HomeMy WebLinkAboutWEST ADDITION KNIK HEIGHTS BLK 2 LT 3West Addition
Knik H
ight
lock 2
Lot
017-371
-33
Municipality of Anchorage page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICE¢
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,.~f,4,/¢¢O/~- PIDNumber: 01'7:77 1'33
~ Name:
A H ~ ~ Wastewater System: ~ New ~ Upgrade
Address:
P.O. ~ IOlO~O~ ~n~ ~ ~¢~0_ ABSORPTION FIELD
Phone: ~73--~ 8~ ~ ~ Deep Trench U Shallow Trench deed ~Mound ~Other
LE GAL D ES C RI PTI O N Soil .aling: Total Depth from original grade:
¢'~ GPD/Sq. Ft. I1,0
Lot: ~ Block: ~ ~'~ t ~Subdivisi°n:~, ~¢~ Oeplh Io pipe bottom~.~lfrom original grade: FI. Gravel d~oth beneath~pipe// Ft.
Township: ~N Range: ~ ~ Seclion: ~ Fill added aboveo.~originalgrade: Fl. Gravel length: ~ / Ft.
WELL: ~/~ ~ New ~ Upgrade Gravelwidth; Number of lines; Oislancebelweenlines:
Classification (Private, AiB,C); Total Depth: Cased To: Total absorption area: Pipe ma[erial:
Fl. FI. l~7~
Driller; Dale Drilled: Sl¢li% Waler Level:Installer: Date inslalled:
~, t~ + ( ~,'~
Yield: GPM Pump Setal: Ft. CasingHeighiAboveGround:Ft. T~NK
SEPARATION DISTANCES u Septic U Holding ~ S.T.E.P.
'~om ~,,~ ~,,,,,, ~, .......~,,,,~~ ...... ~ ....... _ A~c4or~ ~n~ I~o0
well 107 113 I~' -- >~¢' ~e¢l
Surface
Water >1~' >~' >~oo' - - LIFT STATION
Line ~ ' 7~ ~8I ~ -- ~fd~l
Foundation ~7' ~8' ¢7' - 0 N 3" 2~" I Va"
Curtain Pump Make & Model Electrical Inspections performed by:
Drain N,~. ~'~' ~' ~' ' -- ~&l I/~&~ ~.0.
Remarks: ~¢m I~[le~ p~¢ ¢~ BENCH MARK
~ LocaUon and Description;
/
~r~ mOqO~¢¢ ~e~,d¢ ~/IC.~'~/ ~4¢( ~. q~rO¢6 ~p~O,I ENGINEER'S SEAL
' - ' ~-~ ..........
~-~ ~ .* ~ .. ~.~ ~,
Inspections performed by: ~l~n Tec~ ~uc Dates: 1st 7/
Department of Health and Human Services approval '~, ~TH~O06R~ F. A~OO~ .:
Reviewed and approved by: .- Date:.~-
72-0~3 (Rev. 9/91) MOA 25 .Z.-
PermitNo, .~W c~z/O 13~' Page 2. of 3
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: LoT 3, ~LK 2., KNIK HT5 WEST PIDNo.: 01'7'~7133
1"=30'
~ BDR~
House
~,'ELL
Fl~top Technfcal Services
14530 Echo Street
Anchorage, glaska 99519
72-013 A (Rev. 9191) MOA 25
PermitNo. 3~ q~0136" Page '~ of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: LoT 3, 8LK 2] Fair-. HT5 kc'EST
PID No.: 01737
tDIST, PiPE It4V£RT/
~7. fl' 204'
ALL ~ND~
i5oo C~AL
STEP 'TANK
OUTLET INVERT ctS.,
BOTTOM o¢ TRENC~ C~O,~/'
72-013 A (Rev. 9/91) MOA 25
'Lb
.F/aftop Technical Services
14530 Echo Stree[
Anchorage, ~lasl~c~ 99516
T. H. ~2 ~
oR',/ To ~',,~ '
ENGINEER'S SEAL
THEODORE I:. A~OOR~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW940135
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:ALASKA HOUSING FINANCE CORP
OWNER ADDRESS:P.O. BOX 101020
ANCHOR_AGE, AK 99510
DATE ISSUED: 5/23/94
EXPIRATION DATE: 5/23/95
PARCEL ID:01737133
LEGAL DESCRIPTION: KNIK HEIGHTS WEST ADDITION BLK
2 LT 3
LOT SIZE: 46060 (SQ. FT.)
5KIMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
DATE:
Tom Fink,
Mayor
h&unic_pal ty of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
May 23, 1994
Ted Moore, P.E.
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
Subject: Waiver Request for Lot 3 Block 2 Knik }{eights West
Waiver Request #WR940025, PID #017-371-33
Dear Mr. Moore:
Your request for waiver of the required 10 foot separation
between a septic system and a lot line has been approved. The
waived distance is 5 feet from the west property line to the
western trench leg.
This approval applies to the existing septic system lot line
separation only. Any future upgrade to the septic system will
require all separations be met or another approval from this
department.
~.~cerely, ~
~il Engineer
On-site Services
ljw%7
MUNICIPALITY OF ANCHORAGm
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
WR# WR940025 _ PID# 017-371-33
Date Received: May 10, 1994
HA#
Permit
Legal Description: Lot 3 Block 2 Knik Heights West
Engineer: Ted Moore, P.E, Flattop Technical Services
14530 Echo Street, Anchorage, Alaska 99516
Applicant: A.H.F.C.
Waiver Requested: Lot line waiver of 5 feet from the west property
line to the western trench leg
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
Special Conditions:
3. Other:
Waiver is Granted: I/ Waiver is NOT Granted:
List Conditions or Reasons for above: ~Q ~~l~
Date:
N?e of Reviewer
Rec #: 25886/4173 Amount: $ 115.00 Date Paid: may 10, 1994
ES
CIVIL & ENVIRONMENTAL ENGINEERING ,, ENERGY CONSERVATION & ANALYSIS
I'IfEODORE F. MOORE, P.E. 14530 ECHO ST.
f~H: (907) 345-1355 May 6, 1994 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sh's:
The purpose of this letter is to provide the requh'ed design nm~ative in support of our application for a
lot line waiver and permit to upgrade the wastewater disposal system on Lot 3, Block 2, Knik Heights
West S/D, located at 12901 Elmore Road. The existing system failed a recent adequacy test, because it
was found to be in the water table. Soils logs, perc test results, a site plan, design di'awings and
specifications are enclosed for yom' review.
