HomeMy WebLinkAboutFESLER LT 2
MUNICIPALITY OF ANCHORAGE
DE ITMENT 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
Nam° DISTANCES
/P~lLr','C,'~,, ,~'e ~' 1 ¢ .'"- ~ Tn SEPTIC ABSORPTION
AddressFROM~ TANK FIELD WELL
p~--~,~ ........ No ~ ~.d,~m, WELL /~O
LEGAL DESCRIPTION LOT LINE z
~ · c ~ '~[0 N ~ I ~a AS-BUILT DIAGRAM (Shew ~ucaho, ut well, septic system, p,operly hnes, foundahon,
TANKS
~ SEPTIC FI HOLDING _ _ ~ ~
TYPE OF SYSTEM
[~TRENCH ~BED ~ W. DRAIN ~ OTHER
/
Depth to p~pe bottom hum : ] oral d~pth from ongmai grade
or,gmal g,ade / FT ~ /. b~ FT
'~ FT · ' ~ FT
Co~ J~ 24) 2'+ 19~g
WELLS
~ PRIVATE ~ OTHER (Identify) ~ ~lt
FI FI
Scale: J~ ~0' ro~f~ · ENGINEER'S~EAL
~ '~'ll ~ ~o 2' + ~ . ~ Inspections Performed
I cedily that this inspection WaS pedormed according to all
~unicipal and State guidelines in effect on this date: 2
I
/
/2 013 (3/85)
IV[-~V DRILLING, Ine. MUNICIPALITY OF ANCHORAGE
P. O. Box 4-1728 · 2811 Dawson DEPT, OF HEALTH &
A C 90T-279-I741 ENVIRONMENTAL PROTECTIOI~
ANCHORAGF~ ALASKA 99509
OCT 1 g 1987
DRILLING LOG
We. Owner Coo , RECEIVEDuse of Well
(addre~ o,: Townshi,~ R.Ee, Sec,~n, ,~ ~ownj cr distance re.in
~ ~. -
Size o[ c~ ~ nep~ ot Hol. /~0 feet C~ed to ~ feet
Static water level ~ 7 ft. (~), (below) l~d surfak. F~h of weU (check one) open end
Screen ( '); Perforated ( ).
Describe screen or perforation
Well pumping test st ~'0 gallons pe~ (l~) (minute) for
of drawdown from static level.
Date of completion
/ hours with /00 ~ ft.
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
DEPART'MEi:NT (::)1:::' HEALTH AND Ei:NVIF;:I::)ixlMENTAL F:'ROTE!:[TT'ION
8;=:'.5 I.... S'TREE'T', AIqCHC')I::d.~GE, AK 9950 1
264.""'4.72C~
F[.I:~PIIT NO:
DATE 1 ~::~..~ I[ ID.
AF:'F:'I.... :[ CAN T:
· .) ') ::', ......... ~
Al. IL I d::.,::~,:..
C 0 N 'T A C 'T' F:'I'"I 0 N E:
),.:~ ...[ 78
C 6 i :t. 6186
PAl R I C',IA F'IE:S L.. I!.:: R
S.R,, BOX 86 10
BI:RD CREEl<, AK
25E:~"-'7575
L..IE:GAL DEE~CRI F:':
I,.O'T SIZEi:
Fd41xlb[: ,, :I.W
BLCtCK: NA
I cer't:.:L[y t. hat:
:l: am {'ami].:i. al~ with 'l:.he I'equir'emen'Ls ICH" Ol~....sJ.t(~) seweps and we:Lis as set
~'or'.th by the Mun:Lc:i. paJ.:ity c:)[' t.~ncl'~or~age (MOA) arid the State c)t' Alaska,
2,, :1: w:i.].]. :i. ns'l'.al:l, the system :i.r'~ a(:::cc)vdance with a:l. 1 MOA (:::tides and r'.egu].at:i, or'~s,
and :i.n coml::)liance wi'Lb 'l'..he des:i, gn C:Pj. tE~H~j.a':~
::f~;,, ]: wi].:l adhePe 't..(::) all MOA al"~cl State <::)t' Alaska r'equ:Lvements J'(::)v the set back
cl :i. s'l:.arH;:es f r'(::)m any ex ;i. st ing we:L i [, wastewater, d :J. sp(::)sa ]. SyS'I:.~:.gIT) [::)P pL.[J::) ]. :i.C:
s<.::ewer'age syst:.em (::)r'i 'Ll'~:i.s cH" ar'ly adjacent c)r' near'.by
:l:t:::' ALII::"T ST'AT]:ON :I:S IN,~ rAL. L[:.D IN AI',I ARE:A []:)gERED BY MOA BUILDING [:::ODES
T'HE£N ( .1. ) AN I~:I....IE:C"f'R :t: CAI... ' ........ c ............
