
Surface water ~ ~t ~rc> Driveway, parking/vehicle storage area "--
Curtain drain -1~. /~ ~ O Wells on adjacent lots ~)d~
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records that the above system, s are
in conformance with MOA HAA guidelines in effect on this date.
Engineer's Name i'., .~U~/~ ~
HAA Fee $ c~-~'-'~ ' ~
Date of Payment ~
Receipt Number ~ ~/~ ~.,~ ,~
72-026 (Rev. 3/96)*
Waiver Fee $
"Date of Payment
Receipt Number
JUNq6-99 09:33 FROM-GTE ENVIRONMENTAL
zt~r~ C T&E Environmenta'$e tv icc. inc.
%313 P.02/03 F-lO?
CT&II Ref.#
Client Name
Project Name/~F
Client Sample ID
Matrix
Ordered By
PWSm
99255400 !
Tobben Spufldand P,E.
Lt 3 Bk 3 Denalt View
L[ 3 Bk 3 Denali View
Di~'i.g Wa~er
S'~ple Remarks:
0
Client PO# Pre-Pa/d Cobs/NO3
Printed Date/Tiltle 06/15/99 11:44
Collected DaTe/Time 06/08t99 12:45
Received Date/Time 06/08/99 I7:55
Technical Director: Stephen C. Ede
PQL
Attowebte Prep Anoly~i~
Jnl~
o
cot/lOOmg
0.500 ~/g
$~18 9222B 06/0~/99 S~W
JUN-1~-99 09:33 FROM-CTE ENVIRONMENTAL 8618301 %813 P.05/03 F-10?
CT&E Environmental Services Inc.
Laboratory Division r, anIi~mlr, lld~IIIIIIIraI,,I,~dl~,~drI~l'ta~
200 W Pormr Drive
Drinking Water Analysis Report for Total Coliform Bacteria,~,~"or"~",~soT} s~-~ ^~ 99~s.~6os
~AD INSTRUCTIONS ON ~YE~E SIDE BEFO~ COLLECTING SAMPLE Faa: (907) 861-5301
MUST B~ COMP[ETED BY'~ATER SUPPLIER .... TO BE cOMPLeTED g~"'LABO~TO'~Y
PUBLIC WATER SYSTEM I.D, n
PRIVATE WATER SYSTEM
[t Senn R~s.tt$ . [~ ~.n# InVOice
C onla,,g ~
"Fan Npmber
I~ .qend Results ~ -~nd It, vote*
Month Day 5/edt
SAM?~ ! IYPE.
R ;urine gl Treated Water
Repeat Sample (for routine ~am.ple ~ Untreated Water
~vith tab rcf. fla.
Special Purpose
Tim~ Collected
Coll~eI~ By
Analysis shows [h,$ Water SAMPLE to be
Sat~shc;ory
UnsanSt~¢;ory
r~ Sample over 30 hours old, resut~ may
be unrehabl~
Sample too long ;n mnsu; sample should
not be o~er 48 hours old at exammanon
to indicate rehable result, Please send
new sample mlsD~eJaI deli~ru mail,
Date
Time Received
Analysis Began
Analytical Method: ~ Membrane Filter
'~ 'MMO-MUG
* Number ofcotome~lO0
EtEIE 554
t k'bk~ Jun
SAMPLE LOCATION
- Phone{l
P tr, a~¢
BACTERIOLOGICAL WATER ANALYSIS RECORD
Cti~nt notified of unsadsfaetory results:
MMO-MUG gsult: Total Coliform
Membrane Filter: Direct Coua~
Yenfieation: LTB
BGB
Da;¢ 'Teme
Fecal Coliform Confirmation
Final Membralle Fil~t-,..,Results
Call
Caloni~ 100 mi
COLIFIRM~
Collform~lOO mi
OM ~ Om¢r ga,
GENERAL INFORMATION
(a)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
· '~;:;' :' Application Date ,/~-
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions) ~'~. ,
(b) Applicant Name~;'~ Z~/'/~yo/'~ Telephone: Home '~4&"~'~g ~'~:7 Business
Applicant Address ~'~
(c) Applicant, is (ch~(~k. 0ne):'Lending Institution []; Owner/bui~dc;-J~'; Buyer []; Other [] (explain);
(d)
(e)
Lending nstitutip .,n,
Address ' g:¢¢~,~' '~
R~.al Estate'Company and Agent"
Add~e~. _ ~ ~ ~
Telephohe ~' ~:/
Mail the HAA;tO. t~' f~llowing. ,, address:
(f)
Page 1 of 2
TYPE OF RESIDENCE
Single-Family~' Multi-Family [] Other
Number of Bedrooms ~':' ,.',': ,
WATER SUPPLY
Individual Well~' ' Community [] Public []
Note: If community well system, must have written confirmati0'n from the State Department of Environmental Conservation
attesting to the legality and status. ~'
SEWAGE DISPOSAL
Onsitefl~ Public [] Community [] Holding Tank FI
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
72-025 (11/84)
ENGINEERING FIRM PROVIDII' 'NSPECTIONS, ,TESTS, FILE SEARCH, D, , AND INFORMATION
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 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.
