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Home My WebLink AboutSOUTH HILLS BLK 3 LT 7 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 Name:Wastewater System: ~ New ~Upgrade AB~OBPTION Phone: ~5 ~ O~t ~No. of Bedrooms: ~ ~ Deep Trench ~ Shallow Trench ~ Bed ~Mound ~ Other LEGAL DESCRIPTION Soil Rating:. ~ GPD/Sq. Ftl Total Depth from originalj --grade: Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Township: Range: ~ Section: Fill added above original grade: Gravel length: WELL: ~ New ~ Upgrade Srave~ ~pt,h: Number of lines: Distance between lines: Classification (Private, A,B,C): Total Depth: Cased To: Total abeorption area: Pipe material: Driller: Date Drilled: Static Water Level:Ft. Installer: ~ ~ Date i~t~d: GPM Ft.I Ft. SEPARATION DISTANCES ~ Septic ~ Holding ~.T.E.P. From Tank Field Station Tank Sewer Lines~ ~ ~ ~ Material:~ .umbor of Gom~monts: Surface w~t.r ac ~ ~O LIFT STATION Lot Size in gallons: Manufacturer: "Pump on" level at: I "~ump ~f~ Io~1 at: ~i~h wato~ at: Foundation ~.~ 30.~ ~-F ~ i CurtainDrain ~/O ~t-~O j Pump Make & Model Electrical Inspections~pedormed by: Remarks: BENCH MARK Inspections performed by: ~ Dates: 1stI ~ Department of Health and Human Services approval {~;; ~eviewee and approved by: :. Date . ~ 72-013 (1/91) MOA 25 I I SCALE; i - 50 FE TDBBEN SPURKLAN3 P,E, 203 W 15TN. AVENUE ANCH, AK, 99501 LOT 3 BLOCK 7 SOUTH HILL S/B SEC, £5 TI£N RS~' 7440 ~]UR OIVN LANE 99515 SEPTIC SYSTEM ASI)UILT BATE, BEC, 88, 199~° SHEET, £/3 GRI]), 2940 l/B' HOLES ~ 2 £-£ SOLID Monitor Tube INSULATION ELEV, 108,8~ I2' o£ Septic rock -- ELEV. 99.0 ELEV. 16'/07/9,2 ELEV. 94.6 ~EPLACEA£L ORGANI£MATE£IAL TOBBEN SPURKLAND P.E, G75! ~, DIMDND BLVD. ANCH, AK, 99502-3904 LOT 7 ~LBCK 3 SDUTN NILL$ $/~ SECTION £.5 TIPN R3V DOUG LAN6 1250 GAL STEP 0 EXIST. G£OUND FDM TDP OF FoUNDATIoN = lOaO0 ~p-PTIC ~¥~T£M A~BUILT DA~E~ .~£0, ,2B, 1996' 3Hp'ET~ B/B ORID~ £940 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920384 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:VINCENT-LANG DOUGLAS & OWNER ADDRESS:7440 OUR OWN LN ANCHORAGE, AK 99516 DATE ISSUED:il/12/92 EXPIRATION DATE:il/12/93 PARCEL ID:01707219 LEGAL DESCRIPTION: SOUTH HILLS BLK 3 LT 7 LOT SIZE: 38288 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: WAIVER WR920060 GRANTED FOR 85 FT LEACHFIELD TO STREAM AND 70 FT SEPTIC TANK TO STREAM. THE SEPTIC SYSTEM UPGRADE MUST BE INSTALLED IN ACCORDANCE WITH THE REVISED ENGINEER'S DESIGN DATED 11/12/92. RECEIVED BY: DATE: ISSUED BY: ~ ' 'v~ --- /~-L~-~ - DATE: / LOT 203 ~0 15iL Avenue~ Suite 206 ,, . /~BHOF:~BE, ALAS~:A 99501 NOV 1 2 1992 Municipality of Anchorage SEPTIC SYSTEM DESIGN Dept Health & Human Services 7 BLOCK S 'SOUTH HILLS DOUG LANB [:irour~d Water at 4.5 Use FT" (.::,~i~!F$t..~r i Z f~.d ,C.]oi 1 R<'ati n[.]. t..Js~.:~ F:'J. 1 tersand .7 gal/sq.ft. Requir'(:)d Area per' Bedrc)(:)m: l.,~..)/ .7 .... 214..]; sq.ft.. 3 3 x 2.:1.4,,3 = 643 sq,,ft~ SYSTEM CONFIGURATION MOUND TOTAL LENBTH TOTAL WIDTH ROCK DEPTH COVER FILTERSAND SEPTIC TANK 40 FT. 16 FT. .75 FT. 5 FT. 2.5 FT 1250 BAL. STEP ABANDON EXISTING SYSTEM PUMP AND CRUSH EXISTING TANK PUMP, CRUSH, AND BACKFILL EXISTING PIT TOPSOIL AND SEED. '['l"~e instal 1 at :[ (::)n ~::)f th:i. s sei::rt:i c:: system t~J. :l 1 not prevent wel fr(~m be instai l::~d on '[:.h~e adjacent lots. 