HomeMy WebLinkAboutMEADOW BROOK BLK 2 LT 13
MunicipaLity of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES
E-'NVIRONMENTAL 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: ~u.J c~50;~'t~ PiDNumber: o~otAlDO
Name: ~.~¢.,~A~....,N ~.1T1'~'.4~)o/'-./ Wastewater System: D New
Address: ABSORPTION FIELD
Phone: 6ff~ d5O0 No. of Bedrooms:¢ ~DeepTrench ~ Shallow Trench QBed ~Mound ~Other
L E G AL D ESC R I PTI O N soi, Rating: I . ~ GPD/Sq. Ft. Total Depth[ ofr°ml original grade:
Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: I Range: Section: Fill added above original grade: Gravel length:
WELL: E~5~t~ New ~ Upgrad~ Gravelwidth: / Number of lines: Dislance between lines:
Classification (Private, A,8.C): .... Total D~ Cased To: Total absorption area: Pipe materiah
Oriller: ~ UateDdlled: SlaticWalerLeveh Installer: Date installed:
m I., Casin9 Height Above Ground:
Yield: ' ~ p Set at: TANK
~ GPM / Ft. Ft.
/ SEPARATION DISTANCES ~Septic ~ Holdi,g U S.T.E.P.
To Septic Absorption Lift Holding Public/PrivAte MAnufacturer: ~ Capacity in gallons:
Material: Number of Compartments:
Su~f~ce ,+ ~+ ~ LIFT STATION
Water ~ ~ 100 ~ -~
Lot ~ ~ ~ Size in gallons: Manufacturer:
O
Line
t ~ 0 [ ~ ~ _~ "Pump on" level at: ~~ High water alarm at:
Foundation
Curtain ~O ~ ~ ~O( ~ ~ ~ trical Inspections performed by:
Drain
Remarks: BENCH MARK ,_
Location and Description:
Assumed Elevation: ) o¢, ¢ ~,
Department of Health and Human ¢~ces approval 'J ~*' .... ",~
Reviewed and approved
by:
72-013 (Rev. 9/91) MOA 25
Permit No.
SW950245 Page 2 of 2
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
LO']- 15, BLOCK 2, MEADOW BROOK S/D 05019160
Legal Description: PID No.:
'T;1 ST2 / FINAL GRA])E ~ MTi~nCO~/
98,8' -97.8'
9~.~'/ N~,~r-.,~.--'--
o09 o,. %=3,
SgP~'[C
?ANK
,8.?'~
~ 83.( NO ~ATgR
8-18-95
A B
F(:O 51' 27
S"1 52' 28
S-'2 56' 28
~ C~)1 37' 29
[W 1000 (Ak. C~)3 42' 29
SEPTIC TAN( C~)4 80' 30
A':?
72-013 A (Rev. 9191) MOA 25
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 (UPGRADE)
PAGE 1 OF 1
\ IS '.(_lb
PERMIT
PERMIT NUMBER:SW950245
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:CRITTENDEN RICHARD A &
OWNER ADDRESS:lB218 SANCTUARY WAY
EAGLE RIVER, AK 9957'7
DATE ISSUED: 8/27/95
EXPIRATION DATE: 8/27/96
PARCEL ID:05019160
LEGAL DESCRIPTION:
MEADOW BROOK BLK
2 LT 13
LOT SIZE: 10998 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION 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 (ISAACS0) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343 4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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:
/
DATE:
DATE:
ROBERT C. COWAN, RE.
ROBERTA. SHAFER, RE.
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER & WAFER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOWTEST
SITE PLANS
ROAD DESIGN
SOIl_TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSAL. SYSTEM
DESIGN
August 23, 1995
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 13, Block 2, Meadowbrook S/D
Request you issue a permit to upgrade the septic system
serving the three be4room house on the referenced property.
Request you expidite the issuance of this permit due to
partial collapse of septic tank serving the residence.
