HomeMy WebLinkAboutROCKHILL BLK 2 LT 13
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE I E~NEW
UPGRADE
MAILING ADDRES~
LEGAL DESCRIPTION
~oc~,o~ ~o. o~ ~o~oo~s
Well Absorption area Dwelling ~ERMIT NO.
~ DISTANCE TO: P~O00~ ~ 7' ?O' ~30~ [
~ ~ Manufacturer ~ Material No. of compartments
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ W~ Foundation Nearest lot line PERMIT NO.
~ ~ DISTANCE TO:~EO~O~ ~' '+ fO/ 9 ~O ~ i
Length ~f eao~ lin8 Total 18~th of lines Trench width Distano8 betwean linas
~ ~ Top of tile to finish grade Material beneath tile Total
absorption
area
Length Width Depth PERMIT NO.
~ I Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
Clas~ Depth Driller Distance to lot line PERMIT NO.
~ % Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS * I
so~ L T~ST~AT~
INSYAELER
REMARKS' ~
APPROVED DATE LEGAL
PERMIT NO.
FIPPL I CFINT
LF,-:FFT I ON
LEGFIL
LLO'T'D F..EE.=,E
L'iS: B2 ROr:KHiLL
:3400 WILLIWFI L. IF._.LE
LOT SIZE
z, Tz, ~ Ell IS:
TYPE OF SO I L FiBSORF'T I ON ""' :"~ ' [:,RFI i tqF I ELI::,
i'iFIi:.::II"iLIM NUMBER OF E:EDF.:OCd"I':': = 5
276-6262
5475R SQURRE FEET
SO I L F.:RT i NG ': S ..] FT,.."BR ) -"?''
TFiE REQLIIRED StZE OF THE SOIL RBSOF.:F'TION S','S'TEt"'t iS:
"':- Fi r~ ...... c.. [,:.EP T H = 2
£:, E F' T H '-- -':5 L E i'4 G 'T' H :'= J_ ~-z, -_ ~ ~:. r-~ -.- ~
'THE LENGTH DIMENSION IS THE LENGTH (tN FEET) OF THE TRENCH OR DRFIINFIELD.
THE DEPTH OF FI TRENCH OR F'IT IS THE DISTRNCE BETWEEN THE SURFFICE OF THE
GROUND FIND THE BOTTOM OF THE E::'-;CFt',,,'FITION (IN FEET).
]-[-~E TF:E?4,_-:H I.-.i 1] [:,'T-[--~ ! ."----; 5. C4~-_--'~-_"~ FEET-
THE GRFtVEL DEPTH IS THE MINIHUM [:,EPTH OF GRFIVEL BETWEEN THE OUTFFILL PIPE
FIND THE BOTTOM OF THE E',:.:',CFtVFITION (IN FEET).
F'EF.:MIT RF'F'LiC:RNT HI=IS ]'HE RESPONSIE~ILiT'? TO iNFORM THIS [:,EPRRTMENT Df_RING THE
INSTFILLFITiON IN=,FEL. TtLN=, OF FIN'¢ WELLS RDJFICENT TO THIS F'F."PERT'¢ RND THE
,~'~.. t:::,, ~
NUMBEF.: OF F.'.ESIDENCES T'HRT THE WELL WILL : .........
-'F[L4C~ .:2 ~.L' ::, X ~'..~SF'EC::T iT. C,[~4S FtF:E F-.E, .... # ][ F:E[:.
BRC:KFILLING OF RN'¢ S'¢STEM WITHOUT FINRL INSPECTION RND RF'F'I~:O'v'RL B'¢ THIS
DEPRRTMENT WILL BE SUBJECT TO PROSE'E.TiON.
MINIMUM DISTFINCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSFIL SYSTEM IS
:;LETO FEET FOR FI PRIVRTE WELL OR t50 TO 200 FE:ET FROM FI PUBLIC WELL DEPENDING
UPON THE T'¥'PE OF PUBLIC WELL.
