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HomeMy WebLinkAboutSKYWAY PARK ESTATES BLK 6 LT 4 Municipality of Anchorage Page / _of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 34.3-4744 On-Site Wastewater [:)isposal System and/or Well Inspection Report ~ ¢P¢~.1~, Ld~ ¢[~(C~ ~/~ Wastewater System: Q New ~ Upgrade ~c~ W~O l~ '/~/~' ABSORPTION FIELD LEGAL DESCRIPTION soil Rating:~ ¢ ~ GPD/Sq. Ft, Total Depth~ from_ ~grigina' grade: I ~ I Fill added above original grade: Gravel leng~ ~:~ ~,h:, Township: ~ ~ Range ~ Section:~ ~ ~ C~ Ft. Ft~ WELL: B New U Upgrade .O IDislSnce between lines: Driller: DateDrilled: StaticWaterLevel:Ft. ~¢~]]/~*//~' ~/~02~¢;~ ~)6(¢ ~- ~_/ Yield:GPMII Pump Set at: Ft.I[ Casing Height Above Ground:Ft. ~'ANK SEPARATION DISTANCES u Septic U Holding ~S.T.E.P. Surface ~?/~ '<* LIFT STATION Li.e ~' :~'~ Z~' ~/~V //a' Size in gallons: [ Manufacturer:, Curtain /V'f~ (~ Pump Make & Model IBeCricallns~ections,erformeCby: , Remarks: ENGINEER'S SEAL Inspections performed Department of Healt~d/~IqY~ Services approval %;k~.~..~ '%q"~: %oJomes~ F'l~lzSi;e~°reE .°a ?"~ Reviewed and approved by: ~~~ Date:.~-~M~'S>~ 72 013 {Rev. 9191) MOA 25 Permit No..~ ~/ e/c3c~]~,?Z/f Page ~- of ~ Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIFIONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report __ 72-013 A (1/93) * El Permit No. qlW ?~ © ~ _~'- Page of 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 Legal Description: /~. ¢,L/~/_,~ ,~/,F>/Vv'tt Y ~:i~1' ~ ~-.,~/~ F~-'PID No.: James F. Slzemore ! 1517 72-013 A (1/93) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF ON SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950224 DESIGN ENGINEER:JAMES SIZEMOORE & ASSOCIATES OWNER NAME:ROGERS LESLIE NICOLE OWNER ADDRESS:1400 WOO BOULEVARD ANCHORAGE, ALASKA 99515-3214 DATE ISSUED: 8/16/95 EXPIRATION DATE: 8/16/96 PARCEL ID:01915109 LEGAL DESCRIPTION: SKYWAY PARK ESTATES BLK 6 LT 4 LOT SIZE: 57000 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE lin 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 (iSAACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: AT THE TIME OF CONSTRUCTION THE ENGINEER SHALL EXPOSE BOTH THE LIFT STATION AND THE SEPTIC TANK TO VERIFY THE INTEGRITY OF EACH. ENGINEER SHALL CALL THIS OFFICE TO BE THERE AT THIS TIME. ~/~ ISSUED BY: DATE: James Sizemore & Associates Civil Engineers & Surveyors 6410 Switzerland Drive (907) 345-1572 Anchorage, AK 99516 WASTEWATER DISPOSAL SYSTEM SPECIFICATIONS LOT 4, BLOCK 6, SKYWAY PARK ESTATES SUBDIVISION 1.0 GENERAL: 1.1 The scope of the project consists ofinstalation of a new 15 ' by 100' bed drainfield to replace the existing bed drainfield. A visual inspection of the existing STEP tank indicates it to be in acceptable condition. A connection will be made to the discharge line from the STEP tank to the new bed drainfield. 1.2 Construction shall be as shown on the approved site plan and design drawings. Deviations from the approved drawings shall be co-ordinated and approved by the engineer conducting the inspections. 1.3 All construction proceduresand material used to construct the system shall . comply with current Municipal and State regulations. 1.4 Unless specifically agreed otherwise, the homeowner shall be responsible for placement of topsoil and reseeding all areas disturbed by construction after the bed is constructed and the design grade is estsblished. 