HomeMy WebLinkAboutROBIN HILL #1 BLK 2 LT 4Onsite File
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Municipality of Anchorage
On -Site Water and Wastewater Program • (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP191325 PID Number: 017-392-01
Page 1 of 3
Dwelling: ❑Q Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑■ Upgrade
Name:
James Stratton
12821 Mountain PI. Anchorage, AK 99516
Phone Number of Bedrooms
229-9761 4
LEGAL DESCRIPTION
Subdivision Block Lot
Robin Hill #1 2 4
Township Range Section
SEPARATION DISTANCES
To Septic Absorption Lift Station Holding Sewer
From
Tank Field Tank Line
Well 90' N/A N/A N/A >25'
surface water >100' N/A N/A N/A
Lot Line >5' N/A N/A N/A
Foundation >10' N/A N/A N/A
Curtain Drain None Noted
Remarks Tank only permit. Tank is insulated.
Well Waiver # OSV191061
Tank serial # 1776
ABSORPTION FIELD
❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
F Other
Soil Rating Total depth from original grade
GPD/SF F Ft.
Depth to pipe invert from original grade Gravel depth beneath pipe
Ft. Ft.
Fill added above original grade Gravel length
Ft. Ft.
Gravel width Beds: Number of Lines Distance between lines
Ft. Ft.
Total absorption area Number of trenches Dist. between trenches
Ft Ft.
TANK [C Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Oanufacturer
Greer Tank
NA Plastic
LIFT STATION
Manufacturer
Pump on level at
Capacity
1250 Gal.
Number of compartments
2
Capacity
Gal.
Pump off level at High water alarm at
in. in. I in.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank D3034 Tank to
Installer drainfield D3034
Northern Excavation Drainfield EXlstlnq CO/MT
Inspector J. Millette / L. Tidwell BENCH MARK (Assumed elevation) 100 ft
Inspection15' 9/6/19 nd Location and description
dates: 2
3'd 4'h Threshold of front door.
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp
lConditional Approval:
Approved k�jv_�, oa,�ff
Incnartinn Rannrt Q-1-19 Anr.
Date
Date
������ • OF.. ONO
°°° •0O
eo e
g 49th
�A g MICHAEL E. ANDERSON �u
No CE-4381
9/10/19ROFFr°°• ��
1111a®® �
®®���
// // 100500
FEET
1"=50'
4-BDRM HOME
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
PERMIT # OSP191325 PID # 017-392-01
ROBIN HILL #1, BLOCK 2, LOT 4
A B
FCO 28.8
2CO1 30.8
MH 32.7
A
SV 35.9
2CO2 37.8
8.3
12.8
14.9
18.7
19.6
MOUNTAIN PLACE
9/10/19 FLORAL LANEBARN10' UTILITY EASEMENTNEW 1,250 GALLON SEPTIC
TANK w/20" MANWAY.
EXISTING ABSORPTION
TRENCH TO REMAIN IN
SERVICE.
2CO2
2CO1
MHSV
EXISTING WELL
EXISTING WELL
FCO
PLAN AS-BUILT
B
APPROX. LOCATION OF
WELL SERVICE LINE
100' WELL RADIUS
87' WELL RADIUS
8.0'
PROFILE AS-BUILT
(NO SCALE)
93.6
90.3
94.1
98.6FCO SV2COB1250 GAL
SEPTIC TANK
93.4
PERMIT # OSP191325 PID # 017-392-01
ROBIN HILL #1, BLOCK 2, LOT 4
9/10/192COAMH2' INSULATION
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone; (907) 343-7904 Fax. (907) 343-7997 `
http://www.muni.org/0nsite
uh+
QITtIrCrlll'ltt
On -Site Wastewater Disposal System Permit
Permit Number: OSP191325 Effective Date: 8/112019
Work Type, SepticTank Upgrade Expiration Date: 7/3112020
Tax Code Number: 01739201000
Site Legal Address: ROSIN HILL #1 BILK 2 LT 4 G:2838
Site Mailing Address: 12821 MOUNTAIN PL, Anchorage
Owner: STRATTON JAMES F REV TRUST Lot Size in Sq Ft: 93218
Design Engineer: FORGE ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field 0 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (2417).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
1. Contractor shall have the water service line professionally located prior to installing the new septic tank, to
confirm the code required minimum 10 ft separation is being met.
2. The as -built survey provided to close out this permit shall show the standpipes for the existing absorption field,
as well.
4
Received By: r Date: e1
// /,Z�
Issued By:
Date: � I 9
4
P.O. Box 196650 ® 4700 Elmore Road
Anchorage, Alaska 99519-6650 ® (907) 343-7904 ® Fax (907) 343-7997
http://www.muni.org/Onsite
Development Services Department
On -Site Water and Wastewater Section
x x x x VARIANCE/WAIVER. REVIEW x x x x
Waiver#: OSV191061 COSA#: Permit#:OSP191325
PID#: 017-392-01
Legal Description: Robin Hill #1 Block 2 Lot
Engineer: Forge Engineering
Applicant: James Stratton
Your request for a waiver of the required 100 feet horizontal separation from the septic tank to
the private well on this lot has been approved. The approved separation distance is 87.0 feet. See
engineer's waiver request for justifications.
