HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES BLK 1 LT 4
Municipality of Anchorage Page t 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: ¢ ~¢// ¢'7 0'-~-.~, t¢ Pie Number: O kO ~ ~, ~ I -/ ~
Name:
'-% ~¢¢-~, ~L~ ~ Wastewater System: ~ New ~ Upgrade
Address:
¢.o.~ ~/7'7 % ABSORPTION FIELD
Phone: ~. of Bedrooms:~ ~Deep Tree,ch ~ Shallow Trench ~ Bed ~ Mound ~ Other
L E G A L D E S C R I PT I O N soi~ Rail.g: /. ~ GPD/Sq. Ft. Total Depth Item~i~l g fade:
Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: Range: Section: Fill added abov', original grade: Gravel length:
Number of lines: Oislance between lit;es
WELL: ~ New ~ Upgrade eravelwidth: ~ Ft. ~ '~
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Level: Installer: Date installed:
--Yield: GPM Pump Set at: Ft. Casing Height Above Ground:Ft. TANK
SEPARATION DISTANCES ~s.,~ic u ~o~di.~ ~ S.T.~.~.
From Tank Field Slalion Tank s .... ~,~., ~N~H ~kllL
Material: ¢ ~ Number of C%rtments:
Surface
Water ?l~O >,,~-'~ LIFT STATION
Lot Size in 9aliens: Manufacturer:
"Pump on" levm at: "Pump elf" level at: High water alarm
Foundalion I O ~ /
CurtainDrain ~ 0 ~ ~ Pump Make & M~fef Electrical Inspections performed by:
Remarks: BENCH MARK
¢~ ¢~' ~¢AC~ L°cati°nandDescripli°n:~v-~
. ENGInEeR's S~AL
Inspections performed by: ~* Dates: ls~, ~/'' ,".
Department of HeaI~N and ~umaR Services approval '.:, ,, -.
Reviewed and approved by: ~~/' ¢~ Date:¢-~J-¢~
72-013 (Rev 9/91) MOA 25
sT~p~R T~At4
SWING TIES:
CD 21.5 FT
£D 21
CE 28
BE 15
A£ 26
BF' 41
AG 71
BG 72
BENCH MAR/(: GARAGE SLAB
ASSUMED ELEVATION: I00.00 Fl'
// ~_5
i I
85 50 75 100 185 150
£CALE: i' = 50 FL
TOBBEN SPURKLAND P.E.
205 W 151-H. AVENUE
ANCH. Al(. 9950!
(907) 279-5916
MOUNTAIN VALLEY ESTATE BLOC/( i LOT 4
RAND/ COURT OFF HIGHLAND DRIVE ER
L/SE SHORE
I SEPTIC SYSTEA, f AS BUILT
DATE: AUG. 27, I997
SHEET: 2/5 GRID: S1,F65~
PE£P/[T # PD? I1 050-63/ /9 MV£O/O4LDIF6
CO, MONITOR
DOUSLE co's ~
Slondord Trench:
2' Wide
?0' Long
8' Deep
5' Sewer rock
5' Cover
DOUBLE CO'S
~ 1250 GAL S.?
ZD 200 DIVERTER VALVE
INSULA lION
3,
90.5
3 fl of Septic Rock /
Non#or
Cover
NO SCALE
ZD 2OO
DIVERTER VALVE
r INSULA lION
~--- IE 95.5 IE
SILT BARRIER
90.5 1250 OAL £, T,
BENCH MARK, ~ARAOE SLAB
ASSUMEP ELEI/. 100.00
LTOBBEN SPURKLAND P.E.
203 ~/15th Ave
Anc¼or'cge Ak 99501
_27g- ~gl__G__ --
PERMIT ~ SW970268
MOUNTAIN VALLEY ESTATE, BLK 1, LOT 4
RANDY COURT OFF HIGHLAND DRIVE ER
SEPTIC SYSTEM, SCHEMATIC
SEPTIC SYSTEM AS BUILT I
DATE~ AUO, 27, 1997
I
II S.EET, ,~/,~ ORI~, SF~Z~I
P/D // 050-651-19
PAGE 1 OF
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMA/~ SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
A~NCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970268
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:SHORE WILLIAM J
OWNER ADDRESS:P.O. BOX 671775
CHUGIAK, AK 99567-1775
DATE ISSUED: 8/21/97
EXPIRATION DATE: 8/21/98
PARCEL ID:05063119
LEGAL DESCRIPTION:
MOUNTAIN VALLEY ESTATES BLK
1 LT 4
LOT SIZE: 92956 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
THE ATTACHED APPROVED DESIGN.
ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18A_AC72) AND DRINKING WATER REGULATIONS (18AAC80) .
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)
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
THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
DATE:
DATE:
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 279-3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
MOUNTAIN VALLEY ESTATES
BLOCK 1 LOT 4
W. John Shore
Municipality of Anchorage
Department of Health and Social Services
820 1 Street
Anchorage, Alaska 99501
We are submitting an application for the installation of a upgrade septic system for this lot. The
submittal consists of three (3) drawings showing the present improvements on the lot and the
adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic
system is subject to this permit application, (sheet 2/3), and a schematic of the septic system,
(sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic
system design is based on the following:
No Ground Water or Impervious Layer to 18 ft.
Use Standard Trench
Soil Rating. 1 rain/in = 1.2 gal per sq.ft/day
No. of Bedrooms 3
Required Area pet' Bedroom: 150/1.2 = 125 sq.ft..
The bottom of the system should be at 8 feet below ground surface. The silt layer at this level is
not impervious, but due to the unstable sidewalls of the testhole, this layer was not perc'd. The
tank outlet is at elevation 95, with the ground level at 99.5. The area is level.
Total area required: 125 x 3 = 373 sq.ft.
Outlet Existing Tank 95 ft
Ground Level 99.5 ft
Silt Layer at 91.5 ft
Effective Rock depth
Total Trench Length 375 / 6 = 62.5 ft.
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTH 70 FT
TOTAL WIDTH 2 FT
TOTAL DEPTH 8 FT
ROCK DEPTH 3 FT
COVER 5 FT
INSULATION OVER LINE UNDER DRIVEWAY
INSTALL DIVERTERVALVE
MUNICIPALITy OF ANCHORAGE:
ENVIRONMENTAL ,SERVICES DIVISION
AUG 04 1997
RECEIVED
The installation of this septic system will not prevent wells fi'om being installed on the adjacent lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface
runoffwill not result from this installation.
194
~L liCK
HIL L
L~ ~ LU? £0A
Li}T ~_
50 0
LDT 3
\
!
ft
I
I
I '%7.__A vo co n L'
I
TOBBEN SPUN(LAND P.E.
205 ~/ 15TH. AVENUE
ANCH. AK. 99501
(907) 279-5916
II
MOUNTAIN VALLEY ESTATE ]3LOCI( 1 LOT 4
RAND/ COURT OFF HIGHLAND DRIVE ER
LISE SHORE
SEPTIC SYSTEM DES/ON
DATE: JULY 31, 1997
SHEET; 1/S GRID: Sl,F65L
PE£NIT # PIP # 050-631-19 NVEOiO4I,flV5
I
iii!'' } N ..;:~i '
/ 1~, , ~%~ ~ ~
/ ~_ ~.~ .... ~...<~ _~--~
~- ,
0 2S 50 75 700 1~$ 750
SCALE; 7 : 50 FL
BENCH MARK: GARAGE SLAB
ASSU~tED ELEVATION; I00.00 Fr
TOBBEN SPURI(LAND P.E.
203 W 15TH. AVENUE
ANCH. AK. 99501
_(907) 279-3916
MOUNTAIN I/ALLEY ESTATE BLOC% I LO'/' 4
RAND/ COURT OFF' HIGHLAND DR/VE ER
ElSE SHORE
II SEPTIC SYSTEId DES/GM
DATE: JULY 31, 1997
SHEET; 2/5 GRID: SW65~
PEP, MIT Il PIP Il 050-63/ 19 MVEOTO4LDWG
CO, MONITOR
DOUBLE CO'S
oo 0 o
ZD 200 DIVERTER VALVE
INSULA lION
DOUBLE CO'S
Stondord Trench:
2' Wide
70' Long
8' Deep
$' Sewer rock
5' Cover
~ Monffor
/
--- 3' Cover
3 ft of Septic Rock /
NO SCALE
]000 5AL S. L
~ENCH MARK, GA£AGE $~AS
ASSUME~ ELER lO0, O0
.H
ITU]}BEN SPURKLAND P.E.
