HomeMy WebLinkAboutASPEN HIGHLANDS #2 BLK 2 LT 6AAspen
Hi'*ghlands 2
Block 2
Lot 6A
#017�013�96
MUNICIPALITY OF ANCHORAGE
· DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
IPHONE ~'N EW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
~ ~ Manufacturer~~ Material No. of co~artments
Liq. capacity] ~in ga~ns~ IF HOMEMADE: inside length~ Width ~ Liquid depth
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO,
~ - ~ Manufacturer~/~ ~ Material Liq~acity in gallons
Q Well ~ Foundation Nearest lot line PER~T NO.
~ ~ ~ No. of lines Length of each line Total length of lines Trench width Distance between lines
~ ~ ~ Top of tile to finish grade Material beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter ~ ~ Total effective absorption area
~ DIS~ ~' Building foundation Nearest lot line
~ Class Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
SOl L TEST RATING/
APPRO~ ~/~¢ ~5m¢~-~./ DATE LEOAL
72-013 (Rev. 3/78)
,
SURVEYOR'S CERTIFICATION
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
PROPERTY DESCRIBED ON THIS PLAT AND THE
IMPROVEMENTS SITUATED THEREON ARE LOCATED
AS SHOWN ON THIS PLAT.
OAT ED T.,S 2 DA Y OF
LEGEND
0
NOTES:
I,
LOT CORNERS
FOUNDATION
DRAINAGE ARROWS
IT SHALL BE THE RESPONSIBILITY OF THE BUILDER OR OWNER TO VERIFY THA1
BUILDING LOCATION SHOWN MEETS ALL SUBDIVISION COVENANTS AND ZONING
ORDINANCES.
2. IT IS THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL ELEVATIONS WITH
RESPECT TO ALL UTILITIES
3. THIS PLAT REPRESENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
FROM THE RECORDED PLAT DESCRIBING THAT PARCEL. INSTRUMENTS RECORDED
PRIOR TO OR AFTER THE FILING OF THE RECORDED PLAT ARE NOT SHOWN ON
THIS PLAT.
4. THE INFORMATION ON THIS PLAT IS FOR THE USE OF LENDING INSTITUTIONS
SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND
PLATTED LOT LINES OR EASEMENTS , THE PLAT IS NOT TO BE USED FOR
POSITIONING ADDITIONAL STRUCTURES OR FENCES.
"A fi f~u J LT
~,~PF_M HIGtAL_AMD5 3L)E~'D
BESSE, EPPS a POTTS
2220 E. 88th. AVE.
;549-6452 949-6454
DRAWN BY~ K~L-
CHK. BY,
ANCHORAGE, ALASKA 99507
SCALE
t = C-C
DATE'
DWG. NO.
DEEP TRENCH DESIGN
REQUIRED AREA: ~ ~,~ × 170 ~)~/~ ; .~)o ,~*
TRENCH DIMENSIONS REQUIRED: WIDE
SCREENED ROCK DEPTH
LENGTH
~ TRENCH DIMENSIONS: WIDE
J SCREENED ROCK DEPTH
~ LENGTH
COVER
EFFECTWE AREA OF PROPOSED TRENCH'
COVER ,
TOTAL
DEPTH
/
/¥
TRENCH SECTION:
4" PVC WITH
STANDPIPE DETAIL:
STANDPIPES TOTAL
TO. BE CONNECTED
AS SHOWN ON LEFT
NON-TOXIC BARRIER
4' DRAINFIELD PIPE
NOT TO BE CONNECTED AS
SHOWN IN TRENCH SECTION
--SCREENED ROCK
PER M.o.A. HEALTH DEPT. STANDARDS
ORD. 15.65
(9O7) 243-2282
KEN JOHNSON
KEN'S COMPANY
WATER WELL DRILLING
PUMP SALES & SERVICE
35 YEARS ALASKA DRILLING
3163 LINDEN DRIVE
ANCHORAGE, ALASKA 99502
SEPTENBER 10, 1986
LORETTA & DAVE HIOKOX
3333 M. St ',
ANCHORAGE, ALASKA 99501
REi LOT 6A ASPEN HIGHLANDS
0 ft to 1 ft
Ift ~ 4 ft
4 ft to 24 ft
24 ft to 26 ft
26 ft to 71-6 ft
71-6 ft to 78-6
78-6 ft to 83
83 ft to 85 ft
85 ft to 98 ft
98 ft to 108ft
108 ft to 118 ft
118 ft to 120 ft
( Hm, 276-2301 Wk. 349-4595
( Century 21 Interiors Inc, .^~
t, AU~ ~.~. uL~,,~'~,o~c~O~ ~
WATER WELL LOG
Organics
Course gravel & brown silt
Ned. gray & gray silt
Cobbles
~ed gray & brown silt
Clean fine gray & course sand
Water bearing.. Low head ( 8 ft.
Test bail at 5 GPM
Head increases with depth
.)
