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Home My WebLink AboutROLLING HILLS ESTATES BLK D LT 4 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 Waste~wate. r Disposal System and/or Well Inspection Report Permit Number: ,.~,-/*-~}~;~c'J'O' PID Number: Name:~1 t114~ P, ~[~ WastewaterSystem: ~New ~Upgrade ~.d~: 53 /~ ~. ~5 ~v~ ABSORPTION FIELD No. of BeSoms; Phone: ~ ~ j~ ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other BIockALlivisiONon ~ Total Depth fr~ ~riginal grade: LEG DESCRIPTI so, Rating: · ~ GPD/Sq. Ft. Lot: ,, DC: Subd''' ~ ~epth to pipe bottom from original grade: Gravel depth beneath pipe Township: Range: ~ Section: Fill added above original grade: Gravel length: I I I D New ~ Upgra~~ Graveld~:~~~ WELL: Number of lines: Distance between fines: Classification (Private, A,B,C): T~ Cased To: Total absorption area: Pipe material: / ~ Drilled: Ft. Ft. I,~ I ~ SQ. Ft. Date installed: Driller: Static Water Level: Installer: ~Yield~ GPM Pump Set at: Ft. Casing Height Above Ground:Ft. ' TAN K SEPARATION DISTANCES ~septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding 3ublic/Privete Manufacturer: Capacity in gallons: From Tank Field Station Tank ~ewer Lines ~¢~ Material: Number of Compartments: we,,++ Surface , Water JOe+ IO~+ ~ ~t¢~+ LIFT STATION Lot~ ~ Line BO4 JO* leO+ Size in gallons: Manufacturer: "Pump on" level at: " " : water alarm at: Foundation ~O 5~~ }~ ~ High Curtain ~Electrical Inspections performed by: Remarks: ~ ~mK ( ~zS~) BENCH MARK ~J ~ Fl J~/ ~ I~ ~ ~ Location and Description: I ' Assumed Elevation: Inspections performed by: ~ ~ ~ Dates: 1st Department of Health and Human Services approval 72-013 (1/91) MOA 25 Permit No. 5INI~/~10 1 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:545-zW44 On-Site Wastewater Disposal System end jar Well Inspection Report Legal Description Lot 4 Block D Rolling Hills PID No: 01107~7..8 SEPTIC W, 75 rd AVE XiSTiN~XI TING 5 SEPTIC EXISTING WELL Q SITE MAP 1"=100' EXISTING WELL Q ~LA I SW HOUSE CORNER ELEV=IO0'O I Bbl B SE HOUSE CORNER BM A BM B IH IH ASB U LT ~/29/~ Permit_ No. ~I~I~ Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:345-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description Lot 4 Block D Rolling Hills PID No:~ ~ ' DECK PROPOSED EXISTING SURFACE~ = NOTES ~ ] ~ ELEV:92,5 1. CONT~CTOR TO VERIFY MiN. SQ. FOOTAGE 2. CAUTION SHALL BE TAKEN TO MINIMIZE REMOVAL OF EXISTING VEG~ATION OUTSIDE OF SEPTIC AREAS. 3, D~STURBED AR~ SHALL BE SEEDED TO 4, NO WELLS. SURFACE WATER. O~ CURTAIN EL~=86.B B.P. DRAINS WITHIN ~00 ~ OF NEW ELD=86,3 L ~ 5. SYSTEM TO BE INSTALLED A MINIMUM ~.~~2o ' ' , ~. ~ ~ ?'~, ~ y.. ~ '?'. '.~¢.~ OF I0 FE~ FROM PROPER~ LINE. ~. ALL CONSTRUCTION SHALL CONFORM TO M.O*A. ~ I. .I & O.H,H.S. STANDARD SPECIFICATIONS. DONE IN THE SPRING OF 1993, ABSORPTION SYSTEM CROSS SECTION 1"=6' .~, ~ x ~ ... ~ ... ~,~ ~ ~ .. ....~ ~......... tt.e~ -~.. ......... .' ABSORPTION SYSTEk p,n&.pH HORIZ 1"=20' VERTICAL '~6' ~,~' 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:SW920410 DESIGN ENGINEER:ARCTIC SLOPE CONSULTING GROUP OWNER NAME:FIELDING WILLIAM D & OWNER ADDRESS:5316 W 73RD AVE ANCHORAGE, ALASKA 99502 DATE ISSUED: 12/09/92 EXPIRATION DATE:12/09/93 PARCEL ID:01107228 LEGAL DESCRIPTION: ROLLING HILLS ESTATES BLK LT 4 LOT SIZE: 50000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 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 (18AACS0). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: F ENGINEERS · ARCHITECTS · SCIENTISTS · SURVEYORS December 2, 1992 Municipality of Anchorage Dept. of Health and Human Services 825 L Street Anchorage, AK 99501 Re: Septic System Approval Lot 4, Block D, Rolling Hills Est. Attached is the permit application for a septic system upgrade on the above referenced lot. Below is a narrative of probable impacts to adjacent properties. 1. .Wells - There are no existing wells within 100 feet of the proposed new septic system. Wastewater System - No existing on-site wastewater systems are located within 100 feet of the proposed well on this lot. The proposed well/septic system will not adversely affect the development of system on the adjacent lots. Reserved Space - Additional area is available to the north east of the proposed field. Separation distances to adjacent wells will be maintained if the future field is developed. Drainage - The lot gradually slopes to the south. Positive drainage away from the field will be maintained. No concentrated surface water will be directed toward the field and no existing streams are within 100 feet of the proposed field. The installation of this on-site system will have no adverse impacts to adjacent well or septic systems. Very truly yours, CSM:MLT: 1110-0026.048 KEVI~Llfl'iEBN ER SEN/OR CIVIL ENGINEERING TECHNICIAN 301 ARCTIC SLOPE AVE., SUJTE 200· ANCHORAGE, AK 99518-3035 (907) 349-5148 / (907) 267-6250 · FAX (907) 349-4213 301 ARCTIC SLOPE AVENUE, SUITE 200 · ANCHORAGE, ALASKA 99518-3035 ASCG Calculations System Calculations for Lot 4 Block D Rolling Hills Est. 01-Dec-92 Page 1 of 1 Tank Size l Z.. 5 43 ~j a I. Existing Tank.~o ~ ~|~-5~_'~1~d ' ~./1~ ~n Absorption Field Sizing Using an acceptance rate of 0.4 gal/SF/day and a daily load for 4 bedrooms of 600 gal/day. Req'd Absorption Area -- 600 gpd / 0.4 gpd per SF -- 1500 SF System Dimensions 63.0' X 24.0' = 1512.0 SF The laterals are to be spaced 6.0' apart and 3.0' from edge of the bed. Permit No. 1 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 Anchorage, Alaska 99519-6650 Telephone:345-¥744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description Lot 4 Block D Rolling Hills PID No: W. 75 rd AVE XtSTiN~XI TInG /ELL ~VEI~L ~ , BM A BM B SITE MAP 1"=100' 5 ]SEPTIO Permit No. Page 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box lg6650 Anchorage, Alaska gg51g-6650 Telephone:S43-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal DescripUon Lot 4 Block D Rolling Hills PID No: PROPOSED EXISTING SURFACE~ i= NOTES F .... ~/ 1, CONT~CTOR TO VERI~ MIN, SQ. FOOTAGE PRIOR TO P~CING TOPSOIL, 2. CAUTION SHALL BE TAKEN TO MINIMIZE REMOVAL OF EXISTING ~G~ATION OUTSIDE ~. OF SEPTIC AREAS, 3, DISTURBED AR~ SHALL BE SEEDED TO ~, NO WELLS, SURFACE WATER, OR CURTAIN DRAINS WITHIN 100 ~ OF NEW ~ ABSORPTION SYSTEM. -- ~}?'~?~ X' ;;Z;Z Z Z' ZZZ'Z Z'~Z 'Z ' ~ Z~Z];.ZZaZ~Z!"'