MINIMUM DISTFIN. CE FROM FI PRI',,,'FITE WELL TO Ft PRI',,,'FtTE SEWER LINE IS 25 FEET FIND
TO FI COMMUNIT'¢ SEWER LINE IS 75 FEET.
WELL LOGS FIRE REf..'4UIRED FIND MUST BE RETURNED 'TO THE DEPFIRTMENT WITHIN
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MF'I'¥' RPF'L'¢. SPECiFiCRTIONS RND CONSTRUCTION DIRGRRI'"IS RRE
RVRILRBLE TO INSURE PROPER INSTRLLFITION.
i CERTIFY THRT
:[.: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH B'¢ THE MUNIE:IPFILIT'¢ OF FtNCHORFtGE.
2: t WiLL INSTFtLL THE SYSTEM IN FICCORDFINCE WITH THE CODES.
Z.':: I' UNDERSTFIN[:, THFIT THE ON-SITE SEWER SYSTEM MFI'¢ REQUIRE ENLFIRGEMENT IF' THE
RESIDENCE IS REMODELED TO INCLUDE MORE THFIN 5 BEDROOMS.
"In the event that a lift station is installed an
electrical permit and inspection must be
S Z GNE[:,: .................................................. obtained. As-builts cannot be approved un-
RPPLtCRNT LL.O'¢[., REESE til the electrical inspection is received in this
~ . 2' /' ~ * ' ~ r ~ office. The electrical work must be per-
i'~'~i tEE:, B'T'_ ,~; L. /~ .;-;.: ~.9} ,?,,. ;, ..r _~. ,.j ~.,-,-~:= 2~,~//~;'~:.,, ~.~ formed by. a licensed electrician." ',/4. 0
~P~RTI*IENT OF HERLTH ~NO ENVIRONH~NTRL PR. orEcTION
t.l E L L ~ i'-.I [.'~
APPL I CRN ~
LOUM r I ON
LLOYD ~EESE
L'L~ ~2 ROCKH~LL
'~40G HILt. £~,IR GIRGL~
TYPE OF 50IL RSSORPtION
D~KF ILL lng OF
UPON ~E TYPE OF
OF ~E HELL COI,I~EFI
I ~H FRHIL[~ H[I'H FHE REI]UIREHENlr5 FOR
FOR TH ~Y THE PDJN [ C- [ P~L [ [Y OF RHL. H
HDt/ LLUfU K~LD~ ,
PtELL ~ ~-~ [)
PERMIT NO. ( 8~0407 )
FIPPLICBNT JFIK CONSTRUCTION
LEGRL L±~ B2 ROCKHILL
,- ',-' .... 5 995?7 2:49--.Z:J.S&
8i00 FE. TERs)E, UR~ ~..
LOT SIZE '99~999 SQURRE FEET
T"r'F'E OF =,UIL HB--,LF-.F] ION SYSTEM IS TREN_.H
MFIXIMLIM NLIMBER OF BEDF.:OOMS = 5 St']IL F.:FITING (SQ FT,-'E,F...-
THE REQUIF.'.E[:' SIZE OF THE SOIL FIBSORF'TION S"dSTEM IS:
i50
, .... "-~ ~':" L [:,EF'TH=
[:, E F'-~ ~-~ = 11 L E ~-.~,3 T H= ?-'~2; ._~ R ~-~ -. ....
THE LENGTH DIMEN'=;ION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFIINFIELD.
THE DEPTH OF FI TRENCN OR PIT IS THE DISTFINCE BETWEEN THE SURFFICE OF THE
GROUND FIND THE BO]'TOM OF THE EXCFI'v'FITION (IN FEET).
THERE iS NO SET WIDTH FOR TRENCHES.
THE GRFI'v'EL DEF'TH tS THE MINIMUM DEPTH OF GRFI'.,,'EL BETWEEN THE OUTFFILL PIPE
FIND THE BOTTOM OF THE EXCFIVRTION (IN FEET).