This waiver approval applies to the proposed septic tank only. Any future upgrade to the on-site
wastewater disposal system will require all separation distances be met or another approval from
this department.
■.............................................. ■ ................... t ......... ■ 1
Waiver is Granted: X
Waiver is not Granted:
1 G+
Date: I
Approved by: l '�/ V( 0�,
Name of Reviewer
. .............................................................................
1
**** VARIAN C EMAIVE R REVIEW ****
6PLANS
MUNICIPALITY OF ANCHORAGE
Community Development Department Phone: 907-343-7904
Development Services Division Fax: 907-343-7997
On -Site Water & Wastewater Program
ON-SITE SEWERIWELL PERMIT APPLICATION
Parcel I.D. 017-392-01
Property owner(s) James Stratton Day phone 229-9761
Mailing address 12821 Mountain Place Anchorage, AK 99516
Site address Same
Legal description (Sub'd., Block & Lot) Robin Hill #1, Block 2, Lot 4
Legal description (Township, Range & Section)
Lot Size 93,218 Sq. Ft. Number of Bedrooms Four (4)
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF)
❑X
(w/wo ADU)
Septic Tank
❑X
Upgrade FX]Duplex
(D)
❑
Holding Tank
❑
Renewal ElMultiple
Dwellings
❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Well to Septic Tank
Distance: 87'
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: 1995 -
Date of Payment: 7 Ig q.
Receipt Number: 65qq(4/)
Permit No. 05' l / �2;<1011-
Permit App_-'-:- :'-.Ic
Waiver Fees: 11190
Date of Payment: ?A_Zq lq
Receipt Number: cc
Waiver No. W1V ` 16&/
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 30, 2019
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Robin Hills #1, Block 2, Lot 4 – 12821 Mountain Place
Septic System Design
Dear On-Site Services Engineer:
The existing septic tank on the subject lot has outlived its useful life and must be replaced prior to
the issuance of a COSA. We are submitting this permit application for the replacement of the
septic tank. The attached site plan identifies the location of the home and the existing well and
existing and proposed septic tank site. The new tank will be placed inside the 100’ protective radius
of the well on the lot as insufficient area is available to meet setbacks from the foundation, deck
and driveway. A well to septic tank waiver request is included. No conflicts exist between this
proposed system and any other well or septic system on adjacent lots.
Wells on this and adjacent lots are shown. The new septic tank will be a minimum of 87’ from the
well on this lot and 100’ from all wells on adjacent lots and surface water The tank will be 10’
from the house foundation and 5’ from deck and stair supports.
Please refer to the attached plan sheet for the septic design. If this design is followed, there will be
no adverse impacts to adjacent properties.
Sincerely,
Michael E. Anderson, P.E.
7-30-19
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191325, Rebecca Carroll, 08/01/19
PO BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
July 30, 2019
MOA Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Robin Hills #1, Block 2, Lot 4 – 12821 Mountain Place
Well to Septic Tank Waiver
Dear On-Site Services Engineer:
The proposed septic tank on Lot 4, Block 2, Robin Hills #1 Subdivision will be placed 87’ from
the well on the lot to provide 10’ separation from the house foundation. It must be placed at this
location to be at least 5’ from deck and stair supports and to be out of the driveway. The existing
septic tank is in the driveway, under the deck and only 6’ from the foundation. The attached Site
Plan identifies the proposed location of the proposed tank along with the location of the existing
well and septic tank. A recent water sample taken from the well and water system revealed no
nitrate or arsenic concentration in the water and no presence of coliform. The well is obviously
not contaminated from any source.
The proposed septic tank will be located at approximately the same elevation as the existing well,
but surface drainage is away from the well and to the southeast at a 5% grade. Any effluent that
might surface from the tank would flow away from the well. Surface effluent contamination of
the well by the proposed septic tank is virtually impossible.
Underlying soils on the lot are silty gravels (GM) based on test holes completed in the past. The
well on the lot is 280’ deep and the static water level was recently measured at 133’ below the
surface. The well log indicates clay with sand layers the entire depth of the well. We are confident
based on the long term performance of the existing septic system and the water quality from the
well that contamination from the septic tank is not likely.
ADEC POINT ANALYSIS
Bottom of Absorption Trench to Highest Water Table – 133’ 7.2 Points
Soil Absorption Type –Sand w/small amounts of clay 2.5 Points
Permeability – Silt or Sandy Gravel 1.0 Points
Water Table Gradient - +5% 4.5 Points
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191325, Rebecca Carroll, 08/01/19
Horizontal Separation – 87’ 2.5 Points
TOTAL POINTS 17.7
Almost sure to be free from any form of contamination from household sewage.
Sincerely,
Michael E. Anderson, P.E.
