HomeMy WebLinkAboutT14N R1W SEC 6 W3NE4SW4 PTNJury 14 1.9 01:04p Ancftraga Well & Puwip Sac 90724-10742' p.1
C)eveiOpMent Services be
pertMent
Building safety bivision
J, WCter
WasteWCter Program
4700 rtr;o L Woad o4
Mart ROSox 2?6650
wayor '"chOrOge, Ar, 99507
0. ^RSIfiS
(9-07) 343-79(�4
Well Driflihg pel-111it i PuMp Installation Log
Parcel Identj Nun,1)ate (If issue:
ber: OSO-3.?t-55
Legal escriptiol,
7-1`/NX f W PrWe
y Own., Name
A�, I ddress:
3N b) Ll PT_ ti
PUMR Instai'lao
t! U Date"
PUMP Intake De th
p 3 up of W,Jicasfljg: 4tpofect
Pump 1L1:3;2Ufi1CturW., 7
Pux-V LNIodel.
Pump size f hp S
PMES's Adapter Depth -
feel
Pitless Adapter NjajjUfacturer,s Nance:
Pitless Adaptef. Installer:
:Well Dbinfiected Upork Completion'?
Method of Disiateerf.,,: No
Comments: 19
P1111113 Installer Nalne:
v 'CeS Y?C-
RC�O
Mention.- The, p1,111) in-qZ'1]:Ex shall provide aPl-UrIP installation log 10 the DSD Within 30 daye, 0.,
,PUrip in-ta,
'laTion.
vi1
Municipality of Anchorage
Community Development Department Page 1 of 2
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 - http://www.muni.org/onsite - (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP141515 PID Number: 050-321-55 ❑ New ❑✓ Upgrade
Name:
Robert & Marcella Wall
ABSORPTION FIELD
❑ Deep Trench El Shallow Trench El Bed El Mound
Address
18849 Timberline Drive, Eagle River, AK 99577
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
4
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel *depth beneath pipe
Ft.
Subdivision Block Lot
T1 4N, R1 W, Sec 6, W3NE4SW4
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft,
Beds: Number of Lines
Distance between lines
Ft:
SEPARATION DISTANCES
To
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Lift Station
Tank
Line
FC
Ft.
well
100+
NA
N/A
N/A
N/A
TANK 0 Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
Anchorage Tank
Capacity
1250Gal.
Surface water
100+
NA
NA
N/A
Material
Steel
Number of compartments
2
Lot Line
114
NA
NA
N/A
NA
Foundation
23.6
NA
NA
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
50+
NA
NA
N/A
Gal.
Remarks
Pump on level at
in.
Pump off level at
in.
High water alarm at
in.
Pump make and model
Electrical Inspections performed by
PIPE MATERIAL House to tank 3034Tank to 3034
drainfield
Installer
JR's Septic Pumping
Drainfield 3034 CO/MT 3034
Inspector Pannone Engineering Services
BENCHMARK (Assumed elevation) 96ft
Inspectiones: 1sc 12/11/14
Location and description
2
Southernmost corner of structure G, P:"�r�
3rd 4m
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
4� OF, AC
Conditional Approval: Date
r
• St'e'ven • . •�annorae•r
��•�,•
CE 8149
Approved Date q>�`URppNA•.
..
Inspection Report_1-1-12.doc
Municipality of Anchorage Page I of~
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
~l~ ~, ~ J~N~I~ ~.~ Wastewater System: ~ew DUpgrade
Phone~ ~ ~ INo. of Bed~s: ~Deep Trench ~ Shallow Trench '~ed ~Mound ~Other
Soil Rating: ~ ~I ~ Total Depth from original grade:
LEGAL DESCRIPTION ~. ~ ~P~s~. ~ ~.~'~
/~'~. ~, ~ Oepth to pipe bottom from origi,a, grade:~.~,__ +~ 'Ft. Gravel depth beneath pipe~,~ /Ft.
~ ' Fill added above or[gina grade; Ft.
Townsh~ Ran~ ~ I Section: ~ ~ ~ ~7 Gravel length~
Gravel~ 1~ / Number of lines: ~ Distance baleen lines:
WELL: D New ~ Upgrade ~ l~" ~ Ft. ~I ~ / Ft.
Pipe material: ~
~;t~A,B,C): Total Depth: Cased TO: Total absorption area:
Driller; DateDrJlled: StaticWaterLevel:Ft. ~ ~ Dateinstalled~ ~
SEPARATION DISTANCES ~ptic u Holding n S.T.E.P.
