HomeMy WebLinkAboutSCIMITAR #1 BLK 3 LT 2Scimitar #1
Block 3
Lot 2
#051-132-38
Municipality of Anchorage p~g.. 1 of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O, Bo~ 196650 · Anchorage, Alaska 99519-8650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well ~n~pecfion Report
WELL:
PermitNumben SW980068
MM&M Construction
P.O. Box 670495 Chug]ak, AK
688 - 1 236 J No. o~
LEGAL DESCRIPTION
SuDc~iYu1~on:
8~ 3 Scimitar No. 1
Range: Se~lon:
~New ~ U~gra~e
To~i Oeo~n: ~se~ To;
300 ~. 132
PIDNumber. 051 -1 3-238
Wastewater System: ~ New [] Upg~de
ABSORPTION F]ELD
tn Deep Trench k~$hallow Trench D Be,~ rn Mouna ri Other
I . 2 OP~/S~:. ~t. 7 -8 '
Loc 2 D~m ~ m~ ~o~m lmm ~
3 i ~t.
~1[ aooe~ ao~ ong~ ~u~ G~I lengm:
2'-3' ~.
Classificmuon (Pm,ate, A.B.C'c
Private
Sullivan
I. 5 GPM Pumg Se~ at' FL
50
inspections performed bF. A. Harala
Remarks:
:~XSepti¢ ~ Holding :3 S.T.= P.
~-~ ~ Anchorage Tank
1 , 000
N/A ~'"~ Steel
~/A LI~ STAT]ON '
N/A S~e in gallo~
L~/A 'PumDon"l~ 'Pumpo~
BENOH MARK
Bottom of Siding
Foun0ation > 5 ' I > 10 ' N/'A
Lot [ >5' >10' N/A
Line ] .
Well I >10011 >100' I N/A
Su~aC~water "I>~00'' >100'
N/A
N/A
5/13/98 122 ~ . MM&M Contracting
2 ;L TANK
SEPARATION DISTANCES
~/3/98
Dates: 1st 6/3/98
2nd 6/3/98
Department of Health and Huma~ Services approval
Reviewed and approved by: "~~/C ~/~) Date: ;g)'/d'~/~
5 ;~- 1 N/A ;t~
?omi ao;orm,on area; Pipe material:
500 so.;~. ASTM D3034 PVC
MunicipziiV of A,nchorage ~e 3 :t,3
DEPARTMENT OF HF_AL-H AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Bo.~ 196~250 · Anchorace, Alaska 9951~8850 · Telephone: 343-4744
On-Site Wastewater DispoSal System and/or Well :b'mpe. ction Report
P~._m~_it__N._umben. SW980068 PIID Number:. 051 -13-238
M1
3-BR
HOUSe
C4
TH3
/ /
C2
S2
/
A
53.2
53.2
B
17.
13.
56.
56.
64.4
57.7
PLAN AS-BUILT
SCALE 1" = 30'
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Bo:~ 196650 · Anchorage, Alaska 9951~8850 · Telephone: 343--~T44
On-Site Wastewater Disposal System and/or Well :b'us~e. c~on Repo~
~rmitNumben~SSW980068 PlONumben 051-13-238
page
7//v..'. /// '.-'.'~///,..'./// ,~.'.///~"V £/ <~/~7 .~.'.-~T'I
Geotextile Fabric
Septic Rock
Eh~ 1S f10t78)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: /.~.1"' Z..I ~t...~C..44,.. ~
Township, Range, Section:
1
2
4
5
6
?
8
9
I0
11
12-
13
14
15
16
17
18,
19
· 20
SLOPE
WA~GROUND WATER
ENCOUNTERED?
IF YF..~, AT WHAT
D~PTH7
Reading I Date
PERCOLATION RATE
%:
SITE PLAN
{mmu~es/mcl~) PERC HOLE DIAMETER
TEST RU.~N BETWEEN ~f' ~//' FT AND
Net
COMMENTS
~ -- ' HAT THIS TEST WAS PERFORMED
IN
FROM : MMM CONTRACTING PHONE NO. : 6881238 Jul. 17 1998 07:42AM P1
ADDRESS
, .....'.; :.;: ; .::.;: .... , .: .. ;. :' ,,..:.,:.,:;.,, ,.':
Lleer.Type' .~ : :'. :'..,' .:'¥::..: .......... . ',:: .......
