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Home My WebLink AboutCENTRAL BIRCHWOOD LT 168B Municipality of Anchorage Page DEPARTMENT 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: ~-~[J ~3~"~ ~ ~' [ _,C"~ PID Number'. ~;)¢'-~ ! ! '"~'~-'"~ ~~ ¢. ~ ~~¢ ~. ~~ Wastewater System: ~ New ~Upgrade ~:~ ABSORPTION FIELD Phone: INs of~ooms: ~eepTrench ~ShallowTrench ~Bed ~Mound ~Other LEGAL DESCRI PTI O N so,, Rating: ~- 4~PD/Sq. Ft. Total Depth from original grade: Subdivision: Depth to pipe bottom from original g~e: Gravel depth beneath pip~ Ft. Township: I Range: I Section: Fill added above original grade: / Gravel length: WELL: Q New ~ Upgrade Gravel width: C/Ft. Num~nes: I Distance between lines: Ft. ification(Private, A,~,C): - Total Depth: Cased To: Total absorption area: Pipe material: ~[ Driller: ~ Date Drilled: Static Water LevehFt. ~~ ~. Dateinstalled:~/~/~ Yield: GPM ~ Pump Setat: Ft. ICasing Height AbOve GrOund:Ft. TANK SEPARATION DISTANCES ~eptic ~¢~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacityt i~lon~: From Tank Field Station Tank S .... Lines ~ ~~ i~ ~1~ ~ ~ Material: Number of Compartments: Well ~ ~ Surface Water I~'~ ~¢~. ~ ~ ~ LIFT STATION LineL°t, ~/~~ ~ ] I~ I Size in gallons: Manufacturer: Foundation ~l ~ ~ ~ ~ "Pump on" level at: ~:'1[ High water alarm at: CurtainDrain ~ ~[~ ~[~ ~, ~ ~[ ~ pu~ Electrical. Inspections performed by: Remarks: BENCH MARK Location and Description: Assumed Elevation: ENGINEER'S SEAL Inspections performed by: 170~Ea~l. Riv.rLo~R~$,~ lSI~I~'~ ~o; ,. Department of Heard Hum~ Services apprcval// ~eviewed and approved by: Bate: '~'~-~~~~ 72-013 (Rev. 9/91) MOA 25 Permit'No. SW950210 Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 iter Disposal System and/or Well Inspection Report Legal Description.CENTRAL LOT 168:B PID No.: 0511 5347 W-ELIg 100' WELL RADIUS t ' DIVmTER V~ FINAL GR~ 'C01 ~.8' X C~2 MT2 ENGI~~AL & 91.5' NO ~ATER FOUND . , .. ~ ~ ~.,? 72-013 A (Rev. 9/91) MOA 25 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW930210 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:PORTER JACK V & LORETTA E OWNER ADDRESS:19961 BIRCHWOOD LOOP RD EAGLE RIVER, ALASKA 99567 PAGE 1 OF 1 DATE ISSUED: 7/12/93 EXPIRATION DATE: 7/12/94 PARCEL ID:05115347 LEGAL DESCRIPTION: CENTRAL BIRCHWOOD LT 168B LOT SIZE: 44160 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM 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 343-4329 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS DATE: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & ELOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST 4unicipality of Anchorage )EPARTMENT OF HEALTH AND HUMAN SERVICES 325 L Street ~nchorage, AK 99519-6650 ~FE~NCE: Central Birchwood Subdivision, Lot 168B request you issue a permit to upgrade the septic system ~erving the four bedroom house on the referenced property. ~wner reports existing septic system is in a state of ~ailure. test hole was excavated and a percolation test performed. ~he approximate location of the test hole is located on the attached site plan. The monitoring tube within the test hole ~as been checked and found to be dry. Ie do not anticipate any adverse effects on neighboring )roperties by the installation of the proposed septic system. [f you have any questions, or require additional information for your review, please contact us. A. Shafer, P.E. s/nsu/lsu STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP ' SUITE 204 · EAGLE RIVER, ALASKA 99577 1"'= 40' SCALE JUPGRADE I BIRCHWOOD OP __~0 ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Central Birchwood Subdivision, Lot 168B GENERAL: 1. ® The scope of this project includes the installation of a leachfield trench to serve the four bedroom residence located on the referenced property. The existing septic tank is to be excavated to verify integrity. If of poor integrity, the tank is to be abandoned and a new tank installed. