HomeMy WebLinkAboutOUR MOUNTAIN BLK 1 LT 14 Municipality of Anchorage Page __.~_./of ~' 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: ._~¢4'/?5 ¢3 9/ PlO Number:., Name: ~S r/~ ~/~ Wastewater System: ~New ~ Upgrade Address: /~¢ ¢0~o~o~ ~, ~,, ~K ABSORPTION FIELD ~_~ 0 Deep Trench 0 Shallow Trench ~Bed B Mound 0 Other Total Depth from original grade: Lot: fi~ Block:/ ~Subdiv~i°n:~~/~ Depth to pipe bo~om from(¢,original~ grade: Ft. Gravel depth beneat~ip~v.~ Ft. Township: /S~ Range: / ~ Section: /~ Fill added above originsl~ade: Ft. Grave]length: ¢~ Ft. Number of lines: Distance b~n lines: WELL: ~ New ~ Upgrade Gravelwidth: /5 Ft. ~ ~,~ Ft. Classification (Private. A.B.O): Total De~th: Cased To: Total sbsorption area: Pipe materiah Stalic Wa~¢r Level: Da~e installed: Pump Set at: I C~ing Height A~ve Ground: SEPARATION DISTANCES ~Septic ' U Holdin~r U S.T.E.P. To Septic Abso~tion Lift Holding =~Pdvate Manufacturer: Capaci~ in gallpns: sud~ce / N/A LIFT STATION Lot ~ ~ Manufacture~ Line &O ~ ~5 / Size in gallons: Foundation // ' ~S' ~/~ "Pump on" level ~t: ~~- High water alarm at: CuAain Drain ~/~ > Pu~lectrical Inspections pedormed by: Remarks: BENCH MARK Location and Description: I Assum~ Elevadon: EN~,EER'S 8~L Inspections pedormed by: :~:~ Dates: 1st 0¢/7/?~ 2nd Depadment of H d Hum ices approval Reviewed and 72-013 (Rev. 9/91) MOA 25 Permit No, ,.~/7512.~/ Page 2 of 2 Municipolity of Anchoroge DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,O. Box 196650 · Anchoroge, Alosko 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legol Description: OUR MOUNTAIN LOT 14 BLK 1 A CLASS C WELL RADIUS No.: PARKING AREA LOT 14 / / ~/ELL SWING TIES A-C = 138.3 B-C = 183.7 A-II -- 158.1 B-D = 143,8 ELEVATIDNS (NOT TO SCALE) ORIGINAL SCALE 1'=50' - MONITOR TUBE - SEWER CLEANOUT - WELL 7/2:3/96 ENGINEER'8 SEAL :'~...' 49 TH'~~'' '..?. ^~", LOUIS A. BUTERA %%;. ............. PERFORMED FOR: LEGAL DESCRIPTION: Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST /~o~'/~ /~.,'r / O~-,,-/~.'-,,-' Township, Range, Section: 7'wZ 1 2 3 4 6 7 8 10 11 12 13 14 15 16 SITE PLAN SLOPE WASGROUND WATER ENCOUNTERED? ./xJO S L IF YES, ATWHAT O DEPTH? p E Dal~t~ 10 Waler Attar ~/r7 17 18 19 COMMENTS PERCOLATION RATE __ Imsnules/mcnl PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND___.~'-- _FT PERFORMED BY: ~'~/'~' ~-" J I ''~ ~ ~:~ r~ ' ~ CERT[FY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WiTH ALL STATE AND MUNICIPAL GUIOELINESIN EFFECT ON THIS DATE. DATE.. ~'Y~-- )~ ~'~ ' '/~'' : : ~ ~ : : : : : i : : : [ : : : : i ~ : 0 0 0 0 0 0 0 0 0 0 0 0 ~ : : ~ : ~ 0 0 0 0 0 0 0 © 0 0 0 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW950381 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:WHITE CHRISTINA M OWNER ADDRESS:16929 CORONADA #4 EAGLE RIVER AK. 