F'EF.:MIT HPFLI~.HNT HI=IS TFIE F..E=FLN_,IE, ILIT"r' ]'0 INFORM THI'-=, [:,EF'RRTMEI",IT DLIRIt".tG THE
INS]"RLLRTION Ii'.I_,FEUTIUN=, OF FIN¥ WELLS RD.TFICENT TO THIS F'ROF'ERT¥ FIND, THE
NUMBER OF RESIDENCES THFIT THE 1.4ELL WILL SER'v'E.
-'-- , ,-.. ' - S F.:EFJII 11 :I
T ~.-~ C, .:: ~ ":, ~ ~'4 __.-. F E _- T Z
,~t ,,- ...... -' '"' I-'
BFIC:KFILLING OF FIN¥ _T= ~EIi WZTNOUT FINFIL IN=.FE_.TION FIND FIPPRO',,,'RL B'T' THIS
DEPFIRTMENT WILL BE S_EJECT TO PR ZSE;E:LtTZON.
tdiNIMUM DISTFINCE BETWEEN FI WELL FIND FIN9 ON-SITE SENRGE DISPOSRL SYSTEM IS
±00 FEET FOR R PRIVFITE WELL OR ±50 TO 200 FEET FROM FI PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTRNCE FROM FI PRIVFITE WELL TO FI PRIVFITE SEWER LINE IS 25 FEET RND
TO FI COMMUNIT~ SEWER LINE IS 75 FEET.
WELL LOGS FIRE REQUIRED FIND MUST BE RETURNED TO ]'HE DEPRRTMENT WITHIN 30 [)FIb'S
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MFI~ FIPPL~. SPECIFICFITIONS RND CONSTRUCTION DIFIGRFIMS RRE
FIVFIILFIBLE TO INSURE PROPER INSTFILLFITION.
I CERTIFY THFIT
±: I Fii"l FFII"IILIFIR WI]"H 'T'HE REQUIREMENTS FOR ON-SITE SEWERS FIN[:, WELLS RS SET
'FORTH BY THE MUNICIPFILIT'T' OF FINCHORFIGE.
2: I WILL INSTFILL THE S'¢STEM IN RCC:ORDFINCE WITH THE CODES.
2:: I UNDERSTRND THFIT THE ON-SITE SEWER S'¢STEM MFI¥ REQUIRE ENLFIRGEMEN]" IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THFIN 5 BEDROOMS.
'v'4. 0
TJ~= ~. ~1. LE~-tl__i TH = ,;'5 LiRt-I~)KL DEPTH=
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVI RONNIENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:
,_EGA' .ESCR,PT,ON:
S~I_O p E SITE PLAN
1
2
3
4
5
6
· 7
8
9-
10
· '11
12
13
14
15
16
17
18
19
20
WASGRO,.DWATER No s~
E.COUNTERED?
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN
C~MMENTS
PERFORME'~"¥: Cnn ~ ~.'-', CERT, F,~O.¥:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
DATE PERFORMED:
//~ $O1LS LOG'
[] PERCOLATION
TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
WAS GROUND WATER
--5<=~/~NcOuNTERED?
IF YES, AT WHAT
DEPTH?
SLOPE
:
0
P
E
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
' ':~' ;C, . , .... .- TEST RUN BETWEEN
(minutes/inch)
FT AND -- FT
CERT,.,E..JA
DATE:
Date Drilled~ '3
Static Water L~ ! ~ feet
Draw Down i.~ 1 ." feet
Gall OhS P .~lte '%
Total Feet of Casin~_
Type Material Drilled:
~,,feet
to 80 Sand . svel
to 100 sandy Silt w/l+ gpm, water
foot
to 190 Silty Clay
to
29.0 S~ ltv C]av ~Wr~c,,'dors
315*~rev Clay w/~lock
to 325 Sandy Gravel w/W~ter
Hefty Drilling
~R.A. B~x 1553 H
An~ho~,ge~A].a, aka
99507
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTIO~
SEP 5 '1984
RECEIVED
· ...',.,,.:~..~.~ ~., P.O. Box~:~ ~.19~50 , 'Anchorage, Alaska "9 . ~
.... APPROVAL FOR A S NGLE FAMILY DWELLING
1. GENEgL INFORMATION ~-
Complete legaldescription Zo~ /3 ~c°~l~ & ~1~
Location (site address or directions)
.~ ~ ~*..~:'.~,~.~.-~;,~-;~;..~:~{;~,~
Mmhng address
:,'.. ~.:_"Z',:.'..:; 'Address-':~'~GOO'?~OU~ ~T~.
