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Home My WebLink AboutCONIFER HEIGHTS BLK 3 LT 22 Municipality of Anchorage Page I of 3 DEPARTMEN'[ OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~~0 ,~'Z- PIDNumber: Ole~'-.Oc~'~- O~ Name: Wastewater System: D New ~Upgrade Address: -/e 5o ~Zl F~ / F~ ABSORPTION FIELD Phone: ~ No. of Bedrooms: ~eep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other LEGAL DESCRIPTION so,, Rating: Total Depth from original grade: Lot: Block: Subdiv~ion: Depth to pipe botlom from original grade: Gravel depth beneath pipe Township: I Range: ~ Section: Fill added ~bove original grade: Gravel length: WELL: ~ New ~ U pg rade Gravel width: Number of ,~.~: 10i~t~.ce between lines: Classification (Private. A.B.C): To[al Depth: . Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: Date inst~lled: Yield: ~ ~ ~GPM~ [ ~u~p S~t at: Ft. Casing Height Above Ground:Ft. TANK SEPARATION DISTANCES ~ s~pt~c ~ ,o~din; ~ TO Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: Material: Number of Compartments: Surface W~t.r ~ ' LIFT STATION LineL°t ~ ~ Size in gallons:l~ Manufacturer: ~ "Pump on" level at ~ "Pump off" level at: High water alarm Foundation I CurtainDrain ~/A Pump Make & Model.~ Electrical Inspections performed by: Remarks: BENCH MARK Location and Description: I Assumed Elevation:]~ ~ ENGINEER'S ,SEAL Inspections performed by: % ~ Dates:lst %/lC ~:' '~ ~ : ...... "' Department of Health and Human Services approval ~, "',. "'" / RevieweO anO approveO by: , Date: ~ }T -~ ' 72-013 (Rev 91911 MOA 25 I I I I I ~ SCALE; ]" = 50 FL: ~ ZO DIVENTE~ ~ ~, i OAZ S.T I ~ ~ II ~ I , ,:--, /~~~~ / ,,, , , , ~ / X~x~ BENCH WARK: GARAGE SLAB ASSUWED ELEK ~00.00 F[. TOBBEW SPURKLAMD P.E. LOT 22, BE 3 CONIFER HEIGHTS static sYSTEM As BUILT 205 W I5TH. AVENUE CARLTON SMITH DATE: SEP, 12, 1998 ARCH. AK. 9950~ 7~0 GR/FF/rH STREET SHEE[, 27~ OR/D: 2440 ...... ~ -.. ~ ~ / l'"'~'x ............ : ............ e'"~ ~ ~. ~,~r~rr~ ~LVr iO00 9ol ~eptlc tonk /// 4,5' ~e~er rock ~' ~over ~ F~LE on,'to' CZe0 no. ts 77.; 77.7 / BENCH ~ARK: OARAGE SLA~ ASSU~ED ELEVADON ~00.00 FT TB~EN SPURKLAN~ P,E, CONIFER HEIGHTS LOT 22 BE 3 SEPTIC SYSTE~ ~03 WLS~h Ave CARLTON SM/TH DATE: SEPT. 12, 1998 Ak ~01 7630 ORIFFITH STREET SHEET: P79-291q PERWIT ~ SW980542 PARCEL ID ~ 0~5-095-01 CONOS22tDWO PERFORMED FOR: LEGAL DESCRIPTION: Fl: 2 3 4 7 8 10 12 14 17 18 2O Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: Township, Range, Section: (ENGINEER'S SEA'L), SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT 0 DEPTH? p E Depth te Water Alter Monitm ing? Date: SITE PLAN 1 F'I I~[... ~/dtdq'~' Gross Net Depth to Net Reading Time Time Water Drop /¥ ct: jo° PERCOLATION RATE .-~mlnutes/,nch] P~I~HOLE DlAf~p '~/~ ~-' TES~ RUN BETWEEN __ FTAND __FT COMMENTS ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIEELINES tN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CER]IFY THAT THIS TEST WAS PERFORMED iN DATE;_ ¢/¢/¢ ~ MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT U pg rade Date Issued: Expiration Date: Sep 04,1998 Sep 04,1999 Permit Number: SW980342 Legal Description: CONIFER HEIGHTS BLK 3 LT 22 Design Engineer: 0007 Tobben Spurkland, PE Owner Name: CARLTON SMITH Owner Address: 7630 GRIFFITH ST ANCHORAGE , AK 99516-1016 Parcel ID: 015-093-01 Site Address: 007630 GRIFFITH ST Lot Size: 43524 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [~ Disposal Field [] SepticTank [] Holding Tank [] Privy [] Private Well [] Water Storage All construction must 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 engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. 