~ed gray & light brown silt ( dry )
Same ( Weeps 2-3 Gpm ) 5 ft head..
~ed gray & brn silt ( dry )
Same with browner silt
Fractured bedrock., Over nite static 61 ft GL
loc % bail down at 5 gpm .. casing refusal.°
Recovers at 2.23 Gpm
Firm rock..
Perforate casing from '70 ft to 78 ft.
Star perforator ( Sample perf. on top casing )
Surge & develope
Static water level 61 ft. GoL.
Test bailed at 15 plus GPM ~ hr.
No drawdown ( 59 ft head )
Total casing 110 ft ( T0C )
Total depth 120 ft. .( T0C )
D E P A I:R 't" M E Iq'!' H Ii!!'. A I.... T H A I"',1 D E 1',1 V I R O N 1':1 E rq T r:.:'~ ! ...... ..;~ til)'T' E ET'I" I E)Iq
82.5 I .... STI::;~IEET;, AI"'.ICHORAGIE, AK 995.0 1
Eli IP',,.il .......... :ii!E;: ][ "]['" [l!i!ii!] '.!i!iiii[; l[i!~!] 1!,,,,,11Hiii!E: tl:::'~;:'. ;~!!~:F~: ~,,,,,!11EiE b..~ ........ tF:::' E!E: ~.:::::;:: It'""'.~ ][ ' "~
PERPII 'T' !.(
.............. ;.,,,..: E NG I Nli::F:'F~'F::' ~'~ E)IES t GN
! 0 /0 1/',B6
L..liii:GA1 .... DESCF:~ I
LOT '"'
DAVID H!CI<OX
C/O 8EF' 2220 IE 88'f'H AVE:
ANE:HORAGE, Al< 995()7
349 -.-. 645 1
SUBDIVISION: ASPEN ~ ..... ~
SECTION: 25 TOWNSHIF': :L2N
1,,4A (SQ,FT,, OR ACRES)
LOT: 6A
R AN G E: 3 W
E L.. L)L,I.,. ~
I cer'tiFy that:
:1,,, I am ¢'ami].iar' with 'Lhe nec:lu:i.r'err.,er'd:.s i'of on.....si'Le seweps and well!!.=,' as set
~'or'tl"i I::)y tl"t(.:.:-; Mur~icipa].:i. ty (:)~' Ancl'~oi*ar..;je (Iq[)A) and 'Lhe Sta'Le c:,~' Alasl.::a,,
;'..?.,, I t,,.~:i. ]. i :Lr"~s'l.'..:::..':l ]. 'l:.. l'"~ e? system in ac::cc.~l'dance t.,,.~:i, tl"l al. ]. MOA ,::::c, des and r'egLtlat :i. or"~s,
ar'id :J.r't ,':::,.':~mpliance w:i. th the des:i.r...tn cr':i.'t'..er, ia oF 'Lh:i.s per'm:i.t.
3,, I v,.~:i, ll a(::ll"'~er'e .I....,:::~ al.I. MOA and ,'-.'ii'Late r::)l' Alasl::a r'e(::luir'er~terits ¢(::.~r' '('..he set I:::,acl.::
d :i. :~:,tar'Jces ~ r' ,'.::)m any e;-.'..i, st :i. ng we]. 1, .waste~.,~ater, d i Sl:.)os.;a ]. .syst(.:.::,m or' i:::,u.l::) ]. :J. (:::
i.~;(:.:.)~,-,.~(.::.)r' age !iF, y?E.'l:..6.:,rrl ,::::,r'~ 't'..h :i.-:.iii c:q" ,.;.':~.r'iy adj acen'L ,::)r' r".,ear'b¥ 1 crt'..,
/
qooo
SURVEYOR'S CERTIFICATION
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
PROPERTY DESCRIBED ON THIS PLAT AND THE
IMPROVEMENTS SITUATED THEREON ARE LOCATED
AS SHOWN ON THIS PLAT.
DATED THIS ~ DAY OF ~19 ....
LEGEND
0
LOT CORNERS
FOUNDATION
DRAINAGE ARROWS
NOTES:
I.IT SHALL BE THE RESPONSIBILITY OF THE BUILDER OR OWNER TO VERIFY TItAT
BUILDING LOCATION SHOWN MEETS ALL SUBDIVISION COVENANTS AND ZONING
ORDINANCES.
2. IT IS THE RESPONSIBILITY OF THE BUILDER TO VERIFY ALL ELEVATIONS WITH
RESPECT TO ALL UTILITIESt ~r
:~. THIS PLAT REPRESENTS THE PARCEL OF PROPERTY DESCRIBED BELOW TAKEN
FROM THE RECORDED PLAT DESCRIBING THAT PARCEL. IN$'IRUMENTS NECORuP. U
PRIOR TO OR AFTER THE FILING OF THE RECORDED PLAT ARE NOT SHOWN ON
THIS PLAT.
