HomeMy WebLinkAboutPENNINGTON PARK BLK 1 LT 6A
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
Name: ~pgrade
~ ~. ~~ ~~ Wastewater System: ~ New
Address:
t~~ ~~~~ ~ ABSORPTION FIELD
P ~__~ ~ No. of Bedrooms:
~eep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
Total Depth from original grade:
Subdivision: ~ Depth to pipe bottom from original grade: / Gravel depth beneath pipe
Township: ~ Range: Section: Fill added above original grade:~l Gravel length:
WELL; ~ New ~ Upgrade Gravel~ ~~~( Numb~r°f lines:
Ft. Ft.
ion (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:~
~ t/~~ Ft. Ft. I ~ SQ, Ft.
Driller: Date Drilled: Static Water Level:Ft..~~lnstaller: ~~~ Date installedL
Yield: ~ Pump Set at: Casing Height Above Ground:
GPM Ft. Ft. TANK
SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P.
To Septic Absorption Lift Holding ~ublic/Private Manufacturer: _ Capacity i~~
From Tank Field Station Tank Sewer Lines ~~¢
Weld ~1 ~j~l ~ ~ ~ Material~~ Number of~rtments:
Surface
Water I~O'+ i~ ~ -- ~ LIFT STATION
Line ~/ I ~ / ~ ~ ~ Size in gallons: Manufacturer:
Foundation ~ I ~/ -- __ ~ "Pump on" level at: I "Pum~el at: High water alarm at:
CurtainDrain ~ ~,~ ~ ~ ~ Pump Make & Model } Electri~lnspections performed by:
Remarks: ~t~l~ ~t~~~ BENCH MARK
Location and Description:
Department of He~ and Human Services approval
72-013 (1/91)MOA 25
Permit No. ,~V~ ~) ~- O0 ~ ~
Page "~ of ~'
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
--__. J
,EAL
72-013 A (2/91) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920022
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:PISA STEPHEN G & THERESA
OWNER ADDRESS:17300 MARIJANE ST
ANCHORAGE, ALASKA 99516
DATE ISSUED: 3/02/92
EXPIRATION DATE: 3/02/93
PARCEL ID:02018157
LEGAL DESCRIPTION: PENNINGTON PARK BLK
A
1 LT 6
LOT SIZE: 46075 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: -,--,~,
ISSUED BY: ~
/
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
WASTE WATER
DISPOSAL SYSTEM
DESIGN
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
February 25, 1992
CIVIL ENGINEERS
(907) 694-2979
FAX 694-1211
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, Alaska 99501
REFERENCE: Pennington Park Subdivision, Block 1, Lot 6A
Request you issue a permit to upgrade the septic system
serving the referenced property.
An adequacy test was performed on the existing system and the
absorption capacity of the existing trench was found to be
inadequate.
A test hole was excavated and a percolation test performed in
the area of the proposed upgrade. The ground water monitoring
tube within the hole has been checked and found to be dry.
Attached is an upgrade design which shows the location of the
proposed trench.
We do not anticipate any adverse effects on neighboring
properties by the installation of the proposed septic upgrade.
If you have any questions or require additional information
for your review, please contact us.
Sincerely,
ROGER J.
RJS/lsu
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
UPGRADE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
SLOPE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
Deplh to Wa.~tar. TA~., /
Monilorino? _C,,"'.,~---7
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
I ~l~,~/e~- +.~ ----~>" ---
~/ ~' ~.- ~ ~ ~/~' ~/~ ,,
~ ~ ~ ,, U '/~' ~1~"
~agie River, Alaska 995~ ¥ ~ v
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON HIS DATE.
72-008 (Rev. 4/85)
PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER ~-~ #
-CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE:
GRE,~,ER ANCHORAGE AREA BOk
Department of Environment81 Quelity
3330 C Street
Anchorage, Alaska ggs03
JGH
~SPECTI_ON REPORT ON-SITE SEWAGE DISI~SAIj SYSTEM
·
SEPTIC TANK:
DISTANCE /~'-'~ ~'
FRO~ WEU~ ~^NUF^CTURER
INSIDE LENGTH ~ INSIDE WIDTH '--- -. LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAPAC ITY/~) GALLONS.
