HomeMy WebLinkAboutMEADOW RIDGE ESTATES NORTH ADD BLK 6 LT 5 Meadow Ridge
Estates Noth
Add .
Block 6
Lot 5
#051 - 531 - 22
Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP171331 PID Number: 051-531-22
Dwelling: ❑I■ Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New ❑■ Upgrade
Name:
Russell D. & Joyce D. Shoeman ABSORPTION FIELD
Address ❑ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound
PO Box 671981 Chugiak AK 99567 ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
3 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot Ft. Ft.
Meadow Ridge Estates North Add. 6 5 Fill added above original grade Gravel length
Township Range Section Ft. Ft.
Gravel width Beds:Number of Lines Distance between lines
SEPARATION DISTANCES Ft. Ft.
To Septic Absorption ' Lift Station Holding Sewer Total absorption area Number of trenches Dist.between trenches
From Tank Field Tank Line Ft2 Ft.
Well >100' N/A N/A N/A >25' TANK ❑j Septic ❑S.T.E.P. ❑ Holding ❑Other
Manufacturer Capacity
Surface Water >100' N/A N/A N/A Anchorage Tank 1000 Gal.
Material Number of compartments
Lot Line >5' N/A N/A N/A Steel 2
NA LIFT STATION
Foundation >5' N/A N/A N/A Manufacturer Capacity
Curtain Drain None Noted Gal.
Remarks Septic tank replacement only Pump on level at Pump off level at High water alarm at
in. in. in.
Pump make and model Electrical Inspections performed by
PIPE MATERIAL House to tank D3034 Tank to D3034
Installer drainfield
Northern Excavation Drainfield CO/MT D3034
Inspector Jacob Millette BENCH MARK (Assumed elevation) 100 ft
Inspection Location and description
dates: 1st 10/26/17 2nd
3rd 4th Bottom of siding on north-most wall of house
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL En ine rs Stamp
Ib OF A 1
Conditional Approval: Date s,`'�;•• _i •.v,4-#*
49 r .'�
IP
0, . ci.
��
Approved -,,A w�. Date I I-t 3-17
d1 : Q+
Inspection Report_9-1-12.doc
MEADOW RIDGE ESTATES N ADDN , BLOCK 6 LOT 5
PERMIT # OSP171331 PID # 051 -531 -22
I 7'
TONJESS ESTATES BLOCK 3
I LOT21 / I..OT23
- - 1_ - -
MEADOW RIDGE ESTATES N ADDN — BLOCK 6
LOT 5
EXISTING TRENCH (APPROX)
NEW 1000-GAL SEPTIC TANK
W/ DOUBLE CLEANOUT MT
i
A
LOT- FCO B LOT 6A
3-BDRM HOME
A B
SV1 ' 8.7 45.5
SV2 13.9 41.0
2C0 17.0 38.9
- NO WELL-COMMUNITY WATER _ _______
- ----- 10'UTILITY EASEMENT
HOMESTEAD RD
��P���gs�f�°1
LEGEND
6 ... •
F Benjami Schiller MT-MONITORING TUBE
FA .•
•.• CE 12592 •.•ag,, 0 40 80 FCO-FOUNDATION CLEANOUT
111oi..NOFES01.7..s00'�.�� = = II. II. FEET TH-TEST HOLE
l\\��"��4 1"-40' CO CLEANOUT
MEADOW RIDGE ESTATES N ADDN , BLOCK 6 LOT 5
PERMIT # OSP171331 PID # 051-531-22
oN 0
0 > > 0
L. co CO N
- 99.62 — —
INSULATION
r 96.54
j 4\k\
95.64
96,04 1000 GAL 95.84
SEPTIC TANK
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PROFILE AS—BUILT ir Oct 30 CE,2017
(NO SCALE) k\ PROFESS\O'
�JN,<IVALI)y o, MUNICIPALITY OF ANCHORAGE ,,,, ,,,
On-Site Water & Wastewater Program •
.. PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.orgionsite
)u purtutcnt
,N<No-p o'f
On-Site Wastewater Disposal System Permit
Permit Number: OSP171331 Effective Date: 10/25/2017
Work Type: SepticTank Upgrade Expiration Date: 10/25/2018
Tax Code Number: 05153122000 to/Z,./I 7 T
Site Legal Address: MEADOW RIDGE ESTATES NORTH ADD BLK 6 LT 5 G:1462 (zi
Site Mailing Address: 25013 HOMESTEAD RD, Chugiak
Owner: SHOEMAN RUSSELL D & JOYCE D Lot Size in Sq Ft: 21053
Design Engineer: FORGE ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field El Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72)and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
•
Received By: Date: D .)5
Issued By: I • Date: 10/1/207
MUNICIPALITY OF ANCHORAGE
•
t.
