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"'" 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 1PHONE [] NEW
MAILING ADDRESS
LEGAL DESCRIPTION - ' · ~ I ....
LOCATION ' - ' I NC. OF BEDROOMS
Well ~ AbsorPtion area Dwelling PERMIT NO.
DISTANCE TO:
~ ~ Manufacturer Material No. of compartments
Liq. capacitv in 0allons Inside length Width Liquid depth
:
~ ~ DISTANCE TO: Well Dwellin0 PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in 0allons
Q: ~ DISTANCE TO: Well/&t, Foun~o~ Nearest lot ,ine,~ '+ PERMIT ~O~O
~ ~ bet ~/~es
~ Z ~ No. of lines ~ Length of each line Total length of lines Trench widt~
~ ~ Top of e to finis~flrade Matorial boneath tile Total effective abs~r~o~aroa
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~ / Depth Driller Distance to lot line PERMIT NO.
m Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
b3o34 ~
sOl L TEST ~ATI NG
INSTALLER
~ ~.' ~,.,
, ,_,.-
f ~. ~ Ler~ I C. Reid Jr~~,.,..4/ .,
'. ....... ,,. ,
,, ........
, , ,
72-013 (Rev. '3/78)
:~ T Iii;; ~ .::::,.:::, L. ~::. ,./ ',',
::' P L. I C A hl T ',~
) D F.'. E S S ~',
)NTACT F'HC'.,NE ,:
CD IP,,.II ....... S:3; ][: 'T' IEE
SOl LS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
1
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COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264~t720
SOILS LOG - PERCOLATION TEST
DATE PERFORMED:
SLOPE SITE PLAN
PERCOLATION
TEST ~/
Convln
CE-5283
WAS GROUND WATER /qo ~
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
S': lO o O. 7 o
~/7/~$ s: ~o ~o ~.# o, ~
PERCOLATION RATE /4~./7 (minutes/inch)
TEST RUN ~E~EEN 4.¢' FT AND ~' ~T
PERFORMED BY:
LAUI~ A. 5EELE-Y'
f
CERTIFIED BY DATE:
72-008 (6/79)
GRE ANCHORAGE AREA
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSP~ECTION~ REPORT O__~N-__SI_TE SEW__AG_E DISPOSAL SYSTEM
LOC ATI ON
SEPTIC TANK:
DISTANCE
FROM WELL
INSIDE LENGTH.
MANUFACTURER ~
INSIDE WIDTH
MATERIAL
NUMBER OF
COMPARTMENTS
LIQUID DEPTH
LIQUID CAPACITY/~ GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELLj~fi~ FOUNDATION /~ ~
NUMBER OF LINES J/ DISTANCE BETWEEN LINES
ABSORPTION AREA q[O
NEAREST LOT LINE /O r~z''- TOTAL LENGTH
OF LINES ~~Z'!
//~///~ TRENCH WIDTH~' N TOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE ~ t
/'~ / DEPTH OF FILTER /
MATERIAL BENEATH TILE /~? ~ ABOVE TILE /-7/ IN.
WELL:
TYPE
CONSTRUCTION
DEPTH DISTANCE FROM:
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION___ LOT LINE__ SEWER LINE__, TANK , SYSTEM
CESSPOOL
OTHER SOURCES
APPROVED
DISAPPROVED
REMARKS
DISTANCES:
INSTALLED BY: ~ ~,
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
DIAG~ (3~"' YSTEM
DATE
Form LQ-032
GRea ANCHORAGe ARea BOF ~ ·
DEPARTMENT OF' ENVIRONMENTAL QUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
SEWAGE DISPOSAL SYSTEM'~'-' APPLICATION AND PERMIT
INSTALLATION OF: SEPTIC TANK ~'"'"'~'
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
SOIL TEST RESULTS t~
SEEPAGE PIT
L-"'"'~' DRAIN FIELD OTHER
TO BE INSTALLED BY
NOI'E~ 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.
