HomeMy WebLinkAboutT15N R1W SEC 19 LT 2915N RlW
SEC 19
Lot 29
#051-241-19
MUNICIPALITY OF ANCHORAGE 0~"-//- ')////--//9
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Heallh Division
825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
Address ' ' ~ TANK FIELD WELL
AS-BUiLT DIAGRAM (Show location of well, septic system, property li~es, [ound~tion,
TYPE OF SYSTEM
~ TRENCH U BED Q W. DRAIN Q OTHER ~ ~)
Depth to pipe bot[om from [ Total depth from obginal grade [
original grade ~ FT ~ ~ FT '
~' 8~ FT FT
Number of fines 8o~1 raeng Pipe material
~ PRIVATE ~ OTHER fldentifv)
Cla~ificanon (A,B,C) Total Depth FT Cased to ~J
Inspections Pedormed by:
72-013 (3/85)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
DATE PERFORMED:
LEGAL D ESCR I PTION:'~,,/~
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18-
19-
20-
Township, Range, Section: 'l'l~'h.J {2.,tt~J, .%~.~ct.
SLOPE -~i~ PLAN ' -
WAS GROUND WATER
ENCOUNTERED?
s
IF YES, AT WHAT
DEPTH? p
E
Depth to Water Altert
Monitoring? C1¢'~ Date: ~
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER __
TEST RUNBETWEEN ~.J~AND FT
COMMENTS ~ "'~ ~ O I~/k'~'~'~'~'~'~'~'~'~ .
/ ./
PERFORMED BY. . ..... "77 ~/~ ~ ~ CERTIFY THAT THIS~EST W~S PERFORMED IN
Municipality of Anchorage '
Development Services Department
Building Safety Division x
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. HAA # _ D LZ
s ; ' Expiration Date: 1 a —.2 .2- O
1.GE,NRA6NFORMkTI9N
C �mpletetagal descriptioi %/SA/ 41W SECT/dnt 11 GdT �9
Location (site addressor directions) /9W
Current Property owner(s) "412 O /0
Day phone
Mailing address e'
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On-site
9
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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 Health Authority 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.
NameofFirm A/Ogr#9/wt E.t1W154ieIAIG
Address /7.237 ff,�W P,,f&j Uea,
Engineer's Printed Name STE KE J*I'
5. DSD SIGNATURE
t/ Approved for bedrooms.
Disapproved.
Phone 6%-;70,,2d
Date
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By. ��� l� Original Certificate Date:
(Rev. 01/02)
D
Dev
OA1 17
If A B or C provide
rage 4Ar
'i9''81,650...,
eXvau§ u n.e Yy2�'yn e.F,: �LLA F"1
...
L CHECKLIST'"" `
�77--7_.,w 9 ......
=u C $andary seal (Y/N) Wires properly -protected (Y/N)
Cased to 4 ft height (above ground)
✓
/04 in
.Casing
i' s:"1'La„"So „ a[ `sb�,..?r§.-4v 'fir* x -a �+" us i_., -.oa' it.„�
p,
,1-
V7AT INSPIECTI[O
`y..n rtd _``„A ?'` asaKM, x n':r'+.� �s u k: .„4x, s:
>r`a;a h� `
VIVO
ft 37 S Ta c,
tion
9 p
colonies/100 ml
�Ns.-� itr^a{�teern—! —m . ..._ Oth.,e-. r bact_e..r. ra_
. colo _n.,ies./,1
'Mg./I.
Date of sample- �Col(ecfed by rff
eR�k"ti`Sl�rv.}.
a anal /�tICHaRa6E 7, / eEL Dafe Installed
>s
.,�
�a4 Number of Compartments a? Cleanouts (Y/N) V
e* R Depression over tank (YIN) A/ High water alarm (YIN) /V/4
Pumper �S.4f_ A(trA�ey Aus�P r
�2 rating (g or ft2/bdrm) System type ILff
eft, Width .S�' ft Gravel below pipe _ ft.
Width
ft. e..aVe ba ..”
ft Eff absorption area C;CO ftz
_Mo itoring tubeDepression over field A/,
� .oma; a"
acy test —
Results (Pasg)FaiQ .SJ For bedrooms
�"�r`s`�.'�,w..4.g R�' `bks-$''%y+i'—.,.tt�%'a*�*"t
absorptiori 5eltl be ore test � m Water added l04O gal New depth in.
7, u• v�v x<a'r x` ...:cek..ek sasix. ,'ww!zvv^ne d, mas'+.3" 'Rim .. p
l min Final
on tre.,,atment �? as..t.12rx.m,_ofluiidl %dReptiy__5_ inAbsorption ra"t"e
U w606
f"g" p""d.
".,.
If yes, aive date
Manhole/A (bass Y/N
Size m gallon§ _ � �
_. v
el' in. "Pump off' le I at _ in. High w er alarm level at n.
Cycles t ed Me s alarm & circuit requirement !
IDQ f On adjacent lots /U()
Qa " On adjacent lots' /OU`+
w z
/gra Public seWer manhole/cleanout
2 S r7` Holding tank
FRONTSEPTIC/HOLDING TANK�ON`L`OT TO:
f Property line Absorption field/00
Water service line So Surface water
+ Building foundation . Sy r Water main
O r� Surface water 10 r� Driveway, parking/vehicle storage
Wells on adjacent lots QO
nicioal records that the above systems are in
stevan W E
aE 8256
vaw vi
Y.
y((� �ReceiptNumber