HomeMy WebLinkAboutT13N R3W SEC 33 LT 55H-1
MUNICIPALITY OF ANCHORAGE
Development Services Department s Prone: 90-7-343-7904
On -Site Water & Wastewater Section Pax: 907-343-7997
Pump installation Log
Well Drilling Permit Number: Date of Issue: - -
Parcel Identification Number: 0*7-
Legal Description Block I Lot Property Owner Dame & Address:
T1 3N R3W SEC 33
Pump Installation Date: 04 - os -2022
MORRIS, LIISlA D
551-1-1 4920 CHUCK DRIVE
ANCHORAGE, AK 99507
Pump Intake Depth Below Top of Well Casing: 95
Pump Manufacturer's Name: BERKELEY
Pump Model: B7P4JP05221 -02
Pump Size: '50 hp
Pitless Adapter Burial Depth: 12 feet
Pitless Adapter Manufacturer's Name: MARTINSON
Pitless Adapter Installer:
Well Disinfected Upon Completion? f .res ❑ No
Method of Disinfection: PELLETS
Comments:
Pump Installer Name: _
Company:
Mailing Address:
City:
feet
ANCHORAGE WELL & PUMP SERVICE
7640 KING STREET
ANCHORAGE, AK 99518
907-243-0740
State: Zip:
Attention: The pump installer shall protide a pump installation log to On-site within 30 days of pump installation.
Municipality of Anchorage Page I of 2.
: 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
Permit Number: %Wc/qO$(.~' PID Number:
Name: Wastewater System: [] New [~Upgrade
Address:
~o d~u~ ~v~' ABSORPTION FIELD
~(~O/~., ~ ~O7 ~B D Deep Trench O Shallow Trench ~Bed OMound ~Other
LEGAL DESCRIPTION so, Rating: Total Depth from original grade:
~,~ GPU/Sq. Ft. ~,~
Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: Range: Section: Fill added above original grade: Gravel length:
WELL: U New ~ Upu rede Gr~vel width: /~ Ft. Number~of lines: Distance~,~between fines:Ft.
Classification (Private, A,B,C):~. Total Depth: Cased TO: ~ Totalabsorption area: Pipe materi~h ~/0
Driller: Date Drilled: Static Water Level: installer: Date installed:
Yield: Pump Set at: Casing Height Above Ground:
SEPARATION DISTANCES ~s~,tic ~ Ho,~in~ ~ S.TZ.,.
TO Septic Absorption Lift Holding :ublic/P¢ivate Manufacturer; Capacity in gallons:
From Tank Field Station Tank Sewer Li.es ~NCNO~ ~A
Material: Number of CompaHments:
SuCace ,¢ LIFT STATION
Lot ¢ ¢ Size in gallons: Manufacturer:
Foundatio~ /¢ ~ /~ ~ _ _ ~ "Pump on' revel at: ~ at: High water alarm
Remarks: BENCH MARK
Location and Description:
Assumed /~,~
E~evation:
17034 Eagle ~iver Lo~ Road, No, 2~ ,~ ......... ~' ............ ~
Inspections performed by: ~.b River. Alaska ~5~ Dates: 1st /¢-/O-E~ ,,~.~/ ......... ¢
Department
of
approyal~
Health'and Hum~e~ices ~" .... .,..~.~ ~,
Reviewed and approved by' L ,~ ~ Date: [0/~/ /~ '"'" ....
