HomeMy WebLinkAboutBIRCH HILLS TERRACE #2 BLK 1 LT 8~~ Municipality of Anchorage Page
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
Permit Number: ~'/,") ~,O~7~ PID Number: ~:~5"~ -//--//-~ !
Name: ~_~,~. ~(~:.,~,D~::;Mfl,/~,/-.. Wastewater System: ~New ~ Upgrade
Addre~:
Po ~ &7/~7~ ~~ ~ 7 ABSORPTION FIELD
Phone:~7_ ~ ' ~ No. of BeSoms: ~DeepTrench ~ Shallow Trench ~ Bed ~ Mound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION so, R~,.~: '~ ~P~/s~.F~. /O'
Subdiv~ion: ~ Depth to pipe bottom from original grade: Gravel depth beneath p~e
~°': ~ ~'°c~: / ~ ~ z~ ~' ~t. 7 ~,.
I i Fill added above original grade: Gravel length:
Township: Range: etlon: ~ / - ~ ' Ft. ~/
WELL: 0 New ~~ Gravel width: ~'~ ' Ft. Numbero~lines: I Di~ta,~ebetw,e~",~:~ Ft.
Classification Total absorption area: .
_ (Private, A,B,C): ~al Depth: Cased To: Pipe material:
Driller: ~ Date Drilled: Static Water Level:Ft. Installer: ~ ~ Date installed:~
Y~GPM [ Pump Set at: Ft. Ic~ing He'"~t Ab°v~ Gr°und:~t. TANK
SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P.
To Septic Absorption Lift Holding Public/Privatel Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~ ~ ~ /
Well- I~ '~ /~ '~ X Material: ~7~ Number of Compartments:
SurfaCewater !~ ~ IOd'~ LIFT STATION
Size in gallons: Manufacturer:
Line
Remarks: BENCH MARK
Location and Description:
-
Inspections performed by:s&::t~=:~:::=:t:~ Dates', 1st ~./~.~B ,Id~~.~~o~._(_.Z~
17034 Eagle River Co~ R~4, ~ 2nd. ~ '[~ ' ¢ ~ l~ t ,o,,,~ c. cp~.
~gle River, Alaska ~5~ ~t 7G~ .
Department of Health and Human Services approval
Reviewed and approved by: ~ ~~~Date: ~?~
// '
72-013 (Rev. 9/91) MOA 25
~PERMIT NO SW960578 PAGE 2 OF 2
NunicipaLi%y of' Anchopo. 9e
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P,D, Box 1966500Anchopage, ALcxska 99519-6650 e TeLephone: 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL iNSPECTION REPORT
LEGAL LOT 8, BLOCK 1, BIRCH HILLS TERRACE //2 P.I.D. NO. 050--141--31
I-2 I
SCALE
LOT 8
ST1
k [ ST2
)BE1 ALT. SITE
BL2 /
[.~CO1
TRENCH
C02
TH
ST 1 STE
NEW ~79.5
1250 GAL ,
S.T.
MTco CO1 = 84.3'
FINAL GRADE~o2 = 78.9'
INSUI.~T~
/ '~,L_CO1 = 78.5'*
cog = 75.1'
,,j ·
~T1 = 68.3 NO WATER FOUND
62.4' B.0.H.
'~ THE MT WAS INSTALLF, D
· W HIGHER THAN THE
BOTTOM OF THE EFFECTIVE
X~A ~ CO1 IS LOCATED BEFORE THE
TRENCH AND IS 3.4' ABOVE THE
DISTRIBUTION PIPE. THE DISTRIBUTION
PIPE IS LEVEL.
W
APPROX. LOCATION-//~ WI
OF WATER LINE
A B
FCO 25.5' 2.5'
ST1 46.5' 51.5'
ST2 53.5' 39.5'
DBL1 56.5' 45.5'
DBL2 59.5' 46.0'
C01 65.0' 52.5'
C02 100.0' 89.0'
MT1 95.5' 84.0'
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, P.E.
