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Home My WebLink AboutNORTH WOODS UNIT 4 BLK 18 LT 9 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP221045 Work Type: SepticTank Upgrade Tax Code Number: 05106437000 Site Legal Address: NORTH WOODS UNIT 4 BLK 18 LT 9 G:1460 Site Mailing Address: 23410 BLUE SKIES DR, Chugiak Owner: METCALF FAMILY TRUST Design Engineer: FORGE ENGINEERING This permit is for the construction of: Effective Date Expiration Date o ', Rent c ' sir• It n v Department Lot Size in Sq Ft: Total Bedrooms: 3/8/2022 3/8/2023 28123 Disposal Field Q Septic Tank Holding Tank Privy Private Well Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Special Provisions: Locate the beginning of the northern trench prior to installation to ensure that the required separation is being met. Received By: Issued By: Date: Date: S 22 3 MUNICIPALITY OF ANCHORAGE 11 Community Development Department Phone: 907-343-7904 Development Services Division Fax: 907-343-7997 On -Site Water & Wastewater Program ON-SITE SEWER/WELL PERMIT APPLICATION Parcel I.D. 051-064-37 Property owner(s) Matcalf, Bradley & Beverly Day phone 907-223-2305 Mailing address 23410 Blue Skies Dr, Chugiak AK 99567 Site address 23410 Blue Skies Dr Legal description (Sub'd., Block & Lot) North Woods Unit 4, Block 18 Lot 9 Legal description (Township, Range & Section) Lot Size 28,123 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) ❑x (w/wo ADU) Septic Tank ❑x Upgrade ❑x Duplex (D) ❑ Holding Tank El Renewal ❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: � o7a 5 Date of Payment: 3Z? Z -L Receipt Number: 077313 D Permit No. 0 S i, -?'19 0 y 5 Permit App_'- : ,_.,:c; Waiver Fees: Date of Payment: Receipt Number: Waiver No. March 2, 2022 MOA Development Services, On-Site Water & Wastewater Program 4700 Elmore Rd Anchorage, AK 99507 3/2/22 Subject: North Woods Drive Unit 4 B18 L9-23410 Blue Skies Dr Septic Tank Replacement Dear On-Site Services Engineer: The owner of the above lot has a septic tank that has reached its end of useful life. We are submitting this permit application for the replacement of the existing tank. The attached site plan identifies the location of the home and existing septic system. No conflicts exist between this proposed system and any other well or septic system, whether on this lot or adjacent lots. The home is connected to public water, the new tank will be a minimum of 10’ from the water service line and foundation, and more than 5’ away from the existing absorption trenches. The back deck is less than 30” high, and the tank will not be placed directly under any supports. A recent survey to the property indicates that there are missing septic pipes when compared to the as-built drawing on file. The contractor will ensure that all the septic pipes are located and repaired if needed. Please refer to the attached plan for the septic design. If this design is followed, there will be no adverse impacts to adjacent properties. Sincerely, Benjamin Schiller, PE Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221045, Deb Wockenfuss, 03/08/22 Benjamin Schiller CE 12592R EGISTEREDPROFES S I O N ALENGINEER 1"=50' CO - CLEANOUT 2CO - DOUBLE CLEANOUT FCO - FOUNDATION CLEANOUT FS - FLOW SPLITTER VALVE MH - MANHOLE MT - MONITORING TUBE SV - SEPTIC VENT TH - TEST HOLE LEGEND NORTH WOODS UNIT 4, BLOCK 18 LOT9 FEET 0 50 100 NOTE: NO SLOPES >25% WITHIN 50' OR SURFACE WATER WITHIN 100' OF THE PROPOSED SEPTIC SYSTEM NO EXISTING WELLS - PROPERTIES ARE ON COMMUNITY WATER SYSTEM BLUE S K I E S D R I VE 3-BDRM HOME 3/2/22 POST & RAIL FENCE SHED GREENHOUSE NEW 1000-GAL SEPTIC TANK W/ 20" MANWAY CONFIRM DECK HEIGHT <30" AND DO NOT PLACE TANK UNDER DECK SUPPORTS ≥10' REMOVE / DECOMISSION EXISTING TANK PER U.P.C ≥5' EXISTING ABSORPTION TRENCHES TO STAY IN SERVICE LOCATE AND REPAIR (IF NEEDED) ALL MISSING SEPTIC PIPES PUBLIC WATER SERVICE (APPROXIMATE LOCATION) Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP221045, Deb Wockenfuss, 03/08/22 NOTES: 1) THE LOT IS SERVED 81 WATER SYSTEM. 