5. The following special provisions. EXISTING SEPTIC TANK SHALL BE EXPOSED AT THE TIME OF CONSTRUCTION TO VERIFY INTEGRITY. AT THE TIME OF CONSTRUCTION, ENGINEER SHALL BERFORM AN ADDITIONAL PERCOLATION TEST IN ACCORDANCE WITH THE EPA, ON-SITE WASTEWATER DISPOSAL DESIGN MANUAL, PAGE 41. AS-BUILT INSPECTION REPORT WILL NOT BE APPROVED WITHOUT ADDITIONAL PERCOATION TEST. Received By' Date: 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 22 BLOCK 3 CONIFER HEIGHTS CARLTON SMITH Municipality of Anchorage Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 We are submitting an application for septic system up grade for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 16.5 ft. Use Standard Trench Soil Rating. From Testholes Aug. 18, 1998 7 min/in = 0.8 gal per sq.ft/day No. of Bedrooms 3 Required Area per Bedroom: 150/.8 = 187.5 sq.ft. Total area required: 187.5 x 3 = 562.5 sqft Testhole depth 16.5 feet Bottom Rock At 10.5 feet Top Rock At 6 feet Rock Depth 4.5 feet Total Trench Length 562.5 / 9 = 62.5 ft. SYSTEM CONFIGURATION . STANDARD TRENCH TOTAL LENGTH 62.5 FT TOTAL WIDTH 2 FT TOTAL DEPTH 10.5 FT ROCK DEPTH 4.5 FT COVER 6 FT CHECK EXISTING 1000 GAL SEPTIC TANK The installation of this septic system will not prevent wells from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 3 4 8 10 12 14 ~8 20 COMMENTS Township, Range, Section: SLOPE WAS GROUND WATER k ~ ENCOUNTERED? I~ S L IF Y2S, AT WHAT O DEPTH? p Depth lo Water Alter_/ Monitoring? _/'j.,e"- / Date: SITE PLAN Gross Net Depth to Net Time Time Water Drop . 7 PERFORMED BY: I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2o COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -,, PERCOLATION TEST Range, Section: (ENGINEER'S SEAL) DATE PERFORMED. WAS GROUND WATER ENCOUNTERED? SLOPE SITE PLAN S L IF YES, AT WHAT O DEPTH? p E Deptl~ lO Waler Alter Monitoring? Date: Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE 7 (mmutes/~nch) PERC HOLE DIAMETER TES'f RUN BE*¢WEEN 7 FT AND '7'/~..... FT ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DAlE DATE: 72-008 (Rev. 4/85) / ~~ ~/ ,,, ~ ~ ~:--.~-.~ ~ ,: ~ ~ .... ~....~~.~.~ TOBBEN SPUgKLAND P.E. LOT 22, BK 3 CONIFER HEIGHTS SEPTIC SYSTEW DES/ON 205 W ISTH. AVENUE CARLTON SM/TH DATE: AUG, 24, 1998 A~CH. ~. 9950~ r~so (907) PE~ZT I I ~ I I , ~ ~ .5 rr EFFECTIVE R X ~':~ I I / TOBBEfl SPURKLAND P.C LOT 22, BK 3 CONIFER HEIGHTS SEPTIC SYSTE~ DESIGN 205 ~ 15TH. AVENUE CARLTON S~ITH DATE: AUG, 24, 1998 AflCH. AK. 99501 7650 GRIFFITH STREET SHEET: 2/5 GRID: 2440 (~07) 279-~9~6 PE~IT ~ S~98XXXX PI~ ~ YY C~N03222,~5 D/VERrER v,~Lv~ ~0- ~ £CALE o ot_ ~000 90~ £ept/c toni< EX/STING 6,2.,5' L on2 lO. 5' 4,5' Se~er rock 6~ Cover $~eo nou ts / Effective i000 OoL :ep~/'c tank ND SCALE TDBBEN SPURKLAND P,E, II ~o3 Wl%th Ave II Anchor'o, ge Ak 99501 479-,3416 CONIFER HEIGHTS LOT 22 BE 3 CARL TON SMITH 76,~0 GRIFFITH STREET SEPTIC SYSTEM SCHEMATIC DATE: AUG, 24, 1998 SHEET: 3/,~ GRID, £445 PERMIT Ij/ SW9800XX PARCEL ID // XX CONO5225, DWO Name Addless MUNICIPALITY OF ANCHORAGE D[ ,':ITMENT