'Fha:.:, proposed septic sys'b~m ~d. ll not (:::l'~ancje thc~ ar'ea. F'c)nd:[ng al],:zt/(]r c<:mc~:.mtrati(:m <:~f ?Jut.face runo.Ff will 19o~ resLd, t from thi s :i. ns'[:al :1. a'l::J. ~::)n ,. 5 e...,p ~ i (:: ,~ ¥... ~: ~: m D e s :i. r...] n L. cr[:'. 7 Bl oc:k 3 ,c.:buth H:i.l:l.s S/D I I Well '---I II 0 II I[ I 92,~ II II II I I I SCALD 1' = $~ FT. VFD NOV 1 2 1992 Municipality ot Anchorage Dept. Health~H~man Services 99, 4 yy, ~ TBBBEN SPURKLANB P,E, 803 ~ 15TH, AVENUE ANCH, AK, 99501 LOT $ BLOCK 7 SOUTH HILL SEC, 25 TI2N R3V 7440 OUR Olin LANE 99515 REVISE~: /VI]V, 1£ 199£ SEPTIC SYSTEM DESIGN DATE, DCT, ~ 199~ SHEET, 2/3 GRID, £~40 LOT SEPTIC SYSTEM DESIGN 7 HL. OCK ~ SOUTH HILLS DOUG LANG !{.Z~t:,:.:,d i:':~r" ~:.:!,'~:'~ SYSTEM MOUND TOTAL. LEN6TH TOTAL WIDTH ROCK DEPTH COVER FtLTERSAND SEPTIC TANK 2~0 FT. 1250 GAL. STEP ABANDON EXISTING SYSTEM PUMP AND CRUSH EXISTING TANK PUMP, CRUSH, AND BACKFILL EXISTING PIT TOPSOIL AND SEED. Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: "~ O~,~_.~ LEGAL DESCRIPTION: L'7/~'~ 0""e~..-~ 2 3 ¢'ec~ ~ 4 5 DATE Township, Range, Section: SLOPE -(ENGINEER'S SEAL) · T'l;zN, P_.:5 u// SITE PLAN 10 11 12 13 14 15 16 17, 18- 19- 20- WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT / DEPTH? ~, Depth to Water A ~ Moil oriflg? ! "/,~/' Date: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RAVE __ (minutes/inch) PERC HOLE DIAMETER __ COMMENTS TEST F}UN BETWEEN __ FT AND __ FT ~ PERFORMED BY: , CERTIFY T~ATZIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~ c.v-..~ 7~ l &:~ '~2'- 72-008 (Rev. 4/85) I I S OUR Veil I L£T 8 CUK4TAIN BRAIN? LOT 6 S I LOT I I I I RA&gITCR££KR~AD SCALD I' = i00 FT, TOBBEN SPURKLAND P,E, ~03 ~ 15TH, AVENUE ANCH, AK, 99501 LOT ~'.~LO~K SEC, 25 TI2N N3W 7440 OUR £~/N LANE 99:515 SEPTIC SYSTEM DESIGN )]ATEI OCT, ,5, 1992 SHEET, 1/$ GRID, 2940 I I m ~ N SCALD ~' = $0 FT, TD9~EN SPURKLAND P,E. 203 W 15TH. AVENUE ANCH, AK, 9950! LOT 7.0I..OCK ,~. ,90JT/./ HILl.. $/g SEC, P5 H£N £$V 7440 gUP DVN LANE 99515 SEPTIC SYSTEN ])ESIGN DATE, OCT. 5~ 199~ SHEET, ~°/3 GRID, B940 l~ E~4L ST£P TANK Topsoil ond seed M~A 3 Ff oF Cover ELEV, IOl, O~ EXIST, ~4' · SA/VD LAYER ~PLAC~ ALL Z2R~V~C I~ATEP.~L TDBBEN SPURKLAND P,E, 6751 ~, DIMDND BLVD, ANCH, AK, 99508-3904 SEPTIC SYSTEH DESIGN ])ATE~ gCC, 7 SHEET~ 3/3 GRID, ~ Tom Fink, Mayor un c pality Anchorage Department of Health and Human Ser,Jices 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 November 10, 1992 Tobben Spurkland, P. E. 203 West 15th Avenue #206 Anchorage, Alaska 99501 Subject: Waiver Request for Lot 7 Block 3 South Hills Subdivision Waiver Request #WR920060, PID #017-072-19 Dear Mr. Spurkland: The recent request for three waivers to setback distance requirements on the subject lot is denied. The ADEC point criteria for waiver approval is 16 whereas the total points for the subject well to septic tank waiver request is 10.6. As pointed out in the ADEC Separation Distance Waiver Guidelines, "numbers of 16 or less for a continuous source of contamination such as a leachfield should not be waived, unless other mitigating measures are noted or special construction techniques which can mitigate some of the geological concerns are taken." In order for further consideration to be given to the subject waiver requests, you must provide