A test hole was excavated and a percolation test performed
in the area of the proposed upgrade. The approximate
location of the test hole is located on the attached site
plan.
At the 'time of excavation no water was encountered in the
test hole and after seven day ground water monitoring, the
monitoring tube was found to be dry.
Attached is the proposed upgrade design.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E. :'
RCC/gk .
Enclosure
MUNICIPAL//y OF ANCNORAG~
;NV~RONMENTAL SERVICEs DIVISION
RECEIVED
17034 NORTH EAGLE RIVER LOOP SUITE 204 EAGLE RIVER, ALASKA 99577
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: ~:r~~ t5 ~'~/.~'~ ~'-~¢.~h,^\rcc~rT~P__wnship, Range, Section: SLOPE
1
2
3
4
/ 5
7
8
~2
14
~7
~8-
20-
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth to Waler ~e~,. ,
Monitorino? ¥/~"~ Date:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE I (m~nutes/inch) PERC HOLE DIAMETER Lc
U
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: $ & S ENGINEERING i ~',~,J IJtAO~,~'~ CERTIFY 'THAT THIS TEST WAS PERFORMED IN
17034 Eagle River Loop Road No. 204 ~
ACCORDANCE WITH AII~a~.~A~4~I)~UIDELINES IN EFFECT ON THIS DATE, DATE:
72-008 (Rev. 4/85)
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
AND REPOR'~S
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAO DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
W/~TEWATER
DISPOSAL SYSTEM
DESIGN
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot 13, Block 2, Meadowbrook S/D
August 23, 1995
GENERAL:
1.
The scope of this project includes the installation of
a 1000 gallon septic tank and leachfield trench to
serve the three bedroom residence located on the
referenced property. The existing 1000 gallon septic
tank is to be pumped, crushed, and abandoned. The
existing leachfield crib is to be excavated, pumped,
crushed and abandoned.
Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal
Regulations.
The contractor shall be responsible for obtaining any
necessary underground utility locates.
Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
~EPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
The septic tank shall be sufficiently bedded to
prevent settling or shifting of the tank.
Ail standpipes on the septic tank shall extend a
minimum of 12 inches above final grade.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
Page Two
Lot 13, Block 2, Meadowbrook S/D
August 23, 1995
De
Septic tanks installed with less than 4 ft. of cover shall
be insulated.
A foundation cleanout shall be installed one to four feet
from 'the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank)° These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed-up) before
gravel (sewer rock) placement.
Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 13, Block 2, Meadowbrook S/D
August 23, 1995
Se
Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirtymsix (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM ~ATERI~L SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
Se
Be
The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron
ASTM D3034 (PVC)
ASTM F810 (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
Septic 'tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill°
Ail leachfield grave]. (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the #200 sieve.
When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements.
Page Four
Lot 13, Block 2, Meadowbrook S/D
August 23, 1995
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel° A septic tank
may be set in place, but may not be backfilled before
this inspection.
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre-construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities°
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will. inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Page Five
Lot 13, Block 2, Meadowbrook S/D
August 23, 1995
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISIQN
( 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE I)ISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
TPHONE I ~NEW
NAME ~.~ " ~ / [ ;
LEGAL DESCRIPTION ~
-- ' HO. OF BEDROOMS
~. Dwelling PERMIT NO.
l w""
~ ~ Material No. of compartments
~ ~ Manufacturer
~ ~ Liq. capaci~in gallons I Inside length Widd~ Liquid depth
)'~ ~ IF HOMEMADE:
PERMI~NO.
~ ~ DISTANCE TO:~ ~Well
Dwelling
· a ~ ~~ Materia~ Liquid capacity m gal~ons
O ~ ~ Manufacturer
-- ~ Well Foundation Nearest lot line PERMIT NO.
~ % DISTANCE TO:
~ ~ ~ No. of lines Length of each line Total length of lines Trench width Distance between lines
- ~ ~ inches
~ ~ ~ Top of tile to finish grade Material beneath tile inches Total effective absorption area
~ PERMI'~" NO.