Community Development Department ,r Phone: 907-343-7904
Development Services Division Fax: 997-343997
On-Site Water & Wastewater Program %,
ON-SITE SEWER/WELL PERMIT APPLICATION
7.111A"Mil s' '‘%3
OCT 24 2017
Parcel I.D. 051 -531-22 � ti
Property owner(s) Russel & Joyce Shoeman Day phone c5
Mailing address PO Box 671981 , Chugiak, AK 99567
Site address 25013 Homestead Rd
Legal description (Sub'd.. Block & Lot) Meadow Ridge Estates N Addn, B6 L5
Legal description (Township. Range & Section)
Lot Size 21 .053 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(fl all that apply)
Absorption Field n Initial r I Single Family (SF) X
(w/wo ADU)
Septic Tank X Upgrade [Xj Duplex (D)
Holding Tank Renewal
Multiple Dwellings
Privy (SF and/or D)
Private Well
Water Storage
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of p perty owner or authorized agent)
Permit/Rush Fees: c IS j Waiver Fees:
Date of Payment: 0/9410 Date of Payment:
Receipt Number: /� 94.4 D Receipt Number:
Permit No. 0519 11-/&3( Waiver No.
Permit App_ ::..c 3
FORGE ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
October 23, 2017
Municipality of Anchorage
Development Services Dept- On-Site Water& Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: Meadow Ridge Estates N Addn, Block 6 Lot 5—25013 Homestead Rd
Septic tank replacement permit application
Dear On-Site Services Engineer:
The septic tank on the above lot has failed, requiring a replacement. The existing home is a 3-
bedroom. We are submitting this permit application for the placement of a new septic tank. The
attached site plan identifies the location of the existing home, well and septic system, as well as
the location of the new septic tank. The drainage pattern in general will not be changed by the
construction.
The existing tank will be pumped dry and decommissioned per code. The new tank will then be
placed outside the 100' well radius. After the new tank, we will install a double-cleanout and
connect into the existing absorption bed. If needed due to shallow bury, insulation will be placed
above the new tank.
If the system is constructed as designed, it will have no adverse impact:
• On the wells in the area or those to be constructed in the future.
• On existing septic systems in the area or those to be constructed in the future.
• On reserve space on any lots located in the area.
• On drainage patterns in the area. The current drainage pattern will be maintained.
8000.
Sincerely, 47;• ,*�
* • 4 • .
ri
Benjamin Schiller, PE .._ b.
• •4••
•
• '••11 i O••'
I r ssix+Aoobo
LC i
DEMOLISH AND REMOVE MEADOW RIDGE ESTATES N ADDN — BLOCK 6
EXISTING TANK LOT 5
REPLACEMENT 1000-GAL EXISTING TRENCH (APPROX)
SEPTIC TANK W/ DOUBLE MT
CLEANOUT
vz\z
LOT 4 'FCC/ LOT 6A
3-BDRM HOME
NO WELL-COMMUNITY WATER
- 10'UTILITY EASEMENT
HOMESTEAD RD
NOTE:
NO SURFACE WATER WITHIN 100'OF THE
PROPOSED SEPTIC SYSTEM
-"=""G N.;4% NO CONFLICTS WITH WELLS OR SEPTIC
�i, P' -� .17 0 SYSTEMS ON ADJACENT LOTS.ALL LOTS ARE
f*:491N -'•* I ON A COMMUNITY WATER SYSTEM
L'-a +w LEGEND
in Schiller MT-MONITORING TUBE
Be
• .•
CE 12592 � 0 40 80 FCO-FOUNDATION CLEANOUT
. 4
4'67,�PROfES510�a��� FEET TH-TEST HOLE
\������I 1"=40' CO CLEANOUT
! MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
[] UPGFIADE
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS~
DISTANCE TO:
~ ~ Manufacturer~ ~ Mate~~__~ No. of compartments ~
~C~ -- ----~--~ Inside~ngth . Width Liquid depth
~ ~ DISTANCE TO: Well ~// Dwelling PERMIT NO,
~ ~ ~ Manufacturer Material Liquid capacity in gallons
Well Foundation/~/r Nearest ,ot~ PERMIT NO. __
~ DISTANCE TO:
~__ ~o. ofli"eS / ~n~th~l,*~ Tota, i.chos Distancobet~oenIM.s
~ ~ ~ ~of tile to finish grade / Material beneath tile Total effe~iue absor~ area
Length Width ~ Depth PERMIT NO.