The proposed system will be constructed in the vicinity of test hole # 2. As can be seen from the soil
log, the native material between 5.5 feet and 11 feet is a slightly silty sand with a measured perc rate of 2
minutes per inch. Using the slightly conservative soil application rate of 0.8 gpd/sq, ft., this 4 bedi'oom
residence requires a total absorption m'ea of (4 x 150)/0.8 = 750 squm'e feet. Discounting the portions of
the trench legs within 5 feet of the intersection, the proposed u'ench design has a total absorption area of
836 squm'e feet.
A lot line waiver is requested ~lowing the western trench leg to be within 5 feet of the west property
line which abuts Elmore Road. Since this is a public R.O.W. there will be no impact on the ability to
construct futm'e wastewater disposal systems on adjoining lots. The mason for the requested waiver is to
allow concentration of the absorption system in the optimal soils encountered in the vicinity of Test Hole
#2, which is at a higher elevation than Test Hole #1.
The topography of the lot in the m'ea of the proposed upgrade slopes towards the northeast at
approximately 10%
The proposed project will have no impact on present or future water supply and wastewater disposal
systems selMng adjacent properties, nor will. it have any impact on reserved space/surface and subsurface,
or on di'ainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
LOT 2
BLOCK 2
EXISTING SOIL
ABS. TRENCH
HOUSE
SEPTIC / -B2~}
EXISTING 1250 GAL.
SEPTIC TANK
WELL~ ~
50'
PROPOSED
85' TRENCH
I0%
/15% DRIVE
/
/
LOT 4,
BLOCK 2
\
\
-...
WEI.L.~
CNEW 1500 GALLON "' '--,%.
STEP TANK / "~"-.
/DOG "~.
/-,.. RUN / ,,.
· '~ /
\
\
LOT 3,
BLOCK 2 \
R 100'
--LL
'-. /
'" /
,, /
',, /
/
/
/
?
/
//
///
HOUSE
SYSTEM
/
/
/
LOT 3, BLK. 2, KNIK HTS. WEST
WELL AND SEPTIC SYSTEM
SITE PLAN
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, ALASKA 99516
EOT 2
1 INCH = 5O FEET
DRAWN BY TFM
MAY, 1994
NOTE: THIS IS NOT A SURVEYED PLAT.
ALL LOCATIONS SHOWN ARE APPROXIMATE.
EDGES OF TRENCH
EXCAVATION
1 1/2" DIA SCHED 40 NON-PERF PVC
DISCHARGE LINE FROM STEP TANK
-- MONITOR TUBE
(TYP. 4 REQ'D)
1 1/2" DIA SCHED 40 PVC WITH 3/16" DIA.
HOLES IN BOTTOM SPACED 2.5' O.C.
PLAN VIEW
SCALE: 1" = 10'-0"
MONITOR TUB
FINAL GRADE
BACKFILL SOIL --
FILTER FABRIC --
1.5" DIA PERF
DIST. PIPE
1/2" - 2 1/2" DIA
SEWER GVL.
SECTION "A-A"
SCALE: 1" = 5'- 0"
-- ORIGINAL GROUND
LOT 3, BLOCK 2, KNIK HEIGHTS WEST
SEPTIC SYSTEM UPGRADE
PLAN AND CROSS-SECTION
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, AK, 99516
SCALE: AS SHOWN
DRAWN BY: TFM
DATE: MAY, 1994
Flattop Technical Services
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
Lot 3, Block 2~ Knik Heights West S/D
12901 Elmore Road
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of abandonment of an existing 1250 gallon fiberglass septic tank
and soil absorption trench and installation of a new 1500 gallon STEP tank which pumps effluent up into
85 lineal feet of soil absorption trenches containing a total of 5.8 feet of sewer gravel.
1.2 Consu'uction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these ch'awings may be allowed or requh'ed by the engineer conducting the inspections.
All construction procedm'es and material specifications shall confo~n with Municipal and State
requirements. All separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work m'ound any
bmSed utilities.
1.4 The contractor shall provide adequate cover matehal and rough grading over all system
components to ensure that proper ch'alnage is achieved after settlement and that there m'e no residual
depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas.
All 2'ees and brush which are distm'bed in the construction of the project shall be removed from the site at
the contractor's expense.
1.5 The contractor shall be responsible for finish grading after the soil is compacted, as well as
placement of topsoil and reseeding all areas disturbed by the construction.
1.6 If the contractor's construction procedure necessitates more than the five inspections outlined
below (which will be paid for by AHFC), the contractor shall pay the engineer directly for each additional
inspection needed during normal working hours at the rate of $75 per inspection.
2.0 Septic Tank:
2.1 The existing 1250 gallon fiberglass septic tank must be properly abandoned by thoroughly
pumping, removing the top and backfilling with soil. The existing soil absorption trench shall be
abandoned in place with the standpipes removed.
2.2 The new 1500 gallon, 2 compm'tment STEP tank shall be Municipally approved and shall be set
level on undisturbed soil. Each compm'tment shall be equipped with a watertight manhole cover and a 4"
cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type,
rigid insulation. Particular care shall be taken to ensure that the soil under the pipes entering and exiting
the tank is fully compacted, aud the contractor shall accept responsibility for necessm'y repah's should the
ground settle causing the pipes to break.
2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic t~mk shall have a minimum slope of 1/4'" per foot. If the
original foundation cleanout cannot be located, a new double cleauout shall be installed in the waste liue
upstream of the STEP tank allowing the line between the residence m~d the t~nk to be cleaned.
