HomeMy WebLinkAboutKNIK VIEW BLK 2 LT 10MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP201365
Work Type: SepticTank Upgrade
Tax Code Number: 05103141000
Site Legal Address: KNIK VIEW BLK 2 LT 10 G:1557
Site Mailing Address: 22422 INLET VISTA DR, Chugiak
Owner: HENCKEL JEFFREY T & KATHLEEN R
Design Engineer: NORTH RIM ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
enr
Department
9/15/2020
9/15/2021
20000
Disposal Field Q Septic Tank Holding Tank Privy Private Well Water Storage
All construction shall 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 shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Fal Provisions:
ntain 5'to any deck posts.
tank is to maintain a 5' separation from the field.
Received By: 1p Date:
Issued By: Date:
5
1 . O Al E AT
Development Services Department
On -Site Water & Wastewater Section
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 051-031-41
Property owner(s) HenCkel
Mailing address 22422 Inlet Vista Dr
Site address same
Phone: 907-343-7904
Fax: 907-343-7997
Day phone 854-9657
Legal description (Sub'd., Block & Lot) Knik View BLK 2 LT 10
Legal description (Township, Range & Section)
Lot Size 20,000 Sq. Ft. Number of Bedrooms 5
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) 0
(w/wo ADU)
Septic Tank
El
Upgrade Q
Duplex (D) ❑
Holding Tank
❑
Renewal ❑
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of grope
or authorized agent)
Permit/Rush Fees: ,x/68,75 Couto
Date of Payment: 1ho
Receipt Number:
Permit No. 0-5 PZ013ti 57
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Knik View Block 2 Lot 10
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: The current septic tank has failed- the seepage trench still
functions. No adverse impacts are expected from tank replacement. The easements are
depicted on the lot. The slope is indicated in the area of the septic system. No conflicts to
neighbor properties. This will not affect neighboring properties.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
New 2- compartment, 1500 gallon septic tank. Watertight couplings on inlet & outlet.
5 minimum between the tank and trench. 5 to property lines & 10 to house.
4 of cover or insulation is required for tank; an equivalent of 1 insulation for 1 foot
soil cover. Tank & solid pipe must be set on well compacted, stable soil.
No large rocks for tank bedding. Plastic/fiberglass tanks require special bedding per
MOA- sand or pea gravel.
4 diameter cleanouts with airtight caps are required 1 to 4 from foundation wall,
prior to any 90 degree bend in 4 inch line, in each tank compartment, and two adjacent
opposing cleanouts between the tank and the absorption field, not more than 10 from
the tank positioned to provide cleanout access towards the tank and towards the
absorption field.
All cleanouts must extend to at least ground level.
In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
Insulation must be placed over any pipe installed under driveways or parking areas.
Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
Sewer Service Line is minimum 2% slope.
Septic Tank to be pumped every two years or when required.
Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201365, Deb Wockenfuss, 09/16/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201365, Deb Wockenfuss, 09/16/20
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP201365, Deb Wockenfuss, 09/16/20
Municipality of Anchorage Page ~ of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES BIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~'L~ ~OO~O PIDNumber:
%me: ~c~~ ~c~ ~vS~ WastewaterSystem: ~New ~Upgrade
· ~'"': ABSORPTION FIELD
~)hone: NO. of Be~rooins:
~ ~1~-- ~ Deep Trench ~Shallow Trench ~ Bed~__~ Mound ~ Other
'- ~ Total Dept~ ~rom orlgmal grade:
LEGAL DESCRIPTION ~SoilRating: /' ~ GPO/Sq. Ft. 7' ~,
--- Sub~iwsion: ~eot~ to pipe bottom from engine grade: G~avm dep[~ beneath
'rownsmo: Range:~[ Section: Fill a~¢ed aOove originaIo graee: FL Gravel length: ~0 ~l Ft.
Number of lines: Ols~ce be~ lin~
WELL: D New C Upgrade Gtavelwidth: ~ Ft. /. ~
assdicauan IPrwa[e. A.B.C)j Total Oeplh: Cased To; Total abaorption area: Pipe nmterial:
Ordler: Date drilled: S[~I~c Weter Level: Installer: Date installed:
~iel~;GPM ~umg Se~ ac Ft. [ Casmg Height Above_ Gr°und:Ft. TAN K
SEPARATI O N D ISTAN C ES ¢ Septic Q Holding Q S,T.E.P.
