HomeMy WebLinkAboutBOREALIS #1 LT 13
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
MUNICIPALITY OF ANCH~RAC i
DEPT. OF HEAL't-,~f ~ '
£NVIRONMF>dT~] Dr' -~-; .....
984,.
R E CE,1
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE [] NEW
.~J '~;) 1~'O [] UPGRADE
MAILING ADDRESS
1400 OJ ~33 F! t1'
LEGAL DESCRIPTION
Lo"r_ 1_3 /3'~'
LOCATION
Well , Absorption;7
o I ~,ST~NC~TO:
~ ~ J Manufacturer
~ [Liq;ca?ci~L ~ oi~gall°ns IF HOMEMADE'. llnside]ength
~ ,. ~ ~ISTANCE TO' l Well LDweHing
Dwelling I
Material
Width
NO. OF B~ROOMS
PERMIT NO.
No, of com~rtments
Liquid depth
PERMIT NO,
Material Liquid capacity in gallons
,.J
_1
uJ
Well Foundation
DISTANCE TO:
No, of lines Length of each line Total length of lines
Top of tile to finish grade
Length
Type of crib ~///~
DISTANCE TO:
DISTANCE TO:
Width
Crib diameter
Well "2 0 P-..'
Depth
Nearest lot line PERMIT NO.
Trench width Distance between lines
Material beneath tile
x,F,2 v,
Crib depth rWA
Buildingfoundati~n
30,~ '
Driller
Building foundation Sewer line
OTHER
inches
Total effective absorption area
inches
Total effective absorption area I 350
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank ~, ~.~... Absorption area(s)
PIPE MATERIALS
D3o:~.
SOI~- TEST RATING
Iq6O'
INSTALLER
REMARKS i~5'UC~J'~IOAJ
APPROVED DATE
LEGAL
72-013 (Rev. 3/78)
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PRO'I'ECTIOI~
825 L STREET, ANCHORAGE, Al'::] 99501
264-4720
PERMIT NO:
DATE ISSUED:
APPL I CAN]':
ADDRESS: ·
CONTACT PHONE:
O I~ ..... S I T E; ~-i E] W E IF~: II:' E F~ IMt I 'l
08127184 ~
ALASKA ENVIRONMENTAL CONTROL~~ ~
I~)U W. 33RD, SUITE B ~ ~~
ANCHORAGE, AK 99503 ~
561- 5040
LEGAL DI.'".,:~CF~ i F:
L. OT SI ZE:
SUBDIVISION: BOREALIS
SECTION: 2.2 TOWNSHIP: 12N
1680() (SQ. FT. OR ACRES)
LOT: 13
RANGE: 3W
BI...OCK: 1
I certify that:
1. I am familiar with the requirements for on-site sewers and wells as set
~orth by the Municipality of Anchoragm (MOA) and the State of Alaska.
2. I will install the syst'em in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby tot.
IF A L. IF:T STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODE~,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELE:CTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
S I GN ED DATE
APPLICANT: ALASKA ENVIRONMENTA~ .... CON]RO~ .... SERVICES
I.~SUED., BY _ DATE
ALASKA e iUIItO[/m [1TAL COrlTROL $ I UICt $, I[1C.
~nqineerinq f, ~nuironmenlal Studies
SPECIFICATIONS FOR ELEVATED BED ALTERNATIVE WAST~ATER
TREA~lVLENT SYST~4 - BOREALIS SUBDIVISION LOT 13 ~IDCK 1
1.0 GENERAL
1.1 THE DRAWINGS, S~R, RTS 1 THRU
SHALL BE A PART OF THIS
SPECIFICATION.
1.2 ALL MATERIALS AND WORKMANSHIP SHALL MEET THE
REQU~ OF ANCHORAGE DEPARtmeNT OF HEALTH AND
FATVIROb~ENTAL PROTECTION P~IT.
1.3 ALL EXCAVATIONS AND DEPTHS ARE ADVISORY AND ARE TO BE
VERIFIED OR MODIFIED IN THE FIRT,D BY THE ~GINEER.
1.4 IT IS THE RESPONSIBILITY OF THE (7N/gER TO OBTAIN ALL
NEEESSARY PERMITS OR EASEMENTS.
2.0 ~dE LIFT STATION
2'1 THE STOCK MATERIAL FOR THE LIFT STATION SHALL BE EITHER
GALVANIZED ST~T, (AS~M A-4444-76), OR ALUMINUM CULVERT,
CAPABLE OF BURIAL TO 10 FI'.
