HomeMy WebLinkAboutLA FORET LT 1kA I
A 0 %=) 4w 34a -OI
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
NAM
JU13j
Ak;T
PHONE
�
NEW
UPGRADE
MAILING ADDRESS K B O
LEGAL D SCRIPTION
o7- oze sA_j
LOCAr O6e / ,4kAj�
G `I�VI //Vt
NO. OF BED OOMS
Vy
Well
DISTANCE TO: `Qa
Absorp n area
Dwelling
PE ITNIDO
E Q
W F
Manufacturer ��'�
Material
No. of co artments
y
Liq. cap�pjtyn alions
r
IF HOMEMADE:
Inside length
Width
Liquid depth
y
Jaz
DISTANCE TO:
Well
Dwelling
PERMIT NO.
S4
Manufacturer
Material
Liquid capacity in gallons
J
w=
DISTANCE TO:
Well
L�
Foundatio
Nearest lot line
��
PERMIT NOp
O l6
J LL 2
? w
No. of line s%
(
Length cFyline
(
Total len lines
Trench t
inches
Distance between lines
FTop
p
of tile to finish grade
Material beneath tile
_inches
Total eftectiw absorption ar
X 32,
PER O.
W
a
Length
Widfn
Depth
4 H
wa
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
DISTANCE T0:
Well
Building foundation
Nearest lot line
J
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
W
�
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MAT IALS^
Ct'
SOILTESTRATING
INSTALLER
REMARKS
APPROVED DATE LEGAL
79-M.1 IR, V_11750
m
7J
X7
A
A x A
A
A
A
A
A
A
L
y
O O
o
O
O
O
O O O
C
O
C
O
O
O
m
m
my
m
r
� m
m
w
T
m
I
a
v'
L O
ti
N
:r'
F-'
W
r:
W
: N
: O
m
y
H
m
•,�
CA
-
O
ON
:ln
;r^
'
M
A
: pJ r
ti
A
:�
;
:0) W
o
H
:r
:o y
-
m
:w
:x z
-�
o
:t
O
O
T
T
m
: 4�- ,
ro
H
H
H
H H H
H
H
H
H
H
H
:F -
:�
i W
i N
: N i N ir'
e-'
: 1--•
W:
t
i W
i N
icc)
i tb
iQ•
i U]
i
In
W
r
:r
:•
O
:�
k..11: W :W
4-
✓
Fl
:w
a
o
:N
:o No P-0,
:n
: w
:n
:o
:�•
F-':ct
:lL
:'�
:O,
:FJ
:�
:(gyp
c+
: c+
:(D cKD c+:
r
i(D
:(D
'x
:y c) n n Y
F'•XD
n�vH
FJ<+
►
b-
'co
chi
CJS
,v:
r+
:N.
:N
o
mc,� tD :R
m:
H
ci-
:gyp
:kjx
C+
n
(D
(D n 0)
p
H•
uay
O
F J
ro(D
w
O
0
n z
z
Lill
C/
O
T
a
(,y
C
p
r O
JY
n
A
m T
m
na
a
az
m rn
T
r r
O
T
T
T
T T T
T
m
T
T
T
CD
CD
O
O
O
O
T
b
C
a
a:
ClIn
wm
In
11 T
`+
fz
Fl-
:
F�
: (D
C+
F•
.(D
"T
n
m
o
XD
w
DEPARTMENT C_ HEALTH AND ENVIRONMENTAL F7 7ECTION \LYLI-)
m
825 �L STREET, ANCHORAGE, AK. 99t_. �AGAoi
264-4720 rLso,
WF=t-1 F=I"L-- I -F-E: <----,E=-t4F=F;? F=EEFz?-lib I -F
PERMIT NO. 810428 (z \C\ lc_
_� 1 3 495 5 109
8
APPLICANT SUN CONSTRUCTION, INC SRA BOX 474E 99507
LOCATION
LEGAL LOT I LA FORET S/D LOT SIZ a,90,000 SQUARE FEET'
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH 4-2-001
\1
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT/BR)= 240
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
04=F=`F"� ::LO L_E:P4C3-r"— E30 C3F:ZF=lVE=L_ E>F=1=�-r" C -
THE LENGTH DIMENSION 15 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 MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
FZaQUIFREIC} -rF4"K !SI7;pf=- = �L2!53 C3F4L_l O"S;
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
-rWID < ::ZN > I " -0=; > F= IC -r 10 N S; F=l FR.* FE RECD - - - F;ZE:OU I . CA ---
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 THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F=maF;;,>Ml-r EXf= I F2 E [>al1DEEM0aFZ :3::Ls -1_=A IEP:dL
I CERTIFY THAT
1: 1 AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: 1 WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: 1 UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
--------- --- ------------- ---
SIGNED:- APPLICANT __ SUN - CONSTRUCTION, -INC -------
ISSUED BY ------------------------------ DATE__sLal:_a---- V4.0
JNICIPALITY OF ANCHORAGE
Department or Health and Environmental Protection
825 L Street, Anchorage, AK. 99501
264-4720
# # HANDWRITTEN PERMIT # # #
/1 WELL AND;b*R ON-SITE SEWER PERMIT
Applicant:. o" t.� '� S� O Mailing Address:
Location: �,C /� - �� °� s 7" Phone Number.