TO Septic Absorption Lilt Holding Puh~ic/PHvat( nufacturer: Capacity in gallons:
Fro~ Tank Fie,d Station Ta~k SewerLi~es ~~~~J ~
Surface
w,~,r ~+ Z¢¢~ ~ ~ LIFT STATION
/ ~ ~ "Pump ow' level at: ~water alarm at
Foundation
Remarks: BENCH MARK
Loca 'on and Descri tion:
Department of Hea~ and Human Services approval ~, ~,. ~',....o,.,
Reviewed and approved by ~ ~ Date: ~-/~- ~Z
72-013 (1/91) MOA 25
Permit No. ~'~ I
Page ~ 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
72-013 A (2/91) MOA 25
0~tob~r 21, 1991
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
S~TE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Stre~
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: SEPTIC INSPECTION REPORTS:
RECEIVED
OCT 2 2 1991
~v~u~c~,~ai,~y of Anc[~,orage
HeaJth & Human Services
NE ~,SW ~, SEC. 6, T14N, RIW, S.M.
Lot 3, B~ar Park Subdivision;
Lot 6, Block 4, South Fork W~t Subdivision;
Lot 16A, Sec. 15, T12N, R3W, S.M.
Lot 29, Hillsid~ P~k Subdivision;
Lot 6, Block 8, Tr~Is End S~§division;
Lot 3, Block I, Gateway To The Park Subdivision;
0v~r this summer we hav~ p~formed inspections on the installation of
s~pt~c systems located on the above referenced prop~rti~. All of
thee systems w~r~ installed in a satisfa~ory manner and in accordance
w~h the p~mits issued by your offic~.
However, to d~te th~se remain virtually undev~oped prop~s without
foundations installed. 0nc~ foundations ~e installed we will
complied inspection reports with swing ti~s tied into the corners of
the ho~e. The appropriate ~levation data ~an then be tied into a
prop~ benchmark. Therefore, completed s~ptic inspection reports for
th~se prop~ti~ ar~ forthcoming.
If ~ou have any qu~tio~ or comments please contact us.
Sincer~y,
ROGER J. SHAFER, P.E.
RJS/gm
cc: REFERENCED PROPERTY OWNERS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
PAGE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW910252
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:SMITH RICHARD W & JEANINE M
OWNER ADDRESS:17967 SANCTUARY DRIVE
EAGLE RIVER, ALASKA 99577
DATE ISSUED: 8/27/91
EXPIRATION DATE:
PARCEL ID:05032155
LEGAL DESCRIPTION: T14N R1W SEC 6 W3NE4SW4 PTN
1 OF
8/27/92
1
LOT SIZE: 193842 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
v
ISSUED BY: DATE:
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
August 15, 1991
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: West I/3, NE I/4, SW I/4, S~c.
6, T14N, RIW, S.M.
Request you ~sue a p~rm~t to install a septic system on the
referenced property upd~ng the expired p~rmit #900219.
Th~ previous permit was issued for the installation of a mounded type
of absorption bed. W~ propose the same system, however, due to
ordinance amendments in September of 1990 we have hand dug a second
test hole for an alternate site and we have performed two p~rcolat~on
tests. The results of these tests, and designation of the a~rnate
site on the site plan are ~ached. As stated on the original soils
log, we excavated sever~ test holes on the property in the proposed
septic area in J~y, 1990 and found the bedrock depth to vary b~tween
2.5 and 3 ft. below the ground surface.
Due to the size of the property and d~stances to the property lines,
we do not anticipate any adverse effects on the n~ghboring prop~rti~
by the instal~on of the proposed septic system.
Attached is the well log from th~ w~ d~i~l~r under the previous
p~rmit.
If you have any questions or require add~onal information for your
review, please co~act us.
Sincerely,
~ ~ ~R ~ '~SHAF~, - p~. E.~
RJS/gm
ON SiTE
WASTE WATER
DISPOSAL SYSTEM
DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section:
SLOPE
WAS G.OU.D WATER
ENOOD,TEREO?
11
IF YES, AT WHAT
DEPTH?
13 - I~tonitoring?
