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HomeMy WebLinkAboutKNIK HEIGHTS BLK C LT 16Knik H
ight
lock C
Lot :[6
! 7-034
-34
O
Municipality of Anchorage ,¢~
Development Services Department ~~
Building Safety Division "~ ~
On-Site Water and Wastewater Program, 4700 Elmore St.
P.O. Box 196650 Anchorage, AK 99519-6650 Page of
www. ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: OSP iOiI]~ PID Number: 0i'~ -03~/- 3¥
Name:
d%~ ~m~v Wastewater System: ~ New ~ Upgrade
Address: ~¢ t'~ ~( ~ ~ ABSORPTION FIELD
Phone: Number of Bedrooms:
L~ ~'DeepTrench ~ Shallow Trench ~ Bed ~ Mound ~ Other:
Soil Rating: Total Depth from original grade:
LEGAL DESCRIPTION 0.8 GPD/Ft2 j j Ft.
Block: Lot: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe:
Township: Range: Section: Fill added above odginal grade: Gravel Length:
Well: ~ ~- ~New ~ Upgrade Gravel width: ~, S Ft. Number of lines:i Distance baleen lines:,~ Ft.
Classification (Private, ~ B, C): Total Depth: ; Cased to: Total absorption area: Pipe Matedah
Driller: Date Drilled: Static Water Level: Installer: Date Installed;
Yield: GPM Pump Set at: Ft. Casing Height Above Ground:
~. TANK
SEPARATION DISTANCES ~Septic B Holding B S.T.E.P. B Other:
T~ Septic Absorption Lift Holding )ub[iCPrivate Manufacturer: Capacity:
Tank Field Station Tank Sewer Line A~O~C&*6 %~ Gal.
i M terial: ~ Number of Compadments:
~ ~t ~, A, ~, &, LIFT STATION
Lot Line S [+ j 0 :~ ~, A, ~¢, AI~ Size: Gal., Manufacture~
Cu.ain Drain ~ ~* ,~'~, ~.A. / ~ ~ Elect.~, Inspections peffo~ed by:
Remarks;
Lo~tion and Description:
' ' Engineer's Stamp
Inspections performed by: La;5 ~Ouc~l,~ Dates: 1st 01,2J'¢~
I
2.~
Deve,opment Se.ices Depa ment Approva, '
Conditional Approval Date: I :~: ~%~~.,
Reviewed and approved by: /~, e: ~'2~'/O
HUFFMAN RDAD StflNC, TIES
C 25.8' ,58.3'
D $$.6' 42.7'
~ ~ ~ E 36.2' 44.2'
G 37.9' 45.8'
H 85.6' 68.$'
I 84.4' 70.2'
LENGTH 65 FEEl'
] / ~ -- -- ,lOTH 2.5 FEET --
TOTAL DEPTH 11 FEET
ROCK DEPTH 8.2 FEET --
COYER 3.0 FEET
NOTE: THIS IS NOT A SURVEYED PLAT. WELL & SEPTIC _~ ~ / .... ~
-~- DEPARTI~ENT DOCUMENTATION ALL LOCATIONS
APPROXIMATE. ' ~. . . [. .. .. '. .~. ~, . . ,~. .~¥. ~.~. . , ~. ~ .....
m ~'. ,., -. No, £E-~1500
SPURKmNO ENmNEEmNC £0~' !#, B£OCE C ENIK I-IBI~E~'$ SEine S~S~E~ ~S~U~
~0~ ,' ~ S~. ~ VENUE
~NON. ~. ~0~ ~00 HUFFWAN ~0~, ANCNONAG~ AK ~ BA~E: ~UGUS~ ~, ~0~0
(907) 279-a916 JAWES TRO~BLEY SHEET: I/a ~RID: 28a6
PERNIT ~ DSPIOH39 PfB ~ 017-034-34 KnikHei8h~CLlSB~
Standard french:
2.5' Vide
65' Long
11' Deep
B,2' Sewer rock
3+' Cover
NO SCALE
Test Hole
E.G. ELEV.=91.6'
ELEK =89. 1'
ELEK =80.6'
/Monitor
Cleanouts
SiI ~: BarrierS,
3'Cover ~.~ _ .
