HomeMy WebLinkAboutT12N R3W SEC 33 LT 163
Municipality of Anchorage page L of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-665d · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: -5~,'v' c[ H'O I O [ PID Number:
Name:
WILL~ ~, ~IEFK~ WastewaterSystem: ~ New ~Upgrade
Address:
~o~o SHa~b~ Cou~T 22~-/¢ ABSORPTION FIELD
Phone:
3~--IS~ ]Ne. of B~rooms: ~DeepTrench ~ Shallow Trench ~Bed ~Mound ~Othe(
L E G AL D E S C R I PTI O N Soil Ralino: Total Depth from original grade:
O, ~ GPO/Sq. Ft.
Lot: Block: Sdbdivision: Depth to pipe boltom fro~ original glade: Gravel depth benealh pipe
J J Fill added above original grade: Gravel lenglh:
Number ol lines: J Distance between li~es:
WELL: Exl%%~N~New ~ Upgrade G,~.~id*h: 2.E Fh
Classdicalion (Private. A.B.C): Total Oeplh: Casod TO: Tolal ~bsorpDon aroa: Pipe maleriah
Yield:GPM J Pump Sol at: FI J CCsing Heigbl Above Ground:Fi TANK
S EPARATIO N DISTAN CEa ~Septic O HoIdiBg [] S.T.E.P.
Surface , ~
w~ >/oo >/oo ~ - >/~o LIFT STATION
Foundation ~Ot
I
BENCH MARK
~Oe~ ¢,~II ~, ~O~/, AssumedElevati°n)oo,O
ENGINEER'S SEAL
Inspections performed by: _FI-A-WoP ~ECH 5VC~ Dates:lst ~/~a/~q . 9Z ,. ·
Department of Health--man ~v~s approval ~ ~,,o¢o~
Reviewed and approved ate: ~* ,, ...... ~..
Permit No,
59,/ c)~ol~l Page ;2 __of '~
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
LegalDescription: ~L~ LOT I~'~. 5E~ ;~.~ .TI2N. R~k/ PIDNo.: 01~29208
SHANb¥ COURT
72~013 A (2/01) MOA 25
Permit No,
Municipality of Anchora§e
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
LegalDescription: BL/~ LoT IG:Sj Sz~d 33 TI2N ¢ 1~3~/ PIDNo.: OJ~2 ~2Og
1:, B,i"I, io~,o
.' oUT&IDE bO0'~ AT
SLAB
~0
IJ,J
LLJ ~
~,oTTO,"'I
ENGINEER'S SEAL
72-013 A (Rev 9/91) MOA 25
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
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW940161
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:SIEFKE WILLIAM F &
OWNER ADDRESS:4040 SHANDY CT
ANCHORAGE, AK 99516
DATE ISSUED: 6/01/94
EXPIRATION DATE: 6/01/95
PARCEL ID:01828208
LEGAL DESCRIPTION: T12N R3W SEC 33 LT 163
LOT SIZE: 108900 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK 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 (24 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:
DATE:
TECHNICAL S
CIVIl, & ENVIRONMENTAl, ENGINEI'~IUNG · ENERGY CONSERVATION & ANALYSL$
I'}tI.X)I)OIIE 1,'. MOORE, P.E. 14530 ECHO ST.
PIt: (911'I) 345-1355 May 20, 1994 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dem' Sh's:
The purpose of this letter is to provide the requited design narrative in support of our application for a
permit to construct wastewater disposal facilities on BLM Lot 163, Section 33, T12N R3W, S.M., located
at 4040 Shandy Court. Soils logs, peru test results, a site plan, design drawings and specifications ,'u'e
enclosed for your review.
The proposed system will be constructed between test holes #1 and #2. As can be seen from the soil
logs, the native material below 2 feet is a gray gravelly or sandy silt with a measured perc rate of 20 to 40
ininutes per inch. Using the soil application rate of 0.4 gpd/sq, ft. specified in the wastewater ordinance
for soils with a perc rate of 30 - 60 minutes per inch a four bedroom residence rex[uires a total absorption
atea of (4 x 150)/0.4 = 1500 squm'e feet. The proposed 89 foot long soil absorptson trench with 8.5 feet
of sewer gravel beneath the horizontal distributiou pipe has a total absorption m-ea of 1513 square feet.