7-30-19
Received Date/Time 07/09/2019 13:00
07/09/2019 12:20Collected Date/Time
1193662001
Matrix
SGS Ref.#
Client Sample ID Robin Hill #1 B2 L4
Client Name
Project Name/#
Printed Date/Time 07/17/2019 16:40Forge Engineering Inc.
Technical Director Stephen C. Ede
Robin Hill #1 B2 L4
Drinking Water
Sample Remarks:
Parameter Results LOQ Units Method
Allowable
Limits
Prep
Date
Analysis
Date InitContainer ID
Metals by ICP/MS
DSH07/16/19EP200.8ug/LArsenic 07/12/19ND5.00 (<10)B
Waters Department
EWW07/11/19SM21 4500NO3-Fmg/LTotal Nitrate/Nitrite-N ND 0.200 (<10)C
Microbiology Laboratory
VDL07/09/19SM21 9223B100mLE. Coli Negative 1 A
VDL07/09/19SM21 9223B100mLTotal Coliform Negative 1 A
// //10050 0
FEET
1"=50'
4-BDRM HOME
NOTE:
NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE
PROPOSED SEPTIC SYSTEM
ALL WELLS ON SURROUNDING LOTS WITH IMPACTS TO THIS
PROPERTY ARE SHOWN. NO CONFLICTS WITH WELLS OR SEPTIC
SYSTEMS.
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
ROBIN HILL #1, BLOCK 2, LOT 4
MOUNTAIN PLACE
7/30/19 FLORAL LANEBARN10' UTILITY EASEMENTDECOMMISSION EXISTING SEPTIC
TANK PER MOA CODE.
NEW 1,250 GALLON SEPTIC TANK w/20"
MANWAY. MINIMUM 10' FROM FOUNDATION
AND 5' FROM DECK SUPPORTS.
EXISTING ABSORPTION
TRENCH TO REMAIN IN
SERVICE.
2CO
2COMH
SVCONNECT TO EXISTING
DISTRIBUTION LINE
EXISTING WELL
EXISTING WELL
NOTE:
ALL COMPONENTS OF THE SEPTIC SYSTEM
MUST BE A MINIMUM OF 10' FROM THE
WATER SERVICE LINE FROM THE WELL.
VERIFY LOCATION OF WATER LINE PRIOR
TO CONSTRUCTION.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP191325, Rebecca Carroll, 08/01/19
10' UTILITY EASEMENTS
Lot 6
Lot 7
Lot 8
/ WOODEN FENCE
I
I Lot 9
Lot 3
PLOT PLAN ___ AS BUILT X_ SCALE 1 50' GRID _ SW 283$__ Project No. ___ 19-3031A1___
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates, inc. (907) 522-6476 Phone 0000�p��
Professional Land Surveyors ken®keno 5Ian92-46survey5 Fax
com O F A `ooh
jonathan®langsurvey.com
I hereby certify that I have surveyed the following described property:
LOT 4, BLOCK 2, ROBIN HILL SUBDIVISION — UNIT No. 1 (PLAT No. 69-175)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
Dated this the _______ Day of
______, at Anchorage, Alaska
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat.
49TH*I
° . ° KENNETH G. LANG o
G
°•.LS -5202.•°' SJ�O
440�R�FESSIONAL � ��
AECC963
MUNICIPALITY OF ANCHORAGE
DEF>'"'~TMENT OF HEALTH AND HUMAN SERV:-~iS
Environmental Health Division
~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
DISTANCES
Address FRO~ TANK FIELD WELL
'~'i FOUNDATION
Townsb,p, Range, Seclion
. ~ / AS-BUILT DIAGRAM (Show Iocahon of well, septic system, property hnes. foundahon.
driveway, water bodies, otc
TANKS i
Material No. of Compa~ments
(~myX~ TYPE OF SYSTEM / ~"
~TRENCH ~ BED ~ W. DRAIN g OTHER ~X L
Depth to p,pe bottom from Total deptb from obgma, grade '~
Fill added above original grade Gravel depth beneath p~pe /
~ Je~g~h Or~vel w,mh ~ , -
Total absorpt.o, area ¢0~ S~ FT
Instalter ¢~1 ~ ~' Date installed
WELLS
~ PRIVATE ~ OTHER (Identify)
Classification ~A,B.C, Total Dep[h ~TCased t° FT
InstaHei Date Installed:
~ ~ /
. Inspections Pedormed by:
~unicipal and Slate guidelines in effect on thb date: ~ -/~¢
HealthDepadmentApprov~~ ~ ~ Date:~~
Z
[DEPT.[ OF HEAL"LrI-I &
JNVI~ON ..t~NT~L.