OF HEALTH AND HUMAN SER ES '~ (~ Environmental Health Division ~,)/,~' 0 ~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Phone(s) I Permd No. jNo of Bedrooms LEGAL DESCRIPTION Lot I Block Subdiws~on ;22_. t ~ c'~') N l i: l~ r~- I-/ I~ / 6 H'T~ Township, Range, Section TANKS SEPTIC Manulactu~er Material L~ HOLDING Capacdy in gallons No. of Compartments TYPE OF SYSTEM ~TRENCH ~ BED [] W. DRAIN [] OTHER Depth to pipe bottom from oHgmat grade Fdl added above original grade Gravel length FT FT Total depth irom original grade Gravel depth beneath p~pe Gravel width Distance between lines SO FTjp,pe material SO FT /~¢T/-¥ F ~:~/ Date Inst-~-e6 -- -- DISTANCES 'Total absorphon area Number el hnes ISoft rating / L Installer WELLS [] PRIVATE [] OTHER {Identifv~ Ctassd~cat~on (A,B,C) /]otal Depth Cased to FI] F' lnstalJet J Date Installed: WELL ABSORPTION FIELD WELL SEPTIC TANK I 7 ~... Municipal and State guidelines in ellect on this dla e: Health Department Approval: /.gO LOT LINE FOUNDATION AS-BUILT DIAGRAM (Show location of well, septic system, property hnes, foundat*on, dHw!wav water bodies, etc.) N 89'57'30'" E 202,25' lO' _Dr'a (Oo~oe ~a ~er!,,~O ~ 72-013 (3/85) ~-~/ / ¢ r~certify that lhi~pection was performed according to ail Scale: Inspections Performed by: ~ ,, I0,~ Utlll'tj,, £asel~en~__ I I,,1 'l-'l-"l-:- I-:1 PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST L.e~T~,~.. ~ i~. 3,, C.~ ~; ~ ~. ~.~i j~.gTownship, Range, Section: SLOPE SITE PLAN ENCOUNTERED? 15 16 17 18 19 20 COMMENTS S L IF YES, AT WHAT O DEPTH? p E Deplh to Water After/ / Moniloring? ~/'~ 9[ ~,!r Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE I ~'O (.,,',,u[~/h,~;tu PERC HOLE DIAMETER TESTRUNBETWEEN q FTAND I 17/ FT 72-008 (Rev. 4/85) 20 0 2~ LOT 2~ V^c~T~ N 89'57'30' E 202,25' 10' Drat~a,ge Easement O~ __I0' UtlUt)/ Easement~ N 89'50'42' E 202,25' LOT 1 40 60 80 SCALE; l' = 40' 100 i2~ TnI~BEN SPURKLANB P,E. 203 W. 15TH. AVENUE ANCHORAGE, ALASKA (907) i~79-3916 II L O T 22, 3L DCK 3 CONIFER HEIdHTS SEPTIC SYSTEH DESIGN DATE, March 30, 1988 SHEET,/ GR]I),2440 30' 30' LOT 21 V~CANT N 89'57'30' E 202,25~ JO' Dr~l,n,~,,qe ,E~$e~ , I ~i0' UttUt~/ E,a,$el~en't , N 89'50'42" E 202°25' LOT i / WIL ~ WETDD dL ENN LOT 2 20 0 20 40 60 80 100 I£0 SCALE: I' = 40' TDgBEN SPURKLAND P,E. ~03 ~, I§TH. AVENUE ANCHORAGE, ALASKA (907) 879-39t6 LO T 22, £LOCK 3 CONIFER HEIGH TS SEP TIC S Y£ TEN Z3ATE, A. pr/I 5, 1988 Certified Well For....~..,.....~..,..2 ~..~.~ ~. ~.Q~. ..................... .'[ ........................................................................... Location.. I:O..~.._ 2..2...,.....~,].,..O...O..]~... ~. ,......C...O..~. ~..f....e...~.......H...q..~..~..h...t....s. ............................. Date Corn plct. cd....2..-..~.~..-..~.~. ............................................................................................ Depth of well ........... ~.]fJ.....F.~.~,.t; ...... ~ ................................................................................ Size of casing... ~....~.~.~..b ................................................................................................... Distance to watcr....2...2....~....~..e.....e;..t. .......... .... ......................................................................... Distance to water wl~ile pumping ........ :. ............ .~.~.