HomeMy WebLinkAboutBRUIN PARK BLK 4 LT 8 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 /
MAI LING ADD'SS
LEGAL DESCRIPTION
NO. OF BfiDBOOMS~
~ Manufactu rer~p~~E ~~ P~ O~ ~ ~t ~ Mab~ C / No. of compartments
Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
OZ ~ Manufacturer ~ V [ t Material Liquid capacity in gallons
~. DISTANCE TO= Well /OO ' Foundation ~/ NearestTt~. PERMI~5~OO
~Z -- ~ ~~ ' Total ,e~,~nes Tre.c~w~h
~ No. of lines ~ ~n~h.o~each line -
Z Z'~ ~ ~ inches
Materia~eneath tile ~ r~
~ Top of tile to finish grade ~' ~tt ~e~ ~inches Totaleff o nCea
Length Width Depth PERMIT NO.
~ Typeofcrib Crib diameter Cribdepth~/ ~ Total effectiveabsorptionarea
~ Well Building ~u~ati~n ~ Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller ~nce to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line / ~ ~P~c tank Absorption area(s)
OTHER
PIPE MATERIALS
sOIL TEST RATING
REMARKS
PERMIT NO.
DEP~RTMENT [ HEHLTH HND ENVIRONNENTHL )TECTION
825 "L" STREET, ANCHORAGE,
264-4?20
C,[-~--SITE SEI~EF: lJ F"m] F:RD, E F'EF2~'I IT
( 8S0400 )
APPLICANT
LOCATION
LEGAL
RUBY JONES X LOW HAGBER
FORREST DR.
L 8 B 4 BRUIN PARK
727 N. ST.
LOT SIZE
278-4004
i8000 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MANIMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT/BR)= 242
THE REQUIRED SIZE OF THE SOIL ABSORPTION SgSTEM IS:
[:,EF'TH= "i ]: LE[4"STH= L~± ISFIR%-'EL [:,EF'TH= 4
THE LENGTH [:,I NSION lbs THE LENGT (IN FEET::, OF THE TRENC:H OR [',RAIN... . · .ELI:,.
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 HIDTH FOR TRENCHES.
THE GRAVEL DEF'TH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
PERMIT AF'PLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY HELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE HELL. WILL SERVE.
TL-~C, (2) [ ~-ISF'ECTIEI[-IS RF:E ~:En;!IJ Z D:EE:.
BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWRGE DISPOSAL SYSTEM IS
±00 FEET FOR A PRIVATE WELL OR ±50 TO 200 FEET FROM A PUBLIC: WELL DEPENDING
UPON THE TYPE OF PUBLIC HELL.
itlNIMUM DISTANCE FROM A PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIRGRRMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F" E E: i'-I I T E .'>:: F" I E.' E S E:. E C: E I'-1 E: E F-: _---:: :;L .. ::L L:-"- :E-_-: _--<
I CERTIFY THAT
±: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
]:: I UNDERSTAND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 2: BEDROOMS.
........... ¢?
s GN D' ¢
ISSUE[:' E:Y_~-~~ .... [:'RTE. ~' [~2 ~__ '~) ~-/
V4. 0
S & S
7125 Old Seward Hwy. Anchorage, Alaska 349- 6561
SOILS LOG
!~ERCOLATION
TESq'
SOILS LOG - PERCOLATION TEST
SI .hPE SITE PI_,~,N
14-u
15-
WAS G,u.()~AND V'~'A, TI !:
ENCO~!NI' E P, E
DEp'I HTM
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOl LS LOG
PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:
LEGAL DESCRIPTION:
SLOPE
FAn~. sT 8~.- 0~.~
SITE PLAN
WAS GROUND WATER
·. · ENCOUNTERED?
IF YES, AT WHAT
~ ~*~*~ ~ DEPT~
15 '
16 * _~.~__~
lg - , 225 I.E
,I~/C ~-5° ~o°
COMMENTS ~;t
PERFORMED BY:
72-008 (6/79)
Gross Net Depth to Net
Reading Date Time ~'ime Water Drop
5-1 i.~ "~: ?..S ~ .8o --
'~: 5'?' 2-cl - ~-o . ~o
~:_s~ - .q~ --
PERCOLATION RATE '~ ~
TEST RUN BETWEEN 8'/2 FT AND
-lest. ..rr r 8"z'
(minutes/inch)
o~ FT
CERTIFIED BY:
DATE:
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 .~=,'~ i.S
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
~-' l-~ot~'~ DATE PERFORMED: '~'/J'~/~ 3
SLOPE SITE PLAN
WAS GROUND WATER .S
ENCOUNTERED? ~ ~
E
IF YES, AT WHAT
DEPTH?
