HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 4 LT 9
MUNICIPALITY OF ANCHORAGE
DE ,~TMENT OF HEALTH AND HUMAN SER '~S
Environmental Health Division ,
825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720~.~
OH-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION
Address
lZ/0o 5'h_ 7- .-z ~,-,~
Lot ~ I Block Subd~ws~on
TANKS
SEPTIC [] HOLDING
TYPE OF SYSTEM
TRENCH ,~ BE[) ~ W. DRAIN E] OTHER
101¢1 depth from original grade
FT
Fl
Gravel width
FT ,'~ 0 FT
WELLS
Fl
[] PRIVATE [] OTHER (Identifv)
FT
DISTANCES
WELL
SEPTIC ABSOI~PTION
WELL
TANK FIELD
//,F / ~s~-'
f
Lo'r LINE ~ ~-o ~ 2:-o t
__ FOUNDATION ¢/& / ~j,- /
AS-BUILT DIAOaAM IShow Iocahon el well, septic system, property hne~,
driveway, water bodies, etc )
REMARKS:
72-013 {3/85)
.~-/. ~ -
'Ch.,,!l,/:.!l' ) i)i'~d::l::,'li::l..I I!~1'[:!: FIji,
l'91u:r ic pa.,, ty
Anchorage
P.O. ,', 196650
ANCHORAGE, ALASKA 99519-6650
(907) 264-~k!~ 4744
TONY KNOWLES,
MA YOR
DEPARTMENT OF HEALTH & HUMAN SERVICES
January 9, 1987
John Hagmeir
2204 Cleveland, Suite 201
Anchorage, Alaska 99503
Subject: Lot 9 Block 4 Skyway Park Estates Subdivision
On-site Sewer Permit UPgrade #860420
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1986.
Permits are issued on a calendar year basis by authority
of Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system not
installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit.
If a private engineer inspected the installation of the on-site
sewer system the original as-built inspection report (three part
form) must be sent to this office for review and approval, and
for documentation.
If there are any further questions, please call this office
at 264-4744.
Sinc~e~ely,
R.W. Robinson
Program Manager
On-site Services
RWR/ljw
eric: copy of permit
~ I ( )( ,I..
ALASKA B dlROFImeFITAL COFITROL Se uICgS, IFIC.
~nqineertnq 6 ~nuJromenM $1udJcs
SPECIFICATIONS FOR BED WASTEWATER TREATMENT SYSTEM --
SKYWAY PARK ESTATES, BI, OCR 4, LOT 9
1.0 GENERAL
1.1 Till,; DRAWINGS, SHEETS 1 THRU S, StlALI, BE PART OF Tills
SPECIFICATION.
1.2
AI,L MATERIALS AND WGRKMANSNIP SBALL bIEET THE
REQUIREMENTS OR THE MUNICIPALITY OF ANCHORAGE,
DEPARTMENT OF IIEALTH & tlUMAN SERVICES (DNHS}, Tile
CONDITIONS OF TIlE PERMIT, AND ALL APPLICABLE
RULES AND REGULATIONS CUHRENTLY IN EFFECT,
1,3
ALL EXCAVATIONS AND DEPTHS ARE ADVISORY, AND ARE TO BE
VERIFIED Oil MODIFIEI) IN THE FIELD llY A DHIIS APPROVED
INSPECTOR.
1.4
IT IS TIlE RESPONSIBILITY OF TIlE INSTALLER TO ADHERE
TO APPROVED DESIGNS FOR INSTALLATION, TO MAINTAIN THE
SPECIFIED SEPARATION DISTANCES, AND TO HAVE TIIE
APPROPRIATE INSPECTIONS.
1.5
IF TIIE INSTALLATION IS NOT INSPECTED BY AN AECS
ENGINEER, AECS WILL NOT BE RESPONSIBLE FOR TNE
DESISN. AN ENGINEER AT AECS SHOULD BE CONSULTED
PRIOR TO CONSTRUCTION, TO DETERMINE THE NUMBER OF
INSPECTIONS TIIAT WILL BE REQUIRED AND TO EXPLAIN
WHAT THESE INSPECTIONS WILL INVOLVE.
a.O SEPTIC SYSTEM
2.1
THE SEPTIC TANK SHALL BE A UPC-APPROVED TWO COMPARTMENT
TANK, CONSTRUCTED OF la-GAUGE STEEl, WITH BITUMASTIC
COATING, SET LEVEL ON UNDISTURBED SOIL, AN]) INSULATED
WITH AN OVERLYING LAYER OF 2 INCH BURIAL TYPE
POLYSTYRENE.