72-013 (Rev. 9/91) MOA 25
Permit No.Sw940568
Page 2 of 2
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
Legal DescriptionI. 15N, RSW, SEC.53, LOT 55H-1 PIDNo.: 00807255
N.T.S
CO1
C02::
YEW
1000 GAL
SEPTIC
TANK
CO
GR~DE~
(
· 90.5' NO WATER
EXISTING
BDRM
w/
1000 :.GAL. SEPTIC TANK
ABSORBTIO~4 BED
ST[~UCTURES, EASEMENT~ OR ENCROACHM£N~S
SHOWN ON THIS SITE pI~AN Af~E AS SHOWN
~FLEMING SURVEYING SERVICES
i 96 5~
(MT 1 ~'l'~iT2)
'OUND
RO2ERT C. COWAN
CE -8801
72-0f3 A (1/93)
MUNICIPALITY OF ANCHOP._AGE
DEPARTMENT OF HEALTH ~ HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM
PERMIT NUMBER:SW940368
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:MCELLIOTT MARJORIE L
OWNER ADDRESS:4920 CHUCK DR
ANCHOP~AGE, AK 99507
PAGE 1 OF
(UPGRADE) PERMIT
DATE ISSUED: 9/29/94
EXPIRATION DATE: 9/29/95
PARCEL ID:00807255
LEGAL DESCRIPTION: T13N R3W SEC 33 LT 55H-1
1
LOT SIZE: 8689 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PEP/~IT:
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 A1X~D 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 AA!D HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED By: ~'C-~-~~/~ ~ -- DATE:
ISSUED BY: ~ DATE:
ROBERT SHAFER, P.E.
September 14, 1994
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
SOILTEST
PERCOLATION
TEST
STRUCTU L &
MECHAN
]NSPECTIONS
MUNICIPALITY OF ANCHORAGE
Depar~¢nt of Health and Human S~rvic~s
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 55H, Sec. 33, T13N, R3W, S.M.
The motoring tube w~thin the test hole has been checked and found to
be dry.
Attached is the proposed upgrade design.
We do not anticipate any adverse effects on neighboring proprieties by
the installation of the proposed septic system.
The proposed 1000 gallon septic tank is to be placed outside the w~ll
protective radius. Attached is a s~te plan which depicts the location
of the proposed tank.
If you have any questions, or requ~e addition~ information for your
review, please contact us.
O~y C. COWAN, P.E.
A/gk
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP · SUITE 204 ° EAGLE RIVER, ALASKA 99577
?
3OVMOd~
° ~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCR IPTION:~ ~' ~
1
2
3
4-
5-
6-
7-
8-
9-
10-
11
13-
14-
15-
16-
17-
18-
19-
20
COMMENTS
~,~.~, ~'~ DATE
Township, Range, Section: "~'"'l"~-~
SLOPE SITE PLAN
PERFORMED BY:
$ & $ ENGINEERING
ACCORDANCE W~TH A~,~..T~T._E A~ID_~IUNIJDIPA
//o~ ~agle I~lver
72-008 (Rev. 4/85) Eagle River, Alaska
WAS GROUND WATER ~
ENCOUNTERED?~O
L
I F YES, AT WHAT
DEPTH? pO
E
Depth to Water Afte,~.
Mo.itorino? ~ Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~l~inutes/inch) PERC HOLE DIAMETER --
L Ul I~ ON THIS
L,
__ CERTIFY THAT THIS TEST WAS PERFORMED IN
, DATE. DATE:
ROBERT SHAFER, P.E.
ON-$ZTE ~ASTE~ATEI~PZSFOSAL
CONSTRUCTION PRACTICES
FATERIAL SPECIFICATIONS
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
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
REFEEENC. E= Lot 55~1, See_. $$, T15N,
GENERAL=
The scope of this project includes the installation of a 1000
g~on septic tank out~ide the 100' protective well radius to
serve the two bedroom single famlly dwelling (with efficiency)
for the referenced property. The ex~ting 750 gallon septic
tank is to be excavate, pu~ped, crushed, and abandoned in
place.
Construction shall be in accordance with the approved site plan
and design drawings, Municipal permit with any special
provisions or conditions, and all applicable State and
Municipal Wast~water DispoSal Regulations.
The contractor shall be responsible for obtaining any necessary
underground ut~y locates.
Unless specifically agreed otherwise, the property owner shall
be r~sponsible for fin~ grading area~ subsequently depressed
from soit settling. On all l~achfi~ld mound systems, the
property owner shall be responsible for ensuring a satisfactory
vegetation growth over the mounded ar~.
Contractors installing wust~w~er d~posal systems must be
certified by the Municipal H~h Department for system
installations. Owners installing their own systems must also
receive prior approval from the Municip~ He~h Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified septic tank
manuf, acturer. Construction shall include two 4" eleanouts for
p~mp~n~ access.