Gross Net D&pth to Net
Reading Date Time Time Water Drop
;5:57 ~o .'l& .o'F,
~'. 5 (o ~_ct . fl~5 . oo
PERCOLATION RATE ~ (minutes/inch)
TEST RUN BETWEEN ~ FT AND ;,~ '/,2.. FT
PERFORMED BY:
CERTIFIED BY:
DATE:
72-008 1'6/79)
ALASKA eI1UIRO[lmeI1TAL CO[1TROL SeRUICeS, IBC.
~nqineerinq &- environmental Studies
January 28, 1986
MUNICIPALITY OF ANCHORAGE
Department of Health &
Human Social Services
825 L Street
Anchorage, Alaska 99501
Attention: Steve Morris
Dear Steve:
The above referenced lot consists of a one bedroom single family
residence with an individual well and on-site sewage disposal system.
There is no well log available for this lot. The drilling date is
unknown, however, the well was present when the sewer system was
installed in the fall of 1963. The attached well driller report,
dated January 25, 1986 estimates the well depth to be 38 feet to 45
feet and cased to the bottom. The sewer system consists of a crib of
unknown area. Material used were 2 each - 600 gallon perforated
concrete rings. An adequacy test performed on January 24, 1986 shows
the system to be more than adequate. The septic tank is made of 2
each - 600 gallon concrete rings. The attached letter from Dennis Roe
shows that there is a bottom to this tank. We were not able to verify
if the tank has any baffles. From the age of the system and the
adequacy test results, it appears the tank is functioning properly.
The separation distance from the septic tank to the subject well is 53
feet and to the neighbors well to the north, approximately 71 feet.
Back in 1963, the required separation distance from a private well to
septic tank was only 50 feet. This rule did not change until October
1973. Attached is a letter dated April 18, 1975 from DEQ approving
the sewer system and well. A satisfactory water sample was taken
January 24, 1986.
From this information, we request that you approve the sewer and water
system with their existing separation distance and apparent casing
depth.
Sincerely,
Alan~/Wien
1200 U]est 33rd Avenue, Suite [~ ~, Anchoraqe, Alaska 99503 ,(907) 561-50/-10
GRE
ER ANCHORAGE AREA MOl' 'UGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
,INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
~//~ ~
LOCATION~_f)/~¢ 7~ ;/__~//~ f~/~
SEPTIC TANK:
DISTANCE ?F / .-
FROM WELL MANUFACTURER C_'~ T/it (~ ~C_ MATERIAL ~ "~- NUMBER OF
COMPARTMENTS
INSIDE LENGTH '---- INSIDE WIDTH -'--- LIQUID DEPTH -- LIQUID CAPACITY ! O Lr') (") GALLONS.
SEEPAGE PIT:
NUMBER OF PITS / DIAMETER ~ OR WlDTH/.~,~,
LINING MATERIAL ~ /~_~L,)G/- CRIB SIZE'.~ ~(/'~'AMETER
BUILDING FOUNDATIONal I, NEAREST LOT LINE Z0 I...¥.
ADDITIONAL ABSORPTION
/LENGTH 2~, /
DEPTH //
DEPTH ~/ j
DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) ~ ~i
SQ. FT.
WELL:
BUILDING / NEAREST/O / NEAREST
FOUNDATION /C~ LOT LINE SEWER LINE
DISTANCE FROM:
SEPTIC 60 [~-, SEEPAGE
TANK SYSTEM
CESSPOOL ., OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED
LOT SLOPE:
REMARKS:
Form No. EQ~031
DIAGRAM OF SYSTEM
GREATer ANCHOrAgE ArEa BOrOUgh
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C"STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-456 !
