HomeMy WebLinkAboutEAGLEBROOK BLK 2 LT 1
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
POBox 1SV65O 47OOElmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
Permit Number: OSP201175
Work Type: Septic Upgrade
Tax Code Number: 01712118000
Site Legal Address: EAGLE8ROC)KBLK 2 L 1 G:3138
Site Mailing Address: 6450ANDOVER C{R.Anchorage
Owner: SCHVVALENBERGPATRICIA K
Design Engineer: GARNESSENGINEERING GROUP LTD
This permit isfor the construction of:
2 Disposal Field Z Septic Tank Holding Tank EJ Privy
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
S/23/2U2O
8/23/2U21
M Private Well El Water Storage
All construction shall boinaccordance with:
1. The attached approved design.
2. All requirements specified inAnchorage Municipal code Chapters 15.SSand 15.85and the State ofAlaska
Wastewater Disposal Regulations (1 8AAC72) and Drinking Water Regulations (I 8AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall beeither:
a. Opened and Closed nnthe same day, or
b. Covered, sealed, and heated hoprevent freezing
Special Provisions: A flow diverter valve is required after the post tank double cleanouts.
Received
Issued By, Doha:
4
MUNICIPALITY OF ANCHORAGE
�� On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201175
Work Type: Septic Upgrade
Tax Code Number: 01712118000
Site Legal Address: EAGLEBROOK BLK 2 LT 1 G:3138
Site Mailing Address: 6450 ANDOVER CIR, Anchorage
Owner: SCHWALENBERG PATRICIA K
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date:
nr
o S�
Q
Department
Lot Size in Sq Ft:
Total Bedrooms:
6/23/2020
6/23/2021
54763
❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions: A flow diverter valve is required after the post tank double cleanouts.
Received By:
Date:
Issued By: Ll/ Date: 6/7Z ZC�
4
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Fax: 907- 343-7997
On -Site Water & Wastewater Program
Mayor Ethan Berkowitz
On -Site SewerMell Permit Application
JrQS —�i�ilo•Z5
Waiver Fees:
For A Single Family Dwelling
1-�['-b
Date of Payment:
Parcel I.D. 017-121-18
2396
Receipt Number:
Property owner(s) PATTY SCHWALENBERG
Day phone 907-301-1474
Waiver No.
Mailing address 6450 ANDOVER CIRCLE *ANCHORAGE, AK 99516
Site address 6450 ANDOVER CIRCLE *ANCHORAGE, AK 99516
Legal description (Sub'd, Block & Lot) EAGLEBROOK; BLOCK 2, LOT 1
Legal description (Township, Section & Range)
Lot Size Sq. Ft. Number of Bedrooms
4
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DEWELLING:
(®all that apply) Initial ❑
Single Family (SF)
Absorption Field ® Upgrade
(w/wo ADU)
Septic Tank ®
Duplex (D)
El❑
Renewal
Holding Tank ❑
Multiple Dwellings
❑
Privy ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR:
N/A
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal codes.
GARNESS ENGINEERING GROUP, Ltd. i
(Signature of property owner or authorized agent)
Permit/Rush Fees:
JrQS —�i�ilo•Z5
Waiver Fees:
Date of Payment:
1-�['-b
Date of Payment:
Receipt Number:
2396
Receipt Number:
Permit No.
Waiver No.
(Rev. 01/11)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201175, Deb Wockenfuss, 06/23/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201175, Deb Wockenfuss, 06/23/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201175, Deb Wockenfuss, 06/23/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201175, Deb Wockenfuss, 06/23/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201175, Deb Wockenfuss, 06/23/20
o/1
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MUNiCiPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENWRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEER~NG D~VIS~ON
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-S~TE SEWAGE DISPOSAL SYSTEM AND/OR WELL ~NSPECTION REPORT
MAILINC~ADDRESS
PHONE J~ NEW
LEGAL DESCRIPTION
LOCATION
Well
DISTANCE TO:
~Z~ ~ Manufacturer~
~ ~ Liq. capacity ~'~alJ~ns
, ................
