HomeMy WebLinkAboutMOUNTAIN VALLEY ESTATES BLK 5 LT 1
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
http://wwwmuni.org/onsite
l t ortnt�•nt
On-Site Wastewater Disposal System Permit /0,0 ' 3 112*"
Permit Number: OSP171297 Effective Date: 10/4/2017
Work Type: SepticTank Upgrade Expiration Date: 10/4/2018
Tax Code Number: 05065101000
Site Legal Address: MOUNTAIN VALLEY ESTATES BLK 5 LT 1 G:0758
Site Mailing Address: 4430 HILAND RD, Eagle River
Owner: PERRONE LINDA Lot Size in Sq Ft: 57654
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 2
This permit is for the construction of:
❑ Disposal Field E Septic Tank ❑ Holding Tank 0 Privy Cl Private Well 0 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: Double cleanouts shall be provided after the tank, within 10 feet.
•
Received By:goy, akt Date: D
Issued By: PJJCC4A - - / Date: Off 0 7
S kk MUNICIPALITY OF ANCHORAGE
7Z(...,S
_., i rt,
Community Development Department `\ ii
ioi Phone: 907- ,3
Development Services Division - Fax: •% • - - /i
On-Site Water & Wastewater Program tin 3 RUSH. 4
iiiiw ON-SITE SEWER/VVELL PERMIT APPLICATION 1444.2017 )2.-
Parcel I.D. 050-651-01 - 1-.4. -- --e114\,'‘,-
› �h
Property owner(s) Linda Perrone Day phone og
. 6 a L
Mailing address 4430 Hiland Rd. Eagle River, AK 99577
Site address 4430 Hiland Rd.
Legal description (Sub'd., Block & Lot) Mountain Valley Estates B5 Li
Legal description (Township, Range & Section)
Lot Size 57,654 Sq. Ft. Number of Bedrooms 2
A . APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank ❑X Upgrade ❑X
Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑ N.
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FORTeu
111\ Distance:
°I°170 certify that the above information is correct. I further certify that this is in accordance with
.0
applicable Municipal Codes.
V?
(Signature of propert owner or authorized agent)
Permit/Rush Fees: It 3c- -1-- Waiver Fees:
Date of Payment: W 1Li /a Date of Payment:
Receipt Number: 040554 Receipt Number:
Permit No. 05 P I 12 Q3 Waiver No.
Permit App__• ::..c
Pannone Engineering Services ac
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
October 3, 2017
Subject: Mountain Valley Estates B5 L1
Tank Replace Permit Request
Design Narrative
This is a design narrative for a permit to install an upgrade 1,000g Septic Tank to replace an existing
1,000g Septic tank to be issued for this property. The existing tank has completely failed. It will be
decommissioned per code. Currently the lot is developed. The proposed system will utilize a replacement
1,000g septic tank that will be connected to the existing drain field. The existing tank is located
approximately 1001+ from the well. The proposed tank will be placed outside the existing well radius. All
required separation distances will be met.
1. Upgrade Tank Design.
A foundation clean out installed if needed.
The tank will be located: 5'+ from any property line or building foundation
10'+from any water line
100'+ from any surface water
100'+ from any private wells
200'+ from any public wells
The proposed installation will not affect the future development of the surrounding or existing lots.
If you have any questions or concerns, please contact me at 907.272.8218.
Sincerely,
.....as• ,
c OF
i i 4'�
I..4.?• Steven R Pann.ne
• \ �
\F •
644
FE'. _n**4
Steven R. Pannone, P.E.
Owner/Civil Engineer
Mailing: P.U. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
Municipality of Anchorage Page ~ of "Z..-
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: ~:~ 1 ~\ ~ / PID Number: C::~ ~ (~::~- I ~ l
Nam~ c:~ ~..l.~_,..d~ ~ ~ Wastewater System: ~ New ~Upgrade
~d~ ~ ~ ~~ ~ ABSORPTION FIELD
Phone:
No. of Bedsores:
~_ ~ U Deep Trench~ShallowTrench UBed D Mound UOther
Soil Rating:
LEGAL
Total Depth from original grade:
DESCRIPTION O,~ GPD/Sg. Ft.
