HomeMy WebLinkAboutMOUNTAINSIDE VILLAGE #1 BLK 4 LT 19 Municipality of Anchorage Page I of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 e Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~/¢q_20~£~ PIDNumber: O,21:) ~V:2.~,2.
Name: Wastewater System: ~ New [] Upgrade
D/)NIEL f~OGEF~S OR
Address: ,/'J-N C ~/
Pho,,e:3ff~-13~1I 3 ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other
LEGAL DESCRIPTION so, ..,.,~: Total Deplh from original grade:
Lei: Block: Subdivision: Depth to pipe bollom Irom origJnat g~de: Gravel deplb beneath pipe
Townsl~ip:~ ~ Range: 3 ~ SecU°n:~l - , Fill added above originate,5 grade: Ft. Gravel length~ 1~ ff~l ~ 2~ Ft.
WELL: NoT ~ND New ~ Upgrade Gravelwidth: Number of lines: Distance belween lines:
Classification (Private, A,B,C): Total Depth: Cased To: Total ~bsorption area: Pipematerial:H"~E~F~
Driller: Date Drilled: Static Water Level: Installer: Date/installed:
GPM FI. Ft.
SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P.
To Seplic Absorption Lifl Holding PublicrPdvale Manulaclurer: Capacity in gallons:
Flora Tank Field Slalioo T~nk S ...... Li~es ~O~8 T~hl
Material: Number of Compartments:
Surface
Lot ~ Size in gallons: Manufaclurer:
Line JO0 ~1 ....
Foundation ~ ~ ~O~ .... ' O ~ "Pump on" ~evel at: . "Pump off" level at: High water ~larm at:
CurtainDrain ~ .... Pump Make & Model Electrical Inspections pedormod by:
B~NOH MARK
Location and Descriplion:
]OO 0
Assumed
Elevation:
~](~[top ~ec~Jc~] Se~ices ENGiNEeR'S SEAL
d ~ - 1~500 Echo Street
Inspections performed by: FLATTop 'r~cH ~vc5 Dates: 1st 717(/2~ .~
Department of Health a~ ~uman Seryices approval
Reviewed and approved by: Date:_
72-013 {Rev, 9/91) MOA 25
Permit No. S~V' c~ 2,0 I ES Page ;2 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:
PIDNo.: 02.0 '72/02.
HOUSE CORNERS
A
5'+' 8o'
'/2'
Flattop Technical Services
14530 Echo Street
Anchorage, Alaska 99516
72-013 A (Rev 9/91)MOA 25
Permit No. _,~J,V c~2 cD 153 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: Lo'T lC/; B£K' ~ ~,IOuNTAIN$1DE VII. cA5£ ~( PID No,: 0201"/2 ~3-.
cio
Ou'rLE% = 82,0~
7o
INVEI~T
go'i'M
Flattop Technica! Service
14530 Echo Stree~
Anchorage, Alaska 995]~
72-013 A (Rev. g/gu MOA 25
S[ 2E OF AT.ASKA
DEP/%RTk T OF NATUt~3~L i~ESO~IRCES
DIVISION OF GEOLOGICAL AND GEOPHYSICAL S~RVEYS
WATER WELL RECORD
LOCATION OF W~ELL
BOROUGH ~¢'J' /',,/< LOT ,
Ii.~ '.':t~ ~ ~ ~' '7 '~'
DIRECTIONS:
MF2%SLFRING POINT: .[]top of casing
[]ground surface [~other:
Bor<EHOLE DATA: Depth
Material' type and color
~EMA~KS: Municipaht¥
Dept, Hearth &
,er¢ces
CONTRACTOR INFORMATION:
.,. , ,,/! , . ,') , : ~,
Registered Bus~ness N~e
:.,~ ..... , ....... / ~.' .>~..~.
