HomeMy WebLinkAboutMCKINLEY HEIGHTS #1 BLK 4 LT 6McKinl
Y
Heights
Block 4
Lot 6
#051-212-44
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
rPHONE
EW
~UUPGRADE
MAILING ADDRESS
LEGAL ~ESCRIPTION
LOCATION
-- r We area
O :~ DISTANCE TO: '1 ,/.-,~-g~' / Abs°rpti°E
~-- ~ Manufacturer
~ [Lq c~ap~acty nga onsJ
/~ :~,~¢~ ~' IF HOMEMADE:
DISTANCE TO:
Dwelling
ns de length
DweIling
Materi~l
Width
NO. OFBEDROOMS
PERMIT NO.
No. of compartments
Liquid depth
PERMIT NO.
Manufacturer Materlal Liquid capacity in gallons
Well
DISTANCE 'TO:
No. of lines Length of each Jine
Length
to finish grade
Width
Nearest lot line
Trench width
,~ inches
~g~' inches
F o u n d a~n~.;~ ¢,
Total length of lines
Material beneath tile
Depth
P ERIV~JT NO.
Distance between lines
Total effective absorpti?~ area
__ _$-_ ¢_
PERMIT NO.
Type of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
;lass
Depth
Driller
Building foundation Sewer line
DISTANCE TO:
OTHER
PIPE MATERIALS
T RATING
INSTALLER
REMARKS
DATE
Septic,tank I Absorption area(s)
APPROVED
72-013 (Rev. 3/78)
LEGAL
PER:HIT NO.
E:,EPFtRTMENT' OF HEFfL. TH FINE:, Et".I',,,' i RONMENTRL.. F"f;.:OTECT I Oh!
S;F..'5 '" L '" STF.:EET., FtNCFIORRGE.,
264-47'2E~
~::])J ~',*,,It ....... :SS;,, ][ T' IEE:
( 8:~:02iE )
FIPPL. i CF1N"f'
L..OCRT I ON
L.EGFtL
FIF:tHHRN CONST.
LOT 6 BLK 4 MCI':::INL. E"/ HTS.
SR 1667 EFtGL. E RIVER., RL.R:SKFI 694'""277(5
LO'T SIZE D:~C.49.S~S,~ Sg!UF'tRE FEET
TYPE; OF' SOIL f:'tBfiSORP]"tOH SYST'EH IS: TREI'.4C.:H.
HFtXIMUH NUHBER OF' BEDROOI,'IS ..... .i.
SOIL RRTING ,.':SQ F"I",.,'BR)= :L25
"t"HE RE[J)UIRE[:, SIZE OF ]"HE SO.IL. FtBSORt::']"ION G"¢STEt"I IX:
T'I...!E LEI'.,tGTH [:, I MENS I ON 15; THE LENGTH ,:: I N F:IEET ) OF' THE TRE},tC:H DF;' [:,RFt I t",tF' ! EL..D.
THEE DEF'TH C F Ft TF:ENCH OR F't T 1:5 TI...IE D,:t: L::;TFiNC E E~E'f'!-,.!EEN THE 'i.:.';l. t:~"f:'F:l ] E' (."11:::' 'TH.E
GROUN[) FIND T'HE BOTTOM OF' THE E;,',;CF't'v'FtTION ,:.'Ii'-,l FEET).
THERE i:5 NO SET l.,.fIE:,"f'i.-I FOR TF:ENCFIES;.
'Tf-IE ~"'"' ,"-~
:~.r.',~::.L E:,EF"I'H I:S TI.E HINIMItH [:,EF'Tf.] OF' '--E,,':,,,,,= " .... 1 ..... '
- =.. r~, ~..= E,E t ..'.lEb. t',t ]"NE OLI'T'F'FII....L F:' I PE
FIND THE E:O]"'TOM OF:' THE EXCFI',,,'FITION (IN FEET).
PEf;?.H I T FIPF'L.:[ C:Rf',lT HFt:::T, THE RESPONS I B I L I Th" 'TO ZNFORM TH I S DEPf:IRTI'dENT [:,LIR I t",IG THE
it",tS:;T'FiL. L. FFf']:ON INSf:'ECTIOt'.,15; OF F:!N'¢ WE[...L:S FI[':,JRCENT TO THIS PROPERT'-? Bf-,tD THE
NUHEi:EF;?. OF RE:.SIDENCES THF!T 'THE WELL I.,.tiLL. SER'¢E.
f!i~FiC:KF'i' L.L I NG Of::' FIi",I'¢ SY:S"I"Et'"I 1.41THOUT F i Nf::IL. t NSPECT101",! FIND FtF'PROVRL. B"r' TI'"!:[ S
DEF:'FtRTHEt",I'T i.,.iZL. L BE :SUB.]'EDT ]"E) PRO:SECLr'f'ION.