2. The septic tank shall be sufficiently bedded to prevent
s~ng or shifting of the tank.
3. A~I standpipes on the septic tank shall extend a minimu~ of 12
inches above final grade.
4. Septic tanks installed with less than 4' of cover shall be
insulated.
ON SITE
WAS~rE WATER
DISPOSAL SYSTEM
DESIGN
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
Page Two
Lot $5H, Sec. 33, TISN, RSW, S.M.
September 14, 1994
A foundation cleanout sh~l be i~talled one to four feet from the
building foundation. In the line b~tween the tank and the leachfield
there shall be two adjacent cleanouts (unless an effluent pumping system
exists within the septic tank). These cleanou~ sha~ be located on
undisturbed soil not more than 10' from the tank. The first cl~anout,
in line, shall be to ~lean toward the leachfield. The second ~anout
shall be to ~ean toward the septic tank.
6. Final grading over the septic tank shall be such that a positive slope
exists away from the septic tank.
LEAC~F~ELP BEP INSTALLATION:
Excavate the proposed Bed Area to the depth shown on the design. The
bottom of the excavation sha~l be within 2 inches of level. If the
bottom of the excavation becomes smeared, it must be raked or scratched
(roughed-up) before gravel (sewer rock) placement.
If a sand layer is required, place sand over entire excavation to the
required depth shown on the design. The top of the sand layer must be
within 2 inches of level.
Sewer rock shall be placed uniformly throughout the en~re bed.
Perforated distribution pipe must be in~talled level with perforations
down. Gravel depth below the perforated pipe shall be a minimum of six
(6) inches. Gravel depth above the perforated pipe shall be a minimum
of two (2) inch~s. The total gravel depth throughout the entre bed
shall be a minimum of twelve (12) inches.
The perforated distribution pipes must be no more than six feet apart.
The distance between the outermost perforated distribu~on pipes and the
sidewall of the a§sorption bed must be no more than three feet.
Silt barrier material must be installed between the final ~ravel layer
and the native soil backfill. Ensure the sl~t barrier covers the entire
gravel s~rface before placing backfill.
Monitor tubes shall be of four {4) inch diameter and installed at the
locations shown on the design. The portion of the monitor tube
extending through the gravel depth shall be perforated six (6) inches
below the bottom of the horizontal distribution lines.
Backflll over the final gravel layer must not be less than twenty-four
(24) inches. Insulation must be installed when the backfill depth is
less than thirty-six (36) inches. The fi'n~hed grade over the bed must
be mounded to prevent the formation of a depression after settling.
Page Th~ce
Lot 55H, Sec. 33, TI3N, R3W, S.M.
September 14, 1994
Yll~I~Y 14ATERIAL SPECIFICATIONS:
I. Any septic tank proposed for installation must be
Municipally approved septic tank manufacturer.
2. The following pipe materials are approved for usc
installatAons in thc Municipality of Anchorage:
constructed by a
in septic system
Type of Pipe P~rforatcd
Solid
Cast Iron Y~s Y~s
ASTM D3034 (PVC) Yes Y~s
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Y~s Y~s
Use of a type of pipe oth~ than li~ted above must be approved by the
inspecting engineer.
Insulation shall be at least 2" thick extruded direct b~ria~ polystyrene
(Dow Chemical Company Styrofoa~ HI or equal).
Septic tank inlets and outg~ts shall bc fitted with watertight couplings
(Ca~der, Fernco, or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal)
must be installed be~tWeen the final leachfield gravel layer and thc
native soit backfitA.
All leachfield gravel (sewer rock) shaZ1 bc 0.5"-2.5" screened gravel
with less than 3% passing thc #200 sieve.
When sand is being used as a filter material, its gradation
specifications must conform to current M.0.A. or D.E.C. requirementS.
IRSPECi'IO~$:
Typically there will be a minimum of three (3) inspections required during thc
installation of the wastewater disposal system. These inspections will occur as
follows:
I. The first inspeed~ion must bc conducted after the excavation of ditches,
pits, trenches, or beds and before the installation of any gravel. A
Septic tank may be sgt in place, but may not be backfilled before this
inspection.
