HomeMy WebLinkAboutT12N R3W SEC 15 LT 111
Municipality of Anchorage
On -Site Water and Wastewater Section - (907) 343-7904 Page of
ON -SITE WASTEWATER INSPECTION REPORT
Permit Number:.OSP241383 PID Number: 015-483-05
Dwelling: 0 Single Family (SF) R with ADU R Duplex (D) El Two Single Family Project: El New Z Upgrade
Name
METROKIN DENNIS W
ABSORPTION FIELD
Z Deep Trench El Wide Trench F] Bed El Mound
Site Address
10100 OUR ROAD, ANCHORAGE
El Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
1 4
0.8 GPD/SFI
11 Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
2 Ft.
Gravel depth beneath pipe
9 Ft.
Subdivision Block Lot
111
Till added above original grade
VARIES 0.79'— 0.95 Ft.
Gravel length
42 Ft.
Township Range Section
T12N R3W 15
Gravel width
2 Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
756 FF
1
Ft.
Well
**96'+
100'+
25'+
TANK 0 Septic [:1 S.T.E.P. [1 Holding [I Other
Manufacturer
GREER
Capacity
1500 Gal.
Surface Water
100'+
100'+
Material
HDPE
Number of compartments
2
I
NA
Lot Line
5'+
*2y+
Foundation
10'+
10'+
LIFT STATION
Manufacturer
Capacity
Gal.
I
Remarks Deep -burial septic tank. Field insulated. *Previously sent to
MOA for tentative waiver. **Waiver requested w/ submittal.
Alarm location
Electrical installed by
Installer A+
PIPE MATERIAL House to tank 3034 Tank to 3034
drainfield
Drainfield 3034 CO/MT 3034
BENCH MARK (Assumed elevation) 100 ft
Inspector FWC
Inspectes:tion 15' 5/5/2025 2 nd 5/612025
da
Location and description
3rd 5/6/25 4 1h 5/7/2025 IBOTTOM
OF TRIM
ON -SITE WATER AND WASTEWATER SECTION APPROVAL
A
Conditional Approval: Date
AW
TH
Curtis Huffman
Septic System
Approved -
Date
CE 128991
Note: this approval does not include
�*� ,w
\' ,Wow
PROFESS\ *
well permit requirements.
►
(Rev uo/uz/ io)
3B
R
HO
U
S
E
LOT 111
CA
N
T
.
DECK
ASPHALT
DRIVEWAY
GRAVE
L
D
R
I
V
E
W
A
Y
WELL
N 0
0
°
0
6
'
1
5
"
W
3
3
0
.
1
3
'
S
0
0
°
0
6
'
0
0
"
E
3
3
0
.
0
7
'
LOT
110
40
.
0
'
28.0'
21
.
0
'
4.0'5.
0
'
12.0'
24
.
0
'
44.0'
---99.4'---
PID:015-483-05 PERMIT:OSP241383
FIRST WATER CONSULTING
T12N R3W SEC 15 LOT 111
�l 11 t
Municipality of Anchorage
P.O. Box 196650 0 4700 Elmore Road
Anchorage, Alaska 99519-6650 0 (907) 343-7904 0 Fax (907) 343-7997
http://www.muni.org/Onsite
DevelopmentiCDivision
On -Site Water and Wastewater Program
* * * * VARIANCE/WAIVER REVIEW * * * *
Waiver#: OSV261011 COSA#:
P I D#: 015-483-05
Permit#: OSP241383
Legal Description: T12N RM SEC 15 LOT 111
Engineer: First Water Consulting
Your request for a waiver of the required 100 feet horizontal separation from the septic tank to
the private well has been approved. The approved separation distance is 96.0 feet. In addition,
your request for a waiver of the required 10' horizontal separation from the field to the property
line is approved. The approved separation distance is 2 feet.
This waiver approval applies to the existing septic tank only. Any future upgrade to the on -site
wastewater disposal system will require all separation distances be met or another approval from
this department.
