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Home My WebLink AboutALPINE WOODS BLK 2 LT 11 Municipality of Anchorage Page ! of 2_. 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: _%l,d~:i'd 9H7 PID Number: O''~''z--~w/*° Name: Wastewater System: [] New [] Upgrade Address: ABSORPTION FIELD ?h~n3: No of Bedrooms: A~j~HO~C_E.t /~j~_ ~:~'/~ Li ~DeepTrench ~ShallowTrench Uaed UMound ~Other LEGAL DESCRIPTION ~so,, Rating: ~. ~ GPD/Sq. Ft. Total Depth from original Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Township: I Range: Section: Fill added above original grade: Gravel length: I ~ ~ Ft. ~7 Ft. Gravel width: Number of lines: l Distance between lines: WELL: New Upgrade Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level:Ft, ~~ ~l~taller: ~ ~ Date installed:/¢ -- Casing Height Above Ground: Yield: I Pump Set at: TANK GPM~ Ft. Ft. SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ ~ ~' ~ / ~ ~ Material: Number of Compartments: Surface ~ Water /~ ,. /¢ / , -- LIFT STATION Lot Size in gallons: J Ma~ Foundation ~1+ /~,. -- -- -- "Pump on" level at: j "Pump off" level a~: ~,arm at: CurtainDrain -- -- ~¢~ ~¢~ _ _ Pump Make & Model ~ Electrical Inspections pedormed by: Remarks: BENCH MARK Location and Description: Assumed Elevation: /~o,~ ~, ENGINEER'S SEAL ..~' . . S & S ENGINEERI~ ~' '" ': Inspections performed by: ~e ii--r, ~.~k. 77~ Department of Heal Hu~~rvices approval 72-013 (Rev. 9/91) MOA 25 Permit No. SW950447 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 ALPINE WOODS SUBDIVISION, BLOCK 2 LOT 11 01525418 Legal Description: PI D No.: CO1 ~ NEW N.T.S. C02 MT1F94'6' _ C04~ ~.. · -~ 90.T~ FCO 17.5 :23.0 CO1 30.5 [34.5 CO~ 37.0 142.0 C03 40.0 45.5 C04 69.5 53.5 C05 71.5 67.0 C.0..6. A~..O. MT1 69.5 53.5 MT2 71.5 6?.0 MT2 C05 " . .......... 8.3.7 ........... 51t:27 ................................................................................ · 77.7' NO WATER FOUND ~- i ---_ . ~CREEK i 10' UTIL ESMT :: i co, · ..... ~ tblT1 ....................... :: i ......................... [ [ co4 NEW 1250 GALi SEPTIC TANK ENGINEEM'S SEAL SCALE 1" = 40' 72-013 A (1/93) * MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ,t.._/~ ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930447 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:WALKER JACK A & CYNTHIA A OWNER ADDRESS:6541 DOWNEY FINCH DR ANCHORAGE, ALASKA 99516 DATE ISSUED:10/25/93 EXPIRATION DATE:10/25/94 PARCEL ID:01523418 LEGAL DESCRIPTION: ALPINE WOODS BLK 2 LT 11 1 LOT SIZE: 53332 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 RECEIVED BY' ISSUED By. ~~~/ ~ DATE: ROBERT SHAFER, P.E. ROGER SHAFER, P.E, October 15, 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: Alpine Woods Subdivision, Block 2, Lot 11 Request you issue a permit to install a septic system to serve the proposed four bedroom house on the referenced property. Test holes were excavated and percolation tests performed. The approximate location of the test holes are located on the attached site plan. After seven day water monitoring water was found at in test hole #2 at 15.5 feet. This property has enough area for a future septic upgrade which can be seen on the attached site plan. This property is served by a Community Water System. There are no protective well radii which encroach upon the property. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. RAS/LSU/Isu If you have any questions, please contact us. . Shafer, P.E. ~ 17034 NORTH EAGLE RIVER LOOP or require additional information for your review, · SUITE 204 · EAGLE RIVER, ALASKA 99577 Z Z>- C3 {/3 Ld I ~NVq H3NId, L >t3V8 oo1~ I N~gd F 311S i :r'lvOS ,Og = ,,~' / / Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PER FORM ED FOR: /~C/~/~[~__r~ '~K...