~ ~ Type of crib Crib diamete Crib depth Total effective absorption area
~ Well ~ ' Building foundation Nearest lot line
~ DISTANCE TO:
~ Class~mn~,,, ,Depth~-- /~ Driller .~ ~/~7~-,~°l°tline PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
SOILTEST/ ~9 ~RATING
INSTALLER'
REMARKS ~' "'
~ '%'
APP VED /...- DATE LEGAL
~2-o~ (~.~. ~/7~ ~
MUNICIPALITY OF ANCHORAGE
Departmen~ ~f Health and Environment~ Protection
825 L Street, Anchorage, AK. 99501
2 - 720
~ ~ ~ HANDWRITTEN PERMIT ~ ~ ~
Location:/ Phone Nu~er:/ :::-Z ¢¢.:
Legal Description, :: :: :::~:&~:~: Lot Size,
Type of Soil ~.sorption System Is: /
Trench: ,~ Drainfield: Seepage Bed: HoldingTank:
Maxim~ N~ber of Bedrooms: %. Soil Rating(sq.ft/br)
The Required Size of the Soil ~sorption System Is:
DEPTH ~) LENGTH 3-~ GRAVEL DEPTH ~WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minim~ depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
Permit applicant has the responsibility to informthis department during the
installation inspections of any wells adjacent to this p~operty and the number
of residences that the well will serve.
~ ~ ~ TWO(2) INSPECTIONS ARE REQUIRED ~ ~
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of' public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
~ ~ ~ PERMIT EXPIRES DECEMBER~i31, 1 9 8 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I under-~'t~%d that the on-site sewer system may require en. largement if
the,~/~esi~e i~remodeled to include more ~_ t 3 bed:o,~s~
/ ~'~"//' -/:-////~/"'" Issued by :~F~ ~
Signe~: ~f /_l-~:--t_.fA/~-'~...~ _ _
~licant Date: ~ ~
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
/~OI LS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
COMMENTS
y..~&
PERFORMEDB :
72-008 (6/79)
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
~-~:~-t-~-~O¢~ ~-~I:z' '~(,-~--. IF YES, ATWHAT DEPTH7
Gross Net Depth to Net
Reading Date Time Time Water Drop
/,~' /'
PERCOLATION RATE i~/ (minutes/inch)
TEST RUN BETWEEN FT
;04-2079
891 •
ter` _•� 77 Pic 80.
• �; Municipality of Anch age ��� F '��� _
On-Site Water and Wastewater Pr.. am'f` mil I
(907) 343-7904 a OCT 1 LTJil >r s. ETY .
Certificate of On-Site Systems/l a 'royal
051-531-22 CL 6s `
Parcel I.D. Expiration Dae: I
1. GENERAL INFORMATION
Complete legal description Meadow Ridge Estates North Add. Block 6 Lot 5
Location (site address) 25013 Homestead Rd
Current Property owner(s) Russell & Joyce Shoefllan Day phone
Mailing address PO Box 671981 , Chugiak, AK 99567
Real Estate Agent . Cody Kiem Day phone 907-250-9558
2. TYPE OF DWELLING:
2 Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well Cl Individual El
Individual Water Storage ❑ Holding Tank ❑
Community Class A Well Q Community ❑
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: Distance:
Received by: i G]/;J1,(,a 11t Date: 1 !/( 17
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 01107,V) Waiver Fee $
Date of Payment it r l r�- Date of Payment
Receipt Number OCig3rEi Receipt Number
COSA# 650?/61-3 Waiver#
5. 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,
based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Forge Engineering Phone 907-522-7773
Address PO Box 240773, Anchorage, AK 99524
Engineer's Printed Name Benjamin Schiller Date 10/30/17
• OF"4144
6 0
491H '07 11,
6. DSD SIGNATURE ...° aoor .
System #1 Approved for bedrooms
System #2 Approved for bedrooms $ "r :, � • a;
4.42
Disapproved ��''`;'l�1.. 1�. •,•��4
Conditional approval for bedrooms, with the following stipu Irons..