HINII',fUH i}ISTFINCE BETWEEN A WELL FIND, RhlY ON-SITE SEWAGE DISF:'OSRI.... :L].,'YSTEH IS
:L00 FEET FOR FI t::'RZ',,,'Ft]"E I.,.IELI.. OR ::L50 ]';C~ ;F.:'OE'~ FEET FROM H PLIB[..ZC WELL [:,EF'Ei",II.'.':,ING
UPON THE T'.r'F'E OF' PUBLIC WELL.
HZNIHUH [::,:£:S'TRNC:E FROM R F'RIVWrE f.4EL.L TO FI PF:.::[',,,'RTE SEWER LINE iS 25 f:'EET RND
TO FI COMHUN:[T'.:.' 25EI.,.IER LINE tS 75 FEE-I'.
OT'HER REQUIREMENTS i',IFF? Fff:'PL'-?. SPECIFICFrFf':[ONS FIND C:ONSTRUC':TION DIFK3RRHS:; RRE
W,,,'F:IIL. FiBLIE TO I'NSLIRE PROPER INS]"FtLLRTION.
:i: CEf:.".'f' i f:'V ]]'-tRT
:1.: :[ Fd'"i FRt'd:[L. IFtR WITH "['HE REQUIREHENTS; FOR ON-SITE SEWERS F:d'.,ID WELLS FiS:; SET
I::'OF;:"i"H E:¥' THE Mt._INICIPRLI]':'¥' OF' FINCHORFIGE.
2: .I t.,.IZL. L ZI'.,IS]"FtLL. THE S'¢STEM Ii'4 I:::ICCOI.;..'t)RhlC:E i,.lZ. TH TNE CO[.'.',ES.
]:: I UNC, ERSTRN[:, THFtT ]"PIE ON-SITE SEWER 5;%"SI"EM MF:I'T' t:::'.EQUIRE ENLFIRGEHEt'.,tT IF THE
RES;it)ENCE I5; REMO[:,ELED TO INCLU[:,E HORE Tt'..lfat'.,t 4 DED, ROOHS;.
LEGAL DESCRIPTION:
6
7
8
9
10
11
.... 12
13
14
15
16
17
18
19
20
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anctaorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SI~OPE SITE PLAN
WAS GROUND WATER ¢/~./ ~
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
PERCOLATION
TEST
Gross Net Depth to Net
Reading Date Time Time Water Drop
"~' PERCOLATIO~ RATE */* ~'~"' ~' .....
· . TEST RUN BETWEEN FT AND
COMMENTS ,~:~,'~ *',~' ~ ~'>~<'~ /~ ~ .~V?.~ ~ ~ ~.~' ~- /, ~/'
PERFORMED BY: ~ ¢;'""'" 't~ :~: "" *' CERTIFIED BY: ~:~,' ~
(minutes/inch)
__ FT
/~.~ ':%;
DATE:
72-008 (6/79)
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION
DATE - Started
PERMIT NUMBER
Ended
KIND OF FORMATION:
From Ft. to Ft.
From__Ft. to - Ft.
From Ft. to Ft.
From__Ft. to Ft.
From--Ft. to__Ft.
From Ft. to Ft.
From. Ft. to Ft.
From Ft. to Ft.
From__Ft. to Ft.
From__Ft. to Ft.
From Ft. to Ft.
From__.Ft. to--Ft
From__Ft. to__Ft.
From__Ft. to__Ft.
From__Ft. to Ft.
From .Ft. to Ft.
From Ft. to Ft.
DEPTH OF WELL
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
FromFt. to Ft.
From Ft. to_ Ft.
From Ft. to Ft.
From Ft. to Ft
From Ft. to__FL
From Ft. to Ft..
From Ft. to Ft.
From Ft. to Ft.
From Ft. toFt.