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
Date, 7-' /7' ¢~ 7
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
RECEIVED
JUL 18 1997
Municipality of Anchorage
Dept. Health & Human Services
REFERENCE:
The septic inspections for the referenced property were
performed on ~-I~'~ .and ~-t~-97 Prior to submitting
the On-site Wastewater Dlsposa--l~em ;nd/or Well Inspection
Report we are waiting for the ~ ~4~r~ to be
completed.
If we may be of further service please contact us.
Sincerely,
Robert C. Cowan, P.E.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE
1 OF 1
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW960378
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:CASSELLIUS EARL & MARIE E
OWNER ADDRESS:17615 LACEY DR
CHUGIAK, ALASKA 99567
DATE ISSUED:12/16/96
EXPIRATION DATE:12/16/97
PARCEL ID:05014131
LEGAL DESCRIPTION:
BIRCH HILLS TERRACE #2 BLK
1 LT 8
LOT SIZE: 49726 (SQ. FT.) Z ~ J
NUMBER OF BEDROOMS: ~THIS PERMIT:
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 (18AAC80).
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:
ROBERTC. COWAN, RE.
ROBERT A. SHAFER, RE.
CIVIL ENGINEERS
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
April 22, 1997
(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 8, Block 1, Birch Hills Terrace S/D
Request you reissue a permit to install a septic system to
serve the proposed four bedroom house on the referenced
property. Permit #SW960378 was issued on 12-16-97, but
needs to be updated to a six bedroom system. The updated
information is shown on the enclosed site-plan.
A test hole was excavated and a percolation test performed.
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 holes. After seven day ground water monitoring,the
monitoring tubes were found to be dry.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
This property is served by a Community Water System.
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/mg
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
1 .... = 60'
SCALE
SITE PLAN
DESIGN
F"
I'--
20' UTIL. ESMT,
0~
0
~o>~
o
oo ~
~,.~ II~
7121'
F-
:::':%'-o~i~~ '?¢%
,.: :-,';' r,', ~ t
1.': ' :! con
ROBERT G. GOWAN, P.E.
ROBERTA. SHAFER, RE.
November 11, 1996
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
WASTEWATER
DISPOSAL SYS'FEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 8, Block 1, Birch Hills Terrace S/D
Request you issue a permit to install a septic system to
serve the proposed three bedroom house on the referenced
property.
A test hole was excavated and percolation test performed.
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.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
This property is serv~by a Community Water System.
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
17034 NORTH EAGLE RIVER LOOP - SUITE 204 . EAGLE RIVER, ALASKA 99577
~:~~ 0 m ~ 0 - ~- ~-~~
oom~
o .~ ~ o Z
I
NOiS]CJ [
NVId Ills
31¥0~
PERFORMED FOR:
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.~
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
DATE PERFORMED:_
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
19
20
6. o.
~ 1~¢,c~-~ Township, Range, Section: '
~/~ ~ ~Z- SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT ~ ~)
DEPTH? p
E
Depth lo Water Alter · j
Monitoring? I'v 0 Date: i I - i Z - ~ L
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ "Z,s' ~,,~Jq "~ ,
PERCOLATION RATE ''~' {minutes/inch) PERC HOLE DIAMETER L~
TEST RUN BETWEEN ~' -'~ ET AND ~' ~'- F'r
COMMENTS
PERFORMED BY: 17034 Ea~le Riw~ L~.
CERTIFY ~HAT TH~ TEST WAS PERFORMED IN
*CCORDA"CE W~?~%rf¢l~f~AL eU,DEL,NES ,N EFFECT ON ,HIS DATE. DATE:
7?-W~a fRc, v 4/85)
ROBERT C. COWAN, RE.
ROBERTA. SHAFER, RE.