F E.hMI"I" ~1\1][:) .I.N~..q I:.L.I ION MUST BF.:!: OBTAINED~ (~.) AS.-..BU:I:L..TS
NOT BE!: AI.-I.IM..~I D W]:"f'F~[JUT AN EI....E[.Tr'R ]: CAI.... ]:NSF'E[~'T'I[Jlq REPORT] Al\ID (::!~)
ti!i:I_EC]RICAL. WOF/K MUST BE :DONli~: BY A LICEIxlSED EL. Ei:CT'RICI~Ixl.
............................................................................... .,.... :, ....... .................
I...F .' L t.C. AI I1: I::'ATR]:C:I:A
:1: SSUED "]"
ALASKA ENVIRONM=NTAL
CONTROL SERVICi INC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 561-5040
SHEET NO
CALCULATED BY
CHECKED BY
i": ¥O~
SCALE
OF
DATE
DATE
/,',"lex
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
(ENGII~'S SEAL)
D^TE PERFORMED:
LEGAL DESCRIPTION: ~,~-.~ 3 '2-0/
2
3
4
5
6
7
8
9
10-
11
12
13-
14-
15-
16-
17
18
19
20
Z.~7' 30
Township, Range, Section: ~'/O /V~--I~- ~ IO 7t¢' /
SLOPE
WAS GROUND WATER ,.~
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Deplh to Waler Alter
Moniloring? Dale:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
x,'de
PERCOLATION RATE __
TEST RUN BETWEEN
COMMENTS
PERFORMED BY: "~"-~'~ ,'~c .,~v'- ~tgo-zy I ~~FYTHAT
/
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT,I~'N THIS DATE. DATE:
72-008 (Rev. 4/85)
'"~ ('~ (minutes/inch) PERC HOLE DIAMETER __
~" FT AND ,~ t~ FT
s'
THIS TEST WAS PERFORMED In
'-/Jvc, ,Y6
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
DATE PERFORMED:
(ENGINEER'S SEAL)
LEGAL DESCRIPTION: U ,~ /o'f ~ 2 O/ Zo?3o Township, Range, Section: Se e ¢ )'-lc, iV,el
I
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18-
19-
20-
COMMENTS -~ ' "/
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT ~~ t
DEPTH? pO
E
Depih to Waler Aller ~) r~ ~ Ii~ ~
Monitoring? Date: jv~ ~ \
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~--~'f I ~rf~ute$/mch) PERC HOLE DIA~TER ~
TEST RUN BETWEEN ~ ~FT AND ~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC'ff'~N THIS DATE. DATE: ~" .,]C",',',',',',',','~ ~'~
72"008 (Rev. 4/85)
• q 8 9 10 77— --�6• B
•- t7 Municipality of Anchora i •`-, ``A o
t .�_
On-Site Water and Wastewater Progra : ''- mill
(907) 343-7904209t51 E T Y .
SEP O $
L 3L
Certificate of On-Site Systems Ap• ..? al 1 A
C _
Parcel I.D. 090-021 -62 Expiration Date:01 't 9-- S I— !' '
1. GENERAL INFORMATION
Complete legal description Fesler Sub, Lot 2
Location (site address) 159 Steller's Jay Lane
Current Property owner(s) Michael Harne Day phone 575-5181
Mailing address HC 52 Box 8161 , Indian, AK 99540
Real Estate Agent Day phone
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 2
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual El
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: Date: IC)/a5/1 7
COSA to be released to the engin(---- --.12(----
r,unless otherwise requested by the engineer.
