HomeMy WebLinkAboutT12N R3W SEC 27 LT 34
Municipality of Anchorage Page ~ of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 995.19-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: .~'1,¢ 9~z'00~I/~ PIDNumber: ~1 7~J5'17.~/ __
,,,~,~e~ 14,~ ¢; £,4 e No~ff~ar~._, Wastewater System: D New ~ Upgrade
Address:
~ ABSORPTION FIELD
~ ~ Deep Trench ~Shal[owTrench .D Bed ~Mound ~Other
Toial Depth from original grade:
LEGAL DESCRIPTION SoilRating: I,~ GPD/Sq. Ft.
LOt: ~f~ Block: Subdiv~ion: Depth ,o pipe bottom from odginal grade: G ravel dept~be~ath pipe --
12 N ~7 O. ~ Ft. ~7
WELL: E~f D New ~ Upgrade Gravetwid/h: ~,~ Ft. Number of lines:lI 1oislanc~ea~ee~lices
Fl
Classification (Private, A,B,C): Total Depth: Cased TO; Total absorpEon area: Pipe material: ~ - ~/~
~ GPM ~ Pump Set ai: Ft. ~,~ Fl. ~NK
SEPARATION DISTANCES ~ septic ~ Holding a S.T.E.P.
From Tank Field Station Tank SewerLines ~N, I ~ q~
Well' ~ ~ I I ~ ~ ' __ -- ~ ~ ~ Material:(o~ C~/-~ Number of Compartments:
w~t,~ >~0¢' >mo' .... LIFT STATION N.~.
I
,,Pump off,, level al: I --
Curtain Pump Make & Model I Electrical inspections performed by:
Drain
I
Remarks: ~ o~t~n~l Co~e~ ~¢h~ BENCH MARK
~ Location and Description:
Inspections performed by: ~/~f ~¢(4, ~¢~ Dates: 1st ~/~3/~ ~,~~
Department of He man Services approval ~ ,~,.. ,. .,,
72-013 (Rev. 9/91) MOA 25
PERMIT NO: SW950042 PAGE 2 OF 2
PID NO: 01705124
DRIVE
SWING TIES:
FROM: COR. A COR. B
TO:
C.O. "C" 50' 87'
C,O, "D" 60' 97'
C.O. "E" 128' 151'
M,T. "F" 139' 153'
C.O. "G" 167' 166'
NEW 67' LONG
SOIL ABS. TRENCH
//~ WITH 8.3' GRAVEL
NOTE; [~ISCHARGE LINE
F FROM SEPTIC TANK TEES
INTO PERF. PIPI-- 17' FROM
%-- SOUTH END OF DRAINFIELD
EXISTING'
CONCRETE
LS E~P~'I C TAN K,
LD C
PLAN VIEW
SCALE: 1" = 40' - O"
ORIGINAL AND FINISH GROUND 86.0'
86.7'
TBM
EXISTING
GAL. CONCRETE
SEPTIC TANK
WELL
BOT'rOM OF TRENCH EXC. 73.0
T. H,#2
(DRY) PROFILE VIEW
NOT TO SCALE
LOT 34, SEC. 27, T12N, R3W, S.M.
SEPTIC SYSTEM UPGRADE
AS-BUiLT INSPECTION REPORT
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, ALASKA 99516
SCALE:AS-SHOWN
DRAWN BY TFM
MAY, 1995
~ ~ ~ ~ SUgSURFACE EXPLORATION ~/ ._.~/'
6, / TIME DISTRIBUTION HOURS ~ SUMMARY COLUMN
7, GASOLINE
8, OIL
SUPPLIES AND REPAIRS (]TE~dlZE)
8. CASING LOG 9, SOILS LOG
MATERIALS AND REMARKS
~PENARD, ALASKA
'~ fi~z/~ J*~c ~ SUBSURFAC~ EXPLORATIO~
6, TIME DISTRIBUTION HOURS SUMMARY COLUMN
SUPPLIE~ AND REPAIRS (ITEMIZE}
8. CASING LOG 9. SOILS LOG (~ ,' ~'¢) ¢ ' / 'P '
LENGTH NO. FROM TO SAMPLE MATERIALS AND REMAR~
-1~7 ~¢ x~' . =~
;-~2~' ~/-< :- ~ ~¢~¢ 5}.,../~,. ;~ 7/- ~','~/~/~:'~.//~:':
I
~,~ ~/~,h/~, lc../4¢~ ,~,~o~ <;~...~.