99577 DATE ISSUED:il/08/95 EXPIRATION DATE:il/08/96 PARCEL ID:05111146 LEGAL DESCRIPTION: OUR MOUNTAIN ELK 1 LT 14 LOT SIZE: 43950 (SQ. FT. NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (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: RECEIVED BY: ,- ~ DATE: ISSUED BY: _ DATE: To EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294. EAGLE RIVER, ALASKA 99577 Phone 694-5195 RF_C IVED Munimpaiity ol Anchorage Oept. Health & Human Servi(~gject LETTER Please reply [] No reply necessary SIGNED / CBI]RDS (X,Y) t = 4764.80,52_P5.47 ¢ LOT 10 ~'~~ ~.. I LI3T / L3T t TRACT 5 /X ~ / ~ TRAC 6 , / N ~ ~ - TEST HOLE / { x ~ o - SEWER CLEANOUT I ~ ' - ~- - WELL NO SURFACE WATER ~,m PROPOSED LEACHFIELD ~ ~- EX~ST~NO LEACHFIELD NO KNOWN CURTAIN DRAINS m EASEMENT LEGAL: OUR MOUNTAIN LOT OWNER: WHITE -~.." CONTm*CTOR: ,/A ~2..~*~"..~'*. J08~ SS-OS~AI DAT~: 04/30/96 k ~.~. ¢o~ **,¢z¢~/ ~AGL~ R/V~R, A~. ~77 l~%r~ss~o~~.,, ~  COORDS (X,Y) A = 4764,80,52~5,47 :~ B = 5064.~6,5084,46 LOT 10 CLASS C V/EL/\ ~. / N ~ ~ - TEST HOLE / ~ ~ · - MONITOR TUBE ~ SURFACE W~RR ~ ~ PROPOSED L~CHF~ELD ~- EXISTING L~CHFtELD KNOWN CURTAIN 0RAINS m ~SEMENT WELL/SEPTIC SiTE PLAN LEGAL: OUR MOUNTAIN LOT 1¢, BLK 1 OS-OSOAIDATZ: ~/O~/9sl SCALE 1" = 60' EAGL~ RIVER, AK. 99577 (907) 694-5195 FAX: (907) 694-3297 EAGLE RIVER ENGINEERING SERVICES P.O. Box 773294. EAGLE RIVER, AK 99577 (907) 694.5195 JOB SHEET NO CALCULATED BY CHECKED BY OF SCALE Our Mountain Lot 14' BIk 1 10/25/95 Single Family Three Bedroom Home 3BR x 150gpd = 450gpd Soil Rate = < 1 min/inch = 0.7 gpd/ft2 sand filter bed system Required AbsorPtion Area = 450 gpd / 0.7 gpd/ft2 = 643 sf Gravel Depth = 6" below pipe, 2" above pipe Gravel Length = 43' . . Gravel Width = 15' Sand Filter Depth 2' MOA approved filter sand mater/al BOttom of Sand Layer ' = 6" below original ground surface - Bottom of Gravel Layer = 4' below original ground surface G:\WPDO CS\1995\95-039A.CAL SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Our Mountain Lot 14, Block 1 10/25/95 2. 3. 4. 5. 6. 7. 8. 9. BED 1. 2. 3. 4. 5. 6. 7. The well & septic plan is for a single family residence only. The drawing and or site plan shall be a part of this specification. All materials and workmanship shall meet the Anchorage Department of Health requirements. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage requirements. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. Any remaining open test hole excavations shall be filled. The bed is to follow the natural land contour to maintain uniform total depth of the bed bottom. The bottom of the bed shall be level, plus or minus 1.5". The total depth of the gravel layer is not to exceed 4' at any point. 2' sand filter under gravel layer. The bed gravel is to be covered with typar fabric material. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed over the bed. Mounded side slopes not to exceed 3:1. The area over the bed is to be finish graded to prevent ponding of surface water runoff. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. ~ LEACHFIELD DIMENSIONS: BOTI'OM OF FILTER SAND LAYER = 6' BOTTOM OF GRAVEL LAYER = 4' SAND FILTER DEPTH = 2' of MOA/ADEC approved material GRAVEL DEPTH = 6" under pipe, 2" over pipe BED LENGTH = 43' BED WIDTH = 15' SOIL RATING = 0.7 GPD/ft2 BEDROOM CAPACITY = 3 SEPTIC TANK = 1,000 gallon minimum Twenty-four (24) hours uotice required for all inspections. G:\WPDO CS\ 1995\95-039 A.S PC 1 PERFORMED FOR: LEGAL DESCRIPTION; Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Z~¢ r/,¥ /¢/y / f__~,.,, ~ ,,~,,,-,.~ Township, Range, Section: Tff I 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS SLOPE SITE PLAN $ WAS GROUND WATER ENCOUNTERED? S L IF YES, ATWHAT DEPTH? //, 5- O P E DeI~B to Wirer Ailer Monitm'ing? Date~ Gross Nat Depth to Net Reading Date Time TTme Water Drop ~/,,~- PERCOLATION RATE (m~nules/mcl~) PERC HOLE DIAMETER TEST RUN BETWEEN FT AND FT PERFORMED BY: ~/"C' ~_~.j' I ~2~,~.~;~- ¢o ,.~..z.---,--_,% CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: /'¢ ~ '~ 7'~7')~ Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~, LEGAL DESCRIPTION: ~,~' DATE PERFORM6D: /C;' ~ ,:~ o -- ~- Township, Range, Section: DEPTH SLOPE SITE PLAN 1 2 3 4 6 8 9 10 r WAS GROUND WATER ENCOUNTERED? 11 s L IF YES, AT WHAT O 12 DEPTH? ' p E Oaplh to wirer Alter v 13 - Moniloring? ~.,,ry Date: /~ - .z ?.~ 14~ 15- 16- 17- 18- 19- 20- PERCOLATION RATE ~.D_ {mmutes/mch) PERC HOLE DIAMETER TEST RUN BETWEEN -- FTAND __ FT COMMENTS Gross Net Dapth to Net Reading Data Time Time Water Drop / /~-~/ /::z: ~ ~- " I-z: ~ / ....4 z/L//" ~ " ~ '" /.z; 7'~ z¢/ -~-"' z~ /. /2 ; ~5- I ,~,L/ Z/''-//" ~'- I" /;~ : 3& o/ /~ :3? / /-.*.J' ~/"/"" ~/" PERFORMED BY: ~-~,/C' ~_~j I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIOELINESIN EFFECT ON THIS DATE. DATE. Z/'~''--)~V '-2'.)-- Municlpallly ot Anchorage r3EPARTMENT OF HEALTH & HUMAN SERVICES 825 "/" Street, Anchorage, Alaska 99502-0650 SOILS LOG ~ PERCOLATION TEST PERI=QRMEO FOR: DESCR,PT,O : DATE PERFORMED: ~or/,.¢ /~/r'/ /_~.,,- .,~.,'-,~ Township, Range. Section: 1 2 3 6 7 8 10 11 12 13 14 15 16 17 18 19 2O DEPTH o / SLOPE / WAS GROUND WATER ENCOUNTERED? /'~0 IF YES, AT WHAT DEPTH? ne¢$ (o W~ Nt~r i COMMENTS SITE PLAN Reading Date TTme Time Water Drop / /o.~..~'.'¢ /;/~ :~ '-.~'~ :~ ~ , / : /.~ : , o ~, ~ ~, ~ .?,-,,-" ~ " y ,, /:' 1.5';$~ /. 3-.....,,: 5, '-,f ,- ~- ,~ ,, {.,/7 ?'