Legal Description: - OT I L*A�C�F^ `�� Lot Size��1 DU �
Type of Soil Absorption System Is:
Trench:_ Drainfield: _ Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br) �/ Q
�The Required Size of the Soil Absorption System Is:
//
DEPTH _L_`_ _ _._ LENGTH _ GRAVEL DEPTH L 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 minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _ GALLONS #
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
# # TWO(Z) 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 31, 1 9 3 1
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 understand that the on-site sewer system may require enlargement if
the res'd ce is remodeled to include more that 3 bedriacm .
Signed: Issued by: `
ppli t/�
Date:
SWP/024(1/81)
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE �y�(
• DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION f't PERCOLATION
I\ TEST
825 L. Street, Anchorage, Alaska 89501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: :122)` (?00,2 (J U6 a& DATE PERFORMED:
LEGAL DESCRIPTION: .0 !) / / ^GL ! O -Fe;/ 5&.
DEPTH
SLOPE SITE PLAN
O - 17, f4 looa'>
1 - n
,1 Z ',27f J`'/Vl W�Of�l1,VrCs
2
3-
4-
5-
6-
7 4 567
8
9-
10-
11 1011
12
13
,2 — e1z" P/ 6 /K
y
14
15��
16-oe
n 493
18
19
Gogh O. Talbot
,_ No. 4969-E
�IMPo%
WAS GROUND WATER L
ENCOUNTERED?
0
P
IF YES, AT WHAT E
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
2$T11
7;o5
D
z
7;a0
1.5
13 3/
)z V,z
.4
7 5 6
1.5
Il 3I'�
3/
5
g -o5
20 �,
PERCOLATION RATE � � (minutes/inch)
/� / TEST RU)V BETWEEN '3 FT AND �` 5 FT
COMMENTS M L t'2{ G Fis� GG ![/28.0 4• {
PERFORMED BY:
72-008 (6/79)
CERTIFIED BY:
,2 -'O
f_
J ?'
MUNICIPALITY OF ANCHORAGE
• i° DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On -Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # (� \1 ' ? LkQ - C%I
1. GENERAL INFORMATION
Complete legal description t -o f 1 l.a Pref S/A
Location (site address or directions) 13 200 G -t no (e �'t rc le
Property owner If rn4r Srenola- nlor lon Day phone
Mailing address 13 2oy �nnole Crrc(e A.nchofaye ku 9e5 -1>f
Lending agency
6-,M6C Day phone S-62 2t8!
Mailing address y60 W %uo�or Rot
Agent Dan r"' It r'p (3au(�r Day phone S y9 — 76.91
Address lla r E -7 l -vc 14-A chofexe fi k 99,6 r&
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
MWNICtPAL,TY OF ANCHORAGE
ENVIRC.NMENTAL SERVICES DIVISION
I U L 2 2 1991
RECEIVED
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. 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
5.
6.
By:
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm F(.a.fl .e 75-c-41"Cal Ser&'"J Phone '� `✓s" 1355-
Address I y5'30 4FcAo S/ AA c oTye i>k 99S1
Engineer's signature O_U� OT �� Date 7 t9 M
DHHS SIGNATURE
�+4'_Gif A4
1"k
'I.
it
THEODORE F. MOORE ; ` 3
M
CE 3589 Ar
PAIE'SS AW
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
NUTION
Date .2 -/
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/81) Beck MOA 1121
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lo7 1 LA FORET Parcel I.D.