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wast·water Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wast·water disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTB?.?.qTION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Page Two Central Birchwood Subdivision, Lot 168B June 20, 1993 Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INST~?~.qTION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed- up) before gravel (sewer rock) placement· Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. Page Three Central Birchwood Subdivision, Lot 168B June 20, 1993 MINIMUM NATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. 0 The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. e Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. ® Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the ~200 sieve. ® When sand is being used as a filter material, it's gradation specifications must conform to AMC 15.65.060D. Page Four Central Birchwood Subdivision, Lot 168B June 20, 1993 INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. e The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. e The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre- construction meeting will take place on-site. PERFORMED FOR: LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DEPTH (FEET) t 3 4 ! ? 8 10 13 14 17 ~ ' ~,H. 19 20 SLOPE SITE PLAN WAS GROUND WATER hO ENCOUNTERED? S IF YES, AT WHAT ~ g DEPTH? p E Depth to Water Alter,~,,.,..~, Monitoring? ]...) I ~J/ Date: Gross Net Depth to Net Reading Date Time Time Water Drop :~o ~ o 9 Y~ " yz PERCO,AT,ON RATE qO (minutes/inch) PERC HOLE DIAMETER 4-i~z TESTRON.~TWEEN g.$ .TAND 7, COMMENTS f),~g I I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MuNl~u ~ulDEL ON THIS DATEDATE. DATEDI : 72 008 (Rev 4/85) , DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 00501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME [.PHONE [] UPGRADE MAILING ADDRESS LEGAL DESCRIPTION ~~ LOCATION~ NO. OF BEDROOMS J Well ~ Absorption area Dwelling PERMIT NO ~ DISTANCE TO: /~ O '~ /~ ~ /W ~ ~ ~ ~ ~ Z Manufacturer ~~~ Mat~al~-~ ~ N°' of compartments ,~ Liq. cqpacity [n gallons Inside length Width Liquid depth / Z- ~/ ~ If HOMEMADE: ~ DIS~E~ . Well Dwe]ling PERMIT NO. ~ -- ~ M~ac~r~/ ~ Material ' Liquid capacity in gallons ~ Well Foundation Nearest lot line PERMIT NO~~~ DISTANCE TO: / ~ ~ ' ~ ~ ~ -- ~ No. of lines Length of each line lotsI length of lines Trench width Distance between lines ~ ~ / 3 ~ inches ~ Top of tile to finish grade ~'1 Material beneath tile ~ ~ II inches Total effective absorption areaz O.~ t Length Width Depth PERMIT NO. ~ T~~ Crib diameter Crib depth Total effective absorption area m /DI~A~'E T~: Well Building foundation Nearest lot line ~ ~ Class ~/~ Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS 3034 / , . , INSTALLER ~ REMARKS ~ ~ 13 (Rev. 3/78) tV1-W DRILLING, Inc. P.O. Box 10-378 · 10300 Old Seward Highway (907) 349-8535 ANCHORAGE, ALASKA 99511 DRILLING LOG ' JACK %7. ~)l~i~_dR Use of Well Well Owner ~,~ Location (address of: Township, .Range, Section, if known; or distance main road Lot 168 B Centre~ 3~?c!r~x~d ~ubdivision Size of casing. 6" Depth of Hole 76 feet Cased to 75.5 feet Static water level 64 ft. (lfl~ (below) land surface. Finish of well (check one) Screen ( ); Perforated ( ). ~e Describe screen or perforation Well pumping test at. 5 gallons per of drawdown from static level. June 25, lq83 Date of completion open end ( >tx ); (minute) for 1 hours with ]O!TL WELL LOG Depth Ln feet from ground surface Give details of formations penetrated, size of material, color and hardness 0 .TO. 2 Cas~ stickup 2 .TO 3 3 .TO. 10 10 .TO. 22 22 .TO. 38 38 TO. 41 51 .TO. 55 55 TO. 7I) 70 TO. 75 TO .TO. .TO. __.TO .TO .TO. Organic Silty ~ravel $~ty ~ravet Sandy gravel Silty gravel ~ gravel Sm~dy ~mterbearing gravel · ~os. 814 & ~;7r 3- CONTRACTOR PERMIT NO. ~,4,.