HomeMy WebLinkAboutSUE TAWN ESTATE #2 BLK 1 LT 18
Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~-~c~ OlZC/ PID Number:
"ame~/2/.2/~'-~ / ~gCV/~ ~/ WastewaterSystem: D New ~pgrade
Address: ABSORPTION FIELD
Phone: Nc. of ~ Deep Trench ~ Shallow Trench D Bed D Mou~d D Other
LEGAL D ESC~I PTI O N ~o, ~ating: Total Depth from original grade:
~,~ GPD/Sq. Ft.
Lot: ~lo~k: SubdJv~Jo~: )epth [o pipe bottom from original grade: Gravel depth beneath pipe
Township: Range: ~ Section: Fill added above original grade: Gravel length;
d Ft. ~O Ft.
I
WELL: ~ New ~ Upgrade Gravelwidth: Numberoflines: Distaacebe~eenlines:
~ Ft. [ ~/~ Ft.
Classification (Private, A,B,C): ~X/~ Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Level: Installer: Date installed;
Yield: GPM Pump Set at: Ft. Casing .e[ghtAboveGround:Ft. TAN K
SEPARATION DISTANCES ~Sept~ ~ Ho~,ng ~ S.T.E.P.
To Septic Absorption LiE Holding ~ub~ic/PrivatE Manufacturer: Capacityin gallons:
From Tank Field Station Tank Sewer Lines ~~ ~
Number of Compadments:
Material:
su,~c~ ,+ ~ LIFT STATION
Water /~O /0~ ~ ~
Lot ~urer:
FoundaUon 2~~ ~q ~ _ ~ "Pump on" l~l at: "pu.~u~iohwat~ralarmat:~"'~' I~
Cu~ain . ~O~ ~ ~C ~ Pump Make & Model Electrical Inspections pedormed~by:~
Drain
Remarks: BENCH MARK
Location and Oescription:
I Assumed
Elevation:
ENGINEER'S SEAL
S & S ENGINEERING -?
17034 Eagle River Lo~ Road, No. 2~ <~ "
Inspections performed by: ~.~..;vet: Alaska 9~S77 DateS:2ndlSt ~b -I~-~q_/u -99 ~,"~ . '":": "~:'"',
Department of Health~ Hu rvices approval
Reviewed and approved by Dat~ , Y ~
Permit No. $W940129
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: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
SUE TAWN ESTATES #2, BLOCK 1, LOT 18piDNo.: 05150159
Legal Description:
CO1 CO~ MT ~04
~ NEW
~ooo ~^L-.,
.... i I SErT~C ·
N,~.S.
{ A B
1~'C0' $8;0' E;O ....
COl 50.0 20.5
~02 56.5 29.0
D.V. 67.5 43.0
~03 87.0 65.0
C04 74.0 66,0
MT 74.0 67.0
· '7.3' NO WATERiFOUND
TRENCH
SCALE t"
i1000 GAL.
SEPTIC TANK
)USEi DRIVE
DECKi
100' WELL RADIUS
O
WELL
PAGE 1 OF 1
MUNICIPALITY OF ANCHOP~AGE
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:SW940129
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:HENRY LONNIE MELVIN
OWNER ADDRESS:1330 KIOWAI PLACE
KAPAA KAUAI, HI 96746
DATE ISSUED: 5/17/94
EXPIP~ATION DATE: 5/17/95
PARCEL ID:05150139
LEGAL DESCRIPTION: SUETAWN ESTATE #2 BLK 1 LT
18
LOT SIZE: 66369 (SQ. FT.)
~ER OF BEDROOMS: 3 THIS PERMIT: 3
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 (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
Bo COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: ~
ISSUED BY: ~(~/
DATE:
DATE:
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
May 05, 1994
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER &WATER
INSPECTION
ENGINEERING STUDIES
ANO REPORTS
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 'L' Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Sue Tawn Estates Subdivision ~2; Lot 18; Block 1
Request you issue a permit to upgrade the septic system serving the
three bedroo~ho~seonthe referencedproperty.
An adequacy test performed on the existing system by T. Spurkland,
P.E., for Health Authority Approval purposes found the absorption
capacity of the existing system to be inadequate.
A test hole was excavated and a percolation test performed in the area
of the proposed upgrade. The approximate location of the test hole is
located on the attached site plan. The monitoring tube within the test
hole has been checked and found to be dry. Attached is the proposed
upgrade design.