The topography of tile lot slopes down towm'ds tile south at 2 - 15%. The n'ench will be excavated
parallel to tile natural contours of the land. The test holes were dug to 16.5 feet, which was the maximum
reach of the backhoe. In test hole #1, the soil was gradnally getting sandier near the bottom, and there was
ilo indicatio ~ ,o,f a nearby confining layer. Groundwater monitoring during breakup confirmed that there
is no groundwater within 4 feet of the bottom of the proposed U'ench. ~As can be seen from the enclosed
well log, bedrock in this area is at a depth of over 200 feet. In light of the above, we propose to put the
bottom of the ttench at a depth of 12.5 feet below original [,n'ound, so as to keep the total length of the
ttench within reasonable limits.
The proposed project will have no impact on present or future water supply and wastewater disposal
systems serving adjacent properties, nor will it have any significaut impact on rese~wed space/surface and
subsurface, or on drainage.
Please give me a call at 345-1355 if you have any questions on this snbmittal.
Sincerely,
Ted Moore, P.E.
LOT
LOT 160 161
~L SHANDYCOURT (FOLLOWS PROPERTY LINE)
) '. LOT162
, ~-SHED
~ ~ ~ % EXISTING
. ~ _ INS~'~,t-i-~9' LONG SOIL ARS.
"-'.-........~~ENOH W. 9.0' SEWER GVL,
TRENCH SITE
~1~. LOT 190 NO WELLS WITHIN 50' OF LOT LINE
· ~. %~¢~k ELM LOT 163, SEC. 33, T12N, R3W
,~-- ',~'~" ~ WELL AND SEPTIC SYSTEM
/-; ~, ,, ¢r ~ SITE PLAN
TllEODORE F. t~OORE. ~ 14530 ECHO STREET DRAWN BY TFM
3589 ,,, ',¢¢~.~;, ANCHORAGE, ALASKA 99516 MAY, 1994
,'~:.c47~/.¢~,..~¢~x.~; NOTE: THIS IS NOT A SURVEYED PLAT.
~,~:~!~, ALL LOCATIONS SHOWN ARE APPROXIMATE.
~'~-~k __ .1250 GALLO.N, SEPTIC TANK
~' ..~- (INSTALL 100+ FROM WELL) ....
, / / M.T. /
89 LONG SOIL ABSORPTION TRENCH / ~
WITH 9,0' TOTAL SEWER GRAVEL DEPTH "A'
PLAN VIEW
SCALE 1" = 15'-0"
11
ORIGINAL GROUND
BACKFILL
(MOUND 1' ABOVE ORIG GRADE)
--- FILTER FABRIC
ERFORATED DISTRIBUTIOh
PIPE
1/2" SEWER GRAVEL
BOTTOM OF TRENCH
SECTION "A-A"
SCALE: 1" = 5' - 0"
BLM LOT 163, SEC. 33, T12N, R3W
PROPOSED SEPTIC SYSTEM
PLAN AND CROSS-SECTION
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE. AK, 99516
SCALE: AS SHOWN
DRAWN BY: TFM
DATE: MAY, 1994
Flattop Technical Services
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
BLM Lot 163, Section 33, T12N~ R3W, S.M.
4040 Shandy Court
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of abandonment of an existing seepage pit and installation of a
new 1250 gallon septic tank followed by 89 lineal feet of soil absorption U'ench containing a total of 9 feet
of sewer gravel.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
All construction procedm'es and material specifications shall conform With Municipal and State
requirements. All sepm'ation 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
buried utilities.
1.4 The corm'actor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there ate no residual
depressions. Insofar as possible the conU'actor shall minimize damag6 to trees and existing lawn m'eas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
the soil is compacted, as well as placement of topsoil and reseediug all areas disturbed by the construction.
2.0 Septic Tank:
2.1 The new 1250 gallon, 2 compartment septic tank shall be Municipally approved and shall be set
level on undisturbed 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.
2.2 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line f~com the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste
line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot. A
cleanout shall be installed within 5 feet of the bnilding foundation, and a double cleanout shall be installed
within 5 feet downstream of the septic tamk.
2.3 The conu'actor shall take care to ensure that the tank is a minimmn of 100 feet from the existing
private well.
3,0 Soil absorption system:
3.1 The soil absorption system shall be consu'ucted by excavating a n'ench parallel to the natm'al
contours of the land to a total depth of 12.5 feet below the original ground level.
3.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces shall be raked to
allow proper infiltration.
3.3 A total of 9.0 feet of approved sewer gravel shall be placed inthe bottom of the excavation with
the perforated distribution pipes laid level such that the pipe inverts m'e no less than 8.5 feet above the
bottom of the sewer gravel. 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. A minimum
of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet,
two inches of rigid, burial type insulation is to be placed over the enth'e top surface of the gravel, in
addition to the filter fabric.