4. THE INFORMATION ON THIS PLAT IS FOR THE USE OF LENDING INSTITUTIONS
SPECIFICALLY TO SHOW ANY CONFLICTS BETWEEN EXISTING STRUCTURES AND
PLATTED LOT LINES OR EASEMENTS ~ THE PLAT IS NOT TO BE USED FOR
POSITIONING ADDITIONAL STRUCTURES OR FENCES.
A.%PF_Iq t41GtALAFJD$ 5.iLS'E)
349-6452
DRAWN BY' JC~L
CHK. BY ,
BESSE, EPPS 8~ POTTS
2220 E. 88th. AVE
ANCHORAGE, ALASKA 9950'7'
JSCALE, J"~ ~)0' J C-C
UAIE: i/ ~. ~.~:~J FLD. BK.~
349~6454
IDWG. NO.
DEEP TRENCH DESIGN
TRENCH DIMENSIONS REQUIRED: WIDE ,~.
SCREENED ROCK DEPTH ~r,
LENGTH ~0'
PROPOSED TRENCH DIMENSIONS: WIDE
SCREENED ROCK DEPTH
LENGTH
COVER
EFFECTWE AREA OF PRopOSED TRENCH: ?:-/~> -p~ ~:
COVER
TOTAL
DEPTH
/~'
TRENCH SECTION:
4' PVC WITH
BARRIER
4" DRAINFIELD PIPE
SCREENED ROCK
STANDPIPE DETAIL:
STANDPIPES TOTAL
TO BE CONNECTED
AS SHOWN ON LEFT
_1_ NOT TO BE CONNECTED AS
SHOWNIN TRENCH SECTION
PER M.O.A. HEALTH DEPT. STANDARDS
ORD. 15.65
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~ER~ORMED FOR: /¢¢dX'o~'
LEGAL DESCRIPTION: /..oT ~ ~/'~.K-~. }~16.L.,~Or-~.~
' ~ '~ ~ .~ 'k:'~ '
DATE PER FORME~:~~~
Township, Range, Section:
1
2
3
4
5
6--
7
10
11
14
15
16
~7
2O
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT ~--/~-~ ~¢ O
_~DEPTH? ¢_/~ p,
~, ~,,~ M0nit0rino7 Dale:
Z,O,~6 4> '
(.o~tjuF_5
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ! I (minutes/inch) PERC HOLE DIAMETER "7
FT
COMMENTS c.~olcr5 B&4-o~,.) .,~1.1~ ~E~T AEE ~0~~ To ~tE ~O1~C~1
PERFORMED BY: ~~ ~,~ , ~Z ~ ~'{-~'~ CERTIFY THAT THIS TEST WAS PERFORMED IN
- ..,
ACCORDANCE WITH ALL STATE AND NI IPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
Municipality of Anchorage
On -Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEms APPROVAL
Parcel I. D. 017-013-96 Expiration Date: 3-7-/3
1. GENERAL INFORMATION
Complete legal description ASPEN HIGHLANDS #2; BLOCK 2, LOT 6A
Location (site address) 12900 MIDORI DRIVE *ANCHORAGE, AK 99516
Current Property owner(s) HAGEN GAUSS Day phone C/O AGENT
Mailing address 12900 VIDORI DRIVE *ANCHORAGE, AK 99516
Real Estate Agent TERRY GOSE W/ REMAX — Day phone 240-3667
2. TYPE OF DWELLING:
0 Single Family (w/wo ADU)
F� Duplex
F-1 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 On-site
n
Individual Water Storage
0
Individual Holding tank
r]
Community Class—Well
11
Community On-site
M
Public Water System
El
Public Sewer
F-1
Received by: /;X, Date: / �Z/Z/ a
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 901 C)
Date of Payment 1.Z7 -1 9)
Receipt Number 5N (11,71CA
COSA# - 05C� 'e) \75�
Waiver Fee $
Date of Paymen
Receipt Number
Waiver #
6. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat affixed hereto and as of the validation date shown below, / 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 andlor 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 I
information obtained from the Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply andlor 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 GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above, Any reliance upon or use of this report by any
other person orparty is not authorized, nor will it confer any legal right whatsoever.
6. DSD SIGNATURE
—AZSystem #1 Approved for bedrooms.
System #2 Approved for — bedrooms.
Disapproved.
Phone
337-6179
Date 15)12-
Conditional approval for — bedrooms. with tl�e following stipulations:
ON-SITE
WATER AND
WASTEWATER
PROGRAM
The Municipality or Anchorage Develop, emt Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS:
COSA Checklist
Septic System Advisory
Well Flow Advisory
L_//_ Nitrate Adv isory
Arsenic. Advisory
Other
M
3! Original Certificate Date: U - -7- 12
fRev 11105)
If more than I septic system is on the lot:
COSA Checklist * —of—
Structure served by this system
Certificate of On -Site Systems Approval Checklist
Legal Description: ASPEN HIGHLANDS #2; BLOCK 2, LOT 6A Parcel ID: 017-013-96
A. WELL DATA
Well type PRIVATE If A, B, or C provide PWSID# N/A
Date completed 9/10/86 Sanitary seal (Y/N) YES
Total depth 120 ft. Cased to 110 ft.
