HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 17 LT 8 '"'~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
,ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE
MAILING ADDRESS
LEGAL DESCRIPTION
LQCATION NO. OF BEDROOMS
ell , Absorption area Dwelling PERMIT NO.
~ ~ Man~cturer Material No. of comp~rtments
Liq. capacity in gallons Inside length Width Liquid depth
~0 ~ 0 IF HOMEMADE:
DISTANCE TO: Well Dwelling PERMIT NO.
Manufacturer Material Liquid capacity in gallons
~ l We]l , Foundation Nearest lot line PERMIT NO.
No. of lines Eength of each line Total length of lines Trench width Distance between lines
~ Top of tile to finish grade ~aterial beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
Type of crib Crib diameter Crib depth ~otai effective absorption area
~ Well Building foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL ~ RATIN~ ' /
iNSTAlLER '
R EMAR KS
JUNE 25, 1971 ,
APPROVED ¢ DATE LEGAL
72-013 (Rev. 3/78)
~UNICIPALITY OF ANCHORAGE
.~ ' Department ~Health and Environmental~ :otection
825 L Street, Anchorage, AK. 99501
264-4720
-~,z* * * HANDWRITTEN PERMIT * * *
permit ~ ~ Su~ ~r.WA~D/0R
ON-SITE
SEWER
PERMIT
Phone Number:
Location:
Legal Description: L.~% ~'~7-L~/Mj-~F~c/t ~.~.o. CLot Size:
Type of Soil Absorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms: %~
Seepage Bed: ~ Holding Tank:
Soil Rating (sq. ft/br) ~_%'~ 3--
The Required Size of the Soil Absorption System Is:
_ LENGTH '~7 GRAVEL DEPTH c/. WIDTH
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 = ~O~-~ GALLONS * *
~ermit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
Df residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
~ackfilling of any system without final inspection and approval by this departme~
~ill be subject to prosecution.
~inimum distance between a well and any on-site sewage disposal system is 100 fe~
~or a private well or 150 to 200 feet from a public well depending upon the type
)f public well. Minimum distance from a private well to a private sewer line
Ls 25 feet and to a community sewer line is 75 feet. Well logs are required
1nd must be returned to this department within 30 days of the well completion.
)ther requirements may apply. Specifications and construction diagrams are
~vailable to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
Z certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage. -
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more tkat 3 bedrooms.
Signe~: "'~~~-'~Applicant Issued by:~_ ~~/2~ ~
Date: /~/~/73
SWP/024(1/81)
PERFORMED FOR: /~'~'~7~4~,
LEGAL DESCRIPTION:
[] SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
PERCOLATION
TEST
17
1
2
5
6,
7
13
14
1~,
20-
COMMENTS
SLOPE
SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? )'~ L
O
P
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch)
PEREORMED 6¥: L. ~. f-~-,~
DATE:
72-008 (6/79)
•
• Municipality of Anchorage
!IF"-
On-Site Water&Wastewater Program e,Ll
(907)343-7904 s• =T
CERTIFICATE OF ON—SITE SYSTEMS APPROVAL
Parcel I.D. 051-064-49 Expiration Date: ( ^1E^1/
1. GENERAL INFORMATION
Complete legal description NORTHWOODS S/D#4; BLOCK 17,LOT 8
Location (site address) 21407 SNOWFLOWER LOOP,CHUGIAK,AK 99567
Current Property owner(s) MICHAEL&SARA HODGE Day phone 704-245-7951
Mailing address 335 B FEGAN DRIVE,SAN CLEMENTE,CA 92672
Real Estate Agent Day phone
2. TYPE OF DWELLING:
In Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual On-site U
Individual Water Storage ❑ Individual Holding tank ❑
Community Class Well ❑ Community On-site ❑
Public Water System Public Sewer ❑
WaiverNartance request for N/A Distance: -
. � J
Received by: Date:
COSA to be released to the engineer,unless otherwise requestedby the engineer.
