HomeMy WebLinkAboutKIMBERLY MANOR BLK 1 LT 10Onsite File
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Municipality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 995J 9-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: _~lx,' 0 ¥O ,y ~ ~ PID Number:
Name:
~ ~re~?~ Wastewater System: D New D Upgrade
Address:
~d"to ~ De A~o~ ~ ABSORPTION FIELD
Phone:
No.
of
Bedrooms:
~ D Deep Trench D Shallow Trench ~ Bed ~ Mound ~ Other
LEGAL DESCRIPTION sog Rating: Total Depth from original grade:
GPD/Sq. Ft.
Lot: Block: Subdiv~ion: Depth to pips bottom from original grade: Gravel depth beneath pipe
Township: ~ Range: ~ Section: Fill added above original grade: Gravel length:
I
Ft. Ft.
WELL: E~J T ~ New D Upgrade GraveJwidth: Number of lines: I Oistancebetweenrines:
Ft.~ Ft.
Classification (Private, A,B,C): Total Depth: Cased To: Tota~ absorption area: Pipe material:
Ft. Ft. I SQ. Ft.
Driller: Date Drilled: Static Water Levek Installer: I+O~DIN~ ~N~ Date installed:
Yield: GPM I Pump Set at: Ft. Casing Height Above Ground:Ft. TANK
I
SEPARATION DISTANCES a septic ~ Holding ~ S.T.E.P.
To ' Septic Absorption Lift Holding Public/Private Manufacturer: : Capacity in gallons:
From T~nk Field Station Tank Sewer Lines A~O~
Well' 77 Material: ~ ~/ Number of Compa~ments:l
Surface
Water >100' LIFT STATION
Lot size in gallons: ~ Manufacturer:
Line 5~ '
I
Foundation ~ "Pump on' level at: "Pump off" level at: High water ala;m at:
Cu~ainDrain ~ Pump Make & Model Electrical Inspections pedormed by:
BENCH MARK
Location and Description:
Department'of He--nd Hu Services approval ~"~ ....... ..... c~- ~ . ~:,~-~"
Reviewed and approved Date'/
72-013 (Rev. 9/gl) MOA 25
PERMIT NO: 940433 PAGE 2 OF 2
PID NO: 01707331
SWING TIES
FROM: COR."A" COR."B"
TO:
C.C. "C" 37' 43'
C.C. "D" 46' 45'
C,O. "E" 52.5' 48'
LOT 10, BLOCK 1
KIMBERLY MANOR
WELL
DECK
NEW 4000 GALLON
HOLDING TANK
ALARM FLOAT --
PLAN VIEW
SCALE: 1" = 30' - 0"
GROUND ELEVATION 98.4' --/'/'
4000 GALLON HOLDING TANK
~N-~INV. 92.2'
PROFILE VIEW
SCALE: 1" 5'- 0"
LOT 10, BLK. 1, KIMBERLY MANOR
'HOLDING TANK INSTALLATION
AS-BUILT INSPECTION REPORT
FLATTOP TECHNICAL SERVICES SCALE: AS-SHOWN '
14530 ECHO STREET DRAWN BY TFM
ANCHORAGE, ALASKA 99516 DECEMBER, 1994
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.0. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE)
PERMIT NUMBER:SW940433
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:KRETSINGER DAVID
OWNER ADDRESS:7640 UPPER DEARMOUN RD
ANCHOR_AGE, ALASKA 99516
PARCEL ID:01707331
PAGE 1 OF 1
PERMIT
DATE ISSUED:il/17/94
EXPIRATION DATE:il/17/95
LEGAL DESCRIPTION: KIMBERLY MANOR BLK 1 LT 10
LOT SIZE: 34500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
HOLDING 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:
RECEIVED BY: ~~_~ '~
ISSUED BY:,~ /
....... . ~ -~,,=,,= =,,:~ . -·,,··~,~,.~~¢~, ~l~~
CIV~ & ENV~O~MENTAL ENGINEERING · ENERGY CONSERVAT/ON & ANALYSIS
T~EODORE F. MOORE, P.E.