14-
15
16
17
18' t~5 ~
19-
/
Reading Date Gross Net Depth ~o Net
Time Time Water Drop
20-
PERCOLATION RATE ~'r (minutes/inch) PERC HOLE DIAMETER
'rEST RUN BETWEEN ~.-----~ND
FT
COMMENTS .~'
$ & S ENGINEERING ~
17034 Eigb RN~ L~p R~dNo.~/// ///
PERFORMEDBY: ' · ~ - -- ' ' ' // ~/ ~ CERTI
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELI~ECT ON THIS DATE DATE'
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR.'--~ ~
LEGAL DESCRIPTION:
1
3-
4-
5-
7
8
tO
tl
~2
13
14
18-
~9-
20-
DATE PERFORMED:
Township. Range, Section: ~, ~,~ , '~ ~,A/! ./~//./lJ
SLOPE SITE P'LAN
WAS GROUND WATER
ENCOUNTERED?
IF YES. AT WHAT
DEPTH?
Oeplh to Water After
MonitorinD? "~ r]ate:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE '"~"~ (minutes/inch) PERC HOLE DIAMETER
.5 & 3 ENGINEERING
PERFORMED BY: 17~3~4 I==.l~ I~I~.,.~ I ~ o~.~ NO. ~ ~ m ~ ¢ ~CER~IFY THAT THIS TEST WAS PERFORMED IN
.a leRiver Alas ~ ~ ~J ~ '
ACCORDANCE WITH ~LL STAT~ AND~L GUIDELINES IN EFFEC~ O~ THIS DATE. DATE:
72-008 (Rev. 4/85)
rillt g
by
DOC Co, dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 668.2759
O~NER OF LAND ~1
ADDResS /~o7 ~u~<~ ~ "~. ~ .
DATE.Started" I0~0 Ended
PE~IT NUMBER
DEPTH OF WELL ' qO~
STATIC LEVEL OF WATER FT.' ,, /~0
DRAW DOWN FT.
GALS. PER HR ,
KINDOFCASING
KIND OF FORMATION:
From
.'From
From ~
From ~.? Ft. to ./0.~ Ft.
From/O3 Ft to~ Ft.
Fro~ Ft. to--Ft.
From. Ft. to Ft.
F~om~Vt. to~ a'ff Ft. A~o
FromQ~ Ft. to~6~Ft. ~
From ~ Ft. to Ft.
Fro~6Z Vt. toY)~
From ~OFt. to~ Ft.
.F~om~Ft. to ~O~ Ft.
From Ft. to Ft
From Ft, to Ft.
From Ft. to Ft.
From Ft..to Ft.
-- Ft. to°~ Ft.
. Fi. to ~'~ Ft.
Ft. to qg Ft../3t~,¢9~0CC
From
From
From
From
From __
From
From
From__
From
From
From
Ft. to
Ft. to
__Ft. to
__Ft. to
Ft..to
__Ft. to
__Ft. to
_Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
Ft. to
__Ft. to.__
__:Ft. to
.Ft. to
Ft.
Ft.
Ft.
Ft,
Ft
FL
Ft.
Ft.
Ft
Ft
Ft.
Ft.
Ft.
Ft.
Ft.
__ Ft.
Ft
MISCL. INFORMATION:
DRILLER'S NAME
.... >' i..j ~ '· :. .~.
~e foll~ing descr/be~ ~al estate{
~e Week ~e-~ird (~/3) o[
~or~ealt ~e-qu~ter of ~e sou~west encounter
~ (MB 1/4 ~ ~/4) of Section 6, T~nship 14
~ge ~ ~8t, S~wa~d ~idian, in ~e ~orage
~cording D/st~/c2, ~i~d D/82~/C~, Sta2e oE Al~ka,
descrLbed ~ loll~s]
C~ncing a2 ~e West 1/4 corner oE Sec2ion 6,
4 ~)~ T~nsh~p 14 Nor~, R~ge I West, Sew,d Meridian,
~ence Nor~ 89~54~ East, a distance of 1,160.88
ED ~y~ feet to ~e C-W 1/16 corner ~d ~e true point
of beginning, ~ence ~or~ 89~S4~ East, a distance
of ~,320.00 feet to ~e ~nter 1/4 corner and
---- corner No. 2, ~ence S 0~14~20' Bast a distance
o~ 458.35 feet to ~rner No. 3, ~ence North
88e3S~20~ West a d[st~ce o[ 1,320.51 feet to
corner ~. 4, ~ence Nor~ 0~14
~st~ce ~': 423.52 feet to the true ~nt of
beg~nning.
of record.
