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Home My WebLink AboutCHAMBERS LT 80A 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: ~1'dct$014"1ct PID Number: Name: Wastewater System: [] New ~ Upgrade Address: ,*t.o. Z~ox 670370 C/-,,oe,.~,,.-, ,,¢~ ¢~-~7 ABSORPTION FIELD Phone: I No. of Bedrooms: (~ I~ Deep Trench [] Shallow Trench [] Bed [] Mound [] Other I LEGAL DESCRIPTION sci, Rating: /,2. GPD/Sq. Ft. Total Depth from~originalt grade: Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe ;5._~' Township: ~ Range: ~ Section: Fill added above original grade: Gravel length: I I ~ Ft. ~ I Ft. WELL: ~ New ~ Upgrade Gravel width: Number of lines: Distance between lines: ~ · ~ Ft. ~ /~ t Ft. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: ~/V~' Ft. Ft. ~& SQ. Ft. ~ Driller: Date Drilled: Static Water Level: Installer: Date installed: Yield: GPM IPump set at: Ft. JCasing Height Above Ground:Ft. TANK SEPARATION DISTANCES ~ se,t~c ~ ,o~din~ ~ S.T.~.~. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: Material: Number of Compartments: S~rf~ ,+ ~ LIFT STATION Water /O~ /~d ~ ~ ~ - Lot Size in gallons: IMa~ Line ~ ~ q~ ~ ~ ~ F°undati°n IZ-~' ~E' -- ~ -- "~o~",~v~,~,: CurtainDrain -- ~O~"- ~O '~ Pump Make & M°de' I Electrical 'nspecti°ns perf°rmed bY:~ Remarks: BENCH MARK Location and Description: Assumed Elevation: " E~ SEAL 17~4 ~gle Riv~ ~ R~d, Ho. ~ ¢ * Inspections performed by: K~leRi~,Al~skt~577 Dates: 1st /~-~-?~ ~ 2nd. /~ -q-~~ .~ ~, ~.~:~,., ~.. Department of Healed H vi~es approval ~ ~:, ~' : ;;'. Reviewed and approve hate: ~/~ "~:~'":' ~ :' ~ :''''~ . , 72-013 (Rev. 9/91) MOA 25 Permit No. sw930479 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 On-Site Wastewater Disposal System and/or Well Inspection Report CHAMBERS, LOT 80A 05110345 Legal Description: PID No.: ~ C02 ~ ~ ~ ~ 98.2' il ~ ~! i 96.0' 95.5' ..................... .~' ' ' .......... i .......................................... i ........................................... i ................ U ................. :: .................... ~1[1"~ ...................................... ~ '~' NEW i :: ~Al i, lJ[I TANK i i :' i 92.7' ......................... ~.r.s...~ .......................................... ~ ........................................... ~ ........................................... ~ ........................... ~a,~ .......... s,.:~ .............. ~ .......................................... : ~[ ......................................... ~ .......................................... ~ .......................................... :: ........................................ ~ ................................................ :;~ .......................................... ~ .......................................... ~ :: :: :: FC0 -- -- :::: 17.5 14.5 :: ~ ~ ~ ~ C01 23.0 35.0'- ~ -- ......................................... NEW 500 GAL~ ............ ~~'~'~ ......................................... ....... :: ........... ) ~ ........................ "~' ::?'"'MT'I"MT2 BUfO"850 8'1'7~945 ...................................... -- -- SEPTIC TANK ~ ~ ~~~:'? SCA. t' = 40'~ : ~ , :: . A B C D FCO -- -- 17.5 14.5 C01 23.0 35.( -- -- C02 31.5 41.( CO3 46.0 54.£ C04 80.0 81.C C05 54.0 68.(] C06 86.0 93.£ MT'I- BO'JO' '8y7[ ....................... MT2 85.0 94.[ 72-013 A (1/93) * PAGE 1 OF 1 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:SW930479 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:MOODY ROBERT B & LUCY A OWNER ADDRESS:P. O. BOX 670370 CHUGIAK, ALASKA 99567 DATE ISSUED: 11/15/93 EXPIRATION DATE: 11/15/94 PARCEL ID:05110345 LEGAL DESCRIPTION: CHAMBERS LT 80A LOT SIZE: 99204 (SQ. ~T.) OF EDROOMS: IS 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 343-4744 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: 1. INSTALLATION BY OWNER PER WRITTEN REQUEST AT TIME OF APPLICATION. LETTER MISPLACED BY DEPT. RECEIVED BY: ~-'~_~.