2.0 SOIL ABSORPTION DRAINFIELD: 2.1 The soil absorption drainfield shall be a 15 ft. by 100 ff. bed type constructed in accordance with these plans and specifications. The bottom of the 15 ft. by 100 ft. bed will be excavated level to a depth approximately 2.5 ft. below the existing ground level. 2.2 A total of 1.0 ft. of sewer rock shall be placed over the excavated area. The perforated distribution pipes in the drainfield shall be spaced as shown on the drawings and at least 6 inches of sewer rock shall be beneath the invert of the perf pipes, with the pipes being placed level. Sewer rock shall be 0.5 - 2.5" screened gravel, with less that 3% passing the #200 sieve. 2.3 Cleanout pipes and monitor tubes shall be 4" diameter and installed in locations shown on the drawings. The portion of the monitor tube extending through the sewer rock shall be perforated. 2.4 Two inches of rigid, burial type insulation will be placed over the top surface of the sewer rock. The insulation may serve as filter fabric. A minimum of two feet of backfill shall be placed over the insulation. 3.0 ENGINEERING INSPECTIONS 3.1 A minimum of four engineering inspections will be required during construction of the wastewater system. One after excavation of the bed prior to placement of sewer rock, one after the distribution piping is set, one when connecting into the STEP tank discharge line, and one after the insulation is placed and backfilling and grading is complete. 3.2 The contractor shall notify the engineer at least 24 hours prior to the start of construction. It is suggested that prior to start of construction, the contractor and the engineer should hold a site meeting to discuss the project. PROBABLE IMPACTS TO ADJACENT PROPERTIES A} WELLS: The proposed wastewaterdisposal system replaces an existing bed system that has been in use since this house was built. This home is also now served by city water. The proposed wastewater disposal system is designed in accordance with current Municipal and State Wastewater Disposal Regulations, Since most homes in this area are connecting to city water, and adequate separation distance is also maintained between the bed and adjacent wells, ther shoul be no adverse impact from this new bed system. B) WASTEWATER SYSTEMS The system is designed in accordance with current municipal regulations, therefore there should be no adverse impact of adjacent wastewater systems. C) RESERVED SPACE / SURFACE AND SUBSURFACE There is enough space on this lot to put in another replacement system and still maintain the required protective distances between wells and disposal systems, D) DRAINAGE The location of the disposal system will not interfere with any drainage. The area disturbed during construction of the system will be graded and sloped to prevent ponding of water. ,),, .... ~-~ : LoT' 'I ,v ,...:., / 0 0 ' Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORME LEGAL DESCR,PT,ON:/__~/_/i~/~ ~' ,~/tO~),!/ , - , ownsnip, ~ange, becuon: SLOPE SITE PLAN IF YES, AT WHAT DEPTH? 12 / Oeplh to Waler Alter /.{¢~ 7.~/~~ 13 I~ooil0ring? ; /' ~ Date: Gro$~ Net Depth to Net Reading Date Time Time Water Drop /~f ~ ~;.c~ /~ W'c~/-' ~,~, ~ z~ ,' ~ : - 14 15- 16- 17- 18- 19 2O PERCOLATION RATE ~ tm,nutes/mch) PERC HOLE DIAMETER ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THSDATE DATE: //'-- ~ ~ 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 3 4 5- 6 7 8 9 SLOPE SITE PLAN 10 11 12 13- 14 15 16 17 18 19 20- WAS GROUND WATER ENCOUNTERED?~ V E I~aniloring? )' '--' Date: Gross Net Depth to Net Reading Date Time Time Water Drop ~_. '~, r '~ .... ~c-_.