A. WELL DATA
Well type PRIVATE If A, B, or C, attach ADEC letter. ADEC water system number t4.f4
Log present (Y/N) y Date completed 61(5/s/ Driller 5)(RE rpt Mos.
.
Total depth 320 Cased to 320 Casing height 36 If
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Wires properly protected (Y/N) }�
FROM WELL LOG
(.115181
211
�7 g.p.m.
SEPARATION DISTANCES FROM WELL TO:
AT INSPECTION
7 /R/R/
216
ew `3ty'
9.p -m.
Septic/holding tank on lot ti 110 To Co • ; On adjacent lots 7 /oo r
Absorption field on lot x 1140, ; On adjacent lots > /00
Public sewer main ;p /oo ` Public sewer manhole/cleanout -7/00
Public sewer service line
WATER SAMPLE RESULTS:
Petroleum tank NomG 0135E1evED
Coliform 4Il00'm Z Nitrate� P. 1 Other bacteria O /fr+a,n.0
Date of sample: 74/9/ Collected by: 151-67702 TECH. 151/C5 .
B. SEPTIC/HOLDING TANK DATA
Date installed 6/4181 Tank size f� 5'o 6AL Compartments 2
Cleanouts (Y/N)
Foundation cleanout (Y/N) % Depression (Y/N) N
High water alarm (Y(N) N.A, Alarm tested (Y/N)
Date of pumping 7120191 4 _'suaCf
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ^-110 FROM C.O. On adjacentlots > 100, Foundation 12 1
To property line Q 6o r Absorption field 31 Water main/service line 60
Surface water/drainage ? loot
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
"Pump off' level at
Cycles tested
Surface water _
Date installed b 1431 Soil rating 240 ° 18RRM System type TRENCH
Length $6 Width 3C / Gravel thickness
Total depth 4•9
r
Total absorption area I o 3 2 a' Cleanouts present (Y/N) i
Depression over field (Y/N) N Date of adequacy test 74/1/
Results (pass/fail) PpAr for Al bedrooms
Peroxide treatment (Past 12 months) (Y/N) Kau fencwn If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot �Yo On adjacent lots Z /0o Property line
/O
To building foundation N 3 To existing or abandoned system on lot wA ,
On adjacent lots >/ ao Cutbank N • A Water main/service line 1;Z1 80
Surface water 7/00 Driveway, parking/vehicle storage area So'
Curtain drain Noce o8S6R✓ED
E. ENGINEER'S CERTIFICATION
1 certify that / have checked, verified, or conformed to all MOA and HAA
Signature _ q.- 9y1or,.4.
Engineer's Name i/ W4056f . F MOo -e.
Date -7 / 19 /9/
HAA Fee $ % 7a , �'
Date of Payment 7- Z 2 -
Receipt
Receipt Number 76'l $ 2Z. paw`
72-026 (Rev. 3/81) Back MOA 21
in effect o�� G '�/%?F' �)GE
I�r_ NMENTAL HOMES DIVISION
. THEODOkE F. MOORE
Waiver Fee: $
Date of Payment
Receipt Number
JUL 22 1991
CEIVED
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS REPORT BY SAMPLE for WOREorder# 36030
Date Report Printed: JUL 11 91 8 15:11
Client Sample ID:L1 LA FOAET S/D SOUTH HOSE BIB
PWSID :UA
Collected JUL 9 91 Q 15:00 hrs.
Received JUL 9 91 ® 17:00 hra.
Preserved with :AS REQUIRED
Analysis Completed :JUL 10 91
Laboratory Supervis r ;STEPHEN C. EDE
Released By :
.................................................,
Chemlab Ref 0: 913274 Lab Smpl ID: 1
Parameter Tested
-----------------------------------------------
NITRATE-N
Sample ROUTINE SAMPLE COLLECTED BY: CHRIS.
Remarks:
Client Name :FLATTOP TECHNICAL SRV
Client Acct :FLATTOT
BPO t PO # NONE RECEIVED
Req #
Ordered By :TED MOORE
Send Reports to:
1)FLATTOP TECHNICAL SRV
2)
Matrix: WATER
Allowable
Result Unita Method Limits
---------------------------------------------------------
ND(0.10) rag/1 EPA 353.2 10
........................................................................................................