IIII
B.~ P~ oF Septic Rock
Effectivo J~50 gal septic tank
B.O.H. ELEK=74.6'
NO SCALE
BENCH MARK SLIDING DOOR JAM
ELEK =80. 6'
SPURKLAND ENGINEERING II
203 W15th Ave
Anchorage Ak 99501
~79-~91~
KNIK HEIGHTS BLOCK C LOT 16
JAMES TROMBLEY
4400 HUF£WAN ROAD, ANCHORAGE, AK 99516
I ] SEPTIC SYSTEM ASBUILT
DATE, AUGUST I$, 2010
SHEET~ J/$ GRID, SV£836
PERMIT ~ OSP I O I I Sg PARCEL ID tf 017-054-34 KNIKHEIGHTSBCL I 6D$.DWG
On-Site Wastewater Disposal System Permit
OSP101139
01703434000
Septic
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number:
Tax Code Number:
Work Type:
Permit Effective Dates: August 10, 2010 to
Design Engineer: SPURKLAND ENGINEERING
Subdivision: KNIK HEIGHTS
Upgrade
August 10, 2011
Site Legal Address: KNIK HEIGHTS BLK C LT 16 G:2836
Owner/Address: TROMBLEY JAMES J
3499 FARRIOR DR NORTH POLE AK 997056811
Site Mailing Address: 4400 HUFFMAN RD, Anchorage
Lot Size in Sq Ft: 43500
Total Bedrooms: 4
This permit is for the construction of:
Y Disposal Field Y SepticTank N Holding Tank N Privy N Private Well N Water Storage
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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Date:
Date:
~, ~'o ZolO
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650
Anchorage, Alaska 99507
www.muni.org/onsite
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 017-034-34
Property owner(s) James Trombley
Mailing address 4400 Huffman Road, Anchorage, AK
Site address Same
Legal description (Sub'd., Block & Lot) Knik Heights Block C Lot 16
Legal description (Township, Range & Section)
Lot Size
Day phone 244-7237
Zip Code 99516
.Zip Code
Sq. Ft.
Number of Bedrooms 4
THIS APPLICATION IS FOR ([~ all that apply):
Absorption Field []
Septic Tank []
Holding Tank []
Privy []
Private Well []
Water Storage []
THIS APPLICATION IS AN:
Initial []
Upgrade []
Renewal []
I certify that the above information is correct. I further certify that this application is being made for a
Sin/gle Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature ~p~/operty owner or authorized agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
(Rev, 11/05)
Waiver Fees:
Date of Payment:
Receipt Number:
Environmental Consulting and Design
SEPTIC SYSTEM DESIGN
Knik Heights Block C Lot 16
Municipality of Anchorage
Development Services Department
On Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, Alaska 99519
July 30, 2010
Subject:
Septic System Installation Permit
4400 Huffman Road
Ladies and Gentlemen:
I am writing to request a permit to upgrade the septic system for the above referenced property.
The proposed system will serve a 4-bedroom single-family residence. The existing system is
over 32 years old and no longer meets COSA operational requirements. Soil logs, design
calculations, a site plan, design drawings and construction specifications are enclosed for your
review.
Design Calcs:
No Groundwater observed to a depth of l 7feet below ground surface
(7/30/2010)
Soil Rating: From Testhole 7/20/2010
4.2 rain~in = 1.2 gal per sq.fi/day (TH#0
8. 3 rain~in = O. 8 gal per sq.ft/day (TH#2)
8.0 rain~in: 0.8 gal per sq.ft/day (TH#3)
No. of Bedrooms 4
Required Area per Bedroom: 150/0.8 =187.5 sq.ft.
Minimum area required: 187.5 x 4 = 750 sq.fi.
System: We are proposing a 1250 gallon septic tank, and a deep trench absorption field. The
absorption field will be 65 feet long and 2.5 feet wide with 8 feet (1040 sq.ft, effective) of sewer
rock.