~/-1- ~ _ PERCOLATION RATE ~ ' '~ {mmutes/~nch) PERC HOLE DIAMETER TEST RUN BETWEEN 'Z,' ~ FT AND ~--< ~ F7 COMMENTS PERFORMED BY: ~'~ .~3 THIS TEST WAS PERFORMED IN 72-008 (Rev. 4/85) James Sizemore & Associates Civil Engineers & Surveyors 6410 Switzerland Drive Anchorage, AK 99516 (907) 345-1572 Angust t4, 1995 Mr. Dan R01h MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SEI~.VICES Division of Environmental Services On-Site Services Section P.O. Box 196659 Anchorage, Alaska 99519 RECEIVE[) AtJG 1 41995 Municipality of Anchorage Dept, l-lealth & Human Services Reference: Proposed Disposal System Upgrade; Lot 4, Block 6, Skyway Park Estates Subdivision. Dear Dan: As You suggested, I had the septic tank on this lot pumped. The water level in the lift station tank was then monitored for 24 hours. The septic tank was pumped on the afternoon of Augnst 10. I arrived at the site at 6:00 P. M. I removed the hatch cover from the lift station tank. The tank had just completed a pump cycle at the time of pumping the septic tank, therefore the water level in the tank was at its low point. The lift station tank is a steel tank, approx. 3 ft. in diameter by 12 ft. deep. The interior of the tank appears to be in good condition. The tank had been coated before it was originally installed. The top of the tank is approximately. 12 inches below ground surface. There is a hatch with a removable covet' to access the pump assembly inside the tank. The hatch is similar to a septic tank access. I tneasured from the rim of the hatch to water surface in the tank. The water surface was 10 ft. 21/2 inches below the hatch rim. I measured the level again on Aug. 11 at 12:00 P.M. and 6:00 P. M. The measurement remained 10 ft. 21/2 inches. Since the top of the lift station tank is less than 1 ft. higher than the ground level at Test hole no. 2, the water surface in the lift station tank during my monitoring is below the ground water level. No water ran into the lift station tank indicating it to be watertight. Since the tank visually appears to be sound, and no groundwater infiltrated during my monitoring, It would appear that the lift station tank is in satisfactory condition to allow issuance of the permit to construct a replacement disposal field. Sincerely yours, James F. Sizemore P.E.  MUNICIPALITY OF ANCHORAGE · ~i 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 ~k' Z Manufacturer ~ f,~}~p. Matel'ial~f Ct~ [ N°' of compartments ~ Liq. cap~ty~n,~811ons Inside length Widtk Liquid depth , ~ Well Dwelling PERMIT NO. O Z ~ Manufacturer ~ Material Liquid capacity in gallons ~ W011 Nearest lot line~1~ i~ PERMIT O, No. o[ lines Length of each line / 'Total lengt~o~ ~nes Trench width - ~istance between lines ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT ~ Building foundation Sewer line Septic tank Absorption area{s) ~ DISTANCE TO: OTHER ~ '~ ~IPEMATERIALS ~ ~ __ SDIL TEST RATING INSTALLER ~PPROVED DATE LEGAL 72-013 (Rev, 3/78) Vern' s Drilllng STATE OF ALASKA OEPARTMENT OF NATURAL RESOURCES Meridian JoP. Hoehne T 8 1 ~t. g~ray ~ pan sllty g~av e~l -~._uUi~ -g~h-d-~ girg~Y~ seepage seepage _~UNICIPALITY OF ANC~IO~ ~;~¢.; ,,~.~.tJ_ 5, ~)Cable t0o' r~Rota,~y [']Driven []Te~: w,,, E]O,b.r: __ 7, CASING; E~]Threaded ~Welded 6 in. to 81 ft. Depth Weight _-- STATIC WATEN LEVEL: ~]Above ~elow land surface Type of Me,sureme.