803 W15th ~qve
Anchorage Ak 99501
P79-,l?16
PERMIT//
II MOUNTAIN VALLEY ESTATE, BLK 1, LOT 4
RANDY COUR[ OFF HIGHLAND DRIVE ER
SEPTIC SYSTEM, SCHEMATIC
SEPTIC
SYSTEM DESIGN I
DATE: JULY 31, 1997 I
RD / 050-651-19
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG --- PERCOLATION TEST
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
(ENGINEER'S SEAL) ". ~
DATE
Township, Range, Section:
SLOPE ~,~¢",~'¢~ 4f//~! SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
. P
E
Oepth Io Waler Al,er/
~onitoring? 6"[' ~"~ Oa~e:
Gross Not Depth~ ¢~
Reading
Date
Net
/~/'/,~ ~ Time Time Water~ Drop
DISCLAIt~FR:
Past and future presence
from these observFElOnS.
PERCOLATION RATE --I {m,r,,,tes/inch) PERC HOLE DIAMETER . ~'~,~
1EST RUN BETWEEN ~.o FT AND
fir~]~nd~Lr.r_c_onditions indicate_d are for th~ datem shown only.
and/or depth of groundwater can not be predicted
PERFORMEDSY: ~.~. , I ~-~ CERTIFY
. T,H/~T THIS TEST WAS PERFORMED IN
MUNICIPALITY
OF
ANCHORAGE
:~/~ DEPARTMENT OF HEALTH & ENVIRONMENTAl.. PROTECTION
!k ,,~, PI¢_ ~)l ENVIRONMENTAl.. ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
~ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WEI. L INSPECTION REPORT
NAME ~
- ' ~ '::~:~-: ........ NO. OF B'EDROOMS
C
A
T IO
N
~ Z Manufacturer Material No. of compa~
~ Inside length Width Liquid depth
Liq. cap~c~llons IF HOMEMADE:
:, ~ Manufacturer Material Liquid capacity in gallons
~-1 DISTANCE TO: Well Founda~ Nearest Io~ line PERM~ N~
ne Trench width
~Z No, of linesl Length of gc Tota~ Distance between lin~s
.: = ~ inches effective ah~nrn"nh
I ~ Top of ti~e to finish grade Cf~ Materia]beneathtil~ .... ~ ~ Total~ area
Lench Width Depth PERMIT NO.
~ P Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
¢ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER ..................
PIPE MATERIALS ......
SOIL TEST RATfNG
/ ~ O ---
INSTALLER
/
REMARKS ~ MA~T m ~c
,~'~.' ~ '.~ ~,~
.......
APPHOVED DATE LEGAL
72-013 (Rev. 3/78)
CONSULTING ENGINEER
203 W, 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
Municipality of Anchorage
Health and Enviromental Protection
Sewer and Water
825 L Street
Anchorage,Alaska 99501
September 15. 1982
To Whom It May Concern:
This is to clarify that Permit No. 820439 issued to Scott Baldwin is for
Lot4, Block 1, Mountain Valley Estate. The legals noted on the permit and
°F~°rt are in err°r'.
Tobb(~h Spurkland P.E
MUNICIPALITY OF ANCHORAGE
DFPT 0': H~'?J n,
ENVIIt :IL ],,A. I :O ~ [I ,~
S E ? 1 5 1,982
RECEIVED
G!:;;:C~t..t]',![:, FIN[) THE i!:OT"!"OH OF' "[!"IE !~i:;:.:;C:!:]',/FIT;[!Z3i':! ,::iF! FEI!!:'[').
"!'HEF,:E ;[;iii; HD :i!:;!i;"!" i,~;!:.F.:,TH
"!'HE[ (.~[:;;:!:::!',/[iiX... D[i!:F::"i'H :[ :~; "F~..IE !','1
Fff.,ff::, 'FHF:: Df:iTTOi',! Cfi: THE
PERFORMED FOR:
LEGAL DESCRIPTION:.__
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15-
16
lg
20
COMMENTS
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
SI_OPE SITE PLAN
WAS GROUND WATER SL
ENCOUNTERED? N O 0
IF YES, AT WHAT
DEPTH?