SEPTIC TANK SIZE
TYPE.~
SEEPAGE AREA SIZE TYPE
MINIMUM DISTANCES, REQUIREMENTS DIAGRAM OF SYSTEM
ALSO CONSIDER AREA WELLS.
, DRAIN FIELD
0 ~' , DRAIN FIELD
SEEPAGE PIT /0d ('
/0C)[ DRAIN FIELD
(
FOUNDATION TO SEPTIC TANK ~
FOUNDATION TO SEEPAGE PIT /O
SEPTIC TANK TO SEEPAGE PIT WALL /~
SEPTIC TANK . SEEPAGE PiT
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK ~l{~
DRAIN FIELD
WATER MAIN TO SEPTIC TANK / ~
DRAIN FIELD
SEPTIC TANK, ~ ., SEEPAGE PIT
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
~ , LICENSED DESIGNER
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM ISIN ACCORDANCE WITH SAID CODE.
DATE APPLICANT'S SIGNATURE . . ,-
FORM NO. LQ-01 6
. SOII~S I,O(; - PEROI,ATION TEST
Performed for ']O/,v~' ~.~,1~ $ .
Th~s form reports: So,Is log ~ " Percolation
.~_~.~EATER ANCtlORAGL AREA UOROUt._~__~
Department of [nvironmental-Quolity
3330 "C" Street
Anchorage, Alaska 99b03
Depth
Feet
ll =
I4--~o ?
Wa~ ~ g om
I~' "'
Reading
lnd water encountered?
Date Gross Ti me
minute.
_..uete Perfor,:,ed._z~~.
test
if yes,. at whai! depth?
Net Time
instal la~]~,-:- "~-e~ge Pi t_. Drai ,,
Inlet Depth to boctom of pit or
Oepth to Water
Net Orop
Field
trench,
Percolation rate
-Proposed
Depth of
COMMENTS:
EQ- 040 (6/74)
' Certified By:
Date:
~ MUNICIPALITY OF ANCHORAGE '~
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIONs}!
DIVISION OF ENVIRONMENTAL HEALTH
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date /~t o.~
Legal Descril~ti~n ~]'~e lot, block, subdivision, section, township, range)
/..o~ /~' ~ 7 ) 8 (ocl='
Location (address 'Or'directions)
II 05'0 ~o~a,~ A~',o ~ h'e O,.'~
(b) Applicant Name ~o,~z ~;~,~,/?, R¢l~c~';'~-elephone: Home Business
Applicant Address ~. O. J~o~ ~0! ~ Iz/¢~ (n .2 C~w'¢ (4'j ~'~ ltalo'~',a ~ ~ ~'l.,a"~e'''
(c) Applicant is (check one): Lending Institution []; Owner/builder I~; Buyer [] ;. Other [] (explain.);
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] Multi-Family []
Number of Bedrooms ~
Other
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.
4. 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 {11/84)
ENGINEERING FIRM PROVIDIN'~,~NSPECTIONS, TESTS, FILE SEARCH, DA-,~ 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.
Name of Firm
Address I q~'~'~' ~cb~ -~.
Date /"[o.~,
Telephone
Engineer's Seal
6. DHEP APPROVAL
for
Approved
Approved ~ Disapproved~ Conditional
Date
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the 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.
Page 2 of 2
72-025 (11/84)
:~*~V'MUNICIPALITY'~ OF ANCHORAGE (MOA)
~t~'~'~A~' HEALTH AUTHORITY APPROVAL (HAA)
~'~ l S ~''~'~ CHECKLIST- FEBRUARY 1984
264-4744
Legal Description:
WELL DATA
Well Classification.' '~Pr~ ~c~ ~*~
Well Log Present (Y/N)
Total Depth J CO ' Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
If A, B, C, D.E.C. Approved (Y/N)
Date Completed f,(e ~c~w~ Yield
~, ¥0'
Y
Depth of Grouting
Pump Set At ~.~
Sanitary Seal on Casing (Y/N).
Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line N, A.
Cleanout/Manhole N, ~,
Water Sample Collected by "r, ~'.