TILE DRAIN FIELD: ,,_, /~ TOTAL LENGTt4..~ ~-.-_
[ ~ W,OT~/~
ABSORPTION ARE*
DEPTH: TOP OF TILE TO FINISH GRADE
FT. LENGTH OF EACH LINE DEPTH OF FILTER
'
TYPE'S_ eil t~ CONSTRUCTION
IN.
DEPTH DISTANCE FROM:
BUILDING NEAREST N~AREST SEPTIC SEEPAGE
FOUNDATION__ LOT LINE__,, SEWER LINE TANK SYSTEM
CESSPOOL
OTHER SOURCES
APPROVED__ DISAPPROVED REMARKS
DISTANCES:
_,',qF
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE: ~ t ~..~)~ ,, .
Form EQ-032
PERM I l' WI].
i',"! El I'-.I I [: I F' FI L_ I l" '~.' CI F- fsi I'-.I C: Fi El F..'.'. ~ ~]]~ FZ
[:,EF'~RTMEN'T OF HEALTH ~N[:, EN',,,'IRONMENT~L F'ROTECTION
251Et E. TIJ[:,OR RI:,.., ~NCHOR~GE., ~K. 9~5Ei7
27'6-222t
('763:~8)
AF'PL I CANT
L O C A T I O N
LEGAL
=, TE,., E PISA
MARI,IHNE ST
L6 Bi PENN INGTON F'K
8]~20 EL[.EFi..E, EF..RY ST
LOT :., I ,.'E
4~'~.'.1,".:, -':,U JHEE FEET
'I'YPE OF '=;OIL ABSORBTION SYSTEM IS' TRENCH
MR::.::IMLIM NUI',IE:ER OF BEDROOMS
SOIL RHTIN_~ ,'qQ FT,--'BR)= :1..,=: ....
't"HE REL:.!LiIRE[:, SIZE OF THE SOIL ABSORPTION SYSTEM IS'
[:, lEE F' T H = ~'; L E I%! mZi 'T' H = 4 ":-', ~3 !:;: !~ ",,-" E L [:, IrE F' T' H == -:~
THE LENGTH DIMENSION IS THE LENGTH ,:i IN FEET) OF THE TRENCH OR [)RRINF'IELD.
THE DEPTH OF R 'TRENCH OF.: PIT IS THE DISTANCE BETWEEN THE SURFRCE OF THE
GROUND AND THE BOTTOM OF THE E:-qCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL [:,EF"TH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OI..ITFRL. L PIPE
AN[) THE 80TTOM OF THE EXCAVATION (IN FEET).
Ill E ~]:! LI I Fi: E [:, SEC F' T I C: 'r R I'-,! I-::: S I Z E: = :1_ ~:Z~ i:_'E1 ~.:.'i Ci R L... k,. C, f'-,~ D~;
BACKFILLING OF ANY =,~:=.TEfl WITHOUT FINRL INSPECT ION RND RFFR_., HL BY TH tS
'-- ' -' "'1'~"- F,' I .
[:,EF'RR1-MENT WILL E:E =,UE, JEL. T TO FF.'.CL-,ECLTION.
MINIMUM DISTt~NCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS;
&E~O FEET FOR R PR I',/ATE WELL OR 200 FEET FOR R PUBLIC WELL..
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT HITHIN 3:0 DAYS
OF' THE WELL. COMPLETION.
SPECIFICR'TIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE ~0 INSURE PROPER
I NSTALLA'T I ON.
I CERTIF'Y' THAT
±: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS F4S SE'l"
FORTH B'¢ THE MUNICIPALIT'¢ OF ANCHORAGE.
2: I WILL. INSTALL THE SYSTEM IN ACCORDANCE WITH THE CO[:,E'.'-3.
3:: I UNDERSTRN[:, THAT THE ON--SITE S~ER SYSTEM MAY REQUIRE
RES i[:,ENE:E IS; REMODEI..E[:, T~~]D.~f~:E THAN ~: E:EDROOMS.
S I GNED:
RPPL I CANT STEVE P ISR
...... ......