Page Four
Lot $$H, Sec. 33, T13N, R3W, S.M.
September 14, 1994
2. The second inspection must be conducted after the placement of the silt
barrier, gravel, dist~bution lines, standpipes, cleanoats, and
insulation, but §cf ore the placement of any other backfill.
3. The final inspection ~ to occur upon final gradin~ of the property.
Often there will be more than these 3 inspections required, especially with the
installation of multiple trenches, sand filters, pressurized distribution
systems, ~te. Thus, the inspecting engineer is to be contacted at least 24
hours prior to the start of construction. If necessary, a pre-construction
me~ting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractor's activities.
The owner shall contract with the contractor to perform the work outshined in
these specifications and plans and in accordance with the attached M.0.A.
permit. There will be no contractual arrangement existin~ between the
contractor and S & S Enfline~ring. S ~ S Engineering shall be the owner's
representative and will inspect the work as stated above to document the
contractor's activities. Final acceptance of the contractor's work rests with
the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or
omissions of the contractor or any other persons performing work on th~ project
or the failure of the contractor to carry out the work in accordance with these
construction documents. S & S Enginee~ng's inspecting engineer will not be
responsible for the construction means, methods, techniques, sequence,
procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
GR[' "~ER ANCHORAGE AREA BOROUi ~';
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE FROM WELL
LIQUID CAPACITY
GALLONS.
NUMBER OF
MATERIAL ~*~=.~z.~.~: COMPARTMENTS
INSIDE LENGTH INSIDE WIDTH DEPTH__
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS ,,~
LINING MATE~/
NEAREST LOT LINE
OUTSIDE DIAMETER~'~'~'~ OR WIDTH_
DIS~
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA)
, LENGTH ,~"D EPTH
SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL /~)(.~ 2 ·
. FOUNDATION ~'~ . NEAREST LOT LINE /'~
NUMBER OF LINES ~ DISTANCE BETWEEN LIN~S ~? TRENCH WIDTH
ABBORPT,ONAREA BQ. FT. ,ENGTHOFEAC.',N 46
DEPTH: TOP OF TILE TO FINISH GRADE ~ DEPTH OF FILTER MATERIAL BENEATH TILE
TOTAL LENGTH ~-~
, OF LINES
IN. TOTAL EFFECTIVE
IN. ABOVE TILE --
DISTANCE FROM
WELL: TYPE ~-)~r'-'~,"//~:/-~' DEPTH , BUILDING FOUNDATION.
/.~ NEAREST SEPTIC '~.~ ! SEEPAGE
LOT LINE /~ ~=- , SEWER LINE ~ TANK , SYSTEM
WATER
SAMPLE , NEAREST
OTHER
,CESSPOOl ,SOURCES
DISTANCES:
DIAGRAM OF SYSTEM
G.A.A.~.
DATE ~Hi'z~-~/
" GR!~ATER ANCHORAGe ARea BoROuGH
SEWAGE DISPOSAL SYSTEM m APPLICATION AND PERMIT
,NSTA LA,,ONLOCAT'ON ,5
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
SOIL TEST RESULTS
COMPLETION DATE ANTIC]PATED
NOTE: THIS PERMIT I$ NOT VALID WITHOUT SOIL TEST
FINAL INSPECTION: 24 HOUR NOTICE REC)UIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
HEALTH DEPARTMENT AUTHORITY WILL SE SUBJECT TO PROSECUTION.
TYPE
MINIMUM DISTANCES, REQUIREME~.~S(
FOUNDATION TO SEPTIC TANK
FOUNDATION TO SEEPAGE PIT ., DRAIN FIELD
SEPTIC TANK TO seePAGe PiT WALL /~ ~>
SEPTIC TANK ~'.~ * SEEPAGE PIT
TO NEAREST LOT LINE.
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
DRAIN FIELD
· SEEPAGE PIT .
, ALSO CONSIDER AREA WELLS.
· SEEPAGE PiT
SEPTIC TANK, , SEEPAGE PIT , DRAIN FIELD .