We do not anticipate any adverse effects on neighboring properties by
the installation of the proposed septic system.
If you have any questions, or require additional information for your
review, please contact us.
g/LSU/jk
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
°~°S~
o~
o
,~ or..
~t0~cj
ON-SITE WASTEWATEK DISPOSAL SYSTEM
(X)NSTRUCTION PRACTICES
MAT~AL SPECIFICATIONS
Sue Tawn Estates Subdivision #2: Lot 18: Block 1
The scope of this project includes the installation of a leachfield
trench to serve the three bedroom residence located on the referenced
property and excavation of the existing 1000 gallon septic tank to
verify its integrity. If the integrity of the existing septic tank is
poor the existing septic tank is to be excavated, pumped, crushed, and
abandoned in place and a new 1000 gallon septic tank installed.
Construction shall be in accordance with the approved site plan and
design drawings, Municipal permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater Disposal
Regulations.
3. The contractor shall be responsible for obtaining any necessary
underground utility locates.
Unless specifically agreed otherwise, the property owner shall be
responsible for final grading areas subsequently depressed from soil
settling.
Contractors installing wastewater disposal systems must be certified by
the Municipal Health Department for system installations. Owners
installing their own systems must also receive prior approval from the
Municipal Health Department.
SEPTIC TANKINSTALI~TION:
1. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
2. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
3. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
Page Two
Sue Tawn Estates Subdivision ~2; Lot 18; Block 1
May 05, 1994
Septic tanks installed with less than 4' of cover shall be insulated.
A foundation cleanout shall be installed one to four feet from the
building foundation. In the line between the tank and the leachfield
there shall be two adjacent cleanouts (unless an effluent pumping system
exists within the septic tank). These cleanouts shall be located on
undisturbed soil not more than 10' from the tank. The first cleanout,
in line, shall be to clean toward the leachfield. The second cleanout
shall be to clean toward the septic tank.
Final grading over the septic tank shall be such that a positive slope
exists away from the septic tank.
ABSORPTION TRI~%~2~/DRAINFT[~f.h INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The
bottom of the excavation shall be within 2 inches of level. If the
sidewalls of the excavation become smeared, they must be raked or
scratched (roughed-up) before gravel (sewer rock) placement.
Once the gravel is installed, the distribution pipe is to be installed
level with the perforations faced downward. Gravel is then to be placed
over the distribution pipe to provide a minimum of 2 inches of cover
over the pipe.
A silt barrier must be installed between the final gravel layer and the
native soil backfill. Ensure the silt barrier covers the entire gravel
surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter and installed
approximately in the locations shown on the design. The portion of the
monitoring tube extending through the gravel shall be perforated from
the bottom of the trench to the invert of the distribution pipe. This
is equivalent to the effective depth of the gravel as noted on the
design.
Backfill over the final gravel layer must not be less than twenty-four
(24) inches. Insulation must be installed when the backfill depth is
less than thirty-six (36) inches. The finish grade over the trench must
be mounded to prevent the formation of a depression after settling.
MINIMUM
1.
MATerIAL SPECIFICATIONS:
Any septic tank proposed for installation must
Municipally approved septic tank manufacturer.
be constructed by a
Page Three
Sue Tawn Estates Subdivision ~2; Lot 18; Block 1
May 05, 1994
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Type of Pipe Perforated
Solid
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) Yes Yes
Use of a type of pipe other than listed above must be approved by the
inspecting engineer.
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Company Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal)
must be installed between the final leachfield gravel layer and the
native soil backfill.
6. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel
with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C. requirements.
INSPECTIONS:
Typically there will be a minimum of three (3) inspections required during the
installation of the wastewater disposal system. These inspections will occur as
follows:
o
The first inspection must be conducted after the excavation of ditches,
pits, trenches, or beds and before the installation of any gravel. A
septic tank may be set in place, but may not be backfilled before this
inspection.
The second inspection must be conducted after the placement of the silt
barrier, gravel, distribution lines, standpipes, cleanouts, and
insulation, but before the placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Page Four
Sue Tawn Estates Subdivision #2; Lot 18; Block 1
May 05, 1994
Often there will be more than these 3 inspections required, especially with the
installation of multiple trenches, sand filters, pressurized distribution
systems, etc. Thus, the inspecting engineer is to be contacted at least 24
hours prior to the start of construction. If necessary, a pre-construction
meeting will take place on-site. The inspecting engineer will not coordinate,
direct or control in any way the contractor's activities.