1
Teets Performed
See Special
Instructicns Above UA -Unavailable
ND-
None Detected
See Sample
Remarks Above
NA-
Not Analyzed
LT -Lase Than,
GT -Greater Than
OEKMMember of the SGS Group (Soci6td G6n6rale de Surveillance)
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES N1 N U � 1987
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY RECEIVE D
264-4744 �Q—t— ,.�; � 2 /1
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
2V -I / X 6c-/
Location (address or
�4;r�rs ���sf35ea/'�'•
(b) Property Owner Telephone: Home-3�S'��'g4- Business e76-274�
Mailing Address-
(C)
ddress
(c) Lending Institution Telephone
Mailing Address Q
(d) Real Estate Company and Agents
AddressI. S?*'V : j /72 "�^�AC G%vsct a 9�15/C
'-Telephone ��
'10..-
(e) ',Mail the HAA to the following address: or: Check here C3, if hold for pick up.
List contact person andday phone number below.
yw•.. YOi• .. '.�. t"' s 9
2. TYPE OF RESIDENCE
Single -Family t�
Number of Bedrooms
3. 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.
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 72-025 fRev 8/861 From
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 regulations in effect on
the date of this inspection.
Name of Firmye" Telephone
Address — 0-�Oy/�•Z �Xha.-G��P �.L�1�Si/
Date
,,...,
.•
*:•49TH •,*
I'
6. DHHS APPROVAL
Approved for 4"-f C¢' bedrooms by 'a Date /' 2/–B¢
Approved `� Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in
order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data
before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
Page 2 of 2 72-025 (Rev 8/88) Beck
N' HUGH R.59VAN ;
�Jrf•,•
CE 1225
I'
6. DHHS APPROVAL
Approved for 4"-f C¢' bedrooms by 'a Date /' 2/–B¢
Approved `� Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in
order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data
before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
Page 2 of 2 72-025 (Rev 8/88) Beck
MUNICIPALITY EPT. OF ALTH NCHOWE
ENVIRONMENTAL PROTECTION MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
i2 0 O1987 CHECKLIST - FEBRUARY 1984
d G 264-4744
RECEIVED Legal Description:
A. WELL DATA
Well Classification If A, B, C, D.E.C. Approved (Y/N) N4
Well Log Present (Y/N) Date Completed Yield 404.$aen C4' fM� �µn
Total Depth _7e' '5' Cased to 3Z,,2 Depth of Grouting
Static Water Level �� 8 ��� w o•-:2- Pump Set At !/mown
Casing Height Above Ground r Sanitary Seal on Casing (Y/N) i
Electrical Wiring in Conduit (Y/N) i Depression Around Wellhead (Y/N)
Separation Distances from Well:
Al
/ 7,c
To Septic/Holding Tank on Lot AoZ ; On Adjoining Lots /oo
To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots
To Nearest Public Sewer Line �� To Nearest Public Sewer
Cleanout/Manhole//// To Nearest Sewer Service Line on Lot : !V A
Water Sample Collected by .�0; Date 1/- 97
Water Sample Test Results e
Comments
0
B. SEPTIC/HOLDING TANK DATA
fo...,dL boiM mfr^=t;P�% /-�•1-B� os pv N.�e.Or
Date Installed"� �� Size �Z� No. of Compartments Z
Standpipes (Y/N) Y Air -tight Caps (Y/N) y Foundation Cleanout (Y/N) y
Depression over Tank (Y/N) /I% Date Last Pumped A7%2w'?
Pumping/Maintenance Contract on File (Y/N) ^nzp ; for
Holding Tank High -Water Alarm (Y/N) N Temporary Holding Tank Permit (Y/N) N�
Separation Distances from Septic/Holding Tank:
d
To Water -Supply Well To Building Foundation
To Property Line To Disposal Field
To Water 4aW/Service Line �� To Stream, Pond, Lake, or Major Drainage
. it
• ...1
tYpmments_
Ptzttge 1 tMf 2(.
72-02J (Me 8881 Front
11
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed - .6�41- 8/
Width of Field
i,
Type of System Design
— Length of Field
Depth of Field
Gravel Bed Thickness
Square Feet of Absorption Area �0 32 Standpipes Present (Y/N)
Depression over Field (Y/N) N Date of Last Adequacy Test
Results of Last Adequacy Test SVO 9.d�1
Separation Distance from Absorption Field:
To Water -Supply Well ���� To Property Line
To Building Foundation
45 A
Lot 6;,� ; On Adjoining Lots
To Existing or Abandoned System on
To Water Main/Service Line LA To Cutbank (if present) &�
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area -rte
Comments
D. LIFT STATION //�
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
'Pump Off' Level at
Vent(Y/N)
" Check Permitted Bedroom Rating Against HAA Request "'
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I have checkad, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date
Company MOA No.