FROM WELL LOG
Date of test 9/10/86
Static water level b 1 —ft.
Well production 15+ —9 -p -m -
WATER SAMPLE RESULTS:
Well Log (Y/N)
YES
Wires properly protected (Y/N) YES
Casing height (above ground) 12+ in.
AT INSPECTION
11/1/12
2.03 a. D. M.
Coliform 0 colonies/100 mi. Nitrate 8.29 mg./L. Collected by: GEG. Ltd.
Arsenic: ND ug./L. Date of sample: 10/31/12
B. SEPTICIHOLDING TANK DATA DOUBLE C/O'S
PRIOR TO TANK
Tank Type/Material SEPTIC/STEEL Date installed 12/16/86
Tanksize 1750 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout (Y/N) Depression over tank (Y/N) NO High water alarm (Y/N) N/A
Date of pumping Pumper &204k) 1c"1CJ
— T --- T_ I U
C. ABSORPTION FIELD DATA I*BELOW EXISTING GRA
Date installed 12/16/86 Soil rating (g.p.d./ft 2 or(o�� 170 System type TRENCH
Length 31.5 ft. Width 2 ft. Gravel below pipe 8.5 ft.
Total depth *20.66 ft. Eff. absorption area 5,35 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 11/9/12 Results (Pass/Fail) PASS For 2 bedrooms
Fluid depth in absorption field before test 4 in, Water added ** 1800 gal. New depth 51 in.
Elapsed Time: 120 min. Final fluid depth 37 in. Absorption rate >= 300+ g. p. d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
**DRAINFIELD PRE—SOAKED (1500 GALLONS) ON
NONE
If yes, give date —
11/9/12 COMBINED WITH ADEQUACY TEST.
0. LIFT STATION
Dateinstalled— Sizeingallons— Manhole/Access(YINJ
"Pump on" level at—in. "Pump off" level aL----vr— 'High water alarm level
Cycles tested— Meets alarm & circuit requiremenW
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'+ On adjacent lots 100'+
Absoilption field on lot 100,+— On adjacent lots loo,+
Public sewer main N/A _
Sewer /septic service line 25'+
Animal containment areas 50'+
Public sewer manhole/cleanout
Holding tank N/A
Manure/animal excrete storage areas 100'+
SEPARATION DISTANCES FROM SEPTICIHOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption
Water main NZA — Water service line 10'+ Surface water
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
SEE ATTACHED LETTER REGARDING BURIAL DEPTH OF THE TANK & DRAINFIELD.+ RJEP-tta�
---r
I I
G. ENGINEERS CERTIFICATION
1 cedily that i have determined through fleld inspections and
review of Munkol records that the above systems are in ...... .. . .. . ..............
conformance with MOA COSA guidelines in effect an this
.... . .... .. ... ..........
date. f e A. ness.-'
bi.
Engineer's Printed Name JEFFREY A. GARNESS E-753
(> 'v
Date
(Rev. 11/05)
Municipality of Anchorage
Community Development Department
Development Services Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
Nitrate Advisor
Certificate of On -Site Systems Approval # 121550
A Certificate of On -Site Systems Approval inspection and test of potable
water was recently conducted on the well water supply on Block 2, Lot 6A
of Aspen Highlands #2 subdivision. This inspection revealed a nitrate
concentration of 8.29 milligrams per liter (mg/L) was reported for the
property's well water sample. The Environmental Protection Agency (EPA)
has established a maximum contaminant level (MCL) of 10.0 mg/L for
public drinking water systems. While private wells are not subject to this
regulation, EPA standards are based on existing health information and can
therefore be used to gauge the relative quality of water from private wells.
Please see the attached "Nitrate Fact Sheet" for important information
regarding nitrate.
This advisory must be attached to all copies of the subject Certificate of On -
Site Systems Approval.
4
E A. L I OLT
IC
COND OTORETWEENEXISFUDO �TAUC RARES Ar4b PLATTOA LOT LITN� AND�OR AASAAENT� A.E75
NOT 1 0 BE U5ER FOR NDSITIONOWE ADDITIONAL 5TRUCTLEe$. INORCYEIRENT5 OR FO16EF-INES
LASE.ONT�F RTPO40�ATAER THAN TINOSE APPEARING � IT E DE�O� FLAT, ARE NOT ATOM
AS-BUILTSURVEY 1- -30'
RG 1.FUFFl �Fl 1,D �11�
I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY
TO T 6A , BLOCK 2, ASPEN HIGHLANDS UNIT 2 (PLAT 7S-125)
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
" BIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
I' E PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
" IST OTHER THAN NOTED.
