HomeMy WebLinkAboutOUR MOUNTAIN BLK 2 LT 4 Municipality of Anchorage Page t of_'2~ 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 Wastewater System: ~ew D Upgrade Address: ABSORPTION FIELD ~[~ of Bedrooms:~' ~ Deep Trench ~allowTrench ~Bed ~Mou~d ~Other Phone: .' LEGAL DESCRI PTI ON Soil Rating: O, ~ GPO/Sq. Ft. Total Depth from original5/grade:  SubdivBion: ~ Depth to pipe bottom from original grade: Gravel depth beneath pipe Lot: Block: ~ OO~ ~ ~' Ft. Township; Range: Section: Fill added above original grade: Gravel length: WELL: ~w ~ Upgrade Gravel width: ~ ' Ft. Number of lines:/ O~stance beiw~n~ lines:FL Classification~,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: Driller: t ~ Date Drilled: Static Water Level: Installer: Date installed: Yield: Pump Set at: Casing Height Above Ground: t'¢ GPM d~ Ft. ~¢~ ~t. TANK SEPARATION DISTANCES ~eptic D Holding U S.T.E.P. To Septic Absorption Lift Holding ~Private Manufaot~ A ~¢ Capacity in gallons: From Tank Field Station Tank Sewer Lines ~ . Well' ~?¢~ i?~ I ~ / ¢¢~ Material: S~¢~ Number°fC°mpartments: Surface ~O~ ~, ~ Water ~ ,'~ ~0,* LIFT STATION Lot ~ ,~ k i~ ~ ~ Size in gallons: ~Manufacturer: Line ~O ~O "Pump on' level at: "Pump o~/] High water alarm at: Curtain ~0~ ~-- ~ ~(,~ Pump ~~ectrical Inspections performed by: Drain Remarks:~ 9~ ~¢~6~ ¢~.¢~¢¢¢ BENCH MARK _ Location and Description:  Assumed Elevation: ~ ~ .Inspections performed by: 17034 E:g~c RI';c~ L~p ....... o..~ · ~ ~r~/~% Department of Healt~and Human Services approval ~,,>,,. ,..;~ 72~013 (Rev 9i91) MOA 25 Permit No. sW950152 Page 2 of 2 Municipality of Anchorage DEPAR'FMENT 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 LOT 4, BLOCK 2, OUR MOUNTAIN S/D 05111162 Legal Description: PID No.: co 1 co2 I I n / FINAL (BADE SEPTIC I ~' yANK ~ .... COS 07.6' & 8i.6' iWATER FOUND '!'6':: 2 '~ g 5 WELL SCALE i A Bi FCO 6' 36' $1'1 11' 39' $T2 16' 42' · GO't'' '"2'3! 45~ CO2 24' 46' ¢O3 110' 146' 604 58' 73' MT1 108' 144' .......... C'O '~ NEW 1" = 40' C04 CO2 /::NEW 1000 GAL SEPTIC TANK ROBERT C, COWAN CE -8801 72-013 A (1/93) · 5ep 21,95 15:24 No.O04 P.02 PAGE 1 OF 1 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:SW950152 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:VILLAGE VENTURES OWNER ADDRESS:20618 EDWARD CIR CHUGIAK, ALASKA 99567 DATE ISSUED: 7/11/95 EXPIRATION DATE: 7/11/96 PARCEL ID:05111162 LEGAL DESCRIPTION: OUR MOUNTAIN BLK 2 LT 4 LOT SIZE: 115171 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION 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 (18AAC80) . 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: . ISSUED BY: ~~/~ /~ DATE: DATE: HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SiTE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTEWATER DISPOSAL SYSTEM DESIGN ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. June, 19, 1995 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human S~rvices P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 4 & 5 (proposed Lot 4A); Block 2; Our Mountain Subdivision to s~rve th~ proposed three bedroom hou6~ on the referenced prope;~t~. Test holes approx~nate s~ plan. w~re excavated and percolation tests performed. The location~ of the test holes are located on the attached At the time of excavation, water was encountered at q feet in test hole #I and g feet in test hole #2 and after seven day ground water monitoring water was found at 8 feet and 8 feet respectively. This property has enough ar~a for a future septic upgrade which can be seen on the attached site plan. We do not anticipate, any adverse effects on neighboring we~Is, septic systems or drainage patter~ by the, install~on of the proposed septic system. There are no points of contamination within the proposed w~ll radius which can be, seen on the attached site plan. If you require addition~ information, please contact us. SincereZy, Enclosure 17034 NORTH EAGLE RIVER LOOP * SUITE 204 · EAGLE RIVER, ALASKA 99577 d ©~z ~ ~ ~ COO O-WOW ~ d~ ~ o~m z iH3N3SV3 3J_VIS O.