2) DUE TO SNOW & ICE SURFACE LEVEL FEATUF APPROXIMATE. 3) ONLY SEPTIC PIPES FC ARE SHOWN HEREON.1 BE HIDDEN UNDER THE Professional Land Surveyors ngsurvey.com I hereby certify that I have surveyed the following described property: LOT 9, BLOCK 18, NORTH WOODS SUBDIVISION — UNIT IV (PLAT No. 83-333) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the ---L'ZkL— Day of r-'`-'Ipi�_�____, '�^4F' at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. y<........... \�SVT��I 49?H v z • KENN -H G. LAN �4�gFo' 4 ..LS -5202.•' Seo a ... Npo %�R ?FfSS10NA'- �o AECC963 Tract A -1—A _ PLOT PLAN --- AS BUILT _x_ SCALE _1___40__ GRID _ NW 1460__ Project No. --__?3=07fA1 _ 11500 Daryl Avenue, Anchorage, Alaska 99515-3049 Lang & Associates, inc. (907) 522-6476 Phone (907) 522-4625 Fax 0000OpO� o ,� r n nn Professional Land Surveyors ngsurvey.com I hereby certify that I have surveyed the following described property: LOT 9, BLOCK 18, NORTH WOODS SUBDIVISION — UNIT IV (PLAT No. 83-333) Anchorage Recording District, Alaska, and that the improvements situated thereon are within the property lines and do not encroach onto the property adjacent thereto, that no improvements on the property lying adjacent thereto encroach on the surveyed premises and that there are no roadways, transmission lines or other visible easements on said property except as indicated hereon. Dated this the ---L'ZkL— Day of r-'`-'Ipi�_�____, '�^4F' at Anchorage, Alaska It is the responsibility of the owner to determine the existence of any easements, covenants, or restrictions which do not appear on the recorded subdivision plat. y<........... \�SVT��I 49?H v z • KENN -H G. LAN �4�gFo' 4 ..LS -5202.•' Seo a ... Npo %�R ?FfSS10NA'- �o AECC963 MUNICIPALITY OF ANCHORAGE WATER CONNECTION - Location on Record ACCT. NO. ADDRESS BLOCK ADDITION Of? SIZE CONN.DATE MADE NEW CONN.REPLACEMENT CONN. LOCATION: ALLEY Q STREET TYPE OF MAIN () SHOW SKETCH ON REVERSE SIDE CORP STOP CURB STOP C TO C CURB STOP C TO 1 CORP CONNECTOR COUPLING TO C TO 1 X BRASS BUSHING X GALVANIZED BUSHING 2 PART UNION 3 PART UNION SERVICE CLAMP X COPPER PIPE 1 1/4" KEY BOX 2" KEY BOX THAW WIRE LOCATION 4/x£ '-- £ o / Hx /JT' J0* £.O.P • CONNECTION MADE BY THAW PLATE/NUT KEARNY WIRE CONNECTOR OTHER: COMMENTS: BROKEN MAIN, EXT. CONNECTION, CASING, DELAYS, ETC. DISCONNECTS EXCAVATOR APPOINTMENT TIME: TIME READY: INSPECTED BY PERMIT NO. W. CONN. INSP. EXTRA PIPE 31-058 (Rev. 10/97)* STREET O ~^> ^ 1 S X KEY BOX AND SERVICE LINE LOCATION BY SKETCH f* ^INDICATE NORTH ALLEY <6 ii'l' UT 9 S 31-058 (Rev. 10/97)* Back Municipality of Anchorage Page 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: 5 ~.,I ~ ~t0 ~..~ PID Number: O..~'jO Name: ~ ~ ~'~ % L~ Wastewater System: ~ New ~ Upgrade Address: ~o~ ~ L~'/ ~ ~ ~o~ ABSORPTION FIELD Phone: NO. of 8e~ooms: ~ Deep Trench ~w Trenc~ ~ Bed Mound o Other LEGAL DESCRIPTION so,,.