COSA Fee $ Waiver Fee$
Date of Payment q 1260 Date of Payment
Receipt Number Oar( 5i9 Receipt Number
COSA# sc igi ac 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.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E.TUDOR ROAD, SUITE 101 "ANCHORAGE,AK,99507
Engineer's Printed Name JEFFREY A. GARNESS,P.E. Date 9/i V`V
Engineer's Comments:
In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system in accordance with the ,0111.1•■
guidelines and regulations established by the Municipality of Anchorage and industry practices.The reported results describe the 44* OF a II4
condition of the systems on the dates of the evaluation.Separation distances were measured to readily identifiable features. .�c >" 4 �h
Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic \�•''�••••••••I ��
systems depend on a variety of variables including,but not limited to,soil conditions,groundwater levels(that may fluctuate during a j •••' �
• *I
the year),quality of construction(materials and workmanship),and the water usage of the family utilizing the systems.These a *;/ 49 $44\ ; �0
conditions can vary,and are outside the control of GEG.Satisfactory test results do not guarantee future performance of the •,
system/s;therefore,GEG makes no warranty(express or implied)regarding the future performance of the well or septic system. •
•
GEG makes no representation whether an alternative well or septic system can be installed on the properyin the event either of the . . ,,, ,I •
current systems fail.The content of this report is for the sole benefit of the person/party who retained GEG.Reliance upon the • • •r al A. ...m: s : 4r
information provided in this report by any other person or party,including but not limited to subsequent property purchasers,is not ♦ 0% =
authorized.In short,GEG disavows any legal duty to anyone other than the person/party who paid for this report. �,,u . 1% C E- 95 f�I
6. DSD SIGNATURE .4 PROFESS\00••4
LICENSE ,,lr%woo,*�
System#1 Approved for 3 bedrooms. #AEccaaa
System#2 Approved for bedrooms. � �\`{ VI" ivy,:
Disapproved. ,-/->2
J ON-SITE G
Conditional approval for bedrooms,with the following stipulaionsWATER AND
o WASTEWATER o
"-`to PROGRAM ,'
O
By: - ‘^•••-•-• V—. / "/ Original Certificate Date:
?-.2-‘f--(2
The Municipality or Anchorage Develop,emt Services Division(DSD)issues Certificates of On-Site Systems Approval(COSA)based only
upon the represenatations 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. ATTCHMENTS:
COSA Checklist Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
(Rev.10112112)
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: NORTHWOODS S/D#4; BLOCK 17, LOT 8 Parcel ID: 051-064-49
A. WELL DATA PUBLIC WATER
We .e If A, B, or C provide PWSID# Well Log (Y/N)
Date complete. Sanitary seal (Y/N) Wires properly protecte. '/N)
Total depth ft. Cased to ft. Casing hei. .bove ground) in.
FROM WEL .OG SPECTION
Date of test
Static water level ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESU :
Coliform colonies/100 ml. Nitrate mg./L. Collected by:
Ar - c: ug./L. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material S.T.E.P./STEEL Date installed 6/16/20/2014
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) YES
Foundation cleanout(Y/N) YES Depression over tank(YIN) NO High water alarm (Y/N) YES
Date of pumping 9/18/18 Pumper JR'S PUMPING
C. ABSORPTION FIELD DATA *BELOW EXISTING GRADE
Date installed 6/19-20/2014 Soil rating Cp.d.. 'or ft2/bdrm) 0.6 System type DUAL 5-WIDES
Length 76 (2 @ 38') ft. Width 5 ft. Gravel below pipe 4 ft.
Total depth *6.5-7.6 ft. Eff. absorption area 760 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 9/11/2018 Results(Pass/Fail) PASS For 3 bedrooms
**0/ **1,353/ **27.5/
Fluid depth in absorption field before test 0 in. Water added 1.329 gal. New depth 35.5 in.
**1180/ **12.75/
Elapsed Time: 960 min. Final fluid depth 21.75 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) ***NO If yes, give date -
**SOUTH TRENCH/NORTH TRENCH. HOUSE HAS BEEN VACANT SINCE MAY 1,2018-SEE HOMEOWNER QUESTIONNAIRE
***SEE HOMEOWNER QUESTIONAIRRE
*2ND COMPARTMENT OF 1250 GALLON STEP TANK
D. LIFT STATION **SEE ATTACHED LIFT STATION/PUMP VAULT MAINTENANCE CHECKLIST FOR CERTIFIED PUMPER
Date installed 6/19-20/2018 Size in gallons *412 Manhole/Access (Y/N) YES
"Pump on" level at ** in. "Pump off' level at ** in. High water alarm level at ** in.
