HomeMy WebLinkAboutCHANDELLE ACRES LT 11
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP251100
Work Type: SepticTank Upgrade
Tax Code Number: 05106371000
Site Legal Address: CHANDELLE ACRES LT 11 G:1460
Site Mailing Address: 23921 IMMELMAN CIR, Chugiak
Owner: SANTERRE FAMILY TRUST
Design Engineer: NORTH RIM ENGINEERING
This permit is for the construction of:
Effective Date
Expiration Date:
�»�nt
`� fl
-
Delmrt:1nent
Lot Size in Sq Ft:
Total Bedrooms:
4/11 /2025
4/11 /2026
43079
❑ Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: -tom j'' Date:
r f
Issued By: Date: /
4
MUNICIPALITY OF ANCHORAGE
Development Services Department -343-7904
Phone:907
On -Site Water & Wastewater Section
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 05106371000
Property owner(s) SANTERRE
Mailing address
23921 IMMELMAN CIR
Site address 23921 IMMELMAN CIR
Legal description CHANDELLE ACRES LT 11
Number of Bedrooms 4
Engineering Firm NorthRim Eng.
Building Permit Number
Day phone 907-862-1999
Not Applicable F*
APPLICATION IS FOR:
APPLICATION IS AN:
(Z all that apply)
Absorption Field
❑ Initial El
Septic Tank
El Upgrade El
Holding Tank
EJ Renewal ❑
Privy
R
Well
F1
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Permit/Rush Fees: Z 2'
Date of Payment: — V// /2-0 z �—
Permit No. (9 � P Z, 5- 1 t 0,0
Waiver Fees:
Date of Payment:
Waiver No.
Distance:
)ESIGN NOTES.
Existing Trench Remains In Place.
Sewer Service Line minimum 2% slope.
Replace Septic Tank/Decommission Old Tank Per UPC.
Connect New Tank To Existing Trench.
Lots Served by Private Water Wells.
No Conflicts Within 200'.
Check Condition Of Sewer S
Replace FCO If Required r)MAH mrP
Flat Terrain.
NORTHRIM
ENGINEERING
Ste veEnq.com
PO Box 770724
Eagle River. Alaska 99577
907.694.7028
e Line— Replace If Necessary.
Wnidpality d Anchorage
On -site Water and wastewater
REMEVVF-D FOR CODF CONPUANCE
OSP251 100, Curtis Townsend, 0411 li-,
Septic Tank w/DCOs
Decommission Moll
Septic Tank
Existing PER UPC
Trench
10'
i U,G, EASEMENT
Immetman Circle
CHANDELLE ACRES
LOT 11
stm 0V -7 V
!WASTEWATER
4 V 2
iUPGRADE SEPTIC TANK
I' = 40'
DESIGN
LAYOUT
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pality of Ardiorage
fter and Wastewater
FOR CODE CONPUAWA
0, Curtis Tomsend� 04111/-,
Municipality of Anchorage
On -site Water and Wastewater
Thy I M
ENGINEERING SteveEng.com
REVIEWED FOR CODE COMPUANCE
OSP251100, Curtis Tomserxi, 04111r
CHANDELLE ACRES LT 11
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: The current septic tank has failed- the field still functions.
Replace septic tank near same location, decommission old tank per UPC. This lot is about
an acre and on a private water well. Separation measurements to be made prior to
construction. No adverse impacts are expected from tank replacement. Easements are
depicted on the lot. The slope in the area of the septic system is negligible. No conflicts
to neighbor properties.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• New 1500 gallon MOA-approved septic tank. Watertight couplings on inlet & outlet.
• 5' minimum between the tank and trench. 5' to property lines & 10' to house.
• 4' of cover or insulation is required for tank; an equivalent of 1 " insulation for F foot
soil cover. Tank & solid pipe must be set on well compacted, stable soil.
• No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per
MOA- sand or pea gravel.