2.2
THE SEPTIC TANK SIIALI, BE A MINIMUM OF S FEET FROM TIlE
}lOUSE FOUNDATION, AND A MINIMUM OF 5 FEET FROM THE
ABSORPTION AREA.
2.3
THE SEPTIC TANK AND BED SHALL BE A MINIMUM OF 100 FT.
FNOM ANY PRIVATE WELL OR BODY OF WATER, 1SO FEET FROM
CLASS C WELLS, AND 200 FEET FROM CLASS A OR B WELLS,
UNLESS OTHERWISE SPECIFIED. LESS THAN 'rilE REQUIRED
SEPARATION DISTANCE MUST HAVE PRIOR APPROVAL OR WAIVER
BY ALASKA DEPARTMENT OF IIEALTH AND IlUMAN SERVICES
2.4 PIPING SHALL BE FITTED WITH A MECIIANICAL WATERTIGHT
CALDER COUPLING ON THE OUTLET AND INLET OF THE
1200 LUesl 33rd Auenus. Suil* B,Anchoro¥, Alosko 99503,(907) 561-5040
2.5
3.0
3.7t
3,2
3.3
3,4
3.5
3.6
3,7
SEPTIC TANK. PIPING SHALL BE 4-INCH SOLID PVC ASTM
[)3034 OR CAST IRON, SLOPED A MINIMUM OF 1/4" PER FOOT
WITIt A MINIMUM OF 4 FEET OF COVER.
CLEANOUTS SHALL BE INSTALLED AS DESIGNATED AND CAPPED
WITII AIR-TIGIIT RAIN CAPS (JIM CAPS OR EQUIVALENT), AND
HXTEND A MINIMUM OF 2 FEET ABOVE GROUND LEVEL.
SEEPAGE BED
THE SAND FILTER SHALL MEET TIlE FOLLOWING M.O.A.
CRITERIA:
SIEVE SIZE (MM) PERCENT FINER BY WEIGIIT
#4 (4.75) lO0
#IO (2) 75 - 100
#60 (0.25) 5 - 75
#200 (0.074) 0 - 15
THE GRAVEL FOR THE BED SItALL BE 0.5 TO 2.5 INCH,
SCREENED ROCK WITtl LESS THAN 3% PASSING #200 SIEVE
RESIDUAL. ALL SUBSTITUTES MUST HAVE PRIOR DHIIS
APPROVAL.
TIlE BOTTOM OF THE EXCAVATION SHALL BE LEVEL AND RAKED
WITH TIlE BACKHOE BLADE TO INSURE THAT THE BOTTOM HAS NOT
HEEN COMPACTED DURING EXCAVATION.
TIIE DISTRIBUTION PIPE SIIALL BE 4-INCH RIGID PVC WITH
A MINIMUM CRUStl STRENGTIi OF 1500 LBS. ALL PIPES SIIALL
tie LAID LEVEL, AND SPACED ACCORDING TO THE DRAWINGS.
MONITOR STANDPIPES SEALL BE PI,ACED AS StlOWN IN TIlE
DRAWINGS. THEY StlALL BE RIGID PVC ASTM D-3034, OR
OR 4 INCH I)IAMETER CAST IRON. THE SECTION SIIOWN WITIt
HOLES MAY BE EITHER DRILLED 0.5 INCH HOLES ON THE 6 INCH
CENTERS ON OPPOSITE SIDES OF THE PIPE, OR A SECTION OF
REGULAR PERFORATED SEWER PIPE MAY BE CLAMPED TO THE
SOl, ID SECTION WITll A NO-HUB CODPI, ING OR SOLVENT ,JOINT.
A RUltBER RAINCAP (JIM CAP OR EQUIVALENT) SHALL BE PLACED
OVER TIlE TOP OF TIlE PIPE.
