HomeMy WebLinkAboutBIRCH TREE ESTATES BLK 1 LT 31 & 32Onsite File
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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
Name
Address
Phone(s)~.~7/"~ (~J~)j J? 0 (~ j/] (~)j Permit No. lng. of 5d rooms
LEGAL DESCRIPTION
Lot J Subdivisioq ~
Township, Range, Section
TANKS
SEPTIC [] HOLDING
DISTANCES
WELL
LOT LINE
FOUNDATION
SEPTIC
TANK
ABSORPTION
FIELD WELL
AS-BUILT DIAGRAM (Show location of well, septic system, pro~erty lines, toundation,
driveway, water bodies, etc.)
ManufactL~er
Material
Capacity in gallons
No. of Compartments
TYPE OF SYSTEM
[] TRENCH J~""BED [] W. DRAIN [] OTHER
Depth to pipe bottom from Total depth lrom original grade
original grade ~ O '~ ET '/' ~' ~ ET
Fill added above original g,~de/~ Gravel depth beneath pipe
ET ~0"' FT
Gravel length Gravel width
"~8 / ET //~ FT
Distance between~es!
Total absorption area ~'~4 SQ FT F1
Number of lines J Soil rating
~ J /Sg) SQ FT
Installer ~-~'
Pipe material
Date Installed
WELLS
Classification (A,B,C)
[] PRIVATE [] OTHER (Identifv)
Total Depth
InstaJler
REM~
FT
Scale: C.. j:~ ~,0 ,-~! ~.
~2~M~ i~--~do ~'~'~C~'~-'k [~ ~ ~ Inspect,ons~e~o,meObg:
/ ~ ~ g cmily Ihat this inspemion was pedormed according to all
Municipal and State guidelines in effect on this date: ~/~
Health Depa.men, Approval: ~~ ~ ~'
I
72-013 (3/85)
ENGINEER'S SEAL
,% ALASKA EFIUIROFImE~FITAL CONTROL $ERUICE$, Iric.
o ~cline~rincI ~- ~nuironmenl(]l ~ludics
1200 LUcsl 33rd Avenue. Suil¢ ~ · Anchoraq¢, Alaska 99503.I907) 561-5040
TO
: ~ DATE /::~ :...,:
,~ ~f,,'~ ,~., ~:~ r..'.:~ : SUBJECT
~aa0
SEP 6.....~.,.,
EASEMENT
Loyd Walter
5121 Woodhaven Avenue
Anchorage, Alaska 99516
To any future owners of lots 31 and 32, Block 1, Birch Tree
Estates, Anchorage, Alaska: As grantor and grantee of the afore
described lots 31 and 32, I hereby grant a septic system service
and maintenance easement into lot 31. This easement is limited
to access for reasonable service and maintenance of the septic
system that is currently being installed partially on lot 31 to
serve lot 32. This access and maintenance easement ends 6 months
after a public sewer becomes available to these lots 31 and 32.
To be recorded in the Anchorage Recording District.
;
Signed by grantor.and grantee'j~,.~ c .......
Address: Loyd Walter ~' /
5121 Woodhaven Avenue
Anchorage, Alaska 99501
State of Alaska
Anchorage Judicial District
On the. /.~ day of
, 19 ~I~,: , before me
a notary public in and for the State of Alaska, personally
\!
appeared ~.~/.d ~./<~.-b~F· , known to be the person whose
name is subscribed to the foregoing document. He acknowledged to
me that he executed the above instrument and knew the contents
thereof.
7:t88
..-.,, E' REO
JUN fl lll 25
NOTARY /PuBLIO (.. ~ ~,/.,CZ.~4 ,~'., t,
MY COMMISSION EXPIRES
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PO BOX 196650 ANCHORAGE, ALASKA 99519 343-4744
HAND WRITTEN PERMIT
Permit Numb~r:~W9~;/O Permit Type:
Date Issued. S//f/9o /~ Expiration Date:
Design Engineer:~/
Owner Name: L £~ ~/~£~/L Day Phone:
Owner Address: /Roo ~/A~~
Parcel ID: ~/~- /~/-c~
Lot Legal: Subdivision:'~/~/~ ~7-/S~-~ ~5~;~-i Lot: ,~/ Block: /
Section: 5~ Townshi~p:~x/~/ Range: 3f~!
