HomeMy WebLinkAboutSOUTHPARK #1 BLK 3 LT 15 Municipality of Anchorage
On-Site Water and Wastewater Program • (907) 343-7904 EMNf
ON-SITE WASTEWATER INSPECTION REPORT
L.
Permit Number: OSP181241 PID Number: 020-491-41 AUG 2 J 2018
Dwelling: ® Single Family (SF) ❑ Duplex (D) ❑ Multiple (SF and/or D) Project: ❑ New Z Upgrade
Name: ABSORPTION FIELD - EXISTING
Nancy & William Olzack
Address ❑ Deep Trench ❑ Shallow Trench ® Bed ❑ Mound
16221 Baugh Circle, Anchorage, AK 99516 ❑ Other
Phone Number of Bedrooms Soil Rating Total depth from original grade
3 GPD/SF Ft.
LEGAL DESCRIPTION Depth to pipe invert from original grade Gravel depth beneath pipe
Subdivision Block Lot Ft. Ft.
SOUTH PARK #1 3 15 Fill added above original grade Gravel length
Township Range Section Ft. Ft.
Gravel width Beds: Number of Lines Distance between lines
SEPARATION DISTANCES Ft. Ft
To' Septic 'Absorption Lift Station Holding Sewer Total absorption area Ft2 Number of trenches Dist.between trenches
From Tank Field Tank Line -- -- Ft.
Well 200'+ NA ' 200'+ NA NA TANK ® Septic ® S.T.E.P. ❑ Holding 0 Other
Manufacturer Capacity
Surface water 100'+ NA 100'+ NA ANCHORAGE TANK 1250 Gal.
Material Number of compartments
Lot Line 5'+ NA 1 5'+ NA STEEL 2
NA
Foundation 10'+ NA I 10'+ NA I LIFT STATION
i Manufacturer Capacity
Curtain Drain NA NA NA NA ' Anchorage Tank 1250 Gal.
Pump on level at Pump off level at High water alarm at
Remarks Existing septic tanks decommissioned
per code. 44 in. 42 in. 48 in.
Pump make and model Electrical Inspections performed by
Franklin 2445040117— 1/2HP MOA
PIPE MATERIAL House to tank 3034 Tank to 3034
Installer A+ Services _ drainfield
Drainfield 3&34— CO/MT 3031
Inspector First Water Consulting Services BENCH MARK (Assumed elevation) 100 ft
Inspection 1" 8/15/18d 8/20/18 Location and description
dates: 2"
3rd 4"' Bottom of Siding
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Engineer's Stamp
� •� OF ACAS ld
Conditional Approval: Date ,`p•,.
• t
49TH '>.*41,E
ed
i •V•, MICHAEL N. ANDERS^N ;, e
Ire f•. CE 46
r(fil I fisc:• .'''
Approved --f�`�°CC01 Cvuze-el /Date 2 2 1 1 $ 1 Q P
1VRalf SSiC�, A4�
Inspection Report_9-1-12.doc •
Permit No. OSP181241 Page: 2 of 2
Municipatity of Anchorage
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
Legal Description: SOUTHPARK ADDITION 1, LOT 15 BLOCK 3 PID No.: 020-491-41
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3-BR 71
HOUSE
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A-C=28,2' DATE: 8/20/2018
B-C=22.9'
A-D-34,0' DRAWN: First Water Cons. Serv.
B-D=23,4' SCALE: 1" = Z0'
FCO[CO TC01 TCO2 NT NT-•\.. `\\
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STEEL TANK
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se 4
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1 NO CORNERS SET THIS DATE
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I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
OF THE FOLLOWING DESCRIBED PROPERTY 0 OF
LOT 15, BLOCK 3, SOUTHPARK ADDITION 1 0 `51� a6f�p
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
./)0i°, '. SHANE A. HOLT ,'
VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN 04� LS-6914 ,O
THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS p�aA pa p
EXIST OTHER THAN NOTED. ��OpO0000a:
DATED AT ANCHORAGE,ALASKA THIS 20 TH DAY OF THE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND IS
AUGUST , 2018 NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES.
EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN
HEREON ( UNLESS INDICATED)
HOLT LAND SURVEYING NOTE: FENCELINES THAT MAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
9309 GROVER DRIVE PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS.
ANCHORAGE,AK 99507 ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE.
13981, FB 189-44( SWING TIES FOR NEW TANK PG 44) 345-5513
•JHciPAUTy 4p MUNICIPALITY OF ANCHORAGE tnenr
On-Site Water&Wastewater Program No
5�,
PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone: (907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite
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On-Site Wastewater Disposal System Permit
Permit Number: OSP181241 Effective Date: 8/6/2018
Work Type: SepticTank Upgrade Expiration Date: 8/6/2019
Tax Code Number: 02049141000
Site Legal Address: SOUTHPARK#1 BLK 3 LT 15 G:3236
Site Mailing Address: 16221 BAUGH CIR, Anchorage
Owner: OLZACK NANCY P &WILLIAM J Lot Size in Sq Ft: 32536
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 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: Date: op4)
Issued By: ' 1 ' CQ ut,t`�t Date: �/�
MUNICIPALITY OF ANCHORAGE
r`.°)Community Development Department Phone: 907-343-7904
Development Services Division
=_= Fax: 907-343-7997
On-Site Water & Wastewater Program
ON-SITE SEWER/WELL PERMIT APPLICATION
Parcel I.D. 020-491-41
NANCY & WILLIAM OLZACK Dayphone 907-250-5208
Property owner(s)
Mailing address
16221 BAUGH CIRCLE, ANCHORAGE, AK 99516
Site address 16221 BAUGH CIRCLE, ANCHORAGE, AK 99516
Legal description (Sub'd., Block & Lot) SOUTHPARK #1 BLOCK 3, LOT 15
Legal description (Township, Range & Section)
Lot Size 32,536 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field I I Initial I 1 Single Family (SF)
(w/wo ADU)
Septic Tank [1 Upgrade 1>1 Duplex (D) ❑
Holding Tank Renewal n
Multiple Dwellings n
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signatu - • operty owner or authorized agent)
Permit/Rush Fees: 215 COWaiver Fees:
Date of Payment: nb�11D1" Ig* Date of Payment:
Receipt Number: Chc�4100$ Receipt Number:
Permit No. OS Pig Pill Waiver No.
Permit App 9-1-12.doc
Michael N. Anderson, P.E.
Civil/Structural Engineering and Construction
4661 Natrona Ave. Anchorage, Alaska 99516
Phone 345-3377
Fax 345-1391
July 30,2018
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage,Alaska 99519-6650
Fax 249-7847
Re: New Septic Tank Permit
Legal: SOUTHPARK#1 BLOCK 3,LOT 15
The owner has requested we proceed forward to obtain a septic permit to upgrade the
aged septic tank on the subject lot. The proposed upgrade will serve the existing 3-
bedroom house.
The lot and area is served by public water and this system will not impact any of the
neighboring properties due to the lot layout. Please contact me if you have any questions.
Sincerely,
/4/)
Michael N.Anderson, P.E.
DESIGN CRITERIA:
DECOMMISSION EXISTING S.T. PER CODE, INSTALL NEW 1000-GAL SEPTIC TANK
& CONNECT TO EXISTING 500-GAL. LIFT STATION.
MAINTAIN 10'+ TO FOUNDATION, 5'+ TO DECK SUPPORTS, 10'+ TO WATERLINE
& OTHER REQUIRED SEPARATIONS. LOCATE WATER LINE PRIOR TO CONST.
INSULATE TANK IF LESS THAN 4' OF COVER & MAINTAIN 27.+ INTO S.T.
1(1
17.1' ...