~: ~'~ ~'~ Approved Pit inches above grade 12, GROUTING: Well GrouLed: ~] Yes .aterial: [~.eat Ce~nt E] Other: 13. PUMP: (If available) HP Length of Drop Pipe ---- ft. ca.city perforated 58' - 68' Wa. tear _Tempe r at u re: --. Vern's Drilling & Ent Address: ~IPPLL1 Avi on SILL, ~ ~3~:L~ Si,ned, Form 02-WWR MUNICIPALITY OF ~NCHO~OB, ~UI~INO ~F~Y ~IVI~IO~ '3bO0 ~MT ~UT~O~ IN~P~CTIDN~: (907) ~2'=3464 ' ' IN~OI{M~TION: <907) · ,, PHONE ~1: COMMgHT~: POSY-I' '~ brand tax iransmittal memo 767~ ~ o, ,~7; ..... RECEIVED OCT 3 199'J P.Ol MUNICIPALITY OF ANCHORAGE f Health and Environmenta' Street, Anchorage, AK. Department 825 264-4720 ~ ~ * HANDWRITTEN PERMIT WELL AND/OR ON-SITE SEWER PERMIT Location: Legal Description: ~_ cfi ~ Type of Soil Absorption System Is: Trench: Drainfield: Maximum Number of Bedrooms: _~ Protection J9501 The Required Size of Phone Number: ,~/~-~ ~ Seepage Bed:: ./¥' Holding Tank: Soil Rating (sq. ft/br) ~ (~ the Soil Absorption System Is: ~ ~3 ~' ' __ WIDTH XC/ ~ DEPTH ~ _. LENGTH . .X ~c/~' GRAVE_ DEPTH ~,/' The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = //250 GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final'inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 8 2 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. I will install the system in accordance with I understand that the on-site if ~~dTce~ remodeled to T (2) (3) Signe~: are codes. sewer system may ~equire enlargement include more that~/~drooms. Date: ~//~ ~/~ '~ - MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 826 L. Street, Anchorage, Alaska 99501 2.64-4720 SOILS LOG -- PERCOLATION TEST y SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 7 8 DATE PERFORMED: Lo-I- 4 SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND WATER ~0 SL ENCOUNTERED? O IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN CERTIFIED BY: FT AND FT ^TE: MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOl LS LOG /PERCOLATION EST PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 7 8 13 14 15 16 17 18 19 20- SLOPE damp ¢:~Y'ckI sl'H<J dv'~ - vel't) ro:c~l ara DATE PERFORMED:, -J/-'~J'~ /~/ /~'"~'~ SITE PLAN ENCOUNTERED? N() - IE YES, AT WHAT DEWFH? Gross Net Depth to Net Readin9 Date Time Time ~j~ ~ ~ Water Drop I lZ:c~ lO ~qq6 ,005 PERCOLATION RATE /*~--~ (minutes/inch} TEST RUN BETWEEN ~. )~...~.~ FT AND - FT COMMENTS PERFORMED BY: ,p~- t~J/-'//~' L. CERTIFIED BY: 9-o-¢ 7 72-008 (6/7g) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTFI AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST JSOILS LOG [] PERCOLATION TEST PERPO,.MEO FO.: Ca+hI, ~ C~A L DESCRIPTION: 2 3 4 5 6 7 8 9 SLOPE BATE SITE PLAN 10 11 12 13 14 15 16 17 18 19 20- WASGROUNDWATER S ENCOUNTEREB? \~'~; ~ r IF YES, AT WHAT ,~l DEPTH? ~-~ Reading Bate Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) COMMENTS TESTRUN BETWEEN PERFORMED BY: 72-008 (6/79) CERTIFIED BY: FT AND -- FT . 825 L, Street. Anchorage, Amask8 99B01 264-4720 SOILS LOG-- PERCOLATION 'rEST ~J~"~ SOl LS LOG JPERCOLATION TEST EEREORMEO FOR: A/c~/~_ ~ ~ ! LEGA,-' ESOR,' T,ON:_ 7 zo> 4 SLOPE 1 3 4 5 6 7 8 DATE PERFORMED: JUN[:' /dY: I?dY.2 SITE PLAN 10 11 12 13- 14- 15- 16- 17- 18- 19- 20 COMMENTS PERFORMEDBY: P~¥~7~)~'¢~- WAS GROUND WATER S ENCOUNTERED? ~ P E IF YES, ATWHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop i /~.1o,~ , ~ I/, 51 1/2 NI/Y , ~ ~ ' II ,,zt~ Io ~/IY , ~ I · OI PERCOLATION RATE . {minutes/inch) TEST RUN BETWEEN .~-~-FTAND ~ FT f ,d 2,/ CERTIFIED BY: '~ 72-008 (6/79) ALASKA :lUlF:lm:llAL C0[/-I~1~01. SF, ItUtC6,S, lilt. ~nqhltcr'in~ $ ~ntlJt'0nm~lfloJ ~lur]ies MUNICIPALITY OF ANCHORAGE ....................................... ENVh: .! I A..0 E ;: ~! xP COD: ....... ~:~:~:9 .................. TOTAL DEPTH OF HOLE .............................. FINAl. PERCOLATION RA'I'E ..............._~_.