Soils: Three test holes were excavated on July 20, 2010. See the attached soil logs. Silty soils
were observed. Ground water was monitored for through July 30, 2010. Ground water was not
observed. A percolation tests was conducted at the following depths: 1 foot, 3 feet, & 4 feet.
203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
Environmental Consulting and Design
I
Surface Water: There are no surface waters within one hundred feet of the proposed septic
system upgrade.
Topography: The lot slopes to the west. The maximum slope approaches 10%.
Waivers: No waivers required.
The installation of this septic system will not prevent wells and septic systems from being
installed on the adjacent lots. The proposed septic system will not change the general slope of
the area. Ponding and/or concentration of surface runoff will not result from this installation.
If you have any questions or concerns, please contact me at 279-3916.
Sincerely,
Spurkland, P.E.
Civil Engineer
203 West 15th Avenue Suite 203, Anchorage, AK 99501, Phone: (907) 279-3916
Fax: (866) 354-1597, Lspurkland~gci.net
HUFFMAN R£AD
N
Lo-/; 1
~Z
I
I
I
-~- ~,,~ I
I
Lo-I; 16 I.
I
II
I
Lot ~
:o~ 3-
NOTE: THIS IS NOT A SURVEYED PLAT. P/ELL ~ SEPTIC
LOCATIONS TAKEN FROM ON-SITE P/ATER AND P/ASTE P/ATER
DEPARTMENT DOCUMENTATION. ALL LOCATIONS SHOP/N ARE
APPROMt&4TE.
50 100 150 ~00 ~50
SCALE~ 1' = lOO FT,
.... · .....
.._ :.-' ,~j~ ...,_.~,~ ~"~.
3o0 ~ .... '"~ .... ~ ~
II SE~r~ S~SrE~ ~ES~
II
DATE: JULY 27, 2010
SPURKLAND ENGINEERING
205 I¢ 151'1-1. AVENUE
ANCN. AK. 99501
(90Z)
lLOr ~e,
BLOCK C KNIK HZlGHT$
4400 HUFFblAN ROAD, ANCHORAGE, AK 99516
JAMES TROklBLEY
PERMIT # PID # ~7-034-34
HUFFMAN RflAB
~)- ~rell
of: 16
LENGTH 65 FEET
PIlDTH 2.5 FEET
TOTAL DEPTH II FEET
ROCK DEPTH 8 FEET
COVER 3.0 FEET
Lo? ]5
S
S
+ Well
NOTE: ~IIS IS NOT A SURVEYED PLAT. WELL ~ SEPTIC
LOCATIONS TAI(EN FROM ON-SITE WATER AND WASTE WATER
DEPARTMENT DOCUMENTATION. ALL LOCATIONS SHOWN ARE
APPROXIYA TE.
· 49~h
LARS _ANI)
25 0 25 50 75 100 125 150
SCALE: 1' = 50 FT,
II
I
SPURKLAND ENGINEERING
203 PI 15TH. AVENUE
ANCH. AK. 99501
(907) 279-3916
I, OT 16, BLOCK C KNIK HEIGHTS
4400 HUFFMAN ROAD, ANCHORAGE, AK 99516
JAMES [ROklBLEY
SEPTIC SYSTEM DESIGN
DATE: JULY 27, 2010
SHEET: ~/3 GRID: 2836
PERMIT # PIB # 017-034-34 KnikHeightsBCL16B2
l'es! Hole
Stondord Trench:
8,5' ~/ide
65' Lon9
H' JDeep
8' Sewer rock
$' Cover
--0 0
ND SCALE
ND SCALE
SPURKLAN9 ENGINEERING
803 ~15th Ave
Anchorage Ak 99501
27g-~91~
KNIK HEIGHTS BLOCK C LOT 16
JAMES TROMBLEY
4400 HU~F~&4N ROAD, ANCHORAGE, AK 99516
SEPTIC SYSTEM DESIGN
DATEI JULY $0, 2010
SHEETI 3/3 GRIDI $1~£836
PERMIT tit PARCEL ID tit Ol 7-034-34 KNIKHEIGHTSBCL 1603. DWG
Performed For:
Legal Description:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.anchoraqe,ak, us
(907) 343-7904
Soils Log - Percolation Test
James Trombley
Knik Heights Block C Lot 16
~' .:t~'. ..... '"' '~.~ ~ t~
-"' x,.~." A".,¢- u
." 9TH
~ ..Z~ .......... .~~,., .... ~.. ~
,, .,..,-,. ......
