HomeMy WebLinkAboutMOUNTAIN MANOR TR E
MUNICIPALITY 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
hftp://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP231008
Work Type: Septic Upgrade
Tax Code Number: 05068203000
Site Legal Address: MOUNTAIN MANOR TR E G:0255
Site Mailing Address: 19140 JAMIE DR, Eagle River
Owner: BLACKSTONE JILL E & BRADFORD E
Design Engineer: NORTH RIM ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
♦Hent
f�
llepartment
2/27/2023
2/27/2024
1609840
Q Disposal Field L5 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
Special Provisions:
1. A test hole is required prior to construction of the absorption field, in the location of the proposed field, to
confirm minimum separation to impermeable soil and seasonal high groundwater. Construction may
proceed at your own risk prior to 7 -day groundwater monitoring. If results require a design change,
construction shall stop pending approval of a change order. Please submit results with the inspection
report (or change order, if required).
Received By:
v��
�� �� T
Date:
Issued By:
Date:
151
MUNICIPALITY OF
Development Services Department
On -Site Water & Wastewater Section
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 05068203000
Property owner(s) BLACKSTONE
Mailing address 19140 JAMIE DR
Site address same
Phone: 907-343-7904
Fax: 907-343-7997
Day phone 444-1761
Legal description (Sub'd., Block & Lot) MOUNTAIN MANORTR E
Legal description (Township, Range & Section)
Lot Size 1,609,840 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
0
Initial ❑
Single Family (SF)
El
(w/wo AD U)
Septic Tank
®
Upgrade E
Duplex (D)
❑
Holding Tank
❑
Renewal ElMultiple
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 property owner or authorized agent)
Permit/Rush Fees: 5 1?6--
Date of Payment: .2,/4ol 020 a3
Receipt Number: noAe&n
Permit No. 65pg 3%do-?
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
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All
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TI'1M =p
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(VNEERINGSteveEng.com Mountain Manor Tract E 4°� c 2/25/23
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: The current septic system has been functioning adequately
for almost 25 years. A new septic tank & absorption trench planned. The approved
replacement site is being used for this design, to install a new trench, connect the old
trench via Diverter Valve. This lot is very large and on a private water well. No adverse
impacts are expected from trench addition. Easements are depicted in the drawing, distant
from the proposed trench. The slope is indicated in the area of the septic system. No
conflicts to neighbor properties. The previous test hole is being used; an application rate
of 1.2 GPD/FT 2. Trench Length = 500 FT2/5'x 2 = 50' trench, 5' effective. Design to
meet Steep Slope Provisions of AMC 15.65.210.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• Minimum 3' of cover or insulation is required for trench; an equivalent of 1 "
insulation for F foot soil cover. Solid pipe must be set on well compacted, stable soil.
• 10' minimum between the house/ trench, 5' tank to trench, 10' to property lines,
• 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 2nd 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. Manhole Riser required in 1" tank compartment.
• All cleanouts must extend to at least ground level.
O In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
• Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from drain -
rock.
• Drain rock to be Y2 inch to 2 inch screened. Drain rock to be distributed uniformly
throughout the trench.
• Perforated pipe to be installed level with perforations down.
Silt barrier (filter fabric) to be installed above the drain rock.
• Smeared trench sides must be raked or scarified before drain rock placement.
• The finish grade must be mounded to promote drainage away from trench.
• 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,
Y Sewer Service Line is minimum 2% slope.
• Septic Tank to be pumped every two years or when required.
0 Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equ
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231008, Curtis Townsend, 02/27/23
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231008, Curtis Townsend, 02/27/23
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231008, Curtis Townsend, 02/27/23
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP231008, Curtis Townsend, 02/27/23
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ROLLING HILLS VIEW ESTATES
TRACT D
1 "53'10
r -r m -M r A M
89"54'50"
T' 0■a T T
HOUSE DETAIL
SCALE: 1" = 30'
4 OVERHANG
WOOD DEN
ORDERED BY:
BRAD AND JILL BLACKSTONE
84'"w
TIMBER RIDGE SUBDIVISION
MEADOW CANYON DRIVE R,OW
131,80'
DEDICATION
En
M"
E 1/16 coy.