RATED AT ANCHORAGE,ALASKA THIS _21ST — DAY OF
AAROW PUMP & WER SEROCE, LLC
P.O. Box 110496
Anchorage, AK 99511
Office: (907) 346-9355 - Fax (907) 345-0202
Eagle River: (907) 622-9335
CUSTOMER
F
L
JOB SITE
L
M(Mcz
No. 9616
INVOICE DATE
WELL DEPTH
SWL
CHLORINATED
PUMP DEPT�,
SALESPERSON
OUANTITY
DESCRIPTION'
PRICE
AMOUNT
2e- ell
�j
-----
-----
LABOR
HOURS
RATE
AMOUNT
TOTAL MATERfAL
TOTAL LABOR
INORK ORDERED 117
DATE COMP
TOTAL
LABOR
PAY THIS AMOUNT
Thank You
SIGNATURE
(I Hereby Acknowledge the Satisfactory Completion of the Above Described Work and agree that if above work is not paid for in 90 days I agree to allow Aarow
Pump & Well Service, L.L.C. the right to remove unpaid for equipment and charge for labor already performed & labor to remove unpaid for equipment.)
TERMS: ACCOUNTS PAYABLE AT 10TH OF MONTH FOLLOWING PURCHASE.
SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS.
GARNESS ENGINEERING GROUP, Ltd.
CONSULTANTS& GENERAL CONTRACTORS
November 30, 2012
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Rd.
P.O. Box 196650,
Anchorage, AK 99519-6650
(907) 343-7904
Ref. COSA for Onsite Well and Septic System for Aspen Highlands #2; Block 2, Lot 6A,
To whom it may concern:
The referenced property is served by an onsite well and septic system. Upon our initial site visit, it was
discovered that the septic system had received what appeared to be 13'-15' of fill over the top of it.
During some repair work on the system, Wilco Contracting confirmed that the depth from the drainrock
to finished grade is approximately 14.5', and that the tank is approximately 13' deep. During a
conversation with Jay Crewdson with your department on 11/14/12, it was decided that the requirement to
abandon the old tank, and install a new, deep burial tank, would be waived.
The foundation cleanout documented on the original as -built survey and engineer's inspection report was
not present at the time of our inspection. Jeff Poet with your department gave authorization on 11/2/12 to
install double cleanouts near the beginning of the septic tank, to avoid digging up an existing gas line near
the house. During the repairs that took place, Wilco discovered that the steel inlet bung to the tank had
sheared off, and that the inlet baffle was missing. At that time, Wilco proceeded to expose the septic tank
to inspect the water line for any rust pitting or holes. They concluded that the coating on the tank
appeared to be in relatively good shape. At that time we contacted Jay Crewdson with your office. A
retrofit inlet baffle was then approved that would be constructed with D3034 4" pipe, and a sanitary
sweeping "T". The inlet pipe to the tank was to be encased in concrete for support, and bentonite for
sealant. The described repairs were completed, and the elevations of the inlet baffle were constructed and
installed to meet the municipal requirements. (Please see the attached photos)
We performed aAassing septic adequacy test on the drainfield on 11/9/12
R
M.S.
3701 E. Tudor Road, Suite 101 *Anchorage, AK99507-1259
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.gamessengineering.com
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. # ~) / 7 --
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner .~_ '~c~O:~. Day phone
Mailing address
Lending agency C~ ~. ~, ,~'Jq~,, ~ ~ ~_ Day phone
Mailing address
Agent Day 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
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
NameofFirm ' J OJ,'J~..'z'~-'/ ¥ Y'kJ, J ~,J,.~. Phone ~i).,~/- ~'~ J ~
Address ~ 0 '~ ~ ,/~r- J~
I
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
__ bedrooms.
bedrooms,
with the following stipulations:
By:
Additional Comments Note: The well for this property meets existing
State and Municipal Codes. There are nitrates present. It is
suggested that a periodic testing be performed to insure the wells
continued suitability. Nitrate concentration is 7.0 mg/!. EPA
maxim~m.~gnce~ratiqn is 10.0. mg/1.
~JV~l~4 <~t (lq-~ Date ~ / Lg/~-
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA#21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type ~
Log present (Y/N) y
Total depth i ~(2
Sanitary seal (Y/N) )/
Parcel I.D.
If A, B, or C, attach ADEC letter.
ADEC water system number
Date completed ~~ ~' Driller 'V_..z4~'5 ~l~,;~i,~
Cased to J ~' ~ Casing height t¢,,~~t
Wires properly protected (Y/N) y
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
g.p.m.
AT INSPECTIOi~JNIClPALiTY OF ANCHORAGE
¢~/O ~' /7 ~ ENVII~ONMJ~NTAL ,SERVICES DIVISION
s, R ' IVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main i¥//~,.