ENLAR[~EME. N] IF THE
GREATER ANCHORAGE AREA BOROUC"
Department of Environmental Qu, ,ty
3330 "C" Street
Anchorage, Alaska 99503
_ , :) SOILS LO(, t EROLA1 ION FES 1
Performed for' ..>~L<., ~, ~ \ (' ,~
Legal Description: [ ..r (~ P3~('l ~ ,x~,~,~.,. F ~ '-- ~ ~, ' ---r ,
/n~s form reports: Soils' log_~ .... '~. ' Percolation test
Depth
Feet
1 -<.;._1,5-
10-
11 -
12
13-
14-
Was ground water encountered?
If yes, at what depth?
Reading Date
Gross Time Net Time
Percolation rate
mi nute.
Depth to Water
Net Drop
'Proposed installat~=-*-6'n¥'-~if]a.--qe Pit Drain Field
',.)epth of Inlet . Dept}~--t¥-~b~-'-O¥-i)it or t~ench
COHHEIITS' L ~]:: ...... : ]~ ...... . L~ ~ ~-x ~,:~ ,'~ ~o ,~.v~~4 ~¥'--¥¥"~
Performed gy:(~ c;",:~-~x ~ ~(----x.,.. Certified By~i --~k~x, ,'D r-x.~.-. DaLe:
]]OX ~!}~(~9, ~?AR ]~OU?E A ANCltORAGE~ ALASI~A
SIX INCH WATER WELL DRILLED aND CASED OUT TO THE DEPTH OF
DRILLED at THE RATE Of $17.00 Per FOOT.
PROPErtY OWNEr ~. ~lt®~
LOCATION OF WELL SITE Lt. ~ ]~lk~ ~ ~d~l ~6~II~iN~FO~/
DRILLER ~Le Claus of
WELL LOG:
O----ZS' Sand7 ela~ with 15~ gravel.
25---49' Gravel with 20% ela~ binds. Several swmll boulders.
180 fea~;
~---51 ' Sa~ly gravel shewing sm aiga~ ef water. Very small amount.
80--1.~' Sedime~tar~ bed~eck,· Very weak signs ef water en top of bedr~k at 80 feet,
XS~-XSO' Sedimeata~ reek with seae signs of wet ~rou~ reck frea X?O te 1.73.
This well should pttup 2,5 GPM and lmp~ovo to at least 305 GPH ~000 gallons in a 2~
hour time frame, Water standing within ~0 feet of su~faee.
FUroR should be installed 1.0 feet off bettea.
COST INCLUDES' ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLINg.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
DATE
$30~0.00
THANK YOU VERY MUCH.
SERVICE CHARGEOF ~% PER M
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # O -- I - 5
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
' Pro~Perty owner
Mailing address
Day phone '~ ¥~-- of 2_. ~'
Lending agency
Day phone
Mailing address
Agent '~,q~l~,c~.~ I- rt
Address 02 Itl t', ~ ,, ~
Unless otherwise requested, HAA will be held for pickup.
¢._
2. NUMBER OF BEDROOMS: :~'-- '~ rtl c-
3. TYPE OF WATER SUPPLY: rtl,..., ~
Individual well rm ,..,-,
: -'- Community well ~
Public water
-Day phone
NOTE:
4. TYPE OF WASTEWATER DISPOSAL:
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system. ·
. Individual on-site
Holding tank
Community on-site ',,
Public sewer
If community wastewater system, provide wri~en confirmation from State ADEC
a~esting to the legality and status of system.
NOTE:
72-025 (Rev. 1/91) 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 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.
DHHS SIGNATURE
· , ~ Approved for 3
DisapprOved.
Conditional approval for
bedrooms.
bedrooms, with
the following stipulatiOns:
'Additional Comments ~
.:, be Man~c~.,ahty of ?.~R'ch?age Department of Health and Human Services (DHHS) issues Health Author'
'A' ..... '- ,ty
· pproval Cerbflca,te~.§a~ed only upon the representations given in paragraph 5 above b an ~nd
'. , ,' ,~" ,,. Y ' ependent
profess~o,nal engmee¢ registered in the State of Alaska. The DHHS does this as a courtes t
a ..... ,.'~,n _. ~,.~,, ..., ....... Y o purchasers of homes
nd ~e~rlenamg restItutions m oroer 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 p.rofessional engineer's work.
72-025(Rev. 1/91) Back MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: j, OT ~/~: .'~,,.~ Parcel I.D.