~. .................................... at rate of ......... .~..~..Q .................................. gallons per hour. Description of ' Form'ati6B ." ;' :..' '; from to Sand.& ]Gravel.".)' >'",:' {.-,:or~][~.?ard 85 177 Sand &.':O~avel With' Ma,t'e~'... '., 220 . '231. ·- .'?. ...... .v I, :. ~'... .... ANCHORAGE, ,ALASKA' 99501 .',,..:..%,., ,...I. certify the abo~'.itrue and correct. G~._ATER ANCHORAGE AREA ~ ROUGH Department of Environmental Quality 3500 Tudor Road Anchorage, Alaska 99507 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC T DISTAN~ FROM WELL MANUFACTURER~z(' ~ ~'~F / MATERIAL ~}~)~/ NUMBER OF INSIDE LENGTH ... INSIDE WIDTH LIQUID DEPTH __ .LIQUID CAPACITY./5'5'~[2 GALLONS. SEEPAGE PiT: ~/57~ ~ NUMBER OF PITS . DIAMETER _~ OR WIDTH I:~, LENGTH//~ DEPTH ¢ /< CRIB SIZE: DIAMETER ~ DEPTFi ,. DIS'FANCE FROM: WELL _ . ABSORPTION AREA (WALl_ AREA),:~(~ Sq. FT. ADDITIONAL ABSORPTION TYPE CONSTRUCTION BUILDING NEAREST FOUNDATION__, LOT LINE CESSPOOL OTHER SOURCES · APPROVED DISAPPROVED NEAREST SEWER LINE REMARKS DISTANCES: P,PEMATER'AL:4II c'~/' LOT 5LOPE:"~'e~P ~ ~.~--'" REMARKS: ,tm PW-O21~ DIAGRAM OF SYSTEM /.-.7, DATE,~, ,- :' ~/: ~_'-APPROVE. G.K:A.B. A:iCHORAqE, ALASKA 99502 CASE # Performed For C-~{c-' ~/~.~,r..~ Date Performed /O-l~l-?-L Le.qal Descrintion: Lot zz_ Block _~ Subdivis.i. on Co~'/C-'~- //~-~/~7~-~ This Form Reoorts Soils I_o~1_~ Percolation Test rIeDth Feet /z · Soil Characteristics ~ Reading i Date i Gross Time Percolation Rate I L Proposed Insta!latio~,- Deoth of ~nlet cn~.~!~ENTS. Net Time I I Denth to H20 ('e,-:n<~,-le Pit Pr:~i~. Field ......................... Den~T{--~,T-i~'°-~%~'c'r.q r.~,~ Pit. Or Trench. Net Test Performe~ __ ~Pat:a Certi Fief! SEWAGE DISPOSAL SYSTEM GRE /ER ANCHORAGE AREA BO~,.)UGH DEPARTMENT OF ENVIRONMENTAL OUALIYY PERMIT NO. - 3200 TUDOR ROAD POUCH 6-6§O TELEPHONE 279-8686 ///~ - - APPLICATION AND PERMIT INSTALLATION OF: SEPTIC TANK /x SEEPAGE Pit DRAIN FIELD FINANCED THROUGH TO BE INSTALLED BY SOIL TEST RESULTS COMPLETION DATE ANTICIPATED OTHER WITHOUT ~OIL TE:$T FINAL INSI~I[CTION= 24 HOUR NOTICe' REQUIRED. BACKFILLING OF ANY SY$'TE:M WITHOUT FINAL INSPECTION BY THm' HEALTH DEPARTMENT AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, RIEQUIREMENT~ / FOUNDATION TO SEPTIC TANK II '~ / FOUNDATION TO SEEPAGE PIT L~C~ SEPTIC TANK TO SEEPAGE PIT WALL //~.S~ / SEPTIC TANK ~5- / . SEEPAGE PIT TO NEAREST LOT LINE. '~ WELL TO SEPTIC TANK ~D DRAIN FIELD DRAIN FIELD AREA SIZE ' ' TYPE DIAGRAM OF SYSTE:M DRAIN FIELD SEEPAGE P,T ALSO CONSIDER AREA WELLS, WATER HAIN TO SEPTIC TANK ~ /(-/ SEEPAGE PIT DRAIN FIELD SE~IC 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 SOIL, 4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE CAPS, GRAVEl. BACKFIll CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE 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 Parcel I.D. CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~"~ -0 1 ~v HAA # 1~0~,t~,---'~C~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailing address Day phone Agent Address .,~1~ {.~-Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual' well Community well Public water TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public se,~r NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER Se 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 wastewate¢ 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 .. ~ ~ b/o~ ~ <Z~, ~/~, ~ Address ~,~ '5 u~, l.'