TO RIVER, LAKE, STREAM.
CAST IRON INTO AND OUT OF SEPT[C 'rANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRT[(}HT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUgh REGULATIONS REGARDING INSTALLATION.
OR
LICENSED DESIGNER
'I
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHOR AREA BOROUGH OR ANCE NO.
DESCRIBED SYSTEM iS IN ACCORDANCE WITH SAID CODE.
28-68 AND THAT THE ABOVE
327 EAOLE STREET ~-
ANCHORAGE~ ALASKA' 99501
Legal Vescz, i. ption: Lot3'$~Block~
Th~s Form Re~orrs a: So~ls Log
Feet Soil Characteristics Location Sketch
If Yes, At What Depth ~f
Reading
Date Gross Time
Net Time
Depth To H20
Net Drop
Proposed Installat~,on:~eepage Pit Drain Field
Depth' Of Inlet~
COMMENTS: '
d~ ,,; bcd
Data Certified By.
Parcel I.D. #
1, GENERAL INFORMATION
!~ .Complete legal description
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 S NGLE FAMILY DWELLING
Lot 55H; T13N R3W; S~c 35 S.M.
Location [site address or directions)
4920 Ch~k Drive
Anchorage, AK
Property owner
Mailing address
Lending agency
Marq'i¢ McElliott
4920 Chuck Driv~
Day phone ~8-7484
Anchoraq~, AK 99507
Day phone
Day ph0~e
: '. ~': r:~.~ Unless'otherwtse ue wtll be held f~r pt~up:~!::~ ;;~
-. 3. :,. TYPE OF WATER SUPPLY:
............. Individual well
_ ~;~ .............. Community well .
~ ,-- Public water -
..... ...NOTE: If.community well system, provide written~confirmation from State'ADEC attest-
. :;4,~' .TYPE OF WASTEWATER DISPOSAL:
STATEMENT OF INSPECTION BY ENGINEER
As certified bY my sea'l affiXed ....
hereto and as of the Validation date shown below, I verify that my
investigation of this Health'Authority APPrOval apPlication 'shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my inves.ti.,qation 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 s & s ENGINE~IHtd~
17034 Eagle River
Address
Engineer's signature
6. DHHS SIGNATURE '
~ppr°~ed for '~': -~ ' bedroom's.
__ conditional appr°va 'for' ":F" h~, :: :,, bedr~)o:ms, 'with the foll6wing Stipulations:
Additional Comments
By:' f-~-,¢~, fi' ,Y:??'~(--~,
· ~ , '~;¢ ~.~. ~ , - ~ ~,.,
I
The Munm~pah~ o~t~nchorage Bepa~mont of Hoalth and Human 8o~me8 (BHH8) Issues Health Authori~
' .'ApprovalFCe~ific~tes b~s~ only upon the representations given in paragraph 5 above by an independent
'professional ~BgiBeer registered ~n the State of Alaska. The DHHS does this as a cou~esyto purchasom of homes
and tho r ond n~ mst tut OhS n order to ~t s~ ~o~a n f~ra and*tat~ mqu romont~, fimp oyes of DHHS do not
con~Uet inspOet on~ :6r anal~0' ~a ~foro aeo~iflcat~ i~ i~UOd. Th° Munieipaii~ ~f ~nehOra~o ls not
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /--~.¢'H-I; 7-/g/J; ~;~c.~] ~.m.~ /~A Parcel I.D. ,"Joo~o72~~'
A. Well Data
Well type p~v,~'~
Log present (Y/~)
Total depth
Sanitary seal {~N)
If A, B, or C, attach ADEC letter. ADEC water system number /J/,w.