COSA Fee $ 024 Waiver Fee $
Date of Payment 9/11 /0 Date of Payment
Receipt Number ?1G IC Receipt Number
COSA# (. t1'1'7 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 Forge Engineering Phone 522-7773
Address 1399 W 34th Ave, #203, Anchorage, AK 99503
Engineer's Printed Name Benjamin Schiller, PE Date 9/0812017
afiy� 1J . "1
air
.17 4<:
6. DSD SIGNATURE • ' •,. . . .
•
)6 System #1 Approved for Z �
bedrooms oq j- ai :
System #2 Approved for bedrooms eo •.•• •a �`F
' ,. •••�J i7.•• .
Disapproved 8 '�`m
Conditional approval for bedrooms, with the following stipulations
l ft, l S S er G IXC 1 S f P�.�l
PIS 1/LeAel e L t642 ea
_S" ��
AND z'
m VV PSR P-��R o
'off QROGRPA 175
-,
By: -- Original Certificate Date: 1, 6 --/A I
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 engineers work. ,..
sf.?r7►
•
7. ATTACHMENTS: .4,7%i { r .
'
COSA Checklist X Nitrate Acivisory A..
*-r
Septic System Advisory Arsenic Advtso'ly'
Well Flow Advisory Other '1'4%1-0yG.
COSA blue sheet S ' c
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: Feller Sub, Lot 2 Parcel ID: 090-021 -62
A. WELL DATA
Well type Private If A, B, or C provide PWSID# Well Log (YIN) Y
Date completed 7-10-71 Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y
Total depth 100 ft. Cased to 98 ft. Casing height(above ground) 18 in.
FROM WELL LOG AT INSPECTION
Date of test 7-10-71 7-25-17
Static water level 77 ft. 77 ft.
Well production 30 g.p.m. 4.8 g.p.m.
WATER SAMPLE RESULTS:
Coliform ND colonies/100 mL Nitrate 0.595 mg/L
Arsenic ND ug/L Date of sample: 7-11 -17 Collected by: Anderson Eng
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic / Steel Date installed 6/26/86
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) N* Depression over tank (Y/N) N High water alarm (Y/N) N
Date of pumping go/ &3/17 Pumper 'L d .S (' ci..kr
1
C. ABSORPTION FIELD DATA
Date installed 6/27/86 Soil rating (g.p.d./ft2 or ft2/bdrm) 322 ft2/bdrm System type Bed
Length 44 ft. Width 22 ft. Gravel below pipe 0.5 ft.
Total depth 3.0 ft. Eff. absorption area 968 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 7-25-17 Results (Pass/Fail) Pass For 2 bedrooms
Fluid depth in absorption field before test 0 in. Water added 472 gal. New depth 2 in.
Elapsed Time: 1 320 min. Final fluid depth 1 in. Absorption rate >= 300 g p d
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
*A cleanout is shown on the inspection report with swing ties, but not on the subsequent as-built
survey. Neither we nor the homeowner could find a cleanout, despite digging in the area indicated.
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 X751 Public sewer manhole/cleanout >100'
Sewer/septic service line '25' Holding tank >75'
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO:
›5' >5' >5'
Building foundation Property line _ Absorption field
Water main >10' Water service line >10' Surface water >100'
Wells on adjacent lots >1 00'
ABSORPTION FIELD ON LOT TO:
Property line >10Building foundation > Water main 1
Water Service line >10Surface water >1 Driveway, parking/vehicle storage >1
Curtain drain None Noted Wells on adjacent lots >100'
F. COMMENTS
** The water level did not rise immediately in the monitoring tube.
Resulting calculations show that >300 gallons were absorbed.
G. ENGINEER'S CERTIFICATION ic,,4F
I.