IF THE FINAL GRADE OVER THE BED IS LESS TEAN 4 FEET
ABOVE TIlE GRAVEl,, INSULATION IS REQUIRED, USING DOW
EXTRUDED BLUE STYROFOAM BOARD. THERE SHALL BE 1 INC[I OF
4 FEE1 OF COVER, Bur 5HERE MUST BE AT LEAS~,~I8' t. NGtlES OF
SOIL EVEN THOUGII INSULATION IS USED. 'File S~.II) PIFE
EXTENDING FROM TEE SEPTIC TANK TO THE DRAINFIELD SBALL
ALSO HAVE 4 FEET OF COVER OR AN EQUIVALENT LAYER OF
INSULATION COMBINED WITH SOIL TO PREVENT FREEZING OF
TtlE LINE,
IF INSULATION IS NOT NECESSARY, THEN TIlE ORAVEI, MUST BE
COVERED WITH A LAYER OF A NONWOVEN FABRIC (SUCH AS
MIRA]?AI, FIBRETEX 200 GRADE, POLY-FILTER X, OR
EQIJIVALENT ) ,
3,8
4.0
4,].
4.2
4.3
TEE TOP AND SIDES OF THE BED SHALL BE PLANTED WITH A
WHITE CLOVER AND RED FESCUE MIX OR BLUE GRASS.
INSPECTIONS
THIS BED WILL REQUIRE THREE INSPECTIONS. TIlE FIRST
INSPECTION WILL BE OF TIlE OPEN EXCAVATION, TO ASSURE
TI{AT TIlE SYSTEM IS INSTALLED IN PROI~ER STRATA AND
DEPTH.
THE SECOND INSPECTION WILl, BE PERFORMED AFTER SAND FILL
IS INSTALLED, BUT PRIOR TO PLACEMENT OF GRAVEL AND
DISTRIBUTION PIPES. THIS INSPECTION WILL VERIFY THAT
THE FILLER IS PROPERLY INSTALLEI), TItAT IT MEETS
SPECIFICATIONS AND TI{AT IT FULFILLS TIIE INTENTION (IF
THE I)ESIGN.
THE THIRD INSPECTION WILL BE PRIOR TO BACKFILl, AND
VERIFY THAT DISTRIBUTION PIPES ARE POSITIONED PROPERLY,
SUFFICIENT GRAVEL IS PLACED, AND TIIE SPECIFICATIONS OF
THE DESIGN ARE MET.
ALASKA ENVIRONMENTAL
CONTROL SERVIC[ NC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO OF '~
DATE
ALASKA ENVIRONMENTAL
CONTROL SERVIC *' INC.
12OO West 33rd Avenu,~, Suite B
ANCHORAGE, AI_ASKA 99503
(907) 561.5040
SC^L~ / = ! 0
DATE
T
ALASKA ENVIRONMENTAL
CONTROL SERVIC' INC.
1200 West 33rd Avenuu, ouite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO. ~ OF
CALCULATED BY ~?'~_ DATE
CHECKED BY CA~E
SCALE ,~3 ~,
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
tENC~
,~SEAL)
PERFORMED FOR: N/o/I,,
LEGAL DESCRIPTION:
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
DATE PERFORMED:
Township, Range, Section: $~-~. z~-- f.,~/v/~.
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT I~_
Depth to Waler AJler , :2 ~ Oc ~
lYlonilorlng? ~,tr,~ '~ II Oale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE /;~ "~--- (m]nutes/mchI PERC HOLE DIAMETER
TEST RUN BETWEEN _ '~ _ FT AND ~ 0~.. FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT O~THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR: Jo '/~ '~
LEGAL DESCRIPTION:
1
2 ,$/~
3
4
5
6
7
8
9
10
11
13-
14-
15-
16-
17-
18-
19-
2O
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
(ENGINEER'S SEAL)
Township, Range, Section: .~ z .~ ~v z ~.-,~q~J ~'¢.~/-~--
COMMENTS '~"t '~'~ / % 4° ~'
SLOPE SITE PLAN
L
IF YES, AT WHAT O
DEPTH? p
E
WAS GROUND WATER
ENCOUNTERED?
Deplg to Waler Alter ~,- ~
Monitoring? Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE __ (mmuIes/mch) PERC HOLE DIAMETER __
TEST RUN RETWEEN ~-~ ~FT AND ~-~ FT
PERFORMED BY: /~2T ~'~ ~' I ~;'~ER~ IFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
N&bJ OEILLING TEL blo,90?--.M_,-.5247 Jul, o,95 22:17 P,01
""' M-W' DRILLING, Ins
... · ~
~ - P, O, ~x 4.1224 . 1310C aalAIr~rtRoad
' ~ w~ ; (907 2744611 .
; ~t / ~ - ANCHORAGE A~ )9509 ~:.
