HomeMy WebLinkAboutKNIK HEIGHTS BLK H LT 10 MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTFCTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPI~CTION REPORT
NAME I_PI- ONE / NEW
LEGAL D~ESCRIPTION
~ J Well Absorption area f Dwelling PERMIT NO.
~1' ~ Manufacturer ~~ Mate~ ~ No. of compartment~
~Liq. c7~ gal,ohs IF HOMEMA DE: Inside length Width Liquid d0pth
~ M DISTANCE TO: Well Dwelling PERMIT NO.
=-~oz< Manufacturer ~/~ Material L iquidcapacityingallons --
;~; DISTANCE TO: ;~ Nearest. PERMIT NO.
"O. Of lines/ Length o~ac~ line Total leng~ of lin,s ~ Trenc~i~ Distance between line~
Material~en~ath tile ~ inches Total effec~a~¢a
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~u Well Building foundation Nearest lot line
~ DISTANCE TO:
j Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
INSTALLER.
REMARKS --
- APPR ~ DATE, LEGAL
PERHIT
[:,EPFIRTMENT OF HE~L..TH FIND EH, ] I ..HhlEH II-.IL. [:'ROTE:C]"ION 82.5 '"L.'" STREET., FINCHORFIGE., RK. 9~50::!.
,:: 7'8J. 026 ::,
FtPF'L I CFINT
L. 0 C F:I T I El N
LE]:iiFIL
S"F E',,,'E TFICKETT
R I [:,GEWOO[) F.'. [:,
L-iCa B-H KNIK HTS.
RNCHORF:IGE
LOT SIZE
TYPE OF::' SOIL F:IBSORE:T)]ON ~.'.YSTEM IS: TRENCH
MFaXIHUH NUHBER Iii[: E:E[:'ROC~FE.:; = :g
SOIL. RRI":[[.,~S (:.~;g! I::"r',..'E:R:: .... 85
':FHE RE(.:4UIRE[:, SIZ~E OF THE: SOIL f::IBSSORPTION S"r'2;TEH IS:
TI~'IE LENGTH D I MENS I ON I S THE LENG'I'Iq ,:: I N FEET ) OF THF~ 'TRENCH OR [."F4]:::I I t",tF:: I lii;LD.
TI'IE DEPTH OF Ft TRENCH OR PIT .'IS'] THF:2 D ZSTF~",ICE E~ETHEEIq THE S:;IJF;?.FFI(:::E OF: THE
I.':iROUIq[:, FIN[::' THE E'~CIT"f'OM
THERE I.S NO SET WI[:'TH [:OR TI;..'ENCHE2].
THE GI;..'FI',,"EL. [:'EPTH I :E; TtqE P1Z N.T. HUH DEPTH OF:' GRI::I',,,'EI_.. BETHEEN TH[:i: OU'f'F'F'tL.I. P I F:'E
FIHD THF E;OTTOM OF THE IC',:,.h]:Fi'v'F:rTIi:)N (IN FEET).
PERM I T FIPPL I CFINT I-'Ii:::IS THE F..'E.SPONS t E,' I L I '[".r' ]'O I 1"4F'ORH TH I '.F; DEF:'FIF.:THli:"I'.,I'T [:,LIF.: I i'.41]i "FHF:
Z t",I'..;.;TFILLF'IT I ON I I",ISPECT IONS OF FtNY ,WEL..I...S RDJF:ICEIqT TO TH I ::7', F'I:;:'.OF'ERTY FIN[." THE
f',ll. Jl"lE:Ei:lR OF' F,'ESIDE:NCES THFI]" THE; P.IELL I,JILI.~ Si. EI;?.'v'E.
E;I:::ICKF Z L[. I f'4G OF FINY %"r'S'rEM [,.I Z THOUT F Z NFtL. ]: N:'T.';PECT I ON RN[) I::tF'F:'F;:O'v'FIL EFt' Tl"f I
DEPF:IF.'.TMENT HILL. E;E SUBJECT TO PRO'i'!;ECUTION.
r,i:I:N I h'll..IM [:,I STf:tNCE E:E:'I'WEEN Fl HELL FIN[:, FiNY C]l f4 ~rl.:~ i ''Il [~ SEI'''IFIGE [:, I
100 FEET FOR FI F'RI'v'FITE !.,.IELL.; OF.:
L1.50 TO 280 FEE]' FF::OH Ft PLIIF.:L..IC HELl.. DE:PEN[:,If.,IG I...IPOI'.,I THE 'T"¢F'E [DF F:'LIE:L. IC HELL.
