HomeMy WebLinkAboutT15N R2W SEC 25 LT 48
437 "E" STREET, SUITE 303
ANCHORAGE~ ALASKA 99501
STEVE COWPER, GOVERNOR
274-2533
June 22, 1987
Hr. Lou Butera, PE
Eagle River Engineering
Services, Inc.
PO Box 773294
Eagle River, Alaska 99577
SUBJECT: Lot 48, T15N, R2W, SECTION 25, Eagle River
8721-FA-131
Dear Hr. Butera:
The Oepartmedt has reviewed the Engineer As-built plans for the
subject project, Final approval is hereby given for the water
system. Any future expansion of the subject project will
require additional approval from this office,
Sincerely,
SWE:pkk
ENCLOSURE
· '~ STATE OF ALASKA , ,
DEPARiMENT OF ENVIRONMENTAL CONSERVATION
APPROVAL OF ON-SITE RESIDENTIAL WATER AND SEWER SYSTEMS
PROPERTY DESCRIPTION
Lot, BlOCk & Subdivision or U,S, Su~ey
This approval does not constitute a guarantee of any kind, explicit or implied, as to the performance
of the water supply and wastewater disposal systems.
A recent water sample wa~ tested and found to meet Department of Environmental Conservation drink-
lng water standards for total coliform bacteria.
WASTEWATER DISPOSAL
water s stem was
The do~e~ waste y :
[] Inspected"t:~.~he Department of Environmental Conservation and found to be in compliance with
applicable re~'ui~nts of 18 AAC 72; -
[] inspected by _a Pro_f_e~al Engineer who certifies that the system complies with applicable re-
qui'rements.'of 18 AAC 72~..~
[] ln~ Installer who"s~ifies that the system complies with applicable requirements
of 18 AAC 72;or
[] tenet who cer~if!es'th~ the performance of the system Is satisfactory
a~he rninimum s'~.~on distances specified In 18 AAC 72.
This approval is valid for a' [] single family [] multi-family u~ total of bedrooms.
Name TIIle ~ Date
18-0404 (Rey. 8/85) DISTRIBUTION: WHITE--BANK/LENDING INSTITUTION; CANARY--APPLICAN~ PINK--DEPARTMENT
DOG CO. r~Oa
P.O. BOX 670272, CHUGIAK, ALASKA g§se,7 * TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION / ~ 01~ -~'~.'¢.
DATE - Started y ~'/6~7 Ended
PERMIT NUMBER
DEl'TH OF WELL [ 0 0
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
KIND OF FORMATION:
From
From ~ Ft, to
From ~ Ft. to
Fmm.~.Ft. to Ft
.~ro~
From Ft. to__Ft.
From $0 Ft. to /O~ Ft.~~,
From Ft. to Ft,
From Ft. to Ft.
F~m Ft. to , Ft.
From ,Ft. to Ft.
From Ft. to Ft.
Fmm.~ Ft. to~ Ft.
From Ft. to~ Ft.
From Ft. to Ft.
F~m Ft. to Ft,
MI~CL. INFOIAMATION:
From __Ft. to Fr.
From Ft. to Fl,
From~Ft. to Ft.
From__Ft. to Ft~
From FI. to Ft
From Ft. to Ft.
From FI. to Ft.
From__F~. to Ft..
Fromm. FL to Ft.
From Ft. to ' .Ft.
From Ft. to Ft._
From Ft. to ,Ft,
From Ft. to Ft,
From Ft. to__Ft
From ,Ft. to Ft.
From__Ft. to Ft.
From~ Ft. to ,Ft
37 7'0 ~o
DRILLER'S NAME
~ June;: 4, . .!987': ' .
ENGLNV. V. RING ERVICES
P.O. l~ox 773."fl4
Eagle Rivet, Alaska
Telephone (!to'7) $94-519g
· . ..... Depar tment' '-o f -Environmental Conservation '.. ........ .~ ' ....
' :' REFF:'Lot 48, T15N, R2W, Section 25
5-F:'U ~:~7::~:~Eikl% RiVer, Alaska
~:'.:.f'::On -'behalf of. ~ur client, Howard Relocation Services :we are
..... applylng;~..for,.a. ~Class C Certlflcate to construe and operate for an
?. ~'existfngTwellYlocated on the above referenced lot. "'.