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
EEFERENCE: Lot 8, Block 1, Birch Hills Terrace S/D Addn %2
November 11, 1996
GENERAL:
1.
e
e
®
The scope of this project includes the installation of
a 1000 gallon septic tank and a leachfield trench to
serve the proposed three bedroom residence located on
the referenced property.
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.
SEPTIC 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 8, Block 1, Birch Hills Terrace S/D
November 11, 1996
Addn. ~2
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 8, Block 1, Birch Hills Terrace S/D
November 11, 1996
Addn. %2
Bo
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 thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
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 (ASS)
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.
0
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.
e
Ail leachfield gravel (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, which ever requirement applies.
Page Four
Lot 8, Block 1~ Birch Hills Terrace S/D Addn~ #2
November 11, 1996
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:
me
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.
e
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placemen't 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 8, Block 1, Birch Hills Terrace S/D Addn. 92
November 11, 1996
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
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COSA Checklist.docx
COSA Checklist
Legal Description: BIRCH HILLS TERRACE #2 BLOCK 1 LOT 8 Parcel ID: 050-141-31
If more than 1 well and/or septic system on lot, provide separate checklist. Structure served by this system ____
A. WELL DATA - PUBLIC &/OR CLASS “A” WATER
Well log is filed with Onsite (or attached)
Date drilled Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume NA gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date
Comments __________________________________________________________________________________
B. TANK DATA
Measured operating fluid level in septic tank 51”
Date of pumping 6/27/2024
Required maintenance completed, if AWWTS
Comments:
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 6/19/97
ALL standpipes present per record drawing
Total measured depth from grade 12.2 ft (max)
Measured depth to pipe invert from grade 5.8 ft (min)
N/A – pressurized field.
Per record drawings, field is insulated.
Monitor tubes (MT) go to bottom of effective (ED).
If not, state depth into effective 6.5 ft
Presoaked required if
(Required if house vacant or field not used for more
than 30 days prior to date of test)
Gallons introduced gallons date
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Adequacy test date 6/27/24
Results Pass
Fluid depth prior to test 28 in
Water added 600 gal
New fluid depth 38 in
Elapsed time 1440 min
Final fluid depth 27 in (ED missing 6”)
Absorption rate 600 gpd
FIELD STATUS – POST RECOVERY
Effective depth (per record drawings) 84 in (MOA 7’ ED)
Effective depth used 33 in (Missing ED + Final Fluid Depth)
Effective depth remaining 51 in
Comments/Deficiencies: Approximate total measured depths from existing grade. ED per elevation measured shots &
appears approximately 6” or 0.5’ ED is missing.
COSA Checklist.docx
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot) - NA
Septic Tank/Lift Station on Lot > 100’
Yes if No ft
Neighboring Tank > 100’ Yes if No ft
Absorption Field on Lot > 100’ Yes if No ft
Neighboring Absorption Fields > 100’
Yes if No ft
Community Sewer Main > 75’ Yes if No ft
Community Sewer Manhole/Cleanout > 100’
Yes if No ft
Private Sewer/Septic Line > 25’ Yes if No ft
Holding Tank > 100’ Yes if No ft
Animal Containment > 50’ Yes if No ft
Manure/Animal Excreta Storage > 100’
Yes if No ft
N/A – Served by Community Well (not on lot) or Public Water
From Septic/Holding Tank and Absorption Field(s) on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No ft
Tank to Property Line > 5’ Yes if No ft
Field to Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No ft
Water Service Line > 10’ Yes if No ft
Surface Water > 100’ Yes if No ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No ft
If tank or field is under driveway comment below
F. ENGINEER’S COMMENTS
G. CERTIFICATION & 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, indicates that the on-site water
supply and/or wastewater disposal system appears to comply with applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation, unless noted otherwise.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Engineer’s Printed Name CURTIS HUFFMAN, PE Date 7/1/2024
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any or NO estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by First Water Consulting &
7/1/2024
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~~,~F'ALI'I'Y Or: t~x~CHoX~,L;~
ENVIRONMENTAL .SERVICES DIVISION
AUG 1 5 1997
os-¢,-~t -: /
Parcel I.D. #
GENERAL INFORMATION
Complete legal description
Lot 8; Block 1; Birch Hills Terrace #2
Locatio..n.,(,sit~ address or directions)
Pr'6pert¥ Owner
Mailing address'
Lacey Drive
Eagle River, AK
E~hie Mendenhall
Day phone
'702 Cordova Street Anchorage, AK
227-8823
99501
.,.Lending agency
Mailing address
Day phone
Agent
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water xxx
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
XXX
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. 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.