• 4" diameter cleanouts with airtight caps are required 1 ' to 4' from foundation wall,
prior to any 90 degree bend in 4 inch line, in 2nd tank compartment, and two adjacent
opposing cleanouts between the tank and the absorption field, not more than 10' from
the tank positioned to provide cleanout access towards the tank and towards the
absorption field. Manhole Riser required in 1st tank compartment.
• All cleanouts must extend to at least ground level.
• In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
• Insulation must be placed over any pipe installed under driveways or parking areas.
• Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
• Sewer Service Line is minimum 2% slope.
• Septic Tank to be pumped every two years or when required.
• Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
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_ _ _
MUNICIPALITY OF ANCHORAGE
DEl ,TMENT OF HEALTH AND HUMAN SER¥,_--'S
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
~ ~'<'~ t.... ~ ',../~,J,~::~"r'"T' ~ SEPTIC ABSORPTION
Address / WELL
-.., TANK FIELD
,. I,~,m,t No NO ol BedSores WELL
Lot ~ Block SuDdiws,on
~t ~ ~~. ~ FOUNDATION
Township. Range, Section
AS-BUILT DIAGRAM ~Show location of well, septic system, property hnes, foundation,
TANKS N ., N
SEPTIC ~ HOLDING
~nutamur~r Capac,ty ,n gallons
Material No. of Compa~ments
TYPE OF SYSTEM
~RENCH ~ BED ~ W. DRAIN ~ OTHER
F [ added above ongmal grade G~avel depth beneath
Grave~ length G~avel w~dth
Number ~:~ hnes Sod ralmg~
Ipstaller Date Installed ~
WELLS J~
~ PRIVATE : OTHER ildentifv)
Classification (A,B C) ]oral Depth Cased to
~ ~ ~ ~ _ FT ET
]rlstaHE ~ Dale Installed:
REMARKS:
I ceflily that this inspection was pedormed according Io all
'% t, .- ~,-r~.;.
GLE ]NIt 1985
~unicipal and State gmQeunes in ~ / ~ _. - _ ~ ,4"~'~,." .. ,-" .... '~-
Health Depadment Approval: ~ . .... Date:
72 013 (3/85)
owner of LAnD /'/~ Y z Y ~ o 7"
LEGAL DESCRI~ION
DATE,St~[ted _ ~ ~ Ended
PERMIT NUMBER
ST-xH(' LEVEL OF' w-~,I'F.R
I)RA~V I)OWN FT.
GALS. PER HR __ ~¢.5rO
KIND OF FORMATION:
From O · Ft. to ~
From__~' Ft. to g
From ~ ~FI. to ~
From?_~ Fl. to_/I ~
From_/I O' Ft. toJ~=_~7_ Ft.
From/~"q Ft. to tTot'' Ft. "Ct'~ '-q'/~-u_O__i~__~_~._~e-~'
From./_'7-~'Ft.~oOol$ Ft.d,~,ff_r ~
From~ ' - _Ft.
Fromc~_3g]:; Ft.
Fr0m'~/. ~ Ft.
'~:rom ...........
Proem ...... ~-( Fl.
From'___:. :. -Ft.
From- , '' Ft.
From" '-~' ' Ft.
to_ Ft.
to Ft,
to._ . Ft.
to . Fi.
to ..FI
From . FI. to ...... Ft..
From __ Ft. to__Fl
From .... Ft. to__ _ Ft.
From __. Ft. Io___ Fl.
From .Fl. Io FI__
From Fl. to Ft.
From _. Ft. Io FI.
From Ft. to FI.
From Ft. lo Ft
From Fl. to FI.
From .... Ft. lo___Ft.
From Ft. to Fl
From Ft. lo__Ft
From ...... Ft. to_ Fl
From Ft. to Ft.
From Ft. to Ft.