Reading
Gross Net Depth to Net
Date Time Time Water Drop
PERCOLATION RATE ~ ~1~) ~,~1~~ (minutes/inch)
TEST RUN BETWEEN FT AND FT
PERFORMED BY:
72-008 (6/79)
CERTIFIED BY:
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES '~LITY OF ANCHORAGE
Division of Environmental Services ENV TAL SERVICES DIVISION
On-Site Services Sectiqn '
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
AUG 2. 7 ]997
RECEIVED
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
~¢O~, XCJ, ~-O~v~ Dayphone
Lending agency
Mailing address
Agent ~v'~ /,--,~ k.¢.44.,
/
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
Day phone
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State AD£C
attesting to the legality and status of system.
72-025 (Rev. 1/91} Front MOA #21
St
DHHS SIGNATURE
STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, 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.
Address ~ /.~,/~/~ /¢ 9^ ~'. A / ~ ~.
EngineeCs signature ~'
~.~-.~--.. ~. .. - ;. ~.~
~ · ',~
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
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 Municipal ty of Anchorage is not
responsible for errors or omissions n the professiona engineer's work.
72-025 (Rev. 1/91) Back MOA ¢k21
£NVip, ONMENTAL SEP,¥1CES DIViSiON
Municipality of Anchorage AUG ~ 7 1997
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ~)~~4~' ~)
B~met, Boom ~02 ·Anohomge, Almmkm 99~0~ · (9
Legal Description:
A. WELL DATA
Well type ~'~
Log present (Y/N) x/
Total depth ,~ 8 ~ I
Sanitary seal (Y/N) '"//
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Health Authority Approval Checklist
~vI~'UMYAI~i V/-~ LL'~"! /,~7~'~ Parcel I.D.:
FROM WELL LOG
g.p.m.
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to J ~'£') / ~' Casing height (above grounid)
Wires properly protected (Y/N)
AT INSPECTION
Y
g.p.m.
Coliform
Date of sample: "¢/~../~ '/
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Foundation cleanout (Y/N)
Date of Pumping
Tank size /,~'~L' Number of Compartments ,~_ Oleanouts (Y/N)
/V' Depression (Y/N) J~ High water alarm (Y/N)
Pumper
C. ABSORPTION FIELD DATA
Date installed $/~:/¢ '7
Length '7 ~ ) Width
Soil rating (g.p.d./ft2 o~) /., ~,,
¥ Gravel thickness below pipe
System type
Total depth ,,~
Effective absorption area /1/',¢(2 ~¢'
Date of adequacy test N/'////.~
Fluid depth in absorption field before test (in.);
Fluid depth v" (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Monitoring Tube present (Y/N) /
Results (Pass/Fail) ¢'/
. Depression over field (Y/N) __
For t,,/'
Immediately after
Absorption rate =
If yes, give date
gal. water added (in.):
g.p.d.
bedrooms
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
High water alarm level at*
"Pump on" level at*
*Datum
"Pump off" level at*
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
!
Septic/l~4~l~tank on lot
Absorption field on lot !
Public sewer main
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 ~ O Property line bO ~ Absorption field ~
Water main/service line /O Surface water/drainage..)/~o ~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line '! ~ ~ Building foundation ~ I~
Surface water ~/~-0 ~
Curtain drain ~ o ~ ~-
F. ENGINEER'S CERTIFICATION
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
I certify that I have determined thru field inspections and review of Municipal records that the above'systems are
in conformance with MOA HAA guidelines in effect on this date.