\QPM Cy
ON-SITE •;
WATER AND
T 1 WASTFWATER
PROGRAMo
l0 �
t^^- Original Certificate Date: ) ( I3 _ / 7
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On-Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_i: c
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On-Site Systems Approval Checklist
Legal Description: Meadow Ridge Estates North Add. Block 6 Lot 5 Parcel ID: 051-531-22
A. WELL DATA
Well type A If A, B, or C provide PWSID# 211431 Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production _ g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Septic/Steel Date installed 10/26/17
Tank size 1000 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout (Y/N) Y Depression over tank(Y/N) N High water alarm (Y/N) N
Date of pumping Pumper New Tank
C. ABSORPTION FIELD DATA
Date installed 7/14/82 Soil rating (g.p.d./ft2 or ft2/bdrm) 150 SF/BORN System type Trench
Length 57 ft. Width 3 ft. Gravel below pipe 4 ft.
Total depth 8.5 ft. Eff. absorption area 456 ft2 Monitoring tube Y Depression over field N
Date of adequacy test 10/06/17 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 8 in. Water added 461 gal. New depth 15 in.
Elapsed Time: 1440 min. Final fluid depth 8 in. Absorption rate >= 450 g p d
N
Any rejuvenation treatment(past 12 mo.) (Y/N &type) If yes, give date
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in -Pump off' level at in. High water alarm level at in.
Datum Cycles tested _ Meets alarm& circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO
Septic tank/lift station on lot >100' On adjacent lots 100
Absorption field on lot >100' On adjacent lots >100'
Public sewer main '75 Public sewer manhole/cleanout >100'
Sewer/septic service line '251 Holding tank X75
Animal containment areas >50' Manure/animal excrete storage areas >100'
SEPTIC/HOLDING TANK ON LOT TO
>5' >5' >5'
Building foundation Property line Absorption field
>10' 1
Water main Water service line 10 Surface water 1
00
Wells on adjacent lots 00'
ABSORPTION FIELD ON LOT TO,
1 1
Property line 0 Building foundation >10 Water main >1
1 � >10'
Water Service line 10 Surface water 100 Driveway, parking/vehicle storage
Curtain drain None Noted Wells on adjacent lots >100�
F. COMMENTS
*New tank is insulated with 2" of foam and 3' of material cover.
G. ENGINEER'S CERTIFICATION 461V,Aa 1.laIiit
I certify that / have determined through field inspections and �; :.
•, 11 , f*
review of Municipal records that the above systems are in P. ,?„. ,, • }- tj
conformance with MOA COSA guidelines in effect on this date. �n . :f •:
Benjamin Schiller . _ , -
Engineer's Printed Name _ 7,,m d
Date 10/30/17 .� v.; vlism i .: - "
•
i s h
p+s �s%••LIJ. l 1••' n�
ofa Eas `�4
COSA brown sheet 10-10-12.doc
f
/ N
Lot 1 1 // Lot 23 O N
/
/ CHAIN–LINK FENCE
/ 8.2'x16.2' SHED
S 89'55'20"E 140-00'
RETAINING WALL <•
Lot 5 1 f.
c �' , ,``�
21.053 s.f. in .�
• 6.3'x8,2' NEIGHBOR'S
SEPTIC SHED • CHAIN–LINK
CONCRETE PATIO ! PIPES FENCE
12.0'x8.5' DECK ! . , i
1 1,7
47.3'
2 STORY N Lot 6
5.0' -5`a RESIDENCE °;
1.3' 1.3' t 6.7'4'
Lot 4 s 1.1' S-T 22.8' u w 29.0' 14.7 5
...� ---
m 26` • • '
-Li 2.1' CANT
e
co
rn 12.5.x12.0'
N WOODEN PATIO '
0 cs , • SPH -. . .: •.
z a p
•
10' UTILITY EASEMENT ,1O0 52 R�330'00 o
o
0
l__ — ---______–_
�' /*---------- iT
� Ap ROAD
�Q
NOTE: LOT IS SERVED BY A COMMUNITY WATER SERVICE
PLOT PLAN AS BUILT X SCALE 1" = 40' GRID NW 1462 Project No. 17-407/A1
11500 Daryl Avenue, Anchorage, Alaska 99515-3049
Lang & Associates inc . (907) 522-6476 Phone
(907) 522-4625 Fax .. .. ppb
P ro f e s s i o n a I Land Surveyors kenolangsurvey.com P 0 .'.� L %I,
jonathanOlangsurvey.com Od�, . , . S Qnnn
I hereby certify that I have surveyed the following described property: �� 49TH %` v�
LOT 5, BLOCK 6, MEADOW RIDGE ESTATES SUBDIVISION, NORTH ADDITION (PLAT 74-133)v * •• — • * 4�
Anchorage Recording District, Alaska, and that the Improvements situated thereon are g
within the property lines and do not encroach onto the property adjacent thereto, that th
no improvements on the property lying adjacent thereto encroach on the surveyed ' KENNET}i. .. LANG. ..40
premises and that there are no roadways, transmission lines or other visible �'�, o
easements on said property except as indicated hereon. QO�' • 1(('6 LI II
(-2-ti1 aWbti,~;��aU Q, .IrS-5202,. ' c, G"
Dated this the Day of , , at Anchorage, Alaska Q ,o '••'•' �,00
4I k.tf1'SSIONAI-�4
It is the responsibility of the owner to determine the existence of any easements, �4OOQoa‘z:'
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property owner
Mailing Address
Telephone: (home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent 7~.-~c~(~ /_~7'/?~?¢¢-4.-¢ /~.//~¢~
Telephone ~ ¢~-~ ~ ~
(e) Mail the HAA to the following address: (or check here~if hold for pick up.)
