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HomeMy WebLinkAboutHILLSIDE PARK PUD LT 32 , ' 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: ..~' 9%(~Og-r~ PID Number: Name:~or~.y ~ ~g~ ~H Wastewater System: D New ~pgrade ~dd~:~ ~ ~E ABSORPTION FIELD Phone: No.o~ Bed~oms: ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other Total Depth from ori~inal orade: LEGAL DESCRIPTION SoilRating: 0,~ GPD/Sq. Ft. /b,~ Lot: -- Block:. . Subdivisio~ ~ Depth to pipe bottom from originalgrade: Gravel depth beneath pipe Township:~J Range: Section: Fill added above origin~l~grade: Ft. Gravel lengt~ Ft. Gravel ~: Number of lines: Distance between lines: WELL: ~~ew ~ ~ Upgrade ~P~ ~,~ Ft. I ~/~ Ft. Cl~ification (Private, A,B,C~: Tot~ Cased To: Total absorption area: Pipe material: Driller:~ ~ ~ ~e Drille~~Static Water LevekFt. Installer:T~p~ ~1 ~te installed: TANK SEPARATION DISTANCES ~ ~Soptic D HoldinO To Septic Absorption Lift Holding Public/Private Manufacturer: ~ Capaci~in gallo~ From Tank Field Station Tank Sewer Lines ~ ~' ~ '~ ~'~ ~m / Well ~'~ ~ ~'~ ~/~ ~/~ Material: ~ N u,~ber ~,,,pa~ments: ~ Surface Water '~'~ I~" l~'* ) ~ LIFT STAT~N LOt Size in gallons: Manufacturer~ Line ~'~ /0~ ~ ~ ~ I~~ "Pump on" level at: "Pump off" level at: High water alarm at: Curtain Pump Make & Model El~cal Inspections performed by: / / Remarks: )~U~ ~ ~[7~ ~ BENCH MARK Location and Description: I Assumed Elevation: ' ~ ~ . ENGINEER'S SEAL . Inspections performed by: ~ ~ ~~¢' DateS:2ndlSt ~ 1~1~ ../~~,,.~.:~~" ~epartment o~ Health an~ Human ~ervices approyal ~ ~;':~~:. Reviewed and : ~2 ~_/ 72~013 ~l/911MOA 25 ,Per'nit ,0. ~,/~ ~c)O°q'/° 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'-r ?~.~, PID NO.: J 72-013 A fRev. 9/91) MOA 25 · ;: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF / Y, ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT ~'-/~-~ PERMIT NUMBER:SW930026 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:BUSH GARY S & KRISTIN K OWNER ADDRESS:7040 CROOKED TREE DR ANCHORAGE, AK 99516 DATE ISSUED: 3/10/93 EXPIRATION DATE: 3/10/94 PARCEL ID:01531235 LEGAL DESCRIPTION: HILLSIDE PARK PUD LT 32 LOT SIZE: 30928 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 (iSAAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS 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: THE ORIGINAL DESIGN OF THE LEACHFIELD WAS REVISED TO A DEEP TRENCH WITH A TOTAL DEPTH OF 10.5 FT USING 7.5 FT. OF GRAVEL 89 FT IN LENGTH. A DIVERTING VALVE SHALL BE INSTALLED SO THAT THE EXISTING LEACHFIELD CAN BE RETURNED PAGE 2 OF 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 TO ACTIVE S~RVICE IF NEEDED. ~ ISSUED BY: / DATE: ' SCALE SCALE seo!^~es u~tunH ~'q31eeH 3deo SCALE ROBERT SHAFER, P E ROGER SHAFER, P.E February 22, 1993 CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDtES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 L Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 32, Hillside Park Subdivision Request you issue a permit to upgrade the existing septic system on the referenced property. An adequacy test was performed on the system and the absorbtion capacity was found to be inadequate for a four bedroom house. Two test holes were excavated and percolation tests performed on February 9, 1993. Ground water monitoring tubes were checked for water on February 16th and were found to be dry. The soil logs show the soils to be mainly silty sandy gravel which becomes increasingly dense with depth. The proposed upgrade is designed such that the trench is constructed in the less dense soils above the 6.5 ft. depth. The referenced property and the surrounding properties are served by a class "A" well. This well is located more than 200 ft. away from the proposed upgrade. We do not anticipate any adverse effects on the neighboring properties by the installation of the proposed septic upgrade. If you have any questions, or require any additional information for your review, please contact us. . Williams ~ivil Engineer /! SCALE ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS REFERENCE: Lot 32 Hillside Park P.U.D. Subdivision 7040 Crooked Tree GENERAL: me The scope of this project includes the installation of a 500 gallon effluent lift station and a leachfield trench ugrade to serve the 4 bedroom residence located on the referenced property. The existing septic tank is to be excavated to verify integrity. If the integrity is found to be poor, the tank is to be replaced. The existing trenches are to be abandoned in place. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be resposible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. page 2 Construction practices 4. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first oleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTION TRENCH/DRAINFIELD INSTALLATION: Excavate the proposed trench to the diminsions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (ruffed- up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Se Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. page 3 Construction practices MINIMUM M~TERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. e 4 · Se 7e The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, it's gradation specifications must conform to AMC 15.65.060D. INSPECTIONS= Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: 1. The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. page 4 Construction practices The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre- construction meeting will take place on-site. OF Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~/?~X/C/'~:~/J~ _~'~.~,~/~'~ //~__ ~__,~1~ / LEGAL DESCRIPTION:.~.)7,~/ /~-/~---¢~,-~ ~/~/C ~'~ Township, Range, Section: 3 i?.W I 7 8 9 I0 11 12 13 14 15 16 17 18 19 20 COMMENTS SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT . ,~ 0 DEPTH? P E Deplh t0 Water AIIeE_ Monitoring? U[~--~ Date'. ~/¢~X DATE PERFORMED: SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop : ~' I~ q" I ,,~S Io 3~" ~/~ ; PERCOLATION RATE J ~ (minutes/inch) PERC HOLE DIAMETER 3. PERFORMED BY: S & S ENGINEERING i ~ CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle River Loop Road No, 204 V ACCORDANCE WITH I~k~TJ[kjT~i~I~-.~UIDELINES IN EFFECT ON THIS DATE. DATE:  Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESOR,PT,ON; 1 2 3 }4 SLOPE SITE PLAN FEw 6~ea~s. 9 10 11 12 13 14 ~s I5.0,14, 17 18 19 WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT ~ DEPTH7 P E Depth to Water After Monitoring? ~ Date: Gross Net Depth to Net Reading Date Time Time Water Drop '5; ~ "5o~ w g" ~ 20 __ ~'~ PERCOLATION RATE ~'(' (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~-~ . FT AND 8 FT PERFORMED BY: $ & $ ENGINEERING i ~ CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle Ri,er LOop R~o~idDENUOi~E2SO~i" EFFECT "~--'~'~:~"~ ACCORDANCE WITH/~l~[~['~(~aVf ON THIS DATE. DATE: TABLE 3-8 FALLING HEAD PERCOLATION TEST PROCEDURE Number and Location of Tests Commonly a minimum of three percolation tests are performed within the area proposed for an absorption system. They are spaced uniformly throughout the area. If soil conditions are highly variable, more tests may be required. Preparation of Test Hole The diameter of each test hole is 6 in., dug or bored to the proposed depths at the absorption systems or to the most limiting soil horizon. To expose a natural soil surface, the sides of the hole are scratched with a sharp pointed instrument and the loose material is removed from the bottom of the test hole. Two inches of 1/2 to 3/4 in. gravel are placed in the hole to protect the bottom from scouring action when the water is added. Soaking Period The hole is carefully filled with at least 12 in. of clear water. This depth of water should be maintained for at least 4 hr and preferably overnight if clay soils are present. A funnel with an attached hose or similar device may be used to prevent water from washing down the sides of the hole. Automatic siphons or float valves may be employed to automatically maintain the water level during the soaking period. It is extremely important that the soil be allowed to soak for a sufficiently long period of time to allow the soil to swell if accurate results are to be obtained. In sandy soils with little or no clay, Soaking is not necessary. If, after filling the hole twice with 12 in. of water, the water seeps completely away in less than ten minutes, the