HomeMy WebLinkAboutCONIFER HEIGHTS BLK 3 LT 14 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
N~ DISTANCES
~. ~ ~l ~ ~ TO SEPTIC ABSORPTION
WELL
~r~--FROM ~ TANK FIELD
LEGAL DESCRIPTION
I F~R. ~I~F FOUNDATION
Townsh,p, Range, Section AS-BUILT DIAGRA~Sh0w ,ecru,onlY, ~septic system, property ,mBS, loundat,on,
TAN~S .,... X N
Mat'enat No, of Compa~ments
Depth t0 pipe b0~t0m lr0m ~Otal depth Item original grade ='
Fdl added above original grade Gravel depth beneath p~pe ~
'~ FT , ~ FT ~
Gravel length Gravel w,dth X
Total absorption area Distance between lines
¢~ Se~T 1~.-~ FT
Number el hnesJ Sod rahn9 P~pe matenal
WELLS
~ PRIVATE ~ OTHER {Identify)
Classification
(A,B,C)
"~1 F~
Inst~lle~ Date installed:
REMARKS: ~ &~- ~ ~ ~
Inspections Pedormed by:
Health De p admen, Approval: Z - - Date:
72-013 (3/85)
L
Per'm.tt Numl.]er' .' 88()1'74
Date Issued: (::)8/2,9188
Upgrade
Engineer Designe. d
Owner Name: JOANNE WELCH Day Phone:
Owner' Addr'es~s.' 9440 F'ONDEROSA 546-185'7
ANCHORAL~E, AK 99516
I::'arcel ]'.d: ~-.09Z4-09
Lo'L L..ega].~ 8ubdivis~on~ CONIFER HEIGHTS Lot~ 14 Block~ ~
Section: 15 TownshAP: 12N Rangel ~;W
L. ot Size :]~;94()7 (sq. ft, or acres)
Max Bedrooms: This Permi. t: :~ 'T'otal Capacity: 3
SEPTIC TANK: Miq~,mum total septic tank capacity~ 1,000 gallons. Each septic
tank must have at least 2 compartments. Depth to top ~ septic tank (s) < 4.0
feet r'eqLlir'es insulation ovep tank(s).
INSTAL,I_ WIDE DRAIN TYPE AB~ORP'I'ION SYSTEM PER ENGINEERS DEBIGN,,
L..ENGTH,", 2 .... 54' ]"REN['.HEG~ WID'TH: 5'; GRAVEL,. DEPTH: 1'; DEPTH~ 4'
NOTIFY DHHS PRIC)R 'TO EACH INSPEC'TION. 'T'HIS PERMIT IS ISSUED
FOR A S]:NGL..IE F'AMIL. Y RESIDENCE ONI...Y AND E;XPIRES 12/51/G8.
I CER"f'IF:'Y THA'f':
1. I am f'amiliar with the requirement:~ for on-~ite sewers and wells as
For. th by the Municipality of Anchorage (MOA) and the State oF Alaska,
2, I will install the system in accordance with all-MOA codes and r'egulat, ions,
and in compli, ance with the design criteria of this permit.
3. I will adhere to all MOA' and State o~ ~/laska r'equirements for the set back
dis'Lances f'rom any existing ~ell, waste~atep 'di~sposal system or public
sewerage system on-this or any adjacent or nearby lot.
4. I under's'Land that this permit is valid For a maximum o~ 3 bedrooms. I
also under, stand that the capacity of the total system is :S bedr'ooms and
any en],anaement will r'equir, e a
8lc ned: .... DATE:
( 0 w n e r ) J 0 A N ~ W E:I~H / x
Tobben Spurkland P.E.
203 W. 1 §th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
Township, Range, Section: 'TI~-J~J ~_.'~
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT
DEPTH?
t E
Depth to Water Alter ~jpl~ ~
Monitoring? __ Date:
Reading Date
Gross Net
Time Time
Depth to Net
Water Drop
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER
COMMENTS
ACCORDANCE WITH ALL ST AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
TEST RUN BETVV. EEN ~ FT AND ~FT ~
Heal
',UNICIPALITY OF ANCHORAGE
and Environmental Protect
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
)n
INSPECTION
REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LEGAL DESCRIPTION__L Jq ~ 3 C.~JJ~;~I~-,~'
SEPTIC T,~j~%K~, I
DISTANCE i O ~,,..