~ ' t~;'., .... ~::ting ~q ~e legaliCand~ status of system.
4. ~PE OF WAS~WATER DISPOSAL:',:?~¥~.
5. , STATEMENT OF INSPECTION BY ENGINEER
~: As certified ~,y, ?y seal affixed.hereto?nd as of the vahdabon date.shown below, ! verify that my
investiCjati~'. ~ ~hiS Health A~th°ritY A'ppr0~iapprliCati°n shOWs that the on:sit~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 invas.tgqation 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.
Phone
Date
Additional· Comments
,.,,,.'. ¢ ~ Date "'/
The Muni~ipali~ of Anchorage Depa~ment of Health and Human'"se~J~'s'~(~NHs~ i~ues Health Authori~
Approval Ce~ifl~t~ ba~ only upon the repmsenations given, in ,paragraph,5 above by an independem
prof~ional engin~r r~ister~ in the State of Alaska. The DHHS d~ this ~ a cou~ to pumhasem of homes
and their lending institutions in order to ~tis~ ce~ain f~eml and state ~uimmen~: Employes of DHHS do not
conduct insp~tlons or anm~e data ~fore a ce~ificate is~'i~u~:-~he'Muni~ipali~ of Anchorage
respons b e for errom or omi~ions in the profe~ional engin~i'~2-: ? "~';~:"~"'~'/ ::'
Legal Description:
A. WELL DATA
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 3/f~-i'41f4P4qLIT¥ oF
ENVIRONMENTAL SERVICES
Health Authority Approval Checklist
~ ~ ~ J[:'O~ ~4t/.-L Parcel I.D,:
RECEIVED
Well type JE'~.~tO~tOl'm,t. IfA, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~
Total depth --~ S t
Sanitary seal (Y/N) ~
Date completed ~-~-7-
Cased to ,..~ Casing height (above ground)
Wires properly protected(Y/N)
FROM WELL LOG
Date of test
Static water level
Well production ~
WATER SAMPLE RESULTS:
AT INSPECTION
g.p.m. ~ ~1~., O g.p.m.
Coliform 0 Nitrate
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed --q' tS. ~ Tank size
Foundation cleanout (Y,qq)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed ~- 1 ~ - ~' ~}
Length l/O/ Width .~'
Effective absorption area ?
Date of adequacy test ~ro~ ~.
~. I Other bacteria
Collected by: ~Z~:~'Tt~ ~"~J(.~'~c'~
Depression (Y/N)
Pumper '~OTO
6.>
Number of Compartments £ Cleanouts (Y/N)
High water alarm (Y/N) t,J/A
Soil rating (g.p.d./fl2 or fl2/bdrm) tSo ~Zd~' System type $~tle~at~) "'K,~-~
Gravel thickness below pipe ~ ~A//#Total depth 6,;.~
Monitoring Tube present(Y/N) ~'~ Depression over field (Y/N) /,f
Results (Pass/Fail) p~q~nl For 5 bedrooms
Fluid depth in absorption field before test (in.); ~ Immediately aftery2g.~ gal. water added (in.): ~q a ~ ~-,
Fluid depth $ 3~' Minutes later: ~4/ A (in.) Absorption rate = ? e30 g.p.d.
Peroxide treatment (past 12 months) (Y/N) t-) If yes, give date tc, J/A ·
Do
to
LIFY STATION
Date installed ~.~m gallons
Manhole/Access (Y/N) ~ "Pump on' level at*
High water alarm level at,..~ *Datmn
Cycles tested~J
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main ldo ~
Sewer/septic service line ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 7{~/ Property line
Water main/service line C0~tar Surface water/drainage /,ll/[ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~0
Surface water ~ O tO ~
Curtain drain ~,3Ok) ~'
"Pump off" level at*
: On adjacent lots
~ On adjacent lots
Public sewer manhole/cleanout
I~Ot ar.