DHEP APPROVAL
Approved for
Approved -~
Disapproved
Conditional
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon tl~e representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 (11/84) ::
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description: .~/'.~, ~,Z'
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
NOV $
RECEIVED
WELL DATA
Well Classification ~'.-~"~-~/~'~-"/~' If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) / Date Completed J,'~.~'~'~-"/'~' Yield I~. o ~' .~,,~'~
Total Depth ';/~ / Cased to ,,'//~ / Depth of Grouting
Static Water Level ~/./~'~,.,,~ ..r"u,..~.,~c-¢- Pump Set At .,//~,~/~'
Casing Height Above Ground ,,~' /'' Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) yr Depression Around Wellhead (Y/N) A./
Separation Distances from Well:
To Septic/Holding Tank on Lot ,,,~,~ /~,z · On Adjoining Lots
To Nearest Edge of Absorption Field on Lot.,~o' / ~ ; On Adjoining Lots
To Nearest Public Sewer Line AJ~ To Nearest Public Sewer
Cleanout/Manhote ,,,u',~ To Nearest Sewer Service Line on Lot /t)//~
Water Sample Collected by .,.'/-~,~',~' :'~~ f~ ; Date ,~- ~'~-
Water Sample Test Results .~-,~.~ _.,~_~:~,,~/'"'
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ~ -,~'~
/,
Standpipes (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /"'~
To Property Line ~'-~ /
To Water Main/Service Line Cou]se ..~ ,~,~P~
Size .~,~o ..~,~/
Air-tight Caps (Y/N)
No. of Compartments ~-
Foundation Cleanout (Y/N) /~J
Date Last Pumped /'~o Z~-~'~,,
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field ~/.c~,
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026tl 1/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date installed
Width of Field 3 j
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ~'~'~'
To Building Foundation
L o t
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
y,
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ,,~o /
To Cutbank (if present)
/..d
Comments
D. LIFT STATION
Date Installed ~'/.~'~
Size in Gallons
"Pump On" Level 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 during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify t h at~,~c~ ver~ied, or conformed to ali MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ Date /~ ",~-~'~- ~:'~'
Receipt No. ~ / ~//
o / ment
Page 2 of 2
72-026 (11/84)
October 29, 1986
Mun:i. cipality o.¢ Anc::horage
Depar'tment oT Health & Environmental F'rotectior~
825 "1...." Street
Ancl"lorage, Alaska 9951~Jl
"lugh R,, Bevan F:'.E.
d o x 1 .I..~. 8 ~.~:,
Anchorage, Alaska 995.1. 1
9¢7.....522-1383
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PRC,,TFC~ ,ff;N
N0V 5 1986
Gentlemer~ :
During t. he period from October.~..°°.~~ to Oc'hober .... ,c 1986 we performed r'esearc:h,
site :i. nwestigatic~ns, well ¥].ow testing and absorpt.:J, on .field tes'hirl.q, pursuant to
Health AUthc,,-:Lty Approval an the abowe re. ferenced lot.
We i::)er,formed a we].], flow test. and .fourld the well production to be 4.¢ + gallons
i::)~1," m:[r~Ltte (i]pm). Th:i.s exc:eeds 'hhe requir'ed E1.'~125 ":' ,,
. .z, gpm -for a ..:, bedroom home We
took a water sample .for Co].i.form analysis and the results were negative.
We performed an adequacy test on the septic system and determined that it
absorbed at a rate o.f: ].[Z~[Z;I.>.'~ gallons per- day (gpd). This exceeds the 45¢J gpd
required .for a .5 bedroom home. The sept:lc t. ank was pumped and the w:~lume
veri.Fied to be 1[?J¢¢ gallons.
'1'o our I<nowledge ali. o.f the :i.n.format:[on reques'hed on the IaAA C]heck].ist and
Appl:J. cat:i, or'l has been assembled., We are subm:Lttir'lg this data to you for your
review,, F:'le. ase contact us if we can provide any additional in.format:Lc~n.