{.,---4../ //..~,.-' t-1 L! I'-.I 1- C: I t :-, L l- T 'T' II--i F R I'-.I C: H,, F~.' R G E ~ -- DEPRRTMENT AN[:, EN.IR_NMENTHLn - F'R. OTECTION .~c~]}~_~'~' ~" \~ I-IF HEALTH :---:25 '"L'" STREE¥., ANCHORAGE, AK. 99501 264-4720 I-.-IELL RI"-.I[) ,_-"1"-.I--"_=~ I TE CEI...IEF.: F'EF~:t-1 I T ( 8-<05F'~0 ) APPLICANT LOCATION LEGAL JRCK VAN PORTER L±68B CENTRAL BIRCHWOOD 90±± SHRUN CIRCLE 99502 243-0449 LOT SIZE 999999 SQUARE FEET TYPE OF SOtL FIBSORPTION SYSTEM IS: TRENCH MAXIMUM N'L~ME~ER OF BE[:,F,:OOMS = _--.-: SOIL RATING (SQ FT/BR)= 264 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEbl IS: [)EF'TH= 12 L E r-.~ I-~'T H = ~_-i ~.-E~ Ci I(: !:!"..-' E L [:,EF'TH= THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET;). E:E6!LI I E:E[:. SEF'T I C: TAr-IF=:: c I ZE= :1. ~Z~rZl~Zl mSRLLC,~-IS PERMIT HFFLI_.HNT HAS THE RESPONSIBILITY TO iNFORM THIS DEF'RRTMENT DLIRING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE Tb-lC~ < 2 ) I I'-~'_--;F'EC:T I C,l'-.tS RE:E E:ELT!LI I F-:E[:, BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPRO'v'RL BY ;'HIS DEPARTMENT WiLL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN "100 FEET FOR A F'RI'v'ATE WELL OR 150 TO 2E~E~ FEET FROM A PUBLIC WELL [:,EF'ENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM A PF.:IVRTE WELL TO FI PRI'v'RTE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRE[:, AND MUST 8E RETUF'.NE[:, TO THE DEPARTMENT WITHIN 3:0 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY RPPL"r'. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS RF.'.E fl',,"AILflBLE TO INSURE PROPER INSTALLATION. I CERTIFY THAT ±: I AM FAMILIAR WITH THE REL-]UIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH B'-r' THE MUNICIPALIT"r' OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN RCCORDANE:E WITH THE CODES. -<: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MFP'r' REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN _-< E:E[:'ROOMS. SIGNED: RF'PLICRNT JACK VAN PORTER SSI_lED BY_ .... V4. E~ PERI. I E ~ OEPF~ THEN T OF HEF~L TH RNO ENV [RONHEN I'll_ PRO FEC, r t ON RPPL[CRNT .rRcK YRN PORTER ~g~ ~-HF~JN C[R¢I.E ~3-502 LOCR T £ '3N LEOP]L L~r~8 CENYRRL ~I~.CHWOO& LOT TYPE OF '$OH. RSSORPTION ~YSTEM I~: TRENCH ~P Tt~= i2 LENGTH= 6g GR8%.'EL OEPT~= THE L~OTH OIr~ENSI~ IS THE L~ (IN F~T) I~ THE TRE~ OR ~E O~TH OF R TR~2H OR PIT I~ TH~ O[STRNCE BE~ ~ROtJNO R~ rile 80TT~ OF ~ E~CRVRT[~ <~N FEET). T~E I~ ~ ~T WIO~ FOR tREnCHES. ~JD THE 8OTTOM OF ~E ~VRT[ON ~N PERMIT RP~IC~T HRS THE ~5PONiES[LEKY FO [~ORN ~[5 ~RRKI~NT D~[~ THE TtUO ( 2 ) I NSPEO ? X ON5 ARE RK,2U}I RED ~-- DEPAAKHENK W KLL 8~ 5US~ECF TO PROSECU F ~IINIP~UH OI~l'Rt~'E 8EFMEEN · ~ FEET F~ UPON THE rYP~ OF PUBLIC t~[H[t~UH OI~ TRNCE TO R COHHUN [ ~ OF T~ b~L ~HPLE F KON. ~VRfLROI.E TO INSURE PRt3P~ [NSF~LRYfON. ,/ FORD( 8Y THE H~ICIPALITV OF OR rE__ . . =. ___ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PERFORMEb FOR: LEGAL DESCRIPTION: Triad Engineering Test Hole 2 Birchwood Loop Road DATE PERFORMED: 3-8-82 tl Il 1 II I t I I tl II t 1 2 3 4 5 6 7 8 9 lO 11 12 13 14 15 16 17 18 19 2o COMMENTS PEAT, PT SILTY GRAVELLY SAND, SM Frozen~to 2.5' Tan SILTY SANDY moist GRAVEL', GM SLOPE SITE PLAN SE~ A1TA(:HE[ SITE PLf N FI AI'E I WAS GROUND WATER S ENCOUNTERED? N0 L O IF YES, AT WHAT MoiSt to wet DEPTH? Larger gravel at 15.0' TOTAL DEPTH OF BORING 20.0' , PEI~CO LATION RATE No free water observed TEST RUN BETWEEN Gross Net Depth to Net Reading Date Time Time Water Drop SEE ATTA(:HED PLATE 4 [minutes/inch) 6.0 FT PERFORMED BY: Cherie McCracken CERTIFIED BY: J.M. Lambe DATE: 72.008 (6/79) 3 J ~ SOIL AND MATERIALS ENGINEERING AND TESTING John M. Lambe, P.E. 4101 Arctic Boulevard · Suite 205 * Anchorage, Alaska 99503 907-276-4113 March 17, 1982 Triad Engineering 6937 Old Seward Highway Anchorage, AK 99502 Attention: Dave Grenier