SEWAGE DISPOSAL SYSTEM · APPLICATION AND PERMIT
PERMIT NO,
PHONE
INSTALLATION Of: SEPTIC TANK SEEPAGE PIT DRAIN FIELD OTHER
SOIL TEST RESULTS r~ ~ O ~ ' ~/ ~'~-'d ~~NOTE: THIS PERMIT IS NOT VALID WITHOUT SOIL TEST
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~ /~
FOUNDatiON TO SEEPAGE Pit '----~ DRAIN field
SEPTIC TANK TO SEEPAGE PIt WALL
SEPTIC TANK ~'/' SEEPAGE Pit
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK L~u
DRAIN FIELD
WATER MAIN TO SEPTIC TANK .~ ~J DRAIN FIELD
SEPTIC TANK,~ . SEEPAGE PIt .///K , DRAIN FIELD
TO RIVER, LAKE, STREAM.
, DRAIN FIELD
SEEPAGE PiT /~ ~J /
ALSO CONSIDER AREA WELLS.
SEEPAge Pit /~ /'
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING gAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST iRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTight REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
G oA ,A ,B.
OR
LICENSED DESIGNER
OF SYSTEM
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAID CODE. y~~
FORM NO. EQ-0$ 6
GREATER ANCHORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street
ANCHORAGE, ALASKA 99503
Case #
Performed For ~ ~<>S~wo~.. Da ted Performed
Legal Description: Lot ~-- Block . ~/ Subdivision
This Form Reports Soils Log ~ Percolation Test
- Soil Test Must Be Logged To 4' Below Proposed Seepage System -
Soil Characteristics
Depth
Feet
3a
6a
8m
lOm
13--
14--
Was Ground Water Encountered?
If Yes, At What Depth?
Reading Date Gross Time Net Time Depth to H20 Net Drc
Percolation Rate Minute
Proposed Installation: Seepage Pit Drain Field
Depth of Inlet Depth to Bottom of Pit Or Trench
COMMENTS:
Test Performed BY 4~,~,.~. ~ ~
Date Certified BY:
Date:
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E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well on lot)
Septic Tank/Lift Station on Lot > 100'A Community Sewer Manhole/Cleanout > 100'
Yes if No *��+ C
ft ❑E Yes if No ft
Neighboring Tank > 100' 0 Yes if No ft Private Sewer/Septic Line > 25' Q Yes if No ft
Absorption Field on Lot > 100' E Yes if No ft Holding Tank > 100' W Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment > 50' ❑■ Yes if No ft
ro Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' QQ Yes if No ft Q 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'
F■ Yes
if No
ft
Surface Water > 100'
W Yes if No ft
Tank to Property Line > 5'
M Yes
if No
ft
Wells on Adjacent Lots:
Field to Property Line > 10'
❑ Yes
if No
**51+ ft
Private Wells > 100'
❑ Yes if No *80'+ ft
Water Main > 10'
0 Yes
if No
ft
Community Wells > 200'
Q Yes if No ft
Water Service Line > 10'
FEI Yes
if No
ft
If tank or field is under driveway comment below
F. ENGINEER'S COMMENTS
*80' WAIVER FROM TANK TO WELL ON PROPERTY AND TO WELL ON BLOCK 4, LOT 7 (WR070017)
**REQUESTING LOT LINE WAIVER. FCO IS NOT SHOWN ON AS -BUILT SURVEY BUT IS PRESENT IN FIELD.
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 Gamess Engineerinq Group, LTD. (GEG) Phone
Engineer's Printed Name Jeffrey A. Gamess Date _
In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in
accordance with the guidelines and regulations established by the Municipality of Anchorage and industry
practices. The reported results describe the condition of the system/s on the date/s of the evaluation.
Separation distances were measured to readily identifiable features. Hidden defects or encroachments may
exist that were not identified during the evaluation. The operational life of all wells and septic systems depend
upon a variety of variables, including (but not limited to) soil conditions, groundwater levels (that may fluctuate
during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing
the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not
guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding
the future performance of the well or septic system. GEG makes no representation whether an alternative well
or septic system can be installed on the property in the event either of the current systems fail to perform
adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG
to perform the evaluation. Reliance upon the information provided in this report by any other person or party
(including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever.
COSA Checklist June 2022
907-337-6179
V, eff ey •.•••.•ness.