~'~'2~I~' LEGAL DESCRIPTION: L/!/ ~ ~, / /Z~/..~/~./~?_,~,~)~ ~;~Township, Range, Section: SLOPE 4 7 8 10 12 13 14 16 17 18 19 2O DATE PERFOR~~ SITE PLAN WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT '"' O DEPTH? P E Moniloring? Dal~ I ~ ~ ~ Gross Net Depth to Net Reading Date Time Time Water Drop .,/.~ io ,~,~, ~'& " '1~ ~ ; ~ ~ ,, ~ ~ ~' ~/~ ,,_ PERCOLATION RATE ~-C) (minutes/inch) PERC HOLE DIAMETER .// ./ S & S ENGINEERIN~ /./"~ ~/ ~ IFY THAT THIS TEST WAS PERFORMED IN PERFORMED BYITO3~ c..._~!._ R;..."~r-- I_~ R~d H~. ~ ACCORDANCE ~A~LV~A~~ ~['PAL GUIDELI~CT ON THIS DATE. DATE: 72-008 (Rev, 4t85) Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST ~/~ LEGAL DESCRIPTION: ~-/~ /.~2, ~ ~ ~)Township, Range, Section: / ' ~ SLOPE SITE PLAN 4 5 6 7 8 9 J (ENGINEER'S SEAL) 10 WAS GROUND WATER ENCOUNTERED? 11 12 13 14 16 18 19 S L IF YES, AT WHAT O DEPTH? P E Moniloring? ~.'~ Dale: 20 ~/' PERCOLATION RATE ~'~ (minutes/inch) PERC HOLE DIAMETER ~ Gross Net Depth to Net Reading Date Time Time Water Drop I;50 ~ ~" :J~ ~ ~, ~V~~ ~ _ : s~ ~0 ~ ~ '/~" ~1~ TEST R~N.ETWEEN ~ --~ AND "( ~T PERFORME Y ~x ~ ....... THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDE~FECT ON THtS DATE' DATE: 72-008 (Rev. 4/85) ON-SITE WASTEWA TER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MA TERIAL SPECIFICATIONS REFERENCE: Alpine Woods Subdivision, Block 2, Lot 11 GENERAL: 1. The scope of this project includes the installation of a 1250 gallon septic tank and a leachfield trench to serve the proposed four bedroom residence on the referenced property. 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. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. 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. Page Two Alpine Woods Subdivision, Block 2, Lot 11 October 15, 1993 Septic tanks installed with less than 4 ft. of cover shaft be insulated. A foundation cleanout shaft 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, shaft be to clean toward the leachfield. The second cleanout shaft be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists a way from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shaft 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 shaft 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 shaft 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 Alpine Woods Subdivision, Block 2, Lot 11 October 15, 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 So/id Cast Iron Yes ASTM D3034 (PVC) Yes ASTM F810 (HDPE) Yes ASTM D2662 (ABS) Yes Yes Yes No Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). o Septic tank in/ets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier ('l'ypar 3401, Mirafi 140N, or equal) must be instal/ed 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 11200 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 Alpine Woods Subdivision, Block 2, Lot 11 October 15, 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. 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. LEGAL DE,~CnlPTION: L. rY"~ .I I --0/4 A LP~N~ 2 3 4 $ 6 7 10 11 12 13 14 15 16 17 · . .',.. Munlolpallty o! Anchorage ' DEPARTMENT OF HEALTH & HUMAN SERVlC 825 "Li ;lreel, AnchOrage. AlaSka 99502-0650~.~ ':'" ~ ~ · I SOILS LOG ~ PERCOLATION COMMENT0 ENCOUNTER£O? L IF YES, ATWHAT ~ O DEPTH~ P Mop~rfig? ]7~4 =eale,. " i O,os, Net ' O$~th tO '~'. Net: Read;n9 Cede Time Time .' ~ , ~ .w~t~r ' .' O¢0~, ...... ~' /_.~:tk :: ._ . ,..~ If~ . .~,.,~ ~, .......... ; " ?" ~l ,~ ~,-..x .