HEL.L LOGLC., FI[;.'.E F.'.E:(';!LII'RED FIND HIJST E.:E F.:E]"LIF.:NED 1"O THE DEt::-'FIRTM[EN]' H ITHIN
OF THE WELL C:OHF'LETION.
O'T'HEI';:. F?.E[~LI I R[.::MEN]";'~; HIg'r' F:IF'F'LY. SPEC I F I E:FI"I" I OI",IS FII",I[) C:ONL;:;'f'F~:LIC'f'101",1 [) I FIGF¥::IM:5 ]"::fl;'::1:'_::
FI'v'Ft I LI:::IBI...E TO I N'.':JLIRE F:'ROP[~]F.: I N'.~TFILLFIT I ON.
I C:ERTIFY 'FHFIT
:1.: I F:IM FFIMILIFIR !-,.IITH THE: RIE(:]UIf':".EHENTS FOR OI",I'~'SITE SEHERS F'IN[:' ,LIEL..L.:!!!; Fi'.iii;
FORTH I:3Y THE r,'llJN I C I F'I:fL I TY OF I::INCHORFiGE.
2: I HILL INS:;TI::iLI... THE SYSTEM IN FIC:CORDFINCE 14ITH THE: CO[:,[ES.
]:: I. IJN[:,[.:.]:~::2.';Ti:::iN[:, THI:::IT ]"HE ON-SITE :'SEHER '::2.R..?,T[:::]','I i-,II:::iY RE~'i...';!I...I]:i';;:](~. IFZF,!I...F:IRGEMEI'.,FI' Il::' 'FHE
~:tl",l T ~ ":[:MIE "D':ICKE T'I'
I S:';:E;I...IE [:, [~.:"r'. ............ F',FI'f' F: ,'?
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysicol Surveys
LOCATION OF WELL (Please complete either Io, lb or lc.)
..JBorough Subdivision , ~ Lot Block ~1 V4qtr~.
t
DISTANCE ANO DIRECTION FROM,ROAD INTERSECT ONS
WELL LOG
Feet Below
Surface
Top
16. WATER WELL CONTRACTOR'S CERTIFICATION:
Orilling Permit No.
A.DL. No.
wED
OWNER OF WELL:
[] Tost Well [] Olher:
8. CASING: ~] Threaded [] Welded
diam. /~) in to ,/~ '~? ft. Depth Weight ~ :- lbs./fl.
diam. in lo ft. Depth Stickup fl.
9, FINISH OF WELL: .'
Slot/Mesh Size: Length:
Sot between ft. and ft.
Backfilling Gravel pack
I0. STATIC ;WATER LEVEL:~,'", :i ft.
[]A~ve or .[].e,ow la.~ .urtooe
11. PUMPIN~ LEVEL below land surface and YIELD
' ~ '2~ ~ ft. after Z: hrs. pumping . ,' g.p.m.
ft attar hrs. pumping g.p.m.
IB.GROUTING Wall Grouled: [] Yo$ [] No
Materiel: [--I Neat Cement [] Other:
13. PUMP: (if available) HP
Length of Drop Pipe ft. capacity
[] Subm. [] Jet E3 Centrifical [] Other
15. Water Temperature __.o [] F [] C
This well was dri e'd ander/imy u sd c on and Ibis reporl is Irue to the best of my knowledge end belief;
~ .,"~ -., .. , /.., .~, ~_ .... . ,;? .- ~...'//;,' :
,: ¢Regi~tered 8usiness4:¢4ome Contract License Number
,.,-'-~ ~...'~_ ~:-' ....., / ;. . .~--'"',,. , ~ ,,. .;, ,..~ ,, .."
Address:
.,.. :,..,.;". ,.,¢,,.. ,:.: . . ~,: (
Autho¢lzed R~.~esentofive
Form O~'WWR (11/81) Copy Disfribulion: WHiTE-State DGGS~ PiNK-Driller, CANARY-Customer
% ,LSON WELL DRILLII ,3
ANCHORAGE, ALASKA ~ ~ G~'~ 7 PHONE ~
DRILLING LOG
%oeation (address of: Township, Range, Section, if ~mwn; or distance main
I / ,,'1
Size of easing. (/¢" Depth of Hole~ lO feet Cased to
Static water ]eveL/,~D ft. (above) ~ ]and surface. Finish of well (che'~k
Screen ( ); Perforated ( ).