:::.".]].'.'. .......
~ ~o~p:~.....O.C..~.., .......... L.~..~..~: .......................................
~,~,o:~,~, .......... ~..:...~..:.:....[.~.~..<.~..::~.&..G~:...:..:.:...:]..
Distance to water while ~ ~ ~ '
pumping ............................................................... at race
of .......... ..~.....0.....0... .................. gallons per hem'.
Description of Fro'marion
_ .~ ~.~.~~' ...,
from to
/2.
certify the above true anti correc£,
DOT'FEN DRILLING CO.
John's Road
SPI:NAP, D. ALASKA
We advise you to attach this certificate to yo','.r deed,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196680, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE)
PAGE 1 OF
PERMIT
PERMIT NUMBER:SW950042
DESIGN ENGINEER:FLATTOP [~ECHNICAL SERVICES
OWNER NAME:NORGAARD QUENTIN D & SUE B
OWNER ADDRESS:P.O. BOX 110689
ANCHORAGE, AK 99511
DATE ISSUED: 4/10/95
EXPIRATION DATE: 4/10/96
PARCEL ID:01705124
LEGAL DESCRIPTION:
T12N R3W SEC 27 LT 34
LOT SIZE: 108900 {SQ. FT.)
~ER OF BEDROOMS: 4 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION NfgST 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 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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:
CML & ENVIRONMENTAL ENGINEERING e ENERGY CONSERVATION & ANALYSIS
TttEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 March 27, 1995 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Deal' Sks:
The purpose of this letter is to provide the required design narrative in support of our application for a
permit to up~,n'ade the wastewater disposal facilities se~wing the existing residence on BLM Lot 34, Section
27, T12N, R3W, S.M., located on Norgam'd Road off DeArmoon Road. The existing 35 yem' old
seepage pit is presently operating in a surcharged conditiou and would not pass an adequacy test. Soils
logs, perc test results, a soil sieve analysis report, a site plan, design drawings and specificatious are
enclosed as part of this design submittal.
The proposed system will be constructed in the vicinity of test hole # 2. As can be seen fi'om the soil
log, the native material between 6 feet and 19 feet below gn'ound level is a gravelly sand with a measured
perc rate of less than one minute per inch. A sieve analysis of the material taken fi'om the test hole
confirms that it is predominantly sand, so it should be permitted to construct a soil absorption trench
without the need fol' a sand filter. Using the soil application rate of 1.2 gpd/sq, ft. specified in the
wastewater ordinance for soils with a measured perc rate of between 1 and 5 minutes per inch, this 4
bech'oom residence requires a total absorptioo area of (4 x 150)/1.2 = 500 squm'e feet. The proposed 63
foot long n'ench with 7 feet of sewer gravel between 6 and 13 feet has a total absorption m'ea of 882 squm'e
feet. The additional gravel depth beyond the minimum required 4 foot depth which would provide 504
squm'e feet of absorption area is intended to provide an extra degree of longevity to the system, plus
compensate for variations in soil consistency.
According to infmanation provided by the property owner (see attached sketch and calculations), the
existing septic tank is a 1445+ gallon single compm'tment concrete tank with baffles at the inlet and outlet,
which was installed in 1960. It is proposed to continue using this tank with the new soil absorption
system, provided an inspection perfonnexl at the time of hookup reveals the tank still to be in good
condition with functioual baffles. Otherwise, a new 1250 gallon septic tank will be instMIed outside the
100 foot radius fi'om the well.