3.0 Lift station:
3.1 The lift station shall be installed in the second compartment of the STEP tai~ which has an
additional 250 gallon capacity. The lift station package shall be an "Orenco" system as supplied by
Anchorage Tank.
3.2 The conf,'actor shall be responsible to obtain the necessary Municipal electric permit and
inspection, and shall provide a copy of the elecu'ical inspector's report to the engineer overseeing the
construction of the wastewater disposal system.
3.3 The lift station shall be equipped with a watertight, insulated manhole riser m~d cover extending a
minimum of 6" above final grade with positive surface drainage away from the manhole. The contractor
shall be responsible for determining the necessary length of the manhole riser.
3.4 The on, off, and alm'm floats shall be set at the elevations specified by the lift station supplier, and
their proper operations shall be verified by tlie contractor.
3.5 The dischm'ge line fi'om the lift station to the soil absorption system shall be either 1.25" or 1.5"
dia. Sched. 40 PVC. The portion of the distribution pipe which passes under the di'iveway shall be
bm'ied a minimum of 4 feet and shall be insulated with 4 inches of rigid, burial type insulation having a
minimum width of 2 feet.
4.0 Soil absorption system:
4.1 The soil absorption system shall be constructed by excavating 85 lineal feet of trench to a depth of
11 feet below the original ground level in the vicinity of Test Hole #2. The exact configm'ation may be
adjusted to minimize disturbance of trees.
4.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces shall be raked to
allow proper infiltration.
4.3 A total of 5.8 feet of approved sewer ~,n'avel shall be placed in the bottom of the excavation with
the perforated distribution pipes laid level such that the pipe inverts m'e no less than 5.5 feet above the
bottom of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing
the #200 sieve.
4.4 The perforated distribution pipes shall be either 1.25" or 1.5" schedule 40 PVC with 3/16"
diameter holes drilled in the bottoms on 2.5 foot centers. The ends of the distribution pipes shall be
capped, and all joints shall be glued.
4.5 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design di'awings. The portion of the monitor tube extending through the sewer gravel shall be
perforated.
4.6 Approved filter fabric shall be placed over the entire top sm'face of the sewer gravel. A minimum
of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet,
two inches of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in
addition to the filter fabric.
4.7 The top surface of the cover material shall be raised a minimum of 6 inches higher than the
SUla'ounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
4.8 After the backfill material has stabilized the contractor shall provide finish grading to smooth
contom's and place a minimum of 3 inches of topsoil over all disttu'bed m'eas and seed the area to promote
rapid revegetation of all m'eas disturbed by the construction.
5.0 Inspections:
5.1 A total of up to 5 engineering inspections will be provided by the engineer at no cost to the
conu'actor dm'ing the com'se of the project: (1) initial stakeout with the contractor to establish the location
of the system and to discuss the plans, specifications and construction procedures, (2) after the native
material has been excavated to expose the infiltxative surface to ensure that it is level and at the fight
elevation, and conforms with the soil test information, (3) after the sewer gravel is in place and the
dista'ibution pipes have been laid and connected up to the septic tank, but prior to placement of insulation or
filter fabric, (4) after rough backfill and grading is complete, and (5) after the STEP tank has been set level
and the piping connected, but prior to backfill. The tank inspection may be incorporated with any of the
above inspections, however should the conu:actor's construction schedule necessitate more than 5
inspections, he shall pay the engineer dh'ectly for each additional inspection at the rate of $75 per
inspection.
5.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently fax' in
advance to ensure the availability of the engineer during nolrnal working hours.
TEST HOLE # 2,
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
(feet)
1-
COMMENTS:
FLA'I-FOP TECHNICAl_ SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
LOT 3, BLOCK 2, KNIK HEIGHTS WEST
APREL. 21, 1994
AHFC
Pt
ML Fill material
Pt
SM Reddish silty, sandy loam
SP/SM Somewhat silty sand
Ivl% Gray silt
SP Coarse, slightly silty saad
Gray, damp
SM Tall silty sand
Deeser near top
Cleaner and dry
ne~m' bottom
SLOPE SITE PLAN
Depth to Groundwater Date
No gr~mdwater 4/21/94
M.T. Dry 5/2/94
Clock Net Time Percometer Net Drop
Date Reading Time (minutes) Reading (inches)
4/21 12" Presoak 1:58 28
2:03 21 3/8
_ Add water 2:04:30 27 1/2
_ Start 2:08 23 1/4
#t 2:10 2 21 7/16 1 13/16
Add water 2:10:30 23 1/2
_ #2 2:12:30 2 21 11/16 1 13/16
Add water __ 2:i3 23 3/8
#3 2:15 2 21 11/i6 1 ll/16--
Add waler 2:15:30 23 5/8
#4 2:17:30 2 21 13/16 1 13/16
PERCOLATION RATE 2 (minutes/inch) PERC HOLE DIAMETER 6"
TEST RUN BETWEEN 6.5 FT AND 7.0 FT
PERFORMED BY FLA'FrOP TECHNICAL SERVICES. I~"'._~,.~,,,~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /~¢'7 /'{/ '/¢ ¢ ~/
TEST HOLE# ! J
LEGAL DESCRIPTION:
DATE PERFORMED: APREL 21~_1994
PERFORMED FOR: AHFC
DEPTH
(feat) Pt
SM Reddish sandy loam
2 SP Gray gravelly saad
ML Gray Silt
F LA'rI'OP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
LOT 3, BLOCK 2, KNIK HEIGHTS WEST
SP Clean gravelly saud
lenses of ML
Water (north side of
test hole)
GM Gray silty gravel
B.H.