3.6 The top surface of the cover material shall be raised a minimum of 12 inches higher than the
sun'ounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible for re'ranging to have the
site finish graded after the backfill material has stabilized, and for placement of adequate topsoil and seed
to promote rapid revegetation of all m'eas disturbed by the construction.
3.8 The existing undocumented seepage pit is to be properly abandoned by pumping, removing its top
and backfilling with soil.
4.0 Inspections:
4.1 A total 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 plans, specifications
and construction procedures, (2) after the native material has been excavated to expose the infiltrative
surface to ensure that it is level and at the right elevation, and conforms with the soil test information, (3)
after the sewer gravel is in place and the distribution pipes have been laid aud connected up to the septic
tm~k, but prior to placement of insulation or filter fabric, aud (4) after rough backfill and grading is
complete. The septic tank requh'es one inspection after it is set level and the piping connected, but phor to
backfill. This inspection may be incorporated with any of the above inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensm'e the availability of the engineer.
TEST HOLE
FLA'FI'OP TECHNICAL SERVICES ,
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: BLM LOT 163, SECTION 33, T12N, R3W
DATE PERFORMED:
PERFORMED FOR:
MAY 3, 1994
BILL SIEFKE
DEPTH
(feet)
COMMENTS:
Pt
SM Reddish sandy loam
ML Gray, gravelly sandy silt
Dry, many cobbles
Occasional large boulders
Sidewalls smear above 5.5'
Material sandier and
softer diggiog, last 3'
SLOPE
Depth to Groundwater Date
NO GROUNDWATER 5/3/94
MONITOR TUBE DRY 5/16/94
~LL
SITE P~N
5%::::::
Clock Net Time Percometer Not Drop
Date Reading Time (minutes) Reading (inches)
5/3 12" Presoak ___ 11:13 273~8
12:18 25 7/8
Start 1:04 23 1/2
#1 1:34 ' 30 22 3/4 3/4
Add water 1:35 ' 23 5/8
#2 2:05 : 30 22 7/8 3/4
Add water 2:06 ~ 23 5/8 ....
#3 2:16: 30 22 7/8 3/4
PERCOLATION RATE 40 (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 6.25 FTAND 6.75 FT
6,,
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: ~t/ ~.15) / ~1 /-//_
ITESTHOLE# 2
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
FLATTOP TFCHNICAL SERVICES ,
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
BLM LOT 163, SECTION 33, T12N, R3W
MAY 3, 1994
BILL S IEFKE
(foot)
11-
12-
COMMENTS:
Pt
SM Reddish sandy loam
ML Gray saody silt
Some cobbies and boulders
Lenses of coarse black silty sand
SP/SM Gravelly sand
ML Similar to above
SLOPE
Depth to Groundwater Date
NO GROUNDWATER 5/3/94
MONITOR TUBE DRXt 5/16/94
SITEPLAN
#2
Reading
perc hole
Presoak
Crock
Time
12:10
12:53
1:14
#1 1:44
Acid water 1:44:30
#2 2:14:30
Arid water
#3
2:15
2:45
Net Time
(minutes)
30
3O
30
Reading
22
10
12 3/4
13 3/4
15 1/4
135/8
__ 15 1/4
13 3/4
15 1/4
Net Drop
(inches)
1 1/2
1 5/8
1 1/2
PERCOLATION RATE
TEST RUN BETWEEN
Silt removed from perc bole dto'io g.~ itg~/~g2,vas damp
20 (minutes/inch
8.25 FT AND 8.75
PERC HOLE DIAMETER
FT
PERFORMED BY FLATTOP TECHNICAL SERVICES. I~'"'"J ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ,5'/2./2 f,/¢ ~
~NVI~ONMENTAL P~O
�-� Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904
Certificate of On -Site Systems Approval
Parcel I.D. 018-282-08 Expiration Date:
1. GENERAL INFORMATION:
Complete legal description T12N, R3W, SECTION 33, LOT 163
Location (site address) 4040 Shandy Ct. *Anchorage 99516
Current Property owner(s) Rod Hofmeister
Mailing address
Real Estate Agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
11-Z- 2-2-
Complete
2
Day phone 229-1177
Day phone
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual
Individual Water Storage
❑
Holding Tank
❑
Community Class Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver/Variance request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550
Date of Payment 9 1 1,2 as
Receipt Number 6 3 �qG
COSA# OSC.a)_1 3 IO
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
f!l
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm: Gamess Engineering Group, Ltd (GEG) Phone: 907-337-6179
Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507
Engineer's Printed Name: Jeffrey A. Garness Date: _ E311 12-L
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system
in accordance with the guidelines and regulations established by the Municipality of Anchorage and
industry practices. The reported results describe the condition of the systems on the dates of the
evaluation. Separation distances were measured to readily identifiable features. Hidden defects or
encroachments may exist that were not identified during the evaluation. The operational life of all wells
and septic systems depend upon a variety of variables, including but not limited to, soil conditions,
groundwater levels (that may fluctuate during the year), quality of construction (materials and
workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and
are outside the control of GEG. Satisfactory test results do not guarantee future performance of the
system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of
the well or septic system. GEG makes no representation whether an alternative well or septic system
can be installed on the property in the event either of the current systems fail to perform adequately in
the future. The content of this report is for the sole benefit of the person/party that retained GEG to
perform the evaluation. Reliance upon the information provided In this report by any other person or
party (including subsequent property purchasers) is not authorized, nor will it confer any legal right
whatsoever.