Describe screen or perforation
Well pumping test at ~
, L~_gallons per (hour)
of drawdown from static level.
Date of completion / ~
~ f9r ~
one) open end ( );
with
WELL LOG
Depth in feet from
ft.
ground surface
TO_
___TO
~ .TO
Give details of formations penetrated, size of material, color and hardness
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. # O(~-5~Z~--t/O HAA #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency COuN'rR~( %,1 b ~' F uNblt4 G Day phone
Mailing address 15'5' N. LAt<~ ,~VE , ?AsS A DENA .CA
Agent H,A. (' R~C~,:Z~c.6). Dayphone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
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 my
investigation of this Health Authority Approval application shows that the on-site water supply
and/orwastewater disposal system is safe, functional and adequate for the number of bedrooms
and typeofstructureindicated herein. I furtherverifythatbasedor]theinformation 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.
Name of Firm FLA'T-roP TECH .5vC£ Phone 3 qS'- IZ)5',5'-
Address Iq ,9'30 E~CHO
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
.~~ ~ ~ Date
....
~ ~ · EODO~ ~. ~O0~E ~. ~'
bedrooms.
/4¢_7
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does th is 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.
72~025 (Rev. 1/91) Back MOA/f21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
k'~.lK ~fT£ $/D Parcel I.D.
Well type ~R~VAT E
Log present (Y/N) "/
Total depth bio'
Sanitary seal (Y/N)
V
FROM WELL LOG
3q5 '
Date of test
Static water level
Well flow
Pump level1
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed $/I 2/8'7 Driller /~ L P/,qE
Cased to 12 2 Casing height
Wires properly protected (Y/N)
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
g.p.m.
Sewer service line
'~ gO
AT INSPECTION
; On adjacent lots
; On adjacent lots '> / co
Public sewer manhole/cleanout '> /00
Petroleum tank ikl o ~4 E
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
~- ~m..,~,/...~ Other bacteria non~
Collected by: ~-l,~'fTo? T~ Cf/ 5VC~
El. SEPTIC/HOLDING TANK DATA
Date installed I~Jl I 73
Cleanouts (Y/N) ~'
High water alarm (Y/N) N,, A.
Date of pumping 5'/26/~3
Tank size I ooo
Foundation cleanout (Y/N)
Pumper
~A L Compartments P--
~' Depression (Y/N) N
Alarm tested (Y/N) N ,A ,
SEPARATION DISTANCES FROMcS~PTIC/HOLDING TANK TO:
Well(s) on lot c']5 I:~or~ ¢.o. ~ On adjacent lots >!o~r
To property line >- ( o' Absorption field [o'
Surface water/drainage ~ 10~) ~
72-026 (3/93)* Front
Foundation
Water main/service line ~ 70
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed . II /ii
Length 2 '2. Width
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/Ft2) I.~
Gravel thickness
Cleanout present (Y/N) ~'
Results (pass/fail)
System type
Total depth
Depression over field (WN)
PA¢$ for ~'
After test 5~'"
If yes, give date H'/~ '
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot JO3' F~o
To building foundation
On adjacent lots ..~
Surface water .~ I
On adjacent lots ~-/oo' Property line '-~/b
To existing or abandoned system on lot N ,/I,
Cutbank N ,A. Water main/service line ~ ~'0
Driveway, parking/vehicle storage area
Curtain drain NONE- o~SE~VEb
E. ENGINEER'S CERTIFICATION
Signature '¢'~_ ~¢~
Engineer's Name
Date ¢z¥ czj c4r ('
HAA Fee $ / 74, ~
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Waiver Fee $
Date of Payment ? "-~'~ ~ ~-~
Receipt Number ~"-7~ ¢7C ¢~"~72
Date of Payment
Receipt Number
72-026 (3/93)* Back
J~ COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
Member of the $G$ Group (Socibtb G~nOrale de Surveillance)
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
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
Parcel i.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) I~ Iff'/ ~,,~¢ccJooc/ Rtl(
Property owner
Mailing address
Agent Fo
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
Day phone ~' YS-- o ~ ~,/
Day phone
Day phone ~¢~-
9q~o3
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) 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 my
investigation of this Health Authority Approval application shows that the on-site water supply
and/orwastewater disposal system is safe, functional and adequate for the number of bedrooms
and typeofstructureindicated herein, lfurtherverifythatbasedontheinformationobtainedfrom
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 F'/,~F¢'o? 'T'¢c/~¢,~f ..¢¢,~,-~,~,- Phone 3'~/.-
Address I'Y_¢ ~O Echo ,.CC". ,4-~cl~or-~q.¢. ,4-k ?~)5-1~'
Engineer's signature '~'~ ~ ~ Date /~p?'