DATED this
STATE OF A[J~ )
THIRD DISTRICT )
24t_____hday of January , 1972,
On this Z4thday of ,January , 1972, before
the undersigned Notary publicity appear~ KENNETH ROUSE
and JULIA ROUSE, the individuals named in and executing the fore-
going instrument, and ~J~ey acknowledged to me that they signed
and sealed the same as their free and voluntary act and deed,
for the uses and purposes ~herein mentioned.
WITNESS, my haq~,,'~nd official seal the day and year
hereinabove written......' ?~
?)'? ?..:
f~:' ~<'~. "J:[,~ D,,' ,n in an 'A~Dr Alaska
%',,/ : ,... /~.',~- , ., ,,.
.. ,, ,...~.'..
Tom Fink,
Mayor
h/[unicipality Anchorage
Department of Health and Human Services
$25 "L' Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
January 10, 1991
Richard Smith
17967 Sanctuary Drive
Eagle River, Alaska 99577
Subject: T14N R1W Section 6 NE4 SW4
Permit #900219, PID #050-321-55
The subject permit, issued by this office for a sing-le family
well and/or on-site wastewater system has expired as of December
31, 1990 o
A new permit must be obtained from this office for a well and/or
on-site wastewater system ,not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this office for documentation of the installation and to close
the permit.
If a private engineer inspected the installation of the on-site
wastewater system, the original as-built inspection report
(three-part form) must be sent to this office for review,
approval and documentation. All inspection reports must be
submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $90.00 for an
on-site wastewater permit; $50.00 for a well permit; $140.00 for
a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
JW/ljm:200
enc:
Copy of Permit
"KidsAre OurFuture"
l::M:,i' c::l:!.! I i d :~ 050"-':52 ].
L,crL i,,,~e:,ga !: Subd i v :L s i c:~,~ '; 00000 i,,..ot 2 N!E/4SN/4 B ]. oc k
Sec: t i ~:l"t: 6 'f'c:~t,,~l'~ sd"l J. p ~ ]. 4N Rang e
Lalik must. ' ...... a'L ].(~ast. 2 ..... f,~..,:l ..hal,..:. Depth t.e top
.... ..l ...... ,~- -- . ...... - ....... ' :lc: 'Lank (s) < .q.,, 0
i!Ii:S SYSI'iZi*! hIUE!;I B~ii I]',iSfAI_L...ED AS SHOWN C:)N 'II-IIE IENG]:NEIi!!:R'S DIES]:GIx!
OAI ~:).) 7/(,t :I/90 ,, i.)~.li...l'..!i~ l'.It, li; J BE: NO l' ! F: ! iED F'F,t :[ EiR TO AI._L ]: NSPI;::CT IONS ,, A
~. :I ~::'i ~,: I A I .((Jhl l::~l:):r, dt III::d;LS AN iEL.E:C'I R i CAI [i'-!SF:'IEC] ]:ON,, 'IH.(S i::'ERM ]: J :[~;
F'[)i:,' ('~ 4 :0~2:~)ROOM SJ:NDI..I: F:AhI:[I..Y NIESIDENCE ONLY, AND I:EXF-':[RIES ON
:~2/3J/9C,,
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
2
3
4
6-
7-
8-
9-
Township, Range, Section:
SLOPE
/ '/
SITE P
,o- WAS RO'"OWA 'E" ,'JO
ENCOUNTERED?
IF YES, AT WHAT 0
DEPTH? ~ p
E
Depth to Water Aftec~/
Monitoring? ~ Date:
11
13-
/ Gross Net Depth to Net
Reading Date Time Time Water Drop
14-
15-
16-
17-
18-
19-
20 - PERCOLATION RATE ~'"~(minutes/inch) PERC HOLE DIAMETER ~
COMMENTS S & S ENGINEERING T~-ST RUN BETWEEN~~~u
FT
PERFORMED BY: ' . ~. .~ . __r ~'~'~// ~/ ~ CERTIFY THAT~IST~ST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES I~ECT ON THIS DA . : ~ ~/ ' '
~2-008 (Rev. 4/85) /
Municipality of Anchorage
Development Sen/ices Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-321-55
GENERAL INFORMATION
Complete legal description
Location (silo address or directions)
Expiration Date:. _~- ..~ I - O ~
NE 1/4; SW 1/4; W 1/3; T14N: R1W; Section 6
18849 Timberline Dr. Eagle River
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Rick
~m~
smith
Day phone 6Qt,-t, 007
Day phone
Day phone
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site vr~J
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Deve!opment Se.vices Department (DSD) Issues Certificates of Health Authorit'/
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificmtas of Health Authority Approval are required for the transfer cf
title (except between spouses) for properties serged by a single-family on-site wastewater disposal and/or
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the cate of issue for prepare!es served by a private or Class C we!l and may be reissued with
new water sample results. (Certificates may be reissued for a perica of up to one year with valid water samples.)