EXCLUSION NOTES; It Is the owners' responsibiiity to d t rml*ne LEGEND.- SET FND
the existence of any easements, covencints restrict Dims 5/8NRB /CAP* 8- FSB
which do not appear or, the r --corded subdivision plot, NOTE- 125" AL. MON 0 M ONUM ENT
Under no circum5tances should any data hereon be used for HUB & TACK Ej
construction or for establishing property lines. FENCE -.
physi al survey of this property as shcwn on this WOOC DE -
draw'ng and that the improvements situated cher CONCRETE- F&
on are within the property linpr: rnd no encrooch— P�ALT-
n is exist other than noted GRA\EL
LAND & CONSTRUCTION SURVEYORS—PLAN
440 WEST BENSON BLVD #103
ANCHORAGE, ALASKA 99503
WORK ORDER NUMBER: DAM 5C., -E_
APRIL 19, 1999 1"=200'
98iL-395A DRAMBr. aEacm BY GRID NUMBER-
MLJ I I NW 255
NERS—ENG]NEERS
(tax) 561-6626
(907) 562-5291
PLAT u0.
84— 253
BQ0K/PAGEP-
Mi-98
AS —BUILT
Q F LEGAL DESCRIPTION SEPTIC STANDPIPES -
WATER WELL -
TRACT E
MOUNTAIN
MANOR
SUBD.
I
Municipality of Anchorage Page
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: _~¢¢,,/ ¢Z~'/~ PID Number: ~-*¢'~' ~'
Name:Wastewater System: ~New U Upgrade
Address:
t~. ~.~ f/~z~,~.~..C~ ~ ~ ~/ ABSORPTION FIELD
No. of Bedrooms: ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
Phone:~d __ ~
LEGAL DESCRIPTION SOd Rating: /* ~ GPD/Sq. Ft. Total Dept~r~m original grade;
Lot: Block: Subdivision: Depth to pipe bottom from original grads: Gravel depth beneath pipe
,ow.,,,,:~ : ~ Section:~ ~ Fill added above origi~al grade:~ Ft. Gravellength: ~ ' Ft.
WE LL: ~ New ~ Upg rede Gravel width: ~ / Number of lines: Distance between lines:
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Dale Drilled: Static Water Level: In~aller: Date installed;
Pump Set at: Casing Height Above Ground:
~i.~u: ~ G.U ~-~ ~,~-/ ~. ~ ~ FL TANK
SEPARATION DISTANCES /Septic ~ Holding ~ S.T.E.P,
To Seplic Absorption LiR Holding ~ublic/Priva~* Manuf~turer: Capacity in gallons:
From Tank Field Station Tank S .... Lines /~¢ ~. ~. ~ /
Material: Number of Compartments:
Well ~/~ ~ +/~ ~ ~ ~ ~ +/~ ~ ~
Surface
Water */~ ./~, ~/~, LIFT STATION
LineL°t ~ /~ / ~ ~ Size in gallons: Manufacturer:~
~at ~ High wator alarm at:
Foundation I ~ t ~ ~_ "Pump on" level at: .... :
Curtain . Pu~ Electrical Inspections performed by:
Drain ~ ~- ~
Remarks: BENCH MARK
Location and Description:
I Assumed Elevation:
ENGINEER'S SEAL
Inspections performed by: ~ ~' ~ $' Dates: 1st ~-/~-~
Department of Health and Human Services approval ~.~ cn4~ .~
Reviewed and approved bY:~// ¢ ' _
72-013 (Rew 9/gl) MOA 25
Permit No. SW970319 Page 2 of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 1966,50 · Anchorage, Alaska 99519-6650 Telephone: 543-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: Mountian Manor Sub. Tract E
PID No.: 05068203
J
~ ~ ,.~c,~ ~1~ ~-~ m~ X'
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f~// //?
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Sco
e 1"=500'
8/7/98
ENGINEER'S SEAL
~:x.. ........ ..~f~
:~F.'Y.." ~ ".~
~...' 49THai[ "..~
~". Louis A Buter~ ."~
?~%~'... ce-6756 ..."~
Permit No, SW970319 Page 3 of 3
Municipolit¥ of Anchoroge
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,O, Box 196650 · Anchorage, Alaska 99519 6650 Telephone: 545 4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: Mountian Manor Sub. Tract E
PID No.: 05068203
HCUS~
26.8'
~-D = 84,1'
NO NEIGHBORING LOT LEACHFIELDS OR
WELLS WITHIN 200' DISTANCE TO OUR
DEVELOPMENT
NO KNOWN CURTAIN DRAINS
[] - TEST HOLE
· - MONITOR TUBE
o - SEWER CLEANOUT
-,~- - WELL
EASEMENT
LEACHF-IELD
ELEVAT[BNS
(NOT TO SCALE)
TOP OF WELL CASINO
ASSUMED ELEV : 200.00
ORIGINAL
GROUND
LEVEL AT:
Scale 1"~-100'
8/14/98
C�.exttftrb prilling �Evg
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759
OWNER OF LAND agf4 I Jt44 d3(_4 C K F '4rjE BORE HOLE DATA
ADDRESS 100 j',t' /l p cp a�' rV f{ 'y` 5l
LEGAL DESCRIPTION _ /Xr j nj i A raJ OW. -J04
Mg F.