COMMENTS: No moaitor tube iustalled
SLOPE
Depth to Groundwater Date
8' 4/21
SITE PLAN
EXISTING SOIL EXISTING 1250 GAL. ]
_Z%" / /
/ DRIVE
Clock Net Time Percometer Net Drop
Date Reading Time (minutes) Reading (inches)
PERCOLATION RATE
TEST RUN BE'RNEEN
(minutes/inch) PERC HOLE DIAMETER
FTAND FT
PERFORMED BY FLATTOP TECHNICAL SERVICES. I.~_ __'~-.¢_,,,.,(~_ CERTIFY THAT THIS TEST WAS PERFORMED IN
AOCORDANOEWlTHALLSTATEANDMUN[OIPALGUlDELINESlNEFFECTONTHiSDATE. DATE: ~"~(,4.~ ~/ /~¢/,~
T H U 5 ",47 P . 0. ;L
[~500 gAS]' ~UD[)R ROAD
'.(N~P~IIJN~ (90'7)868.~3464 '[N~(]'~M~ION (~)07)2~6"'82~
I, OT: ~ :4I, OCK: ~ SUBD~ KINK HG'rS D~'.~: 711~/199'
o o
o o
'IUNICIPALITY O[" ANCHORAGE
and Environmental Protc on
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SIT~ ...... St:WAGE DISPOSAl,
SEPTIC TAIJK:
I~I~iBi I.ENGItt .... INSiI>E WII)ltl .. LIOUID t)FPIH __ I.IQUID CAPACITY ~ GALLONS.
IlI_E DRAIN F:IELD:
TOTAL LENGTH
[Ht:l,.tK~{ ~ R~:4, ',,'KLI .... FOU;ID/iIlON _ .NI]ARE5] tGI lINE ...... OF LINE
:: O~ I,illOg I)ISI.~.NC[' BEI'.//i[[iN LIN{]5 FRIH',ICII V/I[31t ..... IN TOI'AL EFFECTIVE
._ SQ. f I'. [ [:NGrtl OF ~AC~! t t~E ........................
;~ ~,i;;: IC~ t,; ~lL~ l~ i~r;~SiT GN/q)E MA~[ RiAL NLNEAI~ 'ILL[''/~ ~ ABOVE -FILE
SEEPAGE PIT:
DI..:'MEi[R __ Oil WIDTH __, LI::,GI t .... DEPI'It
Log Crib ___Rings Crib Size: DI;\Mt-I[R .... £J3~1'1t ...... DISTANCE FROM: WELL
'lOl,SL. EFFECFIVE
t,i~ r r:,, i,_'J;i[)/,!lt)': .... NE:/NRLS] IOF IINE__ _ /,,USORPTION AREA {WALL AREA) ........... SQ. FT.
~ c. oJ : ])0 I:
~,]]. Distance To: Lot Line
I j: Sewer Line:
c>J ]3e(trooms: ....................
.,I ~ ~. ~d,: i:i:Zi:'!- i:'~'!i:;; !:'l F:q il::;i iQ j,ii::i i
!i i ! ii::i:? i?i.:i.;ii i i i;'i:: i'ii:¢.l ! :::; i'ii.i'.,.~ I::lj::'i::'l :/ , ';i:,i:'!::;l: i i': i' Il X::Fi' ) I d',ici; i:::il.ii';* !:~'il.,!':::; I !,q ii: i T i i!:./ i;~ i Fi*:q:;'i;::i!'i'::;
Well Log
~o~ .~~Z. ....... ~ ~ ............................................................................
Lo cation~.Z ...... ~.~,.. ~/~. :~.....~.. ...............
Date completed. ../ .... ~..~.,f2 ..............................................................
Depth of well .... ~.~.,.( ............................................................................................
Size of casing ..... ~.
Distance to water .......... ~..~..
Distance to water while pumping.,. ~ ............................................. at rate
of ...... .~.~..~ ................................. gallons per hour.
Formation
Driller
DELTA DRILLING COMPANY
SRA BOX 394 B
ANCHORAGE. ALASKA 99507
Municipality of Anchorage
Development Services Department
Building Safety Division .-
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. 017-371-3,5
e
tO
Expiration Date: ,,, / O -'.//7/
GENERAL INFORMATION
Complete legal description to~
Location (site address or directions) 12901 Elrnore Road
Current Property Owner(s)..l'ame~ a.a teanne Wa~rT.
Day phone
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: ~
12901 Elmore Road Anchorage. AK 99516
Day phone
Day phone,
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
Individual Holding tank
Community On-site
[] Public Sewer
II
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 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 propedies served by a private or Class C well.and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a pedod 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 redly 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 vedfy 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.
Name of Firm Andgr~on En~lnegrln~J
Phone 522-7775)
Address ?.o. Box 240773 ^.chor~e. Ar. 99524
Engineer's Pdnted Name Michael E. ^n~ler~on: ?.E.
Date ' 71512005
DSD SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
,, .., ,,,~'-...?.% \
~:-~%.... ~o, £-4~
bedrooms, with the following stipulatloL-~.~..' . '.
~;.~-' ON-SITE
~c~..~AiERAND · m
~ : WASTEWATER :
~ : , ,,,,,.RAM .'
AdditionalComments Note: The well for this property meets existin~ State and
Munic~pal'Codes. There are n~trate~ pre~¢B~, It ~s sug~e~qted that periodic te~ting
be pcrfo~ed to ~nmure the w~]lm contqn.oR ~,t~.h~q~y. C,,~r..~ -~tr~t- cn-~-~tratton
is available from the On-Site Services Program, at 343-7904.
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date::~~.~_3
Legal DeScription:
A. WELL DATA
Well type Private
Date completed 8/1119'r/
Total depth 99 ft.
Municipality of Anchorage
Development Services Department
Building Salety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
.trot .3, Ialock 2. Knlk Heights West
If A, B, or C provide PWSID #
Sanitary seal (Y/N) Y
Cased to 99 ft.
FROM WELL LOG
Date of test
Static water level
Well production
g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 mi.
6111119Ti
Parcel ID: 017-371-33
Date of sample: 5R/2003
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ,Sfpli~r..C/Ste~l
Tank size 1,1~00 gal.
Foundation clean0ut (Y/N) Y
Date of pumping 5/5/2003
C. ABSORPTION FIELD DATA
Well Log (Y/N) y.
Wires properly protected (Y/N) Y
Casing height (above ground) .. >;24
AT INSPECTION
6r/72oo3,
4.0 g.p.m.