A. Well Data -~--bi,~'[-o[,,t 'P,~
Well type ~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) '"'l Date completed 7/0/'7 ¢o Driller
~ A ~/PA ~ '¥-
Total depth I ~.~ Cased to ~ Casing height j c~'l
Sanitary seal (Y/N) Y Wires properly protected (Y/N) Y'
FROM WELL LOG AT INSPECTION
Date of test ~7/0/ ? ~ ~//~'~/~ ~ ;;~
Static water level ~,~ ~ ~ ~7 I'1'1
Well flow c~, ~'' g.p.m. /o > g.p.m.l-rl~
Pump level1 ~o /~ ~ ~o '~d "~
SEPARATION DISTANCES FROM WELL TO: I;~
Septic/holding tank on lot i(9 ~
Absorption field on lot ( I ~
Public sewer main
; On adjacent lots
; On adjacent lots
125
Sewer service line
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESETS:
Coliform
Date of sample: ~/iq / ~'"
B. SEPTIC/HOLDING TANK DATA
Date installed ~, '(~ , ~,~.-
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Nitrate
~_~ ,~ V~. 1//~' Other bacteria
Collected by:
Tank size //~ ~cO Compartments
Foundation cleanout (Y/N) / Depression (Y/N)
H/~r Alarm tested (Y/N) /'{///--~-
7/7./~] ~' Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Surface water/drainage
On adjacent lots ~ 051 Foundation '3~)
Absorption field ~.4 Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
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 ~-~ · ~ ~
Length 7.~ Width
Soil rating (GPD/FF) ~)./'/
Gravel thickness
System type
Total depth //, ~-
Total absorption area !/b ~ Cleanout present (Y/N)
Date of adequacy test ~ ~/~ ~" Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Depression over field (Y/N) /"'/
for ~'~ Bedrooms
After test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot II -7¢ '
To building foundation ~,~ I
On adjacent lots ~ '5,1D
Surface water N[IO
Curtain drain 1~ (~)
i
On adjacent lots IO,..~ Property line
To existing or abandoned system on lot
Cutbank N 0 ~ ~- Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effec, t on the date of this inspection.
Engineer's Name
Date
HAA Fee $ ~-dJ~. ~
Date of Payment ~-,~/,,/~ ~< '"-'-
Receipt Number / D.~.~,.//".,~,~-')
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
zTL
CT&E Ref.~
Matrix
Client Sample ID
CT&E Environmental Services Inc.
Laboratory Division ~"~'~'~J'~'~l~r~-~r~'f~'~'~'~'~'~r~'~-~-N~jfjffj~ff~jfff~~
95.2 0-1 Laboratory Analysis Report
WATER
L6 BLK1 PENI~INGTON PARK
Client Name TOBBEN SPURICLAlqD, P.E. WORK Order 15606
Ordered By Printed Date 06/22/95 @ 15:52 hrs.
Project Name Collected Date 06/19/95 @ 13:20 hrs.
Project# Received Date 06/19/95 · 15:10 hrs.
PWSID UA
Technical Director
STEPHEN C. EDE
Sample Remarks: SAMPLE COLLECTED BY: LANS SPuRKLAND.
Qc Allowable Ext, Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate-N 2.53 D m~/L EPA 353.2 10. 06/21/95
* See Specxal Instructions Above =UA Unavallable
%~ See Sample Remarks Above NA = Not Analyzed
~i = Undetected, Reported value is the practical quantification limit. LT = Less Than
~= Secondary dilution. GT = Greater Than
200 W. Potter Drive, Anchorage, AK 99518-1605 -- Teh (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS. MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # 02018157
1. GENERAL INFORMATION
Complete legal description
Lot 6A; Block I; Pennin.qton Park Subdivision
Location (site address or directions)/7500 Marija~e_Str6et
Property owner
Mailing address
Teri Pisa
17300 Marijane St., Anchorage,
Day phone
Alaska 99516
279-7611
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well X×
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status ¢f system.
72-025 (Rev, 1/91) Front MOA #21
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
Address
S & $ ENGINEERING
17034 Eagle River Loop Road No.
Phone
Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
.~ Approved for ..~
bedrooms.
Disapproved.
Conditional approval for 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 #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:'~_~k-[~."l I~L4"["~::~I,,./'-~::~"~.~.~'" - Parcel I.D.