Lot Size: ~77-5-~ (~. or acres)
Max Bedrooms: This Permit: 5 Total Capacity: 3
SEPTIC TANK: Minimum septic tank capacity: /P-~ gallons. Each
septic tank must have at least 2 compartments,~ insulation is
required if depth to top of septic tank(s) is less than 4.0'.
Lift stations require an appropriate electrical inspection.
WELL LOG: A copy of the well log must be sent to DHHS within 30
days of the well's completion.
i CmRTIFY THAT:
1. I will install the on-site sewer system and/or well in
accordance with all codes and regulations of the
Municipality of Anchorage (MOA) and State of Alaska , and
in compliance with the design criteria of this permit.
2. I will adhere to all MOA and State of Alaska requirements
for separation distances from any existing well, septic
system, or surface water on this or any adjacent or
nearby lot .
3. I understand that this permit is va~id for a single
family dwelling with a maximum of ,~ bedrooms. I also
understand that any enlargement will require an
additional permit .
4. I understand this permit is issued for the calendar year
and expires on December 31 of the year issued.
5. I will notify DHHS prior to all inspections by the
engineer or well driller.
( owne ride s f gnee)
ISSUED BY: /~ ~
db/ll5
ALASKA enUlROllme[1TAL CONTROL SeRUICe$, InC.
~n~inee~'in§ & i~nuir'onmenl~l Stutlies
1:200 UJes~ 33rd Avenue. Suile [B · Anchoraqe. ,~laska 99503 ,,{907) 561-5040
NORTHERN TESTING LABORATORIES, INC.
2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 907-277-8378 · FAX 274-9645
600 UNIVERSITY PLAZA WEST, SUITE A FAIRBANKS, ALASKA 99709 907-479-3115 · FAX 479-0547
Municipality of Anchorage
DHHS/Water Quality Section
P.O. Box 196650
Anchorage, AK. 99519-6650
ATTN: Dan Bolles
Source: :~Li3t/32,:B 1,:BirCh~:Tree ~stat~~:
Sample ID#: A041190-24
Date Arrived:
Time Arrived:
Date Sampled:
Time Sampled:
Date Completed:
04/11/90
1046
04/11/90
1020
04/11/90
Parameter Unit Result
Fecal Coliform
#/lOOml
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MUNICIPALITY OF ANCHORAC~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
RECEIVED
Reported By:
Date: 04/17/90
Francois Rodigari, Anchorage Operations Manager
ALASKA E I1UIROIlmelITAL COr/TROL SeRUICI S, lilt.
~n~lin¢¢ri~cI ~- ~nuironmcnlaJ Studies
SPECIFICATIONS FOR BED WASTEWATER TREATMENT SYSTEM
LEGAL DESCRIPTION: LOTS 81 & 32, BLOCK 1, BIRCH TREE EST.
1.0 GENERAL
1.1
The Drawings, sheets I thru 4, shall be part of
this specification.
1.2 All materials and workmanship shall meet the
requirements of the Municipality of Anchorage,
Department of Health & Human Services (DHHS), the
conditions of the permit, and all applicable rules
and regulations currently in effect.
1.3 All excavations and depths are advisory, and are
to be verified or modified in the field by the
Engineer or inspecting agency.
1.4
It is the responsibility of the property owner or
installer to adhere to approved design for the
installation, to maintain the required separation
distances and to have the appropriate inspections.
1.5
It is the responsibility of the property owner or
installer to report to the engineer any observed
conditions which would put the system in violation
of state or Municipal regulations.
1.6
If the installation is not inspected by an AECS
engineer, AECS will not be responsible for the
installed system. An engineer at AECS should be
consulted prior to construction, to determine the
number of inspections that will be required and to
explain what these inspections will involve.
2.0 SEPTIC TANK
2.1
The existing septic tank may be used, if it meets
the capacity requirement for the residence and the
approval of DHHS. If not, then specifications 2.2
through 2.6 apply.
2.2
The septic tank shall be a UPC-approved
two-compartment tank, constructed of 12 gauge
steel with bitumastic coating and set level on
undisturbed soil. If the tank is buried at a
depth of 4 feet or less, it must be insulated with
an overlying layer of 2 inch burial type
polystyrene rigid board insulation.