From. - .Ft. to ___Ft
MISCL~. INFORMATION:
~',:::.;:;;'!: :--
_~, !:~, ._~a.:),~:,...~_.,
i~;., ~--~-" '
DRILLER'S NAME
DE:F:'ARTMEI',IT OF HE:AL]-H AND ENVIRONMENTAL F:'ROTECTION
Q~.,_, L STREET, ANCHOR'AGE, AK 9950:1.
264-4'720
.-.:.,,[,~ T ND:
DAlE i E~-':JR.!ED:
LJNI r.-::...: I .... I,IE:.:
G A I I .... Z Y' W 0"I" T
F'. (.'.). BOX 670264
E;HUGIAK, AK 99567
6 ¢¢ 4 - 5 5 .'.")0
I...E:.GPd .... i'bESCRtP: SUBDIVISION: CHANDELL. E; ACRES LOT': 11
SECTION: 3 TOWNSHIF': 15N RANGE;: 1W
LOT SIZE: I.OA (Si]!.F:T. OR ACREES)
tdAX BEDROOMS: 4
BLOCK: NA
t...isted t:>~-.--...',to~.,~ ar-e the optior'~s available t.o you in desigr~ing your' sep±.ic
system. Chc)c:,se the op'li, ior~ that. [)est. fits yC3Ltf" site.
DEF'I"H 'i"E) F::'IPE BOTT'OH (F'T.)
i'BF:;:AVEL.. DEF:"I'I'"i {F']". )
'f'O'TAI .... DEPTH (F"T.)
~, ,A ', ! ...... W I D't' H { t::'"['. ~
GRAVIEL. I_E:NGTH (F']".)
G R A V ElL V OI....U M El ( C U. "¢' D S. )
TANK SIZE (GAL. S)
SOIL. RA'I"J:NG (SQ.F'T. /BR)
4.0 ~" 4.() 4.0
6, () ¢ (). 5 3.5
1(). () 4.5 7 .. 5
2., 5 30.0 5.0
11 '7.0 ~* 57.0 1. 5 1. () *..~-
70 ,, 5 63.4 ~. :[ 1.9
1,:'250.0 .~-* 1,250.0 ** 1,250.() ,~*
349 284 34':;?
· ~,~..~ GF;:AVEL. L. ENG'T'H >
,,j FT. RE','4UIRES MULTIPLE RLINS
-x..~- ['ANI::: ,HUS'T' I...l~.~v[:. A'I LEAS] .... ['WO COMPARTME:;NTS
(NO'T EXCEEDII"4(3 '75 F'T. EACH)
]. c:er"l:i£y that:
.I.,, 1[ am £amilia[' wi'Lh the r-equir'er~er'~t~ for' or,-site sewer's and we].].s as seT..
Cc)["Lb by the Muriicipa].i'Ly o[' Anchor'age (MOA) and the SCare t::)[' Alaska.
2,, i will ~nsCa].]. the system in ac:c:c.~r'dar~ce with alii MOA codes and
a.i']d J.i'] cc)ml:.~].:i, arlce with 'Line-.. design c:r'J, ter'Je (::)f this pepmJ, t,,
:7.!;. I w:i. ll adher'e to all HOA anti State t::~f Alaska pequiPements fop the -.-:..-..et. bacl<
eli. statices ['r'om any exi~t:i, ng ~e'l]., ~astewater' disposal system ol' pLtblic:
s(.::*wer'age system t::)r"! this or' ar'~.¥ adjec:ent or. near'by ].c)t.
.... '-" op a maximum (:].t' 4 be(:JPoE, m~ ,.?:',.F~d
,1-,: ! under'stand that. this I..3ePmit 'is v,:,.~.±d f'
any eri].al-6!erner'.,t ~:i. ll r'equ±r'e.', an additic~nal
'fl:::' A I...:i:t:::T S]"ATION IS INST'AI....I....ED tN AN AREA COVERED BY MOA BLJILDING C[)DES,
· . .I.N,=~F~.L,] ~.t..ll,I MUST BE ("IBI"AINED; (2) AS'-"BLIII....TS
THEI".I ( :f.'~ AN EL.E:C'I'RICAL. PERMI]" A.N[) " c'"',,- ....... ~ .... . ....