~4530 ECHO ST.
PH: 007) 345-1355 November 9, 1994 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
The purpose of this letter is to prOvide the required design narrative in support of our application for a
permit to install a holding tank on Lot 10, Block 1, Kimberly Manor S/D, located at 7640 Upper
DeArmoun Road. The existing soil absorption system is no longer able to accept the wastewater
generated in the residence. Soils logs, a site plan, design drawings and specifications are enclosed for
your review.
Four test holes were dug on the lot in an effort to identify a suitable location for an on-site soil
absorption system. As can be seen from the test hole logs, the soils on this lot consist of a thick peat layer
underlain by dense, impermeable silt. In some locations there are stringers of silty sand below 7 feet, but
these are not of sufficient thickness or consistency to serve as an infiltrative surface, and quite probably are
saturated with water during parts of the year. The predominant silt material was generally dense, cohesive
and hard. It's impmxneability was confirmed by the fact that a shallow groundwater seep encountered in
test hole//3 was not reabsorped in the bottom of the test hole.
In our opinion, a holding tank is the only feasible solution for wastewater disposal on this lot. The
proposed holding tank will be installed in the vicinity of the existing septic tank, but outside the required
75' protective radius fi'om the existing well. .,
The topography of the lot slopes down from nm~h to south at 2% and east to west at 1%. A drainage
ditch consu'ucted along the east property line to intercept seasonal runoff was ch3~ on the date the test holes
were dug.
The proposed project will have no impact on present or future water supply and wastewater disposal
systems serving adjacent properties, nor will it have any impact on reselwed space/surface and subsurface,
or on ddrainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
__ ~ UPPER DEARMOUN ROAD
~ ' .
,, ,,' LOT 10, BLOCK 1 ,, , ,,
;, ,' KIMBERLEY MANOR ~
[ , ~;G ARAG E:!: ,
'.. -~
LOT 11, BLOCK 1 '. [_~S
[ '. EPTIC TANK . -
' '.. INSTALL - -
HOLDI~TANK. _ _
~ T.H. : LOT
~ ~ "~ ~ ~X,ST,,~
, TH [ SEEAGEPIT
.................... ~_. ,~' ... .... -._..
~ ;~ ................... ~ ....................................
...................... /
~ ,- ................................. q ....
LOT 4, BLOCK 1
LOT 5, BLOCK 1
,~ , LOT 6, BLOCK 1
20 0 20 40 60 80 100
~'"":' 3~ L 10, B 1, KIMBERLEY MANOR S/D
~..........~......_ . ~ SITE PLAN
~%. CE - 3589 ~' .~;~'. 14530 ECHO S~ET DRAWN BY TFM
~ ,,., :,-' ~. ANC~O~O~. ~AS~ 995]6 NOVEMBER, 1994
~~.~' NOTE: THIS IS NOT A SURVEYED P~T.
~~ ALL LOCATIONS SHOWN ARE APPROXIMATE.
TESTHOLE# I
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
COMMENTS:
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 10, Block 1, Kimberley Manor S/D
November 3, 1994
Dave Kretsinger
Pt Peat and loam fill
Pt
ML Gray gravelly silt
Dense, cohesive, damp
SM Brown silty sand
NIL Gray sandy silt
Dense, cohesive
Softer than above
SP Black sand w. septage
B.H.
SLOPE
~,~ .~. ,... ·..~ ~ ~ ~
****************************
~* THEODOR~ F ~'~OORE ~ '
......
SITE P~N
HOUSE
~X ~,,> T.H.