~. DATE: DATE: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. November 3, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEAL TH AND HUMAN SERVICES 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 80A, NE 1/4, Sec 9, T15N, RIW, SM, AK Request you issue a permit to upgrade the septic system to serve the six bedroom house on the referenced property. A test hole was excavated and percolation test performed., The approximate location of the test hole is located on the attached site plan. The monitoring tube within the test hole has been checked ~, found to be dry, This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your review, please contact us. Sincerely, RAS/LSU/Isu 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 ~ ~ ~ oo ~I z ~ ~o o~ I ~ 0 t00' ~ELL RADIUS ~~ ~ ~ Zz o~oI ~ o z o~ ~ ~ I ~ ~Z ~o ~o o o ~ ~ ~ 24 10' UTIL. ESMNT. 30V~Odfl ,0~ = ,,L Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL D ESCR I PTIO N :'~::>'~' ~)1 2 3 4 7 8 Township, Range, Section: SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S 11 ¥'~l L IF YES, AT WHAT pO DEPTH? 12 E Depth lo Water A~) 13 Monitoring? Gross Net Depth to Net Reading Date Time Time Water Drop 14 16 17 18 19 20 PERCOLATION RATE ~ [minutesZ~nch) PERC HOLE DIAMETER _ TEST RUN BETWEEN ~T AND ~ FT PERFORMED B~7034 Eagle-Rive; L.p R.d .o. 2~ //~ ~~ERTIFY THAT THIS TEST WAS PERFORMED IN E~I. River, Alaska 99577 ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEL~ ~ECT ON THiS DATE- DATE: 72-008 (Rev. 4/85) ON-SITE WASTEWA TER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MA TERIAL SPEClFICATIONS REFERENCE: Lot 80A, NE 1/4, Section 9, T15N, RIW, SM, AK GENERAL: 1. The scope of this project includes the installation of a 500 gallon septic tank and leachfield trench to serve the six bedroom residence located on the referenced property. The existing septic system is to be abandoned in place. 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 Wastewater 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. Contractors installing wastewater 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 INSTALLATION: 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. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. Page Two Lot 80A, NE 1/4, Section 9, T15N, RIW, SM, AK November3, 1993 A foundation cleanout shall be instal/ed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent c/eanouts (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 INSTALLATION: 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 gra vel 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 Lot 80A, NE 1/4, Section 9, T15N, RIW, SM, AK November 3, 1993 MINIMUM MA TERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes ASTM D3034 (PVC) Yes ASTM F810 (HDPE) Yes ASTM D2662 (ABS) Yes Y~s Yes No Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 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, Femco, 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. All 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 current M.O.A. or D.E.C. requirements. Page Four Lot 80A, NE 1/4, Section 9, T15N, R1 W, SM, AK November 3, 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 grave/. A septic tank may be set in p/ace, but may not be backfilled before this inspection. 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. 3. 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. RECEIVED NOV ~ 199~ Munioipality ol/-~nohor~g~ Dept. Health & Human Services. GRF ER ANCHORAGE AREA BO -'JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 NAME LOCATION INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM MAILING ADDRESS ~1~/ ~0~7 ~'i~i~'g PHONE LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY / GALLONS. SEEPAGE PIT: NUMBER OF PITS t DIAMETER ~ OR WIDTHZ~ LENGTH /r' 7 / , DEPTH LINING MATERIAL-- C/'~.