I certify that I have determined through field inspections and i .• " ' •••9�I
review of Municipal records that the above systems are in *f 49 I i'
conformance with MOA COSA guidelines in effect on this date. """ e
Engineer's Printed Name Benjamin Schiller :"';•��� " •�.",
g �8611}S'i in / WI. o
Date 0/0812017 I�� Ci•12 ' ha
a �'
COSA brown sheet 10-10-12.doc
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. BOX 196650 Anchorage, AK 99519-6650 ' · .
www.ci.anchor, age.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE-FAMILY DWELLING
Parcel I.D. ~
'1. GENERAL INFORMATION
Expiration Date: ~" 3 I-~ ~
' Complete legal description
Location (site address or directions)
Current Property owner(s) ~'~,".~,,o
Mailing address FSo-~
Lending agency ,
., r-s' ,,-~t'
,'~-~,'/~.Day phone ~-d'..<"-
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
.un'less 6therwise requested, HAA w#! be held by DSO for pickup.
2. :~NUMBER OF BEDROOMS: '2_
TYPE OF WATER SUPPLY: '
Individual Weil
· Individual Water Storage
Community Class
Publi~; Water System
Well '
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding tank []
[] Community On-site []
[] Public Sewer I-'1
· The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
.S. upply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 ~days from the date of issue for properties served by a'private oi~ Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to-one-year with valid writer samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
Legal Description:
A. WELL DATA
Bo
Well type
:Municipalit7 of Anchorage
Development Services De'partment
: Building Safety Division
! On-Site Water & Wastewater Program
:,4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL ClLIECKLiST
Parcel ID:
- If A, B, or C provide PWSID # ~
.. Sanitary seal (Y/N)
Cased to c)oc ft.
FROM WELL LOG
"7'{Io !'7!
Date completed 71lo/"/I
Total depth too ft.
'7 7 ft.
y.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:.
Coliform, C;) colonies/100 mi.
Arsenic: ~ mg./!.
SEPTIC/HOLDING TANK DATA
Tank Type/Material i .~¢./~ ~ c..
Tank size l,Z.¢---o .i ga!.
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground).
AT INSPECTION
&'".'7'l"
NitrateO. ¥76' rog.Il.
Date of sample:
¢/ ".~ /'~ e l '
Number of Compartments
Depression over tank (Y/N)
in.
· Other bacteria
Collected by:
Date installed
Cleanouts (Y/N)
Foundation cleanout (~/N) ~ 'y' High'water alarm (Y/N), ~J.
Dateofpumping I'?-:/&¥ {0.?, Pumper i~c Do,'~z.[ c~(~ I~ ~ r,~?'l,~.¢ "Ce ,"Ot~ ~''
ABSORPTION FIELD, DATA 1/'~',, c,,¢e ¢ ~,~ e,o ! $/,'~ a c~ .
Date installed ~' {g- 7~/~g" Soil rating (g.p.d./ft2 or ft2/bdrm) 3' ~.~- c?.._L./ System type
Length ~ ~t ' ft. Width '~-7- ft. Gravel below pipe O..,4" ft.
Tot.al depth ~.79~ ft. ,! Eft. absorption area 76',~ ft'" Monitoring tube "r'
Date of adequacy test i t'z,/I'~ / ~,_? Results (Pass/Fail)
Fluid depth in abso:rpti~nfield before test ! in. Water added lit) gal.
Elapsed Time: ! I~min. Final fluid depth .~'.,~' in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) J,,/o~ E'
Depression over field
Absorption rate >=
~::,,3 o c,..,,.~ If yes, give date
A/
Forl ~. bedrOoms
New depthS'. ~-Cin.
x'/'.5"~ g.p.d.
.~o
0 RECEIYED
t
I!XCLU~IOll IIO1E: Il I~ the
te~pon,qlbllll¥ lc dclcrmln.,t
e::l$l.~nco of any en~eme,,ls, c0wn~nt~.
0r tmtrkllone which d~ ~of ~pp~r
~ ~ t~se~ for conslmctlon m for
EN(31NEI::I~EI · PL'ANNEI~Ei "I~UI~VEY{31qEI
TI
440WEST BENSON BLVD.