Subject: Soils Investigation Lots 168A & 168B in Eklutna, Alaska Dear Sir, This letter presents the results of the soils investigation that we performed at your request on Lots 168A and 168B in the Bi rchwood Loop Road area. This work was requested to be per- formed to the minimum standards of the Department of Health and Environmental Protection (D.H.E.P.). These standards include the drilling of a soils boring to a depth of 20 feet and the visual classification of the soil strata encountered by a field tech- nician. No laboratory analyses are requested. In soils which are visually classified to include more than 6% silt, {soil finer than the #200 screen size), a ~percolation test is required to be performed in the area most likely to be developed for the ab- sorption system. Our procedure for performing the percol.ation test is to drill an additional boring adjacent to the soils log to the depth intended for percolation testing., Coarse gravel is placed in the bottom of the boring. Four inch slotted and per- forated PVC pipe is placed within the percolation test boring and the annular space between the boring and the pipe is backfilled with washed gravel. The percolation boring is filled with water and allowed to saturate overnight. Percolation testing is per- formed the following day according to the standards presented in the E.P.A. publication "On Site Waste Water Treatment and Dis- posal Systems," Page 41, Table 3-8. All soils are visually classified in the field according to the Unified Soils Classification System presented on Plate 5 and the textural classsification system presented on Plate 6. Per- forated 1-1/2 inch nominal standpipe was placed in the deep borings to allow for observation of free water level after drill- ing. In soils with a significant silt fraction, substantial time, often several days, is required to allow the free water level to stabilize. While no free water was observed in these observation standpipes the days when the percolation testing was performed, it should be noted that the free water level may fluctuate seasonally and annually in response to seasonal runoff or heavy rainfall. The results of the field investigation and percolation test- ing are presented on the attached plates. The soils logs are presented on the standard D.H.E.P. form attached as Plates. 2 and 3. The locations of the borings are presented on Plate 1. The results of the percolation testing are presented on our form, P1 ate 4. We were requested to perform this investigation to the minimum standards required by the Department of Health and En- vironmental Protection. It should be noted that, in accordance with these standards, the classifications of the soils are visual and performed by a soils technician. These classifications are subject to change as they have not been verified by laboratory analyses. This work was performed for the the sole purpose of preliminary evaluation by the Department of Health and Environ- mental Protection of the suitability of the lots for on site sewer system development. Any extrapolation of this data for other purposes is not within the intent of the investigation or r. equested services. We trust the foregoing is sufficient to your ~mmediate needs and is comprehensive within its limited scope. If questions arise or if we can be of any further service, please feel free to call. Very truly yours, //John M. La~e, P.E. Civil Engineer 4254-E _ I Birchwood Loop Road , / t H 1 ' Test Hole 2 a /168-A 168-B/ : .... ,/ / , ~ I I ' I , I i ~ I Scale 1" = 100' Notes: 1. Test holes not located by survey methods. 2. Base drawing and contours from preliminary plat provided by lriad Engineering. ,J L SITE PLAN PLATE AMBE AND ASSOCIATES Triad Engineering Soils Iaboratory and Geotechnical En§ineerin§ Birchwood Loop 1 Jobno. 