DHHS SIGNATURE
Approved for'~~ bedrooms.
Disapproved.
Conditional approval for
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 paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does th is as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Em pioyees 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.
72~)25 (Rev. 1191) Back MOA #21
( Municipality of Anchorage ~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-,. /0, ~L~' ~ /(/~IK l-/?'~ 5/p Parcel I.D. O / 17 - ~ 7,)- -/&'~
A. WELL DATA
Well type
Log present (Y/N)
Total depth bl C) '
Sanitary seal (Y/N) "('
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed -~/-~//~ 7 Driller
Cased to ~ 2,2 ' Casing height ~
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~$ To (7, O,
Absorption field on lot I o3
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform O col
of
Nitrate
Public sewer manhole/cleanout
Petroleum tank
7o ~, {~¢-. Other bacteria d~ ¢ol 1too~4~6.
Collected by: ~L/~'rTOP T ECH 5~'¢~
B. SEPTIC/HOLDING TANK DATA
Date installed 11[,[78
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping __
Tank size ~Doo ~; Compartments 2_
FOUndation cleanout (Y/N) ~' Depression (Y/N)
~./~. __Alarm tested (Y/N) I4'/:1 -
· 7//1~ ,/? / Pumper 154ftc;
NoNE
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot o~&' rg¢~q '~.r0,',~ Onadjacentlots_~./oo '
To property line ~'/o' Absorption field
Surface water/drainage >, tod
72-026 (Rev. 7/91) Front
Foundation
Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION N,/~',
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 1(
Length 2 2' .Width ..~
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N) HONe'
Soil rating
System type
-F f~ g ,',l c H
Gravel thickness ~ / Total depth
Cleanouts present (Y/N)
Date of adequacy test
for
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 1o3 F~o~ oo,
To building foundation 2-5
On adjacent lots ;~ _~o'
Surface water ;;:, ~oo
On adjacent lots -~/ce .Propertyline
To existing or abandoned system on lot
Cutbank N./~. Water main/service line
Curtain drain NONE'
Tie
Driveway, parking/vehicle storage area ~ .-Cot
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature_ "~~ .~.
Date ~i[
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
~,~.~ SGS Member of the SGS Group (Soci6D G6nCrale de Surveillance)
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
GENERAL INFORMATION
(b)
(c)
Application Date ~ / ! 7 /',~ 7
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name Rm4,,~~/~''fi~''~a ~x/-'O'" Telephone: Home :~¥..¢-~--t3'~' Business
Applicant Address I~lql Fl,ol~.~ ~, oo~ t~dy flnM~rqvp'~/ /Gtc ?q.~16"
Applicant is (check one): Lending Institution []; Owner/builder [~; Buyer []; Other [] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent O"~c k:
Address ~ P-O/ "~ " S ~, j
Telephone_ 3-~- ff~UOO
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family[] Multi-Family []
Number of Bedrooms ,5
Other
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 72-025 (11.84)
ENGINEERING FIRM PROVIDING 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 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. -~
Name of Firm F(~J-~o/~ 7'~¢4~'~ r,~/' ..c'¢~-~,~¢~,. Telephone
Address /ff'5-.3'42 .~c/~o ..c¢V A,~cAo~',~4o'e., ,4-1~'
Date
Engineer's Seal
DHEP APPROVAL
Approved for --~A
Approved
bedrooms, by ,'~~' ,~' '"~ Date
Disapproved Conditional
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.
MUNiCIPALiTY OF ,-.,'~CHORAQE
ENVIRONMENTAL SERVICES I~lt~IPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MAR ! 8 1987 CHECKLIST- FEBRUARY 1984
264-4720
R E C E J \/E D Legal Description:
WELL DATA
Well Classification ~'t'~/'
Well Log Present (Y/N)
Total Depth ~[0' Casedto
Static Water Level i ~'S J
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 Sg(~r~'c/~o ~'~,
Comments ~ P,/e if'
If A, B, C, D.E.C. Approved (Y/N) N, ,~-
Date Completed II /IC,/ 7¢ ~ Yield ~.$~¢/~
Deptl~ of Grouting N, ,4
Pump Set At '3,¢-.¢
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
(00 ~
e.c,,, ; On Adjoining Lots
I o3 ~ ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date installed !l/f( ?~
Standpipes (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:
Size lOO¢~'~d No. of Compartments
Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N)
Date Last Pumped ~-{?-?('¢?