ANCHORAGE. ALASKA g9503 :662-52gl
LEGAL OE.~;CRIPTION: ' '
SURVEY CEflTIFIC^TION:, I hereby certify that I have turveyed the p*opert¥ et,ow...,f ,t
scribed I,e~a0q of, d lh.! 'the Improvemente tllueled ther6on e,o within lhl Dropas'ly Ilnee emi ,:
enceoaehmemle ewle! f)lhe~ the"
beeke In relation ,to lot
~/o" nEnAn · O
tlU~ ~ TACK 0 ~
MONUMENT ~ ~
AL-CAP ~ ~
IRON riPE ~
~- E LEV~, - OAKUM
ASSUMEO
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. # C3°IC) - I~ ~- b~ HAA#
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) Pltle IOl .~e~r-c~ l/wy
Property owner
Mailing address
Lending agency
Mailing address
Agent C~xrl~n¢
Nor ~h ~orh~o~ Day phone
~t~ Iovxe~ ~ ~o~ o~ ~ele 8ivv~ay phone -
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance .with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm /='/~ ('~>/~
Address
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
--~"~x~.. ' ~ "
THEODORE F MOOR[
,'.. CE - 3589
bodrooms.
STABP
bedrooms, with the following stipulations:
Additional Comments
Date 7- //' ~'~'
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.
'~2-o25(Rev. 1/91) Back MOA~I
Municipality of Anchorage ,~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Parcel I.D.
Well type P~VATE
Log present (Y/N) "/
Total depth J oo
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed -7/I o/71 Driller 1'4 - h/
Cased to ~'~ ' Casing height t5
Date of test
Static water level
Well flow
Pump level1
Wires properly protected (Y/N) "/
FROM WELL LOG AT INSPECTION
7 7 7~
30 .g.p.m. ';>
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot I 5o
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
131
~/OD
Public sewer manhole/cleanout
Petroleum tank 60 '
WATER SAMPLE RESULTS:
Coliform 0 ¢~, ( / ~ oo ~ ~.
Date of sample: ~/'~/gq
Nitrate
- ,~//'~ Other bacteria 0 co/
Collected by: IqA'r-roP T~cH 5'~/c £
B. SEPTIC/HOLDING TANK DATA
Date installed ~/$&
Cleanouts (Y/N) ~'
High water alarm (Y/N)
Date of pumping
Tank size I ~- 5 o G,~ ~ Compartments ::2.
Foundation cleanout (Y/N) lq Depression (Y/N)
14,/~, Alarm tested (Y/N) N,A,
6'{'~ /~;¥ Pumper /~o/o /~oo/"~-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line H
Surface water/drainage
72-026 (3/93)* Front ~
On adjacent lots
Absorption field
/DO
t
Foundation ~0
Water main/service line
Io0
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~
Length H-~ Width
Total absorption area c~
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
322 F
Soil rating (GPD/Ft2) o.H"/
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail) ,,)~.¢ ¢
System type
Total depth
Depression over field (Y/N)
for 2-_
After test ~/~ ,
If yes, give date N ,A,
N
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 15o
To building foundation I oo
f
On adjacent lots ~ 50
Surface water '~ /oo'
On adjacent lots ~. /~o¢ Property line
To existing or abandoned system on lot ~
Cutbank N ,A, Water main/service line
Driveway, parking/vehicle storage area .~'O '
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effec~~ofthis inspection.
Engineer's Na;e ~~ F. ,~
H~ Fee $ ~ Waiver Fee $
Receipt Number ~--~ ~ ~ ~ ~ Receipt Number
72-026 (3/93)* Back
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERT'FICATE OF iNSPECT'ON FOUR HEALTH AUTHORITY APPROVAL ~.~J~)?- ~,~)q
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
!
Location (address or directions)
(b) Applicant Na;ne /¢~7~:,~: ,'~¢/~,~ Telephone: Home $.'r'~r ~/~,/Z Bus,ness .2-rF'-/3"?J",k'J'"'"~/'
~'i APplicant. Address...' ~'2¢.~ .,¢7~. _~¢;/O ~'/,,~ ~_¢~.~ ~¢'J-'~-O
(c) Applic,~nt is (check onei:.Lending Institution []; Owner/builder,,~]; Buyer []; Other [] (explain);
' (d) ' "';Lendin[j Institution
A~ldi~ss' ' - "*~ '~
.;;(e) Real Estate Company and Agent
Telephone
' '"~'/'; i' (f) Mail the HAA to the following address:
' ',
2, TYPE OF RESIDENCi=
.. , ~ingle-Family¢ ;Multi-Family [] Other
:' f:: ~Number of Bedrooms
WATER SUPPLY
In~li~i(Jual 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.