..... Length Width Depth
~ Type of cr b Crib diameter Crib depth ~ Total effective absorption area
~ Well Building found~1' Nearest lot line
m DISTANCE TO: ~///~_ ~.. /
~ ~ Class Depth Driller Distance to lot line PE~IT NO,
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER I _
PIPE MATERIALS
INSTALLER ~ ~v~ ~ ~ ~ .... ~ ..,- '
'5'-"?"
oGR
'~R ANCHORAGE AREA BO' JGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING ADDRESS I'~¢X//¢1 £~/~ /(i~ PHONE
d;d~. LEGAL DESCR,PT,ON l,t /~ g~/( 2 /-/~,A~,~,~
SEPTIC TANK:
DISTANCE ~,
FROM WELLLC ~"~ MANUFACTURER ~,~f~
INSIDE LENGTH
INSIDE WIDTH
NUMBER OF
%'~'-~-' [, MATERIAL (~4 P-'e- k_,.~ COMPARTMENTS ~
LIQUID DEPTH LIQUID CAPACITY. /4)aa GALLONS.
SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL ~--~-;(j __
BUILDING FOUNDATION__
ADDITIONAL ABSORPTION
DIAMETER 7O OR WIDTH I~!. LENGTH f~'~, DEPTH ~ '
CRIB SIZE: DIAMFTER ,~ DEPTH ~ ' DISTANCE FROM: WELL
TOTAL EFFECTIVE -
NEARES"F LOT LINE ABSORPTION AREA (WALL AREA) /'~, ED
SQ. FT.
WELL:
TYPE ( (~'}, b(
BUILDING
FOUNDATION
CESSPOOL
APPROVED
___ CONSTRUCTION
NEAREST NEAREST
LOT LINE SEWER LINE
___, OTHER SOURCES
DISAPPROVFD REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No, EO-O31
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF FIEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
050-191-60 ' HAA fi 7-~'~ ',~'~ (' i
1. GENERAL INFORMATION
Complete legal description Lot 13, Block 2, Meadowbrook S/D
Location (site address or directions) 18305 Karta Circle
Property ownerBarbara Crittenden Day phone694-5500
Mailing address11823 Old Glenn Hwy., Eagle River, AK 99577
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water XX×
If community well system, proWde written confirmation from State ADEC attest-
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
XXX
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1191) Front MOAR21
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, lfurtherverifythatbasedontheinformationobtainedfrom
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 $ & S ENGINEERING Phone 6 ~"/'7' - -~ ct 7 d.j
i~'u34 Eagle River Loop Road No, 204
Address Eagle River, ~lask, a 9,~,5~7~ ,
DHHS SIGNATURE
'~ Approved for /~:~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional ~ngineer 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.
72q)25 (Rev. 1/91) eack MOA #21
KELEIVI:L)
Municipality of Anchorage APR 1,5 199! /~1~
DEPARTMENT OF HEALTH & HUMAN SERVlCE'E~JNI¢IPALITY OF ANCH
Environmental Services Division I~NVIRONMENI'ALSERVICES
825 L Street, FIoom 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
LegalDescription: Lo7~ /3 (~L.,~clc ~ l~o~v
b'arcelI.D.: O5~- )~'/- 60
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESU~ ,~.'~/
Coliform ~
D.ato~mple:
B. SEPTIC/HOLDING TANK DATA
Date installed Z_~ / / ~- /~- Tank size
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
to Casing ~bovC~ ground)
Cased
W~Cfopedy protected (Y/N)
FROM WELL LOG ~ AT INSPECTION
Nitrate Other bacteria
Collected by:
g.p.m.