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ¢'~
Date of sample: /~//~/~ ~---
Nitrate '7. 0 Other bacteria
Collected by:
B. SEPTIC/HOLDING T~NK DATA
Date installed / ~/~'~/ ~,o
Cleanouts (Y/N) y
Tank size
High water alarm (Y/N)
Date of pumping
Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N)
jk/////~ Alarm/tested (Y/N)
'//~'~'-//' '~ ~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To PropertY line
Surface water/drainage
On adjacent lots
Absorption field
Foundation
/.~- .)-- Water main/service line ..~ J'" (~
72-026 (Rev. 7/91) Front CON..'I'INUED'ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
'Manufacturer
Manhole/Access (Y/N)
--'"Pump on" level at "Pump off" 16vel at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed vw"t. Soil rating 1 70 System type e,
�,p V)l
Length Width Gravel thickness -Total depth
Total absorption area Cleanouts present (Y/N)
Depre ssio'n'o'ver field (Y/N) D ate of ad equacy test 11A b 2,
Results (pass/fail) T1,X, eeat for bedrooms
Peroxide treatment (past 12 months) (Y/N) Af yes, give date
SEPARATION'DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /go -Onadjacentlots > '—Property line > 4/0
To buil din g foun dation To existing or abandoned system on lot
On adjacent lots > ILW-2 —Cutbank— t -///A Water main/service line > 5-0
Surface water Driveway, parking/vehicle storage area >
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Sig nature''.
Engineer's Name.
J
Date
CE -2 2
HAA Fee $
Waiver Fee: $
Date of Payment
Date of Payment
Receipt Number
e% 1)
nk-2ni
Receipt Number
72-026 (Ftey. 3/91) Back MOA 21
_r - E3 F__ U rl: t< 13 F_ - E=
203 WEST 15YH. AVENUE SUITE 206
ANCHORAGE, ALASKA 99502-3904
(907) 279-3916
SEPTIC SYSTEM ADEQUACY TEST
LEGAL: Lot 6A Block 2 Aspen Highlands
LOCATION: 12900 Midori Drive
OWNER: Hagen Gauss
RESIDENCE: Single Family, 2 Bedrooms
WELL: Private, On Site
SEPTIC SYSTEM: FROM MUNICIPAL RECORDS: 3 Bedroom System
TANK: Greer Steel 1750 Gal. Two Comparts.
ABSORPTION SYSTEM: Trench
ABSORPTION AREA: 535 Sq. Ft.
SOIL RATING: 170
INSTALLATION DATE: December 16, 1986
DATE OF LAST PUMPING: Isaac's January 15, 1992
DATE OF TEST: January 9, 1992
TEST PROCEDURE: System was inspected and measured. Tank was
found with 5 feet of cover and with a liquid level of 49 inch-
es. Trench clean out was 5 deep and dry. Trench monitor tube was
12 feet deep with 16 inches of water.
500 gallons of clean water was added to the trench while the
water levels in the tank and the monitor tube were monitored. The
water level in the tank did not change, while the level in the
monitor rose 10 inches.. The next day the water level in the
monitor tube was checked. The water level had dropped inches,
indicating that gallons of water had been absorbed.
TEST RESULT: This system meets the code requirements of
the Health and Social Services
Department of the Municipality of Anchorage.
NOTE The operational life of all septic systems depends on the
local soil conditions, groundwater levels that may fluctuate
during the year, and the water usage of the family being served
by the system. These conditions are outside the control of the
evaluator of this septic system. We can therefore not give any
estimate of how long this system will functl�oh',satisfactory for
Current or future occupants.
E3 I=* U r' -C t-"- L- 1Ck tN4 13k F=0
203 WEST 15TH. AVENUE SUITE 206
ANCHORAGE, ALASKA 99502-3904
(907) 279-3916
RESIDENTIAL WELL INSPECTION
LEGAL: Lot 6A Block 2 Aspen Highlands
LOCATION: 12900 Midori drive
OWNER: Hagen Gauss
TYPE OF WELL: Private, Single Family
WELL LOG AVAILABLE: Yes
INSTALLATION REOUIREMENTS MET:Yes
WELL YIELD FROM WELL LOG: 15 Gallons per Minute
PUMP YIELD FROM TEST:
DATE OF INSPECTION:
5 Gallons per Minute
January 9, 1992
TEST PROCEDURE: Well was pumped at a constant rate while the
drawdown was monitored with an acoustic
probe. At the beginning of the test water level was found at 68
feet below top of casing. At a pumping rate of 5 gallons per
minute the water level did not change. A total of 500 gallons
were pumped.
TEST FOR E.COLI AND TOTAL NITROGEN: Water was tested for E.Coli
and total nitrogen on January 10, 1992
E.Coli 0. Total Nitrogen 7.0 mg/l.
Max. allowable Total Nitrogen 10 mg/l.
TEST RESULTS: This well meets the requirements of the
Municipality of Anchorage.
THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR MORE
THAN FOUR HOURS
The Municipal requirement for well flow is 150 gallons of water
per bedroom per day. This well exceed this requirement. The
assessment of the condition of the well applies only to the
conditions as of the day tested. The flow rate may change due to
subsurface conditions that may not be observed from the surface,
and changes in the land use and other factors that may impact the
aquifer feeding the well.