87-341.02 Appr. dMk .Date 3/17/82 Eklutna, ^laska f'~'4UNICIPALITY OF ANCHORAGE f~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street° Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST r"l SOILS LOG [-I PERCOLATION TEST PERFORMEb' FOR: Trtad I~n_atneeri nq LEGAL DEECRIPTION: Test Hole ! DATE PERFORMED:. 3/8/82 Birchwood Loop Road Lot 168A PEAT, PT. 4 5 6 7 8 9 10 11- 13- 14- 17 18 19 20 SILTY GRAVELLY SAND, SM, TRACE ORGANICS Frozen to 2.5' Tan SILTY GRAVELLY SAND, SM moist Few cobbles SLOPE SITE PLAN S~F ,TT~.HIFD !rTE PI'AN FLAI E 1 WAS GROUND WATER ENCOUNTERED? NO P IF YES. AT WHAT E DEPTH? Read;ng Data Gross Nat Depth 1o Net Time Time Water Drop SE' ATTACHED PLATE 4 TOTAL DEPTH OF BORING 20.0' PERCOLATIONRATE ~4 (m;nut~linch) No free water observed - ~l~/~ TEST RUN "ETWEEN ~-~ FT AND ~_n FT COMMENTS PERFORMED BY: Cherie McCracken CERTIFIED BY: O.H. Lambe 72-001 (6~9) DATE: 2 PERFORMED FOR:, LEGAl. DESCRIPTION: (~'"~,'IUNICIPALITY OF ANCHORAGE t'~ · DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 g Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST Triad Engineering DATE PERFORMED: Test Hole 2 Birchwood Loop Road SOILS LOG PERCOLATION TEST 3-8-82 1 2 5 6 7. 8 g 10 11, 12- t3- 14- · l 18' CO['.IM ENTS PEAT, PT SILTY GRAVELLY SAND, SM Frozenqto 2.5' Tan SILTY SANI GRAVEL SLOPE SITE PLAN SCl A'TA(HEI S TE PU q A1 E I MoiSt to wet Larger gravel at 15.0' ENCOUNTERED? ' HO IF YES, ATWHAT ,, / DEPTH? TOTAL DEPTH OF BORING 20.0' PE No free water observe~c°tATl°N RATE TEST RUN BETWEEN SEE ATTAI NED PLATE 4 I [m;nute$/inch) 5,5 FT AND 6.0 FT PERFORMED BY: Cherie HcCrack~n CERTIFIED BY: JoH. Lambe DATE: ~ 0 0o ev~ Triad Engineering Soils La~ratory and Geotechnical En~tneerinD 8trch~ood Loop 4 Jobno.. 82-347.02 Appr. ~ML Da/e~ Eklutna Alaska • • PGt QG • Municipality of Anchorage On-Site Water and Wastewater Program ei 1 (907) 343-7904 SA [*.V CERTIFICATE OF ON-SITE SYSTEMS APPROVAL Parcel I.D. 051-153-47 Expiration Date: SP' —2&P.--/ 1. GENERAL INFORMATION Complete legal description CENTRAL BIRCHWOOD LOT 168B Location (site address) 19961 BIRCHWOOD LOOP ROAD, CHUGIAK,AK 99567 Current Property owner(s) RICHARD &CRISTINA JENSEN Day phone Mailing address 19961 BIRCHWOOD LOOP ROAD, CHUGIAK,AK 99567 Real Estate Agent Day phone _ 2. TYPE OF DWELLING: • Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well ® Individual Individual Water Storage ❑ Holding Tank ❑ Community Class Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: %2ee2 c "% ee/ L Date: ..V.,,/g//88 COSA to be released to the engineer,unless othe s r quested by the engineer. COSA Fee $ 5-061 Waiver Fee $ Date of Payment -J -Ql Date of Payment Receipt Number 6QQ9VO Receipt Number COSA# 666/3/0100 Waiver# 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, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm ARCTERRA CONSULTING,INC. Phone 868-3791 Address 20441 PTARMIGAN BLVD.,EAGLE RIVER,AK 99577 Engineer's Printed Name KENNETH M. DUFFUS Date 2/20/2018 Engineer's Comments:This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface conditions that may not be observed from the surface,changes inland use,local soil characteristics,groundwater levels that may fluctuate during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are subject to these various and dynamic characteristics and are outside the control of the evaluator of the well and septic system. Therefore, ArcTerra can not give any estimate of how long a system will function satisfactory for current or future occupants or can ArcTerra guarantee that no unseen ,•• OF A encroachments,deficiencies or discrepancies exist. 'cks L/,‘) y r * 4iTI-i .' 6. DSD SIGNATURE - AMY KENN • M. 7 y System #1 Approved for bedrooms. � rra 7tt. 1 j System #2 Approved for bedrooms. 