~ .................................. (rain/in) PERFORMED BY ............... ~ ~_ .......................... MUNICIPALITY OF ANCHORAGE .. DEPARTMENT OF HEALTH & HUMAN SERVICES ~i' .... Division of Environmental Services P.O. Box 196650 Anchorage:Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL. FOR A SINGLE FAMILY DWELLING Parcel I.D.# . ¢~]}\¢'~ - "GENERAL INFORMATION.. '- Complete legal description ....... 6 r Location (site address or directions) Property owner.~, Mailing address Lending agency Mai!ing address_ .:.Day phone Day phone Agent _ ' ' ' ......... :'"" Bay phone -- Address -'" ':' :'':';:'?'::'L::'i';'' .... ' '. :: . ":!::::L "' . . "~ - ~ ..... rewues,e,,, HA~.';wfll ,~,r~c~u~. -- .., ...... 2.. NUMBER OF BEDROOMS. ,~,~..; .... $,~.~tPE OF_WATER SUPPLY,. ........................ Indw~dual well ..r. . ............................................ '. .... ' Cornmun ty we -~.-.,. ' '-- .,'.-..:~ ' ' Publlc water . ...... NOTE: If communi~ well system, provide wri~en confirmation from State ~EC att~t-~: . . ....... ~ ~;~ ~ ,. ~ng to the legali~ and status of system . .~ ', ~ ~ . -f~ ,' .~ , h~.~:;f~','?;.;];h; ~u, .~ ~ ,.:.hOommu~ ty on-s NOTE: If commum~ wastewater system, prowde wn~en confirmation from State ADEC .-.; ". ~mii "'""'" "" ': ............ ......... ' "' a~esting to the le y and status of system. 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seai affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval appl cat'on shows that the on-s'te 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 inves_tLgation 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 F rm~- . .- .r Phone Engineer's Signatur . Date -- RECEIVED 001' 1 ? 1995 Munimpality et Anchorage Dept, Health & Human Servicea Approved for bedrooms, '-' :" :' Disapproved; ...... :.: ', ' '- - : ~ .... ' Conditional apPl;o~al'f~'~~'':! *" '- -; :,?-.'-.u b~room8, with the following'stipulations: Date , . _ ,: - !.,,?:. ;.; ,' .- :. The Munioipality of Anchorage Department of Health and Human Servicss (DHHS] I~ues Health Authority ' ;..:' Approva Certificates based oqly .upon the representations given in paragraph 5 above by an independent - -;,'~ -..,;.'' pmf~ona eng neerr~stered ntheStateofA~mka TheDHHSdoesthmasacourt~ytopurchasemofhomes · ~ i,!~'i -.:: ?:'-:"uiand their lending nst tut ons n orderto sat sty certa n fedora and state requ rements. Employees of DHHS do not ,"'~ ~'L: :'i~~:::' n !~..;.-i,;§~:;,¢~,f'~co. du.ct, ,_ inspections or analyze d~ta' before a certificate is ssued, The Municipality Of Anchorage is not '~, ~F-F.y¢.~(,? respons b e for errata orom ss ons ~ the profess ona eng neer's work. ,' '' '~':~" ..... lu~ll~If. Sl" DEPARTMEN~OFH~LT~ &HUMANSERVICE8.~';~ ;:: ................... ~ .... P.O/Box 196650'~ Anchorage; Alaska' g951g~650 ....... .', ~',- - ~', "~'" APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. ~ I ..- Complete legal,descriPtion ~ ~7'~ ~ ~' TYPE OF WASTLWA rER DIS10SAL ., · , 5. STATEMENT OF INSPECTION BY ENGINEER * >,;-. As certified by my seal 'effixed 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, functior~al end adequate for the number of bedrooms and type of structure indicated herein. I fur[her verify that based on the information obtained from the Municipality of Anchorage flies and from my invest, i~lation and inspection, tile on-site water supply and/or wastewater disposal system is in compliance with all MunicilJal and State codes, ordinances~ and regU!a, tions in: effect on the date of this Inspection. . ~ ' r ' 'i:; :' . phone :.,~::~.