~ ~ ./=~ ~_e ...-3 Phone ~'7~-~1~ Engineer's signature '~--~ DHHS SIGNATURE ~ Approved for '7"~ R EE bedrooms. Date Disapproved. Conditional approval for bedrooms, with the following stipulations: Note: The well for this property meets existing State and Municipal Codes. There ar~ ~i~r&~ p~e~en~ i~ is ........... performed to insure the wells continued suitability. Current nitrate concentration is 5.56 mg/i. EPa maximum concengra~ion is 10.0 mg/l. More information on nitrates is available from the On-site Services Program, DHHS, 343-4/44. Additional Comments By: ~ //C7. ,x'~>~'~' Date ~"/?''~9 The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given ~n 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..g~5(Rev. 1/91) Ba~k MOA#21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVIO~LG Environmental ~e~i~es Division 825 L Street, Room 502 · Anchorage, Alaska 99501 Legal Description: J.a~ ZZ. A, WELl. DATA Well type Log present (Y/N) Total depth ~ '~ '! Sanitary seal (Y/N) Health Authority Approval Checklist ~(. ~-~ Go ~ ~v- ~-.-~.~,~-_~ Parcel I.D.: If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to ~ ,~ 1 FROM WELL LOG Date of test _,-~2. , Static water level Well productiOn g.p.m. Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Y g.p.m. WATER SAMPLE RESULTS: Coliform .,. '"' O ----, Date of Sample:__ q/Il/~ ~., Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~/~//~1~ ~, Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Date installed ~/~/c) Length (/,~ ~..,5~' Width Tank size /~hO~ Number of Compartments ~-- Cleanouts (Y/N) . Depression (Y/N) ~ High water alarm (Y/N) ~ J~ Pumper l,b ~.~ t ~ (g.p.d./fF or~) Soil rating Gravel thickness below pipe Effective absorption area ~ Monitoring Tube present (Y/N) '"/ Date of adequacy test 1~///~- Results (Pass/Fail) ~ Fluid depth in absorption field before test (in,); ~ Immediately after System type ~. -.~'"" Total depth /~, ~ Depression over field (Y/N) 1".. I For ~'/ bedrooms · "~'gal. water added (in.): Fluid depth ~ (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) Absorption rate = If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) "Pump on" level at* "Pump off" level at* High water alarm level at* *Datum Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot On adjacent lots Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation Water main/service line ~5' Property line ~7 ~p F' ~-- Absorption field ~.. o ~-/-'- Surface water/drainage ~//C~ Wells on adjacent lots ~ /~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line Surface water Curtain drain Building foundation .'~' ~ ~- Water main/service line ~ ~- ::~ F- ~'-- Driveway, parking/vehicle storage area lO ~ ~'- Wells on adjacent lots ~ ! e-~ ~- ! F. ENGINEER'S CERTIFICATION .... . ..... I certify that I have determined thru field inspections and review of Muntctpal records that the aboye ,sy~stems are in conformance with MOA HAA guidelines in effect on this date. ,j~ ~ Engineer's Name Date ~p HAA Fee $ 30d)-(~) (D a,e o, a men, Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev, 3/96)* MUNICIPALITY OF ANCHORAGE ((~ J DEPARTMENT OF HEALTH & HUMAN SERVICES DIVISION OF ENVIRONMENTAL 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) PropertyOwner"J~,~ ~'{/'~.g,,~ Telephone:Home ~-~'t % Business ~ ~- '-I Mailing Address 7~ ~ ~;~ ~ ~ ~ (c) Lending Institution ~'~ T'~ ~ Telephone Mailing Address (d) Real Estate Company and Agent ~,~.