HomeMy WebLinkAboutSOUTH LAKEWOOD HILLS #1 BLK 6 LT 2
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP251088
Work Type: Septic Upgrade
Effective Date
Expiration Date:
Tax Code Number: 01515122000
Site Legal Address: SOUTH LAKEWOOD HILLS #1 BLK 6 LT 2 G:2638
Site Mailing Address: 11000 Ridgecrest DR, Anchorage
Owner: MOSLEY LOUIE W & AUBREY JANE
Design Engineer: FORGE ENGINEERING
This permit is for the construction of:
^l„ant
r
Ucrhart�n�:�t�t
4/18/2025
4/18/2026
Lot Size in Sq Ft: 31510
Total Bedrooms: 4
R1 Disposal Field Z Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: — r'— C-, 4 y' t `- Date: _
Issued By: Date: F ��
MUNICIPALITY OF
Development Services Department
On -Site Water & Wastewater Section
ON -SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 015-151-22
Property owner(s) Louie Mosley Day phone
Mailing address 6530 Michigan Blvd, Anchorage, AK 99516
Site address 6530 Michigan Blvd, Anchorage, AK 99516
Legal description South Lakewood Hills #1, Block 6 Lot 2
Number of Bedrooms 4
Engineering Firm Forge Engineering
Building Permit Number
APPLICATION IS FOR:
(N all that apply)
Absorption Field
El
F]
Septic Tank
Holding Tank
Privy
Well
Not Applicable FN
APPLICATION IS AN:
Initial
Upgrade
Renewal ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Permit/Rush Fees: S 5
Date of Payment: y, v
Permit No. 1 Z 57
Waiver Fees:
Date of Payment:
Waiver No.
Phone- 907-343-7904
Distance:
April 8, 2025
MOA Development Services, On-Site Water & Wastewater Program
4700 Elmore Rd
Anchorage, AK 99507
Subject: South Lakewood Hills #1 Block 6 Lot 2 - 6530 Michigan Blvd
Septic system design
Dear On-Site Services Engineer:
The owner of the above lot intends to upgrade the existing septic system for this 4-bedroom home
on the property, so we are submitting this permit application for the construction of a new septic
system. The attached site plan identifies the location of the home as well as the existing well and
septic location. No conflicts exist between this proposed system and any other well or septic
system, whether on this lot or adjacent lots.
The ground surface on the lot slopes very mildly in the northeast portion of the lot where the home
is, but does drop off a little more steeply to the south and west. There are no slopes greater than
46% within 50 feet downslope of the proposed trench, but there is a short section of slope greater
than 25% within 50’. The slope does not drop surface height greater than 10’ below the invert of
the drainpipe, so it does not need steep slopes provisions per code. Contours are shown on the site
plan showing the grade and direction of flow. Stormwater drainage will not impact this septic
system. The new trench will be constructed parallel to the slope as much as possible.
Wells on this and adjacent lots are shown. The new system will be a minimum of 100’ from all
wells and surface water, and more than 5’ away from the septic tank. Please refer to the attached
test hole log, plan and section pages for the septic design. If this design is followed, there will be
no adverse impacts to adjacent properties.
Sincerely,
Benjamin Schiller, PE
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP251088, Curtis Townsend, 04/18/25
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
1"=30'
CO - CLEANOUT
2CO - DOUBLE CLEANOUT
FCO - FOUNDATION CLEANOUT
FS - FLOW SPLITTER VALVE
MH - MANHOLE
MT - MONITORING TUBE
SV - SEPTIC VENT
TH - TEST HOLE
LEGEND
2CO
TH#1
SOUTH LAKEWOOD HILLS #1, BLOCK 6 LOT 2
FEET
0 30 60
≥12'
FCO
MICHIGAN BOULEVARD
4-BDRM HOME
SEPTIC PLAN
4/3/25
10' UTILITY EASEMENT
690
680
700
700
10
'
U
T
I
L
I
T
Y
E
A
S
E
M
E
N
T
RI
D
G
E
V
I
E
W
D
R
I
V
E
SHED
DECOMMISSION EXIST.