,.n tur
Engineer's Name
Date /~ ~--'~, l q ~-'~
HAA Fee $
Date of Payment ~/c>~ 7/~/ 7
Receipt Number('¢'~'¥~ ~"~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
PII.I,_-:HCJRFIC~E
F'. 02.' OL'-'
L'T&E Ref.# 975014001
Client Name Tobben SpurkJ. a]]d P.E,
Project Name/# HVE i/4
Clie.t Sample ID HV]E 1/4
Matrix Driuldng Water
Ordered By
Client EOF/
Printed Date/Time 09/02/97 19:34
Collected Date/Time 08/26/97 13:30
Received Date/Time 08/27/97 08:35
Technical Director: Stephen C. Ede
c~! Lm~abLe Prep AnaL?sis
Par-arnuter Reswl,~s PIlL Units /4ethod Limits Dstrz Date
Nitrate-N 0.100 U 0.100 mB/L SHt8 4500-N03F 10 mox 08/29/97 d~i
?otot Co(iform 2 OB/ 100 mL $Ml1~ 9222B h8/~?/97 T/dW
MUNICI!~t~LITY OF ANCHO~GE
DIVISION OF ENV[RONMENTML HEAL%H
DEPAJtTME~i~ OF ~J}l AND ~TIR(~MENTAL PR~ECTiC.N
APPLICATIG~ ~OR gEAI~H ~JTHORITY g~°PROVAL CERTIFICATE
1~ C~ne~ral Informtion Application Date _L. ~ fiJJJ~. __
(a) I2egal Description (include lot, blc,~k,_subdJvJ~kion, ~ct:[cn, t~,gnship, range)
.... i 5~.. 4t ~ J 4/l.t- ~ ~f~. "F~':.z-
Location (addz, ess or directions)
Applicants Address
(c) Applicant is (check one) Lending Institution
Address ................................... :
Ad.ess
2. ~,~ of ~sic~nce
Single-Famil~ []~:. Multi--Fami.l~ []] Othe~
Individual k~ll ~.._.::_.,.J. Con~nunity'[---~, Public
Note: If conmunity well system~ must have w~i ~ten ~nfir~tion from ~e State
~pa~nt of ~viro~r~ntal Conservation attestina to t~ legality ~d ~tatus,
.~= ~e w~ll adequate fo~ the nu~_ of ~lr~s sfecified in thio
Is the wastewater dis~sal system adequate for tine number cf ~dr~m ~ )
[Page ! of 2]
2--!5-84
..... Eg~i.p~erin~:_~ ...... Firm Iq-ovidinq In2pections, %%sts, ~ta and Infor~tion
I ~tify ~at~e c~cked, w~rified, or ~nfor~d to all ~DA ~ g~li~li~s in
effect on t o~.~/~s~ct:Lon.
Sigr~ .. ~ .....~_~ ~te
Te l~phc~
( ENGINEER SEAl,)
Date
6. DHEP ~p.p'roval
Approved for
Approved -~/~7
Disapp~ove~d ~ Conditional
Te~s off Conditional Approval
1lie Municipality of f~%chorage Department of Health and Environmental P~otection dces
not guarantee the continued satisfact:ory pe~formanc~ off' the water: supply ar<l/or the
wastewater disFx)sal system. This approval indicates that, as of tim validation .~ate
sho~n above~, hm,~d on t]~ data and information fu];nished by an e.~girmer registered
the State of Alaska, the water supply and wastewater disposal system is safe and
tional for the nur~m of bedroon~ and tylm of structua, e indicated.
( ~IEP SEAl,)
7. Mail the HAA to the fol].c~ving address:
KB2/d5/s
[Page 2 of 2]
2~2.5-84
A®
MUNICIPALI%"Y OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
WELL DATA
Well Classif icati~ .~/
Well Log P~esent/(Y~N~
Total D~pth ~. ~-- / Card to
Static Water ~1
Casing ~ight
Elec~ical Wiring in ~nduit~)
~p~ation Distance f~ ~11:
To ~ptic~g Tark
To ~a~est Ed~ of ~so~tion Field on
MUNICIPALITY OF AJ~CHORA(~
DEPL OF HEALTH &
ENVIRONMENTAL PROTECTION
MAY ~ '; !Om~.
To Nearest Public Sewer Line £3 /~ To Nearest Public Sewer
Cleancut/Manhole (d I', ~/~ TO Nearest Sewer Se~vic~ Line on Lot /t/'//'J.