~.) ::.r ff"h'~. I i'll.::.l'~ ],..,n~:', mis:AL i r", AI',ID ~:::.l'-~v 3. RONHEEI'4'T'AI_ F'RO"r'EE:T I ON
J ..... c~ I r'~,.::c:. J ,,. Al,ICh .ff'd.:lbk., AK 99501
264..--472 C:'
L. J. ~;i~/'.. ,:.:.:~ d I:;) 6? ]. i::){4 ;a p E.:, t. h (2: i:) Fi t. i o 1"',, !B a v a L ]. ~.'A b ]. (.~? t. (] V i3 Lt i n .4 ~..:: ~::, ,i. (:~ i I J. [] (:}J ',/o .t" !~ :¢:,.:, [3 '(', 'i.
syste:q'n,, Chc.:"~?,~e t. he opt. ion that, br_-'.~st', f:i. ts ¥csur' site,,
DEPTH 'TO Pt'F:'E', BO"FTOPl (FT,,)
GF;~AVE!]_ DEF'TH (FT.
TOTAL. D[ii]::'Tlq (F:"T.)
GRAVE].... W]:D'f'H (F"F.
(};RAVEL L%NG'TH (F~'T'.)
,-.'", ..... "', ,qm l~vq'- (C)U ....
.,.:,l"~.~.~vi::.l... v ......,~., ,.:. . fDS,,
TANK SIZE (GALS)
SOIL. RAT]:NEi (SQ.FT,,/BR
-If'" F;;',: EiE Pq
? 0
14 0
2 5
50 0
44 O
I, 250 0
222
I i;:: l<: I" t. :i. f' y t. l"i a t.:
for'th by t. he Municipa].:i.t.y caf Anc:hor-age (MC)A) ,and 'Lhe St. at(? of' Ata.ska.
2. I ~/.~:i, li ir'ist, a!l the:, system :i.n ac:ccH'dance wit. h all MOA cc)des arid
ar:id irq cc, rnp].iar'ik::e v,,~:J, th the dE.:,SSJ, gl] c:P:i, tei-:ka of t. his pei"mit,.
3,, Z w:i. 1]. aclhei"e.:, Lo all MOA anti State of Alasl.::a r'E~qLtir'exfl6:(d-Yk.?5 {'oi" the iii;et. I::,ac:k
!B6:)(,,JE:'PE~(;iE) !;syst. 6)ifi C)i'"~ 'Lh:J,!s of .any adjac:en't'., c:)t- 1"i6~&u"J::iy ].ot..
X}.,, ][ L.U'iCI(,ePSEtEdq(:J tha'L 'Lh:J.s perm:i.'L is v&~.].id i:'C;)l- a maxiifit..~ffi C:i~' zl. I::)edr'oc)i'ns a~r]d
any enlaPgemen'L w:i.i]. PeCILtiP(.}:, an addit:i.c)f~ai pePmit.,
5[i:::' A L]ZF'T S'I"ATION IS iNSTAL..LED :J:N AN ARIZA COVIERED .BY MOA BIJII...DING CODES,
'f'lqlEN (i) AN EL. ECTRICAL. F'ERMIT AND iNSI:::'ECT']:C)N PtlJST .~::~::. (..~BI~-.~.I. 14[:D~ (2) A.:2-.BL II. I
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
(ENGINE~L)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
20
~'~"~ DATE PERFORMED: /~/~
~'O~/A/f /7~/-Z- Township, Range, Section: '7'~,Z.A/
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water After
Monitoring? Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ,Z~8 (minutes/inch) PERC HOLE DIAMETER
TES~ RUN BETWEEN ~¢,~'* FTAND ~ FT
COMMENTS~O/Z4 ¢4"F~ 4¢ 2--./¢ -~'*,'~:/-~'e,V F,~,¥ '-~- /~" ..,..d ,,~rz,
PERFORMED BY: A~m'C~ ~ ~*'4 I ~ ~ CERTIFY THATTNISTESTWASPERFORMEDIN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: f/'~/~) '° ~'~
! -
tV~LL i
/ /
I hereby certify that I have ~urveyed the following d~l~;'ri~ property, Lot ~ Block
./~?.~YlM t¢ILL .SU,~D, u/VI/" ~//1 Anchorags rracording Precinct. Alaska, end that
the improvements situated' thereon are within tha"~roperty lines ann'.do not overlap or
encroach on the prOPerty lying adjacent thereto# that no improvements on property -
lying adjacent th~eto encroach on the premile~ in clue'~tion and that there are no ?oadweys
tren~miuion line~ or other vitible eeseme~tl on ~aid properly except es indicated hereon,
Book No. Page No.
GAAB-HD- I
GP~t::~TER ANCHORAGE AREA BOROUGH
' ,; HEALTH DEPARTMENT '
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
SEPTIC TANK:
MAILINGADDRESS ~/ ~-~" ~%~-f~-~'~'~ PHONE
DISTANCE FROM WELL ~
LIQUID CAPACITY ,/'~., ~'~') GALLONS.
MATERIAL
INSIDE LENGTH
NUMBER OF ~
COMPARTMENTS -
· ~,~""""""""~Z:~'-/' ~"'.~2 LIQUID
INSIDE WIDTH DEPTH____
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAl
NEAREST LOT LINE
SEEPAGE PIT:
OUTSIDE DIAMETER
OR WIDTH "~'~,,-~ /' LENGTH '"'~'~.~'J" /
'~ , , DEPTH
D,STAN CE ER OM W ~./~ ~ ~. ) .~u ,~, ~ou ~ ,o
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~ SQ. FT.