Water main/service line <~0 t4'
Driveway, parking/vehicle storage area
t~o-r~O Wells on adjacent lots
F. ENGI~..I~I~TIFIC AT ION
1 certi~ that 1 have de~rmmed thrufield iqspe~and review
'gnat2
Engineer s Name ~ ~ l ~ l~
HAA Fee $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
systems are
ztr=
CT&E Environmental Services Inc. '"
Labo~tory Division
Drinking Water Analysis Report for Total Coliform Bacteria ~oo w.
Anchorage, AK 995184 '30~
R£AD LN'STRUCT'IONS ON ~VE~.~ SIDE B~FO~ ~OLLECTI.X'G SA.I~P~ 7~1:
ti
M'UST BE CO.~-WLET~D Wt' WATEK SUPPLIER
O PI:-BLICWATERSYSTE31LD.# il II I--
(3 .~end Inroiclt
~lOnth Day Year
Routin~ ~ Treated Water
Repea~ Sample (for routine sample ~ Unlrealed Water
with lab ref. no.
Time
S~X~L g LOCATION Cogrctcd By
~x: (9071 5~1-5301
TO BE COMPLETED BY L.-kBORATORY
o Sarapl~ over 30 }togr~ aid, results may
be tmtellabD
S~mple ~oo long ia c, ansit; sample ~hovld
uot be ut'er 4~ hoQ¢$ old ~t examinz~ion
co indicatd ¢eli~ble "- ','
new iample via s~i~i del v¢~ mail.
7
Atml}sis Began
A. mllyliCal ~(ethod: ~M~mbrane ~lhe¢
eu MMO-MUG
Number o{'colonies/IO0 r, ll.
.............. "tit"
95.3674 ~0
Clienl notified of ungadsfactoo' results:
Fa~cd
o
BACTERIOLOGIC.~L WATER AN:~LYSIS RECORD
MMIO-MI[G R~sult: TuLal Coliform
.}d*embrnne Filter: Direct Count
Verification: LTB
Fe~[ Coliform Con,treat/on
RepOrted ~~Oale
Matrix
CT&E Environmental Services Inc.
Liboratorl/Division
,~.~,7,~ Laboratory Analysis Repqr!
WAT~
Hame Collected Date 08/29/95
Pro~eet~ R~oeived Daee 08/29/~5 · 09:40 bra,
UA
Teoh~i~] Director ~T~PH~ C.
O')d ~de~e~ged, Reported ~lue la ~h~ practical quan~i//catio~ limit. LI - ~u ~an
" 2~ W. Potler Drive, Anchor~oe...AK 9~fil a:!~(JU .. Tel: (907} 5fl2-2343 F,x: (~7) 561-5301
D H I CONSULTING
· Civil Engineering · Surveying
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
OCT 1 0 1B95
ENGII ED
* Planning
October 10, 1995
W.O.: 95213
Mr. Jim Williams
Department of Health and Human Services
P.O. 196650
Anchorage, Alaska 99519-6650
RE: Lot 13 Block 2 Rock Hill Subdivision/Additional Information
Dear Jim,
The following is the additional information that was requested:
1 ) Septic system:
On August 26, 1995 we preformed an adequacy test on the above
reference property. At the time of the test, we noted 24 inches of
standing water in one monituring tube and no standing water in the
second monituring tube. On the first monituring tube, it was noted that
the standing water was approximately 12 inches below the invert of the
perforated pipe.
We added 761.3 gallons of water to the system. There was no change
in the depth of water in either monituring tube. Therefor, the system
passed the test.
2) Water system:
Prior to the start of the flow test, the static water level was at 146.2
feet. The well was flowed at 3.3 gallons per minute. We were unable
to get the water level in the well at the end of the test because the
sounder would hang up above the water level. The water level in the
well had recovered to the original static water level at the end of 24
hours.