Date Performed: July'~~--
Township, Range, Section:
81ope Sile Plan
7~
8-
9-
10-
11-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS Pre Soaked
WAS GROUNDWATER
ENCOUNTERED? NO
s
iF YES. AT WHAT DEPTH? .......... L
O
Depth to Water After
P
Monitoring? i~,,-~ E
Date: "~/~0
Reading Date Gross Time Net Time Depth to Water Net Drop
PERCOLATION RATE L~ '~::~ {minutes/inch)
TEST RUN BETWEEN 1 FT AND
PERC HOLE DIAMETER
'~.. ft
!
PERFORMED BY: Lars Spurkland I /'~ ,_~~ CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDEILINES IN E~FECT ON THIS DATE. DATE: 7/27/2010
Performed For:
Legal Description:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O. Box 196650 Anchorage, AK 99507
www.ci.anchoraqe.ak.us
(907) 343-7904
Soils Log - Percolation Test
James Trombley
Knik Heights Block C Lot 16
c .' '..-lz t
'49TH : "."
~ ~ LARSE/SPURKLAND.!~,;
Date Pedormed: July 20, 2010
Slope
Township, Range, Section:
Site Plan
1
2
3-
4-
5-
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20-
~o
COMMENTS Pre Soaked
WAS GROUND WATER
ENCOUNTERED? NO
s
IF YES, AT WHAT DEPTH? .......... L
O
Depth to Water After
Monitoring? E
Date:
Reading Date Gross Time Net Time Depth to Water Net Drop
7/20/2010 2:02 pm 0 min 9"
6.375" 7/20/2010 2:32 pm 30 min 9" :3. ~, 7-5 ~
5.375" 7/20/2010 3:02 pm 60 min 9" ~., GZ.~~
5.375" 7/20/2010 3:32 pm 90 min 7_, (~ ~,.~; ~'
PERCOLATION RATE 8.3 (minutes/inch)
TEST RUN BETWEEN 3 FT AND 4
PERC HOLE DIAMETER 6
FT
/,.-- ,,
PERFORMED BY: Lars Spurkland I /~,~~ CERTIFY THAT THIS TEST WAS
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPALT. GU~-DI~LINES IN EFFECT ON THIS DATE DATE' 7/27/2010
Municipality of Anchorage ~ .~
~ Development Services Department ~ '"' ~q-~.s.~..~.,~.~1~!
//'____Y____"~ Building Safety Division
l/ O~i~;~Ir ,']'"'~ ~\ On-Site Water and Wastewater Program
\\~'-.~.f// P.O. Box 496650 Anohorage, AK
~ (907) 343-7904
Soils Log - Percolation Test
Pedormed James Trombley
For: Date Pedormed: Jul~
Legal Description: Knik Heights Block C Lot 16 Township, Range, Section:
Slope Site Plan
2-
3-
4-
6-
7-
8-
9-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS Pre Soaked
WAS GROUND WATER
ENCOUNTERED? No
s
IF YES, AT WHAT DEPTH? .......... L
O
Depth to Water After
P
Monitoring? E
Date:
Reading Date Gross Time Net TimeDepth to Water Net Drop
':,--'."/~",, 'z,'~s ~,,.., '.~o ,,;,, i~ '/z." 3%/
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND 5 FT
PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL~'I~I~EI~INES IN'~FFECT ON THIS DATE. DATE: 7/27/2010
AME
~-AI LI NG~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAl. PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
TPHONE
UPGRADE
LEGAL DESCRIPTION
L©CATION
I Well
-"' DISTANCE TO: I /OD
I- ~ Ma~'u factu rer
~ I- Lie capacity in gallons I
,/.~._ ~'~) ~- HOMEMADE:
DISTANCE TO: lWell
Absorption area
NO, OF BEDROOMS
PEFIMIT NO.