A. WELL DATA ~
Well ty~~~ If A, B, or C, attach ADEC letter.
ADEC water system number
Log present(~4)
Total depth
Sanitary seal (Y/N)
Date completed ~ - I ~ - ~ ~ Driller"~,C-t~-~
Cased to-'~'~::) "~~asing height ! ~-' '+'
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot J ~::) /
Absorption field on lot
Public sewer main
AT INSPECTION
MUNICIPALITY OF ANCHORAGE
~ I ENVIRONMENTAL SERVICES DIVISION
Sewer service line
; On adjacent lots
RECEIVED
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform d Nitrate
!
Date of sample: ~' "~- ~ ~-
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed '~ '(-~ -~J' '~-- Tank size
Cleanout~l~) '~
High water alarm (Y/N)
Date of pumping I,J~
Foundation cleanou (~N) "(/' ,~
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot lz~ /
To property line ¢DO
Surface water/drainage
On adjacent lots
Absorption field
Compartments
Depression
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical ~N)
SEPARATION DI~CE FROM LIFT STATION TO:
Well on ~ On adjacent lots
~°le/Access (,,Y/N)
"Pump on" level..a.t/ ' Pump off" level at
J Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Soil rating
Date installed
Length ~ ::::~' Width
Total absorption area J l (~::~
Depression over field (Y~ ,~
Results (pass/fail)
Peroxide treatment (past 12 months) (/~
Gravel thickness
Cleanouts prese~N)
Date of adequacy test,
for "~
If yes, give date
bedrooms
Curtain drain
Property line
To existing or abandoned system on lot
J('J ~ ~J ~'~ Water main/service line
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
On adjacent lots I ~'~' /
To building foundation '~--~ /
On adjacent lots ,,~.~ t..~ Cutbank
Surface water !~j ~--Jc- Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this insP~tion.
S & S ENGINEERING
Signature 17034 Eagle River Loop Road No. 2C1~4
Iblslle River, Alaska 99577
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
///~ 75~') Receipt Number
72-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE # 50935
Chemlab Ref.# 92.0474 Sample % 1 Matrix: WATER
Client Sample ID : L6A BLI PENNINGTON PARK SD.
PWSID : UA
Collected : FEB $ 92 @ 17:00 hrs.
Received : FEB 6 92 ~ 15:15 hrs.
Preeerved with : AS REQUIRED
Client Name :S & S ENGINEERING
Client Acer :SNSENGP
BPO! :
Req{ :
Ordered By :R. SNAFER
POW :NONE RECEIVED
Analysis Completed : FEB 7 92
Laboratory Sup~vl~or : STEPHEN C. EDE
Released By :~-~ ~_~ ~
Send Reports to:
i)S & S ENGINEERING
Parameter Results Units Method Allowable Limits
NITRATE-N 3.0 .~/1 EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY: J.W.
Remarke:
1 Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected "See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-Greater Than
~-~SGS Member of the SGS Group (Soc,¢t(~ GOn(~rale de Surveillance)
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONmeNTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date_January 3l, 1985
(a) Legal Description (include lot, block, subdivision, section, township, range)
_Lot ~, Block 1~ Pennin~ton Park
Location (address or directions)
17003 Marijane Street
(b) Applicants Name Steve Pisa
Applicants Address 17003 Marijane Street
345-1901
Telephone - Home Business N/A
(c) Applicant is (check one) Lending Institution .~ ; Owner/builder [~ ;
Buyer ~ ; Other ~-~ (explain);
(d) Lending'Institution
Address ~:~.~/4 ~
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. Type of Residence
Single-Famiiy~
NUmber of Bedrooms
3. Water Supply
Individual Well~[
Multi-Family~-~
Two
Other (describe)
Community~-~ Public~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite~--~ Public~-~ Community.~, Holding Tank.~-~.
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
Engineering Firm Providin~ Inspections, Tests~ File Search~ Data and Information,
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 regula-
tions in effect on the date of this inspection.