Datum ** Cycles tested ** Meets alarm & circuit requirements?—*UNKNOWN
***NO ELECTRICAL INSPECTION FOR 2013 INSTALLATION. MET
E. SEPARATION DISTANCES ELECTRICAL REQUIREMENTS PER KENNETH DUFFUS,P.E.2014 COSA
SEPARATION DISTANCES FROM WELL ON LOT TO: PUBLIC WATER
Septic tan/ . . ion on lot On adjacent lots
Absorption field on lot On adjacent • .
Public sewer main '.• ' sewer manhole/cleanout
Sewer/septic service line Holding tank
Ani - -• ainment areas Manure/animal excrete storage areas _
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation *5'+ Property line 5'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 100'+ PVT. &200'TO COMM.
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+PVT. &200'TO COMM.
F. COMMENTS
*MET SEPARATION DISTANCE AT TIME OF INSTALLATION.
looms•
• OF K r••
G. ENGINEER'S CERTIFICATION ��� �� ♦♦j♦
I certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in . ••, .../.......
• ••'
1;'117.1F:4.4:.4........
i
•
•
conformance with MOA COSA guidelines in effect on this 0
date. ♦� J f e, A. or -ss/i
Engineer's Printed Name JEFFREY A. GARNESS ♦♦♦5, C 9553/1
9/ ,� •
Date r LICENSE II'60ESS\ 44
#AECC884
(Rev. 10/12/12)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On'Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
Lot 8; B~ork.17; No~thW°ods #4
Location (site address or directions) 21407 Snow~owe~ Loop
Property owner
Mailing address
Lending agency
Mailing address
Agent Kath~ 0~mstead/
Larry Barnes
P.O. Box 671988
JACK WHITE
Chuqiak,
Day phone
AK 99567
Day phone
Day phone 694~5500
Address 11823 0~d GP~nn Hwy. ;~:Eag£~ River,
Unless otherwise requested, HAA willbe held forpickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
AK 99577
72-025 (Rev. 1/91) Front MOA #21
NOTE:
XXX
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
XXX
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm
5 & .5 £N(~INEE[~IN~
Address ........,....~ ..~..'- ~!-.-== L==~ ~--=E .~!=. ~:~.
. . Eagle River, Ala~a 99577
Engineers s~gna~ure
Sm
DHHS SIGNATURE
/~- Approved
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations, given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska, The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91 ) Back MOA ~1
(~ Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:~"~ ~C:L.W~\'~ t~'~o~;~J~- ~ Parcel I.D. ~ ~'/
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to Casing height
Wires properly protected (Y/N)
ADEC water system number '~' t ~-~ ~::::::~ \
Driller
FROM WELL LOG ~.~¢rJNSPECTION
Date of test
Static water level
Well flow ~ _ g.p.m.
....
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot '~-~
Absorption field lot
on ; On adjacent lots
sewer ,main _ _ Public s~
Public
Sewer service line . ....----P~troleum tank
WATER SAMPLE R~
Coliform ~ Nitrate Other bacteria
~ Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed c~ ~ ~
Cleanouts~/N) ~/
High water alarm (Y~)
Date of pumping
Tank size \ ~,r--~c~
Foundation cleanout ~N)
To property line to ~"~
Surface water/drainage
Compartments ~
Depressio~ (Y~J~ ~
Alarm tested (Y/N);:.:~ p~'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot '¢~ ~
On adjacent lots
Absorption field ~ ~
Foundation ~- \ Jr
Water main/service line ~, E) t-~
72-026 (Rev, 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MO, elec~
S~PA~~ISTANCE FRoM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N) /
~1 at
*/~'/~Cycles tested
Surface water
ABSORPTION FIELD DATA
Date installed
Length ~
Total absorption area
Depression over field (Y,~
Results ~fail)
Width
Peroxide treatment (past 12 months) (Yi~) ~.~c>~?..- ~/---~o ~_~ ~
Soil rating l~"~' ~/(St--!