~ 5. SYSTEM TO BE INSTALLED A MINIMUM 6. ALL CONSTRUCTION SHALL CONFORM TO M.O.A, I ..... ~ * D.H,H.S, STANDARD SPECIFICATIONS. ABSORPTION SYSTEM CROSS SECTION PROPOSED ASCG SOH$ LOG- PERCOLATION TEST PERFO~ FOR: ACREAGE SYglEM~, INC. LEOAL DF. SCRIP~ON: LOT 4 BLOCK D ROLLING EST. TWSHP, RNG, SCTN SW I/4,SEC 3,T.12N.,R.4W SM DATE PERFORMP. lr3: 10NOV92 DEPTH TEST HOLE 1 SLOPE DESCRIPTION -- BM [ HOUSE CORNERA SW OROANICBM 8 SE HOUSE CORNER FILL eM A BM B TH TN IH SANDY /SILT PERK TE3T -- BOTTOM HOLE WAS GROUND WATER ENCOUN2EREU? N IF YES, AT WHAT DEFr~ DEPTH TO WATER AFTER MONITORING? - SITE PLAN DATE: 19NOV92 GROSS NET DEPTH TO NET NO. DATE TIME TIME WATER DROP 1 I 0NE]V92 17:10 0 rain 7'-0,0' - 2 I7, 15 5 mia 7'-0.8" 0,8" 3 17:20 10 mln 7'-0,6" 0,6" 4 i7:25 15 mln 7'-0,2" 0,3" 5 17:30 20 min 7'-0,2" 0,3" 6 17:35 25 min 7 '-0,2" 0,3" 7 17,40 30 min 7'-0,2" 0,3" 10 .... PERCOLATION RATE 20.0 (M]N/INCI-I) PERC HOLE DIAMLrrER 6.0' TEST RUN BETWEEN 7-0.0- FT AND 7-6.0' FI' COMMENTS: PERC HOLF~ WERE PRE-SOAKED FOR FOUR HOURS PRIOR TO TESTING PERFO~ BY: ERIC GROPP / CAREY MEYER CERTIFY THAT THIS TEST WAS PERFO~ IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDFI.INE~ IN EFFE(Tr ON THIS DATE: 10NOV92 ASCG SOIl51 LOG - Pi RCOIATION TEST LEGAL DESCRIPYION: LOT 4 BLOCK D ROI.LING HIIJ EST. TWSHP, RNG, SCTN SW 1/4,SEC 3~T.12N. J~W SM Al(. DATE PERFORMED: 10NOV92 0- 1-- 2- 3- DIAVI'I-I on.r) TEST HOLE 2 DESCRIPTION BMA ISW HOUSE CORNER __ ORGANICBu B[SE HOUSE CORNER BM A BM B TH 1~- 'CH 2 -- SANDY SILT TH 3 TH 4, -- SANDY SI~ ~C HO~ BOTTOM WAS GROUND WATER ENCOUNTERRr~ N IF YES, AT WHAT DEPTH? DEPTH TO WATER AFl'ER MONITORING? - SITE PLAN GROK~ NET DEPTH TO ]qET NO. DATE TIME TIME WATER DROP 1 i 0NDV92 I7:13 0 m;n 8'-0,0" _ 2 17:18 5 mln 8'-0.3' 0.3" 3 17:23 10 mln 8'-0,3" 0,3" 4 17:88 i5 min 8'-0,2" 0.2" 5 17:33 20 min 8'-0,~" 0,2" 6 17:38 25 min 8'-0,;::>'' 0.2" 7 17~43 30 m;n 8'-0.~' 0,~" 10 .... PERCOLATION RATE 26.7 (lVl]N/INCH) PERC HOLE DIAMETEA 6.0' TEST RUN BETWEEN g-Off FI AND 8'--6.0" FI COMMENTS: PERC HOI.Fg ~ PRE-SOAKED FOR FOUR HOURS PRIOR TO TESTING PERFORMED BY: EPIC OROPP / CAREY MEYER CERTIFY THAT THIS TEST WAS PERFO~ IN ACCORDANCE WITH Al,l, STATE AND MUNICIPAL GUIDF, IJNF_S ]lq EFFECT ON THIS DATE: 10NOV92 ASCG SOILS LOG- PERFORMED FOR: LF.~AL DESCR1FrION: TWSI-IP, RNG, SCTN DATE PERFORMED: PERCOLATION TEST ACREAGE SYSTEMS, INC. LOT 4 BLOCK D RO! JJrNG I-m .I.~ SW I/4,SEC 3,T.12N.,R~W SM AK. 10NOV92 6- 8- 9- 10- Il- 12- DEPTH TEST HOLE 3 DESCRIPTION BMAB sESW HOUSE CORNER BM HOUSE CORNER BM A BM B IH IH TH SLOPE ~LT WAS GROUND WATER ENCOUNTERED?. N IF YES, AT WHAT DEPTH? DEPTH TO WATER AFTER MONITORING? DATE: 19NOV92 SITE PL,~ 14- 15- 16- 17- 18- HOLE BOTrOM GRO~ NET DEPTH TO NET NO. DATE TIME TIME WATER DROP 1 1 0NE]V92 - 0 m; n - l0 - - - PERCOLATION RATE ERR (MIN/INCH) PERC HOLE DIAMETER TEST RUN BETWEEN - Fr AND - Fr COMMENTS: PERC HOLES WERE PRE-SOAKED FOR FOUR HOURS PRIOR TO TESTING PERFORMED BY: ERIC GROPP / CAREY MEYER CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNI~ GUIDF, LINES IN E, FFF. C~ ON THIS DATE: 10NOV92 ASCG SOILS LOG - PERCOLATION TEST PERFOP, MI:~ FOR: ACREAGE SYSTEMS, INC. LEGAL DESCRIFrION: LOT 4 BLOCK D ROLLING HlI.l.q TWSHP, RNO, 8CTN SW 1/43F. C 3,T.12N. Rq'W SM AK. DATE PERFORMED: 10NOV92 TEST HOLE 4 SLOPE DESCRIPTION BM A [SW HOUSE CORNER ORGAF0~I e/SE HOUSE CORNER BM A BM B IH SILT TH TH HOLE, BO'rlDM WAS GROUND WATER ENCOUKIERED? N IF YES, AT WHAT DEPTH? DEPTH TO WATER AFFER MONITORING? SITE PLAN DATE: 19NOV92 GROSS NET DEPTH TO NET NO. DATE TIME TIME WATER DROP 1 10N[3VgP - 0 m ln - - 3 .... 