-~ PERCOLATION RATE __ TEST RUN BETWEEN -- 42, ..2 ~- (mlnuleS/inch) PERC HOLE DIAMETER FTAND _L,/ PERFORMED BY: ~-~/C' ~_~j I CERTIFY THAT THIS TEST WAS PERFORMEO IN Municipality el Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: ~'. LEGAL. DESCRIPTION: DATE PERFORMED: Township, Range, Section: 1 3 4 7 8 9 10 11 12 13 14 15 16 17 18 19 SLOPE SITE PLAN WAS GROUND WATER ENCQUNTERED? Il: YES, ATWHAT --~ .._~ ~ ~' DEPTH? Oa~ to W~ ~ / ~i~? ~7 0a~ _ /~ -~ PERCEPTION RATE~ ~ (mmu[e~mc~) PERCHOLEOlAMETER ~ x/ TEST RUN BETWEEN ~ FTAND ~ ~ _FT COMMENTS Reading Date Gross Nat Def3th to NaT Ti'me Time Water Drop / /~'.~'r' i: *~? ~ <~ '/ /; ~ 3 ~ .~ y'- / ~ ~ " 7 '/ I,'7~ ~ '- V" ~ ~' /; s? ,'~-~ ~ .~ ~,~ ~ '-/" ~" ~' [: ~ 3 '' 7~ PERFORMED BY: /,c.,~ ~j I CERTIFY THAT THIS TEST WAS PERFORMED IN Louis Butera, P.E. Registered Civil Engineer October 25, 1995 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Our Mountain Lot 14, Block 1 Narrative & Permit Application Dear Mr. Cross: The proposexl well and septic system will have very limited impact on adjacent properties for the following reasons: 1. The surrounding lots are large, allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space is adequate, due to absorption capacity. 4. Drainage will not be affected and is not a major consideration in our design. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. \G:\WPDOCS\1995\95-039A.NAR P.O, Box 773294 . Ea~le Rivet'. Alaska 99577 · Teleohone f907/694-5195 · Fax (907~ f194-3297 / ~E~T. OF ENVIRONMENT/~L C@NSERV~TION Anchorage Western Districe Office 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 ~ILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 Robert A. Shafer S & S Engineering SRB 196X Eagle River, AK 99577 Dear Mr. Sharer: July 31, 1984 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION AUG 6 qaaa RECEIVED Subject: Lot 14, Block 1, Our Mountain S/D Wastewater Approval. (8521-DA-016) We have reviewed the plans and specifications for the subject project. The plans are approved, conditioned on adherence to the following items: 1. screened rock back fill in deep and wide trenches (3/4" 3"). 2. screened rock back fill in absorption bed (3/4" 1 1/2")~ 3. sufficient area plotted on as,.built for replacement system, This letter constitutes the permit required by A.S. 46.03.720(a) for, plan approval of sewerage systems. It should be remembered that final approval will necessitate the submission of Engineer As Built Plans to include photographs as indicated on page 13 of enclosure. This will consequently mandate that a professional engineer conduct basic inspection of this project so as to be able to sign off on as built plans. Arrangement for this inspection work is the responsibility of the developer. Sincerely, s F. Hayden/~-~' Environmental Field Officer JFH/dd Enclosure cc: Robbie Robinson (MOA) As Built Plans submitted by Approved by Date Date January 4, 1982 Hal W. Freitag Box 70 SR1 Eagle River, AK 99577 Permit ~ 810911 Subject: L 14 B 1 Our Mountain A permit issued by this department for a well and/or sewer system has expired as of December 31, 198].. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal Ordinance. If you have drilled the well, a well log should be sent to this department Lo document the installation date. If an engineeu inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. if there are any further questions, please call this office at 264-4720. Sincerely, Les N. BuchholzF~./S~. Program ~anager~ Sewer and Water Program Enclosure: Copy of Permit F'ERHIT NO, FIF'PI~.. I CRB!T LOE:RT :t: ON I...[EGFIL F.tFII_ 14. I::'F.':E i 'I"FIG I'"IFtF:I<: C I RCL. E L:!..d. B::I.. OUR I'"IOI..JI'4TFIIt'.,! [:,EF'FIR'T'M[.ENT OF HEFILTFI RN[:, ENVIF,'ONHE:NTI:::IL E:2.'5 '" L. '" :STF,':EET., FINE:HOF..'RGiC., Ftl".::. 9.:95Et1., ( O:.OZ!)9::I.,::L ::, E: ':'0.:: ":' '/ R. ~'i ct s--I '~ ,. ~:: ~;F.':::I. E. L.O"F S 12% ]"'fF'E OF E;O I L. F]EESOF::F'T I ON S'¢STEH I S: TRENE'.H i'"IFIX :[ HUH f.,ILIHE:E:I:;;: OF' EE~[',:ff;.:OOH!5 :'~ ,'$ SOIl_ RFITI'NG ,:."i;[.:! FT,-"Eff~?..':,:;~* THE LENGTH D I t'"IE:I",I!~; I ON I S THE tu. EN.r;..JTH < I N FEET :) OF' 'THIZ '['F,i:ENE:H OF.: [::,IRFI:[ NF:' I EL.I:,. THE [:'E]°'I*H 01:;' FI "['RE:NCH OF..' F']:T I:E; THE DIE;TRhfCE: E:E"FI4EEi",I THE s;ur~:'.F'F:I[::E OF 'THE GF.'.OUND I~N[:, THE D[]TTOH CIF THE: E',,::(:::R',,¢wr I ON < ]:N f:'EE:T.'.',. THERE ]:S:; NO SET I.,.I:f. DTH F'OR TI:;tENC:HES. THE GF:'.Ft'¢EL. [:,EF'"FH tS 'THE M]:N:[HUF'I DEF'q"H OF' [:?iFE:FIVEL. E:EFf'I.qE':EN THE: OUTF'FIL. L PIPE FIND T'HE BOTI"OH OF THE: E;",'C:Ia',,,'FITI ON ':: I N FLEET). F:'E:RM :["F FIF'F'L I E'.FIIq]' I.,fiaS THE RIESF'ONE; I E,' I L I "f'"? TO I hlf::Ol:'?.P1 'TlR I E; DEF"F:IF::THEhFF DtJF: I NEi THE ]:r,r:ilTf4LLFff' I O1'.~ :[ NE;PE:CT IONS OI:7 i::II".W WELLS i:i[:,JF:IE:ENT TO 'FH]::5 I:;'ROF:'E!:F.:TV' FIIqlJ." THE: lql...IHE$:]r;~: [:iF: RE:E; I DENC'E:E; I'HFIT 'THE 14ELL N ILL SEF.:',,,'E. [. I...,t,.i: IL.L.t. IIU OF' Fll",l"r' ::,~,:,rE,i'l !.,.IITH[:IU'I' F:I:NflL, ,'[NSF'EC:T.f. ON f:IN[:, FIF'F'F. tO',,,'Fil.. [:,-r "I"Ft:[:!!; DEI,::'FII:~',TMENT I..,IILI_, E:E: :!E;UB.]'EE:T TO PF,.'OSEC:Lr~,ION.; '. I',I]:NIi',II. Jr,1 D:[ET]"i::lf.,tC[E DETI,JEEN Ir"/ WELL [tiN[::, F:lN"r' ON--:E;,f. TE :t. EIO [::'[E'ET FOR I':t PR:EVFITEE NELL OF.: :l..E~E:.l 'T'O 200 FEE'I" FROH UF'ON THE: T'¢PE O1::' F"UE:L. IC 1.4ELL.. 1"III'.4:[HUH D:[S'I"FtNCE: FF.':[)H fa P~::[',,,'F:I'T'E !.4E!...L TO F':I F:'R.f. VflTE SE:!-..IEI:;;: I...]:NF: ]:S 25 F'EET FIN[':, 'FO I::1 COI'"IMLIN :t: T"? %EI,.IEF.'. L :1:. hie :[ S:; '75 FEET. OTHEEr.4: REQLI]:F:~EI','IENTE; MFI"r' RPPL'¢. SPEC:IF]:CFITE[ONS laND CON%TRLIC. TION [:,IFt[~if~'.FIHE; FII:E'.IE R",,'R :1: LRBI-.E 'TO It',ISURE F'F'x]r:'E:F.'