1 o 2 &it)' SSto-�V Disapproved. `•�`-�� Conditional approval for bedrooms, with the following stipulations/. vai_to _PI6D c1-6 Q t- s 0,..:0**4 0L-0 '� SITE ON- m,: WATER AND d WASTEWATER oz PROGRA �, 0441 `Ge<'gO Original Certificate Date: 2' ^1 The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 7. ATTACHMENTS: COSA Checklist X Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory Other---moo cosA blue sheet 10-1O-12.doc If more than 1 septic system is on the lot: COSA Checklist# of_ Structure served by this system _ Certificate of On-Site Systems Approval Checklist Legal Description: CENTRAL BIRCHWOOD LOT 168B Parcel ID: 051.153.47 A. WELL DATA Well type PRVT If A, B, or C provide PWSID#_ Well Log (Y/N) Y Date completed 6/25/1983 Sanitary seal (Y/N)Y Wires properly protected (Y/N) Y Total depth 76 ft. Cased to 75.5 ft. Casing height(above ground) 24 in. FROM WELL LOG AT INSPECTION Date of test 6-25-1983 2/15/2018 Static water level 64 ft. 67 ft. Well production 5 g.p.m. 6.2 g.p.m. WATER SAMPLE RESULTS: Coliform A _1 colonies/100 mL Nitrate 5,79 mg/L Arsenic: A ? ug/L Date of sample: 2/15/2018 Collected by: ARCTERRA B. SEPTIC/HOLDING TANK DATA Tank Type/Material SEPTIC I STEEL Date installed 8.1983 Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N Date of pumping1129H �/J 9/i& Pumper,JR< jet 1-a,Y ptA44 S C. ABSORPTION FIELD DATA Date installed 8/13/1983 Soil rating (g.p.d./ft2 or ft2/bdrm) 264 System type DEEP TRENCH Length 88 ft. Width 3 ft. Gravel below pipe 8 ft. Total depth 13*ft. (see comments) Eff. absorption area 1408 ft2 Monitoring tube Y Depression over field N Date of adequacy test 1/30/2014 Results(Pass/Fail) PASS For 4 bedrooms Fluid depth in absorption field before test 11.5 in. (Below Invert) Water added 790 gal. New depth 2 in. (Above Invert) Elapsed Time: 1365 min. Final fluid depth 13.5 in. (Below Invert) Absorption rate >= 600 g.p.d. Any rejuvenation treatment(past 12 mo.) (Y/N &type) N If yes, give date D. LIFT STATION Date installed Size in gallons Manhole/Access(Y/N) "Pump on" level at_in. "Pump off' level at_in. High water alarm level at in. Datum Cycles tested Meets alarm &circuit requirements? E. SEPARATION DISTANCES WELL ON LOT TO: Septic tank/lift station on lot 100'+ On adjacent lots 100'+ Absorption field on lot 100'+ On adjacent lots 100'+ Public sewer main 75'+ Public sewer manhole/cleanout 100'+ Sewer/septic service line 25'+ Holding tank 100'+ Animal containment areas 50'+ Manure/animal excrete storage areas 100'+ SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line 5'+ Absorption field 5'+ Water main 10'+ Water service line 10'+ Surface water 100'+ Wells on adjacent lots 100'+ ABSORPTION FIELD ON LOT TO: Property line 10'+ Building foundation 10'+ Water main 10'+ Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+ Curtain drain 50'+(NONE KNOWN) Wells on adjacent lots 100'+ F. COMMENTS *System is 13'from existing grade based on recent measurements. 5'of the 8'effective depth is measurable from the sump invert with 5'of cover. The 1993 system is saturated. Subsequently,the 1983 system was pre-soaked per code then tested. The septic tank is 35 years of age and the 1983 field is operating in the upper reaches of the effective depth. It is unknown how long the system will continue to operate satisfactorily for the users,based on these observations. G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. i'� ff,O 4 j4 ' Engineer's Printed Name KENNETH M.DUFFUS / Date 2/20/2018 / * A 9 LI-1 . w: * ��w�i17/ COSA canary sheet_2-6-15.doc / KENNE M.1 /' IS / 4 \ . 7 18\ „„. 'PE SS IOh ' in r0 14) In BIRCHWOOD LOOP ROAD _ N89'44'05"W 148.84' M (N89'49'53"W 148.32' R) 20' T&E ESMT J PP — —0/H— —0/H— r] 0 O FT=—O7 - =0/I4 —e/H! --0/I— 0/H— —0/H-e ELEC N-ELEC PAVED METER D/W in a rn ®WELL ` CEDRE.... RY0 PAVED ift 38.9' .">' 44.0. 11111 D/W LA ,z}- "= �` COVERED 14.0' ENTRY EXISTING 49.o. 13.1' CC 0 N N SE HOU1..