~,,.g: · ~ GPO/Sq F, ~,E~7,~¢ Block: v / Subd~wsion: Dept~ lo p~pe bottom Irom o.gmal grade; Gravel depth beneal~ p~pe Township: Range: ~ Section: / Fill added above eriginal grade: Gravel length: I WELL: ~ ~ .... ~ Upgrade Gravelw,dl, Numberolhnes: ..... ¢ ~t. ~ Classdmadon (Private, A~,C~: , Total Depth: Cased TO: Total absorpbon a.rea: P~pe material: ~ Ordler 'r / ¢ /. /-- Dale Drilled: Stal~c Waler Level: installer: Dale installed: Y~eld: Pump Set at: Casing He~gnt Above Ground: ¢.~ ~,. .,. TANK SEPARATION DISTANCES ~eptic ~ Holding ~ S.TE.P. To se9hc Absorption Lift Hol~ng ~ubhc/Pnvate Manulacturer: Capacity ~ Well >~' ~ ~ ~ ~ Materiab~/ Number°tC°mpanmems: SurfaCewater >/5~' >/¢0' ~/~ ~/~ ~' LIFT STATION ~ Lot Size in gallons: Manufacturer: Line > ~' ~ /~/ ~ ~ Foundation ~ ~ ~ ~ ~ ~ ~ ~ "Pump on" level a~off" level al: Hig~ waler alarm aL Remarks: *~/~ ~~ ~ /~ BENCH MARK Assume~ Elevation: R'S SEAL Inspoctions perlormo~ Department of Health and Human Services approval Reviewed and approved by' Date: 7- ~1- ~ 72-0~3 IRev 9/91) MOA 25 Municipality of Anchorage DEPARTMENT OF HEALTH ANDHUMAN SERVICES I ? .......... : ..................... ENVIRONMENTAL SERVICES DIVISION i P.~ BOx 1~96650, Anchorage, Alaska'99~'i'9~6650, Telephone:. 343-4744 ~[~ ~?~.~'W~t~'~tetDi~'~s~l"S'y~t~'"'~'hdl6~"Weli In~'~fib~'"R~6'~'j "~ ........... ~: .... ~. ?..~.~=~:~:.~ ~, .~,:~~.;.......~,,.. ~ .......... '" ~~ 'Z ............... 438t - E 72-O13 A ;2/9t) MOA 2~ I~ermit No., ~ Lx.) ~ ~ C) ~ ~/~ Page '~ Municipality of Anchorage DEPARTMENT OF HEALTH ANDHUMAN SERVICES .................. E~NVIRONMENTAL SERVI(~ES DIVISION ...... B.~;. Box !:.96650. e Anchorage, Alaska 99519-6650 · Telephone' 343~744 On;Site Wastewater Dis osal S stem a " ...... ~ ..... ............. ~ ............. ? ............. ~ ............................ i ........... ' .......... ~ ............ ~ .................................. i. P ............................ :..Y ......................... p~0r Well InsPe~t.!,o....~....~.~p9.~i ............................. [:egal De~i'~i0~i '"~:'~/~/~'"'",~Ja:~-//L/J~oi_~/~Jo, ,/~ PID No.:' ~/~"~i~"~'7 ....... 72-~13 A (2/91) MOA 2~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW940443 DESIGN ENGINEER:ANDERSON ENGINEERING OWNER NAME:NORTHWOODS INC OWNER ADDRESS:?09 W. INTERNATIONAL APT RD ANCHORAGE, AK 99518-1123 PARCEL ID:05106437 PAGE 1 OF DATE ISSUED:12/02/94 EXPIRATION DATE:12/02/95 LEGAL DESCRIPTION: NORTH WOODS UNIT IV BLK 18 LT 9 LOT SIZE: 28123 (SQ. FT.) NUlVlBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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) 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: DATE: DATE: ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, ALASKA 99524 November 17, 1994 Municipality of Anchorage Department of Heath & Human Services 825 "L" Street Anchorage, AK 99502-0650 Subject: Lot 9, Block 18 Northwoods Subdivision, Unit No. 4 Septic System Design Impacts to Adjacent Properties Dear On Site Services Engineer: We hereby request that a permit be issued for the construction of a septic system on the subject property. The location of the system and and the reserve site are shown on the attached site plan. In addition, the topography of the lot and existing drainage pattern is also illustrated on the plan. Soils encountered during the field study indicate acceptable conditions for an onsite sytem. The lot will be served by a community water system so well construction is not required. If the system is completed as designed the following statements can be made: The system, if constructed as designed, will have no adverse impact on the wells currently in use as the subdivision is served by a community water system. The system, if constructed as designed, will have no adverse impact on existing septic systems in the area or those to be constructed in the future. The system, if constructed as designed, will have no adverse impact on reserved space, either surface or subsurface, on any lots located in the area. The system, if constructed as designed, will have no adverse impact on drainage patterns in the area. .