2.3
2.4
2.8
2.6
2.7
The septic tank shall be a minimum of 5 feet from
the house foundation, and a minimum of § feet from
the absorption area.
The septic tank and bed shall be a minimum of 100
feet from any private well or body of water, 150
feet from Class "C" wells, and 200 feet from Class
"A" and "B" wells, unless otherwise specified.
Less than the required separation distance must
have prior approval or waiver by DHHS or Alaska
Department of environmental Conservation (ADEC).
Piping shall be fitted with a mechanical
watertight calder coupling on the outlet and inlet
of the septic tank. Inlet piping shall be 4 inch
solid PVC ASTM D-$054 or cast iron, sloped a
minimum of 1/4 inch per lineal foot. Outlet
piping shall not be less than 1/8" per foot slope.
If the piping is buried at a depth of 4 feet or
less, it must be insulated with an overlying layer
of 2 inch burial type polystyrene rigid board
insulation.
Cleanouts shall be installed as designated and
capped with air-tight rain caps (Jim Caps or
equivalent), and extend a minimum of 1 foot above
ground level.
If a lift station is required, it shall be a
combination lift station septic tank per Anchorage
Tank and Welding, Inc., design. Specifications
and design drawings are on file with the
Municipality and the engineer.
3.0
SEEPAGE BED
3.1
The sand shall have an effective size of 0.4 to
0.6mm and a uniformity coefficient of not more
than 4.
3.2 The gravel for the bed shall be 0.5 to 2.5 inch,
screened rock with less than 3 percent passing the
No. 200 sieve. All substitutes must have prior
DHHS approval.
3.3 The bottom of the excavation shall be level and
raked with the backhoe blade to ensure that the
bottom has not been compacted during excavation.
Equipment must not be driven on the excavated
area.
3.4
The distribution pipe shall be perforated 4 inch
rigid PVC with a minimum crush strength of 1500
pounds, and shall meet the approval of DHHS for
use as drainfield pipe. Ail pipes shall be laid
level, and spaced according to the drawings.
3.5 Monitor standpipes shall be placed as shown in the
drawings. They shall be 4 inch rigid PVC ASTM
D-3034, or cast iron. The section shown with
holes may be either drilled 0.5 inch holes on 6
inch centers on opposing sides of the pipe, or a
section of regular perforated sewer pipe may be
clamped to the solid section with a no-hub
coupling or solvent welded joint. The perforated
section of the monitor tube shall be located in
gravel only. The portion of pipe above the sewer
rock shall be solid. A rubber raincap (Jim Cap or
equivalent) shall be placed over the top of the
pipe.
3.6
If the final grade over the bed is less than 4
feet above the gravel, Insulation is required,
using burial type polystyrene rigid board
insulation. There shall be 1 inch of insulation
for every foot of soil less than the required 4
feet of cover, but there must be at least 24
inches of soil even though insulation is used.
The solid pipe extending from the septic tank to
the drainfield shall also have a minimum of 4 feet
of cover or an equivalent layer of insulation
combined with soil.
3.7 A layer of filter fabric is required.
3.8 The top and sides of the bed shall be planted with
a white clover and red rescue mix, or with
Kentucky bluegrass.
4.0
INSPECTIONS
4.1
This bed will require a minimum of three
inspections. The first inspection will be of the
open excavation, to assure that the system is
installed in the proper soil strata, correct depth
and meet minimum specified design parameters.
4.2
4.3
4.4
4.5
The second inspection will be performed after sand
fill is installed, but prior to placement of
gravel and distribution pipes. This inspection
will verify that the filter is properly installed,
that it meets specifications and that it fulfills
the intention of the design.
The third inspection will be after placement of
gravel, monitor standpipes, and distribution pipe,
to verify proper installation and position of pipes
prior to backfill.
The inspection of the septic tank installation can
be incorporated with any one of the above listed
inspections.
The lift station will require either an MOA
electrical inspection or certification by a
licensed electrician, depending on whether the
building code applies to this part of the city.
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
~"200 'v'v'~[ 3dra Avenue, SuiL~ g
~.,n ~,~,,~ ~-, ALA3KA .....
SHEET NO. / OF
CHECKED BY DATE
SCALE
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PR0~UCT 204-1 ~lnc., Groton, Mm. 0!.471.