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June 19, 2024
Municipality of Anchorage
Development Service Department
On -Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
Ref: Lot Line Waiver Request for Bruin Park; Block 4, Lot 8
To whom it may concern:
Based upon the recent as -built survey, the closest existing drainfield standpipe is
approximately 9 feet from the north lot line. To account for the trench width (6 feet), we
are requesting a 5 -foot lot line waiver from the drainfield to north lot line that is shared
with Lot 7. The septic system for Lot 7 is 10+ feet from this shared lot line. We are unaware
of any adverse impact associated with this encroachment. If you have any questions,
please contact us at 337-6179. Thank you for your assistance.
A.0amess, P. E., M. S.
ident
3701 East Tudor Road, Suite 101 * Anchorage, Alaska 99507-1259
Phone: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com
— — FOREST DRIVE— — —
� - o
co
Cl) N 3803'00" E 100.00, _ REBAR
X� �ENCE WELL (W
ASPHALT�
DRIVEWAY I
48.0'
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18.1'
HOUSE
w
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Z I - o DECK
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0 1g7'
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LOT 9 C I SEPTIC
G STANDPIPES
N `l
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CD x
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LOT 8
20,000 Sq. ft.
l-
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LOT 7
I �E� UTILITY
PEDESTAL
_S3_ 8°0300" W 100-00'`�OF
ALLEY C11
-:49TH;
------ ,
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.. ......,
• Bu u Sahz : �o
0 15' 30' // s LS -14837 � =
• 5 -
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE
RECORDED SUBDIVISION PLAT (P -222B) ARE NOT SHOWN HEREON.
THIS DOCUMENT DOES NOT CONSTITUTE BOUNDARY SURVEYAND
IS SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT
BOUNDARY SURVEY MAY DISCLOSE.
UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE
USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR
ESTABLISHING PROPERTY BOUNDARIES.
THIS SURVEY REPRESENTS A MORTGAGE LOCATION SURVEY
PREPARED IN ACCORDANCE WITH THE ASPLS MORTGAGE LOCATION
SURVEY STANDARDS.
THIS MORTGAGE LOCATION SURVEY SHOULD ONLY BE USED FOR A SINGLE PROPERTY
TRANSACTION. RE -USE OF THIS DRAWING BY THE ORIGINAL CLIENT OR BY OTHERS, FOR
ADDITIONAL USES ATA LATER DATE WITHOUT EXPRESS CONSENT OF THE SURVEYOR ISA
VIOLATION OF FEDERAL COPYRIGHT LAW. UNLESS GROSS NEGLIGENCE IS DISCOVERED,
THE LIABILITY EXTENT OF THE PREPARER SHALL BE LIMITED TO THE AMOUNT OF FEES
COLLECTED FOR SERVICES IN PREPARATION OF THIS PRODUCT.
JOB # 24101 I NO CORNERS SET THIS DATE I SCALE 1" = 30'
AS -BUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
LOT 8, BLOCK 4, BRUIN PARK SUBDIVISION
ANCHORAGE RECORDING DISTRICT, ALASKAAND THAT
THE VISIBLE IMPROVEMENTS SITUATED THEREON ARE
WITHIN THE PROPERTY LINES AND NO VISIBLE
ENCROACHMENTS EXIST EXCEPTAS INDICATED.
DATED THIS 12th DAY OF JUNE, 2024, AT ANCHORAGE,
ALASKA.
FIXED HEIGHT, LLC C.O.A.122554
Land Surveying Services 907.290.8949
225 VV 23rd Ave., Anchorage, AK 99503 WWW.FIXEDHEIGHTCOM
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 10t, block, subdivision, section, township, range)
','. ", ' ;I" '..
Location (address.or dtrect~ons)''. ~.:.-,'.
(b) Property owner AI~.~-:.~--- · Telephone (home)
Mailing Address "
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
Telephone ~4~ ? -- .3' y' Y' ~ '~'~/¢ -~
(e) Mail the HAA to the following address: (or check here/,~if hold for pick up.)
List contact person and day phone number below:
z.,,-,//
!
2. TYPE OF RESIDENCE
Single-Family [3~',~.. 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 th legality and status.
4. SEWAGE DISPOSAL
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
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,
functiona .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 .,~¢'~'J' ~ Telephone
Address _~ ,4J~,"~ _.~.~'~ ~6~' / ,~'~,,~ ,,~- ~¢j%,z~
Date ///¢ 2/~'?'