From Ft. to Ft
From Ft. to Ft.~
From Ft. to Ft
From Ft. to. .Ft
From Ft. to Ft
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft
MISCL. INFORMATION:
DRILLER'S NAME
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. O51-~1~-44 HAA#
.. ' i Expiration Date:
I GENERAL INFORMATION
Complete legal description~ ' Mc Klnleg Hts. #1; Lot 6, Block 4
Location (site addresSo~: directions) ~)1935 Spring Creek Lene,
Current Properly owner(s) Kirk tg~mo'~. Dayphone -..~uB~.l_.~}_~
Mailing address Same es ';hove
L~nding agency ' -:' '.' ' ~''' '
Dayphone
Mailing address
Real Estate Agent Alnslie Phillips Day phone
Mailing Address Prudentl~l Vista RE. 4~41 B ~;treet: Anehora_~e~
Unless otherwise requeste'd, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water'Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] IndMdual Holding tank []
[] Community On-site []
[] Public Sewer []
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-sita 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 properties 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
period of up to one year with valid water samples.) Certificates are valid for one year for properties served by
Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or
omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
Investigation, based on procedures outlined in the Health Authority Approval Guidelines for this
application, shows that the on-site water supply and/or wastewater disposal system Is(ara) safe, functional
and adequate for the number of bedrooms and type of structure Indicated herein. I further verify that
based on the Information obtained from the Municipality of Anchorage flies and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all
applicable Municipal and State codes, ordinances, and regulations In effect at the time of installation.
Name of Firm KND Engineering
Address 20'441 Ptarmigan Blvd.: E.R.: AK g9577
Engineer's Printed Name Kenneth M. Duffus Date
OF
Approved for ~ '~ ~ '"' '"~
bedrooms.
.
Disapproved.
~ndifional approval for
Phone 691~.6111
05/311Ol
ENGINEER S
STAMP
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date: , (.¢, - .~'"'- o !
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Slta Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
vnvw.d.anchomge.ak.us
(907) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WEII DATA
Well type..D.[Ly.~ ff A. B, or C provide PWSID #
Date completed 04110183 Sanitary seal (Y/N) y
Total depth 160 ft. Casedto 16 ft.
FROM WELL LOG
Date of test 0411 011 gS~l
Static water level I 9 fi.
Well production 4 9.P.m
WATER SAMPLE RESULTS:
Coliform 0 colenlesJl00 mi. Nib'ate 1.81 rog.Il.
Data of sample: 05/24/01 Collected by:
B. SEPTIC/HOLDING TANK OATA
Tank Type/Material Steel
Mc Klnlev Helahte #1. B4. L6 Parcel ID:
051-212-44
WeU Log (Y/N) y
VV]r'es propafly protected (Y~) y
Casing height (above ground) 2 4"
AT INSPECTION
lO.S ft.
4.29 g.p.m.
Other bectefla 0 coloniesll00ml
KND En_elneerln0
Date Inetalle,~ Tank size ..~al. Number of Compartments
Cleanouts y Foundation cteanout y Depression over tank H High water alarm NA
Data of pumpln~,~ Pumper JR'e
C. ABSORPTION FIELD DATA
Data Installe¢[_J~4~r.'l~tl~ Soil rating
Length 37 ft. Width ~
(g.p.d./f~ or ~rodrm) 125 System type Trench
ft. Gravel below pipe 7
Total depth 10 ft. Eft. absorption area 518 ~ Monitoring tube Y Depression over field N
Date of adequacy tast._,0~?,4~, Results (Pass/Fail) *Pase For4 bedrooms
Fluid depth in absorption field before test 58.5 in. Water added 600 gal. New depth 66.5 in.
Elapsed Time: 120 mtn. Final fluid depth 58.5 in. Absorption rate >= 600 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) n9 If yes, give date
D. UFT STATION
Date installed NA
'Pump on' level
Datum
In.
E. SEPARATION DISTANCES
Size in gallons
'Pump off' level at
Cyctes tested.
Manhole/Access (Y/N)
In.High water alarm level at.
Meets alam~ & drcult requirements?.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot 100'~- On adjacent lots
Absorption field on lot 100'+ On adjacent lots
Public sewer main ?~;"!' Pubflc sewer manhole/cleanout
Sewer/septic service line 25'+ Holding tank 1 0 0 ' 1.
SEPAJ~ATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation §'1.
Water main 10'+
Wells on adjacent lots 100'+
Property fine 10'+
Water Sewlce line 10'+
Curtain drain
F. COMMENTS
Pmpert~ line 5 ' +
Water sendce line 1 0 ' +
Absorption field ~ ' t-
Surface weter I
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Water main I 0 ' +
Building foundation 1
Suffaceweter 100'+
Wells on adjacent lots
On'veway, pa~dng/vehlde storage 25+
m~ew of Mun~l m~s ~t ~e a~ s~ems am In ............... ~
~glnee~s P,nted Name Kenneth M. D~, ',~~a~~
Date 05131101 ' - ~
HAA Fee $
Date of Payment
Receipt Number
(Rev.