-J ~<~ no w O0 ~Z 0 NOlS30 NVqd--311S J ~"1¥D~ ,09 = ,,L PERFORMED FOR: Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFO Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18- 19- 20- COMMENTS Iff SLOPE WASGROUNDWATER /YE: ENCOUNTERED? S IF YES, AT WHAT / L ? ° DEPTH? p E Depth to Water Alter Monitoring? SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~ '~ (minutes/tach) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND '~ FT PERFORMED BY: "~ & S ENGINEERING I ~'/.'%"~ ~'~,* J [~ CERTIFY THAT THIS TEST WAS PERFORMED IN 17034 Eagle River Lool~ Rgl~.d..No,,,;~,O4 I ACCORDANCE WITH ~T~j~I~GuIUbc ...... N EFFECT ON THIS DATE. DATE: ~ ~ ) ~ ~ ~ 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES $25 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: /:/¢¢~'~, LE A. DESOR,PT,ON: Z ¢ £ 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS _~.Jl~/'/ ~ . SLOPE SITE PLAN WAS GROUND WATER / ENCOUNTERED? S IF YES, AT WHAT ~L DEPTH? ~ p E Deplh lo Waler Alter 4¢I' Monitoring? Dale: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~,¢2.~ Immures/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND '~ FT $ & S ENGINEERING PERFORMED BY: 1~.~ ~¥~' -~ ¢,C,~ ~¢,&c.J ~,. ~.~ ,,v ~ ,~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH A~'L~A~,I~i~L~J~?I~A~I~ UIDELI NES IN EF F ECT ON THIS DATE. DATE: /,- -/~ ~f'"'-- 72-008 (Rev. 4/85) ROBERT C. COWAN, RE. ROBERTA. SHAFER, RE. HEALTH AUTHORITY APPROVALS SEWER & WATER MAIN ~(TENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ONSIIE WASTEWATER DISPOSAL SYSTEM DESIGN ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 4A, Block 2, Our Mountain S/D June 15, 1995 GENERAL: 1. The scope of this project includes the installation of a 1000 gallon septic tank and five foot wide drainfield to serve the proposed three bedroom residence for the referenced property. 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. 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. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. 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 TANK INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 4A, Block 2, Our Mountain S/D June 15, 1995 Septic tanks installed with less than 4 ft. 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 ft. 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 TRENCH/DRAINFIELD INSTALLATION: e Excava%e 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 (ruffed-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, installed approximately in the locations shown on the design, and extend a minimum of 12 inches above final grade. 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. Page Three Lot 4A, Block 2, Our Mountain S/D June 15, 1995 MINIMUM MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: T_¥pe of Pipe Perforated Solid Cast Iron ASTM D3034 (PVC) ASTM F810 (HDPE) ASTM D2662 (ABS) Yes Yes Yes Yes Yes No Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. Page Four Lot 4A, Block 2, Our Mountain S/D June 15, 1995 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: 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. The final inspection is to occur upon final grading of the property. 