The owner shall contract with the contractor to perform the work outlined in
these specifications and plans and in accordance with the attached M.O.A.
permit. There will be no contractual arrangement existing between the
contractor and S & S Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to document the
contractor's activities. Final acceptance of the contractor's work rests with
the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or
omissions of the contractor or any other persons performing work on this project
or the failure of the contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer will not be
responsible for the construction means, methods, techniques, sequence,
procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
(ENGINEER'S SEAL)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PER*ORMEO POR:
LEGAL DESCRIPTION:
1
2
4
5
6
7
8
9
10
11
12
13
14
15
17
18
19
2O
DATE PE~
Township, Range, Section:
SLOPE
/~\
WAS GROUND WATER ~[ ~'~
ENCOUNTERED?
SITE PLAN
IF YES, AT WHAT
DEPTH?
Depth to Water
Monitoring?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE C~,~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN S'-~ FT AND ~ ~-~ FT
COMMENTS (~[J)(~-~'- ~.¢~z~-~ %~, ~
PERFORMED BY: ~70~ E==~= ~=Y~ [~ RC=~ ~=. 3~/I ' / ~~ , CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WI~tL~8~AL GUIDELI~ ON THIS DATE. DAT~:
72-008 (Rev. 4/85) ~
(~ ~,~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
~ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
~ [] UPGRADE
MAILING A_DDR~SS ,/~ / ~. ~
Well Absorption area Dwelling~ ff~
~¢ ~ Manufacturer ~~, M~teria~T~~ No. of ~,mpartments
iLiq. ca~allons IF HOMEMADE: Inside length Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ < Manufacturer Material Liquid capacity in gallons
;~ DISTANCE TO: Well /~, Foundat~ ] Noarostlotline~ PERMIT~x/V~
~ Totalle thor lees
No. oflines f Length~e~)ine r~ Trench~ ' th
Total ef~absorotJon areo
~ Length Wid~~ ~ inches ~
Depth PERMIT
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ CJass Depth Driller Distance to.lot line PERMIT NO.
Building foundation Sewer llne Septic tank Absorption area(sD
~ DISTANCE TO:
OTHER
PI PE MATERIALS
REMARKS ~
/ ,,.
/
72-0~3 (Reu
DOC Co. dba
P.O. BOX272, CHUGIA~,A~ASKA99567 a TEL~PHQNE688-2759
OWNER OF LAND
ADDRESS /~ ?)
LEGAL DESCRIPTION~
DATE-Started
PERMIT NUMBER
Ended
DEPTH OF WELL / ~vO
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR ~:,C) ~'~
KIND OF CASING __
KIND OF FORMATION:
From~~ Ft. to -~? · Ft..
From -~ Ft. to / & Ft.
From_/~' Ft. to dY~~ Ft._
From Ft. to .... Ft.
From_ ~"' _Ft. to ~:~ ::~Ft,
Fromm. Ft. to Ft.
Ft. to='2 6 Ft.
From / q 2 z ....
Ft. to_/ ~(, Ft.
From~ t~ Ft. to / 'Z,~;3 Ft.
From Ft. to_ Ft.
'~
From~ 7~) 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
From___Ft. to Ft.
From Ft. to_ Ft.
From.___Ft. to Ft,
MISCL. INFORMATION:
DRILLER'S NAME
LOT SIZE
=,T_-,TErl !_,. TRENCH
;.F: '_-IF :,JIL RE'qt','PPTIZN .... -':' "
MAXIMUM NUMBER OF E, ELLL. UM .... ]:
S'."I_ RFFFING (:EL::' F'T,.'"f.3R)=
............ :T.: lEI1
THE ~'F:,I.IIRE[:, ....,I,:.L OF' TF!E 'q-iTl FIBSORPTION .... - ....
THE LENG]'H C, iNENSION IS THE LENGTN (IN F'EET> OF' THE TRENCN OR DRRINFIELD.
THE DEPTH OF' R TRENCH (:IR F'IT I.S THE DISTFtNCE BETNEEN TNE SLIRFRCE OF: THE
GROUND AND TNE BOTTOM OF ]'FIE EXC:RVRTION (IN FEET::,.
THERE IS NO -qET t.4IDTH FOR TRENCHES.