test can proceed immediately. Measurement of the Percolation Rate Except for sandy soils, percolation rate measurements are made 15 hr but no more than 30 hr after the soaking period began. Any soil that sloughed into the hole during the soaking period is removed and the water level is adjusted to 6 in. above the gravel Ior 8 in. above the bottom of the hole). At no time during the test is the water level allowed to rise more than 6 in. above the gravel. Immediately after adjustment, the water level is measured from a fixed reference point to the nearest 1/16 in. at 30 min intervals. The test is continued until two successive water level drops do not vary by more than 1/16 in. At least three measurements are made. After each measurement, the water level is readjusted to the 6 in. level. The last water level drop is used to calculate the percolation rate. In sandy soils or soils in which the first 6 in. of water added after the soaking period seeps away in less than 30 min, water level measurements are made at 10 min intervals for a I hr period. The last water level drop is used to calculate the percolation rate. Calculation of the Percolation Rate The percolation rate is calculated for each test hole by dividing the time interval used between measurements by the magnitude of the last water level drop. This calculation results in a percolation rate in terms of min/in. To de~ermine the for the area the rates obtained from each hole are averaged. percolation rate , . : , . ~_~' Example: If the last measured drop in water level after 30 min is 5/8 in., the percolation rate: (30 rain)/(5/8 in.) : 48 rain/in. 41 MUNICIPALITY OF ANCHORAGE - DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES Address TANK FIELD -- Phone(s) I Permit No. No. of Bedrooms , Township, Range, Section AS-BUILT DIAGRAM ~Show location el wetl, septic system, properW lines, [oundabon, N ~ SEPTIC ~G Manutacturer ~ ~paclty In ga~[ons TYPE OF SYSTEM ~TRENCH ~ BED ~ W. DRAIN ~ OTHER Fill added above original g~e Grav~-depth berleath p~pe Grave length Grave width Total absorption area elsta~ce between hnes ~ O0 SQFT /~ / FT ~ PRIVATE ~OTHER {Identifv)~ FT ET ~ ~ r inspections~ Pe~ormeO by: : I. /, ('~ e~ cedily that this inspection was pedormed aooording to all Municipal and State guidelines in ellecl on this date: -~ ~,'- ~m~ ~ Department of Health & Human Services 825 L Street, Fifth Floor Anchorage, AK 99501 ALASKA erlUiRonmenTAL COIqTROL SERUICeS, Inc. ~nc~in¢~rincI 8 ~.uironmenlal Studies MUNICIPALITY OF ANCHOP. AQE DEPT. OF HEALTH & J u 1 y 26, 19 8 ~)NVIRONMENTAL PROTEC-q'ION JUL :? ? t989 RECEIVED RE: Lot 32, Block F, Hillside Park PUD BACKGROUND In 1981AECS did a soil test on the subject lot. The soils in the area tested show a 1 inch size gravel and saud from 1-8 feet, and then from 8-12 feet was a grey silt, plastic and moist. A permit was issued for the construction of the sewer system. The permit number was 810512. A 1250 gallon _ . tank and a field 67 feet long an~fee~et~-~d)~with 4 feet of rock under the pipe was installed. Inspection was done by Jim Roberts of the MOA. There is no indication where this system was installed in relation to the test hole except that it would appear that the test hole may have been closer to the road. In 1985 Mr. Christ was having trouble with the sewer system and coutracted with AECS to do another soil test. This soil test was done in the vicinity of the existing trench. was a drill hole, but it lilt refusal at 9 feet on cobble. At the bottom of the 9 foot test hole the ground was dry. The soils were rated at 160 sq ft based on a corrected value for a 6 inch percolation hole. AECS's common practice at that time adjusted the percolation test back to the original work done by Ryun in which his work was done with a 12 inch hole. The soils would have been more on tile order of 125 sq ft per bedroom, as opposed to the 160 sq ft per bedroom reported~ In 1985 Alaska Environmental Control Services, Inc. (AECS) did an adequacy test on the subject property. This was done for the purpose of refinancing the home. At that time, the adequacy test failed. During the 60 minute period the total drop in the field was .02 feet. In