TILE DRAIN FIELD:
TOTAL LENGTH
DISTANCE FROM WELL FOUNDATION . NEAREST LOT LINE , OF LINES
NUMBER OF LI~C~''''''''~ TANCE BETWEEN LINES TP, Fe'NC--tt-W4~TH IN. TOTAL EFFECTIVE
TIL N ABOVE TILE__
WELL: x~'~ o/'°-r~'~ /~/~/~/~/~/~/~/~/~/~YO~ - - ~ DISTANCE FROM ,c,....--,-~-W AT E R
TYPE ~¢'d.~ : DEPTH. , BUILDING FOUNDATION. : SAMPLE__
' SEEPAGE
4..,.,.,,,,-~'- NEAREST / SEPTIC ~', SYSTEM , CESSPOOL
LOT LINE ., SEWER LINE , TANK
, NEAREST
OTHER
DISTANCES:
DIAGRAM OF SYSTEM
DATE ~_.~___~ /??~ APP.OVED
·-G~AB-HD-2
GREATEt ' NCHORAGE AREA '"-gROUGH
HEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
Case N o. 7~ ~
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT
RESIDENCE ADDRESS
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH.
PERCOLATION TEST RESULTS
MAILING ADDRESS PHONE NO.
&..x
SEEPAGE PIT ~ ,DRAIN FIELD ,OTHER
ANTICIPATEO DATE OF COMPLETION
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS ~t$ ~¢x~...~ ,PERMIT TO INSTALL A
..... AS DESCRIBED BELOW, SIZE OF UNIT TO BE SERVED
o?..,~ DIAGRA~ OF SYSTE~ '
DISTANCES:
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
with smd code,
above ~i~ed system is in accordance ~--~
~,.~ : ]GREATER ANCHORAGE AREA BOROUGH
(~ '~ ,. HEALTH DEPARTMENT CASE #
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
Performed For ~,~ ~~.. . . Date P~rformed · 3~ /7- 7~ .......
Legal Descrip~7 Lot~lock Z,.~division .. ~o~,m
This Form Repor~ts a: So~ls Log [~. ~ ... . .Percolation Tesz__~
Depth
Feet
Soil Characteristics
Location Sketch
if Yes, At What Depth..~._~.. ! ~ ]
Reading Date
Gross Time
Net Time
Depth To ~20
Net Drop
Proposed Instal~SeeDage Pit ~ Dr~¢~
Depth Of ' ~t ' ~ .... ~,, Field
Inlets_ o _ !)eptn To Bottom Of Pit Or 'i'renc?~~
Test Performed B~:
l. /q / / / q
Data Certified By:IT~.JLJ~i ] /,,/.~_ .~/ Dater
MUNICIPALITY OF ANCHORAGE
MEMORANDUM
DATE:
TO:
FROM:
SUBJECT:
September 21, 1992
Accounting & Budget, DHHS
On-site Services, ESD, DHHS
Request for Refund - Account #2570-9426
The following application for a Health Authority Approval
was applied for on September 15, 1992 and the property owner
requested it be cancelled and pulled from our office on
September 16, 1992. Therefore, a refund needs to be processed.
W~ have not reviewed or processed this appication for
approval.
Please make the necessary arrangements for the refund to
be made. Thank You.
James Stratton
.1'2821 Mountain Place
Anchorage, Alaska 99516
Account ~ 2570-9426
Amount $170.00
Recept ~ 24047/3920
Lot 4 BLock 2 Robin Hills Subdivision
Laura J. Montgomery
On-site Services
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
EnvirOnmental Services Division
Telephone: '343-4744
OS- 24047
ON-SITE SERVICES FEE DOCUMENTATION
TyPe of PaYment: (Indicate~A~O~nt Paid)
~lealth Authority: //~'~ Excavator Permit:
~Sewer & Well Permit: Engineer Permit:
Well Permit:
Sewer Permit:
Copy Request:
72-034 (Rev. 10/87)
Pumper Permit:
Well Driller Permit:
Tank Manufacturer:
(Waste Treatment)
DISTRIBUTION:
WAIVERS:
Lot Line:
Well to Tank:
Well to Field
Field to Surface Water
Tank to Surface Water
WHITE--MASTER FILE CANARY--PROGRAM FILE
EPu_�/us
MUNICIPALITY OF ANCHORAGE
4
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Parcel I.D.