The well is located as shown on the attached plot plan. There
are no waivers requested, as proper setback dj'stances are observed.
~ The..well:~.' produces a sustained 20 minute flow of 10 GPM with a storage
capacity in the well and pressure tank of 107'~allons. At the present
time, this is more than adequate to meet ID and daily requirements for
.a .3 ..bedroom capacity that is the expected demand volume. Water
"sampI-es -have 'been taken for coliform bacteria and nitrate content with '
the results attached.
I'f .there-.ii are any questions
me 'at~::694~5196.-qr ~-".
-::_ Since~.elT;..:'-.:::-:--'%. -:,.
· . LB. bls..:..;, .,_-.,: .......... .
please feel
free to call
P. O. Box 773294
:: .' *. EAGLE RIVER. ALASKA 99577 CALCUL~ED DY ~" ~'~-z¢"~--'~
Phone 694-5195
.' ~, CHECKED DY.
DATE
150' R, ND
CDNTAMINATIFIN
.... SEPTIC
· -, LEACH
PIT
HSE
I
50'
ESMT,
108,900
S,F.
.11
50'
ESMT,
-388'-
EXISTING L~'Ar-J';
NE%/ LEACJ'I FI,F. LO
CLEANDUT
SCALD 1'"
~/ELL AND SEPTIC SITE PLAN
LEGAL~ LOT 48, T15N, PAV/,SEC,B5
/NER, HB~CARD RELOCATION SERVICE
CONTRACTOR, N/A
EAGLE RIVER ENGINEERING SERVICES
PO BX 773894
EAGLE RIVER, AK, 99577
694-5195
MUNICIPALI'TY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
/~ SOILS LOG
[] PERCOLAT(ON
TEST
PERFORMED FOR: /Z//~-~ ~,~/Oc~,~'~. -~-W.~'~/- /~Y~'~-';~'~( DATE PERFORMED:
LEGAL DESCRIPTION: ,~o~-~' ~'f~--~ ,/~/4~/ ..~-~_~ ..~-~'~
3
4'
5
6
7
8
9
10
11
12
13-
14,'
15-
16-
17-
18-
19.-
20-
COMMENTS
SLOPE SITE PLAN
~ '/¢~/-WAS G ROU N D WAT E R ./2//0 S
ENCOUNTERED? ~
E
IF YES, AT WHAT ~ ~,~
DEPTH~
Gross Net Depth to Net
Meading Date Time Time Water Drop
PERCOLATION RATE ~ ~ (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED BY:
72-008 (6/79)
Eagle River Engineering Services
Eagle River, AK 09577
694-5195
CERTIFIED BY: Y~
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.# {'~..~ - ~\-~-i-'~
1. GENERAL INFORMATION
Complete legal description
Location (site address or d!~rections)
Property owner
Mailing address
Lending agency
Day phone
Mailing address
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA ~21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that I~y
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!i_gation 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
Address
Engineer's signature
David R. Dayton P.E.
2UvlU uonalar
~.~Chugiak, Alas,~a 99567
Phone
DHHS SIGNATURE
X Approved for -~
Disapproved.
Conditional approval for
bedrooms,
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in pa.ragraph 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 engineer's work.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A, Well Data
Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) 7 Date completed <~,/~J~'? Driller
Total depth ~ e-C.3 ' Cased to~ ~-,P ' - .5-" Casing height
Sanitary seal (Y/N) ~ Wires properly protected (Y/N)
~'~,~.,~. 5'7 ~/ ~ f FROM WELL LOG AT INSPECTION
Date of test ~,,/~//~ ? ~,/
Static water level ,~$ ~ ~ ;~, ~
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /~
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Coliform ~ Nitrate ~-' ~ ~ Other bacteria
Date of sample: ~-~ ~- ~ ~ '~ Collected by: ~ ~
m i
S. SEPTIC/HOLDING TANK DATA
Date installed /'~, ~
Cleanouts (Y/N) )/
High water alarm (Y/N)
Tank size /Z-$'--~ Compartments /
Foundation cleanout (Y/N) ~ Depression (Y/N) /t/
/'-////~' Alarm te~ted (Y/N) '~.~)-
Date of pumping ~/~/~ ;:' :;
Pumper ~-'~'/~'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
On adjacent lots /.~'-~ '/~- Foundation
Absorption field /'~ Water main/service line
Surface water/drainage /~o -/-
72-026 (3/93)* Front 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/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N).