WILl .... NO"I' BE AF'PROVED W["I"HC.tLtT AN IEL. EiI]'TRICAL. II'4SPE:C".rION RE{F:'ORT; A. ND (3) THE
i!!Xi....I!it3'T'R I CAI... W.r.]Fi'.K MUST BE DEiNE: BY A L.. I CEIx!SED E]....iECTI:-;~ i C ! AN.
.... TLI4 .........
· "'~"" "'""'"' '~' 4 '::, ~ L ':~411'~ T
¢-H'" c' b.[ t...-t-'-lnl ~ ?, .............. ~ ,. ·
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
! !
~-~.~l O~ ~(~;.l~.~ri~_R'S SEAL)
DATE
SLOPE
ENCOUNTERED7
IF YES, AT WHAT
DEPTH.;'
Depth to Water Alter
Monitoring? 1'~ C~'--~,~ DaZe:
S
L
SITE PLAN
' I
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ q-~-~ ~ fl' ~, ~ ~,~ ,,- ~ ~ ....
PERCOLATION RATE q('~ (minutes/tach) PERC HOLE DIAMETER
TEST RUN BETWEEN ~)' FT AND FT
COMMENTS
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI~S IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
Z/O
/
S & S ENGINEERING
SRB 196X
EAGLE RIVER, AK 99577
,o Z
iCIpA~ITY Ol: ANCHORAge'
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
Parcel I.D. # ~.~\ - OIc)q')' ~ ~ HAA #
GENERAL INFORMATION
Complete legal description ,Z'o/-
//
Location (site address or directions)
Property owner ~'~'~-~Jc¢ ¢' "~7-/-/7" ~(.J,,f~,~,,~:~-z. Day phone
Mailing address
Lending agency
Day phone
Mailing address
Address
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water
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:
72-025(Rev. 1/91) Front MOA#21 ~'~/'~
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.
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.
David R. Dayton P.E.
Name of Firm 20210 Dona]ar St. Phone
Chugiak, Alaska 99567
Address L'/~/~-~ ~/:;;2/~ .~ '~x/--~ Date
Engineer's signature ,~_ '- -~- .- -/..
DHHS SIGNATURE
Approved for ~-o~-~',- (~L/)
Disapproved.
Conditional approval for
bedrooms.
bedrooms,
with the following stipulations:
Additional Comments
By: ./~,,~u~ ~-~ 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 DH HS 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 ~i~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ // ~,~,,u~.-~ ~ Parcel I.D.
A. Well Data
Well type j),~ ~'4.'r~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~ ~-"';,.~- Date completed ! 5' ~(~ Driller
Total depth 'Z- ~' ~ Cased to Z. ~. ~' Casing height
Sanitary seal (Y/N) y' Wires properly protected (Y/N) )/
FROM WELL LOG AT INSPECTION
Date of test 7_//~/,f,~, / 0,//~/~
Static water level 2. ~ ~ 2,~' I=1=1
Well flow, ~', 7 ,'- g.p.m. ~' ~' g.p.m, r'r'l
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ / O~ ; On adjacent lots
Absorption field on lot J cu~) ; On adjacent lots I c~.~.t--
Public sewer main ~ ,,~ Public sewer manhole/cleanout
Sewer service line ~"~'~"~ Petroleum tank
OZ
WATER SAMPLE RESULTS:
Coliform c>
Date of sample:
Nitrate ' c>, z~> Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
installed F' //~'~ Tank size
Date
Cleanouts (Y/N) "/' Foundation cleanout (Y/N)
High water alarm (Y/N)
Date of pumping
I P-~ Compartments ~"
~' Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I c~ 5"-
To property line ~ C~
Surface water/drainage
On adjacent lots
Absorption field
j ~, --I.--
/' 0 0 "~ Foundation Z- ~
/ ~, Water main/service line /~:~ ~-'
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
.Cycles tested
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed /-A~/J
Length I I-7'
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) ~ ~'~
Width Z0 ~' ~ Gravel thickness
/~o ~ Cleanout present (Y/N) y
~ c)/t ;5 / ~ _~. Results (pass/fail)
'¢~'¢¢,¢--- System type
~, ' Total depth /~ '
Depression over field ~/N)
~ for
After test ~
If yes, give date
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
~,~ ~' On adjacent lots
On adjacent lots ~ 'r- Cutbank
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
Property line
To existing or abandoned system on lot
Water main/service line
Driveway, parking/vehicle storage area Z.~ ~ ~ '1'~>,~
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.