Well
DISTANCE TO: /0(.~/ ~
No. of lines / Length of each line
Top of tile to finish grade
Length
Width
Type of crib Crib diameter
Well
DISTANCE TO:
Class Depth
DISTANCE TO:
Building fouodation
IDwelling
Material~.~
Widt~ __
No. of c.~partments
Inside length Liquid depth
Dwelling PERMIT NO,
Material
Liquid capacity in gallons
Foundation Nearest lot line PERMIT NO, "7 80
Distance between lines
Total le~ngth o/f lines
l'rench w~.~_ inches
Material beneath the
Depth
Total effective absorption area
'~"~RMIT NO,
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line
Sewer line
Septic tank
PERMIT NO.
A]sorpt on area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
~NSTALLER
REMARKS
/dc) +' ,
APPROVED
DATE LEGAL
77-01.q [R~v 3/7RI
£
~ell yield tested by (pumpinR,~ air)at~
for bouts ~ith_ ~) lt. of dra~do~n from static level.
DRILLER'S MATERIAL LOG
Depth below land
surface in leer
Give description of strata penetrated
(size of material, color, hardness of drilling, and water content
MUNICIPALITY OF ANCI40:~/'f)2
ENVIRONMEN I'AL Pl~OI ECiI~,,~
RECEiVE. O
0[' lien]th :md 1.;Iwiponmentp' 'roteetion
2fi 16 I,~. Tuclor
Anchopage, Alrtska 99507
276 2221
l~his form reports: Soils log
~el) th
~ee t
14-
Was groum
Iteadi ilg
~aLer encountered? ~ If yes, aL whaL
~,~' ~UN'rUIPALITY OF ANCHORAGE
........................................................... t - .,DEP~: -Op.H~ALTH-~
Date Gross [1me Her Time L ~~r._[ Net tJrop '
...... :'_ .... 1 ......... ZZLz_I ....... 1 ....... ~o ...... 1 ....... ..~ ........ ~-~
...... Zt ........... /IY.~ ............ /o ............. o~-/ ......... ~-.~ ............
....... iL .............. !!~_~ .................... ~ ........................................
Municipality of Anchorage
® Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
® P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
0iS%A (907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 01-1- 039- 3q
1. GENEkAL'INFORMATION
r
Fes:
COSA # ()-�'C 16112 V
Expiration Date: --a 0 -- / �
Complete legaWescription Kni k R6 i<a h4,,5 @k C W 16
Location (site address) ggQ0 Nt, fjmcin oeNA
CDrrerit Property owner(s) Jaunt's lror, k 1P V Day phone
Mailing address
a;
Lending agency Day phone
Mailing address
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: q
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank ❑
Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems 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 COSAs upon request to homeowners. Certificates of On -Site Systems 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 Certificate of On -Site Systems 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-s(ie�water
supplyµa d/o4astewater disposal system is(are) in compliance with all applicable Municipal and State codes,
odmanbe ,,and regulations in effect at the time of installation.
.,r.
Name of Firm 30up-f 1CA Enciiiwerir�u Phone V7-3716
Address iti, 151' Ave. 2O2 Anchorage, A k
Engineer's Printed Name LARS our�h.�ahc� _ Date 8/0/20/0
_
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
;.:':.
.CARS 9 SPURKLAND. I'/�
11 Q'
i Ol®fie S�pNP�4
t�
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
`aze • ON-SITE
—WAT K ANN
1A STEWATER e
FHKOGRAM °
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:
(Rev. 11105)
M:1
Municipality of Anchorage *rIE . G
• Development Services Department 4=
Building Safety Division =T
O"n-Site Water & Wastewater Program S A E T Y
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: kn,'k hlybty Qlk C Loi" )6 Parcel ID: 0ld-QM-3y
A. WELL DATA
Well type LAe'
Date completed 45ti Rs
Total depth 140 ft.
If A, B, or C provide PWSID # =
Sanitary seal (Y/N)
Cased to NO ft.