The topography of the lot in the area of the proposed construction slopes gently to~vm'ds the west in a
series of man-made ten'aces separated by 3 - 4 foot lfigh steeper slopes. The rhiveway accessing the house
has a 3' to 5' high cut bank on its uphill side which will be as close as 30 feet from the north end of the
proposed trench. A waiver of the normally required 50 foot separation from a cut bank is requested in
this case. Because of the deep nature of the trench with 6 feet of soil cover over the top of the sewer
gravel, there should be no possibility of septic effluent from the trench daylighting through the cut bank.
. The proposed prqiect will have no significant impact on present or future water supply and wastewater
disposal systems serving adjacent properties, nor will it have any significant impact on reserved space-
surface and subsurface, or on drainage. P ' ·
lease give me a call at 345-1355 if yon have any questions.
Sincerely,
Ted Moore, P.E.
HOUSE
d~WELL
DRIVE
NEW 63' LONG
SOIL ABS. TRENCH
WITH 7' OF SEWER GVL..~,,, /
R.~/~ ..~
#2
T.H.
#3
5%
EXISTING
LOG CRIB
SEEPAGE PIT
(TO BE ABANDONED)
EXISTING
CONCRETE
SEPTIC TANK
LOT 34, SEC 27, T12N, R3W, S.M.
WELL AND SEPTIC SYSTEM
SITE PLAN
FLATTOP TECItNICAL SERVICES 1 INCH = 50 FEET
14530 ECHO STREET DRAWN BY TFM
ANCHORAGE, ALASKA 99516 MARCH, 1995
NOTE: THIS IS NOT A SURVEYED PLAT.
ALL LOCATIONS SHOWN ARE APPROXIMATE.
4" DIA, ASTM F-810 PERF DIST. PIPE /"~"i~-'''"'1~ ~- "A"
4" DIA ASTM D-3034
FROM SEPTIC TANK
CLEANOUT (TYP.) MONITOR TUBE
PLAN VIEW
SCALE: 1" = 10'-0"
MONITOR TUBE
~OUT
BACKFILL 1'
DRIGINAL GROUND
FABRIC
__ 4" DIA, ASTM F-810
PERFORATED PIPE
~2" - 2 1/2" SEWER GVL.
SFOTION "A - A"
SCALE: 1" = 5'- 0"
LOT 34, SEC. 2?, T12N, R3W, S.M.
SOIL ABSORPTION TRENCH
PLAN AND CROSS-SECTION
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, AK. 99516
SCALE: AS SHOWN
DRAWN BY: TFiM
MARCH, 1995
Flattop Technical Services
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
BLM Lot 34, Section 27, T12N, R3W, SM
Norgaard Rd (off DeArmoun Road)
Wastewater disposal system installation
Specifications
1,0 General:
1.1 The scope of the project consists of abandonmeut of an existing log crib seepage pit aud
construction of a new 63 foot long soil absorption trench with 7 feet of sewer gravel beneath the horizontal
distribution pipe.
1.2 Consu'uction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these di'awings may be allowed or required by the engiueer conducting the inspections.
Ail construction procedures and material specifications shall conform with Municipal and State
requirements. Ail separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any
buffed utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to eusure that proper drainage is achieved after settlement and that there m'e no residual
depressions. Insofm' as possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
tile soil is compacted, as well as placement of topsoil and reseeding all m'eas disturbed by the construction.
2.0 Septic Tank:
2.1 The existing 1450 gallon concrete septic tank may be retained in service, only if it's structural
integrity and baffles have been inspected at the time of hookt~p. Any existing septic tank or seepage pit
which is not retained in se~wice must be properly abandoned by thoroughly pumping, removing the top
and backfilling with soil.
2.2 If tile ex}sting septic tank is fouud to not be in satisfactory condition a new 2 compartrnent septic
tank shall be installed on undistta'bed soil. Each compartment shall be equipped with a watertight manhole
cover and a 4" cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of
approved burial type, rigid insulation.
2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. Tim
waste line between the tank and the soil absorption system shall have a minimmn slope of 1/8" per foot. A
double cleanout shall be installed within 5 feet downstream of tbe septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by excavating a 63 foot long trench with a total
depth of 13 feet.
3.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces sbali be raked to
allow proper infiln'ation.