.' I NSTFILLFIT ] ON. I CEI:;i:T I r;"y THF:IT :L: :[ FIH FFIFII[..IF/Fi'. Wi[TH "IT-IE F."OF~'."f'H B'¢ THE HUN I C I PFIL I T"r' [iF FINC:HCIRFI(:~E, 2: I IqILL..f. NSTf::ILL THE S'-¢STEH II',1 FIE:COFi'.DRNC:E NITH THE CODE'.::;. E:: if. UI'.,IE)E:F.:'.:E;TFIND THFFf' "['HE []N,,.-$ITE :5[:T.I,IER S'¢[STE:I'q f"lR"r' F'.EQt.IIF.:E~ ENLI::tI:~tGI:~HE;NT :!:F' "['HIE RES ]: [:,ENCE :[ S F.':EHEK>E;L.E[:' TO E; I I:ii",l[~':l:::,: : ........ : .................................... F FF'.. [ C::h'" Ht::l[ ;, / .[ 483q 'TamPA C~gcLE. A/qCNORP, G-E LITy OF i'"":' i':-. i .:-i':':; ' ~i:'~ MUNICIpAUTY'OFANCHORAGE;t'! . ~':: '~.- '1:'~'.~ DEPARTMENT OF HEALTH & HUMAN SERVICES ',:'" .?: ,-: '~"---.~ .: :..:i D'i~,isi'bn'6f EnVironmental Services .... ~l. 4~o~' . ,: . · .-?,. ..., , ,.,On~ite'~ · ' -' - ' ' ' ' · ' ' ~Y[~I ' :'-:,'. ', ,": :-~ ~';'.' ~'::"-'..P O:Box 196650..' Anchorage"A aska ~.99519;6650t' ','2;/." .. , ; ,;; ON . ".. :' '..-"_', ~' ._ '~. ~'-'"'~:;~ ;. ': ~'", ': ~ER~IF'CA~E~:O~,HEALTH ~UTHOR 'TY"'~ --'': ' I ' ' *' :r[~'~ ''~ ~ :APPROVAL FOR~ S NGLE FAMI'LY DWEEL:'N~ ....... ~' '''--V~'"lJ:' ' ' 1. GENERAE INFORMATION, ~ ~ ...... ., ~ ~ ~..~ ~ ~,_.,,~ ,~ .... ~.~,.. , -.:` , ComPlete;legal.descriptiOn., Zo~-/~ '~/a 'Lo~t~tion:'tsite'address.or-- '- directions) . _ '.~,~ ¢. : ',. · ,~'~., ,_(~.'.; ~_~. . . . . . ~' ',t '.:"-. '~-,' ..... :";"-.,'-., . . -' ~,~,,'~e~.~:~er~;.~t~g~'~ ~'~ '~ ~'~P'~% ~;~Day phone ' ~:):'Mail'ing'~dd[~s~';%~??~g~'- ~¢[~ ~,~¢¢ ~W 2¢%~' ;: .... ":.~L~,ndih'g¢~g'e~c~;': ,,':t:~ ,~..~1 ~.,¢~ - ~, DaY Phone , · - '"' ,' ~¢':;-,', . .,%',, .. , ...,,'.._? ,~'. . . , , . · . - . Age~¢-''4'':*'t'''F'* ' ' Day phone ' Address,. . :. .: 2;. '- 3..TYPE'OFWATER~rSUPPLY:' ' ""' Individual well Coml,~unity well ' '- :'"Public water"' ' Unle~-s'otherwise:requeste~, HAA will be held for pickup- :. ;. .. . NUMBER'OI=BEDROOMS:" "~' "/' ' R ' MAY 0 t 1997 Municipality of Anchorage Dept. Health & Human Services NOTE: If community well system, provide written confirmation from State ADEC attest- ing to'the legality and status of system. ~ 4, TYPE. OF WASTEWATER DISPOSAL: -~ ' ~" : Individual.on-site . H61'ding tank ".'L" Gommunity on-site NOTE: 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) Front MOA #21 Address .u. Uoz 2232o~, Engineer's signature Date STATEMENT OF INSPECTION BY ENGINEER As ce rtified by my:s~al affixed hereto and as of the validationdate shown below, I verify that my '"'iii~st gat on' Of this' Hea th Authority Approval application shows that the on-site water supply "Ca-nd/or wastewater disposal system is safe, functional and adequate for the number of 12edrOoms and t~fpe of str6icture indicated herein. I further verify that based on the information obtained'from the Municipali,ty, qf~Anch orage files and from my investigation and inspection, the on-site water su.p, pl~/,~nd~or'~as~ewater disPosal system is n compliance with all_ Municipal and State codes. ordidances and regulations in effect on the date of this inspection; ' Name of Firm ' ~.,~I.