"Pump off" Level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length E~~ /Z.'
Total absorption area
Date of adequacy test
~ G5~'- Soil rating (GPD/Ft2) ~"~ ~;¢.~/~ System type ,-~-~--~/~"¢~' /¢2/-r-
Width ~'~/- /~' Gravel thickness ~ Total depth /~ ~
~¢ ¢~ 5~ Cleanout present (Y/N) y Depression over field (Y/N) ~
~/~/~ ~ Results (pass/fail) P~ for ¢- Bedrooms
After test /. ~ ~
If yes, give date
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots I ~ ~- Property line
~ To existing or abandoned system on lot
Cutbank /--?'/)- Water main/service line
Driveway, parking/vehicle storage area /'~ ~
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the o ~te of this inspection.
Signature
Engineer's Name
Date
David R. Dayton P.E,
20210 Dona]ar St.
Dovid R. D(~yton
NO. 2205-E
HAA Fee $ /70 ¢D~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Tom Fink,
Mayor
N unicipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O, Sox' 196650 Anchorage, Alaska 99519-6650
July 28, 1993
David R. Dayton, P.E.
20210 Donlar
Chugiak, Alaska 99567
Re: BLM Lot 48, Section 25, T15N, R2W
waiver of Water Well Standards AMC
15.65.060
Dear Mr. Dayton:
This office has reviewed your waiver request to allow an
existing well serving the subject property to be perforated at
depth less than 40 Ft. The waiver has been approved based on
the
following:
1. Water samples taken from the subject well have tested
negative for bacteria and 2.39 mg/1 nitrate nitrogen.
2. According to the well log the casing is perforated at a
water bearing formation between 37 Ft. to 40 Ft. Bedrock is
encountered at 40 Ft. The static water level is at 23 Ft.
indicating some aquifer confinement and protection.
3. AMC 15.55.060(B) allows this office to waive the minimum 40
Ft. depth requirement.
All future Health Authority Approvals issued by this office will
advise that the depth of the subject well is less than the
required 40'Ft. and that the well should be tested annually for
coliform bacteria and nitrate nitrogen· If at any time water
produced from this well fails to meet primary drinking water
standards, abandonment of the well will be required. This
waiver applies only to the exlstl g well.
Sincerely, ~ /
~r~r~m Manager, On-sit Services
D..R. DAYTON, P.E., R.L.S.
]~xz~~]~ Chugiak, Alaska 99567
20210 D0nalar
(907) ~
696-24%7
June 30, 1993
Mr. John Smith
Municipality of Anchorage
Dept. of Health and Human Services
On-Site Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
REF: BLM Lot 48, Sec. 25. T15N, R2W.
Dear Mr. Smith,
On behalf of our'client, Mr. Kenneth Barber, we are requesting
that the Class "C" Well on the subject property be changed to a
Private Well Status.
The well was approved by DEC (Certificate #8721-FA-131) in
June of 1987. Sometime since this date a septic system has been built
on Lot 49. This system has encroached into the 150' radius by 30'.
The separation distance from the new absorption system is 120'.
The well meets all criteria for a Private well with the
exception of being perforated from 37' to 40',
The well is 100' deep with a silty layer from 24' to 34', The
casing is seated 5" into the bedrock.
Water tests show results of: Coliform 0
Other Bacteria 0
Nitrate 2.39 mg/1
The l~ts in the area are primarily 2% acre lots with single
family residences. Many lots are at present undeveloped.
Please review the above and if possible issue a variance from
the Municipal Depth to Perforation Standards along with the attached
Health Authority Approval.
Attached are the well log, State of Alaska Approval Documents
and septic system documentation by Eagle River Engineering Services.
If there are any questions, please contact me.
David R. Dayton.
D,. R. DAYTON, P.E., R.LS.