MUNICIPALITY OF ANCHORAGE
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range).,~--
Location (address or directions)
(b) Property Owner ."~, ~'*-~,O_~. Telephone: Home ~tte'~' ¢~ Business
Mailing Address J~ ~ ~~ ~[
(c) Lending Institution ~} il Telephone
Mailing Address
Telephone
(e)
Mail the HAA to the followina address: or: Check here [~ if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family J~
Number of Bedrooms
' L:/I
i,
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~ Public [] Community [] Holding Tank []
Note: If!cOmmunity well system, must have Writ'~on confirmation from the state DePartment °i EnVironmental conSerVation
attesting to the legality and status.
Page I of 2 72-025 fray 8/86~ Front
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WELL DATA
MUNICIPALITY OF AII~J~(~I~ALITY OF ANCHORAGE (MOA)
ENVIRONMENTAL SERVJ~?AI~.I~J~I~THORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
NOV 0 9 1987 264-4744
Legal Description: /-07'
RECEIVED ,-^N
Well Classification
Well Log Present (Y/N)
Total Depth ./.~.o Cased to I IO
Static Water Level ~ ~1'
Casing Height Above Ground /¢~
Electrical Wiring in Conduit (Y/N) X
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line N o i~ L~
Cleanout/Manhole /'~ ~ ~ ~
Water Sample Collected by "T-, ~
Water Sample Test Results
Comments
1~ E~ .%. If A, B, C, D.E.C. Approved (Y/N) ht'/,~
~ Date Comp,eted '~.~ ~--I al ~:~ (=,, Yield ~)
Depth of Grouting /~/~
Pump Set At ~o'/'T' ~ ~'~
Sanitary Seal on Casing (Y/N) ~"
Depression Around Wellhead (Y/N)
I O ,~ ; On Adjoining Lots
J~"~ 'On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ,~ /'~
SEPTIC/HOLDING TANK DATA
!
Date Installed "I~C. ~'~ Size
Standpipes (Y/N) ~/ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well I 0 ~
To Property Line ///'O lc
To Water Main/Service Line ,~' /
No. of Compartments 'T
Y Foundation Cleanout (Y/N)
Date Last Pumped ~///~,
~v/'~, ;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
Course t'~ 0 I'-I ~--
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 fRev 8/86~ Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ,]~,, ¢__ I ~ ~1,
Width of Field .~. i_it-
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
Depth of Field
Gravel Bed Thickness
~ "~ :~' Standpipes Present (Y/N)
~ Date of Last Adequacy Test
Type of System Design
Length of Field ~'
To Water-Supply Well
To Building Foundation
Lot /~ 13 N E~
To Water Main/Service Line ~ / O
To Stream/Pond/Lake/or Major Drainage Course
To Driveway. Parking Area. or Vehicle Storage Area
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
NoN .
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, v,erif!ed, o~,~onformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~,,~/lul~,,~-,~ Date JO- Z~- ~' 7
Company MOA No.
Receipt No.
Amount: $
Page 2 of 2
72-026 (Rev 8/86) Back
Engineer's Seal
CONSULTING ENGINEER
203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
RESIDENTIAL WELL INSPECTION
LEGAL:
LOCATION:
OWNER: D. HICKOX
TYPE OF WELL:
WELL LOG AVAILABLE:
INSTALLATION REQUIREMENTS MET: YES
WELL YIELD FROM WELL LOG:
LOT 6A, BLOCK 2, ASPEN HIGHLANDS
12900 MIDORA
,¢,..,.,> .,:' ....? ~.
-
SINGLE FAMILY
YES
15 GALLONS PER MINUTE
PUMP YIELD:
7 GALLONS PER MINUTE
DATE OF INSPECTION:
OCTOBER 29, 1987
TEST PROCEDURE: WELL WAS PUMPED AT A CONSTANT RATE OF 7
GALLONS PER MINUTE WHILE THE DRAWDOWN WAS
MONITORED WITH AN ACOUSTIC PROBE. THE WELL WAS PUMPED TILL THE
DRAWDOWN STABILIZED. AT THE BEGINNING OF THE TEST WATER LEVEL WAS
FOUND AT 59 FEET BELOW TOP OF CASING. AFTER 30 MINUTES OF PUMPING
THE WATER LEVEL HAD NOT DROPPED.
TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM'BACTERIA AND
TOTAL NITRATES ON OCTOBER 30, 1987. E.COLI. 0, TOTAL NITRATES
4.6 mg/1 10 mg/1
TEST RESULT:'
THIS WELL MEETS THE REQUIREMENTS
MUNICIPALITY OF ANCHORAGE.
OF THE
THIS WELL WILL PRODUCE MORE THAN 3 GALLONS PER MINUTE FOR MORE
THAN FOUR HOURS.
The Municipal requirement for well flow is 150 gallons of water
per bedroom Der 24 'hours.This well surpasses this requirement.
The assessment of the condition of this well applies only to the
conditions as of this date. The flow rate of the well may change
due to subsurface conditions that may not be observed from the
surface, and changes 'in land use and other factors that may
impact the conditions of the aquifer feeding the well.