Water Sample Collected By ,-(~'? fi-L~/?'I/i?'~L'~-~ ; Date U-.//-~./~ ~' --
Water San%~le Test Results ~ )Af~_~¢'~' '~,~x_p, ,
/ --
Ccrmmnts
Be
? ~-'"'~' 'b~,' ' ,,-.;._, l; ..... ..-'2
Date Instal.l.~(% '/~8-~z~'' ' -? ' '
Size /~? NO. of
Standpi~s ~ ,~,,Air-tight Caps~J~) Foundation Cleanout ~d~)
P~ing~intenan~ ~n~act ~ File (Y,~)/J//% ; for
Holding Ta~ High-Wate~ ~a~ (Y ~5 ~ra~y Holdi~ Tank ~r~t ('f~//f~-
Sep~ation Distan~s ~ ~ptic/Holding Tank:
To Water-Supply Well __z/.' £cZ)
To Property Line /~
To Water~Ma~4.zh/Service Line
Coul'se
Comrents
To Building Foundation 2-/
To Disposal Field -5~'~-
/Stream, Pond, lake, o~ M~jor Drainag9
[Page. 1 of 2] 2-15-84
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed- -/-~/-~zr~ ?~,
Width of Field ~ /t/
~' /~J Type of System Design
Length of Field ~ /
Depth of Field /O
/ ~ravel Bed Thickness
Squa~e Feet of Absorption A~ea ~~ Standpipes P~esent~'
Depression over Field (Y~) ~ ~f Last Ad~quacy..Test ~'-~/~
Results of Last Adequacy Test ~'-~ ~//~rF$~ -F-~/
Separation Distance from Absorption Field:
To Building Foundation ~/~ ! To Existing pr Abandoned System cn Lot /~ / /J ; On Adjoining Lots
To Water .M~/Service Line ~ ~~ To Cutbank(if present) /U .//l
To Stream/Pond/Lake/or Major D~ainage Course /.3 {/FQ
To D~iveway, Parkin~ A~ea, or Vehicle/Storage A~ea
D. LIFT STATION
Date Installed / .
Size in Gallons
"P~t~ On" Level at /
High Water Alarm Level at
Tested for
DimeD~ions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Electrical Codes (Y/N)
Comments
Meets MOA
** Check Per~d~oom Rating Against HAA Request **
I certify t~a(J: I ha~.e/~.~he.~, verified, or conforn~d to ail MOA HAA Guidelines in effect
on the da~f th//~~ ' ,..~.~-~.~%%~ .
~/~///"~///~ "'/"' ' Date
~.;.:~: ~ ~FIB 1~6~
[Pa~ 2 of 2] I
2-15-84
APP~
~ai,~n9 Addre~ PO, ~g~,t' / 7~
Address
FILLS OUT UPPER J-~ "',:':' 'ONLY
Phone
Zip Code
Lending Institution
Address
Realty Co. & Agent
Zip Code
Address
/ Zi~ Code
Type of Residence
[;;;~'~n g I e Family
D Multiple Family No. et Bedroorr'6 -.~
[~ Otller
Phorle
? 7 2 LA'V_.C_/_
Phone.
W a~t e~.u p ply
lC'Individual ATTACH WELL LOG. A well Io9 is reguired for all wells drilled since June 1975.
C] Community For ',','ells drilled prior to Ibat date, give well depth (attacl~ log if available).
[] Public Utility
Sewer Disposal
~ndivideal
[] Public Utility
[] Holding Tank
Year Individual Installed:
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time
Date Date
Inspector Inspector Inspector
Time
Date
Time
APPROVED BEDROOMS
i ~s^PPROVE~
CONDmONA~ ^.PROy^L'
'CONDITIONS OF APPROVAL
Soils Rating Date Sewer Installed
Well 're Absorplion Area
Well to Tank
JWell Log Received
Septic Tank Size
APPLIC FILLS OUT UPPER HAL ONLY
Address . Zip Code
Realty Co. & A~nt Phone
/ zip Code
Address /
Street Locati~ ~ ~ //~ ¢ ~ 5" '~ ~ ,~)1 ~"~ i~ 1.' .
Type of Pesl~nae ~
~ngle :~mily
~ ~ulliple :smily No. of Bedroo~. ~
~ OJher
~lndividu~l ATTAOH WELL LOG. A w~l Icg i8 required for 811 well8 drilled 8inae &uno ~7~.
g OommuniJy For well8 drilled prior Jo lh~J d~le, give well deplh (~J~oh Icg if ~wil~ble).
~ Publio UlilJly
8ewer Disposal
~di~idu~l Year IndlvJduBI Insl~lled: ./~=~
~ ~ubllo Ufllily When Oonneoled ~o Public Uflllly:
~ Holding T~nk
NOT~: TH~ INSP~OTION F~ ~UST AOOO~PA~ ~AON ~ST B~O~ ~O0~SSINg OAN B~ INITIAT~O.
Time Time Time
Inspector Inspector Inspector Inspector
Field Notes:
. [CEI ED
( '~ ) APPROVED BEDROOM8 'OONDITION8 OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
Soils Rating Date Sewer installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
72-023