Waiver is Granted: X Waiver is not Granted&
Date. Approved by:
Name of Reviewer
**** VARIAN C EIWAIVE R REVIEW ****
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / FirstWaterAK@gmail.com
March 3, 2026
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: WAIVERS – FIELD TO PROPERTY LINE & WELL TO SEPTIC TANK
LEGAL: T12N R3W SEC 15 LOT 111 – 10100 OUR ROAD, ANCHORAGE
Tentative Municipality of Anchorage (MOA) approval was provided by MOA on May 7th, 2025, via
email from Curtis Townsend, PE (MOA) for the encroachment of the recently installed field to the
property line. With the recent attached as-built survey by Buku Saliz, LS dated May 12th, 2025, the
field to property line is 2’ and although marked at time of construction by A+ Services it was
discovered that the well to tank is approximately 96.5’. Therefore, we are respectfully requesting
MOA waiver approval of field to lot line of 2’ & the well to septic tank of 96’ be granted at this time.
Granting of the field to property line separation waiver is warranted since the adjacent septic field
consisting of 9’ ED is 18’+ from the newly installed trench with no existing or anticipated issues
expected. Granting of the reduced separation from tank to well is warranted because the well is up-
cross gradient from the septic tank with any potential effluent going & traveling away from the well,
any surfacing effluent would be readily visible and corrected if noticed, the septic tank is composed
of better material (HDPE) than the previous steel tank with little or no chance of deterioration or
leakage that would contribute to any increase in nitrate levels or effluent adverse issues & the well
log indicates tight sandy with silty soils to 85’ below grade protecting to prevent subsurface effluent
from reaching the aquifer & confining the aquifer. The available nitrate analysis of the adjacent well
to the west on Lot 110 shows 5.05 mg/L & the closest well to the east of the subject well has 3.55
mg/L.
Per these justifications, MOA waiver approval of field to lot line of 2’ & the well to septic tank of 96’
are respectfully requested to be granted at this time. Please contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
21.5'
LOT 1A-2
N 90000'00" E 165.01'
UTILITY REBAR
PEDESTALS I
z
z
2-STORY
FRAME
HOUSE
LOT 111
54,470 sq. ft. I }
I�
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I°�
z
Q�
0
SHED 1 0 FL
7
low
to
4.0'
REBAR
W/CAP
30'
A � �
99.4'
12.0' ��
o WELL I
z
28.0' I
Cn
CDDECK�lj
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SEPTIC
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LOT
=
110
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W
SEPTIC I
4 i STANDPIPES
I
ASPHALT
DRIVEWAY
vE�OR\V��P�
Gam' I
I
GAZEBO
-0-
50' ROADWAYAND UTILITY
RIGHT-OF-WAY
30'
*: 49 T
............... ..............
N 90000'00" W 165.00'
.................,
i B u Saliz
LOT 112 j s� LS-14837
0 20' 40'
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE
RECORDED SUBDIVISION PLATAND PATENTARE NOT SHOWN
HEREON.
THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY AND
IS SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT BOUNDARY
SURVEY MAY DISCLOSE.
UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE
USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR
ESTABLISHING PROPERTY BOUNDARIES.
AS -BUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
GOVERNMENT LOT 111, SECTION 15, TOWNSHIP 12
NORTH, RANGE 3 WEST, SEWARD MERIDIAN
ANCHORAGE RECORDING DISTRICT, ALASKAAND THAT
THE IMPROVEMENTS AS DEPICTED HEREON EXIST AS
SHOWN IN RELATION TO THE PROPERTY LINES.
DATED THIS 12th DAY OF MAY, 2025, ATANCHORAGE,
ALAS KA.