FROM WELL
INSIDE LENGTH__.
MANUFACTURER ~MATERIAL_
INSIDE WIDTH LIQUID DEPTH
NUMBER OF
COMPARTMENTS_
LIQUID CAPACITY I~ GALLONS.
TILE DRAIN FIELD:'~III~~''~~
DISTANCE FROM WELL IO0 ~ FOUNDATION
9 of Lines .... / DISTANCE BETWEEN LINES ~TRENCH
Af3SORPTION AREA N % ~ SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER
IDEPTIt: TOP OF TILE TO FINISH GRADE MATERIAL BENEATH TILE
! ~ TOTAL LENGTH I
~ ~' NEAREST LOT UNE ~..~ OF LINE 31~
W I DT H'"~_~IJl N. TOTAL EFFECTIVE
IN. ABOVE TILE IN.
SEEPAGE PIT:
Log Crib
Rings
BUILDING FOLJNDATION ~
DIAMETER--OR WIDTH ....
Crib Size :i DIAMETER ....
NEAREST LOT LINE .
ILENGTH--, DEPTH
DEPTH .... DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA)
,SQ. FT.
Well ~~
Class: Depth:
Well Distance To: Lot Line
Bldg: Sewer Line:
Pipe Materials: ~
# of Bedrooms:
Installer: /~-c~. e_~.~.
Remarks: ~r~m ~ J % J ~.l~
DATE ~JIAPpROVED ---~
F'ERMIT NO.
FIPF'LICFIN'F JOFfNN NELCli
I_OCFI]'I ON PONDEI~'.OSI'::I CT.
L E f3 R L L. :1.. 4 B i:~: C O 1'.4 1 F' E R H'I' S
t125 W 7'1"H FtP'I FI
L.O'1" S i Z E
'2:'?'? ::ii::t. 2 4
FEEt'
'T'¥PE OF SOIL. FIE~SORB]'I[iIN S'¢S"I'EM IS: "I'RENCH
MFtX:[MIJM NUMBER OF 8EL)ROOMS = 3: SOIL RFI'T'INEi (SL4 FT,.'"BR:)=
i'HE RE(;!UIRED SIZE OF '1'HE SC)IL ABSORP"I"ION S¥S].EM IS;
iE:. ~l ~" '"'1t' II-t ~
'f'HE L. ENGT*H DiMENSiON I:5 THE LENG"f'H ,:; iN FEEl") OF' THE TRENCH OR L:,RFIINFiELI.).
'I'HE i}EP'I'H OF Ft "I"RENCH OF.:: PIT iff; THE [:,ISTFiNCE BETNEEN f'HE SURFFICE OF' ]'HE
(31~'.CltjNt.) FIN[)THE BO"F"I"OM OF' THE ENC:FI',,,'Frl"TON (]:N FEE. T).
"I"HERE J:2.; NO .'::;;El' WI[)I"H FOR "t'RENC:HES.
'IHE GI~'.FI'v'EL [:,EP"I"H I"%; THE MINIMUM I":,EP]'H OF' EiRFI',,,'EL BE"I'NEE:t'.,t THE OIJ'I'FP:tLI .... PIPE
PI1'.4D ].'HE BO-II'OM OF ]-'HE E',:.::CFI',,,'FITION ,:'.iN FEE].).