~;~x~~ Chugiak, Alaska 995~7
20210 Donalar
(907)
June 30, 1993
ADEQUACY TEST
Legal Description: BLM Lot 48, Section 25, T15N, R2W, S.M., Alaska
Date of Test: June 29, 1993
Septic Tank: 1250 gallon, 1 compartment, steel tank
Absorption System: 12' x 12' x 6' seepage pit
Soils Rating: 85 sq. ft. per bedroom
Requirements: 3 bedroom - 450 gallons per day
Test:
Water was pumped into the seepage pit at a measured rate,
while monitoring the rise in the liquid level in the pit. After
water pumping was stopped, the level was monitored to determine
the seepage rate.
Results:
The seepage pit accepted 470 gallons of water in 90 minutes
with the level rising 0.35 ft. above the original level of 1.60 ft.
After the pumping was complete, the water level returned to the
original level in 16 minutes.
The seepage pit is currently functioning adequately for a 3 bedroom home.
D..R. DAYTON, P.E., R.L.S .
~xX~J~~ Chugiak, Alaska 99567
20210 Donalar
696-2417
June 30, 1993
WELL FLOW TEST
Legal Description: BLM Lot 48, Section 25, T15N, R2W, S.M., Alaska
Date of Test: June 29, 1993
Well Depth: 100', perforated 37' to 40'
Static Water Level: 23.2'
Requirements: 3 BR - 450 gallons per day
Test:
The well was tested with the existing pump through an outside
hose bib. The valves were fully opened for the last 60 minutes
of the test.
Results:
470 gallons were pumped in 90 minutes. 378 gallons were pumped
in the last 60 minutes at a rate of 6.3 galloms per minute.
There was no measurable drawdown in the well during the test.
The well is capable of producing more than the output of
the pump.
The well is currently producing adequately for a 3 bedroom home.
* OMMERCIALTESTING & ENGINEERING CO.
Chemlab Ref. ~ : 93. 2993-1
Client Sample ID =BLM LOT 48
~.~at rix : WA'I~J~
SEC 25
RF~°ORT of ANALYSIS
T15N RiW
5633 B STREET
ANCHORAGE. AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
Client Name :DAVID DAYTON, P.E. WORK Order :67565
Ordered By : Report Completed :06/29/93
Project Name : Collected :06/23/93 @ 21:00 hrs.
Projects : Received :06/24/93 @ 12:00 hrs.
PWSID :UA Technical Director:STEPHE~ C. EDE
Released By
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: D.R.D.
QC Allowable Ext. Anal
Parameter ResulttJ~lal Units Method Limits Date Date Init
Nitrate--N 2. m.q/L El h 353.2/300.0 10 06/.~5 r. LH
w See Special Instructions Above UA = Unavailable
~'~ See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit, LT = Less Than
D = Secondary dilution. GT = Greater Than
Member of the SGS Group (Soci6t6 G6n6rale de Surveilrance}
ENVIRONMENTAL SERVICES IN ALASKA. COLORADO. UTAH. ILLINOIS, OHIO MARYLAND. WEST VIRGINIA NEW JERSEY SOUTH CAROLINA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a)
(b)
(c)
(d)
(e)
(f)
Legal Description (include lot, block, subdivision, section, township, range)
DOT ~8, ~15N; ~2W~ Section 25
Location (address or directions)
1¢;¢)3(~ ¢,f,TN-R, DRTV~,
Applicant Name ~hT~'H' RARRRR Telephone: Home n/a Business
Applicant Address C/O PTRS~ NA~TONAf, P.O. ~X ??ORb8: F~GLE ~R: ~ 99~77
Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
~Q~AP.~ PRQ~ A~ AD~RE~ AR~ I,~TN~ TN~T~TON~
Lending Institution FIRSm NA~T~NAT, O~ AN~ Telephone 694-2103
Address p Q_ ~Y yT~bR, ~A~T,R RT~R, AK 99577
Real Estate Company and Agent ~TT.T. ~R~IIg~N, R~K ~,~ RRAI,~
Address 121 ~ST ~A~'H'~ T.A~, ATIT~ QOR, ANRR~RA~R, AI,AAKA 99577
Teleohone 276-0000
Mai the HAA to the following address:
~R PT~ ~Y ~A~T,~ R~R ~T~RTN~
694-210q fLITA)
TYPE OF RESIDENCE
Single-Family ~ Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well ~ Community [] Public []
Note: If comm unity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4 SEWAGE DISPOSAL
Onsite ~ Public [] Community [] Holding Tank []
Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
,5.