2.2 THE 36" DIAMETER PIPE FOR THE LIFT STATION SHALL HAVE A
WELDED WATER TIGHT BCYlTC~4 OF THE SAME THICKNESS AND
~ITION AS THE CULVERT.
2.3 ALL P~:~-TRATIONS OF THE LIFT STATION SHAT,T, BE WR[,DED
AND WATER TIGHT. ALL WELDS SHAT,T, BE (2L~ OF SLAG.
W'R'r,Ds ON GALVANIZED STE. RT, WIT,T, BE SPRAYED WITH ZINC
RICH PAINT OR OOATED WITH BITUMASTIC.
2.4 ~ TOP CAP SHALL BE RAIN TIGHT AND S~-T~RELY FASTENED
WITH SCR~NS. A ~WO INCH LAYER OF POLYURETHANE FOAM
SHAT,T, BE GLUED TO THE INSIDE OF THE TOP CAP.
2.5 ALL ELECTRICAL FITTINGS AND CDNNEETIONS IN THE LIFT
STATION SHALL MEET %~tIE R~QU~ FOR A WATER TIGHT
SERVICE.
2.6 THERE SHALL BE A HIGH LEVEL ALARM, PEABODY BARNES 6147
OR ~QUAL SET AT THE LEVEL OF THE SOIL PIPE FROM THE
SEPTIC TANK. THE BUZZER SHALL BE LOCATED NEAR THE
ELECTRICAL CDNTROL PANEL OR IN A LOCATION DESIGNATED
BY ~ h~kw~NER.
2.7 THE SUMP PUMP SHALL BE CAPABLE OF DELIVERING 10 GPM AT
AHEAD OF 20 FEET.
2.8 PROVIDE A CALDER CDUPLING AT THE O0~ION OF THE 4"
SOLID PVC INFLUENT PIPE AND 4" STEEL NIPPLE.
2.9 THE PUMP SHALL BE CDNTROLLED BY A DIFFERENTIAL MERCURY
FLOAT SWITCH, ADJUSTED TO ALLC~ A TWO FOOT SPAN ~WEEN
' ON ' AND ' OFF ' , AS SHOWN IN THE DRAWING. ALL RR[ J~YS
AND Rr,RCTRICAL ODNTACTS SHOULD BE LOCATED OUTSIDE THE
CHAMBER TO PR~ ~ FROM OORROSION, PREFERRABLY
IN A DRY LOCJ~TION WITHIN THE HOME.
2.10 (/OAT THE INTERIOR OF THE CHAMBER WITH BITUMASIC PAINT
OR 'I9.R TO APROXIMATELY 3.5 FEET ABOVE THE BCYI'IC~4.
2.11 MOA BUTT,DING CDDES: WHEN LIFT STATIONS ARE INSTALT~ED
WITHIN THE MUNICIPALITY, AN EL~fRICAL PERMIT AND
INSPECTION ARE R~QU~. IN AREAS NOT CDVERED BY MOA
BUTT,DING CDDES, THE SYSTEM SHALL BE INSPECl~D BY A
LIC~SED ELECTRICIAN 'IO INSURE THAT THE ELECTRICAL
INSTAT,TATION IS IN ACOORDANCE WITH APPLICABLE CDDES
AND R~G~TIONS.
1200 West 33r(I Auenue, Suite B · Anchoraqe. Alaska 99503.(907) 561-50z10
3.0 SRRPAGE BED
3.1 THE GRAVEL FOR THE BED SHALL BE SC_mW.~NED TO THE SIZES
INDICATED.
3.2 THE SAND SHALL HAVE AN EFFECTIVE SIZE OF 0.4 TO 0.6 MM
AND A UNIFORMITY GOEFFICISlgT OF NOT MORE THAN 4.
3.3 THE BERM AROUND THE SRRPAGE ~ SHALL BE CONSTRUCTED OF
IMPf~RMEABLE MATERIAL, AND ON A SLOPE OF 1 FOOT VERTICAL
PER 3 FfX)T HORIZONTAL.
3.4 THE BOTIDM OF %~HE EXCAVATION SHALL BE RAKED WITH THE
BACKHOE BIADE TO INSURE ~T THE BfYI'IOM HAS NOT BEEN
COMPACTED DURING EXCAVATION. ~HE ~ ELEVATION SHALL
BE PLUS OR MINUS 2".
3.5 TWO OBSERVATION PIPES SHALL BE PLACED AS SHOWN IN THE
DRAWINGS. THEY SHALL BE RIGID PVC, AS~M 3033 D-3034.