T.H. ~%
'~ \ PIT
Depth to Groundwater Date
10.75' 11/3/94
Date Reading Clock Net Time Percometer Net Drop
Time (minutes) Reading (inches)
PERCOLATION RATE (minutes/~nch) PERC HOLE DIAMETER
TEST RUN BE'rVVEEN FT AND FT
Soils in this test hole are not suitable for construction of an on-site soil absorption system. No monitor tube installed,
PERFORMED BY FLATrOPTECHNIOALSERVICES. [. ~,~',.~.~ ,~ ~
ADCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATEi
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: November 9, 1994
ITESTHOLE# 2
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(teet)
COMMENTS:
FLATrOP TECHNICAL SERVICES _.-~ OF A-~i
14530 ECHO ST. ~ ~?.-' ,~ *,,
.~.~, .,,% %° /,~, %'m,~ .~-~
i ANCHORAGE, ALASKA 99516 ~2," g9~J ~;
SOILS LOG -- PERCOLATION TEST
Lotl0, Blockl, Kimberley Manor S/D ~) · T~'IEO00~ r ~,o~" ~"
~'~, % C~ - 3589
November3, 1994 ,~/,~_.~, ,,,,..~, ~%~
Dave Kretsinger "q ~,~,~'.
SLOPE SITE PLAN
?t
~ Gray/brown ~rave]ly silt
Dense, cohesive, hard di~sin8
Many cobbies
SM Gray silty sand
#1
Depth to Groundwater Date
No ~roundwater 11/3794
ML Gray silt
Dense, cohesive
Scattered lenses of
SM < 0.5' thick
B.H.
Date Reading Clock Net Time Percometer Net Drop
Time (minutes) Reading (inches)
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
Soils in thi~ ta.~t hole are not suitable for consa'uction of an on-site soil absorption system. No monitor tube in~talled,
PERFORMED BY FLATTOP TECHNICAL SERVICES. I..
AOOORDANOE WITH ALL 8TATE AND MUNIOIPAL GUIDELINES IN EFFEOT ON THIS DATE.
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: November 9, 1994
ITESTHOLE# 3 J
LEGAL DESCRIPTION: ·
DATE PERFORMED:
PERFORMED FOR:
(feet)
1-
COMMENTS:
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 10, Block I, Kimberley Manor S/D
November 3, 1994
Dave Kretsinger
SLOPE
Pt
ML Gray gravelly silt
Very hard and dense
No sand lenses
Water seep at 5.5'
#1
B.H.
Depth to Groundwater Date
Seep at 5.5' 11/3/94
Date Reading Clock Net Time Percometer Net Drop
Time (minutes) Reading (inches)
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
Soils in this test hole are not suitable for con~tn]ction of an on-site ,~oil absom, fion system. No monitor tube installed,
Water seep at 5.5' did not perc into ML at bottom of test hole.
PERFORMED BY FLATTOP TECHNICAL SERVICES. I. ~-'_J,__ ~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: November 9, 1994
TEST HOLE # 4
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(i'eet)
COMMENTS:
~.0 ~ .~.,
FLA'I-rOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, A~SKA 99516
~.~.~..,......,,,...,~.;~
SO LS.. PERCOLAT O TEST
November 3, 1994 .~
Daw ~e~in~er ~~ ,,
SLOPE SITE P~N
Gray~ro~ ~mvc~y
Dens~, cohesNo, ve~
Scatter~ lenses of SM b~low 9'
Depth to Groundwater Date
No ~roundwater 11/3/94
B.H. ' · · - : : :
Date Reading Clock Net Time Percometer Net Drop
Time (minutes) Reading (inches)
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
Soils in this test hole are not suitable for construction of an on-site soil absorption system. No monitor tube installed,
PERFORMED BY FLATTOP TECHNICALSERVICES. I ~~,,~
ACCORDANCE WITH AL.L STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: November 9, 1994
Flattop Technkal Servkes
14530 Echo Street, Anchorage, AK99516
Phone (907) 345-1355
Lot 10, Block 1, Kimberly Manor S/D
7640 Upper DeArmoun Road
Holding tank installation
Specifications
1.0 General:
1.1 The scope of the project consists of abandonment of an existing 750 gallon septic tank and
seepage pit and installation of a new 4000 gallon holding tank with high level alarm system.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
All c. onstmction procedures and material specifications shall conform with Municipal and State
reqmrements. All separation distances shah be in confm~ance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any
buried utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there are no residual
depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the construction.