Name of Firm A. W. i4urfitt Company
Telephone 349- 7531
Address 17003 Mari~ane Street
Date January 31, 1985
DHEP Approval
Approved for bedrooms
Approved ~_~ Disapproved -- Conditional ~
Terms~. of. Con,d~it ion,al_ Approval., ~O/b'/'~L~. ~ ~O~z'~ '~ ~ ~+~~ ,, ~~ .~/~'~ 1'~
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF EEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSb~S HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COL~TESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUI~O~TY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Pennin§t0n Park
MUNICiPALiTY OF AN(~HORAGE
DEPT. OF HEALTH &
Ej'.IV~RONMi~NTAL I'¥.C, i'LCFION
1985
RECEIVED
Lot 6, Block I,
Well Classification Single Famil.y
Well Log P~esent .!Y/N) Yes
Total Depth ] 80 ft.. Cased to
Static Water Level 50 ft.
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)Yes
Separation Distan~s f~ Well:
To Septic/Holding Tank on Lot ] 05 feet
To Nearest Edge of Absorption Field on Lot
2 ft. (pum~house)
If A, B, c~ C, D.E.C. App~oved.(.Y/N) N/A
Date Cc~le~d ..J. uly 10, 1976 Yield 3.5 .qal/mi
]80 feet ~ Depth of G~outing unknown
Pump Set At ] 70 feet
Sanitary Seal on Casing (Y/N)Yes
Depression A~ound Wellhead (Y/N)No
; On Adjoining Lots 183~e~
] ]0 feet; On Adjoining Lots~%q 50 feet
To Nea~estPublicSe~= Line N/A To Nea~estPublic Se~r
Cleanout/Manhole N/A To Nea~est Se~r Service Line on Lot
Wate~ Sample Collected By Allan W. Mu~f~tt ; Date 01/27/85
Water Sample Test Rssults Satisfactoqy
Cc~nts varJance ~ranted for adjoJnin§ well/septic distance.
N/A
B..SEPTIC/HOLDING TANK DATA
Date Installed 6/76 Size 1000 ~al. No. of Cc~pa~nts 2
Standpipes (y/N) Yes Air-tight Caps (Y/N) Yes Foundation Cleanout !Y/N)Yes
Depression ove~ Tank (Y/N) NO Date Last Pumped 1-24-85
Pumping/Maintenanc~ Contract on File (Y/N) No ; fo~ N/A
Holding Tank High-Water Alarm (Y/N) N/A Temporary Holding Tank Permit (Y/N)N/A
Separation Distances f~cm Septic/Holding Tank:
To Water-Supply Well IQ5 fee~ To Building Foundation 45 feet
To P~oper~y Line 20 feet To Disposal Field l0 feet
To Water Main/Se~vic~ Line N/A To St~e~, Pond, Lake, c~ Major D~ainage
Course
Comments
[Page 1 of 2]
2-15-84
Co
ABSO~ICXN FIELD DATA Attached as per Permit No 76338
Soils Rating in Absorption Strata ___~~Type of System Design Trench
Length of Field 50 feet
Date Installed
Width of Field
6/76
3 feet
Depth of Field 6.5 feet
Gravel Bed Thick~ess 4 feet
Square Feet of Absorption A~ea 375 feet Standpipes P~esent (y/N)Yes
Depression ove~ Field (Y/N) No Date of Last Adequacy Test 0]/27/.85
Results of Last ~equac~ Test Satisfactory
Separation Distanc~ f~cm Absc~ption Field:
To Water-Supply W~ll 100+ feet To P~operty Line ~O+ f.~et ...
To Building Foundation 60+ feet To Existing or Abandoned System cn
Lot N/A ; On Adjoining Lots 83 feet
To Water Main/Service Line N/A To Cutbank(i~ P~esent)
To St~eam/Pond/Lake/c~ Major D~ain~ge Course N/A
To D~iveway, Pa~king. A~ea, c~ Vehicle Sto~age A~eal0 ft. drive across (insulated)
Ccmmments 300 gals water introduced to system, no water level change at time of test.
D. LIFT STATION N/A
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm LeveI at
Tested for
Electrical Codes(Y/N) ' -
Ccm~rents ....
** Check Pe~itted Bed~oc~ Rating Against HAA Request
I certify that I have checked, %~rified, c~ conformed to all MOA HAA Guidelines in effect
,
Company A. W. Murfitt Compan7 MOA No. ST84-015 ":'
,
'
[Page 2 of 2]
2-15-84
LE FAMILY-'
E
FOUR