THE SECTION SHGNN WITH MOLES MAY BE EITHER DRILLED 0.5"
HOLES @ 6 INCH C~gTERS ON OPPOSITE SIDES OF THE PIPE
OR A SECTION OF PERFORATED Sf~TER PIPE MAY BE CLAMPED
TO THE SOLID SECTION WITH A NO HUB COUPLING OR
SOLVENT JOINT. A RUBBER RAIN-CAP (JIMCAP OR ~QUAL)
SHALL BE PLACED ON THE TOP OF THE PIPE.
3.6 THE INSULATION REQUIRED SHALL BE DOW EXTRUDED
BLUE STYROFOAM INSULATION BOARD OF THE THICKNESS
SHOWN ON THE DRAWINGS.
3.7 THE TOP AND SIDES OF %lie BED SHALL BE PLANTED WITH A
WHITE CLOVER AND RED FESCUE MIX.
~UNICIPALITY OF ANCHORAGE .
DEPARTMENT OF HEALTH AND ENVIRONMENTAl PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
Ltr' 5(P~ L5 LUb
PERCOLATION
TEST
PERFORMED FOR:
r
.,'/ ~Z~
,. ~/, ~ ~ D~,TE PERFORMED:
/
LEGAL DESCRIPTION:
1
2
5 ME ~AUL',?
6
7-2-?'9'
lO
11
12
13
14
i5
16
17
18
19
20
COMMENTS
~ ,Ir.
PERFORMED BY:
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net ~.
Reading Date Time Time Water Drop
/ 7-2-~? //;/7 /0 ,~/t
(minutes/inch)
"~ PERCOLA'~ON RATE
, TEST, RUN BE'I~/EEF¢ ~ ,0
· eA. gq' ff
CERTIFIED BY:
t
DATE:
72-008 (6/79)
ALASKA ENVIRONMENTAL
CONTROL SERVIC , INC.
12OO West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 561-5040
SHEET NO.
CALCULATED BY
CHECKED BY
SCALE /" = 30 '
OF
DATE .
DATE
ALASKA ENVIRONMENTAL
CONTROL SERVIC , INC.
1200 West 33rd Avenue. Suite B
ANCHORAGE, ALASKA 99503
PhOne 561-50¢0
JOB
SHEET NO.
CALCULATED BY
CHECKED BY
SCALE / ~ /
DATE ,
ALASKA ENVIRON'ENTAL
CONTROL SERVI( ,, INC.
12oo West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 561-5040
JOB ,~)~"~ ~ ~ ~¢/~ / ~ ~
SHEET NO. OF
CALCULATED BY '"~""'""'"'7 DATE
CHECKED BY DATE
1'5
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ALASKA ENVIRO' ENTAL
CONTROL SERVK,=S, INC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 276-1361
JOB
SHEET-NO.
CALCULATED BY
CHECKED BY
o~
DATE
DATE
BHEET NO.
CALCULA~D BY ,
CHECKED BY
OF
DATE . ,
DATE
· PE, o~ FLE,~ AIL%
·Cac. MDu~.e ~40
'r
~i" 303H
1~3'~cb
liFT 5TA T,.T. O/V
,NOTE5:
EH%~P,,iE LId~ F~O~ ~.'3:FT 5TAT/O~J
.5' Tfl'T B~.LOU.) G.~,O~X~O LE~J~:L !
~ T. LE,~ST ? ........
ALASKA ENVIRONMENTAL
CONTROL SERVIC , INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
CHECKED BY
DATE
GRL ANCHORAGE AREA B0L 'H
Depsrtment of Environmental O. uality
3330 13 Street
Anchorsge, Alaska ggs03
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
MAILING ADDRESS
LEGAL DESCR,PT,ON
PHONE
13
SEPTIC TANK:
DISTANCE
FROM WELL ~'2-0~
MANUFACTURER MATERIAL
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY/~0~) GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES
ABSORPTION AREA
FOUNDATION (.0 ~ ~ / TOTAL LENGTH
_NEAREST LOT LINE ,,~-I OF LINES
DISTANCE BETWEEN LINES ~
(.~O g SQ. FT. LENGTH OF EACH LINE (Z23'
DEPTH OF FILTER
DEPTH:
TRENCH WIDTH~¢O IN. TOTAL EFFECTIVE
TOP OF TILE TO FINISH GRADE LC ! MATERIAL BENEATH TILE__ g ~ ..lllll. ABOVE TILE
WELL:
TYPE_.<t'~4;-,¢¢ ¢/;¢ CONSTRUCTION__ ~f-/p/~O L) ~ ~ DEPTH
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION__, LOT LINE__ SEWER LINE.__, TANK , SYSTEM ('~O ~'-'c--
CESSPOOL
, OTHER SOURCES
APPROVED __ DISAPPROVED REMARKS
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE: ~ ~.
