HomeMy WebLinkAboutBIRCH ROAD ESTATES LT 3
.. Municipality of Anchorage Page ! of --~
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: ,~ ~' (~/--~'-~"~/ PID Number:~/~
Name: ~ ~ ~'5 ~ S ~ ~ ~ Wastewater System: ~ew ~ Upgrade
Address:
~.o. ~ 77/~ ABSORPTION FIELD
Phone: ~ ~_ ~ ~/ IN°'°fb~°°ms: ~Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION ~o~,..~.~: ~,~ ~,~ /o ~
Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: I.ang~: JS"c"o~: Fill added above original grade: Gravel length:
WELL: ~New D Upgrade Gravel width: Number of lines: Distance between tines:
Classification (Private, A,B,C): Total Depth: Cased to: total absorption area: Pipe material: {
Date D, illed: Static Water Level'. Installer: Date installe~: ~
Pump Set at: ~ Casing Height Above Ground:
SEPARATION DISTANCES ~..tic ~ Ho~O~ng ~
To Septic Absorption Lift Holding =ublic/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~4~ ~~ /~ __
Material: Number of Compa~nts:
Surface
Water h'O N~ LIFT STATION
Lot Size in gallons: ~ Manufacturer:
Line ~
I I
Foundation / 7 - ~ ~ "Pump on" level at: "Pump off" level at: High water alarm
CurtainDrain ~/ ~ ~ Pump Make & Model I Electrical Inspections performed by:
Remarks: BENCH MARK
Location and ~scription: ~/~
, ENG N'EE~.;SEAL
Inspections performed by: Dates: 1st 7 : ~ ~
Department of Heallth am , Services approval .'., ~:.
Reviewed and approved by: . [ ~~ Date: 0~.[t~ ':.:~;.~.- ......
72-013 (Rev. 9/91) MOA 25
p~IM~RY
+ +
+ +
FF 100.00
19Z98
N
25 0 25 50 ] "
SCAL&
bench
75 I00
=5$FF
I25 i58
TOBBEN SPURKLAND P.E.
203 W 15TH, AVENUE
ANCH, AK. 99501
LOT 3 BIRCH ROAD ESTATES
SEPTIC SYSTEM AS BUILT
DATE: JAN. 20, 1997
SHEET: 2/5 GRID: 2658
PERMIT # S ~/9602£4 PIJ9 015-4 94-03 3£EOOOS£,J9 ~/5
Moniifor
Cleon [Tut;
PRIMARY TRENCH /~ Double C/eon [}u~fs ~~~~.~
Stondord
French~
2'
~5' Lon9
~' ~eep
do,ion 8Zeon
7' Se~er rock
~ ..... ~,h,~,~,,,j
N~ SCALE
/
86.6
/
86.6
oF ~ept/c ~ock
1250 0o[, sept/c tony
6 ~ FENCH ~R~, FIN. FLOON
ASSUME~ ELE~
SPU~KL~ND P,E, LOT 3 BIRCH ROAD ESTATE ~EPTIO SYSTEM ~S ~U[LT
~h Nve
SHEET,
SULLIVAN WATER WELLS
P.O, BOX 670272, CHUGIAK, ALASKA 99567 * TELEPHONE 688.2159
ADDRESS
LEGAL DESCRII-q'ION
DA'I"E - Sl,arted
PERMH' NUMBER
3___~z~,4 £.0 E~' r.
Ended __.¢~; ~r
/
DEPTH OF ,,'EL/ m ~"-' 5
ST.\TIC LEVEL OF' x~-~TER F'f.
DRAW DOWN FT,
C;ALS, P~ .R ...... .4 Fo
//
KIND OF FORMATION:
r~o., O.__r,. to_e?_ ..... F~.___~mr,"'-~
From_e~ ,_
From ._~.__
From_({2 ._ Ft.
From.~.¢ ,Ft.
From._.~
From. ~_ Ft,
From I/~ Ft.
From~] ~Ft.
From,9~ (Fi.
Fr om ..... F t.
From Ft.
l,o_~ ....... ~t. ____Cz.O,P ce.Do ~ ,O~z") Fro,,,.. _ F~. ,o ,,
,
~o./~_ - ...... .. ' ...... .
I
From ~_~Ft, to~
to ...... Fl ..........................
to ........ Ft. From ......... Ft. to .......