,.... . ,: , · . · .,,. . : · . . . ., .:::..,.; .;;..?:~,;r. 2 ';':'''':' :
' Pump Intake. D,pth:
pu~p Size .' .~hp' Brand:[
.Well DiSinfected Upon Com[
~etho'd of Disinfection: ~'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW980068
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:WATSJOLD STANLEY J & HEATHER R
OWNER ADDRESS:
DATE ISSUED: 4/21/98
EXPIRATION DATE: 4/21/99
PARCEL ID:05113238
LEGAL DESCRIPTION:
SCIMITAR #1 BLK 3 LT
LOT SIZE: 39789 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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:
RECEIVED BY: ~/~-~t ~~'~
ISSUED
DATE:
April 4, 1998
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 2, Block 3, Scimitar Subdivision No. ~ \
Septic System Design
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
We hereby apply for a permit to construct a well and an onsite septic
system on Lot 2, Block 3, Scimitar Subdivision No. ¢.1 The attached site
plan and backup documentation identify the size and location of the well
and new septic system to serve the three bedroom home to be constructed
on the lot. The 100' protective radius for the well is also shown on the
plan.
The surface of the lot slopes gently from east to west at slopes
approaching 4%. The surface is fairly flat from south to north. A testhole
placed in the area of the proposed septic system revealed a silty gravel
which percolated at a rate of 15 minutes per inch. The second testhole
revealed nearly identical material with a similar percoation rate. We
have designed a shallow 5' wide absorption trench to absorb the septic
effluent which will be generated by the three bedroom home to be
constructed on the lot.
No conflicts exist between the new septic system and the protective radii
of adjacent wells. Similarly, no conflicts exist between the new well and
the separation distance from septic systems in the area. The only close
system is to the south and is more than 100' from the proposed well. We
are confident the systems can be successfully constructed on the lot at
the locations indicated.
Lot 2, Block 3, Scimitar Subdivision No. ~ \
April 4, 1998
Page Two
If the system is constructed as designed the following statements apply:
The system, if constructed as designed, will have no adverse impact
on the wells in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
The system, if constructed as designed, will have no adverse
impact on reserved space, either surface or subsurface, on any lots
located in the area.
The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern will
be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
2]0.00 {7Q-(,9) ~._ Ns?59'od:w 710 ~,Q (Tn-~n)
~645.~5 474-1~0)
[A51 2640 O0 GLO(I?)
.~,,~,.oo-.. ~,,.~ (,~-~ Avenue
N89'59'OO"W 42,~.11
THIS PROJECT
/0
43,3'1
/ /
2'.
50 ~0"
/
/
210 O0
205 O0
165.00 120.45
175 00
/
/
12 O1
-,.,
/
/
86.58
I
/ I
/
/
/
/
AREA MAP_
SCALE I" = 100'
/
/
/
~,_'-~
/
LOT 2, BLOCK 3,- SCIMITAR NO. 3/
Altern,
Site
Gallon
Tank
x 5' Wide
.ive De
)tion
SITE PLAN
SCALE 1" : 50'
LOT 2,
DESIGN FACTORS:
Three Bedroom Home
Perc. Rate: 15 Min,/Inch
Application Rate: .8 GPD/SF
BLOCK 3, SCIMITAR SUBDIVISION
NO. 8\
SYSTEM REQUIREMENTS:
5' Wide Trench System
1,000 Gellon Septic Tank
4' Dreinfield Rock
3 Bedrooms X 150 GPD / .8 GPD/SF = 562,5 SF of Absorption Area
562,5 SF/5 LF (Width) X .5 (Red, Factor) = 56,25 LF Trench Length
Therefore: Construct a 5' Wide Absorption Trench System With One
Lateral 60' in Length with 4' of Drainfield Rock Beneath the Lateral.
Distribution Pipe in Trench Placed at 3,0' -Below the Original Ground
Surface,
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
NOTE:
Grade Area Over Trench to Drain Away,
Minimum 3' of Cover over Septic System,
Minimum 4' Separation From Groundwater,
Minimum 10' Separation From Lot Line,
~EGAL. DE~IFTION:
DEPARTMENT OF HEALTH & HUMAN SERVICES
625 "L' Street. Anchorage, AJaska 995D2-DSS0
SOILS LOG -- PERCOLATION TEST
Stanley Watsjolds
Lot 2, Block 3
2
3
4
6
?
1i
14
16
17
19
Scimitar No..JJ~
WAS GROUND WATER
ENCOUNTERED?
SITE PLAN
IF Y'~ AT WHAT L
DE"TH7 O
P
E
PERFORMED ~y: ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
~ 'L' ~ Anchorage, Ataslca 995D2-OF, SD
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: Stanley
L~Ak D~RIP~I~N: Lot 2,
Watsjolds
Block 3
DA'T"EPER;
Township, Range, Se=ti=m'
.1
2
3
4
?