reviewing the data, it is noted that on the 1985 pumping receipt that a bacter~aI additive was put into the tank. It appears that the bacterial additives may be detrimental to the on--site field. This is documented in the literature. This may have been part of the reason for the premature failure of the system. Also, it appears that the field may have recovered to some degree. Permit #850631 was issued on September 27, 1985, for extending the sewer system. The permit called for a wide drain or bed to have been installed with one foot of rock. A total depth was set at 9 feet. The records at AECS do indicate that inspections were started, but there was a question that some seeps may have been from perched groundwater. Rock had been added to the 20 foo'L section of the trench. After some heated discussions, the inspectors !eft the property and did not return. Apparently this 10 foot section of the system was filled with rock and the system backfilled. EVALUATION On July 10, 1989, Ted Moore of Flattop Technical Services did an adequacy test and determiued that the combination of the two systems was adequate. One of the original questions brought up by the AECS inspector was that there might have been a groundwater problem and he wanted to investigate it in more detail, but this was not possible. On July 17, 1989, I had a test hole dug southeast 20 feet from the new system. See the soils tog. The purpose of this test hole was to determine if water was present and to determine the general soils type. The hole was dug to 17.5 feet. No water was encountered. On July 24, 1989, the monitor tube was checked. It had been raining heavily for two days but no water was evident in the hole. It is apparent that groundwater was not a cause of the earlier failure. It may well have been that additives to the septic tank from prior pumping may have contributed to the premature failure. Using the information from the excavator, the files by AECS, field measurements, and information from the owner, I was able to determine 'that there was 5 feet of rock installed under the drainpipe. There are 2 trenches, one 20 feet long, then there is a 8 foot divider of undisturbed soil, and then a trench I0 feet long. The bottom of the system is at 13 feet which puts the system 5.5 feet above the bottom of the test hole. CONCLUSION Based on the information obtained from the inspector's notes, the soil test, the adequacy test done by Flattop Technical Services, and the interviews with the owner of the property and the excavator, it is felt that the physical system was installed per the municipal code. It is recommended that the system be approved as presented on the as-built drawing. Municipality ot Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEER'S SEAL) PERFORMED FOR: ~,1~, Q ¢! L' T LEGAL DESCRIPTION: ./~..~¢~0 Z~ Z~ /~,//-/~,,;./~t~-.Township, Range, Section: 7'/~,'~' SLOPE  V'~ ~,~ "~ ENCOUNTERED? IF YES, AT WHAT DEPTH? S L Depth Io Water After ?,~ y,}~ ¢, Moniloring? ,/)'," ~ Date: SITE PLAN I I Il'lq'Ill III I Gross Net Depth to Net Reading Date Time ~11~1 k ll~T~rn~e Water Drop PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER __ TEST RUN BETWEEN FT AND __ COMMENTS ~'~"~ ~?'t~ c'7L- ~J / ' ' ~ ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: FT CERTIFY THAT THIS TEST WAS PERFORMED IN INVOICE N~ 010428 ".¥~4/¢ ~o ?,-,~ CLEANING SERVICE PO BOX 4-2841 PHONE 345-2513 Job Address ANCHORAGE, ALAS-A 99509 ROTOR ROOTER SERVICE CALL TERMS -- 30 DAYS HRS. STEAM THAWING HRS.' TRIP CHARGE HRS. OVERTIME CHARGE HRS. ADDITIONAL LABOR CHARGE HRS ~,, PUMPING SERVICE /5~:~:'~ G A L)HRS PLUMBING RE~AIR CHARGE HRS MATERIALS PLEASE PAY FR(_ M THIS INVOICE 'OMER OP--'E= = ( TOTAL TOTAL FOOTAGE CLEANED OR THAWED BLADES USED PROBABLE CAUSE OF STOPPAGE0'-'~? }'.'t ~"~'3"~ F_,l~'~,,,,, ~. '~'C' P.O. BOX 6650 ANCHORAGE, ALASKA 99502-0650 f907) 264-4111 TONY KNOWLES M,4 Y DR DEPARTMENT OF HEALTH & HUMAN SERVICES January 10, 1986 TO: Permit Applicant Subject: Permit # 850631 Lot 32 Block F Hillside Park Subdivision A permit issued by this Department for an individual well and/or on-site sewer system has expired as of December 31, 1985. Permits are issued on a calendar year