MISCL INFOIhMATION:
Et¸
.. __Ft,
.Ft.
Ft.
to .......... FI.~ .......
to ..... Fl.
to Ft..
'to Ft ......
Io ..Ft.
to ..... Ft.
to Ft.
Ft.
.Fl',
~Ft
Ft.
Ft .........
RECEIVED
JUN 1 2 1997
Muruc;p~h,y oi
Dept. HeaLth & Human Services
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW960224
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:PEPPERS CONSTRUCTION
OWNER ADDRESS:P.O. BOX 771064
EAGLE RIVER, AK. 99577
PAGE 1 OF
DATE ISSUED: 7/31~'-~
EXPIRATION DATE: 7/31/97
PARCEL ID:01549403
LEGAL DESCRIPTION:
BIRCH ROAD ESTATES LT
LOT SIZE: 59347 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT:
4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 (18AACS0) .
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:
RECOMMEND ENTERING EFFLUENT LINE AT OR NEAR
THE MIDPOINT OF THE PERFORATED DISTRIBUTION
LINE TO ALLOW A MORE EVEN DISTRIBUION OF EFFLUENT
ISSUED BY: ~~/~/ V VVu%~F/'~'~
DATE:
DATE:
T SP AND
203 W 15th. Avenue, Suite 203
ANCHORAGE, ALASKA 99501
(907) 27%3916
Fax (907)-276-6013
SEPTIC SYSTEM DESIGN
LOT 3 BIRCH ROAD ESTATE
PEPPER CONSTRUCTION
Municipality of Anchorage
Department of Health and Social Services
820 1 Street
Anchorage, Alaska 99501
July 15, 1996
We are submitting an application for the installation of a well and septic system for this lot. The submittal consist of
three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the
proposed improvements of the lot, of which only the well and septic system are subject to this permit application,
(sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes
are also enclosed. The septic system design is based on the following:
No Ground Water or Impervious Layer to 16 ft.
Use Standard Trench
Soil Rating.
55 min/in = 0.45 gal per sq.fl/day
No. of Bedrooms 4
Required Area per Bedroom: 150/0.45 = 333.3 sq.ft..
Total area required: 333.3 x 4 =1333.2 sq.ft.
Testhole depth 16 feet
Bottom Rock At 10 feet
Top Rock At 3 feet
Rock Depth 7 feet
Total Trench Length 1333 / 14 = 95.2 ft.
SYSTEM CONFIGURATION
STANDARD TRENCH
TOTAL LENGTH 95 FT
TOTAL WIDTH 2 FT
TOTAL DEPTH 10 FT
ROCK DEPTH 7 FT
COVER 3 FT
SEPTIC TANK 1250 GAL.
The installation of this septic system will not prevent wells from be installed on the adjacent lots.
There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots.
The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface
runoff will not result from this installation.
PERFORMED FOR:
LEGAL DESCRIPTION:.
1
2
3
4
5
6
7
8
9
10
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19
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
COMMENTS
DATE PERFORMED~2
Township, Range, Section:
(ENGINEER S-,SE/~L)' :%
WAS GROUND WATER
ENCOUNTERED? ~.O
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water Alterr,~_~
Monitoring? ~ I/-'~ gate:
SITE PLAN
Gross Net Depth ~e =,{~ Net
Reading Date Time Time Water Drop
e.-It~~ ¥~/e/. ?lJp5 '- o.~q '
I~; o5 ~ o, ~q
PERCOLATION RATE ~',~ ~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ ET AND "~ ~ FT
/,
Pi=RFORMED BY: T~ ~' I '~'~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
DATE:
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
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7
8
9
10
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COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
'~.oAD ~$TAT E
DATE
Township, Range, Section:
WAS GROUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water After
Monitoring? Date:
Gross Net Depth ~e ~ f Net
Reading Date Time Time Water Drop
~ ~ /~ & ~ -~/~
PERCOLATION RATE /~:~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~' FT AND 6 k/''' FT
P[=RFORMED BY: ~ '~' __ I ~ ~:3 CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDA.CE W,~H ^LL STATE A.D MU.,C,PA. GU,DE',.ES,. EFFECT ON T.,S DATE. DATE: ,
72-008 (Rev. 4/85)
#4 ,RE£AN #4
LI2T £ ~"~'"7 LI~T 3 L~T 4
PE~C ~Cl
I · I TH ~1
I
I VACANT ~ I ~ ~: ~ ~ ~ ~
~..~..e~ ........................ ~..~ .....