Water Sample Test Results ~/'~'.~=~z..~o~-v
Comments /.~/~-ff ~,~.~'h ~-~ 3~-~.-o~,~
; On Adjoining Lots ~
· On Adjoining Lots ~'
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
N
(OO '
B. SEPTIC/HOLDING TANK DATA
Date Installed ~0 { ~/"/.5" Size I'~.J"~~! No. of Compartments /
Standpipes (Y/N) Y' Air-tight Caps (Y/N) T' Foundation Cteanout
Depression over Tank (Y/N) N, Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) /Y,A, 'for
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well I ! ~ ~
To Property Line I0 ' +
To Water Main/Service Line
Course 105 '
Comments $ g~,/-'~c ~ k'
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
I0' f
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026 (Rev 8t86~ Front
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Type of System Design 7"r~.-~ ¢~.
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
~'(/?/~:b" Length of Field 2
Depth of Field I
(e~.i/~A~/)Gravel Bed Thickness
(~.'~W~ Standpipes Present (Y/N)
Date of Last Adequacy Test
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 .~ ~1,,..¢ctc..~¢ ~
To Property Line .~ (O'
To Existing or Abandoned System on
; On Adjoining Lots ;~, 3 O'
To Cutbank (if present) /V. A,
1 05''
D. LIFT STATION - H, A.'
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 F(~' ~'~.c/~¢~/' ~u~.r MOA No.
Receipt No. ~--O 0/~ O ~
Date of Payment ~/~--'~ ~
Amount: $ ,,x'd') 0 '
Page 2 of 2
72-026 fRev 8/86) Back
~eeeeeeeeee eeeeeeeeeee~eee~
~ ~ THEODOR~ F. MOORE
.......
Engineer's Seal
GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE,FEDERALALASKATAx ID #9951892-0040440TELEPHONE (907)562-2343
~:e=~ul t.-'Un ~ ts
cc, i/iOOml
(0,i) m?"l
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 ~'~4~(~ ~ I~c~"
GENERAL INFORMATION
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name JYum~' ~'~t/~ ~'(a~'~,l Telephone: Home Business
Applicant Address ~' ~' ~ox ~i~ ~ /
(c) Applicant is (check one): Lending Institution ~ · Owner/builder ~; Buyer ~; Other ~ (explain);
(d) Lending Institution ~ ~m~ ~ Telephone ~/~,~'/_ .
Address [00i ~, ~q ~c~or~ ~ ~
Address ~00 ~r'~({ , ~ ~ ~C~O[~ ~ ~(~ ~7
(f)
Telephone
Mail the HAA to the following address:
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA 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,
Name of Firm /~'('~z/f"~/~ /~c~'(' -~'~'~'~¢d~ Telephone
Address
Date 0/ ./~O / ~'~'
Engineer's Seal
DHEP APPROVAL ~.
Approved for ~~.)bedrooms by
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 the 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.
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description:
MUNICIPALITY OF ANCHC'
DEPT. OF HF..AL';~ ~
ENVIRONMENTAL Pi,,,.· ·
1986
WELL DATA
Well Classification I%"u,,o~ f~
Well Log Present (Y/N) IN
Total Depth I OO' Cased to
Static Water Level ~'~' ~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
If A, B, C, D.E.C. Approved (Y/N) ^h/~.
Date Completed (~n/,r Yield
~fO'4' Depth of Grouting -"
Pump Set At
Sanitary Seal on Casing (Y/N) Y'
Depression Around Wellhead (Y/N)
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
I
i00 '
~o ~/e~'/~,~'~ ' on Adjoining Lots I.~O' ~' ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes (Y/N) Y' Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) ~.
Holding Tank High-Water Alarm (Y/N) IN,~,
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~ '~ lO;
To Property Line
To Water Main/Service Line
I
Course ~
No. of Compartments
Foundation Cleanout (Y/N) ~"
Date Last Pumped b~'/'~-O /'~'
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation I0 ~ -I-
To Disposal Field I~
TO Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
Co
ABSORPTION FIELD DATA ,~"/,~
Soils Rating in Absorption Strata ~g~ ~/~'~g} Type of System Design
I0/~/~-~ ~~, ~ ~/~/~ Length of Field
Date
Installed
Width of Field ~ t Depth of Field I
~' ~ ~,~ravel Bed Thickness
Square Feet of Absorption Area 3~ ~~ ) Standpipes Present (Y/N)
Date of Last Adequacy Test
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~"~ .~,"~'~ ~ ~,,t
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) N~/~.