~.~.~ Na m~ of Fir m L,/,:~),~..~,..~..~' ,~ :,.z~_~~ ,,~. ~ ~~ , - 6. '.DHHS SIGNATURE ': :.: ...... ...... .,-,.~: ,i.......~ ~::.:~:. --~-..'..-.'.Appro~ie~ '~o~:' ,.::'. .bedrooms. · ......... '.:-..~,The Mun~ipall~,~fi~Anahor~ge Department of Health and Human So,ices (DHHS) issues Health Authorl~ "::..A~0val' O~i~t~ bas~ 'only Upon the representations given in paragraph 5 above by an independent ' ~prof~s~na o~h~; ro~iatorod in tho 8tato o[ ~laska. Tho ~HHS dooa~hla aa a cou~aY to ,urc~om of homos ~ a~d th$ir Iondin~ Ih~tlt~tlon, in ordor to satla~e,~ain I~0~1 and 8taro r~q~ir~mon~,' ~m~loy~s Of D~8 do not .%,.::_~ eonddet ifi~poetlon~ ...... ?~analy~o da~a b~foro a ~o~ifi~ato ia is~od. Tho Munielpal[~. .. o~. ~n~ora~o~ ~ I~ no~ .... rospon*i~l~ for orro~ or omm~on~ m tho profo~onal ~n~in~e~ wo[,~. ~ ~ - *~ .. ~ /. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICFS Environmental Services Division 625"L" Street, Raom 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: L..z:¢-/:~F~PTY?T,~:~el I.D.: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary. seal (Y/N) IfA, B, or C, attach ADEC letter. ADEC water system tmmber ]2)ate completed Cased to Casing height (above grouad) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m, g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: SEPTICmOLDING TANK DATA ~2,7: ]~. Date installed ~ cd.~b,J~)(~, Tank size I --~ &'q(_9 Number of Compartmeuts ~5_ Cleanouts (Y/N) Foundatiou cleanout (Y/N) ~/ Depression (Y/N) W High water alarm (Y/N) Date of Pumping Pumper C. ABSORPTION FIELD DATA Date installed /1~/?, L/ /~.~ Soilrating (g.p.d./fl2orft2/bdm0 qO-*'/,~7~d/S~ys/t;mtyl}e Length / O0 ( Width [ ~ ( 0 / ~,/r Gravel thickness below pipe Total depth Effective absorption area /~0 ~b Moaitoriug Tube present.m) ~ Depression over field (Yin) Dateofadequa, test ~-~ ;,~,/~'fr~t//Results (Pass/Fail) F~--' % For ~- bedrooms Fluid depth in abso~tion field before test (iu.); hmnediately after gal. water added (in.): Fluid depth_ Minutes later: (in.) Absorptioo rate = g.p.d. Peroxide treatment (past 12 nrouths) (Y/N) . If yes, give date LIFT STATION <77 Date installed .~) Manhole/Access (Y/N) High water alarm level Cycles tested ~'x~.~ Size ill gallons ~Pump on' level at* ~'~;:" // "Pump ofF' level at* *Datum ~0~)c, E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: ~./'-'/-~f C&Y.~Y~(:~,b~' Septic/holding tank on lot ; On adjacent lots Absorption field on lot : On adjacent lots Public sewer main Public sexver manhole/cleanout Sewer/septic service line Lift station SEPARATION DISTANCES FROM SEPT[C/HOLDING TANK ON LOT TO: Foundation ~)LC5)~ , Property ~e ~C~ / Absorption field 3 · b'l Water mai*ffservice line ~ Surface water/drainage ~O:~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Buildiog foundation ~Q2,~ Surface ;vater ~V~ © /) ~ Curtain drain AJ t5 ~/~ Water main/service line / ~_. (eD / Driveway, parking/vehicle storage area / ~.- ,2-53 Wells on adjacent lots ~ / ~)t~ £ F. ENGINEER'S CERTIFICATION i certify that ! have determined thru field inspections and review of Municipal records m confbrmance with MOA H/DI guid~nes in eJJkct on this date. Signatt//_~ ~ '~ ~ - . Engine~'s Name~ ~ ~ /~ % HAA Fee $ c~OO ' rf~' Waiver Fee $ Date of Payment Q --~::~J -- ~'4~ Date of Payment Receipt Number / ~'_~' ("-~/V~)) Receipt Number Rev. 8/95 OSS: haa.wk.doc