THE GRFtVEL D',EPTH Ii; THE MINIMUM DEPTH OF GRAVEL 8ETI4EEN THE OUTFFILL PIPE
AN[:, THE E:OTTOM OF THE E',qCRVRTION (tN FEET).
HH .... FI.I:, [:,EPRF,,:]"MEN"F [:,IJi~:IN!~i 'T'HE
PERMIT' HFF_IL. HNT THE RESF'ONSIEfII_IT'¢ -r_- INFOF-.:M T
ZNSTRLL. RTION INSPECTIONS OF RN'¢ klELL--, A[:,J'F~E:ENT TO TH!_, F~...FEF:t'r Rk!r', THE
NUMBER OF RESI[:,ENE:ES 'l"HFl'f' TNE NELL WILL _,E[~. E.
...... .. m,:. b:-. -_ Z~
']- ~.,~ C'.~ ~" ::7.. ":. ][ P--~ ,::., ~ ' ---._ L- T ]:: ...............
E~FtC:KFILLING OF AN'¢ '='-"= ........ .-F, R,~ ,
.... 1Eli HITHOUT F!!",IFtL II",kEPEC:TIf3N FIND F r:, ,r,,,- E:'T' 'TN!S
DEPFIRTMENT' NIL. L E,E _,LtE, JE_.I Ti PF'SSEZ_TT
MINIMUM DISTFINCE E~ETHEEN R NELL FIN[> ANY ON-SITE SEHRGE DISF'OSRL S'¢STEM IS
!00 FEET' FOR A PRI',,,'RTE HELL OR :l. 50 TO 2E~E~ FEET FROM R PUBLIC I.,tEL. L DEPENDING
UF'ON THE T'T'PE OF PUBLIC HELL
MINIMUM [:,ISTFtNCE: FROM R PRIVATE HELL TO Fi PRIVATE SEFIER LiNE tS 25 F'EET AND,
TO R COMMLINIT"~' SEHER L. INE IS 75 FEET.
OTHER REQUIREMENTS MA'T' APPLY. S;PECIF'ICFtTIONS AMD CONSTF.:LIC'.TION DIAGRAMS ARE
FtVFIILFI[:]LE TO IN'.:_;URE PROPER !NSTlaLLRTION.
I L-:ERTIF'¢ THFIT
~L: I RM FFiMII._IRR 14ITH THE REQUIREMENTS FOR Of.I-SITE SEHERS FIND, !-4EL. LS AS '-:;ET
FORTH B"r' THE MUNICtF'RL!TV OF F~f.,!CNORFIGE.
2: I HILL INSTALL TNE 'S'¢STEM IN ACCORDRt'.,ICE HITH THE CODES.
~:: I UNE:,ERSTFIND THAT TNE ON-SITE SEHER '.E:;'¢STEM MRV REQUIRE ENL. FtRGEMENT IF I"HE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ]: BED, ROOMS.
PERFORMED FOR:
1
2
3
4
5~
6-
7-
8-
9
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SLOPE
.SOILS LOG
[] PERCOLATION
r TEST
.ATEPEREOR.EO,
SITE PLAN
11
13-
14-¢
15
16
17
18
19
2O
COMMENTB
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
PERFORMED
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE //'~// /~ (minutes/inch)
TEST RUN BETWEEN FT AND FT
72-008 [6/79)
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
HAA# ~i~
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Lonnie Henry
Day phone
473 Farrell~ Street Enum~law, WA 98022
Seattle Mortgage / David W~Iz Day phone
560 E. 34th Ave. Suite 100 Anchorage, AK
Day phone
99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Individual well XX×
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
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 i..n_s, pection,
7034
Eagle River Loo~ Road NO:v~C)4
Engineer's signature -/~
o
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms,
bedrooms, with the following stipulations:
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.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~6'- T~,~JN~ ~-5TC, TE~' '1~2- Parcel I.D.
A. Well Data
Well type
Log present {~/N)
Total depth
Sanitary seal t~N)
/~/z~ VA 'F-~ If A, B, or C, attach ADEC letter. ADEC water system number
Date completed iO/Z7/F'l Driller ,~c'c~.lv,~,O
Cased to /?2. ' Casing height /2"
Wires properly protected (~N)
FROM WELL LOG
.g.p.m.
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot /OO
Public sewer main ,q//4
Sewer service line ,Z~ ' +
AT INSPECTION
(¢
' On adjacent lots
; On adjacent lots /~ ' +
Public sewer manhole/cleanout
Petroleum tank /d,/g.