FIXED HEIGHT, LLC C.O.A.122554
Land Surveying Services WWW.FIXEDHEIGHT.COM
600 W 41 st. Ave, Ste. C, Anchorage, AK 99503 907.290.8949
JOB # 24248B I NO CORNERS SET THIS DATE I SCALE 1" = 40'
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP241383
Work Type: Septic Upgrade
Tax Code Number: 01548305000
Site Legal Address: T12N R3W SEC 15 LT 111 G:2536
Site Mailing Address: 10100 OUR RD, Anchorage
Owner: METROKIN DENNIS W &
Design Engineer: FIRST WATER CONSULTING
This permit is for the construction of:
Effective Date:
Expiration Date:
y„t�t�r
�J 01,
f�
('1 r
-.., t)<l�rtttte�ttt
Lot Size in Sq Ft:
Total Bedrooms:
11 /26/2024
11 /26/2025
37950
2 Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
4
Received By:'7_0 L✓ (- Date:
Issued By: Date:
ON -SITE SEPTICIWELL PERMIT APPLICATION
Parcel I.D. 015-483-05
Property owner(s) METROKIN DENNIS & ERNESTINE Day phone
Mailinq address 10100 OUR ROAD, ANCHORAGE, ALASKA 99516
Site address 10100 OUR ROAD, ANCHORAGE, ALASKA 99516
Legal description (Sub'd., Block & Lot) T1 2N R3W SEC 15 LOT 111
Legal description (Township, Range & Section)
Lot Size 37,950 Sq. Ft. Number of Bedrooms
M
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(Z all that apply)
Absorption Field
E&
Initial 0
Single Family (SF) Gi
(w/wo, ADU)
Septic Tank
ER
Upgrade Gi
Duplex (D) M
Holding Tank
El
Renewal F]
Multiple Dwellings ❑
Privy
D
(SF and/or D)
Private Well
D
Water Storage
M
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Sig natu're'of:'p'e6berty owner or authorized agent)
Permit/Rush Fees: 015q5-
Date of Payment: I
Receipt Number:
Permit No.
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / FirstWaterAK@gmail.com
!
!!
November 20, 2024
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC SYSTEM UPGRADE PERMIT
LEGAL: T12N R3W SEC 15 LOT 111 – (10100 OUR ROAD, ANCHORAGE)
The property owner has requested we obtain a permit to upgrade the failed septic system of the
above referenced lot. We propose to install one deep trench and a 1500-gallon deep-burial
septic tank to serve the existing 3 -bedroom residence with an existing 4-bedroom septic system.
The design is based on the recent test hole conducted on November 8, 2024. No groundwater
was observed at test hole excavation or monitoring. The proposed trench is to be installed as
high as possible on the slope as designed. All biomat material of the existing absorption field
within 18’ of the proposed trench will be removed and replaced with insitu GM/sm soils or MOA
sand.
The slopes are 13 -18% at the proposed upgrade location. The lot and area are served by private
water. The design will not impact any of the neighboring properties. Please contact us if you
have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241383, Curtis Townsend, 11/26/24
3B
R
HO
U
S
E
LOT 111
SHED
CA
N
T.
DECK
ASPHALT
DRIVEWAY
UTILITY
PEDESTALS
GRAVE
L
D
RIVEWA
Y
OU
R
RO
A
D
REBAR REBAR
W/CAP
WELL
N
0
0
°
0
6
'
1
5"
W
3
3
0.
1
3
'
S
0
0
°0
6
'
0
0
"
E
3
3
0
.
0
7
'
N 90°00'00" E 165.01'
LOT
110
LOT 1A-2
GAZEBO
50'
50'
40
.
0'
28.0'
21
.0
'
4.0'5.
0
'
12.0'
24
.0
'
44.0'---21.5'---
---99.4'---
VACANT
LOT 2
LOT 1
LOT 3
WELL
APPORX.
LOC.
WELL
APPORX.
LOC.
FIRST WATER CONSULTING
T12N R3W SEC 15 LOT 111
DESIGN CALCS:
NO WELLS WITHIN
100' OF PROPOSED
SEPTIC SYSTEM
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241383, Curtis Townsend, 11/26/24
3B
R
HO
U
S
E
LOT 111
CA
N
T
.
DECK
ASPHALT
DRIVEWAY
GRAVE
L
D
R
I
V
E
W
A
Y
WELL
N
0
0
°
0
6
'
1
5
"
W
3
3
0
.
1
3
'
LOT
110
GAZEBO
40
.
0'
28.0'
21
.
0
'
4.0'5.
0
'
12.0'
24
.