CONSULTING ENGINEER
203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
SEPTIC SYSTEM ADEQUACY TEST
LEGAL:
LOT 6A, BLOCK 2, ASPEN HIGHLANDS
LOCATION:
12900 MIDORA
OWNE.R: D. HICKOX
RESIDENCE:
SINGLE FAMILY, THREE BEDROOMS
WELL:
PRIVATE, ON SITE.
SEPTIC SYSTEM:
FROM MUNICIPAL RECORDS:
TANK: GREER STEEL, TWO COMP.
ABSORPTION SYSTEM: TRENCH
ABSORPTION AREA: 535 SQ.FT.
SOIL RATING: 170
INSTALLATION DATE: DEC. 1986
1750 GAL.
DATE OF PUMPING:
NOT APPLICABLE. NEW SYSTEM
DATE OF INSPECTION: OCTOBER 29, 1987
TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED. TANK WAS FOUND
WITH FOUR FEET OF COVER AND 48 INCHES OF LIQUID.
BOTH TRENCH CLEANOUTS WERE DRY AND 5 FEET DEEP. MONITOR TUBE WAS
13 FEET DEEP AND DRY. 250 GALLONS OF WATER WAS ADDED TO THE
CLEAN OUT AT THE BEGINNING OF THE TRENCH. THIS CAUSED 5 INCHES OF
WATER TO BE MEASURED IN THE MONITOR TUBE.
TEST RESULT:
THIS SYSTEM MEETS THE CODE REQUIREMENTS OF
THE MUNICIPALITY OF ANCHORAGE.
The Operational life of all septic systems depends on the local
soil conditions, groundwater levels that may fluctuate during the
year, and the water usage of the family being served by the
system. These conditions are outside the control of the evaluator
of this septic system. We can therefore not give any estimate of
how long the system will continue to'meet the operational requi-
rements of the Municipality and State.
. (a)
MUNICIPALITY OF ANCHORAGE
DEPARTNt,-,4T OF HEALTH AND ENVIRONMENTAL P,.,JTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name t//~-~ ~ Telephone: Home
Applicant Address ,~,~ ~ '~. ,~. '~//
is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
(c)
Applicant
/
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following addres.s:
TYPE OF RESIDENCE
Single-Family~ Multi-Family F1
Number of Bedrooms ~'~
Other
WATER SUPPLY
Individual Well~ Community D 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 FI Holding Tank FI
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 PROVIDIN~ ~NSPECTIONS, TESTS, FILE SEARCH, DA, ,-~ 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_~-~'-~'-'-.~ ~ ~) ~-,,-7'~' Telephone ~:::::~(/~:~-
f ?/' '
Address ~-~"~;2.."~ ~ ~_~_'~7, ¢~"~:*f'~
Date
Approved for ~ bedrooms by ~ .......
Approved ~ Disapproved Conditional
Terms of Conditional Approval
Date
CAUTION
The Muncipality 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 Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84'1
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
RECEIVED
LegalDescription: Zc:)7- /~,/~ ~z'~c ~-
Well Classification
Well Log Present (Y/N) __~,
Total Depth ,/Z.~ /::7' Cased to
Static Water Level
Casing Height Above Ground .
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~////¢~, Yield
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line /V/.~
Cleanout/Uanhole ,~
Water Sample Collected by
Water Sample Test Results
Depth of Grouting
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots /Cr-~' ~'F
/t'~:~/~ ;On Adjoining Lots
Comments
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B. SEPTIC/HOLDING TANK DATA
Date Installed
/ /
Standpipes (Y/N) L( Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~/~
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ,ICy-)./-
To Property Line
To Water Main/Service Line :--TC~ ,~-';~
Course ~//,~
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped /'~/E?~ 'T,4/,"J K
'for
Temporary Holding Tank Permit (Y/N) /'~/A
To Building Foundation
To Disposal Field
To Stream, Pond, Lake. or Major Drainage
Comments
Page 1 of 2
72-026 fRev 8186~ Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
//,mr'- Type of System Design
Length of Field ~=~/' °~' ~'
Depth of Field ,_,~',~'7- ('l-~ve:,~ ~u= ~,"
Gravel Bed Thickness ~, ~ /
Standpipes Present (Y/N) ~
Date of Last Adequacy Test/',,~'t~.J
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /c2'-)
To Building Foundation
Lot /"J//'~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line ?_%-d- ~_-f-
To Existing or Abandoned System on
; On Adjoining Lots /(_.~b'Y
._-~T..) v-,~=7- To Cutbank (if present)
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N) .----~
"Pump Off" Level at ~
Vent (Y/N) ~
~s during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav_e che~ked/vCri~e~/'~r conformed to all MOA and HAA guidelines in effect on the date of this inspection.
C ompan;~: ~ /~?~ MOA NO.
Receipt No. ~00~"
Date of Payment I~.- ~'~-c~,
Amount: $
Page 2 of 2