WATER SAMPLE RESULTS:
Coliform ~2 Nitrate
Date of sample: (o ~ Z/_c/q ~ (¢--~
Collected by:
Other bacteria /
B. SEPTIC~TANK DATA
Date installed
Cleanouts (~'4)
High water alarm (Y/~)
Date of pumping
Tank size /Z.~'~ ~A/-, Compartments
Foundation cleanout (~N) . VE~ .Depression (Y~
/,~ Alarm tested (Y.(~
/J )/& Pumper '
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /o('J
To property line
Surface water/drainage
On adjacent lots /0o ' -~-
Absorption field ,_~'~ .e
/Od / 4-
Foundation
Water main/service line
72-026 (3/93)* Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Da~ Manufacturer ~
Vent (Y/N) "Pump on" lev~cLat~"~ ~..-.. "Pump off Level at
High water alarm level ~ Cycles tested~-"'""~
Meets~s (Y/N) ~
S[ZPARA~STATION TO:
Well on lot ~ater
D. ABSORPTIONFIELDDATA }/,)Fo~'~7/~'u ~.~V'ex~ ~.x..) UPbP..~Pc~' '~¢.'f-/~zJ ~
Date installed & -/¢ - ~ q Soil rating (GPD/FF)
Length .~0 ' Width ~ ' Gravel thickness
Total absorption area q2.0 ~+'~ Cleanout present.N) YES
Date of adequacy test ~/ -G - ?~ Results (pass/fail)
Water level in absorption field before test '76, ~' After test
Peroxide treatment (past 12 months) (Y~ lO If yes, give date
System type ,0~¢'
Total depth
Depression over field (Y~
for ;~ Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot iq7 ~
To building foundation Gq ~
On adjacent lots .u/4
Surface water /00 ' +"
Curtain drain /U/~
On adjacent lots I O0 ~ 4- Property line lO ~
To existing or abandoned system on lot Iq '
Cutbank s'O ' Water main/service line "J l A-
Driveway, parking/vehicle storage area Is-- ~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformedto/MOA and HAA guidelines in effect on~ l
Eng,neer's N ar~oce4~ii!! ~!i~
Date L~.~'? ~/~/'¢/~'
HAA Fee $ ~
Date of Payment
Receipt Number
Waiver Fee $,
Date of Payment
Receipt Number
this ins~)edtion.
72-026 (3/93)* Back
commercial,Testing & Enginee '
Environmental L~boratory Services
5633 f3 Street
Drinking Water Analysis Report' for Total Coliform Bacteria
READ LN'STR UCTIONS ON REVERSE SIDE BEFORE COLLECTZNG
MUST BE COMPLETED BY WATER SUTPLIER
Anchorage, AK 9951 8-1 600
Tel: (907) 562-2343
Fax: (907) 561-5301
TO BE COMPLETED BY L ~.~B. ORATORY
[ ,~nalysis shows da/s Water S.&¥LPLE to be:
l~ Satisfacto~'
~' [] Unsatisfacto~
[] PUBLIC WATER SYSTE~I I.D. #
PRIVATE WATER SYSTEM
Month Day
SA_~LE TYPE:
,1~ Routine
K Repeat Sample (fgr routine sample []
with lab ref. no. ~ {~ E~' -- )
[] Special Purpose
Time
SAM~PLE LO CATION Collected
Treated Water
Untreated Water
Collected
By
[] Sample over 30 hours aid, results may
be unreliable
[] Samole too long kn u-ansit; sample should
not i~e over 48 hours old at exan~nafion
to indicate reliable re~ts. Please send
new- sample ~5a special delivery mall.
DateRe;ceived -~-- / - ~'/-/
Time Received ~ ~ k ~
Analysis Began ,~UL [} ~ 1994
Anatomical Method: X Membrane Filter
/n' b.LMO-MUG
* Number of colonies/100 mL
Analyst
Sent to A.D.E.C. ~
Fbks
Jun
Date: . . Tkae: g
Client ootified of unsatisfactorY(reSUlts:
Phoned Spoke wSth
Date: TLme:
Faxed
BACTERIOLOGICAL WATER .ANALYSIS RECORD
MMO-.~G Result: Total Cohform
Membrane Filter: Direct Count
Verification: LTB
Fecal Coliform Confirmation
Final Membrane Filter Results
Reported By ~/~
E Coli
~ { ~:~21~ Colonies/lO0 nd
BGB ~. ~. COLIFmM Lt'/{',
Date
(~ Coliform/100 rd
/ oC)
~r~-I~'~ Member o~ the SG$ Group {$oci&l& G&n&rale de SurYeillanee)
CT&ERef.#
Client Sample ID
Matrix
· Commercial Testing & Engineering Co.