3.3 A total of 7.5 feet of approved sewer gravel shall be placed in the bottom of the excavation with
the perforated distribution pipes laid level such that the pipe inverts are no less than 7.0 feet above the
bottom of the sewer ga'avel. Sewer gravel shall be 0.5" 2"
- .5 screened gravel, with less than 3% passing
the #200 sieve.
3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design drawings. The portion of the monitor tube extending through the sewer gravel shall be
perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel before
backfilling with soil.
3.6 The top surface of the cover material shall be raised a minimum of 12 inches higher than the
surronnding terrain to allow fox' subseqnent settlement, and shall be graded to smooth contoors. Fill
slopes shall be no steeper than 3:1.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible fox' arranging to have the
site finish graded after the backfill material has stabilized, and for placement of adequate topsoil m~d seed
to promote rapid revegetation of all areas disturbed by the constrnction.
4.0 Inspections:
4.1 A minimum of 4 engineering inspections will be required during the course of the project: (1)
initial stakeout with the contractor to establish the location of the system and to discuss the plm~s,
specifications and construction procedures, (2) after the native material has been excavated to expose the
infiltrative sm'face to ensure that it is level and at the right elevation, and conforms with the soil test
h~fmrnation, (3) after the sewer gravel is in place and the distribution pipes have been laid and connected
up to the septic tank, bnt prior to placement of filter fabric, and (4) after rough backfill and grading is
complete. The existing septic tank requh'es one inspection at the time of hookup to the new trencb. If a
new septic tank is needed, it also requires one inspection after it is set level and the piping connected, but
prior to backfill. This inspection may be incorporated with any of the above inspections.
4.2 The inst~ller shall coordinate the tinting of the inspections with the engineer snfficiently far in
advance to ensm'e the availability of the engineer.
TEST HOLE# 2, ]
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
1
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 34, Section 27, T12N, R3W .......
Marc h 6. 1995
Quentin and Sue Norgaard
Pt mid roots
SM Reddish sandy loam
SP Brown medium sand
ML Gray silt
SLOPE
SP Clean gravelly sand
Depth to Groundwater Date
bin ~rnnndwnter q/(4/Q q
M.T. Dry 3/27/95
20
COMMENTS:
Clock Net Time Percometer Net Drop
Date Reading Time (minutes) Reading (inches)
~ 12" Presoak 11:01:30 27 1/2
11:02 9.5
1 l:ff~ 1 22
1 h04 1 19 3/4
Add water ~3-0-- 21
Remainder of 5 Gal 1 l:O~:qO _1 1
__ 11:06:30 _ 1 Dry
PERCOLATION RATE <;1 _ (minutes/inch) PERC HOLE DIAMETER 8"
TEST RUN BETWEEN 7,5 FTAND 8,0 FT
Sieve m~alysis of material from perc test hole shows it to be.predominantly sand, so no sand filter should be rcq'd,
CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES tN EFFECT ON THiS DATE. DATE:
TEST HOLE
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
1-
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 34, Section~27, T12N, R3W
Marc h 6. 1995
Quentin and Sue _N~aard
Pt
SM Reddish sturdy loam
SP Brown medium sand
ML Gray gravelly silt
SLOPE
SITE pLAN
SP Gruvelly Saud
Sim. to T.H. #2
Depth to Groundwater Date
No Oroundwa£cr _~3/~/95
14- Reading
15-
16-
17-
18-
19-
PERCOLATION RATE
TEST RUN BETWEEN
Clock Net Time Percometer Net Drop
Time (minutes) Reading (inches)
(minutes/inch) PERC HOLE DIAMETER
FT AND FT
COMMENTS: This test hole was dug solely for the purpose of assessing the continuity of soils encountered in Test Hole #2
No monitor tube was set
PERFORMED BY FLAqq'OP TECHNICAL SERVICES. I ,~~ CERTIFY THAT THIS TEST WAS PERFORMED IN
AOOORDANOE WITH ALL STATE AND MUNIOIPAL GUIDELINES IN EFFEOT ON THIS DATE, DATE:
TI:ST HOLE
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
1-
2-
3-
4-
1
Lot 34, Section 27, T12N, R3W
Marc tl 6, 1995
Quentin and Sue_Norgaard
Pt
SM Reddish sandy loam
SP Brown medium saad
ML Gray saudy sill
SM Silly sand
Louses of ML
Lenses of SP
FLATTOP TECHNICAL SERVICFS
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
SP Medium sand
Clean, dry
Some gravel
15-
16- SM/SP Gray silty sand
Some boulders
17- Lenses of SP
18-
SLOPE
SITE PLAN
Depth to Groundwater Date
Ne Groundwater 3/6/9.5
M.T. Dry___ 3/27/95
Clock Net Time
Reading Time (minutes)
12" Presoak 9:56 27 1/2
10:'~1 -- 23 1/2
1-0:46 15 22 _5j8
RATE~___ (minutes/inch) PERC HOLE DIAMETER
PERCOLATION
]'EST RUN BETWEEN"--~.0 FT AND 7~5 FT
Percomater Net Drop
Reading (inches)
_ 7/8 -
7II
COMMENTS: Pert test discontinued after slo~!gll filled hole. Due to aPl)ar¢!l~b sill cont¢!~l, material p_ere'ed [!t a slowe' ]'ate
2[hall~ad heen2.xpectcd.