Nitrate 6,48 mg./I.
Collected by: ~ Hamla
Other bacteria 1 colonies/100 mi.
Number of Compartments
Depression over tank (Y/N)
Pumper A Plus
Date installed ?116/1994
Cleanouts (Y/N) y
High water alarm (Y/N) y
Date installed 111~31!9~4 Soil rating '(g,p.d./ft= or ft=/bdrm) .8 GPDISF System type Deep Trench
Length 85 fl. Width 2 fl. Gravel below pipe
Total depth 11 fl. Eft. absorption area 1,27'5 fi2 Monitoring tube Y Depression over field N
Date of adequacy test 511911~99 . Results (Pass/Fail) P.aes
Fluid depth in absorption field before test 59 in.
Elapsed Time: 1,440 min. Final fluid depth 59 in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
It,
For _4 bedrooms
Water added6?9 gal. New depthS8 in.
Absorption rate >= 600 g.p.d.
If yes, give date
D. LIFT STATION
Date installed. ?11311994
~Pump on" level at 43 in.
Datum I~ottom of Tank
E. SEPARATION DISTANCES
Size in gallons 1,500 STEP
"Pump off" level at 39 in.
Cycles tested..5
Manhole/Access (Y/N) ¥
High water alarm level at 48
Meets alarm & circuit requirements? Y
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot >100
Absorption field on lot >100
Public sewer main NIP,
Sewer/septic service line >25'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5' Property line >5'
Water main >10' Water service line >10'
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation >10'
Surface water >100'
Wells on adjacent lots >100'
On adjacent lots >100
On adjacent lots >100
Public sewer manhole/cleanout N/A
Holding tank NIA
Property line : :' 7 '**
Water Service line >10'
Curtain drain None Noted
COMMENTS
Absorption field >5'
Surface water >100'
Water main >10'
Driveway, parking/vehicle storage >10'
See [et Line Waiver
ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Michael E. Anderson, P..E,
Date 7/5/2003
Waiver Fee $
Date of Payment
Receipt Number
HAA Fee $
Date of Payment
.ece pt .umber
(R~. 1~)
in.
ANDERSON ENGINEERING
P. O. Box 240773
Anchorage, AK 99524
Ph. 522.7773, F 522-6779
LEGAL: ,,L. ?, P~ % I~-~/I~4' /~'. WDS~'/
WELL Depth: ¢]*7 Ft. Static Level: ~"/,~ Ft.
WELL FLOW TEST
TIME METER VOL VOL Time Flow Level L REMARKS
(G) ( gals.) C (NET) (gpm) (Water) (Chg)
Inspector
FLOW RATE:
Date:
GPM REVIEWED:
Michael E. Anderson
Comments:
ANDERSON ENGINEERING
P. O. Box 240773
Anchorage, AK 99524
Ph. 522.7773, F 522-6779
WELL.Depth:~ Ft. Static Level: ~ Ft.
WELL FLOW TEST
TIME METER VOL VOL Time Flow Level L REMARKS ."
(G) ( gals.) C (NE'I) (gpm) (Water) (Chg)
'lnspe~
FLOW RATE: '.~..'~ :".GPM
Date:
REVIEWED:
Michael E. Anderson
Comments:-
\ \ ,'
\ ~.// .-%
,/
I
· S~'~J~--N'~S OF RECORD, OTHER THAN
lOSE S~OWN ON THE RECORDED PLAT,
hereby c~ t~tat
1~ or o~ ~sible c~ on said propemy ex.pt
FR~ W~ &'~SOCIA~S
Parcel I.D. #
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 HEAL'rH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
01 7-371 -33 HAA#
GENERAL INFORMATION
Complete legal description __~ 3: Rlock 2 ~ Knik ,Heights West
Location (site address or directions) 1 2901 Elmore Road
Property owner Michael & Tami Vania
Mailing address ~ Roar]
Lending agency
Mailin. g address
Day phone
Anchor&ge~ AK 99516
Day phone
345-7733
Agent
Address
D~y. phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
commUnity well
Public water
NOTE:
F_o_ur (4)
XXX
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site Xxx
Holding tank ' '
Community on-site
Public sewer
If community wastewater system, provide written Confirmation from State ADEC
attesting to the legality and §tatus of system. ' '
72-025 (Rev. 1/91) Front MOA~I21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or w~tewatg.[' 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 Anderson Engineerin~
Phone 522-7773
Address . p_n ~ 940773 Anchor=Ne, AK 99524
EngineeCs signature
Date 5/27/99
DHHS SIGNATURE
L'~ Approved for /~'~(///0~
__ Disapproved.
Conditional approval for
bedrooms.
bedrooms, with thb following stipulations:
~ote= ?be well ~or this ~ro~erty aeets e×isti~8 State and ~u~±cipa~ Codes.
performed to insure the wells continued suitability. Current nitrate
concentration ~s ~.= .~S/~. EF~ m=~imum uunu=~L~=Liu, i~ 10.0 m~/1.
More information on nitrates is available from the On-site Services Program,
DHHS, 343-4?44.
Additional Comments
By:
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 DH HS does this as a courtesy to purchasers of homes
and their lending institutions !n 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 e[rors or omissions in the professional engineer's work.
72-025(Rev. 1/91) Bock MOAI¢21I
Municipality of Anchorage J~ E (~ I! IV E D.~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division JUN 1 1999
825 L Street, Room 502 · Anchorage, Alaska 99501 · (%0~8i%,~J~¥14~ ,%ncnorage
uept. Health & ltuman Services
Health Authority Approval Checklist
Lo~ :3.. Block 2¢ Knik Heiqhts . Parcel I.D.: 017-371-33
West
IfA, 13, or C, attach ADEC letter. ADEC water system number
Legal Description:
A. WELL DATA
Well type private
Log present (WN)
Total depth 99 '
Sanitary seal (Y/N)
Y Date completed 8 / 77
Cased to 99 '
Y
FROM WELL LOG
8/17/77
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform 0
Date of sample:
65'
Nitrate
5/19/99
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPEC'TION
5/19/99
64'
g.p.m. 5.2
5.2 mg/L Other bacteria 0
Collected by: MEA
B. SEPTIC/HOLDING TANK DATA
Date installed 7 / 16 / 94 Tank size ! , 500
Foundation cleanout (Y/N)
Date of Pumping 12/14/98
C. ABSORPTION FIELD DATA
Date installed 7 / 13 / r~ 4 _
Length R 5 ' Width
Depression (Y/N)
Pumper A Plus
Number of Compartments 3 Cleanouts (Y/N). Y
N High water alarm (Y/N) Y
Soil rating (g.p,d./fF or ft2/bdrm) . 8
Gravel thickness below pipe
g.p.m.
Effective absorption area ! , 275 SF Monitoring Tube present (Y/N) Y
Date of adequacy test 5/1 9/99 Results (Pass/Fail) Pass
Fluid depth in absorption fiekl before test (in.); 3.2 '
Fluid depth ~ _ ?, (ins) Minutes later:. 2 Hrs.
Peroxide treatment (past 12 months) (Y/N) __ N
72-026 (Rev. 3/96)*
System type Trench
7.5 ' Total depth 11
Depression over field (Y/N) N
For 4 .bedrooms
Immediately after650 gal. water added (in.): 3.8 '
Absorption rate = >600 g.p.d.
If yes, give date N/A
D. LIFT STATION - None on Lot
Date installed 7 / 1 3 / 9 4
Manhole/Access (Y/N) Y
High water alarm level at* 4 8"
Cycles tested 5
E, SEPARATION DISTANCES
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Size in gallons 1,500 ~11cm STEP
43" "Pump off" level at* 39"
N/A
>100'
R~mm O~ Tank
Septic/holding tank on lot > 100 '
Absorption field on lot > 100 '
Public sewer main N/A
Sewer/septic service line > 25 '
On adjacent lots > 100 '
On adjacent lots > 100 '
Public sewer manhole/cleanout
Lift station > 100 '
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation > 5 ' Property line > ~ ~ Absorption field
Water main/service line > 2 5 ' Surface water/drainage > ! 0 0 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
> 1 ~ ' Building foundation ~ 10 '
Wells on adjacent lets
Property line
Surface water > 10 O '
Curtain drain None on Lot
ENGINEER'S CERTIFICATION
Water main/service line > 2 5 '
Driveway, parking/vehicle storage area > 10 '
Wells on adjacent lots > 100 '
I certify that I have determined thru field inspections and re
in conformance with MOA HAA guidelin/~s in effect on this date.
Signature ~,, ~ ~
Engineer's Name Micha~.] R. Anc~c~'r"~c~t3, p. '~' ·
Date 5/27/99
HAA Fee $
Date of Payment
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
C)n-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
0/'7-3-//
'1. GENERAL INFORMATION
Complete legal description
Lot 3; B].ock 2; Knik Heights ~qest Addition
Location (site address or directions)
12901 B~agaw
Anchorage, AK
Property owner
Mailing address
Ed HaL~man Day phone
2140 East Dimond Ancho~aqe, AK 99507
349-603.!
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
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) From MOA #21
5~ STATI-_IViF_i',tT OF INSPECTION BY ENGINEi:R
AS (;ertified by my seal affixed hereto and ds ol ih(. vaiioahon dalo shown hetow, t ve~dy ih~d
~nveshgalion ol this Health Aut~,)~ity Approval ~iDpi~cahol~ shown thnt lhe o~ silq waler ~l
arid/or wastewater disposal sys!eq~ is safo. Iur~ctior'.al ~H~G adoqi~[~te ior th(~ ~iHmhe~ of bedu
~u~d type of slructu~ e u~dicated herein. I further verd/thud nased on tllo tfiform~dio[~ obtained f~
the Municff}alih/of Anchorage files and from my ,pveshgabon and inspeclion: the on-site
supply ~]~d/o~ wastewater disposal system is ,n c()n]pliari(;o wdh al! M{u~icll)al and %1~:o (:(,des
q~dinances, and ~egulations in Ef:ect on the date ol this u~specdop
S & S EF~OtNEERING
Name of FJqn ]70~4 Eadl~Ri~er Lr~ep Ro~d N~. ~0~ Phone ('_ ~!' M - ~ ~ -~ "~
Address [~gle Ri',cr, Alaska
DHHS SIGNATURE
· Approved for
Disapproved
(';onditionat approval for ~
Additional C;omn]ents
with ¢~,; follow,hq stio d;~ i-
:he Municipality ot Anchorage Department of Flealih ]nd ~!,.una!; S~?r¥1ces (DIdFtS) !ssues Henllh Author;tv
Approval Gertificates based only upon tn~ representahon: ~ver~ u! paraqraph :¢ ~/bove by E~r~ ~ndep~ndon(
professional engineer reg~slered in the Stae e[ Alaska ! he 131-4HS .:Joes this as a (:o~ ulosy to pi wchase~ s of homes
and their lending instituhons in orde¢ to salmfv cedau~ federal ]nd sl~qe r(~qu~oi~?rds ! ml~loyees of D~ IHS do
(:OndL!ct inspections or analyze data before a o2rtlf!cflle i: lSqkj,;CJ Fh(~ ~vi~H]l(;Ip;]litv (;¢ An(:hor;~q~ m not
responsible fo~ errors or OllllSS!OllS !fl the l)rOleSSiOna! Cf~ilrqp~r S WOrk
h~UNICI?^LITY OF ANCHOP~GI~
ENVII~ONMENfAL ~ERVICE~
Municipality of Anchorage ~UL 1 8 1996
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmenlal Services Division ~ ~V
825 L Street, Room 50~ · Anchorage, Alaska 99501 · (907) 3 '
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Parcel I.D.:
Well type/~f-~-~//~
Log present (~N)
Total depth ~'~
Sanitary seal ~'N)
Date completed
Cased to 99 /
If A, B, or C, attach ADEC letter. ADEC water system number
Casing height (above ground)
Wires properly protected ~]N)
Date of test
Static water level ~'~ /
Well production
FROM WELL LOG AT INSPECTION
g,p.m.