-x----x--- Zv 52.6' oi i. a - DECK • 79.0' IN c) w LU x N m uu •nnuuonn ll LOT o rn �� LOT 168-A `V x° a) 167 rcoN Q � Ior mN "00 N I O -Cr) SEPTIC• 12.0' i Z O VENT Oo (typ) • W I z $• N I II 1 x LLI • i N w LOT ., 16.0• 168-B 8.0' ; v SHED • : • ‘k_— N89'41'16"W 148.74' r —� (N89'49'13"W 148.60' R) ANCHORAGE RECORDING DISTRICT,ALASKA • =FND ALUMINUM MONUMENT ASBUILT OF: CENTRAL BIRCHWOOD SUBDIVISION O• =FND 5/8"REBAR LOT 168-B PLAT 82-129 _`"\ SURVEY CERTIFICATE:I,John L.Schuller,Have conducted a g OF' .A�N` , . LA U411,- ..... ,4 physical survey of this property as shown on this drawing and that the / `� . .`Qs�1 4 N.° r„ f, improvements situated hereon are within the property lines and no oir<S„!:.' 1 '�'k ,v,w� 1F'G,�t,,�, enchroachments exist other than noted.Under no circumstance should / :' 49TH i\ %.Y 1w N ,0 any information on this drawing be used for construction of fences, % 0, structures,improvements,or for establishing boundary lines. / / U EXCLUSION NOTES:It is the owners responsibility to determine ,o . �� tn. 9," 1:,, n e (C.- HN L. SCHULLER: °/ 1 ' .') the existence of any easements,covenants,or restrictions which ,,p. �,� do not appear on the recorded subdivision plat. 1'�'. LS-10408 . ..' .�._.,,. WORK ORDER NUMBER: DATE: SCAM (-MA 1�e '' , g�j� 1831 Anchorage,Talkeetna Street FEB 23, 2018 1"=40' 1�ap •;$• �a / Alaska 99508 18—010 KN BY:aIEOED en mno M soCK/PAOE: \�°fessionot 'P (907) 227-1455 office JLS NW1256 180111 \\VIieglibill'" (907) 274-4992 fax MUNICIPALITY OF ANCHORAGE DEVELOPMENT SERVICES DEPARTMENT I . `f�,'�!' 907-343-7904 On-Site Water and Wastewater Section `� �� Fax: 343-7997 www.muni.org/onsite OSC181060 Nitrate Advisory' Certificate of On-Site Systems Approval # OSC181060 Subdivision: Central Birchwood, Block: , Lot: 168B A water sample revealed a nitrate concentration of 5.19 milligrams per liter (mg/L). The Environmental Protection Agency (EPA) has established a maximum contaminant level (MCL) of 10.0 mg/L for public drinking water systems. While private wells are not subject to this regulation, EPA standards are based on existing health information and can therefore be used to gauge the relative quality of water from private wells. Please see the attached "Nitrate Fact Sheet" for important information regarding nitrate. This advisory must be attached to all copies of the subject Certificate of On-Site Systems Approval. Mailing Address: P.0. Box 196650 * Anchorage,Alaska 99519-6650 *www.muni.org MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Se[vices Section P,O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description g Location (site address or directions) 19961 Birc/,~ood Loop Road Chuqiak, AK Property owner Jack Po,'~ex Mailing address 19961 B~.c/~oood Loop Road Day phone 688-2602 Chugiak, AK 99567 Lending agency Mailing address Day phone Agent Mike Ga~st/MARSTON PROPERTIES Address Day phone 248-2804 Unless otherwise requested, HAA will be h.eld for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well XY, X Community well Public water NOTE: TYPE OF WASTEWATER DISPOSAL: Individual on-site Y, XX Holding tank Community on-site Public sewer If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. . 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 Se 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 verifythat 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 Engineer's signature DHHS SIGNATURE ~"' Approved for ~ Phone (~;~'Z/ S & $ ENGINEERING ~ bedrooms. 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 p,'ofessional engineer's work.. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.~o-~ 1 ~ ~ ~ ~'C~-~..t~ ~ ¢c~-,e~arcel I.D. A. Well Data Well type ~,,j ~..~ Log present~N) ~ Total depth -7 L.,' Sanitary seal ~/N) ~ Date of test Static water level If A, B, or C, attach ADEC letter. ADEC water system number ~. Date completed ~, ~ ~5'~- E,~ Driller t'~ - X~ Cased to -7 S~, ~"' Casing height 1 7-'('Ir' Well flow Pump level1 Wires properly protected (~N) ~ FROM WELL LOG AT INSPECTION .._Z.-L'- .