Scimitar No. ~
10
14
I7
'1~
&LITY OF AN~'g.)K,~Iz
T. OF HEALTH &
d~4[N [AL PROTECTION
RECEIV[D
by
A 8: 1, DRILLING CO IPANY
BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION
DATE - Started
PERMIT NUMBER
Ended
DEPTH OF WELL
STATIC LEVEL OF WATER Fl',
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
KIND OF FORMATION:
From _Ft. to Ft. __
From Ft. to Ft.
From Ft. to Ft.
From _Ft. to Ft.
From Ft. to__ Ft
From _Ft. to Ft.
From___ Ft. to Ft.
From_ Ft. to__ Ft.
From Ft. to Ft
From_ Ft. to Ft.
Frmn Ft. to__ Ft
From Ft. to__ FL
From Ft. to_ FI.
From _ Ft. to__ Ft
From _Ft. to___ Ft.
Front Ft. to Ft.
From Ft. to_ Ft
From__ Ft. to__Ft
From__ Ft. to .... Ft.
From _ _Ft. to. __Ft.
From _ Ft. to _Ft
From Ft. to -- Ft,
From Ft. to Ft.
From ._Ft. to_ Ft.
From_ Ft. to Ft.
From__Ft. to Ft.
From Ft. to_ Ft.
From _Ft. to_ Ft.
From Ft. to_ Ft
From Ft. to___ Ft
Frmn Ft. to Ft._
From .Ft. to Ft.
From Ft. to Ft.
From _Ft. to Ft
MISCL. INFORMATION:
DRILLER'S NAME
F'E:R r,1 :t: '1"
I I]:IEI:;CI' I F'T' THF:IT
::1.: I FIH FF:IHIL:I:FIF;~: klITH THE:
F'CI:~"I"FI E~'.," THE: r,'llJN: [:IF:'RI ]'T"r' OF:' I:::IN[:::H[)¢~'.F:I[:iEE.
2: I I.,.I]:I_.L ;I:N~STFII. J_ THE: .~ .'~;'T'E~ II",l FICCOI~:[:,¢~I'.,ICE: I.'.IZTH
I~F'F'L I CFII'.,IT I....E/E 151J1_ L I ',,,'FIN .....................
Municipality of Anchorage
O
et
Development Services Department
Building Safety Division
�•
•�,,
On -Site Water and Wastewater Program
4700 South Bragaw St.
❑
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING ✓1
Parcel I.D. 051.132.38 HAA # A140,ZD SD%
Expiration Date: % — q — d 3
1. GENERAL INFORMATION
Complete legal description Lot 2, Block 3, Scimitar Subdivision No. 0
Location (site address or directions) 19746 Tulwar Drive
Current Property owner(s) David Cole
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
P.O. Box 670312 Chugiak, AK 99567
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
Three 3
Day phone 688.9099
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
®
Individual On-site
ED
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSO also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. 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,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is(are) 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineerinq
Address P.O. Box 240773 Anchoraqe. AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
S. DSD SIGNATURE
L"*" Approved for L bedrooms.
Phone 522-7773
Date
-101112002 ,
y ..
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
\QP��t yl OF rAh,�yo
�• C '
Additional CommentsR'
ON-SITE
�_c• VJATEfiANO t
WASTEWATER
vRGGRAM
J O • R
V \`
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineers Report
Well Flow Advisory Other
By: /6 "/ `c, %off'( Original Certificate Date: / 8 - Al ' C O—
(Rev. 1wo)
Municipality of Anchorage °
o'•x s4'f
• Development Services Department '
Building Safety Division '
Or}Site Water 6 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 995184650
www.cl.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot $ Block 3. Scimitar Subdivision No. i Parcel ID: 051132.38
A. WELL DATA
Wen type Private If A. B, or C provide PWSID #
Date completed 5=998 Sanitary seal (Y/N) Y
Total depth 300 ft. Cased to 132 ft.
FROM WELL LOG
Date of test 511311998
Static water level 122 ft.
Well production 1.5 g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 ml. Nitrate 247 mg.A.
Date of sample: 912512002 Collected by: MEA
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SeptielSteel
Tank size 1.000 gal. Number of Compartments 2
Foundation cleanout (Y/N) Y Depression over lank (Y/N) N
Data of pumping 101412002 Pumper Sanitary Pumpers
C. ABSORPTION FIELD DATA
Well Log (Y/N) Y
Wires property protected (Y/N) Y
Casing height (above ground) 24 in.