0
'
---99.4'---
FIRST WATER CONSULTING
T12N R3W SEC 15 LOT 111
DESIGN DETAILS:
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241383, Curtis Townsend, 11/26/24
13030 Sues Way - Anchorage, Alaska 99516
Tel. 907-350-9566 FirstWaterAK@gmail.com
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION: T12N R3W SEC15 LOT 111 – 10100 OUR ROAD OFF O’MALLEY
PERFORMED BY: FWCS / FWC - I CURTIS HUFFMAN CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE & MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: 11/15/24
DEPTH
FEET OG
SOILS
1
ORG/OL
2
3
4
5
6
7
8
GM/sm
9
10
11
12
13
14
15
16
17
BOH
18
19
20
Reading Date Gross
Time
Net
Time
Depth to
Water
Net Drop
11/09/24 30 min 6” 3 2/16”
30 min 6” 3 2/16”
30 min 6” 3 2/16”
PERCOLATION RATE 9.6 (MIN / INCH)
TEST RUN BEWTWEEN 5 & 6 FT
PERC HOLE DIAMETER 6”
PRE-SOAKED PRIOR TO TEST & ALL READINGS TO
THE 1/16TH.
GROUND WATER ENCOUNTERED: NO
IF YES, AT WHAT DEPTH: NA
DEPTH TO WATER AT MONITORING: DRY
DATE: 11/15/2024
TESTHOLE # 24-1 DATE PERFORMED: 11/8/2024
SEE SITE PLAN FOR SLOPE & LOCATION
COMMENTS:
VERIFY GROUNDWATER MT
AT TIME OF CONSTRUCTION
PERFORMED FOR: DENNIS & ERNESTINE METROKIN
11/15/24
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP241383, Curtis Townsend, 11/26/24
LOT 1A-2
N 90000'00" E 165.01'
UTILITY REBAR
PEDESTALS I
LOT 111
54,470 sq. ft
2-STORY
SHED
FRAME
HOUSE
21.5' 44.0'
D
N
z
,p
4.0'�„
A
O
�
12.0'
o_
28.0'
z
_
CD
O
DECK
0
CD
(7)
LOT
110
SEPTIC
STANDPIPES
w
W
O
W
WELL
vE�OR\V��P�
G� I
I
GAZEBO
-0-
50' ROADWAYAND UTILITY
RIGHT-OF-WAY
REBAR
W/CAP
ASPHALT
DRIVEWAY
50'
0
O
0') O
O C
O �13
70
m o
w �
W
O
O
v
*: 49 rH
................ ............
N 90000'00" W 165.00' 2o�z6�2�
..................,
i B u Saliz : _�o r
LOT 112 j s� LS-14837 J
fit F�
0 20' 40'
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE
RECORDED SUBDIVISION PLATAND PATENTARE NOT SHOWN
HEREON.
THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEY AND
IS SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT BOUNDARY
SURVEY MAY DISCLOSE.
UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE
USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR
ESTABLISHING PROPERTY BOUNDARIES.
AS -BUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
GOVERNMENT LOT 111, SECTION 15, TOWNSHIP 12
NORTH, RANGE 3 WEST, SEWERD MERIDIAN
ANCHORAGE RECORDING DISTRICT, ALASKAAND THAT
THE IMPROVEMENTS AS DEPICTED HEREON EXIST AS
SHOWN IN RELATION TO THE PROPERTY LINES.
DATED THIS 14th DAY OF OCTOBER, 2024, AT
ANCHORAGE,ALASKA.
FIXED HEIGHT, LLC C.O.A.122554
Land Surveying Services WWW.FIXEDHEIGHT.COM
600 W 41 st. Ave, Ste. C, Anchorage, AK 99503 907.290.8949
JOB # 24248 NO CORNERS SET THIS DATE I SCALE 1" = 40'
,,~--~O~,y~,,~,,,~,,~..,~,~ MU NI CI PA LI TYOF ANCHO RAGE
DEPARTMENT OF HEAl.TH & ENVIRONMENTAl. PROTECTION
~ ENVIRONMENTAl. ENGINEERING DIVISION
825 L Street - Anchorage, A as (a 99501 Telepl~one 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WEI.L INSPECTION REPORT
NAME ...................................................... PHONE ~EW
MAILING ADDRESS
Po ~,z /o.-3~'7
LEGAL DESCRIPTION
LO A ,O
DISTANCE TO:I~DO ~/ t~/
No. of lines
/
Top of tile to firdsh gra( e /
Length Width
Total length of I'nes
Material beneath tile
Depth
Type of crib Crib diameter Cdb depth
Well
DISTANCE TO:
PERM,T NO. ~? O i
No. of compartments
Total effectiveabsorpti n area
PERMIT NO.