10 - - - PERCOLATION RATE ERR (MIN/INCH) PERC HOLE DIAIVlETER TEST RUN B~EN - Fl' AND - FT COMMENTS: PERC HOLES WERE PRE-SOAKED FOR FOUR HOURS PRIOR TO TES'riNG PERFORMED BY: ERIC OROPP / CARRY MEYER CERTIFY THAT THIS TES~ WAS PERFORMF~ IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDIEIJNES IN EFFECT ON THIS DATE: 10NOV92 i~ MUNICIPALITY OF ANCHORAGE ¢ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 254-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl. INSPECTION REPORT NA/~E IP_H°NE / KEW U~J 1~1 NG ADDR ES~.. - '' DISTANCETO:~~ Materia, ~ ~ Manufacturer ~~ Liquid No. of compare'ts depth ~ ~ Liq, c~t~gallons IF HOMEMADE: Inside length Widt ~ DISTANCE TO: Well ~OO f' ~ Foundation~ / ~ Nearest Iotlin~¢~ PERMITNO~ ~o. of I'nes/ ken,th ~hfiine To'al le~t~l'nes Trench ~h Distance Bet~~~ --~ inchas ~ ~ Top of tile to finish ~rade __ ~ ~ Material beneath tile ~ ~ ~ lotal effectiw absorption area ~ Type of crib ~ ~ ~~ Well B~l~g f~n~i~ N~r~t ~ ~lass Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MA~[RIALS ~ /~ 801L TEST ~ATI ~ INSTALLER i · t A DATE LEGAL PERMIT NO. AF'PLI_.HNT ANNA FIELD. lNG DEPARTMENT O~ HEALTH AND EN',,,'IRONMENT~~ 3~ECTiON 825 "L'" STREET., ANCHORAGE., AK. ~501 ~,4-4, ~0 Old. LOC:AT I ON LEGAL TYPE OF S ' 'cF '' ' .-. -OIL HB-,JRFTIUN SYSTEM I=,. TRENCH LOT SIZE MAXIMUM NLMBER OF EEDROOM=, = 4 SOIL RATING (SQ FT,.'BR)= M~ ~'- IS --ABSORPTION : THE REQI.IIRED :,I~E OF THE _,OIL z--;~ ~ [:~E~TH= ~ LE[-~GTH= .=0000 SQLIRRE FEET ~t~ 6RR"..."EL DEPTH= 4 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND AND TNE BOTTOM OF THE EXCAVATION (IN FEET). THERE IS NO SET WIDTH FO~ TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAYEL BETWEEN THE OUTFALL PIPE AND THE BOTTOM OF THE E~CBVATION (IN FEET). F-,:E~;.~LI ~r RED, SEPT ][ ,-: TRI'-.II<: S I ZE= 2L25LZ-! L3RLLC, I'4S 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. T l..-I,D ~:~-':' -':" ! I%ISP Eg-t T I ,Df-tS FIRE RE,_~LI I REI]~ BACKFILLING OF ANY _,~_,TEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS DEPARTMENT WILL BE .... SI IB,IEF:T TO FRU_,ECUTION.' "---" · MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SENRGE 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 R PRIYRTE 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 THE DEPARTMENT WITHIN ~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. F'ER~,I I T E~-::F' I F-:E="]. [)EE:Er. IBER _---::.1.. I CERTIFY THAT :L: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPRLIT'T' OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. ~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. R~ I CANT RNNR F I ELD I ~ ~ x ...., I :,=,UE[. AT V4. 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 276-2224 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST PEREORUEDFOR: g(/'LL~^H 'D LEGAL DESCRIPTION: 6 7 8 9 10 11 12 13 14- 15- 17- 18L 19"-- 20' ~ L-OC.L~ D H I-'l I:1 L.L ~o~ COMMENTS PERFORMED BY: SLOPE SITE PLAN ENCOUNTERED? J\l C) IF YES, AT WHAT DEPTH? P~---'l-', .... t'-'I i i ~ t Gross ~j,jV~ Net Depth to Net Reading Date Time Time Water Drop t:/¢ ~- /o i~(¢) 7~/ ¢:~ ~7~- ~o /~ ~7~ PERCOLATION RATE TEST RUN BETWEEN I-/ CERTIFIED BY: (minutes/inch) BOX ~3(~9~ S?AR I~lOIJ?l~ A At~CHORAOI~, /~lkLASKA 9~)~0~ SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF DRILLED AT THE RATE OF_ ~7_0.00 PER FOOT. PROPERTY OWNER ~- LOCATION OF WELL SITe DRILLEI B~J'~ ~ Coog oZ ged. L: $2470,00 CodZ o~ Ued. L Sead.: $22,50 COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING. WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF//'~' ~''-- --~ ,~4*,.