20210 Donalar St.
Chugiak, Alaska 995.67..
HAA Fee $ -~
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
D. R. DAYTON P.E., R.L.S.
~~)~:~ Chugiak, Alaska 99567
20210 Donalar .
(907) ~~-]~
696-2417
October 14, 1993
WELL FLOW TEST
Legal Description:' Lot 11, Chandelle Acres
Date of Test: October 13, 1993
Well ~ .pth: 238'
Stati~ Water Level: 208'
Requirements: 4 BR - 600 gallons per day
Test:
The well was tested with the existing pump through an outside
hose bib. Volume and drawdown were measured at regular infe~vals.
Results:
The well ~roduced 657 gallons in 120 minutes at an average flow
rate of('5.5 ga.~ons per minute,
Max~imUn drawdown was 4'. The drawdown was fully recOvered within
10 minutes after pumping was stopped.
The well is currently producing adequately for a 4 bedroom home.
D. R. pAYTON, P.E., R.L.S.
~~)~; Chugiak, Alaska 99567
(907)
20210 Donalar
696-2417
October 14, 1993
ADEQUACY TEST
Legal Description: Lot 11, Chandelle.Acres Subdivision
Date of Test: October 13, 1993
Septic Tank: 1250 gallon, 2 compartment, steel tank (DHHS Records)
Absorption System: 117' long x 6' effective depth trench (DHHS Records)
Soils Rating: 349 sq ft per bedroom (DHHS Records)
Requirements: 4 BR - 600 gallons per day
Test:
As the house has been' vacant, the system was presoaked for 24 hrsl
with 1000 gallons of water.
Oh~10/1~/93 650 gallons of water were pumped into the trench
and the water level rise measured.
After 24 hrs the water level was remeasured.
ResultS:
After 24 hrs the water level was lower than the initial level.
The absorption system is currently functioning adequately for
a 4 bedroom home.
?
MUNICIPALITY OF ANCHORAGE ~ ~ /
DEPARTMENT OF HEALTH & HUMAN SERVICES
o,= s ,v,c s
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL "'
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date Januar~ 29, 1988
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 1!; Chandelle Acres
Location (address or directions)
Immelman Circle
(b) Property Owner Andy' Zywott Telephone: Home 688-2914
Mailin9 Address P.O. Box 670264 Chuqiak, Alaska 99567
Business 276-2761
(c) Lending Institution Home Savin~s and Loan
Mailing Address Anchorage
Telephone
276-1451
(d) Real Estate Company and Agent Re/Max- Andy Zywott
Address 2600 Cordova Anchorage, Ak. 99503
Telephone 276-2761
Mailthe HAAtothefollowino address:or:Check herein, ifholdforpickup.
Listcontactperson and day phone numberbelow.
ordered by Andy Zywott
(e)
TYPE OF RESIDENCE
Single-Family IX:I
Number of Bedrooms
4
WATER SUPPLY
Individual Well~[ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite:~j Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 trey 8/86~ Front
ENGINEERING FIRM P ~ROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Telephone
.~ & .~ ENGJI~iEERIN~
Address "l~'n~a, ~'.~1. I~1~ L_~,,~_ ~ _~__...~_~_ H~.