~ ~' ~, Sincerely, Michael E. Anderson, P.E. SKIES /60 Lot 9, Block 18, Northwoods Subdivision, Unit No. 4 DESIGN FACTORS: Three Bedroom Home Perc. Rate: 23 Min./Inch Application Rate: .6 GPD/SF Reduction Factor: .5 3 Bdrms. X 150 GPD / .6 GPD/SF = 750 SF / 5 LF Wide X .5 Red. Factor SYSTEM REQUIREMENTS: Wide Trench System 1,000 Gallon Septic Tank 4' Drainfield Rock 750 SF of Absorption Area = 75 LF Trench Therefore: Construct 2 Wide Trenches, Each 38' in' Length. 4' of Drainfield Rock Under Laterals Place I NOTE: Maintain 4' Separation from Bottom O;~¢:,::,T~gch ,,,~,,.~to,>,~ ::,' Grade Area Over Trenches to Drain Away. . Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PEF LEGAL DESCRIPTION: 1 2 10 11 12 ~Township, Range, Sectio.n: SLOPE WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT ~/ O DEPTH;' p E 13 Oeplh to Water Alt~ ~ MonilorinD? -.,;,/ ' Dale: SEAL) SITE 14 15 16¸ 17 18 19 Reading Date Gross N~t Depth to Net Time Time Water Drop '' ":'"/'//;¢.¢ /I.':',~-5W:~,'¢ /~.'¢>/¢~/~ ~.~/~,7~ ,¢~ PERFORMED B',: /'/'--- , '~Z~,~ CERT:F* T.AT T~,S TE~T WAS PERFO.,.ED,N AOOORDANOE W'TH A'L mTEANO,,UN,O:p^, GU,OE,,NES iN EFFECT ON,m OATE. :ATE: //I;7l¢/ 72-008 iRev, 4/851 ~..~ J~!~ PERCOLATION RATE //I TEST RUN BETWEEN 7 ~ FT AND FT / / / , Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST SEAL) LEGAL DESCRIPTION: ZOO' ~. 8gO ~/-- /&;~ Township, Range, Section: 2 5 6 7 8 9 10- 11 12 13 14 15 16, 17 18 19 20 S/vt COMMENTS WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? ~ P E Monitoring? ~¢~'0~J~' Date: . "~ Reading Date Gross Net Depth to Net Time Time Water Drop z.~/5' ~.oo . ~,~ E ~o0 /~, ~ .7~ PERCOLATION RATE TEST RUN BETWEEN (minutes/inch) PERC HOLE DIAMETER FTAND 4~ FT PERFORMED BY: /¢¢~ i ~&-~'~ ~4,4'~,/~'~'~T HAT ThtlS TEST WAS PERFORMED /I /7,]'7V ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: CJ 72-008 (Rev. 4/85) IN ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: Lot 9, Block 18, Northwoods Subdivision, Unit 4 GENERAL: 1. The scope of this project includes the procurement and installation of a 1,000 gallon septic tank and the construction of a wide trench drainfield to serve the proposed three bedroom home. 2. Construction shall be in accordance with the approved site plan, design drawings, Municipal Permit with any special provisions or conditions, and all applicable State and Municipal Wastewater DisPosal RegUlations~' : 3. The Contractor shall be responsible for obtaining all underground utility locates. 4. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. Property owner shall also be responsible for revegetation of affected areas unless specifically agreed otherwise. 5. Contractors installing wastewater disposal systems must be certified by the Municipal Department of Health and Human Services for system installations. Owners installing their own systems must receive prior approval from D.H.H.S, before beginning system installation. SEPTIC TANK INSTALLATION 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. Lot 9, Block 18, Northwoods Subdivision, Unit No. 4 November 17, 1994 Page Two 3. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. 5. A foundation cleanout shall be installed one to four feet from the building foundation. Two cleanouts shall be installed between the tank and the drainfield. The first cleanout shall be located on undisturbed soil not more than 10' from the tank. The first cleanout shall be to clean toward the drainfield. The second cleanout shall be to clean toward the tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: 1. The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trenches shall be within 2" of level, Sidewalls of the trenches must be raked before gravel placement. 2. Distribution piping must be placed level with perforations down atop a level bed of drainfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. 3. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 4. Monitor tubes must be 4" in diameter and installed at the locations shown on the design. The portion below ground must be perforated. Lot 9, Block 18, Northwoods Subdivision, Unit No. 4 November 17, 1994 Page Three 5. Direct bury insulation must be placed over the distribution system when less than 3' of backfill depth is available. Finish grade over the trench must be mounded to prevent settlement or depressions. MATERIAL SPECIFICATIONS: 1. Septic tanks must be constructed by a Municipally approved septic tank manufacturer. 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and ASTM D2662 or A.B.S. (perforated and solid). 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain rock layer and the native soil layer. 6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing the #200 seive. INSPECTIONS: A minimum of two inspections are required by Municipal Ordinance. These inspections must be conducted under the supervision of a professional engineer registered in the State of Alaska. The first inspection must be conducted after the excavation of trenches, beds or pits and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled. Lot 9, Block 18, Northwoods Subdivision, Unit No. 4 November 17, 1994 Page Four The second inspection must be conducted after the placement of the geotextile fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Parcel I.D. # 1. 0 "10 q $7 GENERAL INFORMATION Complete legal description MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES -. Division of Environmental Services On-Site Services Section '~:' ~ P.O. Box 196650 Anchorage, AlaSka:', 99519-6650 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address ~,,J c,, Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: -~ 3. TYPE OF WATER SUPPLY: Individual well NOTE: 4. TYPE OFWASTEWATER DISPOSAL: Community well XX. X~ Public water ::'\~ If community well system, provide ~vritten confirmation from State ADEC attest- ing to the legality and status of system. Individual on-site ~ ~ rr Holding tank ~ Community on-site NOTE: Public sewer ~' If community wastewater system, provide written'confirmation from State ADEC attesting to the legality and status of ,. ~? '~ ~ ' r~ 72-025 (Rev. I/91) Front MOA#21 Se 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 num her of bedrooms and type of structu re 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, andregulations in effect on the date of this inspection. NameofFirm ,Z~J0 ~'/'/.~0rJ ~-'~(,/,J&3;~J~ Phone , Address : p,-_ ~o;~ ~.'~0_775 . .- c~. ~ ; q~'z.-.