REMARKS:
Form EQ-032
G.A.A.B.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES H
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date ~"~'~'-°~r~
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a)
(b)
Legal Description (include lot, block, subdivision, section, township, range)
Location ( aj;I.,til r¢~ ~r~d,~./ect i o n s )
Pr~ .... ~, ~ ~~. ,Telephone'. Home
Business
(c) Lending Institution ~~ ~"
~ .... ., ~.~ ~,.-~",~'~'~'""~' ~ ~ ~" ~ . Telephone
~'ailin'~d~¢' :' ,,~'-~.,3 ~_~
(d) Real Estate .Company ~n~Agent~~f~ ~
Address ...... ~/~ Y~~ ~~
Telephone ~' /~17 J
(e) Mail the HAA to the followina address: or: Check her6:~J~, if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family ~ .
Number of Bedrooms
WATER SUPPLY
Individual Well D Community'S' Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
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 8/86~ Front
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.g
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
NJUNICIPALITY OF ANCtt,..,,.;~.'~.G'-~ 264-4720
ENVIRONMENTAL SERVICES
Legal Description:
AUG 2 6 ]988
V E D Approve~N)
Well Classification If A, B, C, D.E.C.
~(~og Present (Y/N) Date Completed Yield
Total'[~____ Cased to __ Depth of Grouting __
Static Water ~ ..... Pump Set At
Casing Height Above, GI'~_____ Sanitary Seal on Casing (Y/N)
El~ing in Conduit (Y/Iq~,,,.,~ Depression Around Wellhead (Y/N)
Separation Distances fro?. ,,W_.e,l.l:,
To Septic/Holding Tank ~i~.ot' ' ~,~ ; On Adjoining Lots __
To Nearest Edge of Absorption'Field on Lot ____ ;~ing Lots __
T~~ ___To Nearest Pubh-'~er
Cleanout/Manhole ~ - _ To Nearest Sewer Service~ot
Water Sample Collecte'd"by ~ .' ; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed / "~'~'~' ? Size
Standpipes~}q)
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~'"
To Property Line /O
To Water Main/Service Line ,/~
Course /~Z~
Comments
Air-tight Caps~N)
No. of Compartments
Foundation Cleanou~l)
Date Last Pumped ~"'/~'~'~' /~'~l~'
.,or
Temporary Holding Tank Permit (Y/N)
To Building Foundation /'~
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /¢~' Type of System Design
Date Installed ~-~'-~'/ Length of Field 4~'-~'¢
Width of Field ~.O" ~ ~,~' Depth of Field /,~ '
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Tes~
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
·
Lot /0
To Water Main/Service Line //' ~'~ .~/ ~t
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Gravel Bed Thickness ¢' -~
Standpipes Present~/N)
Date of Last Adequacy Test
To Property Line
/0
To Existing or Abandoned System on
· On Adjoining Lots /~ ''~
To Cutbank (if present) ~'~/)¢
Comments
D. LIFT STATION
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
(Y/N)
Pumping
luring Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav~ec~,.ve~r conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'~'--'~ ~~ Date ~'%~'~
Company ~"~ ~ MOA NO.
Amount:
Page 2 of 2
72-026 (11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET. SUITE 1334
ANCHORAGE. ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: August 25, 1988
PWSID: 210786
To Whom It May Concern:
According to the records on ?ile in this
OMEGA Water System is in compliance with
Drinking Water Regulations.
office, the 80REALIS
the State of Alaska
Please note that departmental records indicate thai 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.
t? you have any questions, please contact me
Western District o??ice.
at the Anchorage/-
MPL:pkk
Sincerely,
Michael P. Lewis, PE
Environmental Engineer
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
Application Date
Legal Description (include lot, block, subdivision, section, township, range)
Location' (address or directions)
(b) Applicant Name , 7~%~r',~' ~/~,/K. Telephone: Home
'~ic) Applicant is (check One): Lending Institution []; Owner/builder~J~; Buyer []; Other [] (explain);
(d) Lending Institution,
Address ~,r/~
(e) Real Estate Company and Agent ~--~/L//~X
Address Z(¢co g~,~- ~'~ly~" /~
Telephone
,2- 7&--2~T& /
Telephone ~///~/
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~l~ Multi-Family []
Number of Bedrooms
Other
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.