basis by authority of Municipal Ordinance. A new permit must be obtained from this Department for any well and/Or on-site sewer system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this Department for documentation of the installation and to close the permit~ If a private engineer inspected the installation of the on-site sewer system the original as-built inspection report(three part form) must be sent to this office for review and approval,and for documentation. If there are any further questions, please call this office at 264-4720° Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/ljw enc: Copy of Permit DI:.I Ab, l l I.l,lf OF: I'"IEEAL. TH AND I:ZNVII::;~ONMENT.P..~L F:'RCYf'E.:.'C"FION :..:::,.. I_ ,S;T'F;:E:.E:.'T., tAt\tCHOR~:~C'")F.:, A~::: 79,.~_ ~ 09/2'7/EJ5 i':;,'OD CHF:;,' I E~'I" 70.":1.(' .... q ~ .......... ~.~,..; SLIBD I V I S 1 ON SECT ]: ON 704.0 CI::ROOI<ED 'T'FRIEE DRI ~"~' DE:F)"f'H 'I"C) PIF'E BOTTC]H < 3,5 F:'T. REC~UIF~ES II\ISLJLATION ~'~' DIEI:::'TH '1"O F'IF:'liii: BOTTOM < q..O FT.. M(4Y F;:E:G!LJIF~E A LIFT t~¢~ GF~P~VEL 1....ENGT'H :::' '7~:5 F'T'. F~E(?LJIRES IvtUI-TIPLEi: FtlJNt:] (NOT E:XCE:E:DINE~ '70 FT, E:(.~CH) ~"~' 'T'~'::dqK MU,ST l'"lAVlii:.' (-YT' I_IE.(.1ST "tWO COMPARTMENTS £c:,r~t.h l::~y t.h~, Vh..~n:Lc:ipal:i.t.y of (4r'~c:hc~age (HC)P~) and t. he State oF (.~la~l.~:a. :[ t,,~J 1]. actl"~ei"~ t.o all. MOP~ and St. at.e of C:~la~L~l.::a r, ectLtir'emer~t.s f(::m t. he set. t::)ac::l.:: any e)r'~].al"g[~,m~z, rlt. ~J.Z:I. r'(.z.)qL.JiPe] an z~d~JitJ, c)rtaZ pe:,Pmit... Il:r (-:t L]:F:T !.::;'T'(.¥TZDIq i,~i}; IIqE3'TALLE:D IN AN AREA C, OVEI:~!ED BY MOA BLJILDII",IIS "I"HE~N (1) AN li~.L..t.::i:CYT'F(t'C:(-~L I:::'E:RPIlT AND 1:t\I,'.~F'Iiii:C:TICIN I"ILJ~,!~T BE C)BT(..~INI!!!:D~ (~2'.) (-SS-.I~.)LJILT'E~ ?,t]:L..L NC)T [~l.:..i: (4F'F'F~OVE.:C) WI]"HOUT (.:~N E~LE:CTF~IC;(-:d_ ZN!:'..~F'E:C:TIOiq I::~'.E:F'C)F(T; (:~I\ID C];) THIS Ei:L..IS.C:'T'F:~ I CAL.. I,YOF;,'I< I"ILJEVI" BE: DONt!!i: BY f.::~ L.. ]: CI!!i:IqE~I!.:::D E:Lliii:CTt::~ Z C I AN. P~f::'F'L I EY4I\IT': ROD CPIF?. :[ ,~ST ]:,S;E;L.IELD BV ~.,,,~..~._,,,.~ ~ D,.q"f'E:: ~- PERFORMED FOR: .,~r. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~, ~,~-~,/ ~. ~ ~z//_~/~Y~ /)~//'k Township, Range, Section: lg/{/q ..'~ ~" SLOPE SITE PLAN 1 2 3 4 5 6 7 8 9. 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water ADer Monitoring? Date: PERCOLATION RATE ~'~ (minutes/inch) PERC HOLE DIAMETER PERFORMED BY: ~~¢ ¢~¢*¢* I ~¢~ CERTIFY THAT THIS TEST WAS PERFORMED IN Gross Net Depth to Net Reading Date Time Time Water Drop $c 7-/? lc  MUNICIPALITY OF ANCHORAGE , ~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT //~ ....J .PH O1~ E I ~NEW LEGAL DESCRIPTION LOCATION ~ NO. OF BEDROOMS ~ ~ kiq. capacitg in flallons Inside length ~idth Liquid dopth / ~ IF__~HOME~DE: z_~O Z < Manufacturer / ~/~ Material Liquid capacity in gallons Q Well Foundation , Nearest lot line PERMIT NO. ~ ~ ~ No. of lines Length of ea~line Total leng~ o~ines Trench width Distance between lines -~ /CO 7~ ~ inches ~ Top of tile to finish orade Length Width Depth PERMIT NO. ~ ~ Type of crib eter Crib depth Total effective absorption area ~ Bailding ~oundadon Nearest lot Hne ~ DISTANCE TO: JJ Clas~ Depth Driller Distance to lot line PERMIT NO, ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER INSTALLE~/~ ~ REMARKS , APPROVED DATE LEGAL PERMIT NO. FtFFLI ..AN F LOCAT I ON LEGRL ~ D'EF'RRTMENT OF HEAL. TH ~N[:' ENVIRONMENTAL PROTEE:TION c - , - RNP:Hf"RAGE., AK. oo5 '" L '" _,1 REET., 264'472E1 C~'.l ....~q I lB E;EI-~EF: F'ERf4 ~ T' ~ FHIRBHNK-, :,T. ROD ..HRIml 1 ]RE[KE[, TR. EE DR. ~¢ LOT 22 TR. F HILLSIDE PRR~ LOT RE,:,LRFTI.~I S'¢STEM IS: TREN_.H T"r'F'E OF SOIL ""-'' II, '- I-' fIR,.:,IM.M NLIMBEF: OF BEDROOMS SOIL RRTING (E ~ F F,.'BF,.. - ~:,~, ,-- - ,ti , , n. ,-' ': IS THE REQUIRE[:, SIZE OF THE :,uIL HE=LF..FTI.N .:,¢_,TEM : [:,EF'TH= "-" [-, E~ F TFI-- · :- L r£ ~"-~ 13 lr- H = -.i .