PERMIT NUMBER°I}3� Date of Issue' -'-'
TAX INDENTIFICATION NUMBER e - (S'o'd - o
Is well located at approved permit location? ZkYe`s 71 No
Method of Drilling: ,Yg"ir rotary 0 cable tool
Depth of well: /41
Casing Type S7"EF(_,. Wall Thickness { cx inches
Diameter !E inches, depth feet
Liner Type: t)-)uJj
Casing Stickup Above Ground: CRI feet
Static Water Level (from ground level): % feet
Pumping level: feet after hrs. pumping gpm
Recover Rate: gpm
Method of Testing: Iq I I,
Well Intake Opening Type: rKpen End Open Hole
71 Screened; Start feet Stopped feet
C) Perforations Start feet Stopped feet
Grout Type: 76 Volume 5R0 465
Depth: from Q feet, to "°°" feet
Pump Intake Depth: feet
Pump Size hp Brand Name
Well Disinfected Upon Completion? hes No
Method of Disinfection: , f',vl C, 40 J
Comments:
DEPTH
From To
/.�O
! 3}o
f ✓�
Tv�•
Ce4"S` rr..1 Q 11� r 1 C. ,C j 10
4
464 dJ406--.)
W#Y,<,0A4,J
S'1 i- r 1 6,+(,q j
,
6.19"'1' :%, 644 i s ..,.
Driller's Name'
64 4 Ji,:,. rr
ATTENTION: It is the responsibility of the property owner to submit a copy of the well log to the proper authority. Municipality
of Anchorage: Department of Health & Human Services and/or Department of Environmental Conservation. MatSu Borough:
Department of Environmental Conservation.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ROA
PAGE 1 OF 1
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW970319
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:BLACKSTONE JILL E & BRADFORD E
OWNER ADDRESS:P.O.BOX 110224
ANCHORAGE, ALASKA 99511
DATE ISSUED: 9/17/97
EXPIRATION DATE: 9/17/98
PARCEL ID:05068203
LEGAL DESCRIPTION:
MOUNTAIN MANOR TR E
LOT SIZE: 6~,977(SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 (18A_AC80).
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:
PROPOSED TRENCHES MAY NOT BE LOCATED LESS THAN
35 FEET FROM A CHANGE IN SLOPE OF GREATER THAN
25%
RECEIVED BY:~~
//
DATE:
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
September 5, 1997
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Mountain Manor Subdivision Tract E
Narrative & Permit Application
ENVlI~NTAL ~EI~V/C~ O/ViSION
SEP 09 1997
RECEIVED
Dear Mr. Cross:
The proposed septic system will have very limited impact on adjacent properties for the
following reasons:
1. The surrounding lots are large, allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all +30' distance.
3. Reserve space is adequate for the trench systems as shown on the siteplan.
4. Drainage will not be affected and is not a major consideration in our design.
We are requesting a variance for the septic trench and reserve septic trench so that they may be
installed on a slope greater than 25%. The site topography is such that we are forced to place the
trenches in this location as shown on the site plan. The slope is fully vegetated and undisturbed
down gradient of the system location. The location of the leachfield on the slope would not in
our opinion compromise the effectiveness of the leachfield or cause effluent surfacing.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\ 1997\97-058-NAR.DOC
HInos
0
Z
<
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL:
Mountain Manor Subdivision Tract E
9/5/97
A. GENERAL.
1. The well and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Depaxtment of Environmental Conservation requirements.
6. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
B. SEPTIC TANK
1. The septic tank shall be a minimum capacity of 1250 gallons and be of MOA approved design.
C. TRENCH
1. The trench is to follow the existing old road bed to maintain uniform total depth of the trench
bottom.
2. The bottom of the trench excavation shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 9' at any point.
4. The effluent line within the trench shall be laid level within 0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoff.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 9' GRAVEL DEPTH = 5' under pipe, 2" over pipe
TRENCH LENGTH = 50' TRENCH WIDTH = 3'
SOIL RATING = 1.2 GPD/ft2 BEDROOM CAPACITY = 4
SEPTIC TANK -- 1250
Twenty-four (24) hours notice required for all inspections.
\ 1997~97-058-spc.dot
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
8
9
10
11
12
13
14
15
16
17,
18-
19
2O
COMMENTS 'T~11''' ~,4o,[~ I
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED;'
IF YES, AT WHAT
DEPTH?