DISTANCE TO: We
Absorption area~ /_ _
Inside length
Dwe ng
DISTANCE TO: lWellR 8~ I'A
No. oflines / [t_ength of eachlin~¢]]
Top of tile to finish gradei~,5._ ! ~. ~..~ /
Length Width
Foundation
Total length of lines~,~ ~
Material beneath tile
Depth
Dwelling
Materialff~ /
Width
Material
Nearest lot line
'Trench width
~inches
NO, OF BEDROOMS4
PERM,T
No. of compartments
Liquid depth
PERMIT NO,
Liquid capacity in gallons
PERMIT
Distance between lines
Total effective absorption area
PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot line jPERMIT NO.
/
Building foundation Sewer line Septic tank lAbsorption area(s)
DISTANCE
TO:
1
OTHER
"~IPE MATERIALS ~.
d,.'
INSTALLER
REMARKS
APPROVED DATE
LEGAl_
77-013 (R~v 317RI
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ GeophysicalSurveys
LOCATION OF WELL (Please complete either Ia, lb or lc,)
~:~.--]Borough Subdlvieion Lot" Block []
&~.~!,~ !9, ~ ~,,~- ~l ~i I ~ I J--of--of--of--
DI~TANCE AND DIRECTIO~ FROM ROAD INTERSECTIONS
Street Address and Areo of Well Location
WELL LOG
Moferiol Type
Feet Below
Top Bottom
16, WATER WELL CONTRACTOR'S CERTIFICATION:
Drilling PermH No,
A,D.L. NO.
Section No.
Township N[~ Range EEl ~erldlan
sE] wE]
3. OWNER OF WELL:
4. WELL DEPTH: (final) 5. DATE OF COMPLETION
e. [:~:] Cable tool C] I~otory J~ Driven E3Dug
[3 Auger J~ dotted [::]Bored [:::]Other:
7. USE: ~ Domectle [] Public Supply [] Industry
L~ Test Well [] Other:
CASING: [] Threaded .~ Welded
die~._ ~ in. to i 'I~: ft. Depth Weight
diem. in. fo ~t, Deplh Stickup__
lbs,/ff.
ft.
ft.
~0, STATIC WATER LEVEL: i ~:' ff. ~. / '~.
D(3?O
~ Above or [~ BOIOW [ond surface
Equiprnsn? u~ed: ~-~,~
Il. PUMPING LEVEL below lend surface end YIELD
~:~ pumping
=,~_, f t. <~fter ...... hrs.
--.f? after ..... hrs. pumping ~-
lC.GROUTING Woll Grouted: :~ Ye~ Lr~ NO
Malarial: C'_] Heat Cement [~ Other:
IS. PUMP: (if ovailuble) HP
Length of Drop Pipe ft. capacity
15. Water Temperature __o C} F [] C
This We t was dill/led uoder my jurisdiction and this report is true to the best of my knowtedge and belief;
Registered Business Nome Conlroct License Number
Form OZ-WWR {Il/BI) Copy Distribution; WHITE-Stole DSGS, PINK~DHlior, CANARY-Customer
~llUv~um: [.ro~
Alluvium ~ grey
MUNICIPALITY OF ANCHORAGE
Department f Health and Environmenta' Protection
825 ~ Street, Anchorage~ AKo ~9501 /~
264-4720
* * * HANDWRITTEN PERMIT * * *
Permit 9 WELL AND/OR ON-SITE SEWER PERMIT
Location: Phone Number:
Legal Description: Lot Size:
Type of Soil Absorption System Is: F
Trench: ~ainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sqoft/br)
The Required Size of the Soil Absorption System Is:
DEPTH /~- LENGTH __~_~'~ GRAVEL DEPTH _~ WIDTH
The length dimension is the length(in feet) of the trench or drainfieldo 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 = ~/~3~C/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 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 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 31~ 1 9 ~ 3 * * *
I certify that:
(1) 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 the on-site sewer system may require enlargement if
the residence is ~emodpled to include more that ~bedrooms.
SWP/024 (1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENWRONMENTAL PROTECTION
825 L. Street. Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
1
2
3
SLOPE
PERFORMED:
SITE PLAN
9
10
11
12
13
14-
'15-
17
18
,AS GROUND WATER
WHAT
~L~TH ?