SLgn~bu=e o¢ Aubho:LCed Rep:esenEaEZve
Date
SECTION QTRS
TOWNSHIP I P~%NGE I MERIDI~2~
.... · ~.~
W~LL DEPTH: DATE OF CObfPLET~ON:
Depth of hole:..~ ft
Depth of casing:
STATIC WATER LEVEL: /~ ~t. Date
METHOD OF DRILLING: ~air rotary
~cable tool. ~other:
USE OF WELL: ~domestic ~]irrigation ~monitor
~public supply ~other:
CASING: Stick-up ~-~ ft. Diam: (~ in
WELL INTAKE: [] open end
[] perforated
Depths of openings:__ to __
~ screened
~open hole
ft
SCREEN TYPE: Diam: in
Slot/Mesh Size: Length: ft
Set Between and ft
GRAVEL PACK TYPE:
Vol~ne used:
Depth to top:
GROUT TYPE: Volume:
Depth: from ft to ft
DEVELOPMENT METH(~: ~'
Duration: ,~ ~% ,
PUMPING LEVEL kND YIELD:
_%~%~ft after ~ hfs pumping / gpm
PUFLP INTAKE DEPTH: ft Horsepower:
Date Pump Installed -
WATER CHEMISTRY SAMPLE TAKEN? ~yes ~no
..Well disinfected upon com letion? es no
PLEASE MAIL WHITE COPY OF LOG WITHIN 45
DAYS TO:
DGGS
PO BOX 77-2116
EAGLE RIVER, AK. 99577
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW920158
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:ROGERS DANIEL C JR
OWNER ADDRESS:17901 MOUNTAINSIDE VILLAGE DRIV
ANCHORAGE, ALASKA 99518
DATE ISSUED: 6/30/92
EXPIRATION DATE: 6/30/93
PARCEL ID:02017262
LEGAL DESCRIPTION: MOUNTAINSIDE VILLAGE #1 BLK
4 LT 19
LOT SIZE: 112204 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD / 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 (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS
RECEIVED BY:
DATE:
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
TI~ODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 June 23, 1992 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dem' Sirs:
The purpose of this letter is to provide the required design nm'rative in support of our application for a
pe~wfit to construct wastewater disposal facilities on Lot 19, Block 4, Mountainside Village S/D, located on
Mountain Drive. Soils logs, perc test results, a site plan, design drawings and specifications m'e enclosed
for your review.
The proposed system will be constructed in the vicinity of test hole # 4. As can be seen from the soil
log, the native material between 2' and 8.5' is a somewhat silty sandy gravel with a measured perc rate of
4.4 minutes per inch. Bech'ock was encountered at 8.5', which dictates that the bottom of the soil
absorption system be no deeper than 2.5 feet. The proposed design is conse~watively based on 1.0
gpd/sq, ft. instead of the 1.2 gpd/sq, ft. allowed by the ordinance for soils with perc rates between 1 and 5
minutes per inch. Thus, the proposed 3 bexh'oom residence requh'es a total absorption area of (3 x 150)/1
= 450 squm'e feet. The proposed soil absorption system incorporating two 5' wide by 45' long soil
absorption drainfields connected in series has a total absorption m'ea of 450 square feet. A similarly
configured replacement system is designated in the vicinity of test hole #1. Because of the slightly
shallower bech'ock in that area, the maximum depth of the replacement ch'ainfields could be no more than
2.0 feet.
The topography of the lot slopes in the construction m'ea slopes towm'ds the west at between 25% and
30%. Although this slope in places mm'ginally exceeds the 25% specified in the ordinance, there should
be no concern as to daylighting of septic tank effluent since it is to be distributed below grade into excellent
receiving soils. There are no cutbanks within 100 feet downhill of the proposed systems.
The proposed project will have no impact on present or future water supply and wastewater disposal
systems serving adjacent properties, nor will it have any impact on reserved space/surface and subsurface,
or on drainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
(VA C A N
PROPOSED
PRoPos
~bRM
,. ~,~.~
PROPoS~b , ·
',".
............