TO I $eDt[C A0lorptton Ll~t HOl~ng ~u01i¢~d~ate Manufacturer~ Capacity in g~llons:
, Number of Comments;
Well ~ ~0' ~00 ~Ot Material: ~~ I ~0
Surface t ! ~
w~,., ~1oo >/oo >l~ LIFT STATION
' Lot Size in gallons: [Manufacture~
Line ~1¢t ~10t
I
t ~ ~ ~ "Pump on" level at: ["Pump off" level at: High water ~latm a~:
Foundation
/
/
/
Cudain ~ ~p~ ~d~ Pum, Ma,e&M~et ~trtcallnspe~ti0nsperformedOY:
Drain
Remarks: BENCH MARK
A~um~ Elevation:
Inspections pedormed bY: ~ Dates: 1st r . ~l~6~
2nde_
' Department of H~ th an( ~i Se~ices approval ,¢., <.-::.:....~ ....,., .., ~..
Municipality of Anchorage ~,a.~E, Z'. of
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
Permit Number: PtD Number:
cos
003
6~1
coq.
Municipality of Anchorage Page ,~ of '~
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 Fleport
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 PERMIT
PERMIT NUMBER:SW950080
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:SCHMELZER FAMILY TRUST
OWNER ADDRESS:P.O. BOX 799
MARYSVILLE, WA 98270-8856
PARCEL ID:05103141
LEGAL DESCRIPTION:
KNIK VIEW BLK 2 LT 10
LOT SIZE: 20000 (SQ. FT.)
NUMBER OF BEDROOMS: 5 THIS PERMIT: 5
DATE ISSUED: 5/17/95
EXPIRATION DATE: 5/17/96
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACMED APPROVED DESIGN ~n ~2~-~
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 (ISAAC80) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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:
ISSUED BY: ~t~
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
May 9, 1995
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 10, Block 2, Knik View Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
We are hereby applying for an onsite septic system permit for Lot 10, Block 2,
Knik View Subdivision. The location of the new system and the alternate site
are shown on the attached site plan. The topography of the lot is also shown on
the plan and indicates an east to west slope of approximately 1%. :A steep cut
slope of nearly 40% drops from the front edge of the property down to Inlet
Vista Drive. The absorption bed is placed a tninimum of 50' from this slope.
Surface drainage will not be affected by placement of the new system.
Soil conditions on the lot are good and will adequately support an onsite septic
system. In addition, the lot is served by a community water system and all
setbacks have been met. If the system is constructed as designed the following
statements can be made:
The system, if constructed as designed, will have no adverse impact on the
wells in the area. The subdivision is served by a community water system.
The system, if constructed as designed, will have no adverse impact on
existing septic systems in the area or those to be constructed in: the future.
The system, if constructed as designed, will have no adverse impact on
reserved space, either surface or subsurface, on any lots located in the area.
Sincerely,
Michael E. Anderson, P.E.
The system, if constructed as designed, will have no adverse impact on
drainage patterns in the area. The current drainage pattern will be
ma~ntalned. - '- ..
LOT 10 BLOCK 2 KNIK VIEW SUBDIVISION
AREA MAP
22627
CONLEY AVE.
22731 21624
~2705
ORIGINAL AVE.
2~408
ALDER
DAVIDSO~
BLM 46
SITE PLAN o~
1" = 30' D^TE_
DATE.
SHEET NO,
CALCULATED BY ~ ~J['~
CHECKED BY.
EC^LE AS ,~ ~-O ~J,,J
/
. LOT 10 BLOCK 2 KNIK HEIGHTS .~,~- ..... ~.~. -
Lot 10, Block 2, Knik View Subdivision
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Five Bedroom Home
Perc. Rate: 2 Min./Inch
Application Rate: 1.2 GPD/SF
Reduction Factor: .5
Wide Trench System
1,500 Gal. Septic Tauk
4' Drain Rock Beneath Pipe
5 Bdrms. X 150 GPD / 1.2 GPD/SF = 625 SF of Absorption Area
625 SF / 5' Wide = 125' LF X .5 (Red. Factor) = 62.5 LF Trench
Therefore: Construct a Wide Trench System With One Lateral
Totalling 63' in Lengtb. Place 4' of Drainfield Rock Beneath the
Lateral. Place Distribution Pipe at 3'-6" Below Ground Surface.
Mound Over System To Drain Away.