WATER SAMPLE RESULTS:
O
Coliform
Date of sample: '~' '¢ '/'/- ~ ~
Nitrate
~- ¢) ] Other bacteria 0
__ Collected by:
B~C~HOLDING TANK DATA
Date installed 7 ~/~ .-/9 ~ Tank size
Foundation cleanout,~N)
Date of Pumping '7//f~
C, ABSORPTION FIELD DATA
Date installed :7'-/-~ '-
Length o~'~'~~'/ Width
Effective absorption area
Date of adequacy test
,/;~ Depression (Y~/¢O~'' High water alarm (~N)
Pumper ,/)
Cleanouts ~1'4 )
?~,
Soil rating ~or ft2/bdrm) ~ ¢ ~ System type -'~Z¢-'~"//
Gravel thickness below pipe 7,~,47' / //, ~ /
Total depth
Monitoring Tube present~l)/v-~---~S Depression over field
Results ~..~ail)/a,,~l (~ For /7/' bedrooms
Fluid depth in absorption field before test (in.); ~/ . Immediately afterff¢ -? gal. water added (in.):
FlUid depth ~ ~'~ (ins) Minutes later: /7 Absorption rate = ~¢X"¢O .,'- g.p.d.
Peroxide.treatment (past 12 months) (YL/~ ,,v'¢,/~'¢ ,,~'¢¢:,~/If yes, give date ,//-/.
72-026 (Rev. 3/96)*
Do
LIFT.STATION
Date installed 7 --/~
Manhole/Access C~JN) ~"~
High water alarm level at*
Cycles tested
"Pur~p on" level at* ~ ~ "Pump off" level at*
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~olding tank on lot
Absorption field on lot
Public sewer main ,,/t/.
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Sewer/septic service line ~ $--/-/- Lift station /'&cc "~
SEPARATION DISTANCES FROM~G~HOLDING TANK ON LOTTOo~
Foundation -//~'~ /cz, ~ ' -~-~' /~ v4~l v~'~
~roperty ~ine Absorption field
Water main/service line
Surface water/drainage ./0 0 ~'ff'- Wells on adjacent lots
Property line
Surface water
Curtain drain
ENGINEER'S CERTIFICATION
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Building foundation /~ /'~ Water main/service line
/ 0 0 fi- Driveway, parking/vehicle storage area
~/.. &. /~,-/o ~ ru Wells on adjacent lots /~¢'g;'
I certify that I have determined thru field inspections and review of Municipal records tha~.~;#ee~m~,ystems are
in conformance with MOA HAA guidelines in effect on this date.
Signature "-2/~'(~, /.~,----/
HAAFee $ x~ ~ ~ Waiver FeeS
Date of ~.ymont ~ ~ ~ Dato
Receipt Number ~d~)~ C.~¢ ) Receipt Number
72-026 (Rev. 3/96)*
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
GENERAL INFORMATION
Complete legal description
Location (site address or directions) [ ¢_¢ o f ¢//~o~ /'<~__~
Property owner ~1-/ F(' Day phone
Mailingaddress ?.O, Gox /0( o~0 / Anchonc~¢2.~
Lending agency N, A, Day phone
Mailing address
Agent V,~cc p~.lm,%, J--~ck L/.~'A,~. ~'o Dayphone
Address 9 80( "~ " ~C/t. , PrncJ~ or~¢¢ /¢rL< ¢96~O3
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: _
3. 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:
NOTE:
72-~25 (Rev. 1/91) Front MOA#21
Individual on-site
Holding tank '-'"~
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system. . ::, :,',~h.~ :':.,,,, · : ..
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance .with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm /':la/-~/~ 2-~c4 .'~ c~ f _Cg,-~, i(~'_~ Phone
Address /~-~0 ~c~o ~. ~c~ o~¢ ~ ~
Engin~ds signature ~~ ~ ~ Date
DHHS SIGNATURE
'~ Approved for
/
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 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..:.
72-025(Rev. 1/91) Back MOA~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /-.¢,¢'.~; ~/~ ~'., /~,~k- /-J'/-~- txJ'~-t- Parcel I.D.
A, Well Data
Well type Dr, ~' ¢, f~
Log present (Y/N) '7'
Total depth ~) '
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~¢ / 7-7 Driller
Cased to )? / Casing height 8 ?-"
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECTION
E¢/17/77 ¥ fOf~
5- g,p.m, b-, 7
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ! 0 7 '
Absorption field on lot
Public sewer main /~, A.
Sewer service line
g.p.m~r3
; On adjacent lots
; On adjacent lots
Public sewer manhole/deanout N. /)-.
__ Petroleum tank t~o~ %~eO
WATER SAMPLE RESULTS:
Coliform 0 cc, ( /¢o o ,mZ Nitrate
Date of sample: I~/ff ¢'~'¢ .) /I ,/7 /9~'
3.9~
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed 7 ,/f 3 { ? ~' Tank size I,.5-oo CPa [..~ ?~1~ Compartments
Cteanouts (Y/N) T' Foundation cleanout (Y/N) Y' Depression (Y/N)
High water alarm (Y/N) 7' Alarm tested (Y/N)
Date of pumping /'4,/9. (__ Nz~<-, ) Pumper N. /9
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ! 0'7
To property line '8 ~
Surface water/drainage
On adjacent lots ~ (o,o' Foundation
Absorption field 70' Water main/service line
lO0'
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed 7 / I i~ /9 Y' Manufacturer d2r~o ¢o ,/' ,~,n oflo ,"~¢¢¢' ~,o ~
Size in gallons '~nc, L ¢o~/t, of 15-o¢~,~[£7-~PManhole/Access(Y/N)
Vent (Y/N) Y' "Pump on" level at q 3" "Pump off" Level at ~' :)/'
High water alarm level q b" .Cycles tested !