ENGINEERING FIRM PROVIDIN· .o SPECTIONS, TESTS, FILE SEARCH, DA AND INFORMATION
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 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 ali Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm E~,~L~.. I~TVI~,R ~N'P, TN~F;I~,RTNP, S~RV]-CES Telephone 694-5~.
Address P_O_ P~¥ 773294~ ~AP.T,F, RTe.,R: AK 99577
,..,,:, i
DHEP APPROVAL
Approved "'~"~" Disapproved
Yerms of Conditional Approval
Conditional
CAUTION
The Muncipality of ,~nchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 engineer's work.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCH(2RAG:~
ENVIRONMENTAL SERVICE$ DIVISION
WE, E EIVED
Well Glassification ~/~z
MUNICIPALITY OF ANCHORAGE (MO,-v
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~
IfA, B, C, D.E.C. Approved (Y/N) Y ~,~' ~,zT,,~.t¢~'..)
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
Date Complete61 Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Size/.~ ~*'-o ? ¢ /
Date Installed
Standpipes (Y/N) /Y' Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /STp /
To Property Line /~'--*<~ /
/
To Water Main/Service Line
Course ..~/~z~ '
No. of Compartments ;~
,Y Foundation Cleanout (Y/N)
Date Last Pumped ~,,/~ 7
; for '"~/~
Temporary Holding Tank Permit (Y/N) .'~.~
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /? :--~-
Width of Field ~z~-, /~ ~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /~.¢-,..s- /
To Building Foundation ~/'
Lot
To Water Main/Service Line /¢/0
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field z~.r+
Depth of Field "/¢ /
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /'~
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) ~.~
//d ~ /
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed '~'~"~¢'"¢~-~ Date ~'.../,~ .~.~¢- ;2
Company ,./'~/¢,/~,5'. MOA No. ~-~
Receipt No. )f)OI OO~4
Date of Payment G /3dj t~
Amount: $ L (%0 ~ ;eal
Page 2 of 2
72 026 (ll/84)
A. 'WELL DATA
Well Classificatior~ ~'/~ ~'/ '~"
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
If A, B, C, D.E.C. Approved (Y/N)
· :~. Well Log Presem (Y/N) Date Completed ' Yield
::' . ~'_,_To~al· D~{~i;F': :~z2 :~?" ~:~cased tO]' : ~ :'"Depth bi Grouting .....
;'~; :.: :;~;;;~Statlc:.Wate[ LeaF- .... ' ...... : Pump SetAt
....... .
: 7:; Ele~tri~t Wiri~ ~ c'0hd'~it (Y/~) . Depression Ar0uqd Wellhea~.(~/
: - Separation'Distan~s from Well: . ~: :;:. :~: ; . : ~ , ~:. ~; ;: ~ :
. :.To. SeptiS{Holding ~nk on Lot ; On Adjoining Lots
- ' To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
. Cleanout/Manhole
· · .*.,Water Sample Collected by
-:, -. Water Sample Test Results
: Comments .