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 contractors activities. The owner shall contract with the contractor 'to perform the work outlined ii1 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 EngJ. neering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors 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/OWNER 07827 1 97 Reference Building or ~and ~Y~A~UO ~ ~IDB OOT ~ Munimpality et Anchorage ~ ll~nt~lpatt~ of ~hor~, h~r~l~' ~lth & Human Services ~Nunicipalitym, n~ ~ ~-~ (name of Individual,partnership,corporation,or husband ~ Wife if Joint owners) hereinafter the "~erm, and The Thomas Company (name of i~di~ldual,partnership,corpOrition,or husbandAl~ wifi" If Joint owners} hereinafter the "Neighbor-, enter into the following agree~nt which shell become effective on the data the agreement ia fully executed. ~ect~gD_~ The Owner.is e(n)~ ~r ~ (individual, partnership, corpOra(Ion, etc., or t~7,;~ncy by entirety) and Hichael R. TJl~as execute(.~) this agreement on (name(s) of person(s) signing) behalf of the Own~r in the capacity of Preeiden~ lindividual, partner, president {if corporation}, tenants entirety {if husband and wife}) Nichael R. Thomas warrants that he/she has authority (name(s) of person(s) signing) to execute thin agreement on ~ehalf og the ~e Neighbor ts a(n) Corporation (Individual, partuership, corporation, etc., or tenancy by entirety) and Nichael R. Thomas executes this agree=eat on '(name(s) of ~erson(s) signing} behalf of the Neighbor in the capacity of Presiden~ (Individual, partner, president {if corporation), tenants by entirety {if husband and wife)) COVENANT TO PROVIDE ACCESS Page 1 Return recorded agreement tel Municipality of Anchorage Public Works, Building Safety I~nd Use Reviewer (Kathy Johnson) P.O. Box 196650 Anchorage, AK 99519-6650 (Form revised 8/92) warrants that he/she has authority (name(s) of person(z) signing) to execute this agreement on behalf of the Neighbor. ~ The Owner ovns a parcel of real property dsscrib~d esl Lot 4 Block 2 Our Mountain ~lnsert legal description--usually l~-'~lth bldg~ Anchorage Recordin~ District, Third Judicial District, State of Alaska, shown on the ~ap attached hereto as Appendix A, and referred 2o hereinafter as the ~do~inant parcel.~ In order to the O~ner ~ust provide __ Access (speCify what owner aust p~svide) in order to ~eet the requirements of Title 21 of the Anchorage Hunicipal Code. The Neighbor owns an adjacent parcel of real property described ae Lot 5 Block 2 Our No~n~{n (insert legal description of lot-~b~ing parkir~[ Anchorage Recording District, Third Judicial District, State ~laska, shown on the map attached hero,to as Appendix A, and referred to hereinafter as the Wservient parcel." The servient parcel can provide ~ccess ~o Lot (Specify wha2 ~he servien2 Parcel may provide) (specify burden Neighbor agrees t~ put on eer~l~nt parcel) 8~cJ~ The o~m~r and ~olghbor covenant and agree that they and their heirs, successors, and assigns, shall use the servient parcel to p~vide ~Ccesa ~o (sPecify the burden on the eerViin~ parcel) for the us. and benefit of the dominant parcel, and that the above-described use qf the eervient parcel shall not be altered or restricted in any manner without the consent of the ~ It is understood that violation of this agreement shall constitute a violation of Title 21 of the COVENANT ~O PROVIDE ACCESS Page 2 revised 8/92) ~{07827~99 Anchorage Hunicipal Code, and will b~ subject to all the p~naltiem and re~ediea provided by law for such a violation. STATE OF ALASKA ) THIRD JUDICIAL DISTRICT ) '~hI, I. to c.rtify that o, th, _/"~' day of..