Lot: ~ Block:~ ~ ~Subdivisi°n: ~. Deplh to pipe bottom from~,~original grade: Ft. Gravel depth beneath~,~pipe
Township:~ IRange: ~ Section~ Fill added ~bove original grade:~,,~.,.~ ¢,¢' Ft. Gravellength: ~O~I
WELL: ~ ~¢ ~% ~ [~ Upgrade Gra~e,~: ~.OFt. Number~o, lines: Jl Distance between[ OI lines:
Classification (Private, A.B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water L~vel: Installer: Date installed:
Yield:~ ~ J Pump Set at:__ '~'' Ft. Casing Height Above Groun,:[~,,~ Ft. TANK ~¢,~,~
SEPARATION DISTANCES ~Septic ~ Ftolding ~ S.T.E.P.
To Septic Absorption Lifl Holding Public/Private Manufacturer: Capacity in gallons:
From T.n~ Fi.~a Static. T..~ S~,~, Li..~ ~ ~ ~ ~ ~ ~
Material: Number of Compartments:
Surface
Water ~OO'* ~oo ~o¢'~ LIFT STATION ~_
Line ~ ~ X& l ~ ~ Cump on; level~'
level at:
Higt~water
Foundation ~O~~ ~ ~t~ ......
alarm
C~::~ ~"/C-- ~~ P~de' I Electrical Inspecti°ns per'°rmed bY:
Remarks: ~ g~,~l&~. ~[¢ ~ BENCH MARK
Location and Description:
Assumed Elevation:
ENGINE~EAL
~¢~ "o .u,~ ,.....~ ..~
S & S ENGINEERING ~ ~'~-e')'~'d /¥;` '" ~o '.:: '~
Inspections performed by: ~m~ Eagle iive L~p koad NO.~s: 1 st ~' }~ '~ L ~:.~~¢ '~"
F role River, Alaska ~77 2nd ~ - ~ ~ '%~ ,:,~,, ~,~,,,,,~,?~,?,~;. ~
n n.f f..e..r.men, of Heal approva ~, ~ .... ,.:.
Reviewed and approved Date: ~'. ' ' - ,'~ ~ ' 4*~
, ,~.~,, .' ..... . ~,.;...
72-013 (1/91)MOA25
Permit No.
~l"J~210 I~ t Page. ;~
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:
72-013 A (2/91) MOA 25
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 WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910191
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:SINGER ROBERT S ~ SANDRA J
OWNER ADDRESS:HC 85-9422 HILAND ROAD
EAGLE RIVER, AK. 99577
DATE ISSUED: 7/11/91
EXPIRATION DATE: 7/11/92
PARCEL ID:05065101
LEGAL DESCRIPTION: MT VALLEY ESTATES BLK
1
5 LT
LOT SIZE: 57654 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 (iSAACS0).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ENGINEER MUST CONFIRM SIZE OF SEPTIC TANK AS A MINIMUM OF
1,000 GALLONS. ENGINEER MUST NOTIFY DHHS AT LEAST TWO HOURS
PRIOR TO EACH INSPF. CTION.
ISSU .D sY: .JO ,q
DATF.:
June 27, 1991
ROBERT SHAFER, P.E.
ROGER SHAFER
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER &WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Al~ka 99519-6650
REFERENCE: Lot I; Block 5; Mountain Valley Estates;
PERMIT REQUEST NARRATIVE
Request you issue a permit to upgrade the septic system on the
referenced property in accordance with the a~ached design.
An adequacy tut performed on June 12, 1991 showed the existing
leachfield inadequate for a 3 bedroom house. A test hole was excavated
and a percolation t~st performed. The proposed drainfield trenches are
to be placed down the sloping hillside b~low the existing absorption
bed.
Due to the large lot size of the properties in the area, we foresee no
adverse effects on n~ighboring properties by the installation of the
proposed septic system.
If you have any questions or require additional information for your
conta~ u~.
A. SHAFER, P.E.
',/gm
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
,I
SCALE
Municipalily o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
· EG^, DESCR,PT,ON: /" 0 T
1
2
3
4
5
6
7
8
9
10
11
12
13-
14-
15-
16-
17
18
19
20
Township, R,?hge, Section: ,,.~ .~'~ .~ T,'/Y/J~ /~/~,,~,J
SLOPE SITE~"PLAN
w^s GROUND W^TER ~,/0
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
i
Deplh Io Waler Aller
PERFORMED BY: ] 7034. ~"-~¢Ile Rivo:' Loop [~oad No. ~
Eagle Rivet', Alaska 99577
ACCORDANCE WITH ALL STATE AND MUNI(
72-008 (Rev. 4/85)
Reading Date Gross Net Depth to Net
Time Time Water Drop
¢-' t_~z::, \,¢ ,-d,,J. ~';/.~-'. '~/~,"
,¢ ~-¢'. ¢c::, . "~'~ ItC' '/-z.."