S & S ENGINEERING
Name of Firm ,.,,,~ .... ,_ ,,, .................
Address Eagle RiYer, Alaska 99577
Engineer's signature '~./J ~
Phone 6~; q ;Y - ~.c/7 c~
Date I/ //~-/c/7
DHHS SIGNATURE
,,7 Approved for
bedrooms.
Disapproved.
Conditional approval for
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 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, 1/91) Back MOA #21
MUNICIPALITY OF.ANCHORAGF
ENVIRONMENTAL SERVICES DIVISION
Municipality of Anchorage AUG 1 5 1997
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division 0~7~.~4o[D
825 L Street, Room 502 · Anchorage, Alaska 99501 · (9
Legal Description:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Health Authority Approval Checklist
~. ~'1,¢/c/: J.~B~.H J~J-~/-~ 7'~.~fc~Parcel I.D.:
Date of test
Static water level
Well production
c o,,W^;o r S
o~~of ~mple:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~
Cased to ___ Casing height (ab~ _ __
____ . Wiresproperly~;tr~te~ted (Y/N) _ __
M~~INSPECTION .
FRO
g.p,m, g.p.m.
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
LC.
&-/?- ? 7
Number of Compartments o'~ Cleanouts~) /~.5'
High water alarm (Y/N) -'~/~
I ~$o
Date installed Tank size
~. ~I~'~.5 ' Depression (Y~_.~ We
Foundation clea?~.u,t'
Date of Pum,pi!~;
ABSORPTI~/FIELD ~DATA '
~ffoetivo a~o~pg? ama
Dato ol adequacy t~t
Gravel thickness below pipe
System type
Total depth
Monitoring Tube present~_~) ~
I~ Depression over field (Y~
Results (Pass/Fail) For ~ bedrooms
Fluid depth in absorption field before test (in.);
Fluid depth ~ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Immediately after ~gal. water added (in.):
Absorption rate = .g.p.d,
If yes, give date
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons ~
"Pump on" level at* ~'mp off" level at*
*Datum
!
/o ~-
Wells on adjacent lots /0 O ~/'
Cycles tested ~
SEPARATION DISTANCES
SEPARATION DISTANCES FROM W~"'~N LOT TO:
Septic/holding tank on Iot~..~.~ On adjacent lots
Absorption field~Jet' On adjacent lots
Public se~el~main ____ Public sewer manhole/cleanout
S/,~r/septic service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation I0 ~¢ Property line /O /4.- Absorption field
Water main/service line lO I+ Surface water/drainage ./O 0 LF
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ~ ~' Building foundation ~/0 ! ~ Water main/service line
Surface water , [OO ~ -~ Driveway. parking/vehicle storage area ~O
Curtain drain /~O/U~. ~-~,l~o~J ./"] ' Wells on adjacent lots //OC) "~-
HAA Fee $ Jz~-~ ,
,Date of Payment
Receipt .Umber~::::/~4~)/~-~' ~-'~-- (R~ / /
ENGINEER'S CERTIFICATION ~' ' :"
I certify that I have determined thru field inspections and review of Municipal~~~~ l~systems are
in conformance with MO.A~IA~ g~idelin~ in effect on this date. ~~ ~-"~ ~
..... : -
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
1
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