017-392-01
Certificate of On -Site Systems Approval
Expiration Date: (sem �Q 2-d2d
1. GENERAL INFORMATION
Complete legal description Robin Hill #1, Block 2, Lot 4
Location (site address) 12821 Mountain Place, Anchorage, AK
Current property owner(s) James Stratton Trust Day phone
Mailing address
Real estate agent
12821 Mountain Place, Anchorage, AK 99516
2. TYPE OF DWELLING:
❑■ Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
Day phone
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
❑■
Private Septic
❑■
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distan
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 55 a Waiver Fee $
Date of Payment 130 lawn Date of Payment
Receipt Number d lis 0 Receipt Number
COSA # 65C -q01611 -Waiver #
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, based
on procedures outlined in the Certificate of On -Site Systems 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 607-522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's Printed Name Michael E. Anderson, P.E. Date 3/3/2020
6. DSD SIGNATURE
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
. i kk0l1! (OW611.
�- Original Certificate Date: 20
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: Robin Hill #1 Block 2 Lot 4
Parcel ID: 017-392-01
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached) Well production at time of test 5.0 gpm
Date drilled 12/23/70* Water storage tank volume N/A gallons
Total depth 280 ft Well disinfected for coliform test? ❑ Yes FOR No
Cased to 40+* ft ❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 12 in. Collected by Forge Engineering
Date of flow test for COSA 7/1/19 Date of Sample 3/2/20
Static water level at beginning of test 133 ft
Comments *Year of well installation taken from 1986 COSA. Casing of 40+ assumed due to the soil recorded on the well log between 0 and 150'.
B. TANK DATA
Age of tank(s) `1 years
Tank type/material Septic/Plastic
Measured operating fluid level in septic tank NEW
❑ Standpipes/foundation cleanout per record drawing
Date of pumping New Construction - 9/19/19
C. LIFT STATION
❑ Required maintenance completed
Age of lift station N/A years
Lift station material N/A
Comments: NIA
D. ABSORPTION FIELD DATA Deep Trench
Which system tested (date installed) 2/5/86 Adequacy test date 7/1/19
❑ALL standpipes present per record drawing Resu lts✓ Pass For bedrooms
Total measured depth from grade 15 ft (max) Fluid depth prior to test 56 in
Measured depth to pipe invert from grade *N/A ft (min) Water added 801 gal
❑ N/A — pressurized field
New depth 83 in
❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 1440 min
depth into effective *N/A
p
❑ Code -required soil cover over field Final fluid depth 61 in
❑ System presoaked
Absorption rate '600 gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months) No
date of test)
Gallons introduced N/A gallons If yes, enter date
Comments/Deficiencies: `No cleanouts were installed on original septic trench. Monitor tubes only.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
**
90
Yes
Community Sewer Manhole/Cleanout > 100'
r7 Yes
if No
ft
0 Yes
if No
Neighboring Tank > 100' M Yes
if No
ft
Private Sewer/Septic Line > 25' F-/� Yes
if No
Absorption Field on Lot > 100' F,71 Yes
if No
ft
Holding Tank > 100' 0 Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' P/1 Yes
if No
F-1 Yes
if No
ft
if No
ft
F. ENGINEER'S COMMENTS
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' F-/� Yes
if No
ft
✓❑ Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
F Yes if No ft
Property Line > 5'
0
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'
0
Yes
if No
ft
Private Wells > 100' 0 Yes if No.
Water Main > 10'✓�
✓®
Yes
if No
ft
Community Wells > 200'✓0 Yes if No.
Water Service Line > 10'
0
Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
El
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
F,71
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
✓®
Yes
if No
ft
Private Wells > 100' ®✓ Yes if No
Water Service Line > 10'
M✓
Yes
if No
ft
Community Wells > 200' F/ Yes if No
Surface Water > 100'
✓V
Yes
if No
ft
F. ENGINEER'S COMMENTS
**See Waiver No. OSV191061.
G. ENGINEER'S CERTIFICATION �®�F iri
J certify that 1 have determined through field inspections and review+�'�P;.•°'°•° •'•q�
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.• 49th
.......0 sur tunu.e a nat..n stag u..n.
MICHAEL E. ANDERSON e w
No. CE -4381 �c
a
3/3/20•
COSA Checklist yellow sheet �� �� p ......P�
Via
ft
ft
ft
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 OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description ~_~7' ,~ I~LO~' 2 ~:~z~l,4/' /-////.Z,.5 /_l/A/liT ~ /
Location (site address or directions)
Property owner
Mailing address
Lending agency
Day phone
Mailing address; .~'~--'~ ~', .T__,
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
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*025 (Rev. 1/91) Fronl 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 ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm .~/([_./¢ CO/7.5~/ZZ'EIT)~.~ Phone
Address ,~. ~.
Engineer's signature ¢¢', :;~,~/~-' J ' Date
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
'bedrooms.
bedrooms, with the following stipulations:
By:
Additional Comments
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. Em ployees 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 If21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ZO7''4/Z~/-~/20/3'//~',~/~Z/~/T#/Parcel I.D.
A. WELL DATA
Well type
Log present (Y/N) ~
Total depth 2~~) J (~)
Sanitary seal (Y/N) ~J
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ,~C ~2~. ~".OR ,'v~r Driller ~
' R~C~RP~
Cased to ~ ~C~ Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTION
~ - 2 - ,~ ~ MUNICIPALITY OF ANCHORAGE
2 / / / Et,~/IRC)INMENTAL SERVICES DIVISION
~, ~ g.p.m.