(-.I~J~ CRIB SIZE: DIAMETER~/~' DEPTH (~'! DISTANCE FROM: TOTAL EFFECTIVE BUILDING FOUNDATION NEAREST LOT LINE WELL ABSORPTION AREA (WALL AREA) SQ. FT. ADDITIONAL ABSORPTION TYPE CONSTRUCTION DEPTH BUI LDI NG NEAREST NEAREST SEPT lC FOUNDATION , LOT LINE , SEWER LINE , TANK CESSPOOL , OTHER SOURCES APPROVED DISAPPROVED REMARKS DISTANCE FROM: SEEPAGE SYSTEM DISTANCES: INSTALLED BY: PIPE MATERIAL- LOT SLOPE: REMARKS: Form No. EQ-031 DIAGRAM OF SYSTEM DATE GreaTer ANChorage ArEa BorougH DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT no. 3330 "C" STREET ANCHORAGE, ALASKA 99503 TELEPHONE 274-456 ! SEWAGE DISPOSAL SYSTEM -- APPLICATION AND / INSTALLATION Of: SEPTIC Tank ~ seePaGE Pit DRAIN field / ~' OTHER TYPE AND SIZE OF FaCiLiTY TO BE SERVED ~ ~~0~1 ~/~/~ /~/~ ~ SOIL TEST RESULTS ~OT~: THIS PERMIT VALID WIT FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCES, REQUIREMENTS FOUNDATION TO SEPTIC TANK ~ j FOUNDAT,ON TO SEEPAGE PIT ~)/ SEPTIC TANK TO SEEPAGE Pit WALL //3~ ! SEPTIC TANK TO NEAREST LOT LINE. WELL TO SEPTIC TANK / DRA~N FIELD / WATER MAin TO SEPTIC ~ANK DRAin FIELD /~0/ SEPTIC TANK, . SEEPAGE PIT TO river. LAKE. STREAM. , DRAIN FIELD SEePaGE Pit ~) ! DRAIN FIELD SEEPAGE Pit //~ O / ALSO CONSIDER AREA WellS. SEEPAGe PIt ///O / / /~O .DRA'N F,eLD /~_,d / . TYPE DIAGRAM OF SYSTEM 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 ABOV~ D~SCRIBED SYSTEM IS IN A~CORDANCE WITH ~AID FORM NO, EO-01 6 !' ~ DEPT. 07 ~iTALT! & MUNICIPALITY OF ANCHORAGE ENVIRON Vr NTAL ~ ;~ .: ~ iCTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ~ ' ~ ' 825 L Street - Anchorage, Alaska 99501 MAR 11 9 i579 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 RECEIVE , APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIE~~ REQUEST FOR _ DIRECTIONS: Complete all parts on page 1. Incomplete requ~ts will not be proc~sed. Please allow ten (10) days for proc~sing. 1. PROPERTY OWNER~ ~ PHONE MAI LING ADDRESS ~ / PROPERTY RESIDENT (If different from above) / PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION ~ PHONE I MAI LING ADDRESS 4. REALTOR/AGENT , ~ PHONE I MAILING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE [:~:~'"'"SI NG LE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [] Four [] Two [] Five [~"Three [] Six [] Other 7. WATER SUPPLY [~INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if avJilable.) 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY ! **If individual/on-site, give installation date ,z.,z)~-/c-'_ /.~?~ If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR I NSP ECTOR DIRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic ~l-aq_k.or [] Holding Tank Size'. / ~J'-~ If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SIX PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATEINSTALLED INSTALLER SOl LS RATING MANUFACTURER MATERIAL Septic/Holding Tank IAbsorption Area ISewer Line [] OTHER INearest Lot Line 5. COMMENTS E[~APPROVED FOR [] DISAPPROVED DATE LEGAL DESCRIPTION BEDROOMS CONDITIONAL APPROVAL (letter must accompany certificate) IBY (Title) ~ 72-010 (Rev. 3/78) ~CNANICAL ENGINEER DAVID SLENKA~ 694-9055 ENGINEERING MECHANICAL ENGINEERS CIVIL ENGINEERS 196X Eagle River, Alaska 99577 ROBERT A. S}h\FER ~9~-2979 Mrs. Bailey SRB 8030 Chugiak, Alaska 99567 April 2, 1979 ' REF: Three bedroom residence, located on. Lot 80, NE 1/4, SEC 9,'T 15 N, R 1 W. MUNICIPALITY CF ANCHORAGE DEPT,'C ~ E},.!VlROK ~Cf.-._ . ~ qTION RECEIVED A sewer sYstem adequacy test was performed on 30 and 31 March 1979 for the three bedroom home located on the referenced property. The septic tank was pumped and verified to have a ~apaci.ty of 1,250 gallons. The seepage pit was charged with 1,000 gallons of water and, over a 24 hour · period, perculation had removed approximately 823 gallons or 274 gallons per bedroom. It can be concluded that as a result of the above survey and test, the sewer system serving the reference~/~rty is ad?