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DEPAflT.MENT OF HEALTH & HUMAN G~-~r~~¢'~~; 825 %' Street, Anchorage, Alaska gg5~_ ~.'~.~;.-,{.o."l{ °~
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PERFORMED BY:
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT _THIS TEST WAS PERFORMED IN
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Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99518
6.07'
MUNICIPALITY OF ANC
DEPT. OF HEALTH
~ ENVIRONMENTAL PROTEI
JUN 2 1 198
RECEIVE
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] SOl LS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
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DATE PERFORMED:
tA
SITE PLAN
WAS GROUND WATER v S
ENCOUNTERED? j L
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IF YES, AT WHAT 71--~'1
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
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PERCOLATION RATE ~ I ~O(,J (minutes/inch)
TEST RUN ~ETWEEN 6,-¢ FT AND 7~~ .T
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TELEPHONED ~ P'"'~E CArL
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WANTS TO SEE YOU RETURNED YOUR ~il,
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl- PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
2 P1 l.
DATE PERFORMED:
SLOPE SITE PLAN
10
11
WAS GROUND WATER
ENCOUNTERED?
12
13
14
IF YES, AT WHAT
DEPTH?
Reading Date
15
16
17
18
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***THEODORE F. MOORE
CE- 3589 .-'
F. MOORE
20
COMMENTS
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PERFORMED BY: ~(~_.~/~f 7-e~co! .~,rv;c~. CERTIFIEDBY:__O~""~ DATE:
PEF I '¥00 (minutes/inch)
TEST RUN FT AND 7r~ , ET
LOT 3O
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
L. oV 31
.~tO0~ O~P~7' ~l~Oer
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
THEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 June 16, 1989 ANCHORAGE, ALASKA 99516
John Smith
M.O.A. Dep't. of Health and Human Services
P.O. Box 6-8'50
Anchorage, AK 99519
Dear Mr. Smith:
MUNICIPALI'tY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION;
'JUN 9 1 1989
RECEIVED
By means oi' this letter I am requesting your consideration of a deviation
from a design practice set forth in the Municipal Wastewater Regulations, which I
feel is justifiable on an engineering basis. To assist in your evaluation I am
enclosing copies of pertinent backup information.
I have a client, Mr. Lloyd Walter, who owns the house on Lot 32 and the
adjoining Lot 31, block 1, of Birch Tree Estates. The present septic system needs to
be replaced and there is only one suitable area, located on Lot 31, which meets the
required separation distance from the well and a small creek running along the
back of the lots.
I conducted soils tests on the proposed site in the spring of 1986, and have
been periodically checking the water level in the monitor tube since that time. The
problem which we have encountered is that the only suitable soil (a gravel stratum
between 2.5 and 5 feet below ground level) becomes seasonally saturated to within
a foot of the top of the stratum. As you know, section 15.65.077.A.1 of the
Municipal wastewater ordinance specifies that there be a minimum of two feet of
unsaturated undisturbed native soil beneath a soil absorption mound. This
would not be the case here, during times of seasonal high water table.
While I would agree that this provision describes preferable practice, I
cannot think of a good engineering reason why it should be treated as an iron-clad
rule. By building a sand mound up to 4 feet above a seasonally saturated stratum
we can provide for the necessary aerobic decomposition and filtration. There is no
question that the underlying gravel stratum (even if saturated) will still be able to
accept the effluent loading from above.
The only issue is whether at least 2 feet of the required 4 foot vertical
separation from seasonal high groundwater must be native material. I believe a
good argument can be advanced that imported sand would provide a superior
treatment medium than most native materials. As far as I can tell, the Municipal
requirement for non-saturated native soil is not matched in either the State
Wastewater Disposal Regulations or in the EPA manual of "On-site Wastewater
Treatment and Disposal Systems".
Please review this situation, and advise me whether you feel you can allow a
deviation from the 2 feet of unsaturated native soil requirement in this situation.
If so, I will prepare a detailed design of the mound system for submission to your
office for a permit. Thank you for your assistance.
cc: Lloyd Walter
Sincerely,
Ted Moore, P.E.