[j
Gross
Reading Date Time L/~
19
Depth to
Water
Net
Drop
20
(minutes/inch)
FT
72-008 (6/79)
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.# .J~--~ - \ '~ / ~\~ ~_-'_..T~__ _ HAA#
GENERAL INFORIVlATION
Complete legal description
Lot 1 ~
Block 2~ Eagle brook Subdivision
Location (site address or directions) 6450 Andover Dr'i ve
Anchorages AK
Pr, operty owner Vernon Shel ton Day phone 345-3191
Mailing address ' ' 6450 Andover Drive, Anchorages AK 99516
Lending agency
Mailing address
Day phone
Agent
Address__
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUi~/IBER OF BEDROOI~IS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
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.
72-0251Rev. 1/91) Front MOA
STATEI~IENT 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.
Nameof Firm Oi Ifilian Engineer'ing, Inc. Phone 3?6-3005
Address 5751 Mayflower~ ...... Ct . , Wasilla, AK 99654-?880
Engineer's signature ~i~-~' '~~,~_ ¢"'~ Date 7/6/92
. G P.E~
DHHS SIGNATURE
//~__. Approved for
Disapproved.
Conditional approval for
bedrooms.
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~}25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH ALJTHOR~TY APPROVAL CHECKLIST
Legal Description: Lot 1, Block :2 ~zt21ebroo~ Parcel I.D.
WELL DATA
Well type }~rivate
Log present (Y/N) Y
Total depth 112 feet
Sanitary seal (Y/N) %'
If A, B, or C, attach ADEC letter.
Date corn pleted
Cased to 112 feet
ADEC water system number
7/7/83 Driller Foss Drilling
Casing height 16 inches
Wires properly protected (Y/N) Y
FROM WELL LOG
Date of test 7/2Z63
Static water level 15 feet
Well flow 10
Pump level 110 feet
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
100 fto +
100 ft. +
g,p.m.
AT ~NSPECT~ON
6/30/92
12 ft; 10 in.
4.8 g.~
110 feet
; On adjacent lots
100 fto 4
; On adjacent lots ___100 ft. +
Public sewer manhole/cleanout NA
Petroleum tank
WATER SAMPLE RESULTS:
Coliform _.__OJlO0 ml
Date of sample:
SEPTiC~HOLDiNG TANK DATA
Date installed 6/10/83
Cleanouts (Y/N) Y
High water alarm (Y/N)
Date of pu'mping
3/14/92
6/30/92
Other bacteria
Kent .C~eet s
Nitrate ~ (0.10 my/l/l)
Co{}ected by:
Tank raze 1. Compartments 2
Foundation cleanout (Y/N) 'Y Depression (Y/N)
NA Alarm tested (Y/N) NA
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 100 ft o +
To property line 70 ft.
Surface water/drainage
On adjacent lots . 100 ft o + Foundation 18 ft o
Absorption field 8 ft. Water main/service line NA
100 ft. +
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. L~FT STATION
Date installed
Size in gallons
Vent (Y/N) __ "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Well on lot
ABSOF~PT~ON F~ELD DATA
Date installed 6/10/83
Length .5,3 ft. Width 5 £t o
Total absorption area __457 sf
Depression over field (Y/N)
Results (pass/fail) Pass
Peroxide treatment (past 12 months) (Y/N) __
On adjacent lots
__ Soil rating 85 sq.£t./BR
Surface water
System typeDee]P trench
Gravelthickness 3 £t. Total depth
__ Cleanouts present (Y/N) ¥
Date of adequacy test 6/30/92
for 4
~f yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots 100 ft. + Propertyline 26 ft.
__ 30 ft. To existing or abandoned system on lot
Cutbank ,, NA Water main/service line
Driveway, parking/vehicle storage area 10 £t
WeHonlot 100 [to +
To building foundation
On adjacent lots 3_0 ;f_t.. +
Surface water 100 ft. +
Curtain drain iA&
ENGINEER'S CERTiFiCATiON
7.5 £to
bedrooms
date of this inspection,
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect,
Engineer's Name Robert E. Gil/£ili~, P. E.
Date July 6, 19_~92
HAA Fee $ 7 ~7 '-"g-~ Waiver Fee: $
Date of Payment ~_ ~ ~" c~' ~ ~,~,_~5 Date of Payment
Receipt Number ~ Receipt Number
GILFILIAN ENGINEERING, INC.