~.~,/., 19_~_~, before me, the undersigned Hotary Public In and for the State of Alaska, duly conniss:.oned and sworn as such, there to ,. to be th...~,/~,~ of the and he/she acknovl~dqed that he/she execrated the foresoinq Instrument es a free and voluntary act a~ de~ of said for thm uses a~ pub!les therein statmd, ~ on oath stat~ that he/she ~aa authori~ to exerts .~id instrument. In witness whereof, ! have hereunto set my hand and affixed my official seal the day and year heretnabove written, ~ m.t~at,mt J0~SO~ ~ [ ko'r~'w ~'UeUC ii Notary l~blic i~ a~id for Alask~ Hy commission expires~f~ COVENANT TO PROVIDE ACCESS Page 3 (For~ revised 8/92} STATE OF ALASKA ) THIRD JUDICIAL DISTRICT This is to certify that on the 19_~ , before me, the undersigned Notary Public in and for the State of Alaska, duly commissioned and sworn as such, there personally appeared /~.c~.¢f ~__~/~ , kno~ to .. to ~ tho ~ /~ _ of tho ~q~r'~ ~. ~., a~ he/she acknowledged that he/she executed the foregoing instrument as a free and voluntary act and deed of said . for the uses and pur~ses therein stated, a~ on oath ~tated that he/she was authorized to exerts said instrument. lit witness whereof, I have hereunto set my hand and seal the day and year hereinabove written. ~ My commission e~ires~c Z~ STATS OF A~SKA ) T~I}ID JUDICIAL DISTRICT ) 19~, ~Eore ~e, the undersigned Notary ~blic in ~ndOfor the State of Alaska, duly co~issioned and sworn as such, there per,anally appea~ed ~~..~~/ , kn~n A8C~O~OE, a ~untctpal corporation, and he/she acknowledged that he/mhe exeoutad the foregoing instrument aa a free and voluntary act and deed of said Municipal Corporation for the uses and purposes therein stated, and on oath stated that he/she was authorized to execute maid instrument. In witness whereof, ! have hereunto set my hand and affixed my official seal the day and year hereinabove written. Notary Publi)e in-and/fo.~ A)a~a My commissl~u expires_~__ TO PROVIDE ACCESS Page 4 (Form revised 8/92) I" m $0' SiTE-PLAN ~U~'O~ CHUGACH STATE PARK . -~: ; ~ ~ MUNICIPALITYOFANCHORAGE · .,.': ',.i i: 'r'. (,e~j~,~,~' DEPARTMENT'OF H~LTR & HUMAN'SER~iCE~ P,O. Box 196650 Anchorage, Alaska · , ,~ ~, --CERT FICATE OF H~LTH AUTHORI~ ..... '~:.".~':, -:-'-- ,', ;i,.~,"; -, ', ,----------. ,--AP~R~VA/~ FOR A _.-_.-m~/.~-......---FAMILY Parcel I.D. ~ ~ ~ ~ ~ I ~ -~ ~ :;?,,, ~3~ 1. GENERAL INFORMATION ~;~.~? ~.~.~ · ~Mailin~ ad"~Jre~s '~"-"~2727 No,~oods DrZve Ch~giak~ AK , 99567 · .--~ .-. , ..... . ,_ ~.~ ~ , , .... -........:...-.~(~,. '...,,~.:- ..~- ~.-%~endmg.ag~ncy.- .:' -,. Day phone ;~::. :;"~" ;~:.~?;: .: .... "~::.: ; :'.,'i' ~estmg to the' legality . i : 72-O25(Rev. l/91) Front MOA~I.;~.:~',-:; ::; ,;;:' · , L; ,~:.~''' -: · · STATEMENT OF INSPECTION BY ENGINEER' As certified by my seai affixed he~et°'and as 0f;[h~ validation date shown below, I verify that my investigation of this Health Auth~rity'~pPrd~i:~'~:Piic~ij0rn'~shoWs that the on-site water supp y :';:i!i! and/or wastewater disposal system is ~afe, 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.t~ation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and rt~ulations'in'eff°°t ~n the daie of this inspection. S & S ENGINEERING Name of Firm 17~,:,4 ~'~1;" ~;,~.r ~ Addre~ ~l. River, Alaska ~ EngJn.fs signature ¢~~'~ !; ~.'