~uate. · First Fed Savings & Loan ~/-?BERT A. SH?~, P.E CF: (ATTN: Real Estate Br) Century 2i (ATTN: Leona Tyler) VMunicipality of Anchorage, Dept of Health & Environmental Prot 2764429 RE/MAX Properties, Inc. RE/MAX Properties, Inc. 11:39:10 @.m 03-07-2012 2/2 Z. 6 H A " LF i5A25L- A NF 1 4 f doth Robert C J n wn J, J -to,,, 4-11 -6 , +t� AS -BUILT I hereby certify that I have surveyed the following described -property: j 1--/-1 Ine 7- 9-42A a --------- - --- Anchorrage Recording Precinct, Alaska, and that the mprovements situated, thereon are within the property lines and do not overlap or encroach on the property lying adjacent thereto, that no improvements onprop- erty lying adjacent thereto encroach on the premises in question and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated at Eagle River, Alaska this I ROBERT C. JOHNSON SCALE: Registered Land Surveyor No. &LS I'= -5-0 Box 456, Eagle River, Alaska Phone 694-2543 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 GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Robert and Luc~/ Mood~/ 22626 Chambers Lane Chu~iak, Day phone AK 99567 Day phone 688-3465 Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: XXX 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: XXX 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 Sm 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 i~7,e~pliance with all Municipal and State codes, ordinances, and regulations in effect on t~.~ this inspection. Name of Firm /'~/~ ---~hone '~' ~- 7_. ~'~ ~/ 17034 ;;~'.-~.~. L_-~-_,.~c,~.-~ ;~;,:,. '"",,~,,,,i Engineer's signature ~ . DHHS SIGNATURE ~'~ Approved for 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 inde~,endent 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 certa n federal and state requirements. Employees of DHHS c~o 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 and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: Parcel I.D. A. Well Data we, type Log present Total depth Sanitary seal (~:~/N) Date of test Static water level Well flow If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ / ? 7~ Driller Cased to ~r~ 4-- Casing height Wires properly protected (~N) ~/ FROM WELL LOG AT INSPECTION Pump level1 MUNICIPALI'fY OF ANCHOP-,AGE ENVIRONMENTAL SERVICES DIVISION g.Jl~. - 4 1994 RECEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Vt:::, 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: / 2 - ~7 Nitrate Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed /"l'?J/'//'~'~ Tanksize /;~-"o / S'"z), Compartments Cleanouts ~N) ~/ Foundation cleanout((.~/N) / Depression (,Y~} High water alarm (Y~i~) /J Alarm tested (Y/N) /'J;~ Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / ~ t ,~ On adjacent lots /~ To property line ~ 5'~ Absorption field 5- / ~ Surface water/drainage / oZ) Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~cles tested Meets MOA electrica~~'~ ~SE~TANCE FROM LIFT STATION TO: Well on lot On adjacent lots Manufacturer Manhole/Access (Y/N) ~el at Surface water D. ABSORPTION FIELD DATA Date installed ) ~ - / ~ -~-~ Length '7 J ~ Width Total absorption area ~ ~'"'z. ~ Date of adequacy test -- Water level in absorption field before test Peroxide treatment (past 12 months) (Y~ Soil rating (GPD/FF) /, ;2 ~,~ System type .5"' ' Gravel thickness 5~, 5'- / Total depth Cleanout present (~N) ~y/ Depression over field (Y~ Results (pass/fail) for ----'- ~ After test /~r If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / o~ I ~ To building foundation On adjacent lots Surface water Curtain drain adjacent lots ! ~ ~' Property line To existing or abandoned system on lot Cutbank ~ Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, Signature __ Engineer's Name 17034 Eagle Date HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back