./. ~ ~t ~, DR LLING L~ ....
,, i~SjZe 0f casing--6-- Depth of 2i0 C~d to 2q6 ~e~{~{~.,.[ Alt'
''
Static w~er l~veL]'O,(.~t' dow) land surface, ~infsh o~ web (cheekone} open
. . Describe screen or perfo ~-,
Well pumping test at-~? ._ga'
of dr~wdQwn from static
Date of completion~ 16 Jul
Depth in feet from
ground surface
0 ...TO 1
170 __TO- 122
(minute) lot--A- __hours With--- 10,.,:___ i___~t,
, "~)~'~ .. .
WELL ~O~ ~ ~ - '~
Give details o formations penetrated, size of material, color and hardness __
~'- ...... 9, ..~%,.v.; :~,~.f.~,.+.~ · -.. ~,.~,
. ; ........ · :.. ,
~.....'~, :~.~. ~' ~ ~' ·.; . ,;&~ ~..
. · . , ~t'~f,,~ -.~ ,~
. .. . ~ ~, ~ t,,,..?. ~,..
'~',,~.- ar.vet~ m~d~~
Oln,/oy ~r,vo: .... ~ ....... ~ ~ . . , '
.... t~o ~:,'o~b~ . ..,. . .
•
• �.Gt " eO 6 9 70 7i
• Municipality of Anchorage • ,,
-t _ On-Site Water and Wastewater Program `Alai
't{i ._ _
(907) 343-7904 E 7 Y
c2i10 A "'h 4018
4 ti
Certificate of On-Site Systems Approval
Parcel I.D. 019-151-06 Expiration Date: �� �� 7 as 6 9 L 9
1. GENERAL INFORMATION
Complete legal description Skyway Park Estates Block 4 Lot 9
Location (site address) 1305 Woo Blvd.
Current Property owner(s) Jerome & Deborah Larsgaard Day phone
Mailing address 1305 Woo Blvd. Anchorage, AK 99515
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class Well ❑ Community ❑
Public Water System Q Public Sewer ❑
WaiverNariance request for: Distance:
Received by: i i 1 (/ l Date: Lsl T ,
COSA to be released to the engineer,unless otherwise requested W he engineer.
COSA Fee $ 5-At, / Waiver Fee $
Date of Payment 5-12.q[I' Date of Payment
Receipt Number O'jl,EO6 Receipt Number
COSA# O?U'8 /a3S 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.
In conducting an adequacy test,I attempt to provide a thorough,conscientious engineering analysis of the system in accordance with MoA COSA
guidelines and regulations.The reported results describe the performance of the system under the conditions encountered at the time of the test,
and separation distances measured to readily identifiable features. The operational life of all wells and septic systems depend on the local soil
condition,ground water levels that may fluctuate during the year,and the water usage of the family being served by the system.These conditions
are outside the control of the evaluator of this system. All systems eventually fail and satisfactory test results do not guarantee future
performance of the system,nor do they guarantee that there are no hidden defects or encroachments.Therefore we cannot provide any warranty
for future performance, nor can we estimate remaining life of the system. The content of this report is for the sole benefit of the owner listed
above.
Name of Firm Pannone Engineering Services LLC Phone (907) 272-8218
Address P.O. Box 100217, Anchorage Ak. 99510
Engineer's Printed Name Steven R Pannone Date 5/24/2018
OF
;* 2 1\ 9*'4
6. DSD SIGNATURE
System #1 Approved for ' bedrooms •Steven R. 'onnone:
System #2 Approved for bedrooms CE-8149 \ W
Disapproved 11141NOFESSIONA
Conditional approval for bedrooms, with the following stipulations:
�\����;
s
• ON-SITEc:
WATER AND "'
G WASTEWATER o
• PROGRAM
f
// Original Certificate Date: V O
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 blue sheet_f
If more than 1 septic system is on the lot:
COSA Checklist# 1 of 1
Structure served by this system 1
Certificate of On-Site Systems Approval Checklist
Legal Description: Skyway Park Estates Block 4 Lot 9 Parcel ID: 019-151-06
A. WELL DATA
l,L'LC,) J
Well type C L165 A If A, B, or C provide PWSID# Well Log (YIN)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height(above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 9/17/1987
Tank size 1500 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank(Y/N) N Hi water alarm (Y/N) N/A
Date of pumping 3 -36 -L3 Pumper __.\--SC L C Sd viV2T(..--c/
C. ABSORPTION FIELD DATA
Date installed 9/17/1987 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.8 GPD/SF System type BED
Length 51 ft. Width 30 ft. Gravel below pipe 0.5 ft.