Waiver Fee $
Date of Payment
Receipt Number
lit
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)
Property owner ~o~ ~ ~_~,~ -7-,~cu/ Day phone
Mailing address ~(p' i~o~. ~'7.5/ ~ {./OO~, ~,
Lending agency
Day phone
Mailing address
Agent J~-'~_r-P,~ ]-¢ ~¢wm-~ ' /:,~::~,f-¢~ ~pCt¢3 Day phone
/
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
Public water : .... :
If community well system, provide written confirmation from State ADEC
ing to the legality and status of system. '
Public sewer
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/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
Address
Engineer's signature
20210 Dona]ar St.
C;,ug;ak, Alaska 99:~o7
Phone
Date/__~_ z~/~'¢//
,,
DHHS SIGNATURE
Approved for ' ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the fo Iow ng stipulations:
Additional Comments
By: z /
Date
'f: ,'IIPI;
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:
A. Well Data
Well type ~)
O A~7'E'
Log present (Y/N)
Total depth / L~ c~
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~,'//~./oc'--~ Driller ~
Cased to ~ L~ Casing height
Wires properly protected (Y/N) Y'
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG AT INSPECT~ION
'7z:'' g.pom. ,..,,2. ~o
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
/2-0
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
/2<5
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Nitrate
~- 5 ? Other bacteria ~'~
Collected by: T~ ~
Tank size ! ~.-~'-~ Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N)
,L]/?~- Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
On adjacent lots
Absorption field
Well(s) on lot /' ~
To property line
Sudace water/drainage
Foundation ~
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
Hi[gh water alarm level
__"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LiFT STATION TO:
Well en lot
,ABSORPTION FIELD DATA
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
On adjacent lots __
Sudace water
Date installed
I.ength 3 7 '
['otal absorption area
I)ate of adequacy test
Soil rating (GPD/FF)
Width '~ Gravel thickness ___
~-? ~ Cleanout present (Y/N)
, o/~f//.~_,~ Results (pass/fail)
Water level in absorption field before test .__ / '/~'4-/'
Peroxide treatment (past 12 months) (Y/N) __ ~
|or
A|ter test
yes, give date
System type .~-~'~c ~
Total depth ./~"
Depression over field (Y/N) ~
5~ Bedr~ms
:SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
VVell on lot / 2~/~/
I'o building foundation
On adjacent lots ~ ~ ....
S,udace water /~'-~
Curtain drain A/"~
On adjacent lots ! o ~ ~- __ Properly line
To existing or abandoned system on lot _~.
Cutbank ,~/,/,¢h Water main/service line
Driveway. parking/vehicle storage area ~/~
E,, E:NGINEER'S CERTIFICATION
I cedify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on.the date of this inspection.
Signature
Engineer's Name
Date
HAA Fee $ .fL,' C), 0 ~)
David R. Dayton P-E.
20210 Donalar St.
Chugiak, Alaska 99567
72026 (~93)' Back
· '~7/'<7":-- L--
Waiver Fee $
Date of Payment
Receipt Number
00T--~1--94 MON 16:85 D R DAYTON 90? 696 2417 P. 81
D. R. DAYTON, P.E., R.L.S.
20210 Donalar Chugiak. Alaska 99567
(907) 696-2417
October 27,1994
w~,r. FLOW TEST
Legal Description: Lot 6, Blk 4, McKinley Heights #1
Da~e of Test: October 24, 1994
Well Depth: 160 ft.
Static Water Level: 13.9 ft.
Requ±remen~s: Municipality of Anchorage 4 BR -600 gallons per day
FHA 3 GPM for 4 hrs.
Test:
The well was tested with the existing pump through an outside hose bib
for a 4 hr. time period. Drawdown and vollune measurements were taken at timed
intervals during the test period.
The flow was maintained full until the clrawdown reached a stabilized
level and pumping continued for the remainder of the 4 hr. period.
Recovery measurements were taken until the well was fully recovered.
Results:
The well produced 3.8 gpm with a stabilized drawdown of 29.7 ft.. The
well fully recovered within 32 minutes.
A total of 947 gallons were produced in 240 minutes.
The well is currently producing adequately for a 4 BR home under FHA
and Municipality of Anchorage sta~ds.