Total effective absorption area
Building foundation Nearest lot line
Distance to : line
DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING '
INSTALLER
REMARKS
PFRMIT NO.
IAbSorption area(s)
APPROVED DATE LEGAL
I
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~;~:-?'"~'~:'""('_~U'JV'~ "C~:¢' - MUNICIPALITY OF ANCHORAGE
~:~. ,. - ....,~, ~
LEGAL DESCRIPTION: ~/¢'YJ//~ ,-~:'~'~: /~"~ .~4~',"'~ ,~° 3Y~y ~'~,d,~',~ ~;~¢~,
~,~,~ ~.,~. SLOPE
WAS GROUND WATER
ENCOUN'FERED? _'~
P
E
IF YES, AT WHAT
DEPTH? /
SITE PLAN
9-
12
19
20
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
(907) 243-7893
KEN JOHNSON
WATER WELL DRILLING
PUMP SALES & SERVICE
3163 LINDEN DRIVE
ANCHORAGE, ALASKA 99502
tvb~Y 2~, 1982
P & P PRUDUCTIORS
Larry H. Neas
OUR RO~D
~NCHORAGE,
REI 'dater well Lot ~21 Sect° 1~ T 12 N R3W Slvl
WATER WELL LOG
Frozen brown
Course gray and bt, own silt
Corse gr. ava %r~y silt ( tight )
~,ied. gray and bro~a'~ silt
Sand & brn silt weeps 8'..dj. try
Sandy brown silt
Sand.. H2o.. Heaves 5'.. 15' head,.dir'ty
Sand & brn silt
Clean course f~ravel and ~and wa~er bearing
52 ft static water level
Test bailed at 1~
No drawdown
Clearing rapidly
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMEbr£AL HEA3~TH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
General Information
(a)
Legal Description (include lot, block, subdivision,
section, tovmship, range)
Location (address or directions)
(b) Applicants Name~ ..... Tele~J!pne - Home Business
Applicants Address
(f) biail the HAA to the follovrlng address:
l.T.~i[p.~2 f Residence
Single-Family I~[
Number of Bedrooms
Wa~t e r~S=upp ~y
Individual Well ~
Multi-Family E~
Other (describe)
Community ~__~. Public [~[
Note: If community well system, must have written cenfirmation from the State
Department of Environmental Conservation attesting to the legality and status~
4. ~osal
Onsite ~ Public ~ Community [~ Holding Tank
Note: If community well system, must have written confim~ation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5. E__n~i. neerinfu_Firm Providing Inspections. Tests- File Search
~ -~ .z~--~_u.z ......... ~_.~_~ and Info~rma~tio~n
As certified by my seal affixed hereto and as ot! the validation date shown below~ I
verify that'. ~y investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewatar disposal system is safe, functienal 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 file~ and from my
investigation and inspection, the on-.site water supply and/or ~¢as~ewater disposal
system is in compliance ~rlth all Municipal and State codes, ordinances, a~ regula-~
tions in effect on the date of this inspection°
Approved for ~?>//~_ bedrooms
Approved >~_ Disapproved
Terms of Conditional Approval ........
Telephone
CAUTION
THE MUNICIPALITY OF ANCHORAGE I~']PARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ]iSSUES HEALTH AlYfHORITY APPROVAL 6%RTIFICATES BASED SOLELY UPON T~IE ILEPRESENT~
ATIONS GIVEN IN PARAGI~kPH 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 REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED° THE MUNICIPALII~f OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/DI8
[Page 2 of 2]
7-19-84
ae
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
Well Leg Present (_Y/N)
Total Dapt~... ~ 7 Cased to ~'
Static Water Level ..~ ~
Casing I~ight A~ G~nd
Elee~ical Wi~ing in ~nduit !~)
~p~ation Distends ~ ~11:
To ~ptie~olding Ta~ ~ ~t I01'
To ~a~st ~ge of ~so~ption Field on Lot ~' _
To Ne~sst ~blie ~ Line _
Pump Set At
· Depth of Grouting
Sanitary Seal on Casing (Y/N)
Depression A~ound Wellhead _(Y/N)
C].eancut/Manhole_ 61./L To Ne~est Sewe~ Service Line on Lot
Wate~ Sample Collected Bi; '/'/=~/~ ; Date
Water Sample Test Results
Co~t~(~nts
; On Adjoining Lots
; (An Adjoining Lots__~.~oo '
To Nearest Publi~ Sewe~
~,,4,
B. .S.E. PTIC/HOLDING TANK DATA
Date Installed '~/~/~ ~_ Si?~ 1 9_~'~ No. of CQ,~a~tm~nts
Standpipes .(.~/N) ~ Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N)
Depression over Tark (Y/N) N __ Date Last P[mt~ed 5'/E ! /~
Pumping/Maintenanos Contract on File (Y/N) ~l,/~. ! for ~,~.