6. DSD SIGNATURE
.J System #1 Approved for :3 bedrooms
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
bedrooms, with the foll
a Jer uarness:
4 C 7y_
#AECC884
r
o w, °rF S�T� tion'
ulat64v�arr '�Np m=
o pRo A rFR
�T%7`SFRVIcEs���\��,
n
Original Certificate Date: � ^ ?_—
2
The Municipality of Anchorage Development Services Division (DSD) issir es�Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage Is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist_ Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other S c � "f/,l rov y
IN
Legal Description: T12N, R3W, SECTION 33, LOT 163
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Date drilled 6/63
Total depth 202 ft
Cased to UNKNOWN ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) I in.
Date of flow test for COSA 7/20/22
(La"b
J51 ?,-2-
9�
Parcel ID: 018-282-08
Structure served by this system
Well production at time of test 1.7+ gprn
Water storage tank volume N/A gallons
Well disinfected for coliform test? ❑ Yes ❑ No
FOR Coliform bacteria is Negative
Nitrate mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Collected by GEG, LTD
Date of Sample 7/5/22
Static water level at beginning of test 142.3 ft.
Comments "WELL IS IN CONCRETE ENCLOSURE (SEE ATTACHED PHOTO)
COSA Checklist yellow sheet
R,M
B. TANK DATA
C. LIFT STATION
Age of tank(s) 28 years
❑ Required maintenance completed
�.,
Tank type/material SEPTIC/STEEL
Age of lift station year
Measured operating fluid level in septic tank 50"
Lift station material
❑ Standpipes/foundation cleanout per record drawing
Commen
�y
Date of pumping 6/3/22
5
D. ABSORPTION FIELD DATA
Which system tested (date installed) 7113194
Adequacy test date 7/20/22
❑ ALL standpipes present per record drawing
Results QPass For 3 bedrooms
Total measured depth from grade 9.66 ft (max)
Fluid depth prior to test 34 in
Measured depth to pipe invert from grade "2.66 ft (min)
Water added 622 gal
N/A — pressurized field
New depth 48 in
❑ Monitor tubes go to bottom of effective. If not, state
120
depth into effective NORTH=9.41' & SOUTH=6.41'
Elapsed time min
p
Code -required soil cover over field
Final fluid depth 42 in
❑ System presoaked
Absorption rate 450+ gpd
(Required if vacant for greater than 30 days prior to
Any rejuvenation treatment (past 12 months) NIA
date of test)
Gallons introduced NIA gallons
If yes, enter date NONE
Comments/Deficiencies: 'SEE ATTACHED EMAIL FROM OWNER REGARDING NO FREEZING
COSA Checklist yellow sheet
R,M
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
R Yes
Community Sewer Manhole/Cleanout > 100'
r,7, Yes
if No
ft E] Yes
if No ft
Neighboring Tank > 100' [+rj Yes
if No
ft Private Sewer/Septic Line > 25' Yes
if No ft
Absorption Field on Lot > 100' Yes
if No
ft Holding Tank > 100' Yes
if No ft
Neighboring Absorption Fields > 100'
Private Wells > 100'
Animal Containment > 50' (� Yes
if No ft
❑ Yes
'ASSUMED
if No
-
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
Manure/Animal Excreta Storage > 100'
if No
Community Sewer Main > 75' [✓ Yes
if No
ft 0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10'
R Yes
if No
ft
Surface Water> 100'
Q Yes if No ft
Property Line > 5'
R✓ Yes
if No
ft
Wells on Adjacent Lots:
Yes
Absorption Field > 5'
Q✓ Yes
if No
ft
Private Wells > 100'
vJ Yes if No ft
Water Main > 10'
0 Yes
if No
ft
Community Wells > 200'
0 Yes if No ft
Water Service Line > 10'
El Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
Q Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
Yes
if No
ft
Private Wells > 100' 0 Yes if No ft
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' Yes if No ft
Surface Water > 100'
0 Yes
if No
ft
F. ENGINEER'S COMMENTS
MET CODE AT TIME OF INSTALL
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date,
COSA Checklist yellow sheet
4AECC884
www.muni.org/onsite
Septic 'Tank Advisory
Certificate of On -Site Systems Approval #OSC 221390
Subdivision: T12N R3W Sec 33 Lot 163
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks The septic tank for
this COSA / property is 28 years old. A leaking septic tank may be a source of contamination to
the aquifer. Typical replacement costs range from $10,000 to $15,000
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of a 16 -year-old septic tank in failure and should be replaced.