~u[~/., '"~..~,J~Jt~J ,~. 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 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: (f community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ,. 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Approved (Y/N) Well Log Present (Y/N) ~ Date Completed ~1~* ~,~"'~,~ Yield Total Depth ~.~'~ / 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 To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments DePth of Grouting ~/O/~ ~.~. Pump Set At > ~2,~"~ Sanitary Seal on Casing (Y/N) ~/ Depression Around Wellhead (Y/N) I~ · On Adjoining Lots ! ~7 ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on ; Date co/.,/ ¢ B. SEPTIC/HOLDING TANK DATA Date Installed ~ Size /O ~ No. of Compartments T Standpipes (Y/N) 'T'~i~7 Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~/ Date Last Pumped ~'/'*~ ;for 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 Comments ~L Zb Temporary Holding Tank Permit (Y/N) To Building Foundation ~,~ To Disposal Field To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field 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 Lot .~ O To Water Main/Service Line Type of System Design Length of Field Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) ~O ~1,'/~-----'''- 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 hav.e c.,~hecked._~,__ --/.~--verified". -(jor/e~nformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed .~'~', ~ Date Company MOA No. Receipt NO. Date of Payment /"/' Amount: $ / Page 2 of 2 72-026 (11/84) Engineer's Seal 203 W. 15th AVE "C" SUITE 203 ANCHORAGE, ALASKA 99501 TELEPHONE: (907) 279-3916 RESIDENTIAL WE, LL INSPECTION LEGAL: Lot 22, Block 3, Conifer Heights LOCATION: 7630 Griffith OWNER: Joyce Bigelow TYPE OF WELL: Single Family WELL LOG AVAILABLE: Ye s INSTALLATION REQUIREMENTS MET: NO. Well wires Municipal requires wires to be in conduit. are exposed. WELL YIELD FROM WELL LOG: 7.5 gallons per minute PUMP YIELD FROM TEST: 6 gallonS per minute DATE OF INSPECTION: March 14, 1988 TEST PROCEDURE: Well was pumped at a constant rate while the drawdown was monitored with an acoustic probe. At the beginning of the test water level was found at 227 feet below top of casing. At. a pumping rate of six gallons per. minute the water level did not drop during two hours of pumping. ,A total of 720 gallons of water were removed. TEST FOR E.COLI AND TOTAL NITROGEN: Water was tested for E.Coli and total nitrates on March 7, 1988 E.Coli 0. Total Nitrates 4.4 mg/1. Max. allowable Total Nitrates 10 mg/1. TEST R~SULTS: This well meets the requirements of the Municipality of Anchorage. THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE THAN FOUR HOURS FOR ~MORE The Municipal requirement for well flow is 150 gallons of water per bedroom per day. This well exceed this requirement. The assessment of the condition of the well applies only to the conditions as of the day tested. The flow rate may change due to subsurface conditions that may not be observed from the surface, and changes in the land use and other factors that may impact the aquifer feeding the well.