Water Quality:
Water sa~31es were lab tested with the following results:
0 colonies/100 ml
0 colonies/100 ml
2.31 mg/L
0.054 mg/L
Coliform
Other Bacteria
Nitrate
Lead
allowable limit 0 colonies/100 mi
allowable limit 0 colonies/100 mi
allowable limit 10 mg/L
allowable limit 0.015 mg/L
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)
Property owner
Mailing address
Lending agency.
Mailing address
,~f_.z_/~,,~/., ,~,,¢'¢~.=',;,7''~ Day phone
Day phone
Agent Z'~' '~/~,, /,~.v
Address ' ~/~/~ ~"'"'"~'~,' ~"'~'
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4~- N
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
Day phone
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/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.
David R. Dayton P.E.
Name of Firm 20210 Oonalar St. Phone
Chugiak, Alaska 99567
Address .,~_/~~, ~'/~
Engineer's signature Date .
DHHS SIGNATURE
~. Approved for 7
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 Dy 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.
724)25 (Rev. 1191) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Parcel I.D.
Well type /2~1 U/kF'~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
Cased to
If A, B, or C, attach ADEC letter. ADEC water system number
'Y' Date completed ~Z',.~/~'. ~ _Driller
/~' ¢ Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
~.,~2¢[RONMENTAL SERVICES DIVISION
~- g.p.m. ~¢,~ g.p.m.
"z "' RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
WATER SAMPLE RESULTS:
Coliform c~ Nitrate
Date of sample: ~/;~//-~/~ ~
B. SEPTIC/HOLDING TANK DATA
Date installed ~/~//~,')/.z%
Cleanouts (Y/N) ~
~P, ~7¢ Other bacteria
Collected by:
Foundation
Water main/service line
Tank size / Z .5~/.~2 Compartments
Foundation cleanout (Y/N) ~;' Depression (Y/N)
High water alarm (Y/N) ~4~//-). Alarm tested (Y/N)
Date of pumping ~?d'r ~/~P2 Pumper ,,.J ~6
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO:
Well(s) on lot / Z-¢~ On adjacent lots /o ~,>
To properly line ,~ Absorption field
Surface wateddrainage __
72-026 (3/93)* Front 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
ABSORPTION FIELD DATA
Date installed
Length ;~ '/~__
Total absorption area
Date of adequacy test __
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N) _
Width
Soil rating (GPD/FF) / Z:¢~; ~ System type
~ ; Gravel thickness ~2' / Total depth ,/~'
Cleanout present (Y/N) Y' Depression over field (Y/N)
Results (pass/fail) r~-'5 for 4- Bedrooms
.~$ ~ After test. ,..~. :~_4'~.~,¢,.,~.~_
/OW/ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots / ¢'* cP~'- Property line
To existing or abandoned system on lot
Cutbank ,.t./~t~ Water main/service line
Driveway, parking/vehicle storage area
it!.:. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidefines in effect on the date of this inspection,
Signature
Engineer's Name
Date
David R. Dayton P.E.
20210 Dona]ar St.
Chugiak, Alaska
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $ _
Date of Payment
Receipt Number
72-026 (3/93)* Back
D. R. DAYTON, P.E., R.L.S.
~:~J~ Chugiak, Alaska 99567
20210 Donalar
(907) ~l~x~
696-2417
June 22, 1993
WELL FLOW TEST
Legal Description: Lot 6, Blk 4. McKinley Heights
Date of Test: June 22, 1993
Well Depth: 160 ft.
Casing Depth: 16 ft.
Static Water Level: 12.5'
Requirements: 4 bedroom - 600 gallons per day
Test:
The well was pumped with the existing pump through an outside
hose bib. Volume, time and drawdown were measured at regular intervals.
The flow tate was adjusted until the water level in the well remained
constant. Pumping was continued until the daily requirements were met.
Results:
The well produced 638 gallons in 204 minutes for an average
rate of 3.13 gallons per minute. The flow rate at stabilized drawdown
was 3.00 gallons per minute. The maximum drawdown was 19.4 ft.
The well is currently producing adequately for a 4 bedroom home.
D. R. DAYTON, P.E., R.L.S.
~xx~:~ Chugiak, Alaska 99587
20210 Donalar
(907)
696-2417
June 22, 1993
ADEQUACY TEST
Legal Description: Lot 6, Blk4, McKinley Heights ~1
Date of Test: June 22, 1993
Septic Tank: 1250 gallon, 2 compartment, steel tank (DHHS Records)
Absorption System: 3' wide x 37' long x 7' effective depth trench (DHHS Records)
Soils Rating: 125 sq. ft. per bedroom (DHHS Records)
Requirements: 4 bedroom - 600 gallons per day
Test:
Water was injected into the absorption trench while measuring
volume, time, and water level in the trench. After injection was
stopped, the water level was measured at timed intervals. The results
were plotted on a graph of time and gallons absorbed.