~;The I~a~hiSJpality of',~;lchoi'age Departrnenf'of'Hi~alth and H,.uman Services (DHHS) issues Health Authonty ",,...~A pp rova f~ert f ~a~/~ ' b~ised .... on y u.p on ..the . re p m~ntat ons. g ven.~..m p ara g ra p h 5 above· . by an ndependent ~-' prqfess~onal an. g~eer, reg~stered ~n the State of Alaska. The DHHS does th~s as a courtesy to purchasers of homes .."-'- ~,.~ '.~,,: '. . ".v'- ' ' · · .... · * · ' .... .'. .... ' f ' and tl~ (~ndmg msbtubons In order to ~bsfy ~rtmn federal and state r~:lu~rement~. Employoos o DHHS do not -conduct.,lnspectlons or analyze data before ,a, cart ficate is issued. The Municipality of Anchorage is not respons b e for errors or om ss one ~n the professional engineer's work..',: r'2' .J=~:1 --' ~: : .~ ' ': ' : ' ' 72-4)2.SlReV, 1/gt) Back MOA~'~21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744 Health Authority Approval Checklist LegalDescriptiou: ~-.-o'r ~ FS~wT.-- Oo¢- pk~,~,,k~-~ Parcel I.D.: A. WELL DATA Well type }2g.~xlm-x~._~ Log present lg~N) Total depth Saifita~ seal ~) If A, B. or C. attach ADEC letter. ADEC ;vater system number Date completed P~ -~ 4 - c4 5' Cased to ~ ~ Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform O Nitrate Date of smnple: c] ~! ~ ~ 9 ~- B. SEPTIC/~tO~6 TANK DATA Date installed {-,,-%7-'~1 g Tank size Foundation. cleanout (~fi'q) Date ofPumpi~g )/~ C. ABSORPTION FIELD DATA Date installed [,, Length ~'¢ i Width Effective abs0rptiou ar~a Date of adequacy test FROM WELL LOG Casing height (above ground) Wires properly protecte~ AT INSPECTION g.p.m. ~ __ Collected by: Other bacteria & S ENGINEERING 7034 ~agle River ~..,aof E:~gto F, iver, Alaska 99577 Number of Compartments 7-.- Cleanouts(~l) ,,/ Depressiou (Y~ ,-[' High water alarm (Y(~ ~ Pumper ~[~, Soil rating (g.p.d./fi2 or fl2/bdnn) ~ r Gravel thickness below pipe 5-L. ~ ~t Monitoring Tube present(~l) ~ ~-¢~,,d~ Results (Pass/Fail) ~ o, 6 System b'pe ~t[~vucocO / ' Total depth ..c-' . Depression over field (Y/'~ For bedrooms Fluid depth in absorption field before test (in.); ~ hnmediately after '~al. water added (in.): "-"-- Fluid depth ~ Minutes later: '~' ";'(ih:.'} 'AbsOrPtion rate = g.p.d. Peroxide treaUnent (past 12 months) (Y/~). ,,..( If yes, give date -~ D. LIFT STATION Date installed Size in gallons Manhole/Access (Y/N) Wump on" level at* High water alarm level at* C3r~s tested ~'Pun~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/h~:bng tank on lot / '7 5' ~ Absorption field on lot ) 7'7 ~ Public sewer main t3 [,~ Sewer/septic service line .~.._~.- ~ 4- ; On adjacent lots : On adjacent lots Public sewer manbole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/IIONDING TANK ON LOT TO: Foundation "] ~ Property. tine \c:, t '¢ Absorption field 'Z~" Water main/service line lc> ~ -b Surface water/drainage / ° o ~ 4- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation .~ Surface water Cmlam drain Water main/service line / ¢> Driveway. parking/vehicle storage area Wells on adjacent lots F. ENGINEER'S CERTIFICATION ~ ~n l cert!fy that I have determined thrufield inspections and review of?/hmicipal s are in conformance with ~40A H~ guideline~n effect on this date. ~ ~/* ~~ ~ Engineer s Name /~6e ~- c . qe,~ ~ ~,~ ~os~ c. cow,N /~ ..................................................................................... HAA Fee $ ~ ' ~ Waiver Fee $ Date of Payment ~~d~ Date of Payment Receipt Number / 7 ~b C3 ZT~ Receipt Number Rev. 8/95 OSS: haa.wk.doc