COMMENTS '/ !04.~/'
$1PAL GUIDELINE~F
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER ~ q
TEST RUN BETWEEN ~ FT AND__'g~ FT
/
CER]'IFY THAT THIS TEST WAS PERFORMED IN
:ECT ON THIS DATE. DATE:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 LStreet - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE
MAILING ADDRESS ~-~
LEGAL DESCRIPTION
LOCATION
DISTANCETO: Well ~/~ Absorptionareas, Dwelling
Manufacturer Material
lLiq,,:apacty nga OhS Inside length
OD
DISTANCE TO:
Manufacturer
IFHOMEMADE:
Well
Well
DISTANCE TO:
No. of lines Length of each line
Top of tile to finish grade
Length '~ ~ -f ! Width
Type of crib Crib diameter
We A1 /
DISTANCE TO:
°,ass ~D ~
DISTANCE TO ' Buildin~foundaUon
JDwelling
~ Material
IF~bndation Nearest lot line
!
/ ~,,~al length of lines Trenc ~ width
i~/l~Jterial beneath tile
Cr~'b depth
Building f~/~l~i o n
Sewer line
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
R EMAR KS
~-NEW
[] UPGRADE
NO. OF BEDROOMS
PERMIT NO, _~,
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO.
Distance between lines
inches
Total effective absorption area
inches
J , PERMIT NO.
~,...- / 2" o~,'~ 6...-, ~
Totalfeffective absorption area 4~ 5'~'O ~
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorpt on area(s)
MUNICIPALITY OF ANCHORAGE
Departmen~ f Health and Environmenta' ~rotection
825 ~ Street, Anchorage, AK. .~501
264-4720
~ ~ * * * HANDWRITTEN PERMIT
Permit ~ ·
Location: Phone Number:
Legal escription, Lot Si e:
Type of Soil Absorption System Is:
Trench: Drainfield: _ Seepage Bed~ ~ Holding Tank:
Maximum Number of Bedrooms: _~ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption S~stem Is:
The length dimension is the length(in feet) of t~e trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
~ ~ REQUIRED SEPTIC(NS-L-9+N6) TANK SIZE = /0~
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31¢ 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the,.~/~?:id~is remodeled to include more ~be~
Signe~: ~'~,..~..~..~ ~.~-¢..-r.~. ~ Issued by:
SWP/024(1/81)
I];]'"'" SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Stroet, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR: ~'-~'~ '''~) ' "~_.~..~r r .Z~
LEGAL DESCRIPTION:, ~-~/~ /,
/
S/LOPE
SlT~ PLAN
10
11
12
13
14
15
16
17
18
19-
20-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
I
Gross Net Depth to Net
Reading Date Time Time Water Drop
,
COMMENTS
PERCOLATION RATE (minutes/inch)
TEST~UN BETWEEN F}AND ~ FT
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological G Geophysical Surveys
Orilling Permit No.
LOCATION OF WELL (Please complete either la, lb or lc.) A.D.L. No,
Range
Meridian
: ~ i: . /.~...~' . ,, ~ _ [ : --of--of--of-- SE~ W~]
lc. DISTANC~ A~DI~ECTI[N FROM ROAD INTERSECTION8 3. OWNER OF WELL:
~": SR Box 9385
~t~e~t ~re~s ~.~ ~e~ o~ well ~oo~,io~ Eagle Eiver,
Ak.
99577
2. WELL LOG Feet Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETION
Surface ~ (. ~, ff. :,~ -- · : --
-- ~ Irrioatlon ~ ~echarge ~ Comm~rical
~ ~ Test Well ~ Ot~er: _
~ 8. CASING: ~ Threaded ~ Welded
deem. ; in. to ? ; fl. Depth Weight ~ .lbs./ft.
diam,~_~in, to ft. Depth SHckup , ft.
~ 9. FINISH OF WELL:
Slat/Mesh Size: Length:
Set between fl. and ft.
Backfilling Gravel pock
m. STATIC W~T~R LEVEL: ~n. / /
Date
~ Above or ~ Below lend surface
Equip[nenf used:
II. PUMPING LEVEL below lend surface end YIELD
~t. offer hrs. pumping ~.p.m.
IA.GROUTING Well Grouted: ~ Yes ~ No
Material: ~ Neat Cement ~ Other:
Lenglh of Drop Ripe fl. capacity g p.m.