FROM WELL LOG
Date of test 5 15I A
Static water level b0 ft.
Well production Jr g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate o % mg/L
Arsenic: ug/L date of sample: i� j0 IU
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material t n&DrOL O_ (ANa - 156A-
Tank
size 12.50 gal. Number of Compartments
Well Log (Y/N) 1
Wires properly protected (Y/N) Y
Casing height (above ground) �) z in.
AT INSPECTION
3 ZOID
y y ft.
5.d, g.p.m.
Other bacteria -colonies/1100 mL
Collected by: f' Qr5 S12urizlcwj
Date installed 5512 Zoic)
Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) N, A ,
Date of pumping lVew Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating 022DOr ft2/bdrm) 0-3 System type 17eeD renc_k
Length G5 ft. Width 2.,S ft. Gravel below pipe 6— ft.
Total depth 11 ft. Eff. absorption area IDgo ft2 Monitoring tube 'Y Depression over field .A/
Date of adequacy test Ale al Results (Pass/Fail) — For — bedrooms
Fluid depth in absorption field before test — in.
Elapsed Time: -- min. Final fluid depth — in
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Water added ~—gal. New depth — in.
Absorption rate >= g.p.d.
If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"Pump on" level at Z.in. "Pump off" level at in. High water alarm level at in.
Datum Cycles tested Meets alarm & circuitre irements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100+
Absorption field on lot 100
Public sewer main Al'. A
I
On adjacent lots 10D +
On adjacent lots ICC) t
Public sewer manhole/cleanout /\/,A,
Sewer /septic service line ZvS + Holding tank I% A I
i�
Animal containment areas 50+" Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
i i i
Building foundation 5 +- Property line 5 + Absorption field 5+
Water main IV, A Water service line Pit Surface water 100
Wells on adjacent lots +
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
t
Property line 10 + Building foundation 101 �- Water main N, A ,
Water Service line IOF Surface water 1O0 t Driveway, parking/vehicle storage I"
Curtain drain Wells on adjacent lots IDQ� +
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that / have determined through field inspections and ® 49T
review of Municipal records that the above systems are in a '
conformance with MOA COSA guidelines in effect on this date. `:;. : :; .._ ' ' ' /
�� �` • : Pt1RKLAND.
Engineer's Printed Name G.ti -=`i 3i ,
AILS •..S��t• �L�4� f� � 1115
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Date I '7-O 0 1� ��'V l is'
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
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Receipt Number
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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) Legal Description (include lot, block, subdivision, section, township, range)//
(b)
(c)
Location (address or directio, o,o,o,~s)
Applicant Name--C~z/~'---; .~¢.~!~.,4~,¢;'.z...,~-- ~__ Telephone: Hom~ .~a ~/ Business
Applicant Address _ .
Applicant is (check one): Lending Institution ~; Owner/builder~; Buyer ~; Other [] (explain);
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-E mily ~] 0 er
Number of Bedrooms~
WATER SUPPLY
Individual Well~ Community [] Public []
/
Note: If community 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 community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
5. ENGINEERING FIRM PROVIDINL~ INSPECTIONS, TESTS, FILE SEARCH, DATA 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 flies 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 ins. pection, '
Name of Firr~--:'~'2"~/~'//l/-~' '~' /_~,~o-~:, _~'_~.,-~,c' .~ _._ Telephone ,-~"~'~'"/ ~ ~/
/ ~ ~ ~- ~ .... ~