DHHS APPROVAL
A~ppr~'ved for _'~-¢ bedrooms by
A:p'proved ~ Disapproved
Terms of Conditional Approval
Conditional
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 Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
~ MUNICIPALITY OF ANCHORAGE (MOA)
(~'J~lf~,l Health Authority Approval (HAA)
~ ~.;,,,-.i~D ,~CHECKLIST- FEBRUARY 1984
.... · , ~r ':o Di',/t.SlObl~
Well ClaSsification .
343-4744
Legal Description:/-
If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/~
Total Depth /,J'Of/Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit i~N)
SEPARATION DISTANCES FROM WELL:
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
Date Completed U,~..,~,., ~. '~_~,/:,,,,/~..e Yield Depth of Grouting ~',~
Pump Set At
/
Sanitary Seal on Casing~)/N)
Depression Around Wellhead (Y~
; On Adjoining Lots
/00~ / ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date /Z///,'/~' ~
B. SEPTIC/HOLDING TANK DATA
Date Installed ~//7-./ Size
StandpiPes {~N)
Depression over Tank (Y{~)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High.Water Alarm (Y/N) ,'~/,,,9- Temporary Holding Tank Permit (Y/N)
SEPARATION D!STAN~,~;.~ROM SEPTIC/HOLDING TANK:
:t ~ ',~ ~.~, ~- To Building Foundation
To Water-Supp!¥~e!l .,~ % ~_' /
/O~ID No. of Compartments ,~
Air-tight Caps ~N) Foundation Cleanout (Y~)
Date Last Pumped ~-//~'~/~'~' .Z'~.ac---x.
;for /'/'/','~
To Disposal Field
/
Course ,,~/~ 0
To Property Line-'
To Water ~ervice~L1ne~
To Stream, Pond, Lake.,or'~[~ Drainage
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~r~/,,~ 3'
Width of Field ,?~ '~
/,cb
Square Feet of Absortion Area
Depression over Field (Y/~
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
Type of System Design
Length of Field /~ z~Z ! /
Depth of Field ~ /
Gravel Bed Thickness ~' ~
Statndpipes Present (~N)
Date of Last Adequacy Test .~,/"2/~'
To Property Line /~ /
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Par.king Area, or Vehicle Storage Area /O
Comments
,...
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for ~
Meets MOA Ele~odes (Y/N)
Com~
Dimensions
Man~Y/N)
..---"~'Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines
inspection.
Signed ~----~~~P
CompanYDate /t / a ~/!- ~Y~ ..c'..~__
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
in ef!ve~c~ on the date of this
~ ~ ~eeeeeee ~ ~
- sea,
CE-2251 .' ~Sr
....'
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
~-~ \ [~ -' \ CJ~-'~ v ~) \ HAA# ~'~ ~, ~C)t
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 ~.//,/,/~, C.
Mailing Address
Telephone'(home)
Business
(c) Lending Institution
Mailing Address
Telephone
(d) Real Estate Company and Agent
Address
Telephone '~ ) 3~['1"C"¢~03
(e) Mail the HAA to the following address: (or check here [~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ 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 th legality and status.
4. SEWAGE DISPOSAL
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 legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION-4
As certified by my seal affixed ~ereto 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 obtai~ned 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.
NameofFirm /~,~,C,,.~. Telephone ~-)~) ~ ~? -'-~"~'-~'~
AddreSs /L¢/~ Clx1 .~.¢~j~, /CftC. //<.
6. DHHS APPROVAL
Approved for 3 bedrooms by
Approved ~'~ Disapproved
Terms of Conditional Approval
Conditional
Date 2 - /~ - ~' 7
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 Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
?2-025 (Rev. 7/88) Back Page 2 of 2
:~ A. WELLI~.ATA
Well ClassifiCatiOn
MUNICIPALITY OF ANCHORAGE (MOA) ~
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~[~'~-, ~'l ~-~0'/- ~
IIl ,! "[-_
Well Log Present (Y,~/) Date Completed
Total Depth.;~l~Bjc_~ased~..,t=jcf¢~..., to ~'~ ~f''
Static Water Level. "~ A
Casing Height Above Ground I '
Electrical Wiring in Conduit ~,)N)
SEPARATION DISTANCES FROM WELL:
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 09'-'
Water Sample Testiesults ['~O'~_.~"fo~ ,(~
Comments A)~¢/-z- ~-~'~J '"/--~'"T"
Sec.