Sincerely,
I",lugh R. Bevan F'.I.:.{,,
Attachments ,:
HAA Appl :J. cation
FIAA Check 1 :i. s'l:
Sewer As...,.bu:i It
Or:i. ginal Soils Invest:i. gation
Wel 1 Log
Total Col:i..form Analysis
Sept::i.c Tank Pump:Lng receipt
C: C D a n E r i (::: I-:: S C) lq
NORTHERN TESTING LABORATORIES, INC.
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY CLIENT
PRIVATE WATER SYSTEM
Mailing Addrelll.
City State Zip Code
SAMPLE DATE: /'~, Z',;Z ~*& Phone -~:~'= '-,/-~
MO, Day Year
Purchase Order No.
SAMPLE TYPE:
/~' Routine
[] Special Purpose
I~ Check Sample (for original contaminated
sample with lab reference no.
Treated Water
~x Untreated Water
Sample Time
No. Location Collected Collected by
2
4,~Laboratoe~f Ref. No.
3
4
5
6
7
8
9
10
Signature of Representative
','~', ' ,o~o Fo. I'~/'
TO BE COMPLETED BY LABORATORY
Received at: '~Anch. [] Fbks.
Date Received
Time Received _,
/
Next Sample Due
COMMENTS:
SATISFACTORY
UNSAT,S~ACTORY U
RESAMPLE R
OTHER BACTERIA OB
TOO NUMEROUS TNTC
TO COUNT
Direct Verification Final
Count LSB BGfl Result*
0 - · C:'
Comm~ta
*~ Tyt~R~iform Colonies per 100 mis.
Date
Time
ISAACS PUMPING SERVICE
(Norm TIbbetts Owner)
6215 Quinhagak Street
ANCHORAGE, ALASKA 99507
Phone 563-3300
2
- INSPECTION APPOINTMENTS
TIME TIME TIE4E
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR A ,
MUNICIi~_J~:~NCHORAOE
MUNICIPALITY OF ANCHORAGE I~NVIRONMEN1'/~L
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION CEI [
825 L Street-Ancho,a,., Alaska 99501 JAN 2 7 ~gS'i
Telephone264-4720 RE ___ D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
PI RECTIONS: Complete all parts on page 1. Incomplete reques~ will not be proc~sed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
'MAILING ADQR S -
PROPERTY RESIDENT (1~ different ~om ~bovel PHONE
2, BUYE~ PHONE
MAI LIN G ADDR ESS
3. LENDING INSTITUTION PHONE
MAI LIN~ ADDRESS
4, REALTOR/AGENT I PHONE
MAI LING ADD~ ESS
5. LEGAL DESCRIPTION
;TREET LOCATION
6. TYPE OF RESIDENCE ~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
[] Two [] Five
~ Three [] Six
[] Other
7. WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* 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
INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTI LITY
Connection Verified
3, SEWAGE DISPOSAL SYSTEM
[] I N DIVI DUAL/ON -SITE
I--iPUBLIC UTI LITY
Connection Verified
[]Septic Tank or []Holding Tank
Size: I 64)0 If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AR EA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OF BEDROOMS
[] ONE
[] TWO
[] THREE [] FIVE
[] FOUR [] SiX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
MANUFACTURER
MATERIAL
Septic/Holding Tank ~Absorptio~ Area
I
Sewer Line
[] OTHER
INearest Lot Line
5. COMMENTS
DATE
~P~ ROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVEDIBY ~--~'~ ~
72-010 (Rev. 6/79)
CHEMICAL & G£ _,,LOGICAL LABORATORIES ~ ALASKA, INC.
TELEPHONE (907)-279.4014 ANCHORAGE INDUSTRIAL CENTER
274-3364 5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO.
Water System Name
Phone No.
Mailing Address
City
State Zip Code
Mo. Day Year
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
I
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[] Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
[] Membrane Filter
Lab Ref. No. Result* Analyst
I I-T-)
I
I F-[-I
*No. of colomes/100 mi. or No of Posibve portions.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (b)
Rev. 1978
BACTERIOLOGICAL WATER ANALYSIS RECORD
Date CollecteO Source
No.
Presumptive Z0ml 10mi /0mi 10mi 10mi Z.0ml 0.1mi
24 Hours
48 Hours
Confirmatory
24 Hours
48 Hours
EMB
Multiple Tube Report:
Membrane Filter: Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By
Broth 24 hours:
Broth 48 hours:
10mi Tubes Positive/Total 10mi Portions
Collform/100ml
BGB
Dete
Collform/100ml
Time: a.m.
p.m.