--_-=: C-~ F,' Pt %-' E L .... ' 27g-2E~lO 42.'560 '-= C'L FtRE FEET THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF FI TRENCH OR PIT IS THE .F..',ISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EY, CR',,,'RTION (IN FEET). THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE RND THE BOTTOM OF THE E',,.4CRVRTION (IN PEET). PERMIT RPPL. ICRNT HRS THE RESPONSIBILIT'~' TO iNFORM THIS DEPRRTMENT DURIN6 THE INSTRLL. RTtON INSPECTIONS. OF RNa' WELLS RDJRCENT TO THIS PROPERT'¢ RN[:, THE NUMBER OF RESIBENCES THRT THE WELL WILL SERVE. BRCKFILLING OF RN'¢ S'¢STEM WITHOL{T FINRL INSPECTION RND RF'PRO',/FIL B'¢ THIS DEPRRTHENT WILL BE SUBJECT TO PROSECUTION. MINIMUN DISTFINCE BETWEEN R NELL RND RN'¢ ON-SITE SEt.4FIGE [:,ISPOSRL S'¢STEM IS l(,D FEET FOR R PRIVATE WELL OR 15;~ TO 20¢9 FEET FROM R PUBLIC WELL DEPENDING UPON THE T'¢PE OF' PUBLIC NELL. MINIMUH DISTRNCE FROM R PRIVATE {.4ELL TO ~ PRI'¢RTE SEWER LINE IS 25 FEET RND TO R COMMUNIT'W SEWER LINE IS 75 FEET. OTHER RELqUIREMENTS MR'T' RPPL'¢. SPECIFICRTIONS RN[:' CONSTR. UCTION DIFIGRRMS RRE: R',/RILRBLE TO INSURE PROPER INSTRLLRTION. I _.ERTIF~r THRT ±: I FtM FFIr,IILIRR WITH "FHE REQUIREMENTS FOR ON-SITE _,EWER_ RND WELLS RS _,ET FORTH B',' THE MLINICIF'FIL!T'¢ OF RNCHORRGE. ~: I WILL INSTRLL THE S'¢STEM IN RC:CORDRNC:E WITH THE i_.o[.,E:,. <: I I..INE:,ERSTRND THRT THE ON-_,ITE :,EWER Sb'STEM MR'¢ REQI_IIRE ENLRRGEMENT IF THE RES I [:,EN CE I~~ [:, TO INCL U [:,E MO RE THRN 4 BE [:,RO0 ~;FIf~ R. OD CHRIST MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~OILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19. 20 COMMENTS PERFORMED BY: SLOPE DATE PERFORMED: WAS GROUNO WATER ~:~ S1 ENCOUNTERED? If YES, AT WHAT ~ ~ -- DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND -- FT MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519,6650 343-4744 Parcel I.D. # CERTIFICATE OFHEALTH AUTHORITY APPROVALFOR A SlNGLEFAMILY DWELLING HA930139 015-312-35 HAA# 1. GENERALINFORMATION Completelegaldescription Lot 32 H£11s±de Park Subd±v±s±on Location (site address or directions) ?040 Crooked Tree Property owner Mailing address Lending agency Mailing address Gary & Kristen Bush Day phone 346-3749 7040 Crooked Tree, Anchoraqe, Alaska Day phone 99516 Agent Shari Boyd % Area Coldwell Banker Dayphone Address 4105 Tudor Centre Drive, Anchorage, Alaska 561-2488 99508 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Four (4) XXXXXX Public water 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 NOTE: XXXXXXXXX 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/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. NameofFirm S & S Engineering Phone 694-2979 Address 17034 Eagle River Loop Road, Suite 204, Eaqle River, 99577 Engineer's signature Date DHHS SIGNATURE -~'- Approved for ~-- bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health ,~uthority 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 ROBERT SHAFER, P.E. ROGER SHAFER, P.E. HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS SITE PLANS ROAD DESIGN SOIl TEST PERCOLATION TEST STRUCTURAL& MECHANICAL iNSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 15, 1993 DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O.~ Box 196650 Anchorage, AK 99519 REFERENCE: Lot 32; Hillsid~ Park Subdivision CIVIL ENGINEERS (907) 694-2979 FAX 694-1211 RECEIVED JUN 1 5 1993 Municipality ot Anchorage Dept. Health & Human Services This l~tt~r is to certify that th~ rcquir~ment~ ~tablish~d by the Conditional H~Ith Authority Approval (H.A..A.) dated April 1, 1993 have b~n ~atisfactorily completed.. R~qu~st you issu~ th~ Final H.A..A.. 4~BERT A., SHAFER, P.E. at this t~m~. cc Shari Boyd/ Cold~.l Banker 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 32; Hillside Park~Subdivision ri' Location (site address or directions) 7040 Crooked ~'ee, Anchorage, Alaska Property owner c.~ry ancq T<ri,~ten Rt]sh Day phone 346-3749 Mailing address 7040 Crooked Tree, Anchorage, Alaska Lending agency Mailing address. Day phone Shari Boyd/AREA COLDWELL BANKER Agent Address 4]05 Tudor Centre Drive, Anchorage, Alaska Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 N TYPE OF WATER SUPPLY: Individual well Community well ×xx ~ Public water Day phone 561-2488 NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site xxx ',v 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. 72-025iRev. 1/91) Front MOA #21 NOTE: 99508 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/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.  