Depth to Waler Alter
Monitoring? ,'"~'~ Dote:
SITE PLAN
S
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ((' I
-- (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 5 m FTAND ~ I FT
PERFORMED BY: .,~,,,,,~Z~4-,~E~ ,,~/v~.~ ,C?~/,~-/,,~,~F.~/,~. I ~--~1,,~-~'< CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE: Z/~//~'2
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:~ ~ ,~',,~
DATE PERFORMED:
Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18,
19-
20
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED?
s
IF YES, AT WHAT OL
DEPTH? /~// p
E
Oepth to Water After
Moniloring? )ct.&, Dale: ~-~-~
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE '~ ' ~ (minutes/tach) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ x
FT AND '~ ~
FT
PERFORMED BY: ~",,~.~,E' ~/~'~T.,~ ,~-,/,~.,,,~,¢z~'C,~.-m,,~,.;¢. I '"~-=~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~//~
72-008/Rev 4/~L~
Eagle River Engineering Services
Louis Butera, P.E.
lx.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fak
Mountain Manor Subdivision - 09/05/97
Single Family 4 Bedroom Dwelling
LEACHFIELD SIZING
4BR = 600gpd
Soil perc rate = 2.4 minutes/inch
Soil acceptance rate = 1.2 gpd/SF
Required absorption area = 500 SF
Use a trench with 5.0' of gravel, 50' long, 3' wide trench
G:\WPDOCS\1997\97-013-CAL I
Percent Finer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # .. /'~5-~g';~ ~.? ' HAA#
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) ~.c-¢¢ ?<. ~,.~_
Property owner ,~/'~ ¢./-~r/~,., ~
Mailing address ,~,6' /J~2~ ~-{
Lending agency ~-~
Mailing address.
Day phone., ~?~ ......
Day phone
Agent
Address
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:
NOTE:
ing to the legality and status of system,r
TYPE OF WASTEWATER DISPOSAL:
If community well system, provide written confirmation from State ADEC attest- ·
72-025 Rev, I/g1) Front MOA#21
Individual on-site
,Community on-site _
' Public Sewer
If commUnity WasteWater system, provide written confirmation from State ADEC
attesting to the legality and status of system. ' ' ·
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 code~,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm ]~ag~e ]~{.ver ]~ngj.~eet'LaR.
......... '~"-, Phone _
~-~94
Address
Engineer's signature
DHHS SIGNATURE
Approved for . 4
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Muhi~ipality of A~ci~0rage Department of'Health and Human Services D
Approval Certificates based onl,, ,,A,,..,_ .... _ . . . (HHS) issues Health Authority
~ ,,~,,,. L.~ r~presentations given in paragraph'-5 above by an independent
Prbfess!0nal engineer registered in the State of Alaska The DHHS does this as a
and the~ lending institutions in order to satis~, ce'*'=-,^.~__, _ ~ ~ . courtesyto purchasem of homes
' r 'X ',~"? '=u='='.ano state requirements. Employeas of DHHS do not
conduct inspections or analyze.data before,a,,certificatelis.issued. The MuniciPality of Anchorage is not
res~onsibl.~ for errors or omissions in the'pmf~i0nai engir;~r's work.
72-025(Rev, l/91) Back, NIOAe21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVlOESApR
Environmental Services Division ~-~, i999
825 L Street, Room 502 · Anchorage, Alaska 99501 ·
8N~i~(~I~ENTAL SERVIces
Legal Description:
A. WELL DATA
Log present (Y/N)
Total depth
Sanitary seal (WN)
Health Authority Approval Checklist
?~"~'~',,.vt,~./,,~, ,/~?.,~,.~,~.v- ~-r~r,z~ ParcelI.D,: ~_,_,7~'-<~'o~ ~-~
If A, B, or C, attach ADEC letter. ADEC water system number
Y Date completed '~/~ S-/~' ~
Cased to //// ' Casing height (above ground)
/v Wires properly protected (Y/N)
Date of test
Static water level //~'
Well production ~
FROM WELL LOG
g.p.m.
AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:.
Coliform ~ Nitrate
Date of. sample: /--~./~/E?
B. SEPTIC/HOLDING TANK DATA
Date installed ~'~/~ "5'~c Tank size
Foundation cleanout (Y/N)
Date of Pumping /v~,
C. ABSORPTION FIELD DATA
Date installed g-/~-
Length ~-~ ~ Width
Effective absorption area
Date of adequacy test
~, 6 .~'~ "~/'~ Other bacteria
Collected by: ~/~ ~-£
Number of Compartments ~ Cleanouts (Y/N) .