16. WATER WELL CONTRACTOR'S CERTIFICATION:
15. Woter Temperature ~_~o ~ F ~ C
This well was drilled under rny jurisdiction and this report is true lolhe best of my knowledge and belief;
~ ,'~h' ~' '; [ ~ ~ ,', : · ~ '
Authorized Representative
Form OZ-WWR (11/81) Copy Distribution: WHITE-Stole DGGS~ PINK-Driller, CANARY-Custom0r
F'ERMIT NO.
FIF'F'L I C:FINT
LOCFfT I ON
L..E:GFII_
HFILTER J. KRRHOHSKI
L:L B5 MT VRLLE"r' ESTFITE$:
±545 S. HO','T 995EI4
LOT SIZE
57654 SQUFIRE FEET
MINII"IL$t DISTFINCE BETI4EEN FI HELL FIN[:, FtN'-r' ON-SITE SEP.IFIGE [:,IE;F'OSFIL S"r'STEM IS
:1.0El F:EET FOE.'. Ft PRI'v'FITE 14ELL OR 15El TO 2EIE1 FEET FROM Ft F'UBLIC HELL DEPENE:,ING
UPON ']"HE T'~'PE OF PLI.P, LIC P.IELL.
HINIMUM [:,IS, TFINCE FROH FI F'RI',,,'FtTE HELL TO Ft F'RI'v'FITE SEHER LINE IS, 25 FEE]" FiND
TO FI COHMUNIT'f SEHER L. INE IS 75 FEET.
HELL LOGC..; FIRE REQUIRED FIND MUST BE RETLIRNED TO THE DEPFtRTMEN'T' FII'rFHIN ]:E~ DFI'~.'S
OF THE HELL. COMF'LETION.
OTHEI:;..' REQUIREMEN'I"S MFI"r' FIPF'L'~". ':.;PECIFICFiTIONS FiND CONS'FRIJCTION [:'IFiGRFIMS FIRE:
FIVFIIL..FIBLE TO INSLIRE PROPEF-'. INF;TFiLLFi]r'ION.
I CEFr..'.TIF'.r' THFIT
:I..: I FIM F'FIMILIFIF.': HITN THE REQLIIREMENTS FOR ON-SITE SEP.IERS FIND HELLS FIE; SET
FORTH .E:'./ THE MUNICIPFILIT"r' OF FINCHORFIGE.
2: I HIL. L INS'T'F~LL THliE S"r'STEM IN FICCOR[:'FINCE HITH THE CODES.
FIPFL.~.tT z~HFILTER J. KFiRHOHSKI ~ ' ,~, ' '
I SSLIEE. E:'..' - ......... ['RTE--,/- ............. .?~- ',,,',t., C~
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. Cf
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~ ~0-~,~\-~\ NAA# ~ ¢/~ \ ~)o~ \4'~
1. GENERAL INFORMATION
Complete legal description
Lot I; Block 5;
Location (site address or directions) 9422 Miland Road (Mile 5.7)
Property owner
Mailing address
Lending agency
Mailing address
Robert Sin9 ¢r
HC 8~- 9422 Hi6and Road
Day phone
Eagle River, Ak. 99577
Day phone
AgentEua Lokcn RE/MAX OF EAGLE RIVER Day phone 694-4200
Address 16600 C¢~rficld Driv~ #201 Eaql¢ Riv~r~ Ak. 99577
Unless otherwise requested, HAA willbe held forpickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
X~
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:
X~
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
3o @sn snoTDTpn£ -s~nuT~ xed
Pa~eoTPUT I66I
/
suoIIeB IE'O sT aaUeuTPXO IedTaTunN
· a~nulm xed suoli~B ~9 '0 aq o~ X~TnT~onpoxd lisa sq9
'EI aunp uo pa~o~xad ~sa$ iIa~ ag& sluem~OOl~UO!l!ppv
:suo!lelnd!ls I~U!MOIIOJ sql ql!M 'SLUOOJpaq
'SLUOOJpaq
eUOqd
.~o~. leAo~dde leUOp,!puoO
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~UR~VN~IS SHHO
oJnleuS!s s,]eeu!Su=l
sseJpp¥
LU4:I ~O eLUeN
· uo!loedsu! s!ql ~o slop eql uo loejje u! suo!leln6o~ pu~ 'seoueu!pJo
'sapoo elms pue led!o!unlAI lie ql!M eoUe!ldLUoO u! s! LUelSXS lesods!p ]e~eMelSeM Jo/pue Xlddns
JeleM Ol!S-UO eql 'uo!loedsu! pue uo!~eSp, se^u! ,~LU UJOJJ pue sel!J eSeJoqou¥ Jo/~!led!ofun~ oqj
LUOJ~ peu!e~qo uo!leuJJoju! eql uo peseq leql X~pe^ Jeqpn~ I 'u!eJeq peleo!pu! aJnjonJls ~o edXl pue
suJooJpeq jo JeqLunu eq~ Jo~ elenbepe pue leuop, ounj 'ejes s! LUe~S/~S lesods!p Je~,eMOlSeM Jo/pue
Xlddns ]eleM el!s-uo eql leql SMOqS uo!leo!ldde leAoJddv/~poqlnv q~leeH siql jo uo!leS!lseAu!