Gravel thickness ~ ~
Cleanouts present
Date of adequacy test
for ~["~¢_
If yes, give date
System type
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:,
Well on lot '~-~o ~:~\~'
To building foundation
On adjacent lots
Surface water \
Curtain drain
On adjacent lots />" Property line
To existing or abandoned system on lot
.I
Cutbank *"~' ~, Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I ~ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
ignature ./r ~ :~.
Engineer's"Namel.7~034 ~_.~,, p~.._, ...... .
~le Rtv~, Ala~a ~ ,,
· ,,? ~,.::?.
HAA Fee $ / ~0 ' ~ Waiver Fee: $
Date of Payment [ '- ~ ~ Date of Payment
Receipt Number ~ Z7~7 >~52 Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
WALTER J. HICKEL, GOVERNOR
(907) 349-7755
June 4, i993
Mr. Jim Williams
S & S Engineering
SUBJECT: Lot 8, Block 17, (21407 Snowflower Loop) Northwoods Subdivision #4
Class "A" Public Water System, PWSlD 213001
Dear Mr. Williams:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results Was submitted
to this Department on May 11, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on April 21, 1992. This does meet the provisions of 18
.AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample results were submitted to the
Department on April 11, 1993. This does meet the provisions of 18 AAC
80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on June 2, 1992. Based on analysis of
the previous VOC samples results have been satisfactory. This does meet
the provisions of 18 AAC 80.200(a), State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the specified legal description
noted above only.
If you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Environmental Eng. Asst. II
STATE OF ALASKA
DEPARTMENT OF ENVIRONMENTAL CONSERYATION
APPROVAL OF ON.SITE RESIDENTIAL WATER AND SEWER SYSTEMS
Lot, Block & Subdivision or U.S, Survey
PROPERTY DESCRIPTION
Lot 8, Block 17 (21407
NorthwOods No.4
PWSID no. 213001
Snowflower Loop)
This approval does not constitute a guarantee of any kind, explicit or implied, as to the performance
of the water supply and waStewater disposal systems.
WATER SUPPLY
A recent water sample was tested and found to meet Department of Environmental Conservation drink-
ing water standards for total coliform bacteria.
T~%Envir°nmentalg' Assr. TT D"tejune 3,'93
WASTEWATER DISPOSAL
The domestic wastewater system was'
[] inspected by the
applicable re(
~artment of Environmental Conserva
ts of 18 AAC 72;
and found to. be in compliance with
[] inspected by a al Engineer who certifi
quirements of 18 AAC 72
the system complies with applicable re-
[] installed by a Certified
of 18 AAC 72; or
system complies with applicable requirements
[] tested by a Professional Engin
and that the system compli
certifies that the performance of the system is satisfactory
minimum separation distances specified in 18 AAC 72.
This approval is valid fo~ single famil multi,family unit with a total of
bedrooms.
Name Title Date
/
18-0404 (Rev. 8/85) DISTRIBUTION: WHITE--BANK/LENDING INSTITUTION; CANARY--APPLICANT; PINK--DEPARTMENT
i
MUNICIPALITY OF ANCHORAGE
Department of Heallh & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. Cf
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or direction§)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
(b) Property owner .../'--~-~-¢~/z? ~/.,¢¢z,-,/0/¢,4~-%. Telephone: (home) Business
(d) Real Estate Company and Agent
Telephone
(e) Mail the HAA to the following address: (or check here~ if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family,~ Number of bedrooms
3. WATER SUPPLY
Individual Well []
Community~' Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site,~ Public [] Community [] Holding Tank []
Note.' If community well system, must have written confirmation from the State Department of EnvJronmerltaJ
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page I of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND IN'FORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that