~ ~ ~q¢¢~ 5¢¢¢' ,..~.~, .....
I ~ 'T-- - :~
~ I
I
50 0 50 1& 150 ~00 ~50 300
SCALE: ~" = ~00
TOBBEN SPURKLAND P.E. ~OT ~ BIR~ ROA~ ~T~T~ SEPTIC SYSTE~ DESIGN
20~ W 15TH. AVENUE DATE: JULY ~5, ~996
ANCH. AK. 99501 EXISflN6 IMPROVEMENTS
(9o73 279-~916 SHEET: I/5 GRID: 26~B
88.5
N89B5 7 '20'E /98,05
PR/MARY
DATUM
FF I00.5
91.0
/--
TRENCH
I
I15. I
TOBBEN SPURKLAND P.E.
203 W 15TH. AVENUE
ANCH. AK. 99501
f ~t07') 27g-sg 16
LOT 3 BIRCH ROAD ESTATES
PROPOSED IIdPROVEMENrS
SEPTIC SYSTEM DESIGN
DATE: JULY 15, 1996
SHEET: 2/5 GRID: 2658
PRIMARY TRENCH
Monitor
Cleon ZTu
Cleon Out
£ tono/ord Tmenches:
Foundo t/on C/eon out
1~P50 2al Septic ton/<
Double Cleon ZTuts
~' k/ide
95' Lan9
lO' Deep
3' Cover
14 FT.
REPLACEMENT TRENCH
C) Monitor Clean Su~
Cleon ZTut
/VD SCALE
Mira Fi 140
7 £t oF Septic [~ock
ND SCALE
Ex/st, Oround
4' M/n Cover
i£50 9aL sepf/c ton/<
3ENCH MARK,
ASSUMED ELEV,
TBBBEN SPURKLAND P,E,
~03 W15%h Ave
Anchorage Ak 99501
LOT 3 BIRCH ROAD ESTATE
SEPTIC SYSTEM SCHEMATIC
PROPOSED CONSTRUCTION
SEPTIC SYSTEM DESIGN
BATE, JULY 15, 1996
SHEET, GRID', £~35
MUNICIPALITY F ANCHORAGE
Development Services Department Phone: 907-343-7904
On -Site Water & Wastewater Section - Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 015-494-03
1. GENERAL INFORMATION
Expiration Date: 10 —B 7
Complete legal description Birch Road Estates, Lot 3
Location (site address) 5961 Moose Meadow Lane Circle Anchorage, AK
Current property owner(s) Randy Earp & Julie Revocable Day phone 301-3319
Mailing address 5961 Moose Meadow Lane Circle, Anchorage, AK 99516
Real estate agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4
4. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Private Well
0
Private Septic
7
Water Storage
❑
Holding Tank
❑
Community Well
❑
Community
❑
Public Water System
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 550 - DIDWaiver Fee $
Date of Payment 012-L012,0 l Date of Payment
Receipt Number O J 5 0(0 Receipt Number
COSA # OSG I9 I 0? (P ! Waiver #
WM
6. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the
on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater
disposal system is (are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in
effect at the time of installation. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm Forge Engineering Phone 907-522-7773
Address 1399 W. 34th Ave Suite 101, Anchorage AK 99503
Engineer's Printed Name Michael E. Anderson, P.E. Date 6/25/19
6. DSD SIGNATURE SIGNATURE
System #1 Approved for 4
System #2 Approved for
Disapproved
Conditional approval for
bedrooms
bedrooms
bedrooms, with the following stipulations:
l((((((((
011_ S �
o SER q ND m_
r� RSG' 44
0
�. Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
COSA Checklist blue sheet
Nitrate Advisory
Arsenic Advisory
Other ! �,,, �% iS
22 Y� d��
Legal Description: Birch Road Estates Lot 3
Parcel ID: 015-494-03
If more than 1 septic system on lot: COSA Checklist # of Structure served by this system
A. WELL DATA
❑ Well log is filed with Onsite (or attached)
Well production at time of test 2.5 gpm
Date drilled 8/1996
Water storage tank volume NA gallons
Total depth 215 ft
Well disinfected for coliform test? ❑ Yes ❑ Nc
Cased to 215 ft
❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly
Nitrate mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected
Arsenic ug/L ❑ Arsenic less than MRL (ND)
Casing height (above ground) 24 in.