PERFORMED BY FLATTOP TECHNICAL SERVICES, I~.~"'_~,~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUiDELiNES iN EFFECT ON THiS DATE. DATE: ,.~
LABORATORY TEST REPORT
R&M CONSULTANTS, INC,
9t01 VANGUARD DR. ANCHORAGE, ALASKA 99607 PH907-622-1707
CLIENT/PROJECT: _1.= !a~t t_~ p_ ~ e_~_h_ .n_i_c .a_!_S_e r v_ i~ e s.
TEST ON: _Field S_.a_m_..p_!e_
SOURCE: _B~ori~nn~_ SUBMITTED BY: .._TM~___
SAMPLED FROM: __T_esthole //2 ...................... DATE SAMPLED: ._U_n_k..n__o.~_n.
LOCATION'..~:.o_t__34_~,._S_ection 27 ................... DEPTH: 7.5'
R&M PROJECT: 451072
LAB NO.: 5012
FIELD NO.: 1
DATE REPORTED'. 3/15/95
DATE RECEIVED: _3__/6/~,5
GRAIN SIZE DISTRIBUTION CLASSIFICATION COMPACTION
SIEVE %PASS SPEC. UNIFIED I AASHO I FAA
5" % + 10[ I OPTIMUM MOISTURE:
2" % SAND CORR. MAX. DRY DENSITY:
..... ~. '~ ....... ~ ............... % CLAY ~.9 D~
__~.~'.~ .... 91 FSV ~ATURAL DENSITY:
1/2" 80 LL NATURAL MOISTURE:
3/8" 73 PL WEIGHT LOOSE:
~ ] CLASS NFS I l,
~20 35 ~ ............ ~,,0 ............ ~ ...... ~
__, .... _
~o ~ ~o -~i-IIII t
~,oo~.: ,o ~ i i'ld-I- ~ ~ ~
,02MM ° HIll I jllll i , i iiiii i
............................................ Ioo ~o ~ o.~ o.o~ o,oo~
.O05MM
.............................................. 6RAIN SlZ~ (mm)
.002MM
TOTAL WT. TESTED: 1,187 GMS.
COARSE SPEC FINE SPEC
DELETERIOUS MAT,
SPD.,APPARENT
- ~ ............... [ ....... h- ' -~
E ,
N I ! !lll!i i
s ......... I' ............... "-t'-"1
T ' ~ I
F MOISTURE - PERCENT
Tested By: .~.lr~ ..... ~ Chocked By:
ORGANIC CONTENT %: '/ ~._~
L.A, ABRASION LOSS: ................. Sig,,.d Sy: ~,,~' _ _::~ ~
REMARKS: ......................... : ................................................................. _~.~___
_.~._
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
HAA# gt~/~¢'~ I~.~
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Properly owner
Mailing address
Lending agency
phone
Mailing address
Agent ¢1~"'7 ~¢ ~eck~J~¢~2
Address 'E ,~.O¥ I.o'. Alor t~¢rn
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: --
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
/?. C__ Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community W'ell system, provide written confirmation from State ,~.C attest-
lng to the legality and status of system. "..'. ':
·
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~I
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verity 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
X Approved for
Phone
Date /"/¢'y _3'~ ~¢¢.~-
Disapproved.