F"I:IC:t::]RC.;iE PLlar-,tT OPT :[
FI PHCI***::FIGE F'L.I*:Ir.4T i',IFI'*¢ BE IN':;].*I~L.L.E[) Fi]'* ].'HE PERMI]'TEE'*'S OF't-'ir~N SLIBJEE:"I' 1'O ]HE
FOL. L..OW 11'.4(3 E:OND I ] ]: CII'.4L~;:
· 1... EITHER Fi CLFiSS ~ OR ].]. NSF' FIPPR(]'v'E[) PL. FIN]- MFi"r' BE
2'.. Fi L:rJN].'INLIOL~S MFi:[r.,H'Er,,IFiNCE FiGi~'.EEMEN].' IS RE(;~U '.[ RE[:,. iF; Fi MFt:[i'.4].'ENFINCE:
Fi[iiF.,'E.i:::MENT 1S i'.401" KEF'T C:URRENT' YOU i',lFi'¢ BE REL::gUIRE:[:, "1"O ENLFiR(:~i.E: "/'HE~ SO~L..
FtBSORP"I'ION S"r'S"tEM FiI'.,I[:,/OR "r'OU MFi"r' BE SLiB..1EC'I ['O PROSEC':LH':[OI'.4.
BRCKFIL. LIN~3 OF HN'*/ S'~%"f'EM W]:"I'HOU'I" F'iNHL INSPECTION RND RPPROVFIL 8'¢ 'THIS
I)EPRRfMEN'T HIL.L BE SUBJEC]' l'O PROSECU].'iON.
M I N I t'"tLIrq [:,]: STANCE BETWEEN A HELL AND FINY ON-S i"I'E SEWFIGE [:' I SPOSFII... S¥S'I"IEM I S
:'LOO FEET FOR FI PR 'I 'v'Fi'/E WELL OR 2F~0 FEET FOR R PUBLIC: HELL.
WELL L.O(:~iS FiRE REQUIRED FiN[) MUS]' 8E RETURNED TO ].HE [:,EPFIRT'MENT HI].'HI1",I ::~:~:';.~ DFi"r'S
OF TPIE WELl.... C'OIIF:'L.E"f' I ON.
OTHER RE('::!i...I I REMENTS MFt'¢ FIPPL."r'. SPEC I F' I CFi']' IONS FiNE:, CON':-;TRUC]. I ON [) I F:IGRFtMS FIRE
FI'v'RiL. FIBLE T'O INSURE PROPELS'. IN'.E;].'FIL..LFIT'[ON.
I CER"I~ I F'"r' TFIFrT'
1: :[ HM FFIPIlLIFIR H I'I"H ].HE REQLIIREMENT'S FOR ON-SI'I"E SEWERS FIN[) WELL. S F:IS SE1'
FOI.;.:'I"FI B"r' "f'HE MIJN I C: ]: PFtL I T'¢ OF FINCHORFIGE.
2'.: I WILL. Ir.4'.L:;].'FiL. L THE S"r'S:;].'EM IN RCCOR[:'FINCE 14I].H "I'HE CO[:'E::+.';.
ii:: ]: UN[:,EF;.:ST'FIN[:, "I"HAT "I'HE ON-SiTE SEWER S'¢S'fEM MFI"r' REQUIRE E1'.4t_FIR(:;iEMEN'i" :IF THE
RES I [)ENC:E l S 14'.tEMO[:,EI_ED TO I NC:LUI}E MORE 'I"HFiN ::ii: BE[:,RCICIt"IS.
S i [3 N E [:,: .............................................................................................
FIPPL]:CFIN].' .]'OFif.,IN WELCH
ISSUE[:, 6'"r'. ...................................................................... [:,FiTE ............................................ ',,,':2:. 0
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
,NSTALLAT,ON LOCAT,ON
LEGALDESCR,PT,ON '"Y
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
SEEPAGE PIT
DRAIN FIELD
FINANCED THROUGH TO BE INSTALLED BY
SOIL TEST RESULTS ! T¢~ NOTEI THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
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.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT DRAIN FIELD
SEPTIC TANK TO SEEPAGE Pit WALL
SEPTIC TANK , SEEPAGE Pit , DRAIN FIELD
TO NEAREST LOT LINE,
WELL TO SEPTIC TANK SEEPAGE PIT
DRAIN FIELD ALSO CONSIDER AREA WELLS.