5751 MAYFLOWER COURT
WASILLA, Al( 99654-7880
(907) 376-3005 FAX: 373-5686
WELL FLOW TEST DATA SHEET
From Well Log X
Well Depth: 112' X
Static Level: 12' 10" 0
Physical / Sanitary Features:
Sanitary Seal X Cap__
Casing Above Ground Surface: 16"
Pump Wire in Conduit X
Surface Drainage Away from Well:
Good X Poor
From Probing Measurements 0
Well Pump Specs:
Water Supply Line:
Size:
Drop Pipe:
Size:
Depth to Pitless Adapter:
Storage / Pressure Tanks:
Type:
Type:
Time Time Interval Pumping Cumm. Static Comments
Minutes Rate Gal. Level
10:55 5.5 12'10"
11:15 20 5.5 110 41 '10"
11:30 15 5.5 192.5 48'10"
11:55 25 5 317.5 58'1~"
12:25 30 4.6 455.5 59'5"
12:55 30 5 605.5 60'10¼"
13:15 20 4.6 697.5 58'0"
13:55 40 4.6 881.5 59'3"
14:25 30 4.6 1019.5 59'7"
14:55 30 4.6 1157.5 57'8~"
Minutes Average = Gallons Asl
240 TOTALS 4.8 1157.5 36'10"
Time Time interval Static ar Comments
Minutes Level
15:05 10 39'9"
LOCATION: Lot 1, Block 2, Ea.qlebrook, Anchorage, AK
CLIENT: Vernon Shelton
PROJECT NO: 192063
DATE: 06/30/92
BY: Kent Sheets
WELLFLOW.G El
Gilfilian IEngine ring. Inc.
ADEQUACY TEST FORM
Lot 1, Block 27 5aglebrook Subdivision
L0CAT~O~: --
DATE: -~- .6/3Q'/,92
SEPTIC TANK SIZE:, 1250 ,qal.
TYPE OF $.A. So. Tre~nch
pKOJECT ~0.:
time
11:05
11:20
5.5
ql :40 5
12:00 f 5
2:20 4,6
12:35 5
END FLO~
14:30 80
15:00 ~ UO
totals t 616.5
volume liq o 1~1
82.5 48"
182.5 49~"
.~82.5 49½"
374.5 49½"
449.5 49½"
524.5 49½"
616.5 49½"
ite Recovery 48"
49½"
level
20"
20"
22"
23½"
25"
26"
26¼"
26½"
4
HO. OF BEDROOMS:
NO. OF BATIIROOHSo
CALCo PEAK LOAD*:_ 300G~
CALC. PEAK TIME**:.
CALCo PEAK FLOW KATE: 6
HEAS~ AVE. FLOW RATE: 5
comments
~k= 14"
0" Ran v, ater into first
S .T .C .0.
'Estirmte 54% Recovery
lwith 1.8 Hours
*peak load : 75 gallons x (~ bedrooms)
**peak time : 25 minutes x (# bedrooms % ~ bathrooms)
Recorrmend &op rova I
MAT-SU TEST LAB
Soils -- Concrete -- Water -- Asphalt
Field and Laboratory. Testing Services
P.O. Box 871868 o Wasilla, Alaska 99687 o (907) 376-3005 FAX 373-5686
DRINKING WATER ANALYSIS FOR TOTAL COLIFORM BACTERIA
APPLICANT INFORMATION
Name: Vet ~ ,~9
Mailing Address: ~yS--//9 ,An docent'
Sample Information
Legal Description:
Date Collected ~3
Sample Type: /N/Routine
Phone:
State I.D. No.:
Time Collected:~' l~'~rF-~ Collected By: /~'~'
Repeat Sample # Treated Untreated
Fecal
THIS sEcTION:TO'BE COMPLETED BY LAR
ANALYSIS RESULTS
Satisfactory
Unsatisfactory
Sample .Rejected: Over 48 Hou rs in Transit __ TNTC: Colonies Too Numerous to Count
__ Confluent Growth RECOMMEND RESAMPLE WITHIN 24 HOURS
Final Membrane Filter~Results: ~'.Coliform Colonies/100.mrL' ~[~.