based on the information obtained from the Municipality of Anchorage files and from my investigation and
inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
J'-Z.Z -/3××
Name of Firm d~/2~,,,~ /~-,~'~ ,'Z~J'~''~L~J
Address /~ ~'o' ~, /~'"~ ~' ~'P /'~'~- ~'~'
Date ~
Telephone
6. DHHS APPROVAL
Approved for
Approved
._ Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
Page 2 of 2
72-025 (Rev. 7/88) Back
MUNICIPALITY OF ANCHORAGE
; £NVI?.ONMEN~ AL SERVIC~!5
~ ~ MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
? - RECEIVtED
Leg.a~r Desc ri ptio n',,~7-
A. WELL DATA ~ ~,¢f.~¢ ~-~?~/v'
Well Classification
Well Log Present (Y/N)
Total Depth. Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Date Completed
DePth of Grouting
If A, B, C, D.E.C. Approved (Y/N) ~,~,/
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ,.¢- /.2'- ~'3 Size ~ ,¢~ No. of Compartments
Standpipe~N)//'~/~ ~ Air-fig/bt Cap~/) /~-' ~% Foundation Cleanou~)
Depression over Tank (Y(~ ,~'~'//~'
..//Date Last Pumped
Pumping/Maintenance Contact on File (Y/N) ~ ~ ,~'"/~/~ ; for ~/~
'(Y/N) //~///~,~. /
Holding
Tank
High-Water
Alarm
Temporary Holding Tank Permit
SEPARATION DISTANCES EPTIC/HOLDING TANK:
To Water,Supply Well. ////"/~ To Building Foundation /'~
//
To Property Line ;~' ',~ ~ To Disposal Field ,/~ /--/--
To Water Main/Service Line //
To Stream, Pond, Lake or Major Drainage Course //~/'~-""'--."'~- ~
Comments
72-026 (Rev. 7/88) Front
Page1 of 2
! i I
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata Type of System Design
Date Installed //~_/~ -~,_'.~ ~ Length of Field _
Width of Field --~ // Depth of Field
Square Feet of Absortion Area --~
Gravel Bed Thickness ~'~-o //
.~-- '~ Statndpipes Present)
Date of Last Adequacy Test --~'~ -~ -~'~£~
DepressionoverField(/~-
ReSults of Last Adequacy Test _
SEPARATION DISTANCE FROM A~: /
To Water-Supply Well ~/~..~,~. /z./~,~/~ To Property Line
To Existing or Abandoned System on
To Building Foundation - //'f~' /
ToStream, Pond, Lake, orMajor Drainage Course - /¢'~¢/"~ -? ,~'~/----_~/~----~'7'-'-
To Driveway, Parking Area, or Vehicle Storage Area _
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
Manhole/Access (Y/N)
,'Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to afl MOA and HAA guidelines in effect on the date of this
Company
MOA No. ,~-~
Waiver Fee: $ _
Receipt No.
ate Paymenf
Amount: $
12-026 (Rev. 7/88) Back
Date of Payment
Page 2 of 2
STEVE COWPER, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
/
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 1334
ANCHORAGE, ALASKA 99503
563-6775
DATE:
PWSID:
10-26-88
213001
To Whom It May Concern:
According to the records on file in this office, the CHUGIAK UTILITIES?
NORTH~V00DS S/D Water System is in compliance with the
State of Alaska Drinking Water Regulations.
MPL:pkk
Sincerely,
Michael P. Lewis, PE
Environmental Engineer
I sEI~'TIC' LEACH
~'~ -,2~ ~'~ METER THiS TOTAL PER DEPTH DEPTH
GALLONS GALLON~O TANK FIELD
T,~ READ,NG PER,OD GALLONS U'NUTE ,NCHt,S .'NCHES
. , /
APPLIC; FILLS OUT UPPER HAl r-'rJNLY
Mailing Address ,,/.~ ,..;.~ t.,) .~,. . ,
ealty Co. & A~nt / / .
Phone
Phone
Phone
Address //x (~...
Lega~ Description
Street Location
Type of Residence
g/'~in Die Family
ultiDle Family
[] Other
Water Supply
[] Individual
E~],/Community
[] Public Utility
Sewer Disposal
No. of Bedrooms
ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
For wens drilled prior to that date, give well depth (attach Icg if available).
[~lndividual
[] Public Utility
[] Holding Tank
Year Individual Installed: /; "~2-
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes: OJ~ C.' ~'
C~j(' Lr.~..~(..~,~ MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONM2NTAL PROTECTION
RECEIVED
(..~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Dat~h?ewer Installed Well To Absorption Area Well Log Received
~ ~--~'"~* ~'"~ ""' ~ ~-"" "'~ ~ Well ,o Tank Septic ,~k Size