WATER MAIN TO SEPTIC TANK SEEPAGE Pit
DRAIN FIELD
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 5 FEET INTO UNDISTURBED SOle.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL SACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
OR
LICENSED DESIGNER
SEEPAGE AREA SIZE
DIAGRAM OF SYSTEM
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE.
FORM NO. LQ-01 6
September 6, 1977
R&M No. 751215
Ms. Joann Welch
1125 W. 7th, Apt. A
Anchorage, Alaska 99501
Subject: Soils Investigation for Sanitary Sewer System, Lot 14, Block
3, Conifer Heights Subdivision, Anchorage, Alaska
Dear Ms. Welch:
This report is supplementary to our original report of August 16, 1977.
On September 2, 1977, we performed a percolation test at the proposed
location of the sanitary sewer system on the subject lot. The percolation
test hole was drilled to a depth of 9.5 feet and had a diameter of 6
inches. The soils encountered were similar to those described in the
soils log included in our original report. The top of the percolation
test hole was located at original ground surface. The percolation test
was performed within the test hole at the depths shown in attached Table
1. All depths were measured from the top of the hole. The data in the
table show average infiltration from the depths indicated to the bottom
of the hole. The measured percolation rate was 6.45 Minutes Per Inch.
At the time of this investigation, a second test hole was drilled to
provide soils data for the depth interval from 15.5 to 20.0 feet. The
soil encountered in this interval was Gravel With Some Silt And Some
Sand (GM). Groundwater was not encountered.
We appreciate this opportunity to be of service to you. Please contact
us if you have any questions concerning this letter, or if we can be of
additional service.
Very truly yours,
R & M CONSULTANTS, INC.
Michael Mitchell, Jr.
Senior Geologist
Jim McC~slin Brown, Ph.~
Head, Earth Sciences Dep%~-.
MM,Jr./JMB/gld
attachment: Table 1
ANCHORAGE F Al RE~AN KS JUNEAU VALDEZ WASILLA
R&M CONSULTANTS, INrr~. 5024 CORDOVA · BOX 6087 · ANCHORAGE. , ALASKA 99502~ · H . 9 2·-
August 16, 1977 R&M No. 751215
Joann Welch
1125 W. 7th, Apt. A
Anchorage, Alaska 99501
Subject: Soil Investigation for Sanitary Sewer System, Lot 14, Block 3,
Conifer Heights Subdivision, Anchorage, Alaska
Dear Ms. Welch:
At your request of August 11, 1977, we conducted a subsurface soils
investigation at the proposed location of the sanitary sewer system on
the subject lot. The investigation complied with those procedures
required by the Municipality of Anchorage Department of Health and
Environmental Protection.
This investigation, which was accomplished on August 15, 1977, consisted
of a test hole excavated to a depth of 15.5 feet below the existing
ground surface. The test hole was sited according to your instructions
and its location is shown in attached Drawing A-01. Excavation was
accomplished with a backhoe. A sample was taken at the depth shown on
the soils log in Drawing A-01. The sample will be held in storage at
our lab for approximately six months. In addition, all material excavated
was continuously monitored by an experienced engineering geologist.
The topography at the excavation site is generally gently-sloping to the
West. At the time of the investigation the site had original vegetation
consisting of tall spruce and birch. The top of the test hole was
located at original ground surface.
The soils encountered in the excavation are shown in the test hole log
in Drawing A-01. The symbols used in Drawing A-01 are explained in
Drawings B-01 and B-02. This log displays specific conditions encountered
at the test location. However, subsurface conditions may vary in other
parts of the lot without any apparent surficial evidence of the change.
Groundwater was not encountered in the test hole. Bedrock was not
encountered. At the time the hole was excavated seasonal frost was not
present. Permafrost was not encountered.
Based on the visual classification of the soil and the requirements set
forth by the Municipality of Anchorage, a percolation test was not
necessary within the test hole on the subject lot.
ANCHORAGE
EAIRBANKS JUNEAU VALDEZ WASILLA
We appreciate this opportunity to be of service to you. Please contact
us if you have any questions concerning this letter or if we can be of
additional service.