Cemificates ,~re valid for one year for propemies served by Class A or B wells or a public water system. The
Municipality of Anchcmge is not responsible for errors cr omissions in the professional engineer's work.
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
Parcel I.D.
GENERAL INFORMATION
Complete legal description
Location (site address or directions) 18849 TZ~barZina D~.va
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Rick smith Day phone 694-4007
18849 Timb~r£in~ Driv~ Eagl~ Riv¢~, AK 99577
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
4 V
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank '"'
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72¢325 (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 frown 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 ~ Phone C"~¢//~"~¢"~ ?
Address ' . / ._~..= _~ ,-' f ~'
Engineer's signature ,.~ ~i ./~ - Date
So
DHHS SIGNATURE
Approved for ~'~-
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
~ ~ Date
By: /
The MunicipaJity 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 engineeCs work.
To Whom it May Concern,
June 23, 1993
My name is Richard W. Smith and I am the owner of the
property at 18849 Timberline Dr., Eagle River. The house is new
construction and it was not occupied until February 14th. 1993. The
septic system was not in use until the third week of January1993.
Richard W. Smith
Municipality of Anchorage ,~
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. Well Data
Well type ~ I~- ~ \( ,,'xl~..-- If A, B, or C, attach ADEC letter. ADEC water system number
Log present ~/N) \[ Date completed \ o ~ o Driller
Total depth Z~' Cased to
Sanitary seal Y~)
FROM WELL LOG
Date of test \
Static water level
Well flow '~-~--. O .~e~m.
Pump level1 L) ~J"--
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot \ ~'1 ~
Public sewer main ~ ~-
Sewer service line · ~
~ ~ L.,."* 1-~¢-~ Casing height
Wires properly protected ~.~N)
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Date of sample: ~:> ~"~% ~%
Nitrate
Collected by:
B. SEPTIC/HOLDING TANK DATA
Other bacteria 0
S & S ENGINEERING
17034 Eagle River I.e~p Road No. 204
Eagle River~ Alaska 99577
Date installed \ ~ ~-% t, Tank size ~ '~' '~- ~ Compartments_-
Cleanouts~;~N) ',,/ Foundation c eanout~/N) V Depression (~)
High water alarm (Y,~ I~ ~ ¢j/Alarm tested (Y/N)~ '~-' ~ :~('~
Date of pumping ~ ~~ ~ pumper ~ ': ~'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot \ .z~ L~ ~' On adjacent lots ~. ,~- c~ ~"~ Foundation
To property line \~ c~ Absorption field 't ~ \ Water main/service line
Surface water/drainage \ o C~
72-026 (3/93)* Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N) ...--------'--"--
Vent (Y/N) "Pump on" level at ~elat
High water alarm level ~ .~C~ycles tested
Meets MOA electrical codes (Y/N)
SEP~ FROM LIFT STATION TO:
Weql on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed \ o ~¢'~ \
Length '?~o ¢ ~¢'%' Width
Total absorption area ~ °t '7-~'~ Cleanout present~N)
Date of adequacy test %¢.-¢¢-~ .~-r-c-~-b-~ Results (pass/fail)
Water level in absorption field before test
.~Peroxide treatment (past 12, months) (Y/~.).
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Soil rating (GPD/FF) ~,~l ~?'>/¢~.,z.~ Systemtype
Gravel thickness ~ ,~ ~
Total depth
Depression over field (Y/~
for
After test
If yes, give date
Bedrooms
Well on lot \ \"'~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots \ ~ ~ \ ~ Property line
/-~['""1 ~ To existing or abandoned system on lot
Cutbank ~L lA- Water main/service lin~
\~_
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that/have checked, verified, or conforme.¢t.¢~/MOA and HAA~
Signature ~& $ ENG!NEERING
Engineer s Na~gle ~lv.r, Alaska ~7/
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