If A, B, C, D.E.C. Approved (Y/N) ~
~.~.~.¢tDU¢^ i~P~-~'°~?3 Yield ~,~ ~. ~¢ ~",
Depth of Grouting U~
Pump Set At ~
Sanitary Seal on Casing ~N)
Depression Around Wellhead (Y~
To Nearest Public Sewer Cleanout/Manhole
; Date O ~ - (~ 6 - ~'Ct'
; On Adjoining Lots '-~-'"<~ ''~
;On Adjoining Lots /(--) ~ ''/-
SEPTIC/HOLDING TANK DATA
Date Installed ~ - ~-~ Size/~O~) ~:/~/-.No. of Compartments
Standpipes (~N) Air-tight Caps {~N)
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High:~ater A!a..rm"(Y/N)
SEPARATION DI~i.ICANCE,~.:: FROM sEPTIc/HOLDING TANK:
To Water-Supply'Wel.l? .;i'i~.~:~ '/- ' ' To Building Foundation
.',+.
To Property Line ,/,~ .... ~. To Disposal Field
To Water Main/Ser~ be Line
To Stream, Pond, Lake or MajOr Drainage Course /(~(~
Foundation Cleanout (y~l
Date Last Pumped ,~-- ~-~/~ /P"~'~
;for ..
Temporary Holding Tank Permit (Y/N)
Comments
72-026 (Rev. 7/88} Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed C~"- ~..~
Width of Field ?~ ,~
/5-O
Square Feet of Absortion Area
Depression over Field (Ye
Results of Last Adequacy Test^ '
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well /~(2 /
To Building Foundation L~/~? /
Lot L,~k~m~_/t~
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
Depth of Field ~/ ' /
Gravel Bed Thickness L./ '
Statndpipes Present ~N)
Date of Last Adequacy Test
To Property Line /(_.2 t
To Existing or Abandoned System on
; On Adjoining Lots r~,~_.p ' ~--
To Cutback (if present)
Comments
STATION
~'LIFDa~i nstalled
Size in G'afl~..~ _
"Pump On" Level
High Water Alarm Level at-"""-~
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Receipt No
Date of PaYment
Amount: $
72-026 (Rev. 7/88) Back
~[~i,~_ ~. ' ~ ~e f f e c t
.¢~ ~
Receipt No.
Engineer's Seal
Waiver Fee: $
Date of Payment
Page 2 of 2
Date ~-//~-/~
MOA No. 02t't
Tested for Pumping Cycles during Adequacy Test.
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request**,
I certify that I have checked, verified, or conformed to all MOA and HAA on the date of this
inspection(/~.,, ~.,~
Signed
Company t~ , ~' , C.., ,
APPLIC FILLS OUT UPPER HAL ONLY
Property Owner "~k_,...~-')L,,~ ."~(~("Y~'"~ Phone
Mailing Address ~ ~ -~ , ~~L ~ ~ ~.~,, ~._ Zip Code
Buyer
Address Zip C~de
Lending Institution ... P~ne~
Address Zip Code
Legal Description L~ ~ %~ ~ ~W '~ ~ ~% , :'
Street Locati~ ~ ~ ~ ~ ~1~ ~.~ ~ ~
Ty~of Resi~nce
~Single Family .~? ~.~ ~'
~ Multiple Family No. of Bedrooms ~ ?
~ Other
W~r Supply
~ Individual A~ACH WELL LOG. A w~l Icg ~is requi~ed for all wells drilled since June 1975.
~ Community For wells drilled prior to that dat~. give well depth (attach Icg if available).
~ Public Utility
Se~er Disposal
Individual Year Individual Installed:
~- Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
DEPT. OF H~/',LTH e:
~ .. ENV~RONMDxII'AL PROTECTION
RECEIVED
(3 ) APPROVED BEDROOM8 *CONDITION8 OF APPROVAL
( ) DISAPPROVED
( ) CON DITIONAL ~PPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
~ ~ ~ .. Well to Tank Septic Tank Size / (~)d..J O
72-023 (3182)