'-)- Cleanouts ~/N) Y~:~'
/O 0 o Number of Compartments__
/vO
High water alarm (Y/I~ /,J o
Foundation cleanout ~N) "/~ -~ Depression (Y~
Date of Pumping ~//,~'/~ ~__Pumper (,~/Z_ ~
Soil rating'~or fF/bdrm) ), % System type 7
'/~ Gravel thickness below pipe ,~ Total depth
Monitoring Tube present (,.~'N). ¥/~-J Depression over field (Y/(~) ,,~ o
C. ABSORPTION FIELD DATA
Date installed
Length ~ 0 Width
Effective absorption area t/O 0
Date of adequacy test '~ I 6/~t ~) Results Fail) For bedrooms
Fluid depth in absorption field before test (in.); ! ~0 /~ Immediately after~~0. gal. water added (in.):
Fluid depth I ~ (ins) Minutes later: ) ~ Absorption rate = Z/3'0 ~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~J¢Ne~ /c,,Jov-'~/ If yes, give date -'~
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
Size in gallons
"Pump o~~'"'~ "Pump off" level at*
--~Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot
Public sewer main ~ Public sewer manhole/cleanout
Se~wer/septi____~c s~e~'~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ -/- Property line &'~ -J-- Absorption field
Water main/service line /O ~ Surface water/drainage ? 0o -¢-- Wells on adjacent lots
?
~-o0 -¥-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
/, /
Property line
Surface water
Curtain drain
Building foundation /o -J- Water main/service line
-¢'- Driveway, parking/vehicle storage area
~ ~'0L,~ ~ Wells on adjacent lots ~Lo0
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
are
in conformance with MOA HA~uideline~ in effect on this date.
Signature ~ ~/~
Engineer's Name ~ 8 ~ ~ ~y~ ~ ~
/,
/
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MuNICipALiTY OF ANCHORAGE
DEPARTMENT OF HF, ALTH 8~ ENVIRONMENTAL pRoTECTION
B25 L Street ' Anchorage, Alaska 99501
) ENVIRONMENTAL ENGINeeRiNG D~VISION
Tetephone 264-4720
REQUEST FOR AppROVAL OF iNDWtDUAL wATER~eAND~owSE~ER,~ FACiLItiES-
I10) daVS for processing.
~- on page ~. ~ncomplete ~equeS~s w~U not be processed.
REcTtONS~ Comptete ail ~artS _~
~uv ~ enaen ~~ -- -
c~tt
AGEN
Lot ~ s
~ siNGLE FAMILY ~ Three ~ Six
E~ MuLTipLE FAMILY ·
~~LY * ATTACH WE LL LOG. A we~[ to~ ts requi red for ah we~ls dri~le~
~ , ~NDIv~DUAL* s~nce June 1975. For wells drilled prior to tl~a~ date, olve well ~'
~ COMMUNI'TY depth (attach ~og if avahab[e.}
~~~sYSTEM ** If individual/on'site, gwe installation 8ate ~
% sEWAG~ D~¢"_, ~UAL/ON'S%TE'* If system is over two (2~ years old an adequacy test is required
~ INDW~U
ACCOMPANY EACH REQUEST BEFORE pROCESSiNG CAN. BE iNITIATED,
THIS SIDE FOR OFFICIAL USE ONL
INSPECTION APPOINTMENTS
1. TYPE OF RESIDENCE
SINGLE FAMILy
MULTIPLE FAMILY
2. WATER SUPPLy
INDIVIDUAL
COMMUNITy
PUBLIC UTILITy
Connection Verified
3. 8EWA( DISPOSAL SYSTEM
I~INDIVIDUAL/oN -SITE
[~PUBLIc UTILITY
Connection Verified
or /~]Holding Tank
give dimensions: - If Tank is hOmemade
~ROoMS
[~3 ONE [~ THREE ~ FIVE
[~/ TWO [~ FOUR [~3 SIX
OTHER
-:LL TO:
~orptio
CONDITIONAL APPROVAL (letter must accompany certificate)
DISAPPROVED