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 (11/84)
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 Firm //'~-C Telephone
Address
Date
, ',, ~ ~' i '4: bedrooms by
Approved for
Approved '~ f" Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ,&~7'~/'~
Well Classification ~e/~/f#~J'/~"/ If A, B, C, D.E.C. Approved~)N) .-~-~
We~resent (Y/N) Date Completed Yield
Total Dep~ Cased to __~ Depth of Grouting __
Stat~ ~t~ L~ ..... Pump Set At __
Casi~ H~ht Able ~ .... Sanitary Seal on Casing (Y/N)
Electrical Wiring in C~duit (~ / Depression Around Wellhead (Y/N)
Separation Distances from Welt: ~~
To ~pti~H~di~ ~nk ~ ~t ~ ; On Adjoining Lots __
To Nearest Edge of Absorption Field on Lot ~Adjoining Lots ~
To N~r~t Public Sewer Li~ __ To Neares~c Sewer
o.
~:~r~C~t~by ;D~e ~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed /"~'~ ~/ Size
Standpipes ~}q)
Depression over Tank (Y~
Pumping/Maintenance Contract or~ File (Y/N)
Holding Tank High-Water Alarm (Y/N) ,~)/,/~
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line ,/~/
/
To Water Main/Service Line
Course ,/~
Air-tight Caps(~N)
No. of Compartments
Foundation Cleanou~'~)
Date Last Pumped
'for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Yi~I'I~
Results of Last Adequacy~Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation -.-~'
Lot ,/~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course -
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field , v'/7' ~
De pth of Field /'~' /
~.o
/Gravel Bed Thickness ~"
/-~ ~[~ Standpipes Present~)N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
!
/~-~ ~,-
/o/
Comments
D. LIFT STATION
Date
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)
g Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
Icertifythatlhav he ed, v rified, orconformedtoallMOA~ndHAAguidelinesineffectonthedateofthisinspection.
Signed ~,~e~ Date
Company ,/~' M..~A No. ~,
Receipt No. /0 O / O (~
Date of Payment /l//13~/~'~
Amount: $
Page 2 of 2
.
~ ~ ~OY C REID,
72-026 (11/84)
BILL SHEFFIELD, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
Telephone: (907)
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
274-~533
pws I.D.~ '~/ c2 "?d~¢
To Whom it May Concern:
According to records on file in this
~'~'/~ Water System is
Water Regulations
office the /~%/{$ O*~q
in compliance with the State Drinking
Sincerely,
, . DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME ~
DATE DATE DATE
rNSPECTOR,:... 'NSPECTOR ,NSPECTO
:,'~ ,~ I
MUNICIPALITY OF ANCHORAGE MUNIClPALI~ OF ANCHO~GE
DEPT, OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~viRONMENTAL PROTE~ION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION MAR 3 1981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDU E
DIRECTIONS: Complete all parts'on page 1. Incomplete reques~ will not be proce~ed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
MAILING ADDRESS ~ ~~ .~ ' '
PROPERTY RESIDENT (If different ~rom above) ~HONE
MAILING ADD~S
MA~ING A6DRESS ' ~ . ~
15.' L E~GA L~D ESCR I PT~;tI~
STREET LOCATION
6. TYPE E NUMBER OF~BEDROO~S
[cd' SINGLE FAMILY [] One ~
[] MULTIPLE FAMILY
7, WATER SUPPLY
JcNDIVI DUAL*
OMMUNITY
[] PUBLIC UTI LITY
Four
[] Two [] Five
[] Three [] Six
[] Other
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~l N DIVI DUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON -SITE
I-]PUBLIC UTILITY
Connection Verified
~-~Septic Tank or [] Holding Tank
Size: \~d"~. If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OF BEDROOMS
[] ONE
[] TWO
[] THREE [] FIVE
[] FOUR [] SlX
OTHER
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
MANUFACTURER
MATERIAL
Septic/Holding Tank lAbsorption Area
I
5. COMMENTS
DATE
[~PROV ED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
ALASKA P iUIROFImeFITAL COF/TROL Sel dlCe$, IFIC.