1250 GAL SEPTIC TANK
NEW 1250 GAL SEPTIC TANK
APPROX LOCATION OF
EXISTING SEEPAGE PIT
REMOVE SEWER ROCK AND
FILL WITH CLEAN BACKFILL
45' LONG x 6' EFFECTIVE DEPTH
ABSORPTION DEEP TRENCH
MT
MT
CO
CO
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP251088, Curtis Townsend, 04/18/25
SOUTH LAKEWOOD HILLS #1, BLOCK 6 LOT 2
TYPICAL TRENCH SECTION
(NO SCALE)
NOTES:
1. GRADE AREA OVER TRENCH TO DRAIN AWAY
2. PROVIDE 3' OF COVER OVER TRENCHES AND 4' OVER SEPTIC TANK, OR 2'
WITH 2" OF INSULATION
3. CHECK GROUNDWATER AT TIME OF CONSTRUCTION. IF LEVEL IS HIGHER
THAN PREVIOUSLY OBSERVED, CALL ENGINEER IMMEDIATELY
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
4" PERFORATED PVC (HOLES DOWN)
DRAINFIELD ROCK
3'
6"
3'-6"
6'
DESIGN FACTORS:SYSTEM REQUIREMENTS:
600 GPD PEAK FLOW
PERK RATE: 2 MIN/IN
APPLICATION RATE: 1.2 GPD/SF
DEEP TRENCH SYSTEM
1250-GAL SEPTIC TANK
BOTTOM OF TRENCH: 10' BELOW GRADE
FLOW LINE ELEVATION: 4' BELOW GRADE
600 GPD / 1.2 GPD/SF / 6' DEEP / 2 SIDES = 41.7 LF TRENCH REQUIRED (45 LF SPECIFIED)
GEOTEXTILE FABRIC
6"
4/4/25
PROVIDE ADDITIONAL FILL TO
ACCOUNT FOR SETTLEMENT
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP251088, Curtis Townsend, 04/18/25
LEGAL DESCRIPTION:
PERFORMED FOR:
DATE: PARCEL ID#:
SOILS LOG AND PERCOLATION TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
DEPTH
(feet)
TEST HOLE 1
PERCOLATION RATE: (MIN/INCH)
DATE OF MONITORING
DEPTH TO WATER AFTER MONITORING
2.0
SM - SILTY SAND
Professional Engineers Stamp:
SOUTH LAKEWOOD HILLS #1, B6 L2
3/10/2025 015-151-22
ACES
ORGANICS
Benjamin Schiller
CE 12592REGISTEREDPROFESSION A L E N GINEER
PERC TEST LOCATION
TECHNICIAN: J. EARLS16.9'
COMMENTS:
SITE PLAN
USCS SOIL CLASSIFICATION WAS VISUALLY DETERMINED
4/3/25
GM (SILTY GRAVEL)
BOH
DATE READING NET TIME
(minutes)
DEPTH to
WATER NET DROP
(inches)(inches)
3/10/25 1
2
3
4
5
6
159 6
1610 164 11
16 5 5
16
MOISTURE NOTED AT TIME OF DIGGING?No
10
10
10
10
10
159 0
16
159 8
16
159 8
16
159 8
16
159 8
16
3/17/25
164 0
16
164 8
16
164 9
16
164 8
16
164 8
16
5 0
16
5 0
16
4 15
16
5 0
16
5 0
16
NOTE: MEASUREMENTS TAKEN FROM A SECTION OF TAPE, NOT STARTING AT 0"
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP251088, Curtis Townsend, 04/18/25
NOTES:
GROUND LEVEL IMPROVEMENTS SHOWN ARE APPROXIMATE.
THE EASEMENTS SHOWN HARE ARE SHOWN ON THE PLAT BUT
ARE NOT DESCRIBED ON THE PLAT.
PLAT NOTE 2: BLANKET UTILITY EASEMENT HAS BEEN GRANTED.