Holding Tank High-Wate~ Alarm (Y/N) N,~', %%mt~Dra~y Holdirx3 Tank Permit .(Y/N)
Separation Distances f~.cm Septic/Holding Tank:
To Water-Supply Well ~ To Building Foundation ~ '
To Property Line _ ~-~ Iff ' To Disl~Dsal Field
To Water Main/Servic~ Lir~ .
Course _~ ~,
To Stream, Pond, Lake, c~ Majo~ D~.ainage
Comments
[Page 1 of 2]
Receipt :~
Date Paid:
2-15-84
C. ABSORPTION FIELD DATA
Soils l~ating in Absorption Strata
Date Installed 7 ./_~; /~ ~
Width of Field ~"
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
~'7~' m'/l~r,~ Type of System Eesign
Length of Field ?8'
Depth of Field 6 ~/z
Gravel Bed Thickness _ ~ ~
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from A~sorption Field:
To Water-Supply Wall ~6; 3 To Property Line -~
To Building Foundation 3 ~' To Existing or Abandoned System cn
Lot N~. ; On Adjoining Lots ~
To Water Main/Be~vice Line ~,~. To Cutbank(if present)
To Stream/Pond/Lake/ct Major D~ainage Course ~,
To Driveway, Parking Area, c~ Vehicle Storage Area ~'
CcmTents
D, LIFT STATION
Date Installed
Size in Gallons
"Pump Oa" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Comrents
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Meets MOA
** Check Permitted Bedroom Rating Against HAA Request
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
[Page 2 of 2] · '~=R ' ~' -
2-15-84
APPLIC , IT FILLS OUT UPPER HAL ONLY
Address Zip Code
Lending Institution Phone
Address Zip Code
~treet Locati~ f-'~ ( ) ~ 0~ ~.
Type of Resl~nce
~gle Family
Water S~pply
~divldual WELL LOG, A well is for all wags since June 1975.
ATTACH
log
driJled
~ Community For wells drilled prior to that date, give well depth (altech IoW'if available).
~ Public Ulility
Sewer D~sposal
blic Year Individual Installed: ,
Utility
When Connecled to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST REFORE ~OCESSING CAN BE INITIATED.
Time Time Time
Date Date Date
Inspector Inspector Inspector
Field Notes: .f~)
Time
/4/ ) APPROVED BEDROOMS
) DISAPPROVED
) CONDITIONAL APPBOVAL'
DATE ~'- ~//--'
'CONDITIONS OF APPROVAL
Soils Rating
Date~werlnstalled
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size
Novembo.~; 23~ 1982
Subject: I,ot lll Sec, 15 T12H R3W
Approval for the (nd:iv(dual ,qcnmr and wa/et~ ..t(.~.li'hies cannot
~)e JLdnt. cd II,Ifil tho. fei. lowing :Ltenh~-3 have beeY~ completed~
£h~ top of tho well
water tiqht. ,<~,,~L
(hu~l)idi. ty). The well should be f. lushec'l clear by turning
Please notify this Depar.tm(Hlt ~o~? a reinspoction when the
~loted f]i.~c're...~}anci[~s have J3(!e~ correct(HI, .[f ~['lere arq any
" O~.L
further qttestions, })lease (.all this '~ :ice at 264-4720.
ricer.(..J.y ~
RP 2 3 3 /p/l.::[I
Robert. C. Pratt
A;mociahe l,nvit~on(lenhL1 S ~',cJal Jst