Environmental Laboratory Services ~,z~',~7~z~',~'~z~
LABORATORY ANALYSIS REPORT
94.3104-1
SUE TAWN S/D EST #2 BLK1, LTl8
WATER
ClientName S & S ENGINEERING WORK Order 79713
Ordered By R. SHAFER PrintedDate 06/24/94 ~ 11:09 hrs.
Project Name ColleetedDate 06/21/94 @ 10:45 hrs.
Project# ReceivedDate 06/22/94 @ 12:10 hrs.
PWSID UA
Technical Director
STEPHEN C. EDE
Released By~y.~~ _
Sample Remarks: ROUTRqE SAMPLE COLLECTED BY: JACK.
Parameter
QC Allowable Ext. Anal
Results Qua/ Units Method Lhnits Date Date Init
Nitrate-N 3.5 mg/L
EPA 353.2/300.0 10 06/22/94 MCE
* See Special Instructions Above UA = Unava/lable
** See Sample Remarks Ab eve : NA = Not Analyzed
U = Undetected, Reported va/ue is the practical quantification limit. LT= Less Than
82 D = Secondary dib~tion. GT= C~eater Than
5633 n Street, Anchorage, AK 99518-1600 -- Teh (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
Water Analysis Report for Total Coliform Bacteria
READ I. NSTR UCTIONS ON REVERSE SiDE BEFORE COLLECTING SAMPLE
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~-.~.~.~-.~.~-.a~.~'~-~'.a-.ar,~.~
5633 B Street
Anchorage, AK 99518~1600
Tel: (907) 562-2343
Fax: (907) 561-5301
~.~ST BE CON~LETED BY WATER SUPPLIER
[] PIJ-BLIC WATER SYSTEM LD. #
~ PRIVATE WATER SYSTEM
S_&MPL= DATE.
S.~'v~LE TTPE:
~ Routine [] Treated Water
[] Repeat Sample (for routine sample [] Untreated Water
wSth lab ref. no. )
[] Special Purpose
Time Collected
SAMPLE LOCATION Collected By
TO BE COM_vLETED BY LABORATORY
Pmalvsis shews dq/s Water S:&MPLE to be:
Satisfactory
[] Unsatisfactory,
[] Sample over 30 hours old, results m~-
be mm-eli able
[] Sa.,~ole too lonz in tr .~a~dt: semele should
not 6e over 48 ~ours old ~t exa,;r,&nafion
to indicate reliable results. Please send
new sample via special del~yery mrS!.
-7/zr
Date Received
Time Received ['~ I ~
Analysis Began
Analptical Method: ~.,Membrane Filter
[] M~MO -M-O G
* Number of co!redes/100
Lab Reft N% Result*
Analyst×
Sent to A.D,E.C. ~ Fbks Jun
Client notified of unsatisfacto~' results:
Phoned Spoke~Sth
Date: Time:
BACTERIOLOGIC.&L WATER A_NALYSIS RECORD
E Cell
Colonies/100 mi
MMO-MUG Result: Total Coliform
Membrane Filter: Direct Count
Verification: LTB~
~ecal Coliform Confirmation
Final Membrane Filter Restl~ts
Reporte By .]· ~;
BGB COLIFIRM
/100 mi
Member of the SGS Group {Seci6t~ G4n6rale de Surveillance)
-:NVIRONMENTAL ~ACILIT/ES IN ALASKA, COLORADO, FLORIDA, ILLINOIS. MARYLAND, NEW JERSEY, OHIO, UTAH. W~ST VIRGINIA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range}
Location (address or directioqs)
(b) Property Owner ~.~t/? fi[fi~ Telephone: Home
Mailing Address ~OX lb& C~u~I~I~
(c) Lending Institution Telephone
Business
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the followinq address: or: Check here~, if hold for pick up.