MICHIGAN BLVD \
o �
I
S 89'59'E790�.90WELL,
100' PROTECTIVE WELL RADIUS
GRAVEL N I
1.8' CANT 2.0' CANT
N 28. 19.7' /
139. 1.3' x 5.8' CANT
\ 2.8' (n
i 1.9' BALCONY 8 0' /
ti V� O
p
O \ M•^��Z � O //
GRAVEL_ .: 3 m�
Lot 1 0) M
\ a DECK / 0
rn / 1.6'
_SEPTIC PIPES
8.0' x 11.2' PLAYOUSE W n
WITH WRAPAROUND DECK (Tl)
Lot 2 N 16.2'
LO
30,400 s.f. (MOA)
10' EASEMENTS iv
N 89'59'W 190.97'
30.0 yl
Lot 3 I I I Lot 4
I
DATE OF SURVEY: 25 & 26 FEBRUARY 2025
PLOT PLAN __— AS BUILT _X40_ _ SCALE _ 1_== GRID SW 2638
- — -- Project No J25-006161
Lang & Associates • Anchorage, inc P.O. Box e, A005 Z�
Alaska 99521 0005
Professional Land Surveyors sure
curvey0l ngrve64su6com y. ooP.`�............ -9s4p0
1 hereby certify that I have surveyed the following described property:
LOT 2, BLOCK 6, SOUTH LAKEWOOD HILLS SUBDIVISION (Plat No. P-61 1) p°O 49
Anchorage Recording District, Alaska, and that the improvements situated thereon are"""'"""" "' """' "' '_"'-�
within the property lines and do not encroach onto the property adjacent thereto, that Q Y G
no improvements on the property lying adjacent thereto encroach on the surveyed Q•
premises and that there are no roadways, transmission lines or other visible Q -)0 JON.... N LANG o G
easements on said property except as indicated hereon. %�'•, ���
7�t 0 P LS-9944. • J
Dated this the = Day of _ _�A k�h ___—_, at Anchorage, Alaska p0 `tea
�Qo
It is the responsibility of the owner to determine the existence of any easements, 404R"FfSSIONA�
"'000NA-
covenants, or restrictions which do not appear on the recorded subdivision plat. State of Alaska AECC963
ANCHORAGE AREA BOm tGH
Department of Environmental Quality"
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION
MAILING ADDRESS -~/~/~ '~ 7'~'
LEGAL DESCRIPTION L.
SEPTIC TANK:
D,STAN E '
INSIDE LENGTH INSIDE WIDTH
MATERIAL
NUMBER OF
COMPARTMENTS
LIQUID DEPTH
LIQUID CAPACITY /~,~? GALLONS.
SEEPAGE PIT:
NUMBER OF PITS
LINING MATERIAL ~
BUILDING FOUNDATION__
ADDITIONAL ABSORPTION
DIAMETER OR WIDTH
CRIB SIZE: DIAMETER
NEAREST LOT LINE _~ .
LENGTH-I)', DEPTH / /
DEPTH DISTANCE FROM:
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) .SQ. FT.
WELL:
CONSTRUCTION
NEAREST NEAREST
LOT LINE SEWER LINE
OTHER SOURCES
DISAPPROVED REMARKS
TYPE
BUILDING
FOUNDATION
CESSPOOL
APPROVED
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK SYSTEM
DISTANCES:
Pipe MATERIAL: ~//
LOT SLOPE:
Form No. EQ-031
DIAGRAM OF SYSTEM
//
DATE
GRE:ATEr ANCHORAGE Area BOROUGH
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
FINANCED THROUGH
SEEPAGE PIT , DRAIN FIELD OTHER
NOTE: THIS PERMIT IS NOT VALID WITHOUT BOIL. TEST
COMPLETION DATE ANTICIPATED
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
DIAGRAM OF SYSTEM
MINIMUM DISTANCES, REQUIREMENTS
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
FOUNDATION TO SEPTIC TANK
fOUNDATiON tO seEPAge PiT ~ ro [ , DRAIN fieLD
SEPTIC TANK TO SEEPAGE PIT WALL //,~ '
WATER MAIN TO SEPTIC TANK
I CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAge AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCR[BED~SYSTEMs/~//7~//IS IN ACCORDANCE WITH SAID CODE. ~ '~~/~ /~
DATE APPLICANT'S SIGNATURE
The sediments were
fairly loose with a
low Water content. The
were some erratic Sw
and M1 bodies but thes
accounted for les~
5% of the total sed-
iments.
eOMNENT$: 2 e..*~~p~n ~o ~ott'o~ Of Pit Or '~renc~
T~s~ Po~o~ By: Perooo ~ .....
