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Home My WebLink AboutT13N R3W SEC 13 LT 106 W120' GR~ :ER ANCHORAGE AREA BOROUgh'{ DEPARTMENT 0F ENVIRONMENTAL 0. UALI'I, 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME LOCAT~O~ SEPTIC TANK: ~3 MAILING ~ ~:::2/' .~--_.~.~,.~'~--' ~ ~ PHONE ADDRESS LEO L DISTANCE FROM WELL ~-~/~'~-,,~ LIQUID CAPACITY / ~ ~'~>' .GALLONS. NUMBER OF ~ MAT E R i A L ~f~ .~..~p'~' ~,~'~ -~r~"'~-~'~.~=~.,~--~ C OM p A R TM E NT S ~/p 7/~.~.-~.~/-,,~/~.,r ~/~ ~z,,,,~,/p,,,,~:'~-.,~-~_~..~:~ LIQUID INSIDE LENGTH ~ INSIDE WIDTH ~ DEPTH-- SEEPAGE SYSTEM: NUMBER OF PITS __ / OUTSIDE DIAMETER ~ OR WIDTH LINING MATERIAl ('~/P/~/~'d-~ ~/-'4~r~ . DISTANCE FROM WELl ~--~'/.~ NEAREST LOT LINE_ '~'~"~ / TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA} SEEPAGE PIT: '~'?~?/~'~'~'~'"-~ , LENGTH. , BUILDING FOUNDATION SQl FT. ~ TILE DRAIN FIELD: /(///~' TOTAL LENGTH DEPTH: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE iN. ABOVE TILE ~ ~/' -,~'~ DISTANCE FROM WATER WELL: TYPE ~"~",~-~--~ DEPTH ~ , BU LDING FOUNDATION._._ ~ SAMPLE ~ NEAREST NEAREST ~.~EPTIC ~-~-----~ SEEPAGE OTHER LOT LINE '~ , SEWER LINE , TANK , SYSTEM__ ~ , CESSPOOL ~ , SOURCES (" . DISTANCES: DIAGRAM OF SYSTEM G.A.A.B, GREAt'ER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALITY 3~00 TUDOR ROAD POUCH 6-650 ANCHORAGE. ALASKA 99502 TELEPHONE 2:79-8686 SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT INSTALLATION OF: SEPTIC TANK ~ SEEPAGE PIT ~ , DRAIN ~[ELD OTHER / COMPLETION DATg ANTICIPATED FINAL iNSPECTION= 24~HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL I~NSPECTION BY THE HEALTH DEPARTMENT AUTHORITY WILL SE SUBJECT TO PROSECUTION~ MINIMUM DISTANCES, REQUIREMIrNTS FOUNDATION TO SEPTIC TANK SEPTIC TANK TO SEEPAGE PIT WALL * DRAIN FIELD SEPTIC TANK ~--' SEEPAGE PIT ¢~D ~/ · , DRAIN FIELD . TO NEAREST LOT LINE. WELL TO SEPTIC TANK (*' f?/L- LZ - SEEPAGE PIT ALSO CONSIDER AREA WELLS. DIAGRAM OF SYSTEM DRAIN FIELD TO RIVER, LAKE, STREAM. CA~T~LRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF 4 INCh DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT FITTED WITH AIRTIGHT REMOVABLE GRAVEL BACKFILL CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION. HEALTH I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO, 2S-68 AND THAT THE ABOVE DESCRIBED~/~/~/-~SYSTEM IS IN ACCORDANCE WITH SAID CODE. ~r~/~/~Y~ ~~ DATE / ~ APPLICANT'S SIGNATURE . ,, 2. 3. 5, INDIVIDUAL SEWAGE AND WATER FACILITIES P P Y ~ ~/-'~..~- ~ Numb~ of bedrooms in house ~--~ ~. h. Detergent .... ~. II ~;~ c. Cas~n~ Szze . / ~.___.houses, ba.n, Sewage dzsposal system. a. Age of system , . / c. Name of septic ~k manufac%u~gm 1. If "home made" show diagram on meverse side of this form. d.' Disposal field or seepage pit size and type 1, Distance to property line to house foundation ,,__. f. Percolation Test performed by · Use the reverse side of this form to show diagram. Diagram should include ~he fol].owing information: p~operty llnes~.well location, house location~ ~pt~c tank locatlon~ disposal area location~ location of percolation test~ a~ direction of ground slope. The ~]for,~tion on %his form is true and correct to th~ best of my knowledge. S~gnature of Applicant Date Sign'ed T_O BE FILLED OUT BY HEALTtt DEPART~.JENT PERSONNEL ~above described sanitary acllmt~es are hereby approved~ subject to the fqllow~ng con~ffons: Conditions: /~ ~r)4_~._. The above described sanitary facilities are disapproved for the following reasons: ''Signat%~ of ~?~fic?fRT~ ¥"~: ~. r ~. 'Date ~",' Approval is valid fop one year following the date of approval. CPJ: cw MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES.· Division of Enwronmenta Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.Q. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE O F HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Location (site adi:iress or directions) ,,, Property owner Mailing address Lending agency' address ' '' - Agent' -~- --. Address Day phone Day phone Day phone ...... Individual well ' ' '? ' _=i:.i:-::': "' ' :'-~' Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legahty and status of system ..... ,¢ , ~, '~ I,)t,I b. .' .~. > ,.¢.',.'~', ,,,, "/./.~ -, . ... . _ . . ?.,~,;.',,~' ,. ~.~ . 4 TYPE OF WASTEWATER DISPOSAL: _ ? ~X,,, -I ", ':"k .. . v' "; .t · · Holding tank ; -,, ~ ~/ - , . Commumtyon s~te · · ~. . ~ ..~,, -~. ., ~ ........ ... ..... :,.,'/.~,'~ .... , ~, .. - ' - "':'-: -'- Pub csewer . ~'~'t,' ,-.' NOTE: If community Wastewater system, provide written confirmation from State AD attesting to the legality and status of system. ...... :' --'~ UMe~s'otherwise requested, HAA will be held for pic ~p. > ' ;:/:~: _.. - :' - ...... ~- ...... ' ........... "~ ' ........ ~ -- -'" 2r~ ' NUMBER OF BEDROOMS: ...... ~ '~ --.- · , r'T1 .= ~ ~ -. = 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 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. NameofFirm :l~)e/o~ (~u~<._[.~ "'1~~~___ Phone Address ~2..0 ~ ~ /5-~-~/ /~ ~7.0 3 Engineer's s,gnature ' ~ ~ ~ Date t DHHS SIGNATURE Approved for -~' bedrooms.' ' Disaeoroved. ' ....................... : .... ' ~ ~ Conditional approval for . bedrooms, with the following stipulations: ] · "". i -- ' , '"" ~:'~' ":';; ~;' " Additional Comments Date ',,The M(J'nici~ality of,A~"dhorage Department of Health and Human Services (DHHS) esues Hea th Author ty 'Approval C~rt~flcat~besed only upon the representat OhS g~ven m paragraph 5 above by an independent p ofess~onal engineer registered ~n the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and theft lending ~nst~tubons in order to satisfy certain federal and state requirements, Em ployees of DHHS do not conduct respect OhS or analyze-data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the p~'ofessional engineer's work.. .,: ,::, Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: ~-~/~. TI31',J,, ~-3~,,, ~/P,.,r)I ParcelI.D. A. Well Data ~ ~, t) ~ L (L r ~)/3, L~ Well type If A, B. or C, attach ADEC letter. ADEC water system number. Log present (Y/N) Date Completed Driller Cased to Casing height FROM WELL LOG Total depth Sanitary seal (Y/N) Date of test Static water level Well flow Pump level1 Wires properly protected (Y/N) .g.p.m. AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed I qTI Cleanouts (Y/N) y High water alarm (Y/N) Date of pumping Tank size I ~ Compadments ~ Foundation cleanout (Y/N) ~/ Depression (Y/N) ~'~//,~3r Alarm tested (Y/N) I'h///~ ~/~/, ~' Pumper ~ ,,5 G.A. ~/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /"//~ To property line ~ ~ Surface water/drainage On adjacent lots ,/5/,,/~ Foundation Absorption field J ~ Water main/service line CONTINUED ON BACK PAGE 72-026 (3/93)* Front .;; : ' ' ~ C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at .Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Sudace water D. ABSORPTION FIELD DATA Date installed Length t C) Width Total absorption area ~- L/'C~ Dateof adequaoyte. Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) ~ ~ Gravel thickness ~, Cleanout present (Y/N) y Results (pass/fail) ~'~ I tt System type ~,,,/c,¢/-~ Total depth Depression over field (Y/N) for ~ Bedrooms Aftertest ~ '7 If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~'f~//'~- On adjacent lots ~"//'~ Properly line To building foundation ?>~) To existing or abandoned system on lot On adjacent lots Sudace water Curtain drain Cutbank ~[,e ~ ¢.L Water main/service line Driveway, parking/vehicle storage area ~ / 0 E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines, ioeffeo, t, on th~date oflhtsjnspection. Engineer's Name Date HAA Fee $ Date of Payment ., Receipt Number/,,/~:0 Waiver Fee $ Date of Payment Receipt Number 72-028 (3~93)' Back