.~y...,.,:. ~ ~o~
14530 Echo Street ~ ' -.
anchorage, Alask~ 9951g
~ ...... ~
~o~TOe T A~ C'O'J
PLAN V~EW
SECTION A~A
Flattop Technical Services
!' 145S0 Echo Street
~nchorage, Alc~ska 9951 ~
SOIL. A$So~'PT/o~ DRA~NFI£LD.q
PLAN 4_ CROSS - <~ECT/oN
Flattop TechnicaI Services
14530 Echo Street, Anchorage, AK 99516~
Phone (907) 345-1355
Lot 19, Block 4~ Mountainside Village S/D
Mountain Drive
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of installation of a 1000 gallon septic tank and two parallel
5' wide x 45' long soil absorption drainfields connected in series.
1.2 Construction shall be as depicted on the approved site plan and design ch'awings. Minor
deviations from these drawings may be allowed or requh'ed by the engineer conducting the inspections.
All construction procedures and material specifications shall conform with Municipal and State
requirements. All sepm'ation 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 around any
buffed utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensm'e that proper drainage is achieved after settlement and that theme are no residual
depressions. Insofm' as possible the contractor shall minimize damage to trees.
1.5 Unless specifically agreed otherwise, the homeowner 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.
2.0 Septic Tank:
2.1 The 1000 gallon septic tank shall be Municipally approved with two compartments, 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.
2.2 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste
l/ne between the tank and the soil absorption system shall have a minimum slope of 1/8'~ per foot. A
cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed
within 5 feet downstream of the septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by carefully stripping the shallow peat and reddish
sandy loam strata from the proposed 5' wide by 45' long soil absorption drainfield site's to expose the top
of a slightly silty sandy gravel stratum at a depth of approximately 2 feet. The maximum depth of
excavation shall be no more than 2.5' below the original ground surface on the uphill side of the
excavation.
3.2 A level bottom surface for the ch'ainfields shall be created by placement of coarse, clean filter sand
as necessary to bring the downhill side np to the desired grade. Leveling sand shall comply with
Municipal specifications for filter sand.
3.3 A total of 1.0 feet of approved sewer gravel shall be placed in the bottom of the drainfields With
the perforated distribution pipes laid level such that the pipe inverts are no less than 6 inches.above the
bottom of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with lesg than 3% passing
the #200 sieve. The non-perforated pipe connecting the upper and the lower drainfields shall incorporate a
6" high "bump" causing septic tank effluent to favor initial distribution into the upper drainfield
3,4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design drawings. The portion of the monitor tube extending through the ~ewer gravel shall be
perforated.
3.5 Approved filter fabric shall be placed over the entire top surface 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.
3.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
3.7 All areas disturbed by the construction and/or soil absorption drainfield top and side slopes shall
be covered with 4 inches of topsoil and seeded with an approved grass seed to promote rapid revegetation.
This topsoil and seeding shall be accomplished by the property owner after the backfill has consolidated.
4.0 Inspections:
4.1 A total of 5 engineering inspections will be required during the course 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 infiltrative
surface to ensure that it is level and at the right elevation, and conforms with the soil test information, (3)
after the sand levelingmaterial has been placed, (4) after the sewer gravel is in place and the distribution
pipes have been laid and connected up to the septic tank, but prior to placement of insulation or filter
fabric, and (5) after final backfill and grading is complete. The septic tank requires one inspection after it
is set level and the piping connected, but p~4or to backfill. This inspection may be incorporated with any
of the above inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensure the availability of the engineer.
PERFORMED FOR:.
...... 14530 Echo Street
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~oc~I~RS
LEGAL DESCRIP':ION; L J~j ~ur., N'T'NSIDE ¥1LL~(_~Township, Range, Section:
1
2
3
4
5
6
7
8
9
10
11
12
13'
14
15
16-
17
18
19
20
C~MMENTS __
B~bRoc~<
"FILM, R3~v'
SLOPE
WAS GROUND WATER
ENCOUNTEIR ED? --- ~
IF YES,. AT WHAT
DEPTtt?