~nqineerinq $ (!nuironmentol Studies
TERRIE PISA
REMAX REALTY
2600 CORDOVA SUITE 100
ANCHORAGE ALASKA 99503
SELLER--
11/18/86
TERRIE PISA
REMAX REALTY
2600 CORDOVA SUITE 100
ANCHORAGE ALASKA 99503
60574
LEGAL:BOREALIS SUBDIVISION BLOCK 1 I,OT 13
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST DATE-10/20/86
THE TYPE OF ABSORPTION SYSTEM IS A BED WITH AN AREA OF 1350 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 847 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
4 BEDROOM HOME.
SEPTIC TANK ADEQUACY
TIlE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR
THIS 4 BEDROOM HOUSE.
THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 11/4/86
THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER
SUPPLY OR WASTEWATER SYSTEM.
1200 LUest 33rct Ptuenue, Suite [~ * Anchoraqe, ,qlask~ 99503 *{907) 5614040
ALASKA eFIUIROFImI FITAL COFITROL $1 RUICI $, Il'lC.
I~nqineerinq ~ I~nuironmental Studies
MUNICIPALITY OF ANCHORAGE
DEPT, OF MEALTH &
I:NVIRONMENTAL PROTECTION
Century 21/ Tom Szymanski
207 E. Northemn Lights Bl~d.
Anchorage, Ak. 99503
March 16, 1981
MAR 1 8 1981
Seller - S. Gazowy
Subdivision - Borialis Sub. #1 Block-O Lot 13
The type of Absorption system is a drsinfield with an area
of 1008 sqft.
The system is capable of accepting 600 gallons of water per
day.
Based upon the test data the system is acceptable for a
4 bedroom home.
The septic tank was pumped on 9-4-80.
1220 LUest 25th Aucnue · Anchorage, Alaska 99503 · (907) 276-1361
Mi. LABORATORIES, INC,
712'7 OLD SEWARD HIGH' ¥
ANCHORAGE, ALASKA 99518
(907)344-1~$1
LABOR,"'rO~Y I.D.
BACTERIOLOGICAL I~TER ANALYSIS
TO BE CONPLETED BY MATER SUPPLIER
DATE COLLECTED
IMONTH DAY
.. //- I{.
l.O. NO. (PUBLIC 'SYSTEMS)
NA~E OF SYSTEM
SYSTEM ADORES5
CITY /~cl~/ STATE
COLLECTED TYPE OF SYSTEM
~'0 PUBL!C ~:] INDTVZOUAL
CTRCLE CLASS
B C Residential
TELEPHONE NUMBER
ZIP CODE
LOCATION YHERE SAMPLE MAS COLLECTED
COLLECTED BY:(SIGNATURE)
TYPE OF SAMPLE
(CHECK ONLY ONE THIS COLUlel)
~,,.DRINKING MATER
~'CHECK TREATHENT
D CHLORINATED
I~FILTEREO
C]UNTREATED OR OTHER
I~ RAN SOURCE #ATER
I~ HEM CONSTRUCTION OR REPAIRS
I'! OTHER(Specify) L
IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMING SAMPLE?
!'1 YES 'NO PREVIOUS COLLECTION DATE
ANALYSIS REQUESTED (IF OTHER THAN TOTAL COLIFORM)
SEND REPORT TO:(PRINT ~UI~L NA~E,ADDRESS AND ZiP CODE
NAME , /~~C~ -~
ADDRESS /~ l~' ~r~J~ /~ $#/~ ~
CITY .~/, STATE /~'. ZTP
BACTERIOLOGICAL llLRTER ANALYSIS RECORD
TFOR LAB USE ONLY
OTAL COLI FORMS
D FECAL COLIFORMS
--1 OTHER
FOR LAB OSE ~LY
I'1 RESUBMIT SAMPLE
Sample rejected because:
CHECK ONE OR MORE
I'1 Sample too long tn transtt.
Sample should not be over 30 hours.
i'lSample received too late tn week
C~Not tn proper container
[~]Leaked out
[-I InsuCftctent information provided.
Please read Instructions on form.
[:}Other (Specify)
DATE /'/',/~E,, m TXME ~.'~'~
AN~HOD:
~HB~NE FILTER
~ ~NTATION TUBE
Date &Ttme Started
Date &Ttme Completed
So,
LABORATORY RESULTS
~ Other Bacteria
D Test unsuitable because:
[] Confluent Growth
Hembrane Filter: Direct Count
Vertffcatlon: LTB
Ftnal Membrane Ftlter Results
Reported B~
READ SANPLE COLLECTION INSTRUCTXON$ ON BACK OF FOIOI
0
BGB
Date
Col i form/lOOml
Col i form/lOOml
Time A.M.
P.M.