List contact person and day phone number below:
:~ & 5 ENGINEERING
17034 Eagle River Loop Roa~ No. 204
P. ag e River. Alaska 99.577
2. TYPE OF RESIDENCE
Single-Familyd2~/ Number of bedrooms
3. WATER SUPPLY
Individual Well [] Community¥12¢ Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWA?E/~ISPOSAL
On-site~:] 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.
72-025 (Rev 7/88) 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 th is
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.
S & S ENGINEERING
17034 Eagle Ri~er Loop Road No. 204
Eagle River, Alaska Y'~-~7
Name of Firm
Address
Date
Telephone
6. DHHS APPROVAL ~
Approved for -~ bedrooms by :' ~
Approved ~ Disapproved Conditional
Terms of Conditional Approval
Date //-//'gr'-- 8~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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 Mun ici pality of Anchorage is not responsible for errors or om issions
in the professional engineer's work.
72-02S (Rev. 7/88) Back Page 2 of 2
./,~'' :' ~M.~I~I~;IPALITY OF ANCHORAGE (MOA)
~',~';',~'~;'~"" ,l~palth Authority Approval (HAA)
¢.~,~,~// ;. \~?~HECKLIST - FEBRUARY 1984
~--------~-~ ~ 343-4744
Legal Description:
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
Date Completed
Depth of Grouting
If A, B, C, D.E.C. Approved(C~N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
"~ 4-- ; On Adjoining Lots
'"7_.,c>c~ 14-- ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ¢ - I C: - C~"~Size
Standpipes ~N)
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N) ,
Holding Tank High-Water Alarm (Y/N) ~/,A/
Air-tight Caps ¢~N)
No. of Compartments
~/ Foundation Cleanout ~::~N) '-/
Date Last Pumped /[ ~ I
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata \ ~"~::~'9~/'~---- Type of System Design
Date Installed ~ - \~5 -- ~5'~ Length of Field ~7 I
Width of Field '~' '~'~ ~ ~ /
Depth of Field
Gravel Bed Thickness
~ [~ ~' Statndpipes Present ,(_~N)
~ Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
Square Feet of Absortion Area
Depression over Field (Y/~
Results of Last Adequacy Test
To Water-Supply Well
To Building Foundation
Lot t~/,~
To Water Main/Service Line
Y
To Property Line ~
To Existing or Abandoned System on
; On Adjoining Lots "-~'~ c:~
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date Installed
Dimensions
"Pump On" Level at"~'~-~~
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
---'"-'---~P~.m~ng Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
inspection.I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of,thjs_~
S & S ENGINEERING
Signed ..... ~..~. ~;ver Loo~ Road No. 204
C o m pa n ~agie River, Alaska 99577
Date ~".////,,~¢/
MOA NO. ~_,~ ~
Receipt No.
Date of Payment
Amount: $
72-026 (Rev 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE /
3801 C STREET, SUITE 1334
ANCHORAGE. ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: November 9, 1988
PWSID: 211431
To Whom It May Concern:
According to the records on file in this office, the O~.~.Z~
MEABOWRIOGE SUBDIVISION Water System is in compliance with the
State of Alaska Drinking Water Regulations.
Please note that departmental records indicate that the public
water system was installed prior to the 1978 implementation of
the Alaska Drinking Water Plan Review regulations. No as-built
plans have been reviewed or approved by the department, nor are
any necessary. Since the system has submitted acceptable water
samples on a regular basis and received a satisfactory sanitary
survey evaluation by the department, the system is acceptable
under the standards in effect at the time of installation. An
official "Certificate to Operate" may be issued upon receiving a
complete set of as-built plans. Any expansion of the water
system after 1978 will require plan review and the issuance of a
"Certificate of Operation" permit.
VEC:pkk
Sincerel y,
Vera E. Craig ~
Environmental Field O??icer