~2e&U '~ THANK YOU VERY MUCH. DATE_ S¢i~c 7~o,~, 1~]80 BERN; US"OF RAMPART DRILLING WORKS Parcel I.D. # 1. 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 GENERAL INFORMATION Complete legal description /6 Location (site address or directions) .~'~ / (,. iv'. Property owner I~v/~l(/,'~"/ ~ . 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: ,-¢ .i TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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. Name of Firm /~ .~ C ~ l~c., Phone '2.-~7 -~-z~ E) Address ~l A~t~ ~]o~ ~¢~, ~o~+~Z~ ~, ~ ~1~ Engineer's signature ~ Date ~_5/'z~/ 6. D.HI~lS SIGNATURE /fi~'~ Approved for Disapproved. Gonditional approval for bedrooms. bedrooms, with the following stipulations: By: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the Professional engineer's work. 72-O25 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /---¢~'/-- z/~.~Z, /'~o//t,~J~' ~//"~5 ~----L"-~'TL..Parcel I.D. ~ j ~D ~ ~ A. WELL DATA Well type ~¢~ d~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) X/ Date completed -~ ~ /~Driller ~F~ Totaldepth I ~ 4:~' Sanitary seal (Y/N) b~),~ Casedto~ [~o~ ~,~ - ~ FROM WELL LOG Casing height Wires properly protected (Y/N) Y~ g.p.m. AT INSPECTION {~. O g.p.m. < Date of test Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: .+. Septic/holding tank on lot Absorption field on lot I~,~ Public sewer main Public sewer service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: /. Coliform (,J d Nitrate ~' Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Cleanouts (Y/N) '~ Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping /",/~- ~.~ ) Compartments Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I I ~ -j- Onadjacentlots To property line ,~'0''P Absorption field Surface water/drainage Foundation__ Water main/service line ~ 42 72-0~6 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level ~ Meets MOA electrical code~ SEPARATION DISTA~FROM LIFT STATION TO: Well on lot ./ On adjacent lots Date installed IS-ZZ~ I~."Z.~'~.. Soil rating Manufacturer ~ Man.N) "Pump off" level at Cycles tested Surface water //Width , System type ~'-D ~ ~/' ~'""-G ravel thickness Length Total absorption area Depression over field (Y/N) ~'--Jo Results (pass/fail) ~IE~ Peroxide treatment (past 12 months) (Y/N) Cleanouts present (Y/N) Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot I ~ O To building foundation On adjacent lots I ~ Surface water /~ ~ Curtain drain [ ~ · H- -P On adjacent lots I ~.4Z) Property line ] 1 -P' To existing or abandoned system on lot I ~"-~' Cutbank ) ~-O Water main/service line Driveway, parking/vehicle storage area G o'+ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer's Na HAA Fee $ Date of Payment Receipt Number Waiver Fee: $ Date of Payment Receipt Number e>ARCTIC