List contact person and day phone number below. ' ·
2. TYPE OF RESIDENCE
Single-Family ~
Number of Bedrooms
WATER SUPPLY
Individual Well t~ 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 confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2
72-025 fRev 8/861 Front
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 o n-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 ~V~/b~ '~//~J~,-/'~.q~ b, ~M~. Telephone ~ - ~7~ ~
Address ~0/ ~ ~t~ ~ ~ ~ ~ ~ ~ ~', ~5~Z
Date /Z//~/~
Engineer's Seal
DHHS APPROVAL
Approved for "/~'"'¢~"~'"S)bedrooms by
Approved Disapproved Conditional
Terms of Conditional Approval
CAUTION
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.
Page 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: /-- /'~
Well Classification
Well Log Present (Y/N)
Total Depth /,~6t/d~" Cased to
Static Water Level /$,e '/~,"
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) ,Y
Separation Distances from Well:
If A, B, C, D.E.C. Approved (Y/N)
Date Completed /~/~/,e' / Yield
Depth of Grouting
Pump Set At A-'~,.,"
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N) /'/
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole /¢2/-"
Water Sample Collected by
Water Sample Test Results
Comments .~z/~' / L
; On Adjoining Lots /--~'~ '
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
B. SEPTIC/HOLDING TANK DATA
Date Installed /~'~/ Size r'~O No. of Compartments
Standpipes (Y/N) ,}/ Air-tight Caps (Y/N) ,~ Foundation Cleanout (Y/N) /V
Depression over Tank (Y/N) /'/ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) /Y' ; for
Holding Tank High-Water Alarm (Y/N) ,~,//¢' Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course /'-¢'~'~' ~
To Building Foundation ~/
To Disposal Field ,~'~
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/N) /'/
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /~
To Building Foundation 2
Lot
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 %~.E./,J.~ ~
Length of Field ~. ?/
Depth of Field ~/~"
Gravel Bed Thickness ~ ~--'~
Standpipes Present (Y/N) $
Date of Last Adequacy Test /'~.,/~/~,,
To Property Line /~
To Existing or Abandoned System on
On Adjoining Lots .~"~ ~ ¢'
To Cutbank (if present) ~),¢ ~" ,,~,~',¢.~-.z/~-
Comments
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to a MOA ar)d HAA guidelines in effect on the date of this inspecbon.
Company _'.~t]/¢/) I~,~ ~dg, AG. MOA No.
Receipt No.
Date of Payment
Amount: $
Page 2of 2
Engineer's Seal
J Time~ ~ : \~,,,. 'Time ~...~
Date Date Date
Inspector Inspector Inspector
Comments Conditional Approval
' ('~) Aop 'eyed B~drooms
Date Sewer Installed ~ Permit No. Septic Tank Size
J[~ Holding Tank Size
Soils Rating Well To Absorption Area ~ Well Log Received
Well to Tank ~ ~
A~PLI;~T FILLS OUT LOWER HALF ONLY
Mailing Address ~. ~'. ~,~.~:%~ ~,...,~;. ~t~{/~7[~/ /-~ ~'[~ ~' ~7
Buyer ~ F~ ~,,) ~{~ ·
Address
Address-
Realt~ Co. & Agent ~.1 ~'~ ,~ Phone
Address ,/' '
Type.f Residence ~; % *
~*gingle Family ~
B Multiple Family / No, of Bedroo~s
~ Other
Water Supply
~'hdividual · A~ACH WELL LOG. A well log is required for all wells drilled since June
~ Community 1975. For wells drilled prior to that date, give well depth (attach log if
B Public Utility , · ' ~' available.)
~lndividu~l. -'~ Year Individual Installed: ~ '
B Public Utility ~¢~¢..,; When Connected to Public Utility:
B Holding Tank '-'
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
March 4, 1982
Lonnie Henry
P.O. Box ].06
Chugiak, AK 99567
Subject'~ Lot lg~, Blk I Sue Tawn Estates %~2
Approval for the individual sewer and. water facilities cannot
be granted until the follov~ing items have been complete¢~:
o ~qe water analysis report needs to be submitted to this
office from the Chem Lab, 5633 B Street, for our review.
The permit for tile installation of the on-site sewer system
will expire December 31, ].982. We have not receive(] the
as-builts of the installation in this office. If a private
engineer inspected the system, please send us the report
for our files and_ review.
Please notify this department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office ~at 264-4720.
Sincer~y, '
Robert C. Pratt
Associate Environmental Specialist
RP48/p/EH