(]eplh to Water After
Monitoring?. ~) P,'"/,
SITE PLAN
Reading
Date Gross
Tired
7; SS:qo
7: ,~'~: I0
$:ol :1o
~:o1: 3o
~:03',3o
PERCOLATION RA}E
TEST RUN BETWEEN
Net
Time ~1~
Depth to
Water
Net
Drop
PE~ORMEDBY: FzA'rToP T£c/-I. ?c~;. _.l __.'~'~ ~__ - CERTI~'Y THAT THIS TEST WAS PERFORMED iN
ACCORDANCE WITH ALL S'rA'TE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ / ~-,-~ Z~ ~.
72-008 (Rev, 4/85)
~' ..... ~[4530 Echo Street
A" h ~:a
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
~OIL~ LOG ~
LEGAL
1
2
3
4
5
6
7
8
9
10
11
12
13'
14
15
16
17
18
19,
20-
COMMENTS
DESCRiPTioN. L Jc~ ~L~ M'T~SI~.E ~/ILL~(~Township, Range, Section: BE(: II, TIIiq,
SLOPE SITE PLAN
, PT
.BANoy GI~v E- L
~.t-1.
B~b~oc~
WAS GROUND WATER
ENCOUNTERED?
IF YES, ATWHAT
DEPTII?
Doplh Io WaLer Atler ,
Monitoring? . ~ P?{, '? Date:
Reading Date Gross
Time
PERCOLATION RA]E
TEST RUN BETWEEN
Net
Time
Depth to
Water
(mmules/inch) PERC HOLE DIAMETER
FTAND . .FT
Net
Drop
PERFORMED BY: F'/._.___~TToF~ _ TE(~ Sl/,~._~ .... ' ---¢~"~--~'~-~ ...... CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STA'TE AND MUNICIPAL GUIDELINES IN EFFEC~ ON THIS DATE. DATE: 0'~/2.,,~ ,/~r~
72-008 (Rev, 4/85) .... '
PERFORMED FOR:
=' ..... 14530 Echo Street
Anchoracm,
Uun|~lpallt,y o~k kQnSc]~gr a g~e9~1 ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION 'TEST
LEGAL DESCRIP':ION: ,L I°/j B q., M'TN SID~ ¥1LL_/L~_~Township, Range, Section: SEC II,
1
2
3
4
5
6
7
8
9
10
11
12
13'
14
15
16
17,
18-
19-
:20-
C~MMENTS
TIIN
SITE PLAN
pT
51,'1 REbblSH SANb'/ Lo,~M
5ANbY GRAVEL
~ £ b~Oc k:
SLOPE
WAS GROUND WATER
ENCOUNTERED? N
Monitoring? ])l?-..y~ ?,E
Gross
Time
Reading Date Net Depth to Net
Time Water Drop
PERCOLATION RA]E
lES] RUN BE]WEEN
(mmules/inch) PERC HOLE DIAMETER
FT AND FT
ACCORDANCE WITH ALL S'rA'TE ~AND MUNICIPAL GUIDELINES IN EFFEC] ON THIS DATE. DATE: _ ~(/ '~ ~ /~q ~
72-008 (Rev, 4/85) --'
PERFORMED FOR:. ,~N
~:: 14,530 Echo Street
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "h" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL OESCRIP':ION: L l~; Bq., N_~NSIb~ Vl'LL~6~7ownship, Range, Section: SEC II, TII lq, ~ :3tv'
I
2
3
4
5
6
7
8
9
10
11
12
13'
14
15
16
17
18
19
20
O~)MMENT8 . [/~/
SLOPE
WASGROUND WATER
ENCOUNTERED?
SITE PLAN
IF YES, AT WHAT L
Monlt0rinu? DRY. ~8.~ Dale:
Roadino
Gross
Time
lo; to'. /$
lo;Is:
lo; 2f: I~"
Io;26;
lo:g/: qS
Net
Time
Depth to
Water
~/~
PERCOLATION RATE L~../~ (minutes/tach) PERC HOLE DIAMETER
TEST RUN 63ETWEEN 2.~' FTAND, 3 FT
Net
Drop
CERTIFY ] HAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STA'TE AND MUNiCiPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: _.~1/
72-008 (Rev, 4/85)
" .... ]4530 Echo Street
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
LEGAL DE$CRIPTION:.._~
1
2
3
4
§
6
7
BEb~OCK
8
9
10
11
12
13'
14,
15
16
17
18
19,
20
Hq'~.SI~)/~..~V(LL~¢ETownship, Range, Section: SEC II, l-mIN,
SLOPE SITE PLAN
~ANbV ~RAVEL
TAN', ~,~NY CoBB/£_< ~ ~"
WAS GROUND WATER
ENCOUNTERED?
fF YES, AT WHAT
DEPTH?