/UO Date completed ~-/~7/ Driller
~ ! ~ ~ Cased to ~/0 ' ~ Casing height
~/~s Wires properly protected (~N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
/
/
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/l~l~li~j tank on lot /Oq
Absorption field on lot
Public sewer main ~..S- '
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform (-,) Nitrate
Date of sample: /o ~ ,,~/--/~ ~'~
Other bacteria
Collected by: ,~ / 5 ~/~/~
B. SEPTIC/I~t~IL~Bt~i~ TANK DATA
Date installed
Cleanouts (~N) y~ Foundation cleanout (~)
High water alarm (Y~) ~J~
Date of pumping
Tank size /~co d.-~-c. Compartments
Depression (Y~
Alarm tested (Y~ ~o
Pumper ,u//~4
SEPARATION DISTANCES FROM SEPTIC/14~L~A~i TANK TO:
Well(s) on lot /0: ~ On adjacent lots
To property line C ' Absorption field
Surface water/drainage /~4; '+
Foundation
Water main/service line
/(:3 ~
72-026 (3~3)° Fro~t CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level ~
Meets MOA electrical codes (Y/~bl~
SEPARA~CE FROM LIFT STATION TO:
Well.~orrl~t On adjacent lots
D, ABSORPTION FIELD DATA
Manufacturer ~
Ma~nho~ccess (Y/N)
~ "Pump off" Level at
Date installed /o -/3 _c) ~/ Soil rating (GPD/FF)
Length ~'/' Width 15'' Gravel thickness
Total absorption area ~/,¢' Cleanout present (~/N) y~
Date of adequacy test ,,'J//~,- zw'w ,~l'~f~ Results(pass/fail) ,,"J//~
Water level in absorption field before test ~J/,~
Peroxide treatment (past 12 months) (Y,~ /do
System type p¢~o~?~'/o,,~
/' Total depth ~,~
Depression over field (Y~)
for /J/~ Bedrooms
After test
If yes, give date /d
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~o '
To building foundation
On adjacent lots /o '-~
Sur[ace water /co ' ~
On adjacent lots /oc~/4- Property line /o '
/?-' To existing or abandoned system on lot N,/,'~
Cutbank ~'o '-~ Water main/service line
Driveway. parking/vehicle storage area /0¢ '
Curtain drain No,~e
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect,
Engineer's Name /(70 -'/'¢ e ~¢¢ ?' ~..
Date ]0 /~"-(o /¢-t ~-/'
CE - 880]
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93)° Back
Waiver Fee $
Date of Payment
Receipt Number
107~B~ - ~1:5~ CT~E ENbIRONHENT~L L~B SERVICES
~t~ O om m ere,., Te.fing & Engineering 0o.
E~vk~ental Laboratory ~ervi~es
c~ ~f.~ ~ . -~ ~BORATORYANALYSIS REPORT
,ga~ple Remark~ kbove aA--,NOI~ ~llalyzed
5633 B Street, Anchurage, AK 95618-1600 --Tell (907) 562-2343 Fax: (907) 6G1-5501 .._
ENVIRONMENTAL FACILITIES IN ALASKA. COLORADO, FLORIDA. ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH. W£$T VIRGINIA
REQUEST FOR APPROVAL OF
INDIVIDUAl, SEWER & WATER FACILITIES
FOR
Aoproval Requested By: ~
Address:
Phone: ~'
,Phone:
Number of Bedrooms: ~-'
6. ~ell Data:
A. Type
~. ' Construction ·
7. Sewage Dls.6osal System:
A. Installed
B. Depth
D. Bacterial Analysis
,- B. Installer
C. --Septic Tank: 1, Size '2. Manufacturer
D. Seepage Pit: 1. Size 2. Materiel
E. Disposal Field: Total· Length of Lines
Distances:
Aa Well To:
Septic Tank ~&' , Absorption Area
, Nearest Lot Line /~'7~o~, Other Con'tamination
Foundation to Septic Tank //~ "
~ Ab'§orption Area
Absorption Area to Nearest Lot Line /O
..., Sewer Lines
'~eque~t for Approval of ~\ividua~ Sewer & ~at.e~ ~aciiiti~
Page Two
A Dot ore
·
Disapproved Date
Valid for One Year Prom Date Signed
Greater Anchorage Area Borough, De,cartment of Environmental Quality
DIAGRA~ OF SYSTE. M
I certify that the information contained in this request for approval to be a true
and accurate representation of the sub.iect sewer and water facilities located st:
.. Signed Date