additional supporting data or other mitigating measures. There are two alternatives to granting the waivers, namely (1) if the soils'and groundwater are acceptable in the vicinity of the existing wel'l, consider relocating the well and install the upgrade system in the vicinity of the existing Well, or (2) install a holding tank. Further action on this waiver request will be deferred pending your response to this letter. If there are any further questions, please call our office at 343-4744. Sincerely, . ~ ~ ~.~/,/ ~'. .. (- ~,_ ..... 1)_ ~',; ~-4-- ....... ~obert ~, ~obinson Civil Engineer On-site Services Concur: // ,~n Smi/~hf~. E. ~rogram Manager On-site Services RWR/ljm#431 Tobben Spurkland P E I I Date Dril.led : HEFTY DRILLING {,{/~ll ~l;,~tc, -- It% n~lurallv 6elterl 8540 ^KULA DRIVg , TELEPHONE: ANCHOF~AGE~ ALASKA §g$I6 {907) 345-0593 WELL LOG 10=4-87 P.01 RECEIVED NOV 199 Municipality of Anchorage . Dep!. Health & Human 8erviOem. Doug Vincent Lan9 . 7440 Our Own Lane ~tati¢ Water,'Level 20. Feet Draw Dow~ N/A .._Feet Gallons Per Minute 20 Total Feet of Casing 74 Material Drilled: ft. ft. to 6 ft. Overburdon tO 17 ft, Gravel and sand with H20-.- 17 ft. to 20 ft. to 20 ft, Silty clay 50 ft. Gravel with H20 50 f~ tO 55 ft, Clay 55 ft, to 74 ft, Gravel and sand with H20 to to. HF.,FTY QnII.LINS' 8540 AKU~ DRIVE (907~ 345-0593 ' ? CHEMICAL & GEOLOGICAL LABORATORY .. A DIVISION OF COMMERCIAL TESTING & ENGI[',~EERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (9071 561-5301 kNALYSIS RESULTS for INVOICE e 59981 Chemlab l~ef.# 92,.5939 Sample ~ 3 Matrix: WATER Client Sample ID : 7/3 SOUTH }{ILLS - 7440 OUR OWN RD. PWSID UA Collected · OCT 23 92 Received OCT 23 92 @ 13:00 h~e, ?resezved with = AS REQUIRED ~lient Name :TOEBEN SPURKLAND Cllent ~¢ct :TOBBENS BPO~ ' POS :NONE RECEIVED R~q~ : Ordezed By :TOBBEN SPU~KLAND Analysis Completed ; OCT 23 92 Labozatory Supervisor :. STEPH~]N C. EDE Reiea, ed By: ~d~' ~ Send Report~ to: 1)TOBBEN S?URKLkND, P.E. ?aramete~ Results Units Method Allowable Lir~,ts NITRATE-N 1.04 mg/1 EPA 353.2/300.~ 10 Sample ROUTINE SAMPLE COLLECTED BY: STUART. Remazks: 1 Tests Pe~£o~med ' See Special Inetruction~ Abo~e UA=Unavailable ND- None Detected ** See Sample Remarks ~bo~e NA- Not Analyzed LT-Less Than gT-Greatez Than ~SGS Member of the SGS Group (Soci~t~ G~n~ra[e de Surveillance) COMMER~ Drinking TESTING & ENGINEERING CO. AK DIV & GEOLOGICAL!LABORATORY LEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY [] PUBLIC WATER SYSTEM I.D. # L [] PRIVATE WATER SYSTEM Mailing Address c~y SAMPLE DATE: Mo. SAMPLE TYPE: Day ~Routlne [] Check Sample (for routine sample with lab ref. no. [] Special Purpose ~/ATER SUPPLIER Phone No. State Zip Code Year ! ) i [] Treated Water , ~[~.Untrsated Water SAMPLE No. LOCATION 31 41 51 Time Collected Collected By ' TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ~ Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results, Please send new sample via special delivery mail,.. Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi, Lab Raf. No. Result* I A~t A.D.E,C. READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATER ANALYSIS RECORD Final Mere brahe ~Ule~Resulta Reported By TNTC = Too Numerous To Count OB = Other Bacteria Membrane Filter: Direct Count ~ / Verification: LSB (/~- , BGB Fecal Coliform Confirmation /jegc~/[x/e Date Time: PART ONE OF TWO REMAINDER TO FOLLOW & ~ Coliform/lO0 mi (~ Coliform/lO0 mi /~- ~ ~-~/~ a.m. p.m. 