4, SEWAGE DISPOSAL
Onsite~ 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 (11/84)
ENGINEERING FIRM PROVIDIk NSPECTIONS, TESTS, FILE SEARCH, D~ . 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 o?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 . ,.~/~-
Address
Date
Telephone ,.~ ~-- 5 '-~ ~0
Terms of Conditional Approval
DHEP APPROVAL :~.':~':::'~ -
.., A?.P[0yed for -~o~"z-) bedr0om'~'.b.yi~ ~. ~~
Approved ' ~" DisaPpro:ved '~ '-~/A~'~:-r: Conditional
Date
CAUTION
The Muncipaiity of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anbhorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
, ,., ~.,, ~< ~\o:'-/~°~MUNICIPALITY OF ANCHORAGE (MOA)
~1~,~\(:,\\~h'\ i ',t'~:':,, ~'., !!~ °?~V';\~ALTH AUTHORITY APPROVAL (HAA)
~.~%~,~7,'::t-~ ' ~ CHECKLIST- FEBRUARY 1984
- (~ '~7 264-4744
Legal Description: / -7~
WELL DATA
Well Classification . ¢¢)¢-~ u ~ '/-6 . If A, B, C, I~.E. CvApproved (Y/N)
Well Log Present'N) Date Completed '~/~'O//''//~/ Yield
Total Depth '~"//~O Cased to q¢62 - Depth of Grouting
Static Water Level '~
Casing Height Above Ground
Electrical Wiring in Conduit~F,¢~4)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Water Sample Collected by
Water Sample Test Results
Comments
Pump Set At
Sanitary Seal on Casing ~t~N)
Depression Around Wellhead (Y/~)
; On Adjoining Lots ~ Z'Z.~ /
; On Adjoining Lots .;:>/5"(.-~"
To Nearest Edge of Absorption Field on Lot /_~..O/./
To Nearest Public Sewer Line /~)/'"~ To Nearest Public Sewer
Cleanout/Manhole /4Jj"l-~ To Nearest Sewer Service Line on Lot
]' (?~ , ,'~ ; Date ~/~'3',,/~'
B. SEPTIC/HOLDING TANK DATA
Date Installed¢2~'' *z? '-')"~- ¢g' Size /
Standpipes~4) Air-tight Caps ~'d)
Depression over Tank (Y/~)
Pumping/Maintenance Contract on File (Y/N) /t.,/
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /'~,_tT, --/ !
To Property Line '~ ~ 2.,/
To Water Main/Service Lir~e%
Course , /2/,,4 : "~
No. of Compartments 'Z.
y-
Foundation Cleanout (Y/~.
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N) AJ,/'/¢¢
To Building Foundation ~::~"
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026 fRev 8/861 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ¢2 (, - .¢ '~
Width of Field ~'. Z
Square Feet of Absorption Area
Depression over Field (YEf~-N~))
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ,/ZO ~' /
To Building Foundation
Lot /~7~ /
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ~/~,' /
Depth of Field ,:~ 't
Gravel Bed Thickness /
Standpipes Present ,~N)
Date of Last Adequacy Test
!
To Property Line /0
To Existing or Abandoned System on
; On Adjoining Lots ~ Z.o /
To Cutbank (if present) '¢"/'/~
/
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump.Off"- L~vel at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I havejT::becked~ verifie¢, or conformed to all MOA ar)d HAA guidelines in effect on the date of this inspection.
Signed ,.""~/(.~~ Date /~//~/~:'~
Company ./~.'(-f."~d'~~ MOA No. C~- ~ -'-~
Receipt No. /~/¢~¢~
Date of Payment /~ ~
Amount: $ /~ ~
Page 2 of 2
72-026 IRev 8/861 B~ck