Conditional approval for
bedrooms.
A: P
bedrooms, with the following stipulations:
Additional Comments
x...T, he ~bniqfpality of'~'nchorage Department of Health and Human Services (DHHS) issues Health Authority
,Approval Certificat~ based only upon the representations given in paragraph 5 above by an independent
professional en~i~r registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and t heir' iendin'g institutions in order to satisfy certain federal and state requirements. Employees of DH HS 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 enginoor's work.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AU'rHoRITY APPROVAL CHECKLIST
Legal Description:
'T t Z ,',t,, R ~ t,.,,,
A. Well Data
Well type
Log present (Y/N)
Total depth
Sanitary seal
Parcel I.D.
If A, B, or C, attach ADEC letter. ADE~C water system number
Date completed 6/fo., to/do.. ,~/zo Driller t¢),, (ctn~ [ty/q,~c~.., O,~f'f-en
Casedto 88&" Casing height ¢9" ($¢e Not-~'~'
y Wires properly protected (Y/N) Y
FROM WELL LOG AT INSPECTION
tot/70 _
Date of test
Static water level
Well flow
Pump level1
t o g.p.m. 2. 2 +
SEPARATION DISTANCES FROM WELL 'FO:
Septic/holding tank on lot _
Absorption field on lot
Public sewer main
Sewer service line
Rg ~
~ 2' ; On adjacent lots
25' Petroleum tank
Public sewer manhole/cleanout J~?A, ~ ~.
WATER SAMPLE RESULTS:
Coliform 0 Co(/,'ora mZ
Date of sample: ,5' / I '7 I
Ntrate. ¢2, ,6'y r.~/'~- Other bacteria no,~e_ rtf~or~M
Collected by: _~l~f-t-o ? 'r'ec4 £ uc
B. SEPTIC/HOLDING TANK DATA
Date installed _ ? /~0
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size _ I,~'0~ ~'~ t Compartments /
Foundation cleanout (Y/N) . N Depression (Y/N)
N, A, Alarm tested (Y/N) N, ,4,
5"1 ~ / ?.C Pumper__
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
(t.~eIo. t s~p~,~,o~ C°o t-,.~e
Well(s) on lot ~' ~ ~On adjacent lots ~ t o o'
To properly line ~ I co ' Absorption field~ ¢7'
Sudacewater/drainage ~ i oo,
Foundation
Water main/service line ;> ~¢' '
72-026 (3/93)' Froni CONTINUED ON BACK PAGE
C. LIFT STATION F, Ion e
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
Date installed 5' / -~ / 9.G
Length ~' 7' Width
Total absorption area t I I '~
On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Soil rating (GPD/Ft2) I. ~
Gravel thickness
Cleanout present (Y/N) Y
Results (pass/fail)
/v
Sudace water
HAA Fee $
Date of Payment
Receipt Number
72-028 (3.~3)* Back
Sudace water > I o o '
Curtain drain ,V o,) e see,,
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Po.rd for ~ Bedrooms
After test o
If yes. give date /v. A..
Well on lot I ,,/~
To building foundation
On adjacent lots --~ 30
On adjacent lots '> I cO ' Property line ~ ?0 t
To existing or abandoned system on lot ~'o '
Cutbank "/$" ~' r,,,~or %4 ~ Water main/service line > 'a.¢ '
Driveway. parkingJvehicle storage area ~ 5'o '
E. ENGINEER'S CERTIFICATION
I cerYfy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect O~ the~date,~¢,(1)is inspection.
Engineers Name
Date
Waiver Fee $
Date of Payment
Receipt Number
Date of adequacy test /V. A, (
water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type 7-re/~ ¢ 4
2, Total depth I :i'. 0
Depression over field (Y/N) N'