Depression (Y/N) ~/ High water alarm (Y/N)
Pumper ,"'~,,/.~
Soil rating ~r fF/bdrm) ,/, ;:L System type
Gravel thickness below pipe ~ ~ Total depth
~Monitofing Tube present (y/N) /v, Depression over field (Y/N)
Results (Pass/Fail) ,,'v/~F For
Fluid depth in absorption field before test (in.); /'///4- Immediately after --'-- gal. water added (in.):
Fluid depth ~ (ins) Minutes later: ~ Absorption rate --- --'-- q.p.d.
Peroxide treatment (past 12 months) (Y/N) ~v~' ---'- If yes, give date '--
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION~
Date installed
Manhole/Access (Y/N)
High water alarm level
Cycles tested
Size in gallons
"Pump on" level at*
E. SEPARATION DISTANCES
*Datum
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot 7" /~ /
Absorption field on lot '/--/~ /
On adjacent lots
On adjacent lots
Public sewer main /V,~, Public sewer manhole/cleanout
Sewer/septic service line ~' ~- ~ Lift station "~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ?~ / Property line -~'/4, '
Water main/service line 7~/~ ~ Surface water/drainage Y-/d,~ ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~/~ ~ Building foundation ~"~ /
Surface water 7~ ?~ ~
Curtain drain
F. ENGINEER'S CERTIFICATION
Absorption field ~ d /
Wells on adjacent lots Y-/~ ~'
Water main/service line
Driveway, parking/vehicle storage area '/- !
Wells on adjacent lots ~'-/~)"
I certify that I have determined thru field inspections and rewew of Municipal recor~
in conformance with MOA HAA guidelines in effect on this date. _~.,'~
Siglnature ~ ~ ~_~'%~.~,,.
Engineer's Name ~,~ ~ ~'~ ~ ~-~ ~:~
Date ~/~ ~/~ ~ ~
HAA Fee $
Date of Payment
Receipt Number
S a~
Waiver Fee $
2z - ? Date Payment
72-026 (Rev. 3/96)*
APR-16'90 lB:30 FRO~'CTE EMVIRONI~flTAL 56)530) T-O41 P.OI/Ol F-?8g
Ztk CT&E Environmen~l Services Inc.
Laborato~ Division
20Q w. Po~e¢ Dr,ye
Tm (907)
3rinking Water ~alysis Repo~ for Total Colifo~ Bacteria
RE,~ [~$TRUCTIONS ON ~VE~ $1~E BEFO~ CO~CTING S~PLE Fa~ {~7) 561
fie COMPLETED ~Y LABo~TORY
MUST BE COMPLETED B~ ~R SUPPLIER
PUBLIC WATER sYSTEM !.[}- #
PRtVATE wATER sYSTEM
SAMPLE DATE; ~
Month
F,A MPLE TYPE
~ RouTine
:~ Repeal Sample (fnr routtlte saxttT~e
with lab Itel. Itu, __ ~)
C] Special Parpose
~,,M PLE LOCATION
~ Trea~ed Water
~ Untceat~l Water
Time= C°il~:~d
cotl~:md By
~nal:~sss shows d.s Wmef SAMPLE to toe
Uflsausfacto ~
Sample ov~ ~ hou~ o1~ ~ul~ m~y
he un~t~ablc
Sample ~ long in ~s~r, ~lc should
nOT ~ 0~ 48 ho~ Ol~ ~ e~ma~on
to ~ndlca[e ~[labie ~s~l~ ~c~ send
ue~ s~plc vm sp~a~ ~v~ ~}
Time ~ -
Aaa}~ttc~ M~h~: ~ ~ FIIT~
BACTERIOLOGICAL WATER AINALYSIS RE. CORD
mm, CT&E Environmental Services Inc.
·
CT&E Ref.# 990310001
Client Name Eagle River Engineering
Project Name/# N/A
Client Sample ID Tract E Mountain Manor
Matrix Drinking Water
Ordered By
PWSID 0
Sample Remarks:
Client PO#
Printed Date/Time 01/27/99 08:29
Collected Date/Time 01/19/99 17:07
Received Date/Time 01/20/99 12:10
Technical Director: Stephen C. Ede
Parameter Results PQL Units Method
Allowable Prep Analysis
Limits Date Date Init
Nitrate-N
Total Coliform
0.629 0.100 mg/L
18 08/100 ML, NO COLI
EPA 300.0 10 max
SM18 92228
01/20/99 01/20/99 SCL
01/20/99 KAP