~t~- ~tf'led.: " '" ' ' : ' ............ ~'~ ~::~ ...........
MUNICIPALITY OF ANCHORAGE ,~
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. Cf
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)
Location (address or directions)
(b) Property owner/~o~,¥
Mailing Address
(c) Lending Institution
Telephone: (home) ~¥~-95// Business
Telephone
Mailing Address
(d) Real Estate Company and Agent f~
Address "~ ~-00 Cor'o(o~.
Telephone ~ 7~'- ~-7~'/
(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 Stat~ 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
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MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
A. WELL DATA
Well Classification P r~[/~-e
Well Log Present (Y/N) ~ Date Completed I¢ '7 'i~
Total Depth /?~-' Cased to /7~E' Depth of Grouting
Static Water Level /3o '
If A, B, C, D.E.C. Approved (Y/N) N, ~,
Yield _~ C, ~',/¢~ ~¢~u' tf~120
Pump Set At 178 r
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line N,
To Nearest Sewer Service Line on Lot
Water Sample Collected by r~/,cf'~,,
Water Sample Test Results
Sanitary Seal on Casing (Y/N) '¢
Depression Around Wellhead (Y/N) h/
PC ¢.c., ; On Adjoining Lots
Io¢" ¢-¢ c,o. ; On Adjoining Lots
To Nearest Public Sewer
~ ~c~ ; Date
Comments
SEPTIC/HOLDING TANK DATA
Date Installed 5-/$1 / 7 '/' Size I ~ ~',~( No. of Compartments
Standpipes (Y/N) Y' Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~ Date Last Pumped I / l¢' /90
Pumping/Maintenance Contact on File (Y/N). N, · ; for /~f'~'
Holding Tank High-Water Alarm (Y/N) N./I-. Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well lC"?" ,c~,, ~. ¢,. To Building Foundation /7 /
To Property Line 8Y~ To Disposal Field
To Water Main/Service Line ~> ~,F ~
To Stream, Pond, Lake or Major Drainage Course ~ f
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
[)ate Installed 'T/ ~l / ? y
Width of Field 16 '
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
'/t5',¢'~,~ ,~ Type of System Design
Length of Field / ? t
Depth of Field h~
Gravel Bed Thickness 5' ~
Sta)~hdpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well Icg'
'Fo Building Foundation
Lot
'FO Water Main/Service Line
'Fo Stream, Pond, Lake, or Major Drainage Course
'Fo Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line ~ ~o '
To Existing or Abandoned System on
; On Adjoining Lots ~ 3'0 '
To Cutback (if present) _
D, LIFT STATION N, A,
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (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, c,~Cl~.~?~Z~rl~ffect on the date of this
inspection. ~?;:.... 0,~... ?t ¢,¢_~
~/ ~ ~' ~Englneer's Seal
Date ~ (~ ~¢ ¢¢ ~D~.,~,.~t~...,.,,,,.
MOA No. ~_~ % ". ~H~o~o~E ~. ¢,~oo~: N
~.. · ,~
.......
Receipt NO, ~/¢~/ Receipt NO. *~¢
of . ment /-/¢-¢b ¢ W iver
Amount: $ /~ a~
, Date of Payment
72-026 (Rev. 7/88)Back Page 2 of 2
~ FLATTOP TECHNICA~SERVICES -- ~'f_ff/ /~/~.//'..~....,.