NOTE:
TYPICAL WIDE TRENCH SYSTEM
(NO SCALE)
Maintain 4' Vertical Separation From Bottom of Treuch
to Groundwater Table.
Grade Area Around Drainfield to Drain Away FrOm the
Trench.
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
£
(ENGINEEWS ~'EAL)
LEGAL DESCRIPTION:
1
2
3
4
5-
6
7
8
9
10
11
12
13
14-
15
16
17
18
19
2O
COMMENTS
Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH?~ , PE
Depth to Waler After/] ~ I
Monitori~lg? ~'' ~ Dale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE .___ (minutes/tach) PERC HOLE DIAMETER __
TEST RUN BETWEEN __ FT AND ____ FT
ACCORDANCE WITH ALL STATE: AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
THAT THI/S T~ST WAS PERFORMED IN
-79 I s
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION "I'EST
;i- ~ (:ENGIN EE~II;S,SEAL)
LFGAL DESCRIPTION: ~''~''' I0, ~uoc~, Z.-
Township, Range, Section:
2
3
7
8
12
~4-
~8
2O
/~,,,,¢1~
P'C lo .
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water Alter,4~,/c
Monitoring? ' '" ~" ~; Oate:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
/I: I l,, , ~ Li~ ,, ,/~ ,,
/I; I'1 ; 7" I/1., "
//:/~, ?~. " '/z. "
//,'/'t ~ " '/~, '
//~ ~ ,~ Y¢ ,, ,/~ ,,
//: Z/ ,] ,, ,/~ ,,
PERCOLATION RATE ~" tm~nutes/mch) PERC HOLE DIAME:TER __
TEST RUN BETWEEN &l~ FT AND ~' FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE:
72-008 (Rev. 4185)
THAT Tt~IS T,EST WAS PERFORMED IN
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: Lot 10, Block 2, Knik View Subdivision
GENERAL:
1. The scope of this project includes the procurement and
installation of a 1,500 gallon septic tank and the
construction of a shallow bed drainfield to serve the
proposed five bedroom home.
2. Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
3. The Contractor shall be responsible for obtaining all
underground utility locates.
4. Unless specifically agreed otherwise, th(; contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. Property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
SEPTIC TANK INSTALLATION
1. A septic tank is to be constructed by a certified sePtic tank
manufacturer. Construction shall include two 4" cleanouts
for pumping access.
2. The septic tank shall be sufficiently bedded to prevent
settling or shifting of the tank.
Lot 10, Block 2, Knik View
May 9, 1995
Page Two
3. All standpipes on the septic tank shall extend a mimmum of
12 inches above final grade.
4. Septic tanks installed without 4' of cover shall have a
minimum of 2" of direct burial insulation.
5. A foundation cleanout shall be installed one to four feet
from the building foundation. Two cleanouts shall be
installed between the tank and the drainfield. The first
cleanout shall be located on undisturbed soil not more than
10' from the tank. The first cleanout shall be to clean
toward the drainfield. The second cleanout shall be to clean
toward the tank.
6. Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown
on the design. The bottom of the bed shall be within 2" of
level. The bed shall not be installed on a slope greater than
10%.
2. Distribution piping must be placed level with perforations
down atop a level bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion below ground
must be perforated.
5. Contractor shall verify the septic tank and drainfield are a
minimum 100' away from any water wells in the area.
Lot 10, Block 2, Knik View
May 9, 1995
Page Three
6. Direct bury insulation must be placed over the distribution
system if less than 3' of backfill depth is available. Finish
grade over the trenches must be mounded to prevent
settlement or depressions.
7. Grade area surrounding the absorption trenches to drain
away.
8. A minimum 2' of accepting soil is required below the
drainfield rock. Contractor shall verify this condition prior
to placement of the rock. All pockets of unacceptable
materials must be removed and replaced.
MATERIAL, SPECIFICATIONS:
1. Septic tanks must be constructed by a Municipally approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated, but
not solid) and ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must
be installed between the final drain rock layer and the
native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than
3% passing the #200 seive.
Lot 10, Block 2, Knik View
May 9, 1995
Page Four
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of inspection.
Contractor shall provide a copy of all field survey layout and
construction notes for use in preparing the certified as-built
of the completed system.