Collected by FORGE ENGINEERING
Date of flow test for COSA 4/25/19
Date of Sample 6/24/19
Static water level at beginning of test 170 ft.
Comments Well was shut off mid -test. Well flow rate determined by monitoring static levels.
B. TANK DATA
Age of tank(s) 22 years
Tank type/material Septic/Steel
Measured operating fluid level in septic tank 50"
❑ Standpipes/foundation cleanout per record drawing
Date of pumping 4/11/19 - A+ Home Services
D. ABSORPTION FIELD DATA Deep Trench
Which system tested (date installed) 1/18/97
Al ALL standpipes present per record drawing
Total measured depth from grade 102 ft (max)
Measured depth to pipe invert from grade 2.5 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective
❑ Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced NA gallons
Comments/Deficiencies: FCO under access door In deck
COSA Checklist yellow sheet
C. LIFT STATION
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments: NA
Adequacy test date 4/25/19
Results P- Pass For 4 bedrooms
Fluid depth prior to test 54 in
Water added 704 gal
t
New depth 66 in
Elapsed time 1440 min
Final fluid depth 47 in
Absorption rate 600+ gpd
Any rejuvenation treatment (past 12 months)
If yes, enter date
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
Yes
if No
Community Sewer Manhole/Cleanout > 100'
r- Yes
if No
ft
M Yes
if No
Neighboring Tank > 100' Q✓ Yes
if No
ft
Private Sewer/Septic Line > 25'✓Q Yes
if No
Absorption Field on Lot > 100' P/ Yes
if No
ft
Holding Tank > 100' Yes
if No
Neighboring Absorption Fields > 100'
Yes
if No
Animal Containment > 50' QQ Yes
if No
F/ Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' Yes
if No
ft
F,(� Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' Q✓ Yes if No ft Surface Water > 100'
ft
ft
ft
ft
ft
Q✓ Yes if No ft
Property Line > 5'
Yes
if No
ft
Wells on Adjacent Lots:
Absorption Field > 5'✓Q
Yes
if No
ft
Private Wells > 100' F71 Yes if No
Water Main > 10'✓0
Yes
if No
ft
Community Wells > 200' Q Yes if No.
Water Service Line > 10'
Q✓ Yes
if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' ®✓ Yes if No ft If absorption field is under driveway comment below
Property Line > 10'
Q✓
Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'✓Q
Yes
if No
ft
Private Wells > 100' [✓ Yes if No
Water Service Line > 10'
Yes
if No
ft
Community Wells > 200' ❑✓ Yes if No
Surface Water > 100'
0
Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
COSA Checklist yellow sheet
hb 49th
MICHAEL E. ANDERSON
vllc
�°� No. CE -4381 ,*"+
7/14/19 a°°o+ �•
s........... ,% p9
ft
ft
ft
ft
Rx
Y
kSBUILT
HEREBY CERTIFY THAT I HAVE SURVEYED THE
OLLOWING DESCRIBED PROPERTY:
ND THAT NO ENCROACHMENTS EXIST EXCEPT AS
4DICATED. IT IS THE RESPONSIBILITY OF THE
NNER TO DETERMINE THE EXISTENCE OF ANY
ASEMENTS, COVENANTS, OR RESTRICTIONS
RICH DO NOT APPEAR ON THE RECORDED SUBDI-
'SION PLAT. UNDER NO CIRCUMSTANCES SHOULD
4Y DATA HEREON BE USED FOR CONSTRUCTION
- FENCE LINES, OR FOR ESTABLISHING BOUND -
?Y LINES.
SEWARD & ASSOCIATES LAND SURVEYING 694 -
SCALE:
)F A4
DATE;
TH
GRID:
FB: Duane Mark Seward 0
.. . 5� _• 91 IV
DRAWN.
DEVELOPMENT SERVICES DEPARTMENT
On -Site Water and Wastewater Section
www.muni.org/onsite -�
Septic 'Tank Advisory
Certificate of On -Site Systems Approval #OSC090264
Subdivision: Birch Road Estates lot 3
Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for
this property is 22 years old. Typical replacement costs range from $6,000 to $9,000.