2/0 Holding Tank:
2.1 The existing septic tank and seepage pit must be properly abandoned by thoroughly pumping,
removing the top and backfilling with soil.
2.2 The new 4000 gallon holding tank shall be Municipally approved and shall be set level on
undisturbed soil. The tank shall be designed by the manufacturer for burial up to 6 feet below ground
level.
2.3 All pipe connections to the tank shall be equipped with waterProof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of 1/4"' per foot. A double
cleanout shall be installed at the point where the new waste line is connected into the existing waste line
coming from the residence.
2.4 The holding tank shall be equipped with a low voltage, high level alarm which triggers an
approved visible and audible almrn mounted inside the residence. The float shall be positioned tO trigger
the alarm when the fluid depth in the tank is 57" above the bottom of the tank, leaving approximately 600
gallons of capacity remaining in the tank. .
3.0 Inspections:
3.1 A total of 3 engineering inspections will be required during the course of the project: (1) initial
· stakeout with'the contractor to establish the location of the tank and to discuss the plans, specifications and
construction procedures, (2) after the tank has been set in the ground and the piping connected, but prior to
backfill, and (3) after the rough backfill is complete.
3.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensure the availability of the engineer.
~1~'~ ~ J ~ R ANCHORAGE AREA BORO~'~H
HEALTH DEPARTMENT
327 EAGLE fir. ANCHORAGE, A[ASI~. 99501 279-2511
N.o
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
MAILING
ADDRESS -~'.21-~.~,~, ~/.-~X ~.~'~'~ ~
DISTANCE FROM WELL ,J¢'~' / MATERIAL ,~./~'-~.~.~-~/ NUMBER OF
COMPARTMENTS /
)"~-,'~(-~' -,Y~4..-~ ,~.,,~,~a~, ,__.,.~.- LIQUID
LIQUID CAPACITY ,~,~d-~) GALLONS· INSIDE LENGTH / INST'DE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT..
NUMBER OF PITS / OUTSIDE DIAMETER OR WIDTH //~
· . . DEPTH
LINING MATER~AL ~'4-.¢~-~-~/~ ..~.~'/J~-~-.~.~ . DISTANCE FROM WELt
BUILDING FOUNDATION
NEAREST LOT LINE/~.'~/~' ~'-" TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) '~'"~'~' SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL //~0, FOU ATIO~N~
NUMBER OF LINES ~ DIST ETNDATION
DEPT~: TOP OF TILE TO FINISH GRADE DEPTH OF FILTER MATERIAL BENEATH TILE
/~'~TOTAL LENGTH
NEA RES~JINE. /,~DF LINES
EACH LINE. ~.J~ENCH WIDTH ~~E
IN. ABOVE TILE
WELL:
LOT LINE
~ DISTANCE FROM
TYPE ,?.,~//-,.:~/~ DEPTH ~
, , BUILDING FOUNDATION.
NEAREST ~ SEPTIC ~-_-~ .~ SEEPAGE
./F_2 z-~z~ , SEWER LINE , TANK ~ ~ , SYSTEM
WATER
SAMPLE ..,ff/~ , NEAREST
OTHER
, CESSPOOL ~' SOURCES4--~
DISTANCES:
DIAGRAM OF SYSTEM
DATE ' ~z ' '¢ ~' ~ " '
z/ APPROVED
HEALTH AUTHORIi'¥
GREATE?i. ANCHORAGE AREA ~ OROUGH
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE
NAME OF APPLICANT C~
RESIDENCE ADDRESS
LEGAL DESCRIPTION
APPLICATION TO INSTALL: SEPTIC TANK
TO SERVE THE FOLLOWING FACILITY
FINANCED THROUGH
PERCOLATION TEST RESULTS
D s ,os^. sYsTE, - &
MAILING ADDRESS ~ 'S?~'-~ PHONE NO.