Very truly yours,
Staff Geologist
Jim McCaslin Brown~
Head, Earth Science Department
JMA: JMB/r s
Attachments: Drawings A-01, B-01, B-02
TIME
11:11
11:12
11:]3
11:14
11:15
11:16
11:17
11:18
11:19
11:20
11:21
11:26
11:31
11:36
11:41
11:51
12:0;
12:11
ELAPSED
TIME
0
1
2
3
4
5
6
7
8
9
10
15
20
25
30
40
5O
60
TABLE NO. 1
PERCOLATION TEST
Joann Welsh
TEST HOLE NO. 1
INCHES
30.0
31.0
31.4
31.9
32.2
32.6
32.9
33.1
33.3
33.5
33.7
35.0
35.8
36.4
36.7
38.5
38.8
39.3
R&M No. 751215
DROP IN
INCHES
0.0
1.0
0.4
0.5
0.3
0.4
0.3
0.2
0.2
0.2
0.2
1.3
0.8
0.6
0.3
1.8
0.3
0.5
9.3 Inches Total Drop
6.45 Minutes Per Inch
SOILS
CLASSIFICATI_ON~ CONS[STE:':CY AND SYMBOLS
CLASSIFICATION: Identification and classification of the so{1 is accomplished in
accordance with ~he Unified Soil Classification System. Normally, the grain size
distribution determLnes classification of the soil. The soJ/ is defined according to
major and minor constituents with the mhnor elements serving as mod{fiefs of the
major elements. For cohesive soils, the clay becomes the principal noun with the
other major soil constituents used as mod{fief; i.e. silty clay, when the clay particles
are such that the clay dominates soil properties. Minor soil constituents may be
added to the classification breakdown in accordance with the particle size proportion
listed below; i.e. sandy slit w/some gravel, trace clay.
no call- 0- 3% trace - 3 - 12% some - 13 - 30%
SOIL CONSISTENCY - CRITERIA: Soil consistency as defined below and determined
by normal field and laboratory methods applies only to non-frozen material. For
these materials, the influence of such factors as so{] structure,, i.e. fissure
systems, shrinkage cracks, slickensides, etc., must be taken into consideration
in making any correlation with the consistency values listed below. In permafrost
zones, the consistency and strength of frozen soils may vary significantly and
unexpla{nably with ice content, thermal regime and soil type.
C ohe sionle ss Cohe sire
N*~olows/ft) Relative Density
Loose 0- 10
Medium Dense 10- 30
Dense 30 - 60
Very Dense - 60
*Standard Penetration "N":
0 to 40%
40 to 70%
70 to 90%
90 to 100%
Blows per foot of
a 140-pound hammer falling 30 hnches on a
2-inch OD split-spoon except where noted.
T- (tsf)
Very Soft
Soft
Stiff
Firm
Very Firm
Hard
0 - 0.25
0.25 - 0.5
0.5 - 1.0
1.0 - 2.0
2.0 -4.0
-4.0
DRIL LING SY>iBOLS
WO: Wash Out WD:
WL: Water Level. BCR:
WCI: Wet Cave In ACR:
DCI: Dry Cave In AB:
WS: While Sampling TD:
While Drilling
Before Casing Removal
After Casing Removal
After Boring
Total Depth
Note: Water levels indicated on the boring logs are the levels measured in the
boring at the times indicated. In pervious unfrozen soils, the indicated elevations
are considered to represent actual ground water conditions. In impervious and
frozen soils, accurate determinations of ground water elevations cannot be obtained
within a limited period of observation and other evidence on ground water elevations
and conditions are required.
G.L.B.
3- I-7~
S~ALE: N/A
GENERAL NOTES
~IO N/A
.~.---"~-J. N 0 -~'~-N E R A L
LOG OF TEST HOLE NO.