This advisory must be attached to all copies of the subject Certificate of On -Site Systems
Approval.
This is an example of what the metal of a 20 year old steel tank MAY look like.
- 6ar � �,* �� ` ' ` ' m r ''c`.�, _.
91-' � ��W201 O N�
�� � �� ��In �i !ng �►�dt~�Ss�,��s ��� 196650 � C a ��Ai s a�9951 6.50 � � a��� �;„
�'",.sa4;w
Parcel I.D. #
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
~/o~
1. GENERAL INFORMATION
Complete legal description
LoT ~ ~,lO-CH
Location (site address or directions)
?roperty
Mailing address
Lending agency
Mailing address
Agent
Address
phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
q
RECEIVED
~¥ ?. 1 1957
Municipality of Anchorage
Dept. Health & Human Services
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
I ndivici~;..'! -.m-site
Holdin§ 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. 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.
NameofFirm "-~e~ ~?~,r~~ '~-~ Phone
Address ~.~ 'A ~ l~-~.,g~, ~ Z.o "~
Engineer's signature "X~ ~~ Date
_~ SIGNATURE
· Approved for
Disapproved.
bedrooms.
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
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)'
Health Authority Approval Checklist
Legal Description: I-OT~ '~llP..~.~ ~-o~l::). /.E. ST/-k~'I~. Parcel I.D.: O I~'- ~q_ - ~J c~ '5
WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
' '~ If A, B, or C, attach ADEC letter. ADEC water system number
Date completed '~/~ ~,
Date of test
Static water level
Well production ~
WATER ~AMPLE RESULTS:
Coliform [~ ~ Nitrate
Cased to o~/,'~
7
FROM WELL LOG
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
g.p.m, g.p.m.
["~.._['~ Other bacteria
' Collected by: T~,
B. SEPTIC/HOLDING TANK DATA
Date installed l~/~7 Tank size /~:~-L3 NumUer of Compartments
Foundation cleanout (Y/N) .~/ Depression (Y/N) t',l High water alarm (Y/N)
/
Date of Pumping t¥//,~.~. Pumper
ABSORPTION FIELD DATA
Date installed
Length ~,--~ ' Width
Soil rating (g.p.d./ft2 ~) ~). ~- System type I~_,,~.~¢
Gravel thickness below pipe 7 I Total depth
Effective absorption area
Date of adequacy test
Monitoring Tube present (Y/N)__~_ Depression over field (WN)
Results (Pass/Fail) For bedrooms
Fluid depth in absorption field before test (in.);
Immediately after gal. water added (in.):
Fluid depth (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Absorption rate =
If yes, give date
g.p.d.
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ! ¢) I!
Absorption field on lot ;~ I....~ I
Public sewer main
Sewer/se ptic service line
"Pump on" level at*
*Datum
"Pump off" level at*
RECEIVED
D Munloipality of Anchora e
ept. Health & Human Se~es
I
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
¢ t
Foundation / 7 Property line ~ ~ Absorption field 1
I
Water main/service line ~'¢q-5 Surface water/drainage I"//c~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Surface water
Curtain drain
I
Building foundation ~ ~ Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots /~
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review
in conformance with M~HAA gu~lin~s in effe~ on this date.
Signature
Engineer's Name '"'~'~ ~ I,p.~_.. ~
Date ~'~ ?, ~ ~ 7
HAA Fee $
Date of Payment
Receipt Number ~,~ (~0 ~J
!
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
r',lAY-2Fl-199'7 16: 1E, CTSE ESI
Zt~ CT&E Environmental Services Inc.
RNF:HEIF.'F~GE
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
972306002
Tobben Spurkland P.E.
N/A
Lot 3 Birch Rd Est.
DrinkSng Water
Client PO#
Printed Date/Time 05/19/97 18:28
Collected Date/Time 05/09/97 10:05
Received Date/Time 05/09/97 14:50
Technical Director: Stephen C. Ede
Sample Remarks:
CT&E Microbiology Drinkh~g Water Program certification status is proviskmal as of 4/8/97.
Parameter Resutts PQL Units Method
Nitrate-N 0.100 U 9.100 mg/L
]oral Coliform 0 O
NEGA[IVE
A(iowaD(e Prep
Limits Date
SM18 4500-NO~F 10 max
$M18 9222B
Ar~alysi~
Date Init