Municipality of Anchorage
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
July 12, 1989
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject:
Lot 31, Block 1 Birch Tree Estates
Proposed Elevated Mound Wastewater Disposal System
Dear Mr. Moore:
We have reviewed your June 16, 1989 letter which requested a
deviation from AMC Section 15.65.007. .This section requires
that an elevated mound system be installed on a soil stratum of
at least 2 feet of unsaturated undisturbed native soil above
seasonally satura£ed horizons or bedrock.
Based on preliminary information which you provided, this
Department agrees, in concept, with your proposed design of an
elevated mound wastewater disposal system. It is our
understanding that your proposed design will require the use of
fill material to achieve the necessary vertical separation
between the bottom of the disposal system and the seasonally
high groundwater. AMC S~ction 15.65.040.G.3 does allow the
Department to approve the installation of an on-site wastewater
disposal system on fill material.
It is understood that issuance of a permit will be contingent
upon review and approval of the final design documents. In
order to satisfy the intent of the ordinance and to adequately
protect seasonally high groundwater the following items will be
required as part of the design, construction, inspection and
testing of the system:
Fill material which is installed to meet the two foot thick
separation requirements, specified in AMC 15.65.077.A.1,
must be placed and compacted to 95 percent of maximum
density. The density must be confirmed by ASTM D1557. In
addition, the compacted fill must be field verified to have
a percolation rate between 5 and 60 minutes per inch.
"Kids Are Our Future"
Ted Moore, P.E.
July 11, 1989
Page Two
A monitoring tube must be installed adjacent to the mound
system which will facilitate sampling and testing of
groundwater for a period of one year. Specific testing
requirements will be included as an addendum to the permit.
If test results indicate contamination of groundwater,
abandonment of the system will be required.
If you have any questions or concerns, please contact me at
343-4360.
Sincerely,~/~ ~ _
Jo Smith, P.E.
Program Manager, On-site Services
(-;':~'=r r_: ,:.~, ANCt'IORAOE AREA BO, 'JGH
E~:PARTMENT OF ENVIRONMENTAL OUALI ,-.
SEWAGE DISPOSAL SYSTEg -- APPLICATION AND PERglT
2192
......
~]: INSTALLATION OF: SEPTIC TANK ~
:'7~ TYPE AND SIZE Of FACILITY TO BE SERVED ~
~- FINANCED THROUGH
~.- TO BE INSTALLED BY
/ SOIL TEST RESULTS
- ~ NOTE= THIS PERMIT IS NOT VALID WITHOUT ~IL
~'.'' FINAL I~TIOH~ ~ HOUR NOTI~ R~UIR~D. ~A~iL~IN~ OF AN~ ~ WITHOUT FINAL INSPECTION ~ tH~
~_:. HEALTH DEPARTMENT AUTHORI~ WILL B~ ~UBJEGT TO PRO~CUTION.
/ ~,/~ ~' SEEPAGE AREA SIZE
MINIMUM DISTANCE~, REQUIREMENTS
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT .
-:: ~'$EPTiC TANK TO SBEPAG~ PIT WALL _..
TO NgARE~T ~OT
DRAIN FIELD ....
WATER MAIN TO SEPTIC TANK
· , DRAIN FIELD
DRAIN FIELD
, SEEPAOE P,T/
-, ALSO CONSIDER AREA WELLS.
. SEEPAGE PIT
DRAIN FIELD_
:SEPTIC TANK,. , SEEPAGE Pit /~ , DRAIN
TO RIVER, LAKE, STREAM. FIELD
-CAST IRON INTO AND OUT OP' SEPTIC TANK AND INTO CRIB CROSSING GAP OF
:.;~-i-EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
~4, INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC T~NK A_ND SEEPAGE Pit
FITTED WITH AIRTIGHT REMOVABLE GAPS.
GRAVEL ~ACKFILL
CONFORM TO BOROUGH REGULATION~ REGARDING INSTALLATION.
LICENSED DESIGNER
TYPE
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.
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. # ~)!7'--
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone ~J~, - ~'~"-' ~.~~,1:::,
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT 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.
NameofFirm "~ ~/-¢/¢~// ~/~o¢~--g/~fJ P~_m~ Phone ¢~-,~"~/'~
Address ~ ~ ~ k~f '//"'~/o
Engineer's signature ~'~..- Date
6. DHHS SIGNATURE ....... '---"
Approved for ~'~'~' [~-~) bed roe ms.
Disapproved.