Scale: 1"=3'
0.0'
I 1 ~ ORGANIC MATERIAL
~ ~~ -- 0.5'
it.~.....~''~ ORGAMIC SANDY SILT (~5)
~~ Brown, Medium Dense
b:~, ~ 2.0'
--~.J'~ SANDY GRAVEL W/SOME SILT (GM)
j Occasional Cobbles and
~.Z.~ Boulders,
~:' 9: Brown, Medium Dense
G__rav~ Medium Dense
, S~LT w~oi~ S~D (~) ~.0'
I.~"~ Tan, Medium Dense
0,.~ Brown, Dense
1 ~.
~ ~ Propose~l
Corner --uildi-'- -- 10.5'
L '.'~)"
~.'q,
Groundwater was not encountered.
Not to Scale This log depicts s~surface soils
observed within the test hole at the
Distances shown are approximate location sho~.
and have not been measured by
surveying methods. See Drawings B-01 and B-02 for
explanation of s~ols.
SCALE: see above .. CDWG'NO'A-O1
~?~.......... ~,q_~,q- '
~,~r ... ~ ... o~ I. I
builder, prior ~o eonst~ucQon, to veri~y ~he ~,~ ~~ ~'..' ~ '~(~ *~ I
I
proposed building grade relative to finished ~,~~~,
grade and utility connections and to deter- ~~~~ [* * '*' * "* " ....
mine the existence of any easements, cov~ ~-~.....~.~.~.~;~.~r~ ~
nants, or restrictions which do not appear on ~ ~ ~ Robert M. Sc~e~.~ ~ [
· , ~ '.. .."~ ~ I
'~°~ss,0.~ I
the recorded subdivision plat.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
OF ON-SITE SEWER AND WATER FACILITY
264-4744 4"~D I S -- D~/3'"'~)q
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Owner r~c~l~. I~/jcJ~ Telephone: Home
(b)
Property
Mailing Address
(c) Lendinglnstitution ~.% .~¢4..C~k L,o~-ri'.~ Telephone
Mailing Address
(d) Real Estate Company and Agent
Address ~O~ ~ "~" ¢ ~'~-
Telephone ~ ',~ ~-:~ '- ~'~
(e) Mail the HAA to the followina address: or: Check here [~ if hold for pick up,
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family
Number of Bedroom§
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 8/863 Front
5. 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 ins~_~.~
Name of Firm Telephone
Address
Y
Engineer's Seal
DHHS APPROVAL
Approved for ~ bedrooms by
Approved ~ Disapproved
Conditional
Date
Terms of Conditional Approval
CAUTION
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.
Page 2 of 2 72-025 (Rev 8/86) Back
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description: J.-~ 7-
SEP - 2 1988
RECEIVED
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth .~ g
Static Water Level~'
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Cased to
If A, B, C, D.E.C. Approved (Y/N)
Date Completed /~" ~ .7' ? 7 Yield
~ ~ 'f' Depth of Grouting
Pump Set At
90 '~ Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
/ ¢ ~ ; On Adjoining Lots
//C~
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Man hole f'"'/7/~
Water Sample Collected by
Water Sample Test Results
Comments ~"
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~'/ 7
Standpipes (Y/N)
Depression over Tank (Y/N)
Size /g'~ No. of Compartments Z"
Air-tight Caps (Y/N) '~/ Foundation Cleanout (Y/N)
!
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~////-'~ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Date Last Pumped
'for
To Building Foundation ~ ~
To Disposal Field ~' O
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 fRev 8/861 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /St ~%,~ /
Width of Field ~ -/
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
//
Type of System Design
Length of Field / 0
Depth of Field ~-
Gravel Bed Thickness /~ '/
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water-Supply Well
To Building Foundation
Lot / 0
To Water Main/Service Line 7/0
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line / ~ '/"
To Existing or Abandoned System on
· On Adjoining Lots ~ "~ O
To Cutbank (if present) /~'/Z/~/4 ~;2
.¢o ¢"
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 thatJ have checked, v.,erified, CC'conformed to atl MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'-'-~'~~ Date
Company / MOA No.
Receipt No. . ~O,~
Date of Payment
Amount: $ /
Page 2 of 2
72-026 fRev 8/86~ Back
Engineer's Seal