---- ¢.,~ ~ o g.p.m. ~r' g.p.m. ,~ ~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot \ Public sewer main Sewer service line ~-~'~' tltt WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~:;)-~ ~'5 Tank size '~ '?-..~-'-,:~ Compartments Cleanouts ~/N) ~ Foundation cleanout (~/N) ~ Oepression,(Y~;I.~ High water alarm ('~ J Alarm tested (Y/N) h'~[ Date of pumping ~ _~c_,[~ Pumper "~-~ ~..~..s.Spoo SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot \ ~?'7-~ ~ On adjacent lots To property line \ ~ ~ '~ Absorption field Surface water/drainage ~ ~ o Foundation Water main/service line 72-026 (3~3)* Front CONTINUED ON BACK PAGE C. LIFT STATION Manufacturer Manhole/Access (Y/N) .----- ..--- ~s tested Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) ..~ SEPARATION~E FROM LIFT STATION TO: Well on lot On adjacent lots D. ABSORPTION FIELD DATA ~ l"~¢'-¢-- (-~{5 ~ Surface water ------- After test If yes, give date Date installed '7-~/~'~ ~-~ Soil rating (GPD/FF) ~, ~5"- System type Length ,/~ ~ / Total depth / Width ~ J Gravel thickness ~', ~ ~ Total absorption area ! ~ 5'~'~ ~ Cleanout present {~;/N) V Depression over field (Y~) Date of adequacy test /~J/~ -~ ~l~J~ Results (pass/fail) ~ for Bedrooms Water level in absorption field before test Peroxide treatment (past 12 months) ~ 1 Well on lot / To building foundation On adjacent lots Surface water Curtain drain SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots /~ o / ~- Property line ~' ~ ~ To existing or abandoned system on lot '~ ~ ! ~- Cutbank "¢'~/r- Water main/service line ! o ~ ~ ¥ 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 o~n. J¢e.. ,,, ~¢~te... ~,, of this inspection. Signature $ & S ENGINEERI 17034 Eagle River I.~d No. 204 Engineer's Namea¢_~ R!,,e_., Date HAA Fee $ ~:) - ~--~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) ,/ Property owner Mailing address Lending agency Mailing address Agent Ad dress ./¢¢ .¢ / Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer 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. Name of Firm Phone David R. Daytolt P.E. Add ress 20210 Dona{ar-~t. Chugiak, Alaska 99567 Engineer's signature Date DHHS SIGNATURE ~ Approved for J 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. 72-025 (Rev. 1/91) Back MOA #21 ( Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L~T//~'~ (_~o'.r/z,~._ g~C_z:~o Parcel I.D. A. WELL DATA Well type f2£~ t,,/tw-'~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~,'/2~//~F'-5 Driller /~4:/ 7 (-~ ' Cased to -/'~-~ ~5'~- ' Casing height A~? Wires properly protected (Y/N) 'Y/ Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION '"" -'~:~5:~' g.p.m. '~' -- ~ 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 ~ Date of sample: ////Z-~'/'~' Nitrate Collected by: bacteria B. SEPTIC/HOLDING TANK DATA Date installed ¢//~/~_-3 Cleanouts (Y/N) ~ High water alarm (Y/N) Tank size /~ 5'~~Compartments ~__ Foundation cleanout (Y/N) /~Y,/ Depression (Y/N) Alarm teSted (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line On adjacent lots I oc:~ ~ Foundation ~"0 Absorption field 2- ~ Water main/service line ~/'~ Surface water/drainage 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer 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 9//~)/ Length ~'~ ' Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating Z ~ ~ Z~£ System type Gravel thickness .-~ / Total depth Cleanouts present (Y/N) ~/ Date of adequacy test I/~/~, for ~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I ~) On adjacent lots ~ ~ -r- Property line To building foundation ~ To existing or abandoned system on lot On adjacent lots ;;~"P- Cutbank '~/'/~ Water main/service line Surface water ? ~ ~ Driveway, parking/vehicle storage area ~c:> Curtain drain /~J//~ 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 Date David R. Dayton P.E. ~,-~i~ I:~nalar St. Chugiak, Alaska ~567 HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number