On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date 'lnst~iled /~dS- Size/..-2. Z"o ¢, ~ /
_ No. of Compartments ~
Standpipes (Y/N) ,/v' Air-tight Caps (Y/N) -~' Foundation Cleanout (Y/N) /~
/
'-Depression over Tank (Y/N) /~ Date Last Pumped -~,,/~' ·
!:L:i Pumping/Malntenance Contract on File (Y/N) /~,/~ ; for
;.:Holding:Tank High-Water-Alarm (Y/N) '/~//'~ Temporary Holding Tank Permit (Y/N) ."~'/~
' Separati0n~ Distances from Septic/Holding Tank: ': : '
;; :~;-T0: ~a~r:. ~ain/se~i&e ~in~; · ~/¢ :T~.Stream, Pond. Lake, or Major Drainage
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ' ,,~S--
Date Installed
Width of Field ¢~-~-' /,¢-'
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /.~--.~-
To Building Foundation ,~ /
Lot
To Water Main/Service Line /¢/o /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type ol System Design
Length of Field z:-~'f~
Depth of Field .,D
Gravel Bed Thickness o
StandpJipes Present (Y/N)
Date of Last Adequacy Test ~'--/~,./,~ 7
To Property Line /'~'
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) "~'/~
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Oft" Level at
Vent (Y/N}
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, veritied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
'Signed "~~ Date ~',../~ ~,r/P 2
MOA No. .5'~-~,=.2. 60-
Company
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
~ /~ I~ ~ REQUEST FO~ APPROVAL OF
~/ ]~ INDIVIDUA~ SEWAGE AND WATER FACILITIES
~/ [~ ~ (Fzll out in Triplicate)
Name .of person requesting approval
Nu~-'o~ ~edrooms in house
5. Wate~ Analysis:
a. Bactemial
b · Detergent
Well data:
a. Type ,
b, Depth,
c. Casing Size
Distance from well to closest existing or prooosed:
1. Sewer line
2. Septic tank,, .
!
3. Seepage Area~ ~..(~) (>
4, Cesspool'~
5. Property Line
Other sources of possible contamination, i.e., creeks, lakes,
houses, barn~ dralnaEe ditch~ etc. ·
Sewage disposal System.
a. Age of system ~/y~Z6~,~.
b. Septic tank capacity in gallons ,/~)0 ~-~,
c. Name of septic tank manufacturer
1. If "home made" show diagram on reverse ~ide of this form.
Disposal field or seepage, pit size and type, ~''. ~ ~ ~ (;~ ~ ! '
l0 ~stanoe to p~o~ept7 ~e to, ~oase ~o~datio~,_
~HA Form 2573-
]U. S, DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT
FEDERAL HOUSING ADMINISTRATION
HEALTH AUTHORITY APPROVAL
INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART L--TO BE COMPLETED BY FHA
INSURING OFFICE MORTGAGEE
SUBDIVISION NAME ,- ~, (~!) ~
ERIAL NO,
BLOCK NO. LOT NO.
Can a~c or other area be made into
additional bedrooms?
(if Yes, how many~)
r-1 Yes []No
SYSTEM DESIGNED FOR
WATER SUPPLY
[] Public system [] Community system [] Individual
[] Public system [] Community system [] Individual .:~ [] Yes o
PART fl.--TO BE COMPLETED BY HEALTH DEPARTMENT
HEALTH DEPARTMENT INSPECTOR'S SKETCH
It is the opinion of the [] State [] County [] Local Department of Health that this individual water-supply system
[] is [] is not satisfactory as a domestic water supply for the subject property.
It is the opinion of the [] State [] County
tern with proper maintenance:
p~'] Can be expected to function satisfactorily, and
is not likely to create an insanitary condition
DATE I SIGNATURE
, (
NOTE: The health authority should, complete the appropriate opinion statement above and affix date, signature and tltJe in the
sp~cos provided. .......
Use of the above grid 'for Health Department nspoctor's sketch as wall as use of the back of this form is at the option of the
health authority.
[] Local Department of Health that this individual sewage-disposal sys-
[] Cannot be expected to function satisfactorily
J TITLE
San~ta~n
PART Ill.--FOR USE OF FHA OFFICE
TO THE CHIEF UNOERWRITER:
I have reviewed the foregoing and the pertinent FHA Compliance Inspection Report, and recommend that the
Individual water-supply system be considered [] Acceptable [] Not Acceptable
Sewage disposal be considered [] Acceptable [] Not Acceptable.
__i CHIEF ARCHITECT
DEPUTY FOR CHIEF ARCHITECT
DATE IGNATURE
INDIVIDUAL
~I, IALTH AUTHORITY APPROVAL ~h
rER SUPPLY AND SEWAGE DISPOSAL ,/TEM
FHA Form 2573
Rev. July 19S8
Z7
Z9
NOTE:
CERTIFICATE OF OWNERSHIP & DEDICATION
DTl002492
AREA 205 ACRES
PL AT OF
LOTS I,2, 8~ 3,
A RESUSDIVISION OF LOT :53
ALASKA
ASSOCIATES