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 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~ ~ Date
Company ~/~
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal
~ 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
GENERAL INFORMATION
(a) Legal Description (include lot, block subdivision, section, township, range)
/_ d, T/ _3 f / .
Location (address or directions)
Applicant Name 4°" ~ -~'~fgF4~elephone:Home. /
(b) Business ~'~'-~ 7~
Applicant Address
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other [] (explain);
(d) Lending Institution .~.d~,~-4 /-?¢',~' ~ ~'~-/ Telephone
(e)
(f)
Address
Real Estate Company and Agent
Address
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Well,~ Community [] Public [] "'
Individual
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legalit~and status.
4. SEWAGE DISPOSAL
Onsite~.J~ 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 I of 2 72-025 {11/84}
ENGINEERING FIRM PROVIDIN~I/NSPECTIONS, TESTS, FILE SEARCH, DA~"J~AND INFoRM~,TION~
As certifie, d 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.
Name of Firm /dr~-~"~' ~/,-'~d_ Telephone ~-~f'- ~-~O~-/wO
Date
Approved for ~-'~""'--'~-'bedrooms b Date
~,~ Disapproved Conditional
Approved
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the 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.
Page 2 of 2
72-025 (11/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOAT~
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
MUNICIPALITY OF ANCHORAGE
DElft. Of: HEALTH &
ENVIRONMENTAL PROTECTION
NOV 2 5
Legal Description:
Well Classification
Well Log Present (Y~)
Total Depth lO~'~l' Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in ConduitIYtN)
Separation Distances from W~II:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~--~
CleanoutJManhole
Water Sample Collected by ~. ~
Water Sample Test Results
Comments
If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~(4[~0~./~ Yield ~"~- ~---~-~.
~(~ rf Depth of Grouting
Pump Set At
Sanitary Seal on Casing (~)
Depression Around Wellhead
/'/~ /'~ '-~' ~- 'On Adjoining Lots
Y- · On Adjoining Lots ~ fO0"
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed /0-'~-
Standpipes(~N)
Depression over Tank (Y{~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding, Tank:
To Water-Supply Well ~"~' //0
To Property Line /0
!
TO Water Main/Service Line
Course
Size [c~ ~-0 No. of Compartments /
Air-tight Caps(~/N) Foundation Cleanout~N)
Date Last Pumped ~/(*"~ ~ ~'~
/~"/4 'for /~
/'~/A Temporary Holding Tank Permit (Y/N) /~
To Building Foundation /0
To Disposal Field ,/'~ '
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026{11/84)
C., ABSORPTION FIELD DATA
-
Soils Rating in Absorption Strata /~
Width of Field
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
~=~/~) Type of System Desigr~
Length of Field
Depth of Field
~ravel Bed Thickness
Standpipes Preset)
Date of Last Adequacy Test
To Water-Supply Well (~'~.~'
To Building Foundation
Lot //I vt L?
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
· On Adjoining Lots
To Cutbank (if present)
To Property Line 4~7- /~
To Existing or Abandoned System on
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Man h,C~f/Access (y/N)Dime~
/~ ~ump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
../-
** Check Permitted Bedroom Rating Against HAA Request **
Company /~-~ ~c~ MOA No.
Receipt NO. '~/,~ ¢/-~ ~'
Date of Payment- "~////r'~/~
Amount: $ ~ ~
I certify that I have,_ che~k_ed,~) - verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed /) ~.._~, /",_c-.(' Date
Page 2 of 2
72-026 (11/84)
ALASKA IIUIROnm I1TAL CONTROL IllC.