Conditional approval for
bedrooms,
with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev, 1/91) Back MOA ~1
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type
If A, B, or C, attach ADEC letter.
Date completed
Log present (Y/N)
Total depth ~> ~! I
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Parcel I.D. ~ 17- I¥1'-~/=
ADEC water system number
t¢7 Driller
Cased to ~ I1 J Casing height
Wires properly protected (Y/N)
FROM WELL LOG
AT INSPECTION
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform (~ Nitrate
Date of sample: t/ I'~.10 '/~'"'1 l ~ ~t ~
Collected by:
et he.~.~ba~
B. SEPTIC/HOLDING TANK DATA
Date installed ~'//~/~'/_D
Cleanouts (Y/N) y
High water alarm (Y/N)
Date of pumping
Tank size Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N)
Alarm¢'tested (Y/N)
NO u/ [~, ~ ~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot J 0 ~ On adjacent lots
To property line ~, ~'"'t~
Surface water/drainage __
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"PumP off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION:FIELD DATA
Date installed ¢7/~ ~
Length ~ ~' Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating /'"'-%~ ~ System type /~' ~':-'' L-~
Gravel thickness ~ I f Total depth "~
Cleanouts present (Y/N) ! OA~/
Date of adequacy test _
for ~' bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots ~' /f-~"~ Property line
To existing or abandoned system on lot
Cutbank J~ ¢ t,¢-~-.._- Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name . ~'~O .~'~'ut ,,,.~ U ~[~ ~ P ~
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $,
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
MUNICIPALITY OF ANCHORAGE ~i~
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. # Ol']' IHI- O~> ~__7- 37---- NAA# ~/--~P--~7'~P..-
1. GENERAL INFORMATION
Oompletplegal description ~'
Location (site address or directions)
Property 'owner
Mailing address
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
m
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ~
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide ~written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev, 1/91) Front MOA #21
STATEMENT 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.
Name of Firm ~ ~:::'"' Phone ,~-
Address ;~,- O _~ _- ~' - -.-_-- ~ ~~ ......
Engineer's signature ~ Date
DHHS SIGNATURE ".~= ~-~
Approved for
bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the follOwing stipulations:
Additional Comments
By: Date
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-O25(Rev. 1/91) Back MOA~21
Legal Description:
A, WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C, attach ADEC letter. ADEC water system number
t~.~ Date completed I ~ '~ .~ Driller
! I } Cased to '~ I I ~ Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
g.p.m. -~, ~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot I
Absorption field on lot
Public sewer main
Sewer service line
g.p.m~ ~ ~
o
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
~> 15'D
WATER SAMPLE RESULTS:
Coliform /~ Nitrate
Date of sample: I~[~ ~ ~' [O~ ~1 ?---
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed g l'7 } ~ O
Cleanouts (Y/N) Y
Tank size ~ ~
Foundation cleanout (Y/N) ~
Compartments
Depression (Y/N)
High water alarm (Y/N)
Date of pumping ' ~.~ ~/ .L.~, t ['~ ~ ~'- Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) onlot J 0 ',~1,, On adjacent lots
To propertyline ~ .~ (::2 Absorption field !-7
Surface water/drainage
Alarm tested (Y/N) [~/f,/A
Foundation
Water main/service line
72-026 (Rev, 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION ~/~,
Date installed
Manufacturer
Size in gallons
Manhole/Access (Y/N)
Vent (Y/N)
'"Pump on" level at
"Pump off" level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed J'/'7 1 ~ D
Length ~ ~ Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail) ~
Peroxide treatment (past 12 months)
Soil rating
Gravel thickness
J -~ System type
~ II Total depth
Cleanouts present (Y/N) y
Date of adequacy test''~ 0/~.
for
bedrooms
If yes, give date
SEPARATION DISTA'NCE FROM ABSORPTION FIELD TO:
Well on lot ~11
To building foundation
On adjacent lots ~' J,~'"'~.~
Surface water '~
Curtain drain
On adjacent lots '~ /o-~:~ Prpperty line
~ Z, ~ To existing or abandoned system on lot
Cutbank ~o ~ ~ Water main/service line
E. ENGINEER'S CERTIFICATION
~-~'~'~. Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name" "~ ~,,~' ~ ~
Date N O v/ It t j' ~ ~j Z--.
HAA Fee $ // 7/~)' ~
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number