On adjacent lots l> [ (cc,' Surface water l> too '
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot [ o '-z '
D. ABSORPTION FIELD DATA
Date installed "7 / ~'~
Length ¢5- t Width '8'
Total absorption area / '8 -75-
Date of adequacy test hi. ,4.
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) O. ~
Gravel thickness -7,¢'
Cleanout present (Y/N)
Results (pass/fail)
System type -7-r e,~ c4
Total depth //. o
'T' Depression over field (Y/N)
/,,I. ,4-. for
After test
If yes, give date
N
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / / 3 '
To building foundation ¢ E '
On adjacent lots 2> 3
Surface water ) (O
Curtain drain Non f'.
E. ENGINEER'S CERTIFICATION
On adjacent lots ~ IO~,' Property line
To existing or abandoned system on lot
Cutbank hi, 4. Water main/service line
Driveway, parking/vehicle storage area 9'¢ '
72-026 (3/93)* Back
HAA Fee $ ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect~t~ of this inspection.
Engineers Name
','~
MUNICIPALITY OF ANCHORAGE
DEPARTNIENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL NEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Application Date ~:;~'{ /.--7-m.[-~t:;;:'~.,... { ~' I';~ ~'-'
Legal Description (include lot, block, subdivision, section, township, range)
(b)
(c)
Location (address or directions)
/!~ ~(:~/~. "-','~ '
Applicant Name ~)~,~=7¢_~-
__ Telephone: Home "?)"t'b~ .. ,C}~¢~'-jOr~ Business
Applicant Address _.~
Applicant is (check one): Lendin9 Institution []; Owner/builde/; Buyer [];
Other
(explain);
(d)
(e)
(f)
Lendin~ In'stitution _ . , _
Telephone
Mail the HAA to the lollowing address:
TYPE OF RESIDENCE
Single-Familyy Multi-Family?[
Number of Bedrooms_ ~T
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 {-I 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 PROVIDII'~d INSPECTIONS, TESTS, FILE SEARCH, Dt,~A 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.
~'~,.~'~:<~ /--ff-'~,~ ,, _~. Telephone
Name of Firm ~
Address %%~ ~.~ ~ ~?
Approved t': , '-~'¢' Disapprove-~/- · Con~ii;i'~r :.
Terms of Conditional Approval
Engineer's Seal
~ ~' ROFESS~B~
Date ~/,~/~ '
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
an.alyze 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
h~Ct.~O~,I~:L~'ALT" AUTHORITY APPROVAL ("AA)
ij~.),~_~...~.~'"'~,c,c,c,c,c,c,c,c,c,~;t~.,.~.rl, Ot4 CHECKLIST, FEBRUARY
1984
--'- ~..~ ~o~c~, 264-4720
~ ~ ~ Legal Description:
Casing Height Above Ground
Well Classification ']7~ ~*,/~''~ =r~' If A, B, C, D.E.C. Approved (Y/N)
Well Log P[esent (Y/N) ~ Date Completed ~"?/?"~ Yield
Total Depth 'c-¢r7 Cased to 4~ Depth of Grouting
Static Water Level _ c/~2~~' / Pump Set At
/~- '~
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Sanitary Seal on Casing (Y/N) .~.
Depression Around Wellhead (Y/N)
To Septic/Hold,,i.n.q.,Tank on Lot /OO¢/'~ ; On Adjoining Lots
To Nearest' ~e ~.~, Absorption Field on Lot _! r.z'~'~' ~'r ; On Adjoining Lots /Go
To Nearest Publid Sewer Line _ ,,~/A To Nearest Public Sewer
Cleanout/Manhole /'~./~ To Nearest Sewer Service Line on Lot ~<~-]+' ~r-
Watei Sample Collected by /'~, /¢~'~,¢'~6'~_ ;Date
Water Sample Test Results C-'~"~'T¢;~^~'~'.~_~/
Comments ~_~2~-6-_- ./VTrAC~?~_ (_,¢Rw'a-~ -27-~--isr
B. SEPTIC/HOLDING 'rANK DATA
Date Installed Io/'7'7 Size /~_~'8_::) ~- No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /"-J ~ Date Last Pumped _
Pumping/Maintenance Contract on File (Y/N) /, ¢,//'~ ;for .,',//~
~., lA Temporary Holding Tank Permit (Y/N)
Holding Tank High-Water Alarm (Y/N) _ /' __
Separation Distances from Septic/Holding Tank:
To Water-Supply Well /c.~)'+ FT To Building Foundation '7o
To Property Line ~-~"cr To Disposal Field _ /~
To Water Main/Service Line c?.~
Course ~--~///~
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field ~L~
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
/oo+ ,cT-r-
To Water-Supply Well
To Building Foundation
Lot .',J,/,~
To Water Main/Service Line
.%r:/~P-. Type of System
Design"~,o
Length of Field -~_~
Depth of Field ~'~
Gravel Bed Thickness; /o
Standpipes Present iY/N) ..~L.(
Date of Last Adequacy Test c~/
To Stream/Pond/Lake/o'~ Majgr Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area ~-t- ~-r
To Property Line
To Existing or Abandoned System on
;On Adjoining Lots
To Cutbank (if present) ,.,u ~ A
/,
~ /A
Comments·
LIFT sTATiON
Date Installed
Dimensions ~
Manhole/Access (Y/N) . ~
"Pump O~
~ .~--'"~e nt (Y/N)
~..~~ Pumping Cycles during Adequacy Test, Meets MOA
Comments ~
**~itted Bedroom Rati.ng Against HAA Request **
I certify that I h?e chec, k, ed.eve,¢i '~ed,,¢' conformed to all MOA and HAA guidelines in effect on the date of this inspection,
Signed ,~/~-~'?~,.~/,~//'/' ~4..~/-, - Date
Size in Gallons'
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Page 2 of 2
72-026 (11/84)
Loo% tion:
Lot:
Client's Name:
Addt:ens:
Zni~ial Reading c~ Heter: ..... -/~/~/-/L~
GAIJ~
T/.HE