AT INSPECTION
9MI12002
Blocked ft.13A4_ L_OVj 10&Q')C
A4* -u- SrO ILS
3A g.p.m.
Other bacteria 0 colonies/100 mi.
Date installed 61311998
Cleanouts (YIN) y
High water alarm (Y/N) N
Date installed 61311998 Soil rating (g.p.d./W or ft2fbdrm)12 GPDISF System type S Wide ShatlowTrench
Length 50 ft. Width 5 ft. Gravel below pipe 4 ft.
Total depth 8 ft. Eff. absorption area 500 ftr Monitoring tube Y Depression over field N
Date of adequacy test 911712002 Results (Pass/Fad) Pass For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added514 gal. New depttr0 in.
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N if yes, give date
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (YIN)
"Pump on" level at _ in. "Pump off" level at _in.
High water alarm level at in.
Datum Cycles tested
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankilift station on lot >IW
On adjacent lots MOM
Absorption field on lot >100'
On adjacent lots MW
Public sewer main WA
Public sewer manholefdeanout WA
Sewer /septic service line >2S
Holding tank NIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >S Property line >S
Absorption field >T
Water main NIA Water service line
MW Surface water MW
Wells on adjacent lots >1W
SEPARATION DISTANCE FROM ABSORPTION FIELD
ON LOT TO:
Property line >10' Budding foundation >10' Water main MW
Water Service line MW Surface water MW
Driveway, parking/vehicle storage >2S
Curtain drain None Noted Wells on adjacent lots
>100'
F. COMMENTS
Unable to Robe Well. Casino Blocked by Corrosion Arrester.
�s�� �I
P
• • • •
G. ENGINEER'S CERTIFICATION
�F� •'•• ..
I certify that I have determined Nuough field inspections and
review of Municipal records that the above systems are in "`"' .....
conformance with MOA HAA guidelines on effect on this date. `.......'
r : 71 A%r s
W% E. Z,tsc:k
iP sf &Vi;
Engineer's Printed Name Michael E Anderson, P.E.
E 1 :
Data 10Hf2002
it Lt '; s 4
•,t
HAA Fee $ 3 73 GAO Waiver Fee $
Date of Payment Date of Payment
Receipt Number q2-63 4 0 Receipt Number
(Rev.lvoo)
Telephone: 907-357.6304
Date: September 17, 2002
Legal: Lot 2, Block 3. Scimitar Subd. #1
Well Depth: 300 FL
VE -TECH
Engineering Technical Services
PO 873141, Wasilla, AK 99687 Fascimile: 907-357.6305
Project#: M0251
Inspector. T.L. Kimbrough
# Sdrms. 3
Static Level:
UNK
FL
BLOCKAGE IN WELL COULD NOT PROBE:
Yes
Is wells sanitary cap installed?
Yes
Elevation of well casing above ground level:
1
,Zyoe of Svstem Tested:
U Public Water Supply:
PWS ID #
N
Single -Family
Is this system currently in compliance?
❑ Multi -Family,
❑ Commercial
Tyne of Test Performed.,
❑
Well Flow Only
❑ Septic Adequacy Only
Both
Well
ST MT#1 MT#2
Time
Flow
Cum.
Static
Liquid Liquid MT# 1 Liquid
MT#2 Meter
Comments
Rate
Volume
Volume
Level
Level Level Delta Levet
Delta Reading
(gpm)
(gals)
(gals)
(ft)
(in) (in) (in) (in)
(in)
10:12
UNK
50 0 NA
1786
start
:22
4.0
40
40
51 0 0
1826
:32
3.6
36
76
.51 0 0
1862
:42
3.6
36
112
51 0 0
1898
:52
3.4
34
146
51 0 0
1932
11:02
3.6
36
182
51 0 0
1968
:12
3.6
36
218
51 0 0
2004
:42
3.4
103
321
51 0 0
2107
12:22
3.1
125
446
51 0 0
2232
12:42
3.4
68
514
51 0 0
2300
End SAS
14:12
3.4
378
824
2610
End Well
3.4
Average Gals/Min Well Flow
Septic Peak Load Test Calculations:
(# bedrooms x 150
gaVbdnn + 10%- # of gallons required for test)
..
3
x
150
= 450 + 45
495
Gallons
Rvcpyffm
Time
ST
MT#1 MT#2 Static Comments
12:42
51
NA NA NA Start SAS
14:12
50
End SAS
ADEC Code Comollance:
Does septic tank need pumping?
Yes
Is well wire in conduit?
Yes
Is wells sanitary cap installed?
Yes
Elevation of well casing above ground level:
1
FL
U Public Water Supply:
PWS ID #
Is this system currently in compliance?