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Day phone ~,ddress Day phone o Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~-5 TYPE OF WATER SUPPLY: Individual well '~,' Community well Public water 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: 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. Name of Firm AI,.~I~ Water & Was~/e~fater Phone 7320 East Chester H~if. ([ircle Address A.,4T~ra ~/d(.t~,l~ 99504 Engineer's signature ?~-~ f////' (.-/~ k, ~-I~ ,,.'"/~ Date DHHS 81GNATURE ~ Approved for %~4E[ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: By: Additional Comments Waiver request CJWR920060 is amended from the previously approved 70' from the septic tank to the stream to 69' per Jeff Garness, P.E.¢ Alaska Water & Wastewater Consultants. Inc, inspection and measurements. 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 pumhasers 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#21 825 E Street, Legal Description: /'¢'J-' 7',' ~/~,~ A, WELL DATA Well type .~//1. ~ . If A, B, or Log present (Y/N) y Total depth '7 ~ t Sanitary seal (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform i:Date completed !- /0 --/~- <~; ingheigh{ (abOVe` ground) FROM WELD'LOG AT INsPEC~TION g.p.m. '~" ~' -I- g.p:,m. ~ ~, ~ I Other bacteda Nitrate _ Date ct sample: (o~ / "/-¢~' 'Co eCted by: /~-/x2/.,~ /~-~ '¢);X Tanksze /~_,5-o NumberofcomPartment~',/~- Ceanouts(Y/N)~ F0'undati°n cleanout [Y/N)' y ~ Depression (Y/N) /~/ High watei~'i~larm (Y/N) ' y. C. ABSORPTION FIELD DATA Date installed / 2. - ~ ~ b Length ~ Width Gravel thickness below p pe ~. ~' Total depth y Dep es Effective absorption area ~' ~ O Monitoring Tube present (Y/N) r sion over fi Date of adequacy test ~' ~ / '7- ~y¢ : Results (Pass/Fail) ~ ~ Fluid depth in absorption field before tes{ (in.); , ~;~,- Immediately after ~' ¢~gal; Water added Fluid (ins)M nutes later: t~ IA- ' Absorptio Peroxide treatment (past 12 months) (Y/~) .d. 72-026 (Rev, 3/96)* LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested 2_~ Y Size in gallons "Pump on" level at* ~//Jr *Datum ~ OT'I-O'W "Pump off" level at* oF E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots / On adjacent lots / ~_~ Public sewer manhole/cleanout Lift station l SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation '~. ~- ~ Property line / ~ / 4- Absorption field .~/-4- Water main/service line % ~ / ~ Surface water/drainage "/I ~ p~zo~ --~.~ ~/o · Wells on adjacent lots / SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line / ~ ! Building foundation / ~/~ Water main/service line Surface water ~. 2. ~ E,~-J3 Iv~'T- ~ Driveway, parking/vehicle storage area / Curtain drain I~ ~.~3b,.~J Wells on adjacent lots ] I certify that I ha~e~de~r~nin~ru f,~.ld inspections and review of Municipal records that the above systems are in conforman~ wifh ~A ~..~guidetines in effect on this date. ~ ~_~ Receipt Number HAA Fee $ '--~/at~ ' ~ Waiver Fee $ Date of Payment ~ b~-'-J9 ~ Date of Payment Receipt Number ~ ~ Yc~ ~_~ ,~ G ~ 72-026 (Rev. 3/96)* I I Facsimile Transmittal Alaska Water & Wastewater Consulting Engineers Number of Pages Including Cover: Attentiom }~ 0 A,/ ~ ~-~3~5 ' From: Jeffrey A. Go_mess, P.E., M.S. Reply ~e~ ~ Yes O No ~ g / 7320 ~ ~r Hei~ Ci~le * ~om~e, ~as~ 99504 * Ph~: (90D 337~179 * F~ (~D 228-2246 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 Parcel I.D.