800 East Dimond Blvd. Suite 3-545 Anchorage, Ak. 99515 Ph (907) 344-1385 Fax (907) 344-1383
I believe the above answered your questions.
ly y.ours,
Dee High, Pt
Principal
cc: Gail High, DHI
2_13dwl 0o.ltr
800 East Dimond Blvd. Suite 3-545 Anchorage, Ak. 99515 Ph (907) 344-1385 Fax (907) 344-1383
· ..j
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ] 1-19-RR
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 13 Block 2 Rock Hill S/D
Location (address or directions)
(b)
Applicant Name LlOyd Reese Telephone: Home 346-3899 Business
6541 Limestone Circle, Anchorage, Alaska 99516
Applicant Address
(c) Applicant is (check one): Lending Institution []; Owner/builder I~i Buyer []; Other [] (explain);
(d) Lending Institution Fleetwood Fund
Address Anchorage, Alaska
Telephone
(e) Real Estate Company and Agent
Address
Telephone
(f) I~e HAAtothefollowingaddress:
S & S ENGINP. RRING
SRB 196X
Eaqle River, ~]~ka 99577
TYPE OF RESIDENCE
Single-Family [~ Multi-Family
Number of Bedrooms
Other
WATER SUPPLY
Individual Well [~Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWA~J.SPOSAL
Onsite L.~ Public [] Community [] Holding Tank'Fl~ ,
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
'5.
ENGINEERING FIRM PROVIDING mNSPECTIONS, TESTS, FILE SEARCH, DA'I .. 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 regulations in effect on
the date of this inspection.
Name of Firm _~ & $ _~NG!NFI:R!NG
Address ~!~1~ 196X
Date EAGLE RIVER~ AK 99577
Telephone
Approved for .,~/~/"~% bedrooms by /~- ~/4"Z Condition~aI
Approved ~ Disapproved
Terms of Conditional Approval
Date
' !1 CAUTION,:, ;'
The Muncipality of Anchorage Department ~f Health and 'Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations give~ in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does. this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and stat(~ ~e~luirements. 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,
Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
NOV
Legal Description: ~-~ '/~
WELL DATA
Well Classification
Well Log Present(~N)
Total Depth ~ Cased to
Static Water Level /' 5' c> t
Casing Height Abo~e Ground
Electrical Wiring in Conduit (~/N)
Separation Distances from Well:
If A, B, C, D.E.C. Approved (Y/N)
Date Completed 9 - ~-.'~- -,-~"~ Yield
~_ ~- ~ Depth of Grouting
Pump Set At ~'/¢--
~.~ l Sanitary Seal on Casing ~)N)
Depression Around Wellhead (Y,~)
Water Sample Collected by
Water Sample Test Results
Comments \/'J ~-~-
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
.~.=4~. ,'- ..- ,~,.j ; On Adjoining Lots (''c-~p'//"-
)~TO I~" ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~'/"/'
~;/~ ~ ~ c-.~.~:/-~; Date
/ /
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes ~N)
Depression over Tank (Y~[~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Co u rse /'J~//~
Size d ~ No. of Compartments '2'.~
Air-tight Caps ~;N) Foundation Cleanout~/N)
Date Last Pumped //--/~-~'
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /
To Building Foundation
Lot h,///~
TO Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design (/~'~J~---~'/
Length of Field /'/(2> /
Depth of Field
Gravel Bed Thickness ~--/
Standpipes Present ~N)
Date of Last Adequacy Test
To Property Line /
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed /~
Size in Galtons
"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 thatJ have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ?~ S ENGINEERING Date /'/'~/~ -~
:~RB 196X
Company EAGLE RIVER, AK 99577M°A No.
Receipt No. ~ c~' t - ~"'~'~
Date of Payment I
Amount: $ ~o,~'O~
Page 2 of 2
72-026 (11/84)
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF ~ALTH AND ENVIRONMENTAL PROTECTION
· APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
Location (address or directions) ~._,o~5 ~. F'q' ~ L IZ~l ff % q Z>,'4LT') t':'lP~C~l
Applicants Name L J&~D l?G-~2%ff{ Telephone - Home Business
Applicants Address
(c) Applicant is (check one) Lending Institution
Buyer ~--~ ; Other~--~ (explain);
(d) Lending Institution
~--] ; Owner/builder~ ;
Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single-Family~-~
Number of Bedrooms
3. Water Supply-
Individual Well[~
Multi-Family ~--~
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]
5. Engineering Firm Providing 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./~M~:o'~k~._~' /.47(- Telephone p~/~-~/
DHEP Approval.