14530 Echo St., Auchorage, AK 99516 ,J-'-.x~"--~' ' '*--'~'"~-
Ph. (907) 345-1355
ADEQUACY TEST DATA SHEET
Legal Description: LoF ~, r31octv~/ S~. Lct&e~,.-,o,:~'
Street Address: It' 00~ ~c~4fi
Client Name: ~mm~,/
Test Date: f/~ ~
TeSted By:
Initial Conditions:
Float #1 in c..oaz~d~ C,O,
Float #3 .in set "b.t.o.. "pipe w. fluid
Float #4 in set--" b.t.o. " pipe w.--"' fluid
Water added through:
set 13-~" b.t.o. ~-Z" pipe w. %¥ " fluid /&
set 7~" b.t.o. 2~'" pipe w. ,~-Z" fluid ~-~
ACTION TIME H20 METER NET. GAL WELL FLUID LEVEL
TAKEN LEVEL ~'~,~.~./¢ ~ __
o -tt
q ' q7 ~ -- -- ez~ --
Adequate for ~ + Bdrms
Measured Well Yield
Unit Absorption Capacity =-'7'£'~P'~"f~,,-' - _- 3~,' Surge Capacity =
Average Absorption Rate = ~';~
-Zq,----~.~ =~o~$~Adequate. for ~ Bdrms
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
Application Data
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
I.~.t' ~ tg(oct'r 6"~ .Co. t. alreto,,oo( I¢,lt.r ~/.c,
Location {aOOress or directions)
(b) Applicant Name ~o~.r'~ ~m~ Telephone: Home 3 ~-
(c)
Business
ApplicantAddress '1(,000 R,~er~ l~. /¢~1c6of'~¢,~ ~
Applicant is (check one): Lending Institution []; Owner/builder [~'; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate COmpany and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [] 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 Environ mental Conservation
attesting to the legality and status.
4. 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 (11184)
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 wast~water 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 J~i'~ '~(~
Address / u/.5-.3 (7 t~-C40
.~¢ rw'C,~' Telephone
,.4-,,c4o,-,T~,e., xS~'
Engineer's Seal
Approved for bedrooms
;;; rrn~V;;c o n c ~l~o~al Approva~isappr°ved~ '
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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MUNICIPALITY OF ANC~KLIST - FEBRUARY 1984
DEPT. OF HEALTH & 264-4720
I~NVIRONMENTAL PROTECTION
Legal Description: ~o~
MAR 3 ,198
WELLDATA RECEIVED
Well-Classification ~'r~ u~-'~'~' If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~ Date Completed 1.9 ?~ Yield
Total ~'-l"Z~'.a'e~ Cased to ~ 1~7' Depth of Grouting ~-
Depm ~e~
Static Water Level I ~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole ~1, ,4.
Water Sampie Collected by
Water Sample Test Results .~,~'t~,,,'~C~y
Pump Set At ~,
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots ~' i00 '
lO~"¢ec~ On Adjoining Lots '~' tOO'
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date ;~/17
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes (Y/N) ~ Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well IO.q ~
TO Property Line :2~ ~O~
TO Water Main/Service Line ~' ~,
Course ~ t
No. of Compartments t
Foundation Cleanout (Y/N)
Date Last Pumped '~/P-I /"~'
; for H,~,
Temporary Holding Tank Permit (Y/N)
To Building Foundation 1'7¢
To Disposal Field ~* (_31~ .~e~.~ C.o.~S'~
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 (Y/N)
Results of Last Adequacy Test
~'/~3~,"~ Type of System Design ~'i'~
Length of Field I ? ~
Depth of Field fl'
Gravel Bed Thickness ~' '
Standpipes Present (Y/N) ~
Date of Last Adequacy Test -~ //~ ¢'~'
Separation Distance from Absorption Field:
To Water-Supply Well I0'i ~ .~¢'~,,'~ ~, o, To Property Line ~_
To Building Foundation ~¢ ¢ To Existing or Abandoned System on
Lot N~, ; On Adjoining Lots ~ ;~ ~
To Water Main/Service Line /~1, A. To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course ~. ~'o¢ '
To Driveway, Parking Area, or Vehicle Storage Area ~ ~
Comments ~/'~0(- (~o,~! ~ $~ /¢',F ~ ~'+ ~toc~e¢- ¢.~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~_'~.,"~'~'~-~ ~'. ~ Date
Company ~(~-~¢'~ ~c~¢~¢~/' ~'¢~' MOA No.