· /~LU leLJ], XJ!JO^ I 'MOl@q UMOqS elep uo!lep!le^ aql jo se pue o~eJeq pex!jJe leOS XuJ Xq pe!j!lJeo sv
~':I::INIgN=1 A8 NOliO~dSNI gO IN~IVLS
'9
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
ADEC water system number
Date completed ~7 ~ ~ c>-~'~ Driller
Cased to ~ "z'~ Casing height
Wires properly protected ¢;.~N)
Legal Description:
A. WELL DATA
Well type '~:2¢.\ ~
Log present ~/N)
Totaldepth
Sanitary seal ~/N)
If A, B, or C, attach ADEC letter.
g.p.m.
FROM WELL LOG
Date of test
Static water level
Well flow \,
Pump level ~,~--
SEPARATION DISTANCES FROM WELL TO:
Septic/,b~,',dh'~g tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
; On adjacent lots_ .
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Colleoted by:
B. SEPTIC/HOLDING TANK DATA
Date installed (-¢"~-~ ~¢~
Cleanouts (~)'N) ~
High water alarm (Y~J~
Date of pumping I~TM )c;, ¢"H
Other bacteria tk.~ ~ ~-
S & S ENGINEERING
170:~4 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Tank size \ oc:;,c:> Compartments
Foundation cleanout (Y/N) _;~ Depression (Y/~
Alarm tested (Y~[~ ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~c~c~'~'
To property line ~ \'~'
Surface water/drainage
-026 {Rev. 3/91) Front MOA 21 ~--¢-¢~v~L.- ~c~PJk"~-~¢.~
On adjacent lots \o~ to Foundation
Absorption field ~5' Water main/service line
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical code~¢¢i~
SEP~FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N)
"Pump on" level at .,~ump off" level at
~ Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Width
Date installed -
Length
Total absorption area
Depression over field (Y/~
Results (pass/fail) ~/A--
Peroxide treatment (past 12 months) (Y,~
Soil rating O,L~ ~&/Crl''~/
Gravel thickness '7~. 6;>
Cleanouts present (~)N)
Date of adequacy test
for 'J/~-
/~ If yes, give date
System type ~--~A~-t..L.-~J 'T'¢..~c~
Total depth '~ ,~-~ ~
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
On adjacent lots ~.C>o ~ ~ Property line
\ O~4- To existing or abandoned system on lot
Cutbank ~'~::~ ~ Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelin
of this inspection.
5 &$ENGINEERING
Signature 17034 Eagle EiYer Loop Roa¢{ No.
Eagle River, Alaska 99577
Engineer's Name
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back
Waiver Fee: $
Date of Payment
Receipt Number
APPLI( NT FILLS OUT UPPER ONLY
Property Owner
Buyer
Address
, ,i '¢ ' ~:,,:- ./t' (.~. Zip Code
Zip Code
Phone
Lending Institution
Address k'")
Zip Code
Realty Co. & Agent
Address
Zip Code
Legal Descriplion
Street Location
Type of Residence
[~ Single Family
[] Multiple Family No. of Bedrooms
[] Other
Phone
Phone
Water Supply E~ Individual
[] Commurdty
[] Public Utllily
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 Ulility
[] Holding Tank
Year Individual Installed: ~?' '~¢
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
ime Time Time
~ate Date Date
~spector Inspector Inspector
("~ APPROVED BEDROOMS
( )DISAPPROVED
) CONDITIONAL APPROV,~L*
'CONDITIONS OF APPROVAL
Soils Rating
LDate Sewer [~stalled
Well To Absorption Area
Well to Tank
Well Log Received
Septic Tank Size