DateAnaysisCompeted: ~'~-:'1~:~__ ReportodBy: (~.~_
MICROBIOLOGY LABORATORY RECORD-COLIFORM ANALYSIS
Date Received: g-~(,,"~-2- Time Received: ff;O~_J Lab Number:,
Date Test Started: ~~-_ Time Test Started: ( ~C~9 _ Analyst:
TEST METHOD TEST RESULTS DATE/TIME/ANALYST
Direct Count: ~ Colonies/100 mi '~_~~}
Membrane Filter , '-
(MF) Verification: LTB__ BGB____ EC
Tube #
Presumptive (LTB) 24 Hr,
48 Hr.
Tube #
Confirmatory 24 Hr,
(BGB) 48 Hr,
Tube #
Fecal (EC)
24 Hr,
REFER TO BACK SIDE FOR INSTRUCTIONS
MUN~CIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES ~ /
CERTIFICATE OF INSPECTION fOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL.)
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner E¢'~'/~/'(e" R¢[oca/z,~,, Telephone: Home N, 4- Business
Mailing Address ~0 ~, ~c~ O~% E4,~., ~IL
(c) Lending Institution ~ ~ ~ ~ ( ~ ~ Telephone
Mailing Address ~O/ ~. ~ ~ ~,~ ~, ~_~~
(d) Real Estate Company and Agent ~.~(f~ ~ ~¢ ¢
Address .... ~fO0 ~1_ R~ j ~o~_~ ~/~
Telephone ~ - O~O /
(e) Mail the HAA to the followine address: or: Check he~, if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family []
Number of Bedrooms
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [] 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.
Page 1 of 2 72-025 fRev 8/86/ Front
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~/tUN~CIPAL~TY OF AHCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEEiRUARY 1984
2844744
Legal Description:
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
JLJN 5 1987
RECEIVED
WELL DATA
Well Classification Pr-[~, ~/' ¢
Well Log Present (Y/N) ~
Total Depth __f ! 8 ' Cased to __
Static Water Level ~/~-E"
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
-lo Septic/Holding 'lank on Lot
If A, B, C, D.E.C. Approved (Y/N) N, A.
Date Completed 7/~/ ~ Yield
Depth of Grouting /~,
Pump Set At /X~ ~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) N
; On Adjoining Lots 7~ 1'¢'¢ '
To Nearest Edge of Absorption Field on Lot ~ 8¢ ' ; On Adjoining Lots
To Nearest Public Sewer Line ___~,~_ ...... To Nearest Public Sewer
Cleanout/Manhole N, ~, To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample 'lest Results
Comments
B. SEPTiC/HOLDiNG TANK DATA
Date Installed ff Itc,~'
Standpipes (Y/N) _ '¢' .
Depression over Tank (Y/N)
Purnping/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 N, ,4.
Course ';;> fO O
Size l 83"¢ ~, ~l No. of Compartments ~ d
Air-tight Caps (Y/N) '¢ Foundation Cleanout (Y/N) __~*
Date Last Pumped ~'¢ [ ['//~¢¢~
N,/~. __ ;for ~,A,
N,/~. Temporary Holding Tank Permit (Y/N) hi, ,4 .....
To Building Foundation /~¢ '
To Disposal Field ¢ '
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72 026 /Rf'v ~'86', Fronl
C. A~SO~PT~O~ F~ELD DATA
Soils Rating in Absorption Strata
Date Installed ¢ (Io / O$
Width of Field __¢'0 '
Square Feet of Absorption Area ¥,¢ 7
Depression over Field (Y/N) N
Results of Last Adequacy Test A~¢~¢,.~¢~/~
Separation Distance from Absorption Field:
To Water-Supply Well / ~¢'
To Building Foundation ;~ ¢
Lot ~, ~.
To Water Main/Service Line N,/~-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
/$ ¢4¢-,~ Type of System Design
Length of Field ,~?'
Depth of Field _ ~-.
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~ d' '
To Existing or Abandoned System on
; On Adjoining Lots '~ ~'o'
To Cutbank (if present) ¢4, .4.
D. LiFT STATION ¢4, .4,
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
certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Date ~ /~( ~ 7
MOA No.