-'_ Engineer's signature ~{~''', ' (~ ~-Cu~ Date DHHS SIGNATURE ~)~ Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: By: Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based °nly uP°n 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 pumhasers of homes and their lending institutions in order to satisfy certain federa and state requirements, Employees of DHHS do not conduct inspections or analyze daia 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 ,; ,?il, (k~"'~) '* DEPARTMENT oF H'~.~kI~T~'~"HUM~,N'SERV CES_ ': ;.~,' ~ ,~4~ ':;;-/-,;:~. Division of Environmental Se~ices --~ . ,r,,: -:+',?,:,: ; ,. :.,,. On-Site Se~ices Section - · . . ., ., P.O. Box 196650 Anchorage"Alaska 99519-6650 ~.. ' ~,. - : ..........~. 3~7~~: - , .: CERTIFICATE OF HEALTH AUTHORI~ APPROVAL. FOR A SINGLE FAMILY DWELLING Parcel I.D..~ , ~,~. GENERAL INFORMaTION .. ,..; ' : ~ 'Cdmpi~t~ iegal de~&i ~ti'&n Location (site address or directions) ' : '" .................. ' .... " Pr6P'ei-ty Owne'~ ?'~'~ ';' ¥'"'- ,". :'.~-.~.,. aail~ngaddre~s~, . . ', -,':"~:~'~ Day phone ' Day phone .~,- Unless otherwise : :!:::;'~!'~' to theiegalityand statUs ofsystern?i,~:~t'L~,:':"::' -: ~"! : '.: 4." ~PE OF WASTEWATER DISPOSAL: ':' t:': ': ::' :~'" ::"'~':"":::"'' . ~:: :::lndiVidualon-site ~ :. fi,,, :,~,, NOTE: 4:4f communi~ wastewate~ s~stem,,prowde wnffen confirmation from State ADEC 5. STATEMENT. OF INSPECTION BY ENGINEER' As certif ed 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. " NameofFirm X/~:~'~O/J ~_..~J~l~Jl.=-i~tl~J~, Phone Address Engineer's signatu.r,e ' Date 6.';'DHHs SIGNATURE ' Appr°v*' ;;r; s-O '3 Ji: ;~ Disapproved~-:, XX ;..;,,,: . '-;: ~:'-; ¢~. i;:'conditi°hal 'approval for bedrooms, :.'.':;; i}?; bedrooms, with the following stipulations: 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) ~ack MOA~21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A, W®II Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Parcel I,D. 0~'"/0 ~ '~,,~ '7 If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test Static water level Well flow Pump level1 .g.p.m. g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on tot Absorption field on lot Public sewer main Sewer service line ~ ~.O0/ ~ ~00~ WATER SAMPLE RESULTS: Coliform Date of sample: ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~ /] ~ /¢/~' Tank size Cleanouts (Y/N) Y~ Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping ~.~ ~/- .~. Compartments 'Y Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ ZOO To property line .),~.<::) Surface water/drainage On adjacent lots /'~//~ Absorption field ,~/~ i /5'O Foundation Water main/service line CONTINUED ON BACK PAGE 72-026 (3/93)* Front C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~'//~' Z.O/q ~ Soil rating (GPD/Ft Length ~0o ~ i Width ~. I Gravel thickness Total absorption area ~)~' ~ Cleanout present (Y/N) System type ~'#~IJ-e ~Tr/..~-~ ~ Total depth '7. ~' Depression over field (Y/N) ~ Date of adequacy test /~ ~E (~J ~ ~J ~,~ . Results (pass/fail) Water level in absorption field before test O Peroxide treatment (past 12 months) (Y/N) /k~ '"~A 5_5 for ,~ Bedrooms After test ~ If yes, give date /~J/A SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /'~ O ~ To building foundation On adjacent lots ~' ~ / Surface water '~ Curtain drain /~ O On adjacent lots ~, Z. OD Property line Z.~' I To existing or abandoned system on lot Cutbank /~Jo ~ ~ Water main/service line Driveway, parking/vehicle storage area > ?o E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA date of this inspection. Engineer's Name Date 7/17 / HAA Fee $ Rece,pt Number Waiver Fee $ Date of Payment Receipt Number