Date of Payment _~ °'~t~(- ~,
Amount: $
Page 2 of 2
72 026 (1~/84)
Seal
GREATER ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C' Street, Anchorage, Alaska 99503 274-4561
~~ Date Received 2'
REQUEST FOR APPROVAL OF
1. Approval requested by:
Mailing Address:
2. Property Owner:
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Phone:
Mailing Address: . . ..-
3. L e.ga~_l nD e~crip~o~l.:. _~ .~L.,~ ,2~ /~ ~ ~ ~
5. Type of facilit3~ ~6 B~e inspected ~' /re. ~. No. of bedrooms
Well Data:
A. Type~ B. Depth
C. Constructio~ ~ ~ ~ D. Bacterial Analysis
Sewage Disposal System:
A. Installed /~¢"
C. Septic Tank: 1. Size
Installer
2. Manufacturer
D. Seepage Pit: 1. Absorption Area
2~ Material
E. Disposal Field: Total length of lines
8. Distances:
A. Well to: Septic tank
Nearest lot line
, Absorption area
, Other contamination
, Sewer Lines
B. Foundation to septic tank ~ , Absorption area
C. Absorption area to nearest lot line
EQ-034 (1/74) Page ] of two pages
· Page~2~f two pages - Re~'st for Approval of Individual /~'~'er & Water Facilities
Lega!' Description
Comments
Approved ~ ~, ~isapproved Da~e ~/~,4~
/
Approval Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental Quality
DIAGRAM OF SYSTEM
I certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED/'~, Dater
EQ-034 (l/74)
3330
GREATER ANCHORAGE AREA BOROUGH-..
Department of Environmental Quality
"C'~ St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
1. Type
2. Property Owner:
Mai-ling Address:
3. Name of Buyer:
Mailing Address:
of Inspection: CMRO VA FHA
~-~x~y'~z~- 4~ ~ ~] Day
CONV v/
Phone.~m. ~ ~-
Day Phone
4. Name of Lending Institution:
Mailing Address: Phone
5. Name of Realtor or.Agent:
Mailing Address: Phone
o
o
Location: /~
Type of Facility to be inspected: ~/~:/~ No. Bdrms..~
Water Supply
TYpe of Supply: Public Utility Individual
If Individual, number of dwellings presently served
If Individual, depth of well
/
Sewage Disposal System
Type of System: Public Utility Individual
If Individual, date of installation_
(on-site)
EQ-037 (l/74)
DEPARTMENT OF ~EALTN AND SOCIAL SD. DIVISION-O~PUBLIC HEALTH
INDIVIDUAL ~AND SEMI-PUBLIC
BACTERIOLOG I CA [.-WATER
~DIVIDUAL ~ 'SEMI PUBLIC [] CHLORtNE RESIDUAL PPM ',
CITY .r . ~'.- ZIPCODE '
ADDRESS
COMPLETE THIS SECTION -~"~ '
ONLY IF WATER IS AN INDIVIDUAL SUPPLY .
DATBCOLEECTED, ~ ' : Z j T S~ TIMECOLLECTR[~ . ' %] ~'~
Som~)leCo~lected From I~ K,lc~enTo~) [] BathroomJo~ ' ~ ........ tTo~
Asbe ~s,~-
[] Yes
Well- [] Dug [] DriVer 0 )dll~d ' [] Bored
SOURCE []] Spnng [] Cistern 00lner
· Walls-- [] Wood · [] Concrete E Meta O.Tile 0 BriSker
LOCATION: [] In Basemem
or Other Dra,nage Pi~,eC~'
READ NSTRUCTIONS
A-NA'LYSIS
OFFICE
[]]] Un[btisfa~lorv
SANITARIAN'S REMARKS
ON.
REVERSE SIDE
BEFORE
/\
COLLECTING SAMPLE
[]
Roar% '. :
06 1220 (bi BA6rERIOLOGICAL WATER ANALYSIS RECORD
Dole Received ~/./ /'~'~./~'~ ~-- TlmeReceiveO
Lactose Broth ~ % ~. 1 Otc 1 Oct 1 gcc 1 Oct .10cc I .Oct I .Oct
24 Hours "' x'
EMB ~'~'~' ~'~' AGAR
Loc[oSe BFolh 2~ hfs . 48 r~F5 Gram
1 ............. dl~a les Coliform ~ s~s to~¢ C Absent ~,