SLOPE CONSULTING GROUP, INC. WELL LOG DATE: LOCATION: Subdivision: Client's Name: Address: Block: / v } Initial Reading on Meter: DRAW TIME GPM GALLONS GALLONS FIELD MONITOR METER DOWN VOLUME TOTAL LEVEL READING Production Rate: ~, ~ GPM 24-Hour Capacity Gallons Arctic Slope Consulting Group 301 Danner Avenue, Suite 200 Anchorage AK 99518 Attn: Kevfn ~. Our Lab #: Location/Project: Your Sample ID: Sample Matrix: comments: NORTHERN TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-3125 2505 FAIRBANKS STREET ANCHORAGE, ALASKA 99503 (907) 277-8378" FAX 274-9645 Report Date: 03/03/93 Date Arrived: 02/25/93 Date Sampled: 02/25/93 Time Sampled: 1604 Collected By: KL A122445 Lot 4,Blk D,Rolling Hills Fielding Outside Hose Bib Water * Definitions * B = Below Regulatory Min. H = Above Regulatory Max. E = Estimated Value M = Matrix Interference D = Lost to Dilution MDL = Method Detection Limit Date Date Lab Units Result * MDL Prepared Analyze Number Method Parameter <MDL 0.1 03/02/9~ A122445 EPA 353.3 Nitrate-N mg/1 Microbiology Supervisor DA'FL RECEIVED '~ INSPECTION APPOINT)~ENIS' J ~I~ , ~4~L~..)~ ~.'~--y~ ~/~ TIME TIME TIME . ~ , /I . INSPECTO ~ffiI~IP~LITY OF ~HO~G~ ~NICIPAUIY DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~EPT. OF I~,:',,~'1;! 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ~ L, ::TECTIOM ENVIRONMENTAL SANITATION DIVISION J~.~ Telephone 264-4720 A...OVA. A.. : DIRECTIONS: Complete ali parts on page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER. PHONE P~OPE~TY ~ESlDENT (If different from ~bove) PHONE 2. BUYER PHONE MAI LING ADD,ES8 3. LENDING INSTITUTION PHONE MAILING ADDRESS 4. REAL~OR/AGENT ~ PHONE I MAILING ADDRESS 5. LEGAL DESCRIPTION , STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS ~'~'S [] One [] Four INGLE FAMILY [] Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATF~R SU~.PPLY J~ INDIVIDUAL' [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. Awell log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM ~IN DIVI DUAL/ON-SITE'* [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] iNDIVI DUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: )~-.~"O If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER~.// . . ~ TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS [~'~/~PPROV ED FO R ,~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE BY .~.~,~ ' A chora e ANCHORAGE, ALASKA 99501 (907) 264~4111 GEORGE M, SULLIVAN, MAYOR DEPAFITMENT OF HEALTH AND ENVIRONMENTAL PROTECTION December 15, 1980 William/Anna Fielding 5316 West 73rd Avenue Anchorage, Alaska 99502 Subject: Lot 4 Block D Rolling Hills Estate Subdivision Approval for your individual sewer and water facilities cannot be granted until the following items have been completed: [ J~i ) The water analysis report needs to be delivered to this office from the Chem Lab, 5633 B Street, for our 'review.. ) A well log submitted to this office for review. If there are any further questions, please call this office at 264-4720. The well seal on the well needs to be tightened so that it. is water tight. This will need to be reinspected by this office. Sincerely, Robert C. Pratt, R.S Associate Specialist RCP/ljw CC: First National Bank of Anchorage Mortgage Loan Division Post Office Box 720 99510