..„1.Total depth ' ft. Eff. absorption area 1530 ft2 Monitoring tube Y Depression over field N
ti
Date of adequacy test 5/22/2018 Results (Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption` field before test 0 in. Water added 600 gal. New depth 0 in.
Elapsed Time: '/`A0 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d.
N
Any rejuvenation treatment (past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (Y/N)
"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
WELL ON LOT TO:
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10+ Property line 5+ Absorption field 5+
Water main 10+ Water service line 10+ Surface water 100+
Wells on adjacent lots 100+
ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 10+
Water Service line 1 0+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain 50+ Wells on adjacent lots 100+
F. COMMENTS
`{mss S . ft( f4 ,,f p,aZ
G. ENGINEER'S CERTIFICATION �~`�`"�x
�c�°F ALs1
I certify that I have determined through field inspections and AvTij- �4,-.1:;44
review of Municipal records that the above systems are in A?*: T '/\ •ytr y
conformance with MOA COSA guidelines in effect on this date. -••• •• i�
Engineer's Printed Name Steven Pannone �-�f
9� � S�ev R. •annone
5/25/2018 h-V.-•• CE-8149 0�
Date9C%;?'
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s ��
t�1v\a��i �
COSA canary sheet_2-6-15.doc
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The location of the structure(s)as ,4 . , It,+�,t a. lab
,�� a shown on this record drawing 3'a sM`` • f; +' `"/ `�
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k ,o (as buil complies with Title 21,AMC. L ><r ` �S. �
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SURVEY CERTIFICAROW r,,�
' a,wii,, Prepared by
.
+++. Robert E. Johns, Jr. & Assoc.
PLOT PIAN
„„,�.,..w�,,rrNIl». 44411,....,.. ♦�P..••••• •'•: � 1 Professional Land Surveyors
M.IN oww.w.n.......e.,a.114 r •M. (� , i 700 BRINK DR.
I....r...e w 44114444 4 I M e.rr... a J;'
•o.....w�w 4 b ew 114 N re, I _, ANCHORAGEt ALASKA 99504
n......•..w NNdt I 9 . ) r Scale: Rec. Lot S.F. Roc. Plot Fle No.
FOUNDATION AS-BUILT r• �/•••. /„ •• 1” c 30 1
L ww.n a+.wa r..Trey<war,Vol I / •••• ..r Date Surveyed: Drown by. Checked by.
Iw.......1:,,.74 :rMew eT 9-29-06 A REJ JT�x
1.,,. .w .M wN e,w
411444 Ne •` :• ROBE N5, k- Dote Drown: Grid: W.O.
DIDOM FINAL STRUCTURE
•44 444 �•. ' 21- eta• 28„Q6 2729 7021/6370
FMAL STRUCTURE AS-BUILT .$ ; •
f 'LegalDescription:
L www a be.r.,Jr,Mrt__ ver I49 444 en
r or Yr +e�ea '••............•••• ,,,,§44e 1
4444 444. d le141 d e.eN Woe ♦+� pro Teeetonek`":�.- I'Ot' 9 Block 4
w M.e.M I......_I-...1 r..... Ile. Skyway Park Estates
dem AldnM
tJ LOT SURVEY SVRVc.. 'TYPE SYMBOLS
O FOUNDATION AS-BUILT
O rINAL STRUCTURE AS-WILT • SET REHAB 77 W DRAINAGE ASPHALT
❑ PLOT PIAN . . .AS-BUILT. . .LOT SURVEY. . . TOPOORARHY
0 FOUND REBAR ..........--0. WOOD FENCE [•••••••• 1 CONCRETE
❑ AS-rdLT...HG caeTIISS w D awzryG7D11 AS-$pT...No comma art ® ASSUMED ELEV. = ;r METAL FENCE ® MOOD DECK
PLOT PLANS k LOT SURVEYS HQX:
IT IS THE RESPONSIBILITY OF THE BUILDER OR OWNER, PRIOR TO ONLY THOSE IMPROVEMENTS ABOVE GROUND AND VISIBLE WILL BE
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE SHOWN. FENCES, WELLS, SEPTIC CLEANOUTS, SIDEWALKS. DRIVEWAYS,
TO FINISHED GRADE AND UTILITY CONNECTIONS AND TO DETERMINE ETC., ARE SHOWN IN THEIR APPROXIMATE LOCATION, ONLY. SNOW
THE EXISTENCE OF ANY EASEMENTS, COVENANTS OR RESTRICTIONS MAY PREVENT SOME IMPROVEMENTS FROM BEING SEEN AND LOCATED.