J~',4, ; for
N. ,4, Temporary Holding Tank Permit (Y/N)
To Water-Supply Well c] 3' ~'n~,~ ¢. o.
To Property Line ~ (o'
To Water Main/Service Line /~, ,4.
Course ~ ~Od''
To Building Foundation
To Disposal Field t
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026Ill/841
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ii { I / 75
Width of Field ~'"
8,5' ~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field ¢-8'
Depth of Field ll~
Gravel Bed Thickness 6' /
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I ¢ E ' .¢::,-o r~
To Building Foundation ~,-¢'
Lot At, A.
To Water Main/Service Line
Y
· P_. / 2_.7 {67
To Property Line ':~ to ~
To Existing or Abandoned System on
; On Adjoining Lots ~ 3'o '
To Cutbank (if present) N. A-
To Stream/Pond/Lake/or Major Drainage Course ~,
To Driveway, Parking Area, or Vehicle Storage Area
Comments on ~ /~/~7~ ~ ~a/
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 -~aT-~ ~' ~ Date
Company F~.~/~,/¢ '~cfind~¢~' C'u(/ MOA No.
Receipt No. ~ ~ dO /~ ~0~ /
Date of Payment ~ ¢/¢¢ ~ ~
Amount:$ /O 0 ~ ~ ¢4 ~:
Page 2 of 2
72-026 01184)
Engineer's Seal
3Aunicipa., ty p.o. x 196650
ANCHORAGE, ALASKA 99519-6650
OF~ (907) 264-4111
Anchorage
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
March 24, 1987
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject: Lot 10 Block K Knik Heights Subdivision
Waiver Request WR87-022
Dear Mr. Moore:
Your request for a waiver of the 100 foot separation required
between the septic tank and well on the subject property has
been granted. This distance has been waived 'to 92 feet in this
case. This waiver is based on your assessment that site
conditions are such that a waiver can be granted without posing
a risk to public health.
This waiver is valid for the existing three bedroom single
family dwelling only. Upgrades or enlargements of the existing
septic tank will invalidate this waiver.
Sincerely,
Stephen S. Morris
Civil Engineer
On-site Sevices
CC
Gus Andress, P.E.
Manager, On-site / Water Quality
FLATTOP
TECHNICAL SERVICES
CIVIL & ENVIRONMENTAl. ENGINEERING · ENERGY CONSERVATION & ANALYSIS
THEODORE F, MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 ANCHORAGE, ALASKA 99516
March 17, 1987
M.O.A. Dep't. of Health and Human Services
P.O. Box 6-650
Anchorage, AK 99501
RE: Waiver Request - Lot 10, Blk H, Knik Heights S/D
Dear Sirs:
Pursuant to the new fee schedule instituted at the beginning
of this year, our application for the subject waiver is
accompanied by the required $240 to cover processing costs. My
client contends, and I agree, that the fee should not be imposed
in this case, since the necessity for the waiver process at this
time is simply to correct an error made by the Municipal
inspector at the time of construction in 1978. The present
owners bought the property based, in part, on the assurance
provided by the 1979 Health Authority Approval, certifying that
the water and wastewater disposal systems were in full compliance
with Municipal requirements.
Please review and act upon this request, as my client should
be entitled to a refund of the waiver processing fees.
Sincerely,
Ted Moore, P.E.
FLATTOP
TECHNICAL SERVICES
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
TItEODORE F. MOORE, P.E. 14530 ECHO ST.
March 17, 1987
PH: (907) 345~1355 ANCHORAGE, ALASKA 99516
Steve Morris
M.O.A. Dep't. of Health and Human Services
P.O. Box 6-650
Anchorage, AK 99501
RE: Well-Septic Separation Waiver - L 10, Blk H, Knik Heights S/D
Dear Mr. Morris:
By means of this letter I am requesting a waiver of the well
to septic tank separation distance on the subject lot down from
the required 100 feet to 92 feet. A site sketch and copies of
pertinent backup documents are euclosed.