Phone Name of Firm 17034 Eagle RJver/l~ o, 204 Address .~ Engineer's signature 6. DHHS SIGNATURE Additi~~om monts / c2Q Approved for bedrooms. Disapproved. Conditional approval for ~/",--(-¢/~bedrooms, with the following stipulations: By: Date ./,,Z_ 7,~?~¢,- The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given Jn 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: ~-~-~"~ ::~::~" fl/L/..~.P',~_. 2P,~%--- ~& Parcel I.D.---... A. WELL DATA Well type ~/"~4/u/~J,7,¥ Log present (Y/N) Total depth Sanitary seal (Y/N) If(~, B, or C, attach ADEC letter. ADEC water system number c~' I~'q'cj~ / /L)//~ Date completed ~//~ Driller /~)/~ ~ Cased to ~/~ Casing height ~ ~/~ Wires properly protected (Y/N) ~/~ Date of test Static water level Well flow FROM WELL LOGAT IN!CTION ~ ~' g.p.m, g.p.r~ ~ ~ Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAM~E RESULTS: -- _~E~- Co f~rm /g//;/~" Nitrate Date of sample: /v'//~ B. SEPTIC/HOLDING TANK DATA Date installed ~-I ~'~<~ ( Cleanouts ~_~N) ~ High water alarm (Y/~ Date of pumping ; On adjacent lots ; On adjacent lots Public sewer manh°le/cleang~t Petroleum tank /v~/,~ Other bacteria Collected by: /~"//'~ Tank size I~,~r-~O ~R-L Compartments c~ Foundation cleanout (~N) Y Depression (Y/~) ~ /~ Alar~:te[sted,(¥/N). ~i/h;~'rl . :: SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~-~Jh On adjacent lots To property line ~.~ ~4- Absorption field Surface wa~ter/drainage J©O r ¢_ Foundation ~'~0 C/_ Water main/service line ~0 ~¢- 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer  ess (~/N) Vent (~N) \/~ "Pump on" level at "Pump off" level at High water alarm level ~1" Cycles test~ ~/~ --~ ~. Meets MOA electrical codes ~) / ~'~ ~c ~ Well on lot ~/~ On adjacent lots ~ '~ Surface water D. ABSORPTION FIELD DATA D~te installed ~/~ (~ ['~ ~ ~. Length ~ Width Gravel thickness '"~¢ 5 Total depth Total absorPtion area J ~S .~.~' Cleanouts present (~N) Depression over field (Y~))' Y Date of adequacy test Results (pass/fail) ~/~' /~:¢f'~ ---~Y-~7j-¢=~ for_ z¢~ Peroxide treatment (past 12 months) (Y/¢ bedrooms If yes, give date ~.J/~/r SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~//~ __On adjacent lots To building foundation ~-~,~ On adjacent lots ~CO ''/ Cutbank Surface water /~{J Curtain drain ~0NE.- Property line /(~ /'/- To existing or abandoned system on lot Water main/service line E. ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature $ & $ ENGINEERING 17034 Eagle River Leop Reed No. 204 Engineer's N~I~ P!v~,r, AI~__~ _e_e_~77 Date ~ ---- 2..~ --~,~ HAA Fee $ _/ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 ANCHORAGE, A~S~ 99515 //...e-~-~-~-~'""~""~' ' ~'~ ~" ::"~:'-~Fbrua 12 1993 / Mr. Jim Williams S & S Engineering WALTER J. HICKEL, GOVERNOR (907) 349-7755 SUBJECT: Lot 32, Hillside Park Subdivision Class "A" Public Water System, PWSID 212461 Dear Mr. Williams: I have completed a review of this office's files concerning the monitoring status of the above-referenced Class "A" Public Water System and found the following: The last satisfactory Total Coliform Bacteria Sample results was submitted to this Department on February 4, 1993. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. ~ The last inorganic Chemical Contaminants Sample results wbre submitted to this Department on July 2, 1990. This does meet the provisions of 18 AAC 80.200(a), of the State Drinking Water Regulations. The last Radioactive Contaminants Sample results were submitted to the Department on December 1, 1992. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC) were submitted to this Department on November 12, 1991. Based on analysis of the previous VOC samples results have been satisfactory. This does meet the provisions of 18 AAC 80.200(a), State Drinking Water Regulations. Issuance of this letter does not imply that the above-referenced Class "A" Public Water System is in compliance with other provisions of the' State Drinking Regulations. If you have any questions on the above information, please do not hesitate to contact this office at 349-7755. Sincerely, Michael Lu Environmental Eng. Asst. II :t:1~.t S ? ~:: !: :]: ,i: :J~ Time