WHICH DO NDT APPEAR ON THE RECORDED SUBDIVISION PLAT._ ALL,9ISTANOES BIE RECORD UNLESS- OTHERWISE NOTED.
UNDER NO CIRCUMSTANCES SHOULD AN AS-BUILT BE USED FOR CONSTRUCTION OR FOR ESTABLISHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPONSIBILITY FOR THE INITIAL TRANSACTION ONLY AND ASSUMES FINANCIAL LIABILITY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCALING. REPRODUCTION MAY CAUSE ERRORS IN SCALE.
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. f¢O l O~ -- I ~ I -- O,(¢2:,
1, GENERAL. INFORMATION
Complete legal description L~"L-. o~
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address.
,Dayphone _r~'-/'~-- t%¢Q
Day phone..
Agent
Address
_ Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATEFI DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
,/
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-O25 (Rev. 1/91)~ Front MOA t/21
5. STATEMENT OF INSPFCTION BY ENGINEER
ordinances, and regulations in effect on the date of this inspection.
NameofFirm "-~¢~-¢-~ ~j,C't,¢,~.~'~.~- Phone
Address
Engineeas signature
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 fides and from my invbstigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with afl Municipal and State codes,
~ ~'~¢ b~drooms.
DHHS SIGNATURE
~/~ Approved for
Disapproved.
Date
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Mqnicipality of Anchorage Department of FieaKh 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
responsiblb for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91} Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A, Well, Data
Well type ~...
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
\/ _Date completed ? - / f~ ~ '7 ¢ Driller /~
/
Cased to ,~ ¢-,/t2 26) ¢ f Casing height
Wires properly protected (Y/N) y
FROM WELL LOG
Date of test
Static water level '~, O
We,, f ow
Pump level1 '~'~ '~ ~,'~1_
AT INSPECTION
SEPARATION DIS'rANCES FROM WELL TO:
Septic/holding tank on lot //(.,9 ~:
Absorption field on lot I ~0 .¢;i
; On adjacent lots
; On adjacent lots
Public sewer main
Sewer service line
WATER SAMFLE RESULTS:
Coliform
Date of sample:
Public sewer manhole/cleanout
Petroleum tank
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
/
Date installed I~f~e' ,.?
Cleanouts (Y/N)
High water alarm (Y/N).
Date of pumping ~/t~- .~/~ .~
Tank size /,;,; ~'~' ¢.;' Compartments ~
Foundation cleanout (Y/N) y Depression (Y/N)
Alarm tested (Y/N) t'¢,~(
Pumper /~6- ~.,,~¢) ~,¢- d~¢~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I /
To property line ~'
Surface water/drainage
72-026 (0/93)' Front
On adjacent lots
Absorption field
Iq o
Foundation
Water main/service line
CONTINUED ON BACK PAGE
LIFT STATION
Date installed
Manufacturer
Size in gallons
Manhole/Access (Y/N)
Vent (Y/N)
"Pump on" level at
"Pump off" Level at
High water alarm level
Meets MOA electrical codes (Y/N)
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
~llO~ I~'~? rating (GPD/Ft2) ¢~-2~ /~ Systemtype
Date installed Soil ,
Length ?~ ! Width '?~ O Gravel thickness /.~;, II Total depth
Total absorption area I~ ~)f'~ Cleanout present (Y/N) 7 Depression over field (Y/N) '.,/ ,,,,
....
Date of adequacy test ~Z Results (pass/fail) for ~) Bedrooms
Water level in absorption field before test .(".¢~ After test I H
Peroxide treatment (past 12 months) (Y/N)
If yes. give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
we, on lot I AO
On adjacent lots ~ /0~0 Property line
To building foundation ~)E) '!
' To existing or abandoned system on lot
On adjacent lots ~ /O C.~) Cutbank N ~9 Vt¢¢- Water main/service line
Surface water ~ ¢;~ t,'~ 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 guideline¢ !~ effe~:the date of this inspection·
Engineers Name
Date
HAA Fee $ c~g)¢ ,' ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)° Back
%v- ~