~'1~--__~ .. · _',.. . Phone ¢/'¢'-'~/~ DHHS SIGNATURE .~. Approved for '7-~EEd/~ bedrooms. Disapproved. Conditional approval for (! \/ .'-, bedrooms, with the following stipulations: 'Additional Comments The Municipality'~f Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 1/91) Back MOA #21  Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICEs Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-~4z 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 Cased to '/~ ;;~ Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production /°5- WATER SAMPLE RESULTS: Coliform Date of sample: .//- ;z ,.,, FROM WELL LOG ~-~ -?4 .g.p.m. Nitrate AT INSPECTION g.p,m. 5, '2 d '~,2/~- Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ?- ~' Foundation cleanout (Y/N) Date of Pumping Tank size / ~,o Number of Compartments ',~- Cleanouts (Y/N)__ ~ Depression (Y/N) ,~J High water alarm (Y/N) ~/~ Pumper C. ABSORPTION FIELD DATA Date installed 7 ,/?¢. Length ~ 3 Width Effective absorption area ~ Date of adequacy test p //I- Gravel thickness below pipe Monitoring Tube present (Y/N) Results (Pass/Fail). Soil rating (g.p.d./fF or fF/bdrm) ¢, ? d:'~/~ystem type d' /~ Total depth __ Depression over field (Y/N) For '--- bedrooms Fluid depth in absorption field before test (in.); '~ Irnmediately after % gal. water added (in.): Fluid depth '-- (ins) Minutes later: peroxide treatment (past 12 months) (Y/N) -~ Absorption rate - g,p.d. ---- ,-',~/.4 If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES F. Size in gallons "Pump on" level at* *Datum On adjacent lots On adjacent lots SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot /~/o~ Public sewer main /v/,~ Sewer/septic service line /Co / SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation // Property line Water main/service line '/-/¢ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: -~D ' Building.foundation -?~' Property line Surface water ./--/cz, / Curtain drain /~ ~ ENGINEER'S CERTIFICATION "Pump off" level at* ,w Public sewer manhole/cleanout Lift station /'4 /,~ Absorption field Wells on adjacent lots -¢-/~-~¢ Driveway, parking/vehicle storage area Wells on adjacent lots "/'/%¢ ' I certify that I have determined thru field inspections and review in conformance with MOA HAA guidelines in effect on this date. Signature ~~-~'~ Water main/service line Engineer's Name HAAFee $ '~ ' r~ Date of Payment Receipt Nu mber~::~ ,~ Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* ~'ample Remarkq;: S~.mpl* colic_crud by: LB ..... CF&,E Microbiology Dt, it~aug Water p~og~am ccr6ficafioli smtu~ ia promaong! :ks o~ 4/g/gT. o