~ PERCOLATION RATE ~ tmlnule~/inchl '" TEST RUN BETWEEN FT AND ~0'd ~00'ON £~:;; £6,S$ d3S S~;~-SP£-Z06:dI '3NI SN31SAS 39U333U 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 o m Location (site address or directions) Property owner t~,j~r'z.O ~ i~t~ Mailing address ~-"~- ~-- ~ Day phone Lending agency Mailing address Day phone Day phone "7[~Z.'-~/// Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: lng to the legality and status of system. If community well system, provide written confirmation from State ADEC attest- TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank. Community on-site Public sewer NOTE: If Community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER. 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 furtherverifythat 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 com 31lance with all Municipal and State codes, ordinances, and regulations in effect on the date A!aska Water & Name of Firm W~ntp. waterServ; ,es _ / Address Engineer's signature this inspection. Phone ~ Date ¢0/~/ DHHS SIGNATURE · ~ APproved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: · Additional Comments Date 7- ¢-¢7 'The i~;'ni~pality of*A~ci~orage 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 engi~er'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{Re~.1/91) Ba~k MOA~21 MUNICIPALITY OF ANCHOP.~GE ENVIRONMENTAL Sl::RVICF.,S DI¥181ON Municipality of Anchorage JUN 2 3 1997 DEPARTMENT OF HEALTH & HUMAN SERVICF::j~ E'- Environmental Services Division ,x I.. (, E i V E D 825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744 Legal Description: L..c:;'F- t ~j Health Authority Approval Checklist t~¢. '2_ ,~LAg~,,/~_- ~ Parce I.D.: c::, 15'- - 3.74 A. WELL DATA Welltype O--'(-~~t~3~" N) Date completed Cased to Sanitary seal (Y/N)~ FROM~ECTION If A, B, or C, attach ADEC letter. ADEC water system number Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample: g.p.m. Collected by: Casing height (above ground) Wires properly protected (Y/N) Nitrate ~ g.p.m. Other bacte~ B. SEPTIC/HOLDING TANK DATA Date installed /o/~/~ Tank size Foundation cleanout (Y/N) Date of Pumping /,2.~---0 Number of Compartments__~ Cleanouts (Y/N) ~/F----~ Depression (Y/N) ,,,VO High water alarm (Y/N) Pumper -~/~'~'/~"~' C. ABSORPTION FIELD DATA / Date installed /O/c"~-~ Soil rating (g.p.d./fF or fF/bdrm) *' (~ ! Length -7 7 Width .2., ~- Gravel thickness below pipe Effective absorption area /0 ~7 ~ Monitoring Tube present (Y/N). ~ Date of adequacy test ~/).~/cj '"7'- Results (Pass/Fail) IP'Zk~ ~ For ,dc- Fluid depth in absorption field before test (in.); ~r.. O" Immediately after gal. water added (in.): System type '7 / Total depth __ Depression over field (Y/N) /k) C) bedrooms /7. g" Fluid depth (~ (ins) Minutes later: I0 ~)&) Absorption rate = Peroxide treatment (past 12 months) (Y/N) /u~,~-~- P--~a ~J~'~f yes, give date 72-026 (Rev. 3/96)* g.p.d. Date installed ~._~ Size in gallons Manhole/Access (Y/N) ~~~~~,~ ~"Pump off" level at* H~ *Datum '-Cycles tested E. SEPA~~CES ' SEPARATION DISTAN~L ON LOT TO: Septic/holding tank on tot ~'-.--~._ On adjacent lots Absorption field on lot Public sewer main ~ Public sewer manhole/cTC~ef~~ Se~~'- Lift station SEPARATION DISTANCES FROM SEPTIC/HO_I.~ING TANK ON LOTTO: / ! Foundation ~./0 Property line ~o~' C Absorption field /O-f"' ~ / / Water main/service line '~ I0 Surface water/drainage //~ ~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: / / / Property line ~"'~ -+ Building foundation /~ 4- Water main/service line ~',/'~ Surface water /0~- f~ Driveway, parking/vehicle storage area / / Curtain drain ~JO ~-- ~.,~0 L~/~ Wells on adjacent lots ENGINEER'S CERTIFICATION l , certify that, hav__e d~rnino~t¢ ~,d inspections and review of Municipal roco_.