Date Eagle River, Alaska ~577
DHHS APPROVAL
Approved for .~b,.- ('~) bedrooms by
Approved /~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in
order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data
before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
Page 2 of 2 72-025 fBpv 8,86/ Back
MUNICiPALIF¥' OF AI'.:CHO:~t~[INICIPALITY OF ANCHORAGE (MOA)
ENVi;~ONMENFAL $~:,:~.,';:.J~ DWtR~I. TH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
~ , ~:~ 2~-4744
Legal Description: ~ ~T //
RECE VFD
WELL DATA
Well Classification
Well Log Present ~N)
Total Depth Z..~ ~ Cased to Z.,~ ¢:~'
Static Water Level ~_
Casing Height Above Ground /
Electrical Wiring in Conduit (~N)
Separation Distances from Well:
To Septic/Hofffmg Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments -~ V,J
· -~. ~ If A, B, C, D.E.C. Approved (Y/N)
Date Completed / 9 ~, L _~ Yield
Depth of Grouting
Pump Set At L~, I~...
Sanitary Seal on Casing ~)'N)
Depression Around Wellhead (Y/~
· On Adjoining Lots
/~/ · On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
~, ~- ~ ~ ~Z~,,/~J~/~_~,,,/u- ' Date ~- - / -
B. SEPTIC/H;~E;;B;~ilG TANK DATA
/ z.. S'o
Date Installed
Standpipes ~N) Air-tight Caps ((~)
Depression over Tank (Y/~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) /~//~:3~
Separation Distances from Septic/Holding Tank:
No. of Compartments ~__
Foundation Cleanout (~N)
Date Last Pumped .~. 2_- ~ - ,~ .~
; for
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation ~-'~
To Disposal Field /(-~ ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 (Rev 8/86~ Front
Co ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed L~ - / O
Width of Field
Type of System Design
Square Feet of Absorption Area /~/0~
Depression over Field (Y/~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well / ~
To Building Foundation , ~'¢' ~
Lot ~/~
Length of Field
To Water Main/Service Line /c~/¢-
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Depth of Field /c~ f
Gravel Bed Thickness (.~ i
Standpipes Present (~%1)
Date of Last Adequacy Test
To Property Line ~-- ~' ~
To Existing or Abandoned System on
· On Adjoining Lots .~/'/
To Cutbank (if present) /w/Pr
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed
Company
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 ~Rev 8/86~ Back
Date
MOA No.
& GEOLOGICAL LABORATORIES OFALASKA, INC.
~_.~ 5633 S STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343
FEDERAL TAX ID # 92-0040440
AI~LYSlS I~EPO~ BY SAMPLE
Ci lent POt : VERBAL Req t:
Client Smpl ID: Lll, CHANDELLE ACRES
8a~kole Rec'd : FEB 1 88
Ordered By :
Send
Reports To:
$ & $ ENGINEERING
R 8CHAF. FER
17034 EAGLE RIVER LOOP RD., 1204
~GLE RIVER, AK. 99577
Work Order No. : 4997
Client Account : 8NSENGP
Date Report Printed: FEB 3 88
Released By :
Reports Aaaress #Z
14:23
Special ~PLg COLLECTgD 2-1-88 AT 1100 HI~. COLLECTED
Instruct:
Chemlab Ref 1:8986 Lab Smpl ID: 1 Matrix: Water
Allowable
Parameter Tested Remit/Units Method Limits
NITRATE-N NI)(O.IO) mg/I EPA 353.2 10
Sample ROUTINE &~H~Lg
Remarks: ANALYSIS CO~P~D: 2-1-88
LABORATORY ~UPERVISOR: b'TEPHEN C. EDE ~---~- ~
I Tests Performed , See Special Instructions Above
ND= None Detected ** See Sample Remarks Above
NA= Not Analyzed LT=Less Than, bT=oreater Than