R E C E IV E O
SEPARATION .DISTANCES FROM WELL TO:
Septic/holding tank on lot /'~_2'
Absorption field on lot / ~' 7c~ /')~df'~'3L~ ~"~; On adjacent lots d)/'~/o
Public sewer main
Sewer service line : ,A/~
WATER SAMPLE RESULTS:
Coliform
J
Date of sample:
Nitrate
Public sewer manhole/cleanout
Petroleum tank
/%/D Other bacteria
Collected by: ,~.
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
®
Tank size /~,~'~ Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N)
Alarm tested (Y/N)
/V
Date of pumping ,.,.C-G-.DZ.,
a tie cA ed
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /~/~2';~¢7zl (~0 Onadjacentlots ~o ~//~ ~/'~,~ Foundation ~ '~
To property line ~Absorption riel ~' Water main/service line
Surface water/drainage
72-026 (Rev. 7/91) Front
Pumper_
CD.
CONTINUED ON BACK PAGE
'C. LIFt STATION
Date installed
Size in gallons
Vent (Y/N) ¢~~Oycte
High water alarm level s tested
Meets MOA elect~
SE~CE FROM LIFT STATION TO:
~Well on lot On adjacent 10ts
Manufacturer ~ '
Manhole/Access (Y/N) ~'
"Pump on" level at ' ' .' · - ' ~evel at
Surface water
D. ABSORPTION FIELD DATA
Date installed (~)_2-5- ~
:' Length : ~O*' '
Total, abSorption area
Depression over field (Y/N) ~/¢ru _r//'~,~/ ¢l,,¢f' ~"8,o~ Date of adequacy test
ReSults (pasO/fail) for
Peroxide treatment (past 12 months) (Y/N) /~' If yes, give date
Soil rating ~Z/4.r~/~;~,-'rn System type
Gravel thickness ~ -~' Total depth
Cleanouts present (Y/N) ¢/V'
bedrooms
',,D, A~ ~=~0 SORPTION-'F T°
sEpARA~I0N IST E M AB IELD : ,
n n lot Prope~yline ~d~/¢~
-,-', -. ...... .... : ......, '. ~ ~ /0~ .- "" ..... '
To building foundation ~/' To existing or abandoned sYstem on lot
~i~in/~¢ Cutbank~~ater main/service line ,~
surface water ~e ~O~//~/n/D~' Driveway, parking/vehicle storage area
Curtain drain
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 th'is inspection.
Signature
Engineer's Name ~('7L~c'¢f') -~'- /"//~J-/~'~
Date ,~ -/~ ~
HAA Fee $ /~0¢~
Date of Payment ~- /~- ~
Receipt Number ~0~
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE i: 57846
Che~f~ab Ref.t 92.4658 Sample t 1 Matrix: WATER
Client Sample ID ; L4 E2 ROBIN HILLS UNIT ti
PWSID : UA
Collected : SEP 3 92 @ 08:18 hrs.
Received : SEP 3 92 @ 06:40 hrs.
Preserved with : AS REQUIRED
Analysie Completed : SEP 4 92
Laboratory Supe~isgr
Client Name :S [ L H CONSULTANTS
Client Acot :SKLHCUN
EPOt :
Reqt :
Ordered By
Send Reports to:
1)S K L H CONSULTANTS
POt :NONE RECEIVED
Results Units Method Allowable Limits
Parameter - ___-
NITRATE-N ND(O.iO) ~/1 EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY: S.H. PRIVATE WELL.
i Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected "See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-Greater Than
Member Of the SGS Group (Soci6t6 G6nsrale de Surveillance)
SKLH CONSULTANTS
Ref: Lot -A ei,'-.*k. ;~ Rc, biri i-~iiis {Eh.ibdi'.'isicq"~
Jim ekd (2,:,iieer~
No s~ati~ wateP level was ~.~eec, Pded dL~iiq_q thee adequacy 'best pe'r'-
f,z,r.n~ed o,r~ 9.-;~--9R. The bolts ho!dir~g the sar~i'taPy seal we~e seized and
it was r~o'~ possiOie so Pemove the well ~ap. Subsequen~iy~ a well
d~i].!er e~)as ¥--etained bo p~errl,?vm the rexis'~irq:~ s~ai arid to Pep!ace it
with a new one arid while on site was a~ked to, p'pobe fo~ the static wa-
ret- ievei. Yhe well dr-ii].eP was ur:able to pr'o~)~:~ beyor~d 135'feet below
the top of the well casir~B, l~t this depth no Btati~ wate~ level was
encountePed. Or~ 9-ii-9~ i visited 'the e.i'te arid was able to pPobe to a
maxir~um deuth of 165 feet befope the p?obe became entan~!ed in the
eieo'tPi~al' wii'*e~ ieadir~d to the ~ump and othep obs'tpu~tior~s in '~he
c-asir~. (4~air~ iqo wateP ~,~-ve! ~.~at5' ~-:c-,::,,.ti-~t~?md to, this depth. No addi-
tior, a~ at~empts have beer, made t,z, de'l;ey'mi'r~m 'the ssta'bic water' ie,/e! foi"
the wel ;.,
lJLtPllq~ %ne ;i,le~'.iaey test. the ~*~e).! :~p,z,d~ac~d a .~s'be~,dy fl.z:w c,'ff ~,~a-'
RECEIVED
SEP 1 f 1992_
[vluruc~pa~q/c~ ,",,,cnorage
Dept. Health & Human Serwces
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4726
Application Date
GENERAL INFORMATION
(a) Legal De~scription (include lot, block, subdivision, section, township, range)
/or 4
Location (address or directions)
(b) Applicant Name ~D~g~, Z,/~"~ Telephone: Home ~--(2Z---~¢? ? Business ~-X,~Z¢.--~"~'"~'/.