LOCATION OF INSTALLATION
, DRAIN FIELD , OTHER.
SEEPAGE PIT
~;~,~
TO BE INSTALLED BY.
ANTICIPATED DATE OF COMPLETION.
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
THIS IS TO SERVE AS
AS DESCRIBED BELOW. SIZE OF~UNIT~O BE SERVEB /c~ "-~'~i~
SEPTIC TANK SIZE ,'~-Q'~'"'~ TYPE e~ ~%~oeb SEEPAGE AREA.. TYPE ~:)'
~ ~v'~
LLTH AUTHORITY
ENSED DESIGNER
I certify that I am familiar with the requirements of Greater Anchorage Area Borough Ordin~Fe No. 28-68 and that the
above described system is in accordance with said code. t~,~r-- ~,_)~_ ~x.~ N_~ {*Q~)/(~)[~"l ._~'~-(~ ! C~-
~"TE APPLICANTS SIGNATURE
'EATER ANCHORAGE AREA.BOROUGH
HEALTH DEPARTMENT
327 EAGLE STREET
ANCHORAGE, ALASKA 99501
CASE #
u t
Performed For Arthur Andries Date Performed__ 8/28/70
Legal Descrip~~~n
This Form Reports a: So~is Log xx
Depth
Feet Soil Characteristics Location Sketch
gray clayey silt (CL)
gray silty sand with
few gravel (SM)
8~ I gray fine to coarse sand
10 ~_ (ow) ·
If Yes, A+ <~a~ Depth 11,.~, feet__
Gz'c-s~_~ Time Net Time Depth To H20 Net D~
I
PPop%ed !nstal~Seepage Pit D~ain Field
Depth Of' Inlet Depth To BoEtom Of Pit Or '~ ""
COMMENTS:
___~_m~ea~ar~ ~age ~equired is 167 squ§re fe~t per bedroom
T~$~ Performed By: R. E. Carli.._sle These recommendations are computed from
' ~ visual observation and based on the uni-
fied classification system.
Data Certified By: National Testin~ Service Inc.
Da~e:
Parcel I.D. #
1.
GENERAL INFORMATION
Complete legal description
' MUNICIPALITY OFANCHORAGE ' '
DEPARTMENT OF HEALTH & HUMAN SERVICES_
Division of Environmental. SerVices
On-Site Se~ ces Sect on ......
P.O. Box 196650
Anchorage'A aska 99519-6650
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Location (site address or directions)
Property owner D~ u;,~(_ /~r-e_ ~n~_,- Day phone
Mailing address
Lending agency
. . Day phone
Mailing address ~- ~, ~o~ I~ ~'
Agent 51.~.
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
m
Individual well
NOTE:
Community well
Public water
.:
If community well system, provide written confirmation from State
lng to the legality and status of system. . .
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of 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 verifythat 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 s in compliance with ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm fCl~(-~? 7'~c/~ ~¢~[ ~er~;c~' Phone
Address l~1~30 ~o ~/) ~o~; A~
Engineer's signature ~~ ~ '~
DHHS SIGNATURE
/~ .. Approved for
Disapproved.
Conditional approval for
bedrooms.
STA /tP
bedrooms, with the following stipulations:
· -Additional Comments
' ~ "/ "' Date /
By.
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 i.n the professional engineer's work.
72-O25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: I-c,{" (d,'/ ~3 ]lc ~) I~,,~¢,'-Iy Parcel I.D.
A. Well Data
Well type i> fi ua/-~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) hi Date completed l? 7~2 Driller
Total depth ~_ o,5-' Cased to
Sanitary seal (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot -Z? '
Absorption field on lot /',/,,,~-,
Public sewer main
Sewer service line
~n k-
Casing height
Wires properly protected (Y/N)
AT INSPECTION
~-/7
1~'7~
.g.p.m.