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
051-031-41
HAA #
GENERAL INFORMATION
Complete legal description
Knik View
Lot 10, Block 2
Location (site address or directions)
22422 Inlet View Road, Chugiak
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Brian & Chon~ McCarthy Day phone
22422 Inlet Vista Road, Chugiak, AK 99567
Day phone
Vista Real Estate/Les Bailey
16635 Centerfield Drive, Suite
689-6451
Day phone
103, Eagle River, AK 99577
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 5
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
X
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) Fronl 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/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 Eagle River Engineering Services Phone 694-5195
Address P.O. Box 773294, Eaqle River, AK 99577
Engineer's signature CY~'~'~~ Date '/~ - / 7 - ¢¢
DHHS SIGNATURE
t/' Approved for d
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
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 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.
72~25 (Rev. 1/91) Back MOA ~i21
MUN,ClPALI]'Y Oi: ANC~HOP, AC~I:
I]NVIRONM~NTAL SERVICES DIVISION
Municipality of Anchorage DEC
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental ServiCes Division 1I~ E C
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description: /4:'/V//4: ~/~/,v ~0~/¢, /~¢_/L ~-- Parcel I.D.:
A. WI=-'LL DATA
Well type
Y/N) Date completed
Total depth ~ Cased to
Date of test
Static water level
Well production
g.p.m.
WATER SAMPLE RESULTS:
If A, B, or C, attach ADEC letter. ADEC water system number
Casing height (above ground)
Wires properly protected (Y/Ni ~
AT INSPECTION
:
Coliform /¢,/~/ Nit rate
Collected by:
Other bacteria
Date of sample:
g.p.m.
C. ABSORPTION FIELD DATA
Date installed 0~'/~5~ . Soil rating (g,p.d./ft2e~-fta/bdr-m) /~'- Systemtype
/ /
.¢//,¢~/
Length ~--), / _Width ~ Gravel thickness below pipe ~"'/ Total depth ,~ ~-- '
Effective absorption area ~z/~ z~ Monitoring Tube present (Y/N) ,,Y~% Depression over field (Y/N) //J~
Date of adequacy test /'////') <~ ~2 Y(,) Results (Pass/Fail). /-3//,-S5 For_ _~ bedrooms
Fluid depth in absorption field before test (in.); ¢¢/~ Immediately after '¢,'~ gal. water added (in.):
Fluid depth /¢/4 (ins) Minutes later: ~/-¢
Peroxide treatment (past 12 months) (Y/N) ~//'q'
72-026 (Rev. 3/96)*
Absorption rate =
If yes, give date
g.p.d.
B. SEPTIC/140'~BING TANK DATA
Date installed ¢'~/~s"/~'- Tank size // '~¢¢
Foundation cleanout (Y/N) ,{/¢=¢ Depression (Y/N) ./v/~ High water alarm (Y/N)
Date of Pumper
Number of Compartments
Date installed
Manhole/Access (Y/N) ..-.-~Pu~vel at*
~Gyetes~teste d
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/l~rld~g tank on lot ,¢¢~, z,./,,~ u,.,,:,/-~,~-
Absorption field on lot /¢,.,.z/,~_ ~.~., ,~ ~ ,~
On adjacent lots
On adjacent lots
Public sewer main /V//? Public sewer manhole/cleanout
,Sewer/septic service line ,v ,//~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation / / t Property line _z_,--/ / Absorption field _5-
Water main/service line ~/~ / Surface water/drainage "/'~'~ ' Wells on adjacent lots /v/,~t
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line '~,o / Building foundation ¢P--S' ' Water maif~/service line
Surface water -¢-/DO Driveway, parking/vehicle storage area p/o
Curtain drain ./t/~/VE /¢~/°/¢/2¢,/¢'/~ Wells on adjacent lots /¢2-o°/
ENGINEER'S CERTIFICATION
I certify that/have determined thru field inspections and review of Municipal records:'-'tl~at';~, a~t~;.'~/stems are
in conformance with MOA HAA guidefines in effect on this date.
Engineer's Name /_.,D u/.5 /-.~ f/¢'-~f//¢/
HAA Fee $
Receipt Number ~,~'~ ? (/'-,~ ~';2_.Zf /
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
" :"~;';~"~';:':' DEPAR~"MENTOFHEAI:TH;& HuMAN:SERViCES'-: % ,_' ~ ':.
CERTIFICATE OF HEALTH AUTHORITY
.......... ~';~'APPROVAL'FOR A SINGLE FAMILYDWELLING
~0
RMATION :_
"Location (site address or directions)
· ' Lendipg agency ........ Day phone
?.??~,:¥-- :. Madmg address ...................