I-
\iy\ a 1,1
Er
P)
in Iv
eee
¢ P 3-BR
6 .. . HOUSE
0
Via
DECOMMISSION E . . �ti•
soft
PER CODE, INSTALL NEW 27.1' Q
1000-GAL ST. & CONNECT �3Py
TO EXISTING 500-GAL. L.S. 15.7' FCO
MAINTAINING 10T ""'''l'l"'ii DECK 0
FOUNDATION, 5'+ TO DECK
SUPPORTS, 10'+ TO /
WATERLINE & OTHER 23.1,
REQUIRED SEPARATIONS. CO MI
COLIFT
co' STATION
- C
ChtTl, Lo
EXISTING FIELD
S80 27'79"E o
237.97'
LOT Sc ADJ. LOTS ARE SERVED BY PUBLIC WATER
Septic Design Prepared for 40.1161`"O
AllrNANCY & WILLIAM OLZACK i �� �F AL• ..,
SOUTHPARK ADDITION 1, LOT 15 BLOCK 3 ,Gj`� ��, ty ,
ANCHORAGE, AK * 49TH 1\ *AI
Michael N. Anderson, P.E. DATE: 7/30/2018 $ MICHAEL Ni ANDERSON.
4601 Natrone Ave. 1
Anchorage, Alaska 99516 DRAWN: FIRST WATER CON. SRV. Ozo li ../:74411(
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(907)727 8864/FAX: (907)345 1391 SCALE 1" = 20' \\\�=�
Municipality of Anchorage Page I 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: '~'~¢;~0 PIDNumber:
~_-.-¢-A¢---c.¢~ ~/. l,.J~'~¢-~--~(~ Wastewater System: [] New pgrade
Address:
tL,,¢-'~l -¢,~A¢.~ ~ ~ ABSORPTION FIELD
IND. of Bedrooms:
Phone: ~HG-Hol~ ~ ~ Deep Trench O Shallow Trench DBed ~Mound ~Other
LEGAL DESCRIPTION so.,ati.~: ~*~GPD/Sq. Ft. Totai Depth from original g~ad~:
Subdivision: Depth to pipe bottom ~rom original grade: Gravel depth beneath pipe
Lob ~ ~ Block: ~ ~¢~ / ~.~ Ct. ~'~ Fl.
Township: I Range: ISection; Fill added above original gra~/ Ft. Gravel length: ~/
WELL: D New D Upgrade Gravelwidth: ~ I Numberoflines: Distancebetwee~ines:
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: -- Date Drilled: Static Water Leveh Installer: Date installed:
Yield:GPMII Pump Set at: Ft.[~Casing Height Above Groond:Ft. ¢¢ ~1 ~ ~ TANK
SEPARATION DISTANCES ~eptic U Holding U S,T.E.P.
TO Septic Absorption Lift Holding )ubl[c/Private Manufacturer: Capacity in gallons:
F~oR~ Tank Fie~d Station Ta~k Sewer Lines ~
f Material: Number of Compartments:
s.,f~o~ '1~'+ ~'~ ~'~ LIFT STATION
Water ~
Lot /
Line W~ 1~/ ~ / Size~: Manufacturer:
on" ~evel at: "Pump off" level at: High water a arm at:
Foundation ~1 ~/ ~1 ~ ~ "Pum~. I [~ I
Curtain Pump Make & ModelJ Electrical Inspections performed by:
Drain ~ ~ O~ ~ ~ ~ ~ ~l ~ J ~~
BENCH
Remarks: OL~ ~%~ ~¢E~,
( Location and Description:
I Assumed Elevation:
ENGINE~R'S~EAL
17034 Eagle River Loop Road, No. ~4 ~..~&~/;~ ~..
Inspections performed by: ~.¢e ~t~e~,A~:A~ ~5~ Dates: 1st
Department of Health and Human Services approval ~¢~?~'?' '
Reviewed and approved by: ~ Date: ~-~ -~ "% : ' "-'.-'
72-013 (Rev 9/91) MOA 25
PermitNo. RWg2D29n Page C of ~
Municipality of Anchorage
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
Legal Description: SOUTHPARK SUBDI~S1ON #1, BLOCK 3, LOT 15
PID No.: ozoosz§5
FINAL C04
99.9~
9§.4'/ ~.95.2'
MT4
· 100' GROUNDWATW, R FOUND
72-013 A (Rev. 9/91 ) MOA 25
PAGE 1 OF 2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 3'L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920290
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:WEBSTER CHARLES V &
OWNER ADDRESS:16221 BAUGH CIR
ANCHORAGE, ALASKA 99516
DATE ISSUED: 9/16/92
EXPIRATION DATE: 9/16/93
PARCEL ID:02005155
LEGAL DESCRIPTION: SOUTHPARK #1 BLK 3 LT 15
LOT SIZE: 32536 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD 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 DRINKINS WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
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:
1. REVISED DESIGN SUBMITTED 4-21-93 APPROVED. RESULTS OF
WATER MONITORING THRU HIGH WATER PERIOD SUPPORT
REVISION AND RELOCATION OF SYSTEM.
2. VERIFY INTEGRITY OF EXISTING SEPTIC TANK.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
3. PROPERLY ABANDON FAILED SYSTEM.
RECEIVED BY:
DATE:
DATE:
PAGE 2 OF 2
FOLD
Subject:
To:
ROBERT A. SHAFER, P.E.
& .gi.eering 6o . 9 9
17034 EAGLE RIVER LOOP ROAD, SUITE 204 FAX; 694-1211
EAGLE RIVER, ALASKA 99577
LOT 15; BLOCK 3; SOUTHPARK SUBDIVISION #I
SUSAN OSWALD
MUNICIPALITY OF ANCHORAGE
MESSAGE
HEALTH AUTHORITY APPROVALS
EXCAVATING / CIVIL ENGINEERING
WORK ARRANG ED I ADEQUACY TESTS I SOIL TESTS
WATER & SEWER LINES & MAIN EXT.
ON SI~'E INSPECTIONS
iINATOR
DATE OF MESSAGE
ORIGINATOR
ROUTING SYMBOL
Water monitoring in accordance with you request at the referenced property h~
revea£ed the fo~£owing resutts:
FOLD
I. 4-29-93 5.5 feet
2. 5-3-93 6.0 feet
It appears that high water has passed. Water monitoring indicates that the
excavation depth shown on our red,sign dated 4-22-93 do~s provide for a
water tab£e separation in ~xc~ss of 4 fe~t.
Recuest you approve the red,sign so the contractor can resume work.
REPLY
From:
DATE OF REPLY
SIGNATURE OF REPLIER
ROUTING SYMBOL
TITLE OF REPLIER
RETAINED BY ADDRESSEE
.to
.0£ = .I
':191 "lO~ld/91¥1~ O
NMOHS S'V
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LE(~^L DESCRiPTiON: ~'\~ ~.~
Township, Range, Section:
1
2
3-
4-
5-
6-
7-
8-
9-
10-
11
13-
14-
15-
16-
17
18
19
2O
COMMENTS
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Depth Io Water Afier,~
monitoring?
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~"'~ (minutes/inch) PERC HOLE DIAME:i'ER : .
PERFORMED BY: S & $ ENGINEERING ~ ¢'~-~(""~ CERTIFY THAT THIS TEST WAS PERFORMED IN
12'034 Eagle River L~ep Road No, 204 \. ~ ,~--"'~'7_...~'~ ~
ACCORDANCE WITH ~T~,~N~t~I{)~UIDELINES IN EFFECT ON TFI ~ DATE. DATE:
72-008 (Rev. 4/85)
Munlclpalily ol Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:,L~ ~::~--'~ '~
Township, Range, Section:
1
2
3
4
5
6-
7'
8-
O-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS
ROGER J.: HAFER ~
No.
SLOPE
WAS GROUND WATER
ENCOUNTERED?
DEPTH?
E
Monitoring? [ ~' gale:
SiTE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
4 ,-s'. ~ ' s~/~'
~ ~'.~ ~ ~/4' ~(~
PERCOLATION RATE Z~.~ (minutes/inch) PERC HOLE DIAMETER
TESTRG.. TWEEN '5 ,TAND ET
PERFORMED BY: $ & S ENGINEERING I ~ t..P--.~/'~/~ CERTIFY THAT THIS TEST WAS PERFORMED In
17034 Eagle River Loop RoadNo. 204! ~c~ ,- I c>-~]~''"
ACCORDANCE W~TH A~f~.t~¥~C~,~U~DEUNES ~N E~ECT ON TH~S DATE. DATE:
HUNICI?'ALI?¥ 0~? ANCHOIi~AGB~ BUILDING SAPE?Y DIVISION
:3500 l;~'~:>.C 7LIDOI'~ ROA1)
]:~SP~C]~IONS (907)~6;3-3464 INfO'NATION (007)786 q32iI
NAME: SPARROW S ELBCT, ~--~ PBB, HI~: ¢:: c, :7~ -.-. '7 5 0 :1
/0,
].'YPB 0)7 INSPBC[fiON: BLECTRICAL ROUGI~:
0 0
O O
~'. ] b,l!f,I, RI~BXA*'qlNE ~T ,'.)~'~X[/ ]Nb}')i:,CTftq.~ ~ ~ uO NOT CONCI:JAI,
CONNt~NTS ~
~ .i //.
.... BA'I E ,,
WH}.,N ~REC'rlONS ARE HAI)B~ j~I, EAoB CALl., ['OR INo~EC,] ION
, ,s BO NOT REHOVE THIS NL.t.I. CB
STATE OF ALASKA
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
APPROVAL OF ON-SITE RESIDENTIAL WATER AND SEWER SYSTEMS
PROPERTY DESCRIPTION
~t, Block & Subdivision or U.S. Su~ey
Lot 15, Block 3 (16221 Baugh Circle)
SouthPark Subdivision #1
PWSID no. 213475
This approval does not constitute a guarantee of any kind, explicit or implied, as to the performance
of the water supply and wastewater disposal systems.
WATER SUPPLY
A recent water sample was tested and found to meet Department of Environmental Conservation drink-
ing water standards for total coliform bacteria.
DatMaye 25, '93
En~. A~sL. ii
WAST EWAT ER DISPOSAL
The : wastewater system was:
[] insl the Department of Environmental Conservation and found to be in compliance with
applicable irements of 18 AAC 72;
[] inspected by a sional Engineer who certifies th; complies with applicable re-
quirements of
[] installed by a Certified
of 18 AAC 72; or
[] tested by a Professional
and that the systen
This
)lies
Ifora[] single family []
system complies with applicable requirements
:ertifies that the performance of the system is satisfactory
mmum separation distances specified in 18 AAC 72,
:i-family unit with a total of bedrooms,
The Date
18.0404 (Rev. 8185) DISTRIBUTION: WHITE--BANK/LENDiNG INSTITUTION; CANARY--APPUCAN~ PINK--DEPARTMENT
WALTER J. HICKEL, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
May 25,1993
(907) 349-7755
Mr. Jim Williams
S & S Engineering
SUBJECT: Lot 15, Block 3, (16221 Baugh Circle), Southpark Subdivision #1
Class "A" Publio Water System, PWSID 213475
Dear Mr. Williams:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on April 1, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on May 6, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample jesuits were submitted to the
Department on December 1, 1992. This does meet the provisions of 18
AAC 80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on November 6, 1991. Based on
analysis of the previous VOC samples results have been satisfactory. This
does meet the provisions of 18 AAC 80.200(a), State Drinking Water
Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the specified legal description
noted above only.
Mr. Jim Williams
May 25, 1993
Page 2
if you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
Tom Fink,
Mayor
unicip lity of
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
September 16, 1993
Deanna R. & Thomas M. Field
16221 Baugh Circle
Anchorage, Alaska 99516
Subject: Lot 15 Block 3 Southpark Subdivision #1
Permit ~SW920290, PID ~020-051-55
The subject permit, issued September 16, 1992 by this office for a
single family well and/or on-site wastewater system, has
expired as of September 15, 1993.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well
this office for documentation of the
close the permit.
log must be sent to
installation and to
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questions,
~rog .r .amy ~Mana .ge_ _r _
On-site Services
please call this office at
343-4744.