The septic tank is a 1000 gallon, two compartment steel tank
manufactured by Greer. According to the Municipal inspection
report approved by John Kennedy on November 1, 1978, the distance
from the well to the septic tank is 100 feet, and to the absorp-
tion field is 120 feet. Since the well log is dated Nov. 10, one
must assume the well was in the process of being drilled at the
time of the Municipal inspection. On May 4, 1979 Les Buchholz
signed a Health Authority Approval of this system.
On February 26 of this year, I measured the separation
distance from the well to the septic tank cleanout to be 93.7
feet, and to the cleanout at the closest end of the absorption
trench to be 103 feet. The 92 foot separation distance waiver
being requested is to allow for the presumed underground position
of the tank.
The surface topography in this area slopes towards the
northwest at 2 to 3%, which means that should the system back up
and overflow, effluent would flow away from, rather than towards
the well. The house foundation is also between the well and the
septic tank. According to the on-site sewer permit, the soil in
which the system is constructed is rated at 85 sq. ft. per bdrm.,
and this classification is supported by a rapid absorption rate
observed at the time of the septic adequacy test on February 27.
According to the well driller's log, the underlying soil
consists of large rocks and hardpan between 30 feet and 1118 feet,
with a stratum of blue clay just above the bedrock interface at
122.5 feet. The first water reported by the driller was a small
flow at the bedrock interface. The driller then continued down
through the bedrock to a total depth of 310 feet, reporting a
total yield of 2.5 gpm from fissures in the bedrock.
When I tested the well on February 26, the yield turned out
to be 170 gallons per day, or only enough for 1 bedroom. To cure
this situation, the homeowners decided to have the well deepened
another 100 feet. The new well log is attached, showing a yield
of 2 gpm and a static water level at 155 feet. I retested the
well on March 16, at which time the yield measured out to be 2.3
gpm. Based on my tests, it appears that virtually all of the
well production occurs from fissures in the bedrock more than 300
feet below the surface of the ground. It is my opinion that the
bedrock, acting in conjunction with the overlying strata provides
a good barrier to surface contamination.
This lot is approximately one acre in size, and the
magnitude of the waiver being requested is less than 10 % of the
required separation. We are only concerned with the septic tank,
which should pose less of a hazard than an absorption system.
For these reasons, it is my opinion that the requested waiver can
be granted without endangering the public health.
Please feel free to call me if you have any questions.
cc. Kinney and Martha Baxter
Sincerely,
Ted ~oore,
OF/I¢%
Flattop Technical Servfces
14530 Echo Street
Anchorage, Alaslca 99516
got II
F
IViUNiClPALITY OF ANCHORAGE DEP'F ~ ~&
DEPARTMENT OF HEALTH& ENV ~ONMENTALPROTE~J~r' -' ' ~' '-
825 L Street- Anchorage, Alaska 99501 - ~L~C [1~,
Telephone 264-4720 ~ ~f
DIRECTIONS: Complete all parts on page 1. Incomplete requests will trot be processed. Please allow ten (10) days for processing.
1, PROPERTY OWNER PHONE
~AILING ADD~ESS
PROPERTY RESIDENT (If different from above) PHONE
PHONE
MAILING ADDRESS
4, REALTOR/A~NT / PHONE
MAILING ADDRESS
O'T1
5. ~_DES~,? PTION
TYPE OF RESIDENCE NUMBER OF BEDROOMS
/~ [] One [~] Four
SINGLE FAMILY ~ Two [] Five
[~ MULTIPLE FAMILY [] Three [] Six
[] Other
7, WATER SUPPLY
INDIVIDUAL" ~ ATTACH WELL LOG. A well Icg is required for all wells drillee
COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach Icg if available.)
8,
SEWAGE
DISPOSAL
SYSTEM
/~ INDWIDUAL/ON-SITE~
. If system is over two (2) coors old an adeouacy test is recuired
[] PUBLIC UTILITY
Dy this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INIT ATED.
72-010(3/7B)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR I NSPECTO R INSPECTOR
DIRECTIONS:
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
Connection Verified
INSTALLER
[]Septic Tank_or [] Holding Tank
Size: /C)l~O If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER ,/~. , . .
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELLTO: 1 ~) I~) ~ '~...~ 0
I
Absorption Area to nearest Lot Line
5, COMMENT8
APPROVED EDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Tit. l.e/!/ //~
LEGAL E~ESCRIPTIQN
72-010 (Rev. 3/78)