(c) Applicant is (check one): Lending Institution []; Owner/builder~'; Buyer []; Other [] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-Fami!y [] Other
Number of Bedrooms ¢
WATER SUPPLY :
Individual Well~ Community[] Public[] ' . ~
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
sEwAGE DISPOSAL
Onsite'~ Public [] Community [] Holding Tank [] "
Note: if community well' system, must have written oonfirmation from the State Department o~f Environmental Conservation
attesting to the legality and status.
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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
Address /,,~ /.~//
Date
DHEP APPROVA.~L ~ c...~. ~~
Approved for.~-c::~d~''P~ bedrooms by/~J'~W~~ate
Approved ~.~(d/? Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Muncipali'~y of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
~IUN~C~PALll~ OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) MAR 1 glg86
CHECKLIST- FEBRUARY 1984
264-4720 . RECEIVED,
Legal Description: ~-~"'-¢
WELL DATA
Well Classification
Well Log Present~)
Total Depth ,~"O / Cased to
Static Water Level ~--~ ~-/%-~
Casing Height Above Ground
Electrical Wiring in Conduit(~)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ,/J/,~
cleanout/Manhole
?,4'
Water Sample Collected by
Water Sample Test Results
Comments ~
If A, B, C, D.E.C. Approved (Y/N)
Date Completed /~,~' ~'~ - ?¢ Yield
¢~ /'¢~ Depth of Grouting
Pump Set At ,,4'//~
Sanitary Seal on Casing~)'N)
Depression Around Wellhead (Y(~
; On Adjoining Lots
?¢.~ / ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
/* x;~//E'~' ;Date ,~-
B. SEPTIC/HOLDING TANK DATA
Date Installed ,~
StandpipesCN) ,~. Air-tight Caps~N)
Depression over Tank (Y(N~
Pumping/Maintenance Contract on File (Y/N)
,1~
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
/¢/
To Water-Sup. ply Well
To Property Line
To Water Main/Service Line
Course
Size /~'>~ ~'/'r¢~ No. of Compartments
Foundation Cleanout./,(YO
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
/
To Building Foundation ~
To Disposal Field .~L~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y(~
Results of Last Adequacy Test ,4/'/~
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot /'O "(--)/"Z~'
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field .~ /
Depth of Field /.~ ~ '-
Gravel Bed Thickness ? !
Standpipes Present(~N)
Date of Last Adequacy Test
To Property Line -~¢ /
To Existing or Abandoned System on
; On Adjoining Lots /¢~2
To Cutbank (if present)
'?,~O / ¢-
Comments
LIFT STATION
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
M a ~ ~ line/t Co~; S~vY; N~ )t :
Y/N) _ OA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I h~,a..v/e chic ked,//e, rified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~t'/'~' ~//-"'"~'~ Date ~ ~-'~
Company MOA
Receipt No. '~ ""7
Date of Payment ~
Amount: $ (-e
Page 2 of 2
72-026 (11/84)
ALASKA E ,, IROFImE FITAL COHTROL S NulCES, linC.
~nqineedn§ ~, ~nuironmcnlr~l $~udies
1986
ROGER & MAGNEA LABER
229 A CREST STREET
ANCHORAGE ALASKA
99669
SELLER-SAME
WILL PICK UP FROM OUR OFFICE
60070
LEGAL:ROBIN HILL SUBD/BLOCK 2/LOT 4
FLOW TEST ON WELL
WELL FLOW DATE-FEB 18 1986
A FLOW TEST WAS PERFORMED ON THE WELL. 601
PUMPED AT A RATE OF 6 GPM OVER A DURATION OF
THE DRAWDOWN WAS 2.2 ' WITH A RECOVERY TIME OF
AND THE STATIC WATER LEVEL WAS 219.3 FEET.
THE WELL IS ADEQUATE FOR THIS 4 BEDROOM HOME.
GALLONS OF WATER WAS
1.6 HOURS.
1 MINUTES
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
;1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO OF
CA~CULATEDEl¥ /f' ~J/~'// DATE... ~''~1-'~
CHECKEO Ely DATE
scA,~. /: 30