Mailing Address P O Box 196650 *Anchorage, Alaska 99519 66150 *www muni org �
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MUNICIPALITY OF ANCHORAGEi
DEPARTMENT OF HEALTH & HUMAN ~ERVICES_
Division of Environmental Servibes
On-Site Services Section ~
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~/'~' -- ~' <~'2. - OoQ'
HAA #
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone 5' ~/5-- / ? 5' ~
Day phone
Agent t~ct~-¢~'~ ~oco J¢~ ~ ~A pro¢¢~o*¢'/ Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
?.7 ~ - ~77~
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
72-025(Rev, I/91) Front MOA~Y21
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system. ~':" '-~
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 ~pe 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 ~'1 ~x ~/'o? T'ec4~'~c* ( ~'e",';¢,'~' Phone '3
Address I fi'5- ~O /E_-CA~ £/..~ A,~c4 ~,-,~q(,, ~
Engineer's signature ~'...'/-~ ~. ~'/-~,,.-~ Date
for
Disapproved.
4
.
· ....
bedrooms.
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 Certific.,a.t. es based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DH HS does th s as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do hot
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;?.h : ; ~: ,.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type
Log present (Y/N)
IK~ ~'¢c33, Ttz~/zz~ParcelI.D.
If A. B. or C, attach ADEC letter. ADEC water system number
Y Date completed d'/~,7 Driller
Total depth So 2' Cased to
Sanitary seal (Y/N) Y'
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
I00'
g.p.m.
'Lo a_' Casing height
Wires properly protected (Y/N)
AT INSPECTION
19¥~
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ! ~.£'
Absorption field on lot !
Public sewer main IV, ,4.
Sewer service line ~ ss'
; On adjacent lots
; On adjacent lots ~. ~,o,
Public sewer manhole/cleanout
Petroleum tank /,~o,~ e
WATER SAMPLE RESULTS:
Coliform 0 co( /~' oo ~.~
Date of sample:
Nitrate
Collected by:
Other bacteria ,~o/;'e /"e?o,"/-,-~'
B. SEPTIC/HOLDING TANK DATA
Date installed '7 /
Cleanouts (Y/N) Y
High water alarm (Y/N)
Date of pumping
Tank size / '2yo ~, / Compadments
Foundation cleanout (Y/N) Y' Depression (Y/N)
N, ,~, Alarm tested (Y/N) /,4. ,~.
N, 4. ( ~ ~q~-) Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK '['O:
Well(s) on lot 1o_¢' On adjacent lots
To property line I ~,P' Absorption field
Sudacewater/drainage ~> ~oo'
Foundation
Water main/service line
72-026 (3/93)' Front CONTINUED ON BACK PAGE
C. LIFT STATION ~l, /:) .)
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed 7 //~
Length ?,~, 5' Width
Total absorption area /S'~ v
Date of adequacy test tq, A. (~
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot He' '
To building foundation ~o'
On adjacent lots ~ 7 o'
Sudace water ;, , oca'
Curtain drain ~o,,, ,,
E. ENGINEER'S CERTIFICATION
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Surface water
Soil rating (GPD/FF) O. ¥ System type 7-r¢,~c4
Gravel thickness ~. 7' Total depth I ~'
Cleanout present (Y/N) y' .Depression over field (Y/N) N
Results (pass/fail) N, ,~. for ~' Bedrooms
O After test o
if yes, give date ,~. ,4.
On adjacent lots ;> /~,o' Property line ~'
To existing or abandoned system on lot ~ :~.'
Cutbank N, A-, Water main/service line > z~'
Driveway, parking/vehicle storage area ~ ~c,~ '
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name "7-/,
Date d) c,Zo
HAA Fee $ ,~ o~ ~-~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
C~-3589