Results:
The septic system absorbtion trench is currently functioning
adequately for a 4 bedroom home.
NoLe:
There was 5' of water standing in the trench before the test
was started. At the end of the test there was 5.3 ft of water with
the level still dropping. The water standing in the trench may
indicate the trench is in its waning stages.
Prop2r~y Owner
Mailing Address
FNLLS OUT UPPER HALr ONJLY
Zip Code
Phone
Buyer ( ¢~
Address Zip Code / ' !" /
~hone
Lending nstitution
Address Zip Code
Phone
Realty Co. & Agent .....
Address Zip Code
Legal
Description
Street Location , ' , . ., : . · '
Type of Residence
[.~ Single Family
b~ Multiple Family
[] Other
No. of Bedrooms
Water Supply ~] Individual
[] Community
[] Public Utility
ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
For wells drilled prior to that date, give well depth (attach Icg if available).
Sewer Disposal ~ Individual
[] Public LJtility
[] Holding Tank
Year Individual Installed:__/' '
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
Time
Date
Inspector
Date
Inspector nspector
RECEIVED
iL i C) APPROVED BEDPIOOMS
( ) DISAPPROVED
CONDITIONAL APPROVAL*
DATE
*CONDITIONS OF APPROVAL
j Date Sewer Installed
Soils Rating
.
Well To Absorption Area " ,
Well Log Received
Well to -rank /,'_,~tr) ( Septic Tank Size
72-023 (3t82)
Upon your application for Health Authority Certificate approval
for the individual sewer and water facilities cannot be g~anted
until the following circled items have been completed:
A well log submitted to this office our
for
files
and
review.
2. The top of the well casing should be sealed so that it is
water tight.
3. The depression or pit around the well casing needs to be
filled with impervious ty~e soil so that it slopes away
from the well casing.
4. The well casing needs to be extended twelve (12) inches
above ground level.
Exposed electrical wires to the well head are in violation
of the Municipality of Anchorage codes and must be encased
in conduit.
o
o
10.
The water facilities were not turned on at the time of the
scheduled inspection. Please call this office for another
appointment.
The water analysis report needs to be submitted to this
office from the Chem Lab, 5633 B Street, for our review.
Expose the well for our inspection to determine proper
construction, also to insure minimum distance requirements
are met between the well and sewer system.
The septic tank pumped with a receipt submitted to this
department.
The septic tank pumped with a receipt submitted to this
department. ~fae total number of gallons p~mped needs to be
on the receipt and verified by a registered engineer as to
the actual number of gallons pumped. This is to verify the
size of the septic tank.
11. Expose the septic tank manhole to verifty its existence.
12.
Locate and expose the cleanout to the seepage pit and/or
leaching area for our inspection. %his is to insure the
minimum distanoe requirements are met between the well and
sewer system.
13. A four (4) inch cleanout needs to be installed to the septic
tank.
13a. A four (4) inch cleanout needs to be installed to the ].eaching
area.
14.
An adequacy test needs to be performed on the existing
leaching area. ~Ihis test will deter~n[ne if the system is
adequate according to National Standards. A listing of
private firms performing the test is enclosed. This report
needs to be submitted to this office for omu review.
15.
A maintenance contract for the Jet unit serving the sewer
system needs to be obtained from Consteel Company,
376-5919, and a copy subraitted to this office for our
review and our files.
]_6.
~he permit for the installation of the on-site sewer system
w:i.11 expire December 31,].98 . We have not received the
as-builts of the installation in this office. If a private
engineer inspected the system, please send us the report
for our files ar~ review.
17.
%he application shows the n~nber of bedrooms exceeds the
number the on-site sewer system was originally ~esig~ed
for. An upgrade will be required. Prior to any upgrade,
a permit needs to be issued from this department.
18.
An outside water tap was not available. Please call. this
office to make arrangements to have an inspector to meet
you at the site.
19. ~he depression over the sewer' systems will need to be filled
so that s~rface water drains away from the sewer system.
20. ~he standpipe to the sewer system need caps on them.
21.
The water sample could not be taken due to silt content
(turbidity). The well should be flushed clear by turning
on a garden hose until clear water is evident over an
extended period of time. Please contact this department
for a rese~npling appointment.