Receipt No. /0 d 16 U �
Date of Payment f 10l 4 -4-�',�• �F 9' . 4'r t� ,
Amount: $ /o0.�- j y�� Engireal•,fq+
Page 2 of 2
72-026 (Rev 8/86) Back
*;'d9TH Plin ;*
�•• HUtiH N Bfi VAN040 CE 1225
6
BEVAN ENGINEERING
Annc0Ved Well & Septic Engineers
Jan�ary 16�, 1.907
Municipality of Anchorage
Department of Health & Protection
825 xLx Street
Anchorage, Alaska 99501
a , Box 112852
MUNICIPAIATY OF ANCH2 e, AK 99511
ENVIRONMENTAL PROTECTION (907) 522-1383
(907) 25&0584
����u/
�
v �7
RE, CE
����k~ � U � �U�
Re :: Jim Bumgardner, Health Authority Approval (HAA) Application
Lot 1 LaForet Subd"
Gentlemen �
During the period from January 14 to January 16, 1.907 we performed research�
site well flow testing and absorption field testing pursuant to
Health Authority Approval on the above referenced lot,
We performed a well f1ow test and found the well production to be 4,4 gallons
per minute ((jpm). This exceeds the required 0"4167 gpm for a 4 bedroom home" W(61
took a water sample for Cpliform analysis and the results were negative^
We performed
an adequacy test
on the
septic system and
determined that it
absorbed at
a rate of 840 gallons
per
day (gpd). This
exceeds the 600 1::) (A
required for
a 4 bedroom home.
Since
the houase has been
unoccupied and the
septic tank
had been recently
pumped
we offer the MOA
septic as—built
inspection report
as dqcumentation
of
the tank volume.
To our knowledge all of the information requested on the HAA Checklist and
Application has been assembled" We are submitting this data to you for your
review" Please contact us if we can prov1de any addition�l information"
Sincorely,
...�.. .`. ~^,... ..�^
Attachments
HAA Application
HAA Checklist
Sewer As�built
Original Soils Investigation
Original Well Log
Total Coliform Analysis
cc Jim Bumgardner
87200- ws
OF -V,.
,"^°,"���
^ °
,
tjUGHR,9EVAN :'44
AAW
0 poll
v
RECEIVED
INSPECTION APPOINTMENTS
.7:a
TIME
TIME
TIME
DATE- - - - -
DATE -
DATE- -- -
INSPECTOR INSPECTOR INSPEC
MUNICIPALITY OF ANCHORAGE®'
MUNICIPALITY OF ANCHORAGE DEPT, HEALTH &
DEPARTMENT OF HEALTH &ENVIRONMENTAL PROTECT tAL fR0'(CCTION
tryvIRONMEN
- 825 L Street - Anchorage, Alaska 99501 - - -
®
ALIG 1 �
ENVIRONMENTAL SANITATION DIVISION
Telephone 264.4720 � ���j��
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWS:
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) daysfor processing. - -
1. PROPERTYWNER — PHONE
MFlILING AD )
� •1L - 7. -
PROPERTY RESIDENT (f different fro above) - PHONE
2. BUYER - - -/ -
PHONE - -
MAILING: ADDRESS - -- -
3. LENDING INSTITUTION PHONE
iY��
MAILING ADDRESS - - - - - - - -
4:• -RT'--_-_ ,� ,., _ ',,,1 PHONE -.
MAILING ADDRESS _ ----
5.LEGAL DESCRIPTION
STREET LOCATION -Wz
- - -
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS -
SINGLE FAMILY Cl One ❑ Four ❑ Other_
CI Two 1:7 Five
MULTIPLE FAMILY Three 0 Six
7. WATER SUPPLY
INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled,
COMMUNITY since June 1975. For wells drilled prior to that date, give well
El PUBLIC UTILITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM - - -- - - -- -
` l INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED.
E:1 PUBLIC UTILITY
NOTE.: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFOREPROCESSINGCAN BE INITIATED:
72-010 (Rev. 6/79) �-,^`.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE
❑ TWO ❑ FOUR ❑ SIX
❑ OTHER
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED /
7
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: /13-0 If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES -
WELL TO:
Septic/Holding Tank
Absorption
Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
CY APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
((A�) 1¢�`�`
BY