Address ~/~ ~_~/~.S / ~ ~ ~ ,
Date /~ - /~' ~ ~ ~
DHEP APPROVAL-
Approved /./"' Disapproveo%
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage 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 ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Descriptio[~: ''~/'¢ / ~
Well Classification ~'/~///~¢ 2'''~ If A, B, C, D.E.C. Approved (Y/N)
Total Depth ~/ / Ca' sad to ~ Depth of Grouting ~'
Static Water Level ~¢~ /
Casing Height Above Ground ~ ~'
Electrical Wiring in ConduitS) ~
Separation Distances from Well:
Pump Set At ./,.37/
Sanitary Seal on Casing(~)
Depression Around Wellhead (~/~1~)
To Septic/Holding Tank on Lot /~4) '-/-'-- ; On Adjoining Lots
To Nearest Edge of Absorption Fieldon/Lot /-~¢~ '~ ; On Adjoining Lots
To Nearest Public Sewer Line _ ~ To Nearest Public Sewer
Cleanout/Manhole _ ~ ~ To NearesLSewer Service Line on Lot
Water Sample Collected by _~ ~/ ~A~ ; Date /O --
Water Sample 'fast Results ~ ~'~ ~~
Comments ~¢ ~ ~/~ ~¢'~ ~%~ ~ ~'~
B. SEPTIC/HOLDING 'TANK DATA
Date Installed "¢J~?~¢ '--~'~¢ Size /,~".~:~ No. of Compartments ~"'-
StandpipeiC~l) >/t'¢~--% __ Air-tight Cap/¢ (Y~) ,/b'~.-~ Foundation Cleano~)
Depression over Tank (Y/N) /~ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)"~ ;for. './~.~ ,
Holding Tank High-Water Alarm (Y/N) .~* Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well __
To Property Line
/
To Wat4~Main/Service Line ~,~ -/--
Co.rse
To Building Foundation
To Disposal Field ,,'/',~¢
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72~026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~J~ ,.~z¢' --
Width of Field -~;' //
~~,¢,;,¢-,/ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present~)
Square Feet of Absorption Area ~'¢=~,~
/
Depression over Field (Y~') -'f//-.'~.._ Date of Last Adequacy Test
Resu,ts of 'Last Adequacy Test '*
/
Separation Distance from Absorption Field:
./
To Water-Supply Well
To Building Foundation
Lot /t'//~ '¢-" -'~ /'/? ~-~'z¢'/,¢-/¢/
To W.a.te~-.A4ain/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line -'-~¢
To Existing or Abandoned System on
; On Adjoining Lots /z~
To Cutbank (if present)
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
Signed/
Compafl~ ~;~'"~¢--~"~'~ MOA No.
Receipt No. ___ /~ ~/~ (D~"~ .>
Date of Payment
Amount: $
** Check P~.'~ed Bedr~m. Rating.;, Against HAA Request **
I certify th (t I)~a,~,Ch, eck~/¢~fied, or conformed to all MO,5 and HAA guidelines in effect on the date of this inspection.
Page 2 of 2
72-026 (11/84)
Engineer's Seal
: APPLI( NT FILLS OUT UPPER HAl ONLY
Pro ~rly Owner
, ~,~,,~, ,,j ~.j ~ ,,
Phone
.¢,i~f :">' 7 /
Buyer /~//~
Zip Code
Address
L~nding Institution /~'~.- ~/~ /~ //'~L~ ('2;;.,,.-~;/,.. / ~JIc~
Address
Zip Code
Realty co. & Agent
Address
Zip Code
Phone
Phone
Eega[ Description
Street Locatioo
Type of Residence ~ Single Family
[] Multiple Family
~ Other
No. ot Bedrooms /-/
Water Supply ,~ Individual
[] Community
~ Public Utgily
Sewer Disposal ~ Individual
~ Public Utility
6] Holding Tank
ATTACH WELL LOG. A welt log is required for all wells drifted since June 1975.
For wells drilled prior to that date, give weg depth (attach log if available).
Year Individual Installed:__ ¢/'~ 7~J('~
When Connected to Public Ulility:
NOTE: THE INSPECTION FEE ML)ST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Inspector
~rime
Date
Inspector
Time
Date
Inspector
Time
Inspector
PJeld Notes:
~rCIPALITY OF ANCHORAGE
hEP[ Of tf/',L'i]i ¢
ENVIRON,'./,EN I Al_ FPLOTEC [ION
N0V ii'];' :
( ) DISAPPROVED
) CQ, NDITIJ~AL APPROVA? ~
'CONDITIONS OF APPROVAL
Dale Sewer Installed
Well To AbsorptiOn Area /"~
Well to '~ankY~'?/ /~
Well Log Deceived
Septic Tm-~k Size
Soils Rating