Oeplh to Water After
I~onJloring?
Reading Date
PERCOLATION RATE --..
TEST RUN BETWEEN
0818:
Gross
Time
Nat
Time
Depth to
Water
---. (minutes/inch) PERC HOLE DIAMETER __
-- FT AND __ FT
Net
Drop
PERFORMED BY: . .F&ATT~o?__ T[c/.___JL.__ ¢;v~c ~. _ ,
--- CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STA'TE AND MUNiCiPAL GUlDELtNES iN EFFECT ON THiS DATE. DATE:
72-008 {Rev. 4/85) ~.- _. ..
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.
HAA# ~l'tr~ q ~c'~\q \
1. GENERAL INFORMATION
Compietelegaldescription hoC' I~/ 611, ~t., I"lo~,~/-~l~.~,r/(,, (.,',/1~,,¢ .~/D +~1
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent hi, ~.
Address
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
individual well
Community well
NOTE:
Public water
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
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.
72-025 (Rev. 1/91) Front MOA #21
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/orwastewaterdisposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verifythat 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.
NameofFirm rc- ld~f./-r.,fl 7'~ch/~'~ ¢~[ .~.,-~'~'c~, Phone .~q,5--
Address / q~f-.~ O ~c.l-~ .?/.¢, ,/rnd,~o ,,'o~¢ ~/-r
Engineer's signature ~~ ~ ~ Date /~,",/
DHHS SIGNATURE
Approved for
Disapproved.
~.~...~ ~,, ......
bedrooms.
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~)25 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: 19/~ I~fo¢-~n~ms¢Me ('/~1(~_~¢- Parcel I.D.
A. WELL DATA
Well type ¢'~'
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
IfA, B, orC, attach ADEC letter. ADEC water system number
Date completed I,~ /1~/ /¢~- Driller
Cased to 7 Casing height__
Wires properly protected (Y/N)
g.p.m.
FROM WELL LOG
Date of test I0 / ~5' / ? '~
Static water level lq/'
Well flow !
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main _
Sewer service line
AT INSPECTION
; On adjacent lots _
; On adjacent lots
Public sewer manhole/cleanout /~' '~.
~ C=
"/2
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ ¢~(
Date of sample:
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ~,/I /~?~
Cleanouts (Y/N) Y'
High water alarm (Y/N)
Date of pumping N. ~.
Tank size IOoO ~,~/ Compartments ~-
Foundation cleanout (Y/N) Y' Depression (Y/N)
/~. Alarm tested (Y/N) f'/' /¢-
~.~.o~_ Pumper__ I',1, ~.
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To propertyline--(Oo'
Surface water/drainage
On adjacent lots
Absorption field
tOO~
Foundation
Water main/service line
72 026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Surface water
Date installed ~ /I /92-
Length gO' Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Soil rating I,O ~,to~/..¢f ~-
Gravel thickness ¢', ,5"'
Cleanouts present (Y/N)
Date of adequacy test
for _~
System type
Total depth
Y
bedrooms
Peroxide treatment (past 12 months) (Y/N) /1/
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot
To building foundation
On adjacent lots '~
Surface water ~, ~oo'
Curtain drain N~,~e S~e,n
If yes, give date N.
On adjacent lots :>' lOC' Property line 7,¢' '
To existing or abandoned system on lot N.~..
Cutbank No,~ Water main/service line ~, ~oo'
Driveway, parking/vehicle storage area ~ '
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature 0'~~ ~'.
Engineer's Name
Date ~/~/ l~/
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-028 (Rev. 3/91) Back MOA 21