❑
Yes
Test Results: N �P/a�ssed ❑ Failed
Reviewed By: nfED
❑ No
❑ No
❑ No
❑ No
Date: /0—/ -Oz -
0
0—/ -OZ-
❑ NA
❑ NA
❑ NA
Test results are indicative of conditions at time of testing. Ve-Tech nor Michael E. Anderson make any
representation to the future life of Bre systems nor any of the mechanical components of the systems.
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
Parcel I.D.# 051 -I 3-238
1. GENERAL INFORMATION
Complete legal description
Lo/ 2,
%lock 3, 9ci~'nitar Subdivision
Location (site address or directions)
Property owner ,?!~:~,~ Coatractin,z Day phone ,33:~-123~
Mailing address ~ O so;~ ~i'7.3~ 95 ?~ , ~' -,'-
Lending agency
Mailing address_
Day phone
Agent
Address
Day phone
o
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: Phree ( 3 )
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.
STATEMENT OF INSPECTION BY ENGINEER
As certified by rnyseal 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 An,'nderson Engineering Phone 522-7773
?.O. Sox 240773 Anchorage, Al( 99524
Address
Engineer's signature
DHHS SIGNATURE
~ Approved for '~C~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By: .. "~" Date /'~'
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 (Re,/. 1/91 ) Back MOA ~r21
Municipality of Anchorage ~
DEPARTMENT OF HEALTH & HUMAN SERVICES I~ E (~ ~ IV E
Environmental Services Division , ~ ~
825 L Street, Room 502 · Anchorage, Alaska 99501 o (907) 34~-~4174~ 2.. ~998
Municipality of Al~chorage
Health Authority Approval Checklist Dept. Health & Human Services
Legal Description: Lot: 2,
A, WELL DATA
Well type Private
Log present (Y/N) Y
Total depth 300 '
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform 0
Date of sample: 8/19/98
B. SEPTIC/HOLDING TANK DATA
Date installed 6 / 3 / 98
Foundation cleanout (Y/N)
Date of Pumping New
C. ABSORPTION FIELD DATA
Date installed 6 / 3 / 98
Block 3, Sci. mitar #1 Parcel I.D.: 051 -13-238
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 5/13/98
Cased to 132 '
FROM WELL LOG
5/13/98
122'
1.5
g.p.m.
Casing height (above ground) 2 '
Wires properly protected (Y/N) ¥
AT INSPECTION
Nitrate
g.p.m.
.1 mc.f/L Other bacteria 0
Collected by: MEA
Tank size 1,000 Number of Compartments 2 Cleanouts (Y/N)___
Y Depression (Y/N) N High water alarm (Y/N) N
Pumper Construction
Length 5 0 ' Widtl~. 5 '
Effective absorption area..500 SF
Date of adequacy test _ Nc_w Cr~ n .~ h.
Fluid depth in absorption field before test (in.);
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
_ Soil rating (g.p.d./ft~ or ft~/bdrm) 1.2
Gravel thickness below pipe
Monitoring Tube present (Y/N) y
Results (Pass/Fail) p.~ ~ .~
Immediately after,..
Absorption rate =
System type i ~e~~._c h
4' _Total depth. 7/' - 1~
Depression over field (Y/N) N
For 3 .bedrooms
· gal. water added (in.):
~g.p.d.
If yes, give date.
D. LIFT STATION - None on Lot
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT 'TO:
Septic/holding tank on lot > 1 0 0 '
Absorption field on lot > 100 '
Public sewer main ~ / A
Sewer/septic service line > 10 '
Size in gallons
"Pump on" level at*
*Datum
On adjacent lots > 1 0 0 '
On adjacent lots > 1 0 0 '
Public sewer manhole/cleanout
Lift station N / A
"P Jmp off' level at*.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation > .5 ' Property line > 5 ' Absorption field. > !5
Water main/service line __> 1 0.' Surface water/drainage _ > 1 0 0 ' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation > 1 0 '
Property line > 10'
Surface water > 100 '
Driveway, parking/vehicle storage area
Wells on adjacent lots > 1 0 0 '
Curtain drain None on Lot
Water main/service line > 10 '
>20'
ENGINEER'S CERTIFICATION _.~.~.%.,~%%\%.
I certi that l have determined thru field inspections and review of Municipal rec,~_'~'~¢o~,~terns are
= ........ "~me Michael E Anderson, P.E. ~ ~~~
Waiver Fee $.
Date of Payment _.
Date of Payment ~
Receipt Number
Receipt Number
72-026 (Rev. 3/96)*