{~n§ineerinq F.. {~nuironmenlal Studies
NOV 20 1985
HOME EQUITY #362-129
P 0 BOX 8026
WALNUT CREEK CALIFORNIA
94546
SELLER-DOWN SCHMOHR
WILL MAIL FROM OUR OFFICE
50722
LEGAL:CROMWELL HEIGHTS SUBD/BLOCK 1/LOT 6&7
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST DATE-OCT 24 1985
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 384 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 675 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
3 BEDROOM HOME.
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR
THIS 3 BEDROOM HOUSE.
THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON JUNE 14 1985 .
FLOW TEST ON WELL
WELL FLOW DATE-OCT 24 1985
A FLOW TEST WAS PERFORMED ON THE WELL. 675 GALLONS OF WATER WAS
PUMPED AT A RATE OF 5.5 GPM OVER A DURATION OF 2.5 HOURS.
THE DRAWDOWN WAS 11 ' WITH A RECOVERY TIME OF 40 MINUTES
AND THE STATIC WATER LEVEL WAS 38 FEET.
THE WELL IS ADEQUATE FOR THIS 3 BEDROOM HOME.
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
NOV 2 5
RECEIVED
1200 {.]Jest 33cd Auenue, Suite B ·/~nchm'aqe, Alnsko 99503 .(907) 561-5040
· MUN1CIPALIT'~ OF AN,.,HORAGE 2 'T. G;" ;]".~i. & '
DEPARTMENT OF HEALTH & EN,'.,;iRONMEr4TAL PROTECi~HJ'%:DNi¢!ENJA['';~OTECTION
,,:~[~,j.,, ENVIRONMENTAL ENGINEERING DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTID;{S: Comp. le;e all pr-.~s on psge 1. Incomplele request2 will not be proces$ed. Please ~:;cw ten (!0) d3¥"s for processing.
PROPERTY OWNER PHONE
David Matthews 344-3774 Home
MAILING ADDRESS
NHN Hillside Dr. SRA 2389
~ Offi,:e
PHONE
PROPERTY RESIDENT (It differen~ from above)
2. BUYER I PHONE
Jack White Co. I 277-1553
t~A~L~,'O ADDRESS
3201 C St. Anchorage, Alaska 99503
3. LENDING INSTITUTION
MAILING A~DRESS
PHONE
4. REAL~OR,"AGENT J PHONE
Clair Rams'ey Jack White Co. [ 277-1553
,MAIL~NG ADDRESS "
3201 C St. Anchorage, AlasAa 99503
5. LEGAL DESCRIPTION
Lot 6,a~ 7, Block 1, Cromwell ~eights
STREET LOCATION
Hillside Dr.
6. TYPE OF RESIDENCE NUM3EF. OF ~EDROOMS
.r-q 0r~e ,._~'r'--' Four ~ 01her
~ SINGUE FAMILY ~ Two F-'t Five
~ MULTIPLE FAMILY :,'"~i Three ~ Six
7. WATER SUPPLY
INDIVIDUAL*
COMMUNITY
PUBLIC UTILITY
ATTACH WELL LOG. A wel! log is required for ~11 wells drilled
since June i975. For wells dri!led prior to that date, give well
depth (attach Icg if available.)'
8, SEWAGE DISPOSAL SYSTEM
** If individual/on-site, give installation
INDIVIDUAL/ON-SITE*'
PuBLIc UTILITY
If system is over tv.,o (2) ,,,ears cid zn adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
September 11, 1979
David Matthews
Star Route A Box 2399K
Anchorage, Alaska 99507
Subject: Lot 6 and 7 Blo~k I Cronnmll Heights Subdivision
Approval for your Lndividual sewer and wa~er £a~llitiem
can no~ be grante~'= un, il the £ollowing ~ems have been
oompleted:
(1) A well log submitted to this department.
(2) The water analysis report be delivered to this office
from Chem Lab, $633 B Street, for our z~viow.
If there are any ~urther questions, please c~on'taet this
off,ce at 264-4720.
Sinoorely,
Robert C. Pratt,
Aasooiate Specialist
cc: Clair Ramsey
3201 C Street 99503