; On adjacent lots '~. ~oo '
g.p.m. <~
; On adjacent lots
Public sewer manhole/cleanout /,/. ,4.
Petroleum tank Non ~
WATER SAMPLE RESULTS:
Coliform ~ col / ~ 0 0
Date of sample:
Nitrate
Collected by:
Other bacteria hi
B. SEPTIC/HOLDING TANK DATA
Date installed I ~-/' 7 / ~ ¢/
Cleanouts (Y/N) Y
High water alarm (Y/N) ¥'
Date of pumping bL /~.
Tank size ~ 000 ~ ~ / Compartments
Foundation cleanout (Y/N) 'T' Depression (Y/N)
Alarm tested (Y/N) ~'
n ,~<~) Pumper N,/J-.
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot -7~
To property line
Sudace water/drainage
On adjacent lots '~ 76-' Foundation ?--~ '
Absorption field N,/~. Water main/service line '~ z-,.5''/
lO0~
72-026(3/93)* Front CONTINUED ON BACK PAGE
Co LIFT STATION /x(, 6.
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D, ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Date of adequacy test
Width
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
On adjacent lots
8oil rating (GPD/FF)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E, ENGINEER'S CERTIFICATION
Surface water
System type
Total depth
HAA Fee $
Date of Payment
Receipt Number
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on.J,.~ate of this inspection.
. ~ ~,'~r;?:]i,
On adjacent lots Properly line
To existing or abandoned system on lot
Cutbank Water main/service line
Bedrooms
Waiver Fee $
Date of Payment
Receipt Number
Driveway, parking/vehicle storage area
Depression over field (Y/N)
for
After test
If yes, give date
GREATER ANCHORAGE AREA BOROUGH'
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD
ANCHORAGE, ALASKA 99507
279-8686
REQUEST FOR
INDIVIDUAL SEWER
DATE RECEIVED:. /~/'///~/~_-
APPROVAL OF
AND WATER FACILITIES
FOR
APPROVAL REQUESTED BY: m~:/~//~- ~-~ J~/~/~-~:/--'
ADDRESS: ~'/~ ~~ ~://~ ~~:~/ ~:~
PHONE: ~~ ~:~
WELL DATA:
A. TYPE
B. DEPTH
PROPERTY OWNER: .::/-//~-~ PHONE
TYPE FACILITY TO BE INSPECTED:://~:~~/~STREET:
NUMBER OF BEDROOMS: ~ "
/
D. CONSTRUCT*O,
E. BACTERIAL ANA,YS*S
SEWAGE DISPOSAL SYSTEM:
SEPTIC TANK
1 . SIZE
2. AGE
3. '
4.
(IF HOMEMADE, SHOW DIAGRAM
ON BACK)
APPROVAL REQUES~,-.~OR SEWER & WATER FACILIIIL~,
PAGE TWO
o
SEEPAGE PIT
-
/
2 L I N I N G~/~-~ ~ ~/~/'~:~~':/
DISPOSAL FIELD
1. NUMBER OF LINES
2. TOTAL LENGTH_
REQUIRED MEASUREMENTS
A. WELL TO SEPTIC TANK
B. WELL TO SEEPAGE PIT
C. WELL TO SEWER LINE
O. WELL TO PROPERTY LINE___,/__~ /~
E. WELL TO OTHER POSSIBLE CONTAMINATION
F. FOUNDATION TO SEPTIC TANK
G. FOUNDATION TO SEEPAGE PIT_
H. SEEPAGE PIT TO PROPERTY LINE_~
-~_~.~ ~) "" DISAPPROVED:
APPROVED: '
DATE :~/,7~,/~,~'. DATE:
APPROVAL VALID FOR ONE YEAR FROM DATE SIGNED.
GREATER ANCHORAGE AREA BOROUGH DEPARTMENT OF ENVIRONMENTAL QUALIT