Approved for
Approved ~ _
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES 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 COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. ~MPLOYEES 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
A®
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIS'E - FEBRUARY 1984
Legal Description
I.
Well Classification /~Di~
Well Log lhresent (Y/N)
Total Depth ~ ~_~- ! Card to
Static Wate~ ~1
Casing ~ight ~ G~nd
Elec~ical Wi~ing in ~nduit (Y~)
~p~ation Distance ~ ~11:
To ~ptic~olding Ta~
To ~a~st ~ of ~so~tion Field on
To ~est ~blic ~ Line
Clean~t~a~ole
Wate~ S~le Colle~ed By
Wate~ S~le Test ~sults
NOIID]LO~]d -~V£N~NO~ IAN::t
~ HI'IVBH dO
]O'~oHDNV JO )d. FtVdlDINn%N
If A, B, Cm C, D.E.C. Approved(Y/N) /d/~
Date C~cgleted ,~:~ - ~ ~ - ~ Yield ~--~,
~ ~ ~ ~pth of Grouting ~/~
~ ~t At 200'
Sanit~ ~al on ~sinG (Y~)~
~ession ~nd ~l~ead (.Y~)k~O
; On Adjoining Lots ~ / ~ Ch
; On Adjoining Lots ~
To Nearest Public Sewer
To Nearest Sewer Service [~ine on Lot
; Date
C~ments
B. SEPTiC/HOLDING TANK DATA
Date Installed ~- 13-~57> Size /~OO ~AL No. of Cc~r~artnmnts ~
Standpipes (Y/N) ~[~c> Air-tight Caps (Y/N) V~5 Foundation Cleanout'(Y/N) l{~%c%
Depression ove~ Tank (Y/N) ~0 Date Last Pumped ~///~ flJ~-D~ S~.~7%~
Pumping/Maintenanc~ Contazact c~ File (Y/N)M//A ; for
Holding Tank High-Water Alarm (Y/N)~d/4~ Temporary Holding Tank Permit (Y/N) --
Separation Distances f~om Septic/Holing Tank:
To Water-Supply Well l~ ~!
To Deoperty Line ~ ]~ /
TO Water Main/Service~ Line ~///~
Cou e
To Building Foundation ~ ~
To Disposal Field r7 /
To Stream, Pond, Lake, c~e Major D~ainage
/
Con~nents
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Stmata
Date Installed
Width of Field
Square Feet of Absorption A~ea
Depression over Field (Y/N) ~0
Results of Last Adequacy Test
~/~ Type of System Design
.
Length of Field l 1 (~ '
Depth of Field
Gravel Bed Thickness ~7 /
Standpipes P~esent (Y/N)
Date .of Last Adsquacy Test
Separation Distance frc~ Abscrpt/ion Field:
To.Water-Supply W~ll I~O/ To P~operty Line >,IO!
TO Building Foundation ~ [ ~' To Existing or Abandoned System cn
Lot ~,/J~ ; On Adjoining Lots ~20 /
To Water Main/Service nine ~//~ To Cutbank(if present) ~J//~
/
To Stream/Pond/Lake/c~ Majo~ Drainage Course ~///~
To Driveway, Pa=king A=ea, c~ Vehicle sro=age A~ea ~ ~)~)W
Cc~x~nts
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codos(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
M~ets MOA
Con~ents
** Check Permitted Bedroom Rating A~ainst HAA Request
I certify that I have checked, verified, c~r confczm~d to all MOA HAA Guidelines in effect
on the date of this inspection. [ ~
Signedt/~/~ ~~~--- Date ~_~3~-c~¢ ~a~.~
[Page 2 of 2] ~
2-15-84