~.~~a¢~v~.~ms ,n conforrnan~w~tll//~l~At-~u, ./,nes in effect on this date. I A Date &/~l ~ are HAAFee $. ~)~ · ~ Oa eo,,a, en Receipt Number "~~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* 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. # O) ~p~Z~3R 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUI~HORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~ HAA # ~ ~ OI ~ ~ In.'~ Alpine Woods Subdivision, Block 2, Lot 11 Location (site address or directions) 6541 Downey Finch Drive Property owner Mailing address Lending agency Mailing address Agent Address Jack and Cynthia Walker Day phone 6541 Downey Finch Drive Anchorage, Ak 99516 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: 4 Individual well Community well xx Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my inves.tLgation 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 · o Phone Address Eagle~ Engineer's signature DHHS SIGNATURE .~'~. ' Approved for bedrooms. Date Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage ~i~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ,J~ ~ ~c:,,~,./~' /.z~O~'D .~ ,.~,~. Parcel I.D. A. Well Data Well ~pe ~~. If A, B, or C, aEach ADEC le~er. ADEC water s~stem number Log present (Y/N) ...... Date completed ~ Driller / Total depth .... Cased to ~ Casing height Sanita~ seal (Y/N) ...... Wires prope~rotected (Y/N) FROM WELL' LOG /AT INSPECTION MUNICIPALli'Y Date of test ~~ / E~IRO'~EN~ At SERV ICEs DIVISION Static water level ~~ / ~ ~DE{; Well ,IOWpump level1 __~/p.m. ~ SEPARATION DISTANCES FROM WELL ~ . Septic/holding tank on lot ~ ~ ; On adjacent lots Absorption field on lot ~ ~ ; On adjacent lots Public sewer manhole/cleanout Public sewer main / Sewer service line WATER SAMPLE RESULTS: Coliform / Nitrate / Date of sample: / / Petroleum tank Collected by: Other bacteria B. SEPTICR'I~I~I~I~TANK DATA Date installed /~'£~/- Cleanout~/~/N) ~/ High water alarm (Y/~ Date of pumping Tank size Foundation cleanout..~N) /~ ~'~ ~- Compartments ~ t ~-,/' Depression (Y~ ~// Alarm tested (Y/N) X_2/~3. Pumper / ~'/&-~/_x._2 ~-~/~-- SEPARATION DISTANCES FROM SEPTIC/HOL-Dff~,,.-.TANK TO: Well(s) on lot X-J/TzL. To property line /~ /4-- Surface water/drainage On adjacent lots Absorption field /~-~ ~-- Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons ,~Vfanhole/Access (Y/N) Vent (Y/N) "Pump on" level a .~''/~ "Pump off" Level at High water alarm level // Cycles tested electrical (Y/N/~. Meets MOA codes SEPARATION DISTANC~OM LIFT STATION TO: Well on lot ,// On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~ Soil rating (GPD/FF) E¢, ~¢' System type ~)/__¢~-"¢~ -/")~.-~C Width ?..~_/_ Gravel thickness ~' Total depth / / / /~'~,~ Cleanoutpresent,~N) Y Depression over field /(~ /"--/ ~/¢:~ Results (pass/fail) ~'~/'~- .~-~.~./~, for --~ Bedrooms ~/,z~ After test /'-'}//:~' /'--/ If yes, give date /L~//~' ' SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation /~' '-/- On adjacent lots ~ ~-- Surface water Curtain drain Property line /~ ~/- To existing or abandoned system on lot /~///,~ Cutbank ~-)///~ Water main/service line Driveway, parking/vehicle storage area /D"& E. ENGINEER'S CERTIFICATION I certify that I have c~~d to afl MOA and HAA guidelines in effect.,,, .,...~. ,.°n' the..,, date of this inspection. Signature .. ~/2~.~"~ ~,~.,~ · g~:::. :::.' .:, '.:: ::::5:: ::: :::: ~:: ;:7 ~/~::~::~. ~:::~;~::~:.:::::~?:::~:: ~¢::¥:..:.~:::: EngineeCs N~~RING 17034 Ea~iver L~p R.d No, HAA Fee $ ',- :~0 Date of Payment Receipt Number /.24 70 Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back