Time ~ ~,,~e Date Date Date Inspector Inspector Inspector Comments Conditional Approval Date Sewer Installed Permit No. Septic Tank Size / ~.o --- ~ ! Holding Tank Size Soils Rating Well To Absorption Area Well Log Received Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner /l~:~ ~ ~ ~ ~ ~/~ ~ ~ ~ r ~ ~ ~ Phone Mailing Address ~ Buyer ~ ~ Address Lending Institution tz"-~'~ ~ ~ W~ ~, oz, ~ t /~. ~ ~ Phone Realty Co. & Agent ~ ¢ ~ -~ , Phone Address Street Location /6 Typepf Residence ~ Single Family D Multiple Family No. of Bedrooms ~ Other Water Supply ~ Individual A~ACH WELL LOG. A well Icg is required for all wells drilled since June Community. 1975. For wells drilled prior to that date, give well depth (attach Icg if ~ Public Utility available.) Sew~e Disposal ~ Individual Year Individual installed: D Public Utility When Connected to Public Utility:_ ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) · Location (address' or-directions) (b) Property ow:;¢,:' (c) Lending Institution ~, . -,"- Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here,E~, if hold for pick up.) List contact person and day phone number below: 2. TYPE OF RESIDENCE Single-Family,[~ Number of bedrooms 3. WATER SUPPLY Individual Well [] Community,~ Public [] Note: If communitY well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site j~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status· 72-025 (Rev. 7/88) Page 1 of 2 IBuo!~!puoo leAoJdd¥ iBuo!~!puoo J.o SLUJ@L peAoJddes!Q ./~ peAoJdd¥ ~q swooJpeq ~o~ peAoJdd¥ lV^Ol:Jdd'~ SHHQ '9 ? / "~ 7 w~14 J.o eWeN .uo,~oedsw s~4~ ~o e~p aq~ uo ~oe~a u~ suo~eln~e~ pu~ 'seou~u~p~o 'sapoo at~S pu~ led~o~un~ lie qtt~ eoUe~ld~OO u~ s~ ~e~s~s lesods~p je~e~etse~ ~o/pu8 ~lddns Jats~ a3~s-uo aqt 'uoltoedsu~ pug uo~eS!tseAw ~ ~o~t pu~ seiki eSeJoqouv to ~t.l~d~o~un~ aqt ~o~t peu~etqo uo,te~otu~ aqt uo peseq ~4~ ~JeA JeqsJn~ I 'u!eJe4 pe~empui ejn~onJ)s ~o edX~ pus swooJpaq ~o jeqwnu eM) Jo~ e)enbepe pub leUO!~oun¢ 'e~es s! we~sXs lesods!p je]e~e~se~ Jo/puB Xlddns ja~e~ a~!s-uo e4] ]e4~ smo4s teAoJddV X~!Joq~nv q~leeH s.45 jo uo~eS.~seAw ~ ~e4~ ~JaA I '~oleq u~o4s e~ep uo!$epHeA a4~ ~o se pub o]aJe4 paxwe leDS XW Xq pew~Je3 sv '9 MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: ~, Well Classification ¢~2~1' Well Log Present (Y/N) Total De pth Cased to Static Water Level Casing Height Above Ground - Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by If A Date Completed Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) B, C, D.E.C. Approved (Y/NJ Yield ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ; Date Water Sample Test Results Comments ¢" DJEC SE~TIC/Rq~I¢~ATA Date InCtalled No. of Compartments tan,¢p,!pes.,(,'i'/N~)x,:,~ /7_ ~' uepre§sidn over T~n~) Pum ping/Maintenan,ce Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ,~//'z/~'8 ; for Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Building Foundation To Disposal Field To Water-Supply Well ~. '~o ' To Property Line .~ ¢o' To Water Main/Service Line ~' ~,~ ' To Stream. Pond, Lake or Major Drainage Course Comments 72-026 qev. 7/881 Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata ~,~' Date Installed &"('tS~ Width of Field -- Square Feet of Absortion Area_ 5'.1'~'..~,0 / Depression over Field (Y/N) Results of Last Adequacy Test ~-ot'~'~/'! .~¢ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well To Building Foundation Lot I'"e.' I~.~/'~' C,O.'$ TO Water Main/Service Line ~ ~' ' To Stream, Pond, Lake, or Major Drainage Course ~ to~ ' To Driveway, Parking Area, or Vehicle Storage Area ~ ~,~'~ ' Comments A.~-,~,lt' .., ~;1~ ~/ ~a~/ ~ ~o ~,~ Type of System Design 7-~"¢p~ Length of Field ~ .? .~o.~ / Depth of Field Il' ~~ Gravel Bed Thickness q ~ .~' Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~ to t To Existing or Abandoned System on ; On Adjoining Lots ~ ~¢ ' To Cutback (if present) D. LIFT STATION //tiS. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping ~~T est. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in ~{fe4xt, on the da'[e of this Signed Receipt No. ~ X 'SX~ /~ (Dto2 Receipt No. Date of Payment ~ ~ O, OO Waiver Fee: $ Amount: $ ~_ ~ ~01 Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2