Signed ~"~/~,~,~
Company F(c~P/¢/'
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72 026fRev 8/86) Back
Engineer's Seal
EiUN~C~PAUTY OF ANCHORAGE
DEPART~iENT
OF
HEALTH
AND
ENVIRONMENTAL
PROTECTION
D~V~SION OF ENV~RONi~ENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORi~AT~ON
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name .~'_¢_¢'~:~_ ,,~t"' ~J Telephone: Home ..~_ZA'~_"~_¢ Business
Applicant Address ¢~¢,;,¢~ z~_¢4¢¢~''¢r ~)~¢¢ 2_ ~¢-~t~¢_~_¢~ /~'~ ~¢,,,¢'J¢
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d)
(e)
(f)
Lending Institution_~'¢~(¢
Address ~O ~(~
Real Estate Company and Agent
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family ~ Multi-ad)J2
Number of Bedrooms ~.,/
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department o~ Environmental Conservation
attesting to the legality and status.
Page 1 of 2
SEWAGE DISPOSAL
Onsite [] 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.
72-025 (11/84)
ENGINEERING FIRM PROVIDING ~NSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, ~ 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 end 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 ~(~..~ ~c&~"~c~! ~ ~ Telephone ~ ~" ~3~
Address _~_ ~0 ~ ~ ~ ~(~o¢~ ~ ~(~
Date I~ ~ ¢~ / ~
Approved_ ~¢ bedrooms b,~¢ 'Disapproved
Terms of Conditional Approval
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based soldy upon the representations given in pemgraph 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.
Page 2 of 2
Well Classification
MUN~CIPAL~TY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHEC~(L~$T- FEBRUARY 1984
264-4720
Legal Description: ~0¢' .~ 6 ('~c~' ~'~
If A, B, C, D.E.C. Approved (Y/N) __~, ~-
Well Log Present (Y/N)
Total Depth __~-~ ~"
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot _
To Nearest Public Sewer Line
Cleanout/Manhole ~ ,~,
Water Sample Collected by
Water Sample Test Results
Comments
Date Completed '~/~/~.,,~ Yield
Cased to ._~ ~ ~, ~ Depth of Grouting _~
Pump Set At ___~_¢~
Sanitary Seal on Casing (Y/N) __~¢-_
Depression Around Wellhead (Y/N)
; On Adjoining Lots
~.[¢~ . ; On Adjoining Lots
1''o Nearest Public Sewer
To Nearest Sewer Service Line on
~¢~' · ; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~¢'~'¢¢~--~--__ Size t ~'¢'¢ No. of Compartments ~
Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~' Foundation Cleanout (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
Course . ..~, ,~¢-0'
Date Last Pumped ~O/'¢ '~ ~_ ~__~'~__ ....
Temporary Holding Tank Permit (Y/N) ~*~o
.... To Building Foundation ~¢"
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ___~/¢ ~'O ¢¢ ~'
Width of Field ~O '°
Square Feet of Absorption Area ~A¢_7
Depression over Field (Y/N) __ ~
Results of Last Adequacy Test .. ~¢¢~'¢
Separation Distance from Absorption Field:
To Water-Supply Well ~ ~'~'
To Building Foundation 3¢ ~
Lot ~0 ~.
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test ..
To Property Line ~¢ ¢
To Existing or Abandoned System on
; On Adjoining Lots .... ~_ ;~¢ ~
To Water Main/Service Line ~, ~.
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Cutbank (if present)
D. L~FT 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 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'~ ~ ~ Date
Company __~_(~_~ 7~r.~ .,¢~.¢~-, MOA No.
ReceiptNo. /O O ~..._.~O~ /
Date of Payment _~/_¢/20~
Amount: $ ~,~ ~
Page 2 of 2
72-026 (11/84)
Engineer's Seal
APPL (
P,operty Owner
Ma'Hng Address
Buyer
NT F LLS OUT UPPER NA " ONLY
ZipCode Z'2' '"/i'
Phone
Address
Lending Institution
Address
Realty Co. & Agent
Address
Zip Code
Zip Code
Zip Code
Phone
Phone
Type of Residence
~ gle Family
~ Multiple Family No. of Bedrooms
~ Other
Water Supply
,~hl'8'ividual ATTACH WELL LOG. A well log is required for a~l wells drilled since June 1975.
[~ Community For wells drilled prior to that date, give well depth (attach ~og if available).
F~ Public Utility
Sewer Disposal : .. /.~, ¢>
[Z~¢f*~¢ivldual Year Individual Installed: ~/~ ~-~
[] Public Utility When Connected to Public Utility: _
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
PP--ROVE~ BEDROOMS
I( ) DISAPPROVED
'CONDFFIONS OF APPROVAL
T
Soils Rating I Date Sewer Installed
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tenk Size