# ~"~/'7 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA # Location (site address or directions') Property owner Mailing address Lending agency Mailing address Agent Address '~o-x~J.~5 'L~.. Day 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 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: 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 o 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 -! ~6/o~--~'/ ~,'¢'J~f.~t~'Pj~-' Phone Address ~"0~.,'/~ Date ~ ~~~- Engineer's signature ..~S SIGNATURE /'. Approved fo r ~'/'~--~'~- ~ ~ Disapproved. Conditional approval for bedrooms. 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) Bsck MOA#21 ( Municipality of Anchorage · ,Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal DesCription: t~,'~ 7~ ~1~ ~ ~/.~/,'//,~ Parcel I.D. 0/'7 - ~ A. WELL DATA Well type '~. If A, B, or C, attach ADEC letter. Log present (Y/N) ~/ Date completed Total depth '7/1/ Cased to Sanitary seal (Y/N) /~/ · FROM WELL LOG Date of test I~)/~ 1~"7 Static water level Well flow ¢;~) g.p.m. Pump level ADEC water system number J~/~' '7 ~ Casing height Wires properly protected (Y/N) ~ AT INSPECTION IZ/7/f ~ MU~!~mALITY OF ANCHORAGE ~7 ~IRONMENTALSERVICES DIVISION g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ! C) ~.. Public sewer main !~/A SeWer service line ~ liP ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout I'~/,~ Petroleum tank b,,J / C) WATER SAMPLE RESULTS: Coliform ~ Nitrate / Date of sample: 0 q Other bacteria Collected by: .~..z4/'o. r' '~ B. SEPTIC/HOLDING TANK DATA Date installed I Cleanouts (Y/N) ~'/ High water alarm (Y/N) Date of pumping Tank size /~.~' 0 Compartments Foundation cleanout (Y/N) 7 Depression (Y/N) / Alarm tested (Y/N) ' f }~///~. ~ Pumper Well(s) on lot To property line Surface water/d rainage 72-026 (Rev. 7/91) Front SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: On adjacent lots Absorption field ~, / ~ Foundation ~4~0 ~' Water main/service line ) I C) CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) 7 High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) /7// Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) 7 SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot ]0 .~ On adjacent lots '~ /~ Surface water D. ABSORPTION FIELD DATA Date installed 'L- Length /'~/O Width Total absorption area Depression over field (Y/N) O. Soil rating ~' Gravel thickness Cleanouts present (Y/N) Date of adequacy test Results (pass/fail) ~ for_ Peroxide treatment (past 12 months) (Y/N) J~l SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot /O~-- To building foundation ~:) ~), ..~ Onadjacentlots ~ ~--L3 Cutbank Surface water ~ Curtain drain On adjacent lots System type Total depth If yes, give date P.r0perty Ii ne To existing or abandoned system on lot ~,¢./yt.~ Water main/service line Driveway, parking/vehicle storage area bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, vedfied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer's Name ' ~'~1 "~b ¢ ~' k[~Lut~ ~ HAA Fee $ /'~'~ Date of Payment /',~2 Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number