, ~" -; :-:j::,~OTE: .:-',¢~ community well system, provide wrttten conftrmaOon from State ADEC attest- -- ~ . .,. . mg to the legahtyand status of SYstem.
............ Commumty on.site ~
....... Pub c sewer , - ......... · .
"' ' NOTE: ~'lf community wastewater system, provide writteD confirmation'from :State ADEC
'" ' ....... 'a~estin~ to the ~ega,ty ano'sr
As ce~ified by my seal affixed hereto and as. of the validation date shown below, I veri~ that. my
'nvestigation of this Health Authori~ Approval application showsthat the on-site water supply
an d/or wastewater disposa~ system is safe~ functional and adequate for th ~ number of bedrooms
and ~pe of structure indicated herein. I fu~her 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'r~ulations in effect on the date of this ~nspection; ,' ~ ' - ',~ ;:~¢~- .
Engineofssignaturo ~ ~ ~ Date
The MunicipaliW of Anchorage Depadment of Health and Humah Se~iC~'~'(DHHS),'isSu~¢' Health Authori~ '"
Approval Ce~ificates bas~ only upon the representations given in paragraph 5 above by an independent
~rofo~ional oncn~r m~stomd in th~ 8tato of~l'~a, lbo ~s88 ~oos this as ~ coU'~ to ~umha~om of homes
andthoirlondin~ insfitution~i~ o[d~[~0_~ls~co~ain f~ra!a~dstatoroqu mm~nts fimp oy~sofBHHSdonot "~
conduct in~¢octions or analy~e data Boforo a ~ce~ificato ls issuod..~ o Muniei~ali~ of ~nehora~o is not
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SEP, VICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4'}'44
Health Authority Approval Checklist
Legal Description: LOt iq l~/.-O£1t-- ~--,_ lZ~tt'~
~/ma,~ Parcel I.D.: O :~
""tO3iq. I
A. WELL DATA
Well type CO~tq~J tO t'r~ IfA, I3, or C. attach ADEC letter. ADEC water system nmnber
Log present (Y/N)
Total depth
Sanita~ seal (Y/N)
Date of test
Date completed
Cased to
FROM WELL LOG
Casing height (above grouud)
Wires properly protected (Y/N)
AT INSPECTION
t,,.O t..o 12
Static water lcvel
Well production
WATER SAMPLE RESULTS: /~/A
Coliform Nitrate
g.p.m, g.p.m.
Other bacteria
Date of sample:
Collected by:
B, SEPTIC/HOLDING TANK DATA
Date installed ~/Iq/q~' Tank size ~/
Foundation cleanout (Y/N) %}/' Depression (Y/N)
DateofVumpingN~J Pumper ~,t~t,! 5'T/LO r, Ar'tO/,J
C. ABSORPTION FIELD DOTA
Number of Compartments ~'~ Cleanouts (Y/N) ~('
High water alarm (Y/N): ~
Length 61t9 2, ~ 'Z- t t
Width ~.~ t Gravel thickness below pipe Total depth
Effective absorption area ~'t'/3 .~ ~ Monitoring Tube present(Y/N). Depression over field (Y/N) /~]~
Date of adequacy test /~ Ct~ G ~ ~ Results (Pass/Fail) '~P. S $ For /'7~x/~ bedromns
Fhfid depth in absorption field before test (iu.); O hnmediately after gal. water added (in.):
Fluid depth /J/t~ Minutes later: /q']*~ (in.) 'AbSorotion rate = '~~1~/~*0 g.p.d.
Do
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" level at*
*Datum
"Pump ofF' level at*
Cycles tested
E. SEPARATION DISTANCES
Fo
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer ~nain
Sewer/septic service line
: On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation / I Property. line '0/0 Absorption field
Water main/service line )' to'"g>t Surface water/drainage '>'/g;'O t Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~0
t
Surface xvater '>'/O 0
Curtain drain /~O,',J ~-
Water main/service line '2 ~O
Driveway, parking/vehicle storage area
Wells on adjacent lots PS/
ENGINEER'S CERTIFICATION
i certify that I have determined thrufie/d inspections and review of Municipal rgcords that the above syS't~ms are
in confbrmance with A'[OA HAA guidelines in effect on this date.
Signature '~
Engineeffs Name
HAA Fee $
Date of Payment
Receipt Number _,Z~,r~
Waiver Fee $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc