HomeMy WebLinkAboutPARADISE VALLEY BLK 9 LT 14Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 2
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221151
PID Number: 020-414-02
Dwelling: ❑■ Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New ❑■ Upgrade
Name
ALYSON PYTTE
ABSORPTION FIELD
❑ Deep Trench ❑ Wide Trench ❑ Bed ❑ Mound
Site Address
6120 ROMANIA DRIVE
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
GPD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Ft.
Gravel depth beneath pipe
Ft.
Subdivision
Block Lot
PARADISE VALLEY
9 14
Fill added above original grade
Ft.
Gravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Distance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. between trenches
From
Tank
Field
Tank
Line
Ftz
Ft.
Well
100'+
NA
NA
NA
25'+
TANK ❑■ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer
GREER
Capacity
1250 Gal.
Surface Water
100'+
NA
NA
NA
Material
Number of compartments
Lot Line
51+
NA
NA
NA
NA
HDPE
2
Foundation
10'+
NA
NA
NA
LIFT STATION
Manufacturer
Capacity
Remarks TANK REPLACEMENT
Gal.
Alarm location
Electrical installed by
Installer
PIPE MATERIAL House to tank 3034 Tank to3034
drainfield
CIC General
Drainfield CO/MT
Inspector PES
BENCH MARK (Assumed elevation) 100.0 ft
Inspdection 15` 9/13/22
2nd 9/14/22
Location and description
3rd
4,h
Bottom Step from Deck
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
OF
•'
Date
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.... .. .......
annoRe
Septic System1
••.. CE 8149
Approved
Date �/
• 2023.04.10 ••
••.,��
N t : this approval does not include well permit require ent .
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NOTES: PANNONE ENG SVC LLC (C.1. 1088) REVISIONS DATE
RECORD DRAWINGS P.O. BOX 1807 PALMER, AK 99645 ,SOF 04/10/2023
PHONE (907) 745-8200 FAX (907) 745-8201 P•' SCALE
DRAWN t_JC PARADISE VALLEY BLOCK 9 LOT 14 P.I.D. NO
CHECKED ALYSON PYTTE "�3even anrioee 020-414-02
CE 8149 PERMIT NO.
SITE: 6120 ROMANIA DRIVE? •; 0 P221151
SITE PLAN ANCHORAGE, AK 99516 SHEET
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MUNICIPALITY OF ANCHORAGE
On -Site Water& Wastewater Program
puBox 1oonmo *7ouElmore Road
Anchorage, Alaska esmeooao ph04 Fax: (907) 343-7997
Permit Number: OSP221151
Work Type: SapUcTankUpUrodo
Tax Code Number: 02041402000
Site Legal Address: PARADISE VALLEY BLK 9 L 14 G:3538
Site Mailing Address: O12OROMANIA DR, Anchorage
Owner: PYTTEALYGONC
Design Engineer: PANNDNEENGINEERING SERVICES
This permit bafor the construction of:
Effective Date:
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms:
6/7/2022
6[7/2O23
O Disposal Field 0Septic Tank 171 Holding Tank 0 Privy O Private Well [] Water Storage
All construction shall beinaccordance with:
1. The attached approved design.
2. All requirements specifiedi Anchorage Municipal d Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (1 8AAC72) and Drinking Water Regulations (I 8AAC80)
— The wastewater code requires inspections during ".""."^""""".' The engineer shall notify the Development
Services Department per AMC 1E.85.Provide notification by calling (907) 343-7904
4. From D�ober15toApril 15.emubsu�aceooUobso�tiunsystem under cnnahuchonduh�gfreezing weather
shall beeither:
a. Openedand Closed onthe same day, or
b. Covered, sealed, and heated hoprevent freezing
Special Provisions: Please note: The Greer plastic tanks are only approved for installation in groundwater no
higher than 1ftabove bottom oftank.
/
Received By: Date: —
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-414-02
Property owner(s) Alyson Pytte Day phone
Mailing address 6120 Romania Drive, Anchorage AK, 99516
Site address 6120 Romania Drive, Anchorage AK, 99516
Legal description (Sub'd., Block & Lot) Paradise Valley B9L14
Legal description (Township, Range & Section)
Lot Size 22,667 Sq. Ft. Number of Bedrooms 3 - __ ...
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) X❑
Septic Tank
X❑
Upgrade X❑
(w/wo AD U)
Holding Tank
El
Renewal
Renewal ❑
(D) ❑
Privy
❑
Multiple Dwellings ❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 0 �� 5 Waiver Fees:
Date of Payment: IZT��
0.2 2 Date of Payment:
Receipt Number: 0 � 3 3 0 ( Receipt Number:
Permit No. OS PZa 9 i rJ Waiver No.
Permit App_-'- : ._...:c:
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221151, Rebecca Carroll, 06/07/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221151, Rebecca Carroll, 06/07/22
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
Address ~ SEPTIC ABSORPTION
)dr.) /~,v 27t~V~'-, ~-2¢/e ~,~-r.,g~ ~,~r?7, TANK FIELD WELL
/ Permit No.
~o^~ cEsc...T,O. LOT LINE
Township, Range, Section ~ '
AS-BUILT DIAGRAM (Show location of well, septic system, propeHy lines, foundation
~/¢ ~ ~ 5 ~ '~ ¢ driveway, water bodies, etc.)
TA. s N
~ SEPTIC ~ HOLDING
Manufactur r Capacity in gallons
Material NO. of Compa~ments
TYPE OF SYSTEM
~ TRENCH ~ BED ~ W. DRAIN ~ OTHER )/
originaIDepth tOgradePipe bottom~from/ FT Total depth from original grade ~ / FT /
Pill added above original grade Gravel depth beneath pipe
Gravel length i Gravel width
~0 FT FT
Total absorption area / Distance between lines
~ 0 SO FT ~' FT
Number of lines J S°il rating Pipe material
Installer Date Installed
WELLS ~
Glassibcation (~.~,G) ~tal ~epth CaseO to _
FI FI 1
REMARKS: ;; ,-
Scale: ~% . ENGINEER'S SEAL
~.~,~ ' .
I Z' *"' cedily ,hat this bspe.,0, was ped0r.ed acc0rdi.g ,0 aH
j Municipal an~ State guidelin~ in effect on this date: /¢ /~/] ¢~
by
DOC: Co. cll)a
SULLIVAN WATER WELLS
P.O. B'OX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688.2759
OWNER oF.LAND
ADDRESS
DATE- Star~ed Ended ///r~rJ~' GALS. PER HR
PERMIT NUMBER KIN[) OF CASING
DEl'TH OF ',YELL ~ C:, ~
STATIC LEVEL OF WATER F'F.
~- a) ,O . .
KIND OF FORMATION:
From O Ft. to ~ Ft.
From c,~ Ft. to ,~ ' Ft.
From ~ Ft. to ,-g'fi"' Ft.
From ' ' Ft. to Ft.
From',~-~" Ft. ,o qa Ft.
From Ft..to ' . FtC'
From: q~- Ft. to
From~Ft. to
From/,~-'ff' Ft. to ! 70
From~Ft. to
From !70 Ft. to
From ~'~ 3'~ Ft. to
From ~10 Ft. to
From Ft. to
From~Ft. to .
From Ft. to
~/'
From Ft. to FI.
From Ft. to__Ft.
From Ft. to Ft._ ~5.
From Ft. to Ft.
From Ft. to Ft._ "
From__Ft. to__ Fl.
From__Ft. lo__Ft.
From Ft.,,R E C F~,LV_ED_
JUL 28 1997
Municipality of Anchorage "
Dept. Health & Human Services
DRILLER'S NAME
/
Iq U Iq I C] I P A L I T ¥ 0 F A N C H [.) Fi A G E'
82'5 L Str. eet, Anchor'age, A].a~l..':a 99~0I 34.3--.47~:0
0 N '- S I T E S E W lie IR & N E L.. L P E R M I ]"
t;::'e r' ~11 i t NLtc~be r' :l
Date ]:sst.ted,', 07107188
Engineep Designed
(]wrier' Name: DC}iq SETTERS
Owner' Addr'ess: F:',,O,, BOX 77:1.12Zl-8
ANCHORAGE!, AK 9?5'77
Day Phone:
694-3439
Pal-c:el Id: 020-4:[4-02
Lo'L L.egaJ.: Subd:[visic)n: PARADISE VALLEY SUBD Lo'L:
Section~ ;[:[ 'Tc)wnship: 12N Range: 5W
t....ot Size 22880 (sq. ft.. oP ac:res)
Max E¢ecJr'ooms: 'l"his Per'nlit~ 3 'f'o'Lal Capacity:
B1 oc k: 9
SEF'TIC TANK: Minimum tc:rl:.al sept. ic: tank capacity: 1,000 ga].lc~ns. Eac:h septic
tank must have aC leas'L 2 compartments. Depth to top o¢ septic:: 'Lank(s) <
fee'L r'equir'es irtsu].ation c)veP tank(s).
WELL,: [,..oil mus'L be subm:i.'Lted to Munic:ipa:l. ity c,£ AnchoPage Depar.'Lment of' Health
anc:l Human 8er'vic:es wit:hin 50 days c~f well completion.
II~IFORM D.H,,14,,S. I:::'RiOIR TO 1ST & 2ND INSF:'E!:C]"IONS BY ENGINEER, IF:
AFTER OFF'ICIE HOURS,. CAI...I_ .343'""468 :[ AND LEAVE A MESSAGE
C'ONSTRUC]" F'ER IEI',IGINEERS A]"TACHED AF:'PROVED DES.~GN
T'H :[ S F'ERH:t:"I' EXF:'I RES :[~?./3 :[/88
]'H]:S F:'ERMI]" VAL..ID [:'OR A SINE~LE FAMILY RtESIDENCE ONI..Y
I C:;IERT I t:::'Y 'f't'"l~T~
1. I am f'amiliap with the i"equiPemerrLs fop on-site sewer's and wells as set
for.'Lh by 'Lhe Murl:i. cil:~al~ty of Anc:hopage (MOA) arid the State of' Alaska,
2,, I will install the system in 8c:c:opdalqce wi'Lb all MOA codes al"id I"e~]Lt].atic)ns~
arid J.l'~ c:c:)mp].J, ar'H2(,9 wi'Lb the design c:rJ.t..el-ia mf th:Ls p¢:)pmit.
:5. I w'.i. ll adhePe tc~ all MOA and State of Alaska nequi~ements fop the set back
distance~ Cnom any existing well, wast..ewatep disposal, system eP public
sewer'age system on 'Lhis on any adjacent on neapby
4. I under"s'Land that Chis pe~-mi{ is valid Fo~ a maximum
al. so ur~del*s'Lar~d that the capacit'..y el{' 'Lhe t.c:)tal sys'Lem is 5 bedr'c:~oms ancl
any enlar'gement, wi:l.~ r'equir'e an additional pePmit.
(Omr'le r' )~~ ~ ............................................
ALASKA EFIUIROIlmEFITAL conT[ OL SERUICES, Inc.
~n~lineem~ f~ I~nvironmentd
SPECIFICATIONS FOR A FIVE-WIDE WASTEWATER TREATMENT SYSTEM
LOT 14, BLOCK 9, PARADISE VALLEY SUBDIVISION
1.0
GENERAL
].1 The drawings, sheets 1 through~,~hall be a part of this
specification.
All materials and workmanship shall meet the reqnirements of the
Municipality of Anchorage, Department of Health & Human Services,
(DHHS), the conditions of the permit, and all applicable rules and
regulations currently in effect.
!.3 All elevations and depths are advisory and are 'to be verified or
modified in the field by a DHHS approved inspector.
]..4
It is the responsihi]ity of -the installer to adhere to approved
designs for installation, maintain the specified separation
distances, and have the appropriate inspections.
1.5
If the installation is not inspected by an AECS engineer, AECS will
not be responsible for the installed system. An engineer at AECS
should be consnlted prior to construction, to determine the number of
inspections that will be required and to explain what these
inspections will involve.
2.0 SEPTIC SYSTEM
2.1
The existing septic tank may be used, if it meets the capacity
requirements for the residence and the approval of DHHS. Older
systems ]nay need 'tank integrity verified. If not, then specifications
2.2 through 2.6 apply.
2.2
The septic tank shall be a UPC approved two--compartment tank,
constructed of i2-gauge steel with bitumastic coating, set level
on undisturbed soil and insulated with overlying layer of 2 inch
burial type polystyrene.
2.3 The septic tank shall be a minimum of 5 feet from the honse
foundation, and a minimum of 5 feet from the absorption area.
2.4
The septic tank and drainfie!d shall be a minimum of 100 feet from
any private well or body of water, 150 feet from Class C wells, and
200 feet from Class A or B we]]s, unless otherwise specified. Less
than the required separation distance must have prior approval or
waiver by Alaska Department of Environmental Conservation (ADEC).
2.5
Piping slmll be fitted with a mechanical watertight calder coup].ing
of the inlet and outlet of the septic tank. Piping shall be 4-inch
ASTM D3034 or cast iron, sloped a minimum of 1/4 inch per foot.
1200 ~Jes! 33r~ ]~uenu~. Suil¢ 8-]~n¢~oPa~]e, AJos~ 99503.[907) 561-5040
2.6
Cleanouts shall be installed as designated, capped with air-tight
rain caps (Jim caps or equivalent), and extend a minimum of 2 feet
above ground level.
8.0 DRAINFIELD SYSTEM
3.1
The gravel for the drainfield shall be 0.5 to 2.5 inch, screened rock
with less than 3% passing the #200 sieve. All substitutes must have
prior DHHS approval.
3.2
The bottom and side of the excavation shall be raked with the backhoe
blade to ensure that it has not been compacted during excavation.
The bottom elevation shal] be leve].
3.3
Monitor standpipe(s) shall be placed as shown in the drawings, and
shall be rigid PVC ASTM D3034, or 4-inch cast iron. The section
shown with holes may be drilled 0.5 inch holes on the 6-inch centers
on opposite sides of the pipe, or a regular sectiou of perforated
sewer pipe, clamped to a solid section, with either a no-hub coupling
or a solvent joint. A rubber rain cap (Jim cap or equivalent) silall
be placed over the top of the pipe.
3.4 The distribution pipe shall be 4-inch rigid PVC with a minimum crush
strength of 1500 lbs or equal. All distribution pipes shall be laid
level.
If the final grade of the drainfield is less than 4 feet above the
gravel, insulation is required using Dow extruded blue styrofoam
board or equal. There shall be I inch of insulation for every foot
of soil less than the required 4 fee'c of cover, but there must be at
least 18 inches of soil cover even though insulation is used. The
solid pipe extending from tile septic tank or lift statioa to the
drainfield shall also have 4 feet of cover or an equivalent layer of
insulation to prevent freezing of the line.
8.6 If insulation is not necessary, the gravel shall be covered with a
layer of nonwoven engineering fabric.
8.7
It is recommended that the area excavated in tile vicinity of the
drainfield shall be planted with a white clover, red rescue mix and
Kentucky blue grass.
4.0 INSPECTIONS
4.1
A minimum of three inspectious are required for installation of the
trench. The first inspection will be of the excavation to verify
that the installation will be in-the proper soil.
4.2 Tile secoud inspection wilt be after placement of the gravel, monitor
standpipe(a) and disiribution pipe to verify proper instaliation
before backfill.
4.3 The third inspection shall be after the drainfield is backfilled and
the ground graded.
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~'~--~ ~f~/~ DATE PER~
LEGAL DESCRIPTION: '"~'//Y 4~ ?
TownShip, Range, Section:
SLOPE
/Fo
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
S
'L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water After / ~'~'~b ~
Monitoring? .~, ? Dote: ,
SITE PLAN
' Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE __ (mmutes/mch} PERC HOLE DIAMETER
TEST RUN BETWEEN __ FT AND
PERFORMED BY: Z, ~.~,~ I --"
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
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if/~ A P~T PLAN OF: i, PREPARED FOR: .,
ii · ' LoT I~ ~L~ .q ~u ~[ .........
~ i ~ ~.d on ~U~O datum. )~. DATE: ~ID
~, % ~. 314~S .~ ~A~ t shall be the r~ponsibility of the ~ der or ow~r to verify ~1-~
~": that the build ng ~tion s~wn m~ts oil subdivis~n
~a " ...... ...... ~ ~ ,.~ ~o.~.~ ~ 0~ ~i=.~. KARABELNIKOFF
~sslo. tt~}~~' SURVEYING
'5,
'~N~RoL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
S.EET.O / oF
CALCULATED BY Z, ~_,~ DATE
CHECKED BY DATE
SCALE
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..... :~ ~ ..... ~ .... : .... : ..: ..... : ; ............. ~ :: .... ~ .... ~ .... ~ : ~:-. ~: : : -~ ..... ~ ...... : ~ .......... ~ .......... i ............ : .... : .......... -?-'"~ ......
:'"' _: :. ....................
..... : ~ ..: : ........ ~. : : ~ ~, ...... ........ : ~: :~
~. ::: ...... .................... : : :~ ~ : : ~
PO O'~tlt 6-650
ANCHORAGE, ALASKA 99502-0650
(907) 264-4111
TONY KNOWLI'S.
MA YOR
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Permit ~: 840114
January 31, 1985
TO: Permit Applicant
SUBJECT: Lot 14 Block 9 Paradise Valley Subdivision
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1984.
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
and the yellow copy 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,
Keith E. Bandt, Supervisor
Environmental Engineering Program
KEB/ljw
enc: Copy of Permit
SWP/057
h!L1i'-,! _T C.: i F'!::~L. I T:'r' OF F:Ih!C:HORF:JGE
DE:F'F!F::TME!:',IT OF HE!::!!_TH FiNL-:: EI:!V]iIEiCINMEiNTFIL PROTEOTIOI:',!
82Fz1 I_ S'TI;:EET., F!b,IIi':HCIE~:.I:::IGE., FIK 99[5Eti
26.4.-.4.720
PEF:HtT NO:
E:,RTE I E;~I..JE[:I:
FIF:'PL I CFIhI'F:
RDDRES:S:
CONTRCT PHONE:
8 4. e :I. i 4
O,i~.,.,'Ei2:...' 8 4
F' f" E:O;:{ :.1..2~:~8
EFIGLE' E:. , E .':., FI!'::: 99577
SUB[:, ! ',,,' X S I ON: PFfRRD :[ SE
SEC"F Z ON: :I.:!. "['0i.,.!i'4
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FINL-:, I N C:OMF'L I Fib TH GN C :.'. t TEF.: t FI OF F'I:".-':F~:I','I I T.
! H:[LL F![:,Hr:'::F:E:: ]"C ILl.. ["tCFzl '.:J;TFfI'EE iF:' F!LFt'i'~;KF!/,~.r.:.,.:.:,..,~.mrz. r~ ]"4TE; FOR THE '-:;El' E:I::ICK
D i STI::INCES F:'lqPld"t F:IN'?' i..EI ........ ISTEP-!FiTEi~/D ! S,F'IiISFfl_ S'¢E;TEi"! OF"-': F'LIE',L. Z C':
:T,E:i-,.!EF~:FIGE '::;'/'STE.", ON THIS; OF: FIIi:'..I'FI~ :EI",!'T OR ~¢I['ZI"qRE:':' L.OT.
f LII",I[::'E:RSTFIN[:' TFIFIT ..... ':'
... iH,[ ....PERi IT IS ","FIi.Zf::' FOR/FI MFIHIMUH r'~F' '4. E:EDRCIOM$ FIND '
RN'T' ENLF!F.:GEHENT P.!!L.L. ~'c'-:~ '
, ,.: .' ,., I F I::!N
iF A LIFT S'i"RTIOI",I IS INSTFILLIEE:, Ii'-
THEN (i.':, FtN EZ.E{C':T'R!CRL. PERMI"r' FINE:,
I.,.tlL. L NOT 8E FIF'PF:OVEI;, !.,.tITHOUT RN ELE
ELECTRtCRL 1.,.!ORI< MUST E',E DONE FJh.' R LI(
Of,IFIL F:'EF.:H i T.
OI.iiVEP::E[.', EP?' MOR BUILDING 130E)ES.,
MI..IS]" E',E OBTFIINED.; ':12;' RS.;-BUILTS
3F:IL INSF'EE:TIOI"4 REF'OFi:T.~ FIND ,::7!:)'t"FIE
,tSEED ELECTF: :[ C: I FIN.
PERFORMED FOR:
LEGAL DESCRIPTION:
1
7
8
9
12
13
14
15
16
17
18
19
2O
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
OL
SLOPE
0
E
IF YES, AT WHAT
DEPTH?
DATE PEI~FORMED: ·
SOILS LOG
PERCOLATION
TEST
,.
~ Depth to / Net
Reading Date ~ Ti m ~s..~,~ Net~
Time .~ter / Drop
PERCOLATION RATE 5
TEST RUN BETWEEN :~ Y~"
72-008 {6/79~ '
CERTIFIED BY:
ninutes/inch)
, FT AND ~ FT
Parcel I.D. #
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
- ~-/ '"'/ --~) ~- NAA# ~,~::~c'~'''-~L~'~J\-'~
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
prOperty owner
Mailing address.
Lending agency
Mailing address
Day phone
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
3
Public water
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
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.
S & S ENGINEERING
Name of Firm 170_~4 "_*_¢,, m,,,.. ~ ,,,~,. ~,,~,~ ~,,. 704 Phone ~ c'i ¢'/- ~L 9 7~
Eagle River, Alaska 99577
Ad d tess
Engineer's signature '?~/' ~ M~/~---- Date '7/& ¢/¢' ?
6. DH~NATURE
k' Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
/
Date '~/~ ~/~7
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.
72-025 (Rev. 1/91) Back MOA ~1
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
JUL ~ 8
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Legal Description: ZOT- t/-/ ~-o ¢~. ~
A. WELL DATA
ParcelI.D.: Otto - /-//~/ -O D..
Well type ~4,
Log present ON)
Total depth 6¢
Sanitary seal ~/N)
If A, B, or C, attach ADEC letter. ADEC water system number
n~
7,4 ~.~/~¢) Date completed
Cased to ~ $ ~/ / ~''
Casing height (above ground)
Wires properly protected (~/N)
I
t/4; J'
FROM WELL LOG AT iNSPECTION
Date of test / S' 7 /
u/A-
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform O
Nitrate ~ ' / Other bacteria
$ & S ENGINEERING
Date of sample: '7 //~ ~' / cl 7 Collected by: ',7~34 -~&~jle ~;~,~r J. gep Road ~o, 204
Date installed / 0//~/~ ~
~' Tank size ) '~' 5"'0 Number of Compartments "% C eanouts t~/N)__
Foundation cleanout (~)/N) ¥~ J Depression (Y~ ,,~ a High water alarm (Y~.
Date of P0',mPiflg ./_4. :' r. :. Pumper
C, ABSORPTION' FIELD DATA r., '
Leng,th ~"O Width
EffectiVe absorption area_
Date of adequ~:cyteSt .~v ~/~ ~ Results (Pass/Fail) For
in absorption field before test (in.)~ ~~r added (in.):
Fluid
depth
Fluid depth. (ins) Minute~~. Absorption rate = .g.p.d.
Pero~hs) (Y/N) If yes, give date
g.p.m.
Soil rating (g.p.d./ft~ or~I '( $* O System type
~' Gravel thickness below pipe ! Total depth
~r2- Monitoring Tube present &N) YgJ' Depression over field
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" I~~evel at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ! o
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
Property line Absorption field
Water main/service line /D .-/- Surface water/drainage / ~O /,f Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line /o ¢- BUilding foundation fo --/ Water main/service line
Surface water / 88/,.O'--
Driveway, parking/vehicle storage area
Curtain drain N a ,~ ¢_ ~ ~" ~ ~,~ r¢ Wells on adjacent lots ) ~ 0
F. ENGINEER'S CERTIFICATION
/¢o '+-
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA ~uideline, s in effect on this date.
Signature
Engineer's Name
Date '7 /~ ',~ / R ?
HAA Fee $ ~
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
CTS~E ~vironme~ta! Services Inc.
Client PO#
CT&E Ref.# 97397600~ Printed Date/Time 07/25197 08:22
Client Name S & S Engineeri~g Collected Date/Time 07/22/97 11:15
Project Name/// N/A ReCeived Date/Time 07/2Z/97 12:45
Client Sample ID L 14, B9 paradise Valley Technical Director: Stephen C, Ede
Matrix Drinkiog Water n · ~
Ordered By ~nmuu~ ..... 0 R~leased By
Un, tS
~ 2.10 0.500 mg/L $M18 4500-flO3F 10 max
~itrate-N cot/lOO~L SM18 9ZZg8
Altowable pre~ Anaty$(s
Oa:e Ioit
Method Limits Oat__e _.
071ZZ/97 JRJ
07/ZZ/97 T~