enc:
Copy of Permit
cc: S & S Engineering
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
PO BOX 196650 ANCHORAGE, ALASKA 99519 343-4744
HAND WRITTEN PERMIT
Permit Number: SW
Date Issued: ~--
Design Engine~er:
Owner Name: ~/~ ~',7~
Owner Address: /
Permit Type: -~>~'~.. ~L~
Expiration Date: ~/~
Day Phone:
Parcel ID:
Lot Legal:
Subdivision: Bloc : 3
Section: Township: Range:
Lot Size:~2. ~(sq.ft. or acres)
Max Bedrooms: This Permit: ~ Total Capacity:
SEPTIC TANK: Minimum septic tank capacity: /~-U. gallons. Each
septic tank must have at least 2 compartments, insulation is
required if depth to top of septic tank(s) is less than 4.0'
Lift stations require an appropriate electrical inspection.
WELL LOG: A copy of the well log must be sent to DHHS within 30
days of the well's completion.
CERTIFY THAT:
1. I will install the on-site sewer system and/or well in
~ ,, ~ accordance with all codes and regulations
(~1~%~' n ~}~3 ~ ~,~n~cioalitv of Anchorage (MOA) and State
~ ~35~ ~J~-~om~lian~e with the design criteria of this permit.
~.~ 6 -~ 2. I will adhere to.all MOA and State o{
%\ ~ for separation distances from any exzsLxn~.
%~\ ~ \~ system, or surface water on this or any a~jacenn o
~ ~ 3. ~ei~r~nd that.this per~it ms v~lm~ {or a smn%l~lso
~' family dwelling w~th a maxmmum of ~ De~r?oms.
understand that any enlargement will require an
additional permit.
4. I understand this permit is issued for 365 days and
expires one year from the date of issue.
5. I will notify DHHS prior to all inspections by the
engineer or well driller.
SIGNED ~C-.~.
(6~ner/designee)
/
DATE:?/
DATE:
db/ll5
S~pt~m§~r 8, 1992
ROBERT SHAFER, P E
ROGER SHAFER. P E
CIVIL ENGINEERS
(907) 694-2979
FAX 694 1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
Municipality of Anchorag~
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Str~t
P.?.. Box 196650
A~c~orag~, Alaska 99519-6650
REFERENCE: Lot 15~ Block 3~ So~hpark Subdivision #I
R~qu~st you issu~ a p~rmit to upgrade th~ septic syst~ s~rving th~
r~fer~nc~d prop~rty.~
Th~ ~xisting l~aehfi~ld monitoring tub~ was Znsp¢ct~d and found to hav~
an abnorma2~y high liquid l~v~ indiGativ~ of a system in a stat~ of
failure..
W~ do not anticipat~ any adv~rs~ ~ff~ets on n~ighbor~ng prop~rti~ by
thc i~stallation of th~ proposed upgrad~.~
If you hav~ any qu~tio~ or require add~onal informc;~ion for your
r~v~ew, pl~as~ contact uS.,
Sincerely,
ROGER J'i SHAFER, P.E.
RJS/gm
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
I
I
.0£ = ../
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
1
3-
4-
8-
9-
10
11
12
13
14
15
16
17
18
19
20
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water Alter
Moniloring? Date:.
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE --
(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: S & S ENGINEERING i ' ~--.z ¥--~
17034 Eagle River Loop Road Ne, 204 ATE
ACCORDANCE WITH ~,J~I~T~T~,j~I~Ni~GUIDELINES iN EEFECT ON THIS D .
72-008 (Rev, 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
Municipality of Anchorage ~ ~t~"*"~' ' ~
825 L Street, Anchorage, Alaska 99502-0650 ~J~ ROGER J, 8~AFER ~ ~
so, s -
LEGAL DESCRIPTION:
Township, Range, Section:
4-
5-
6-
7-
8-
9-
10-
11
13-
14-
15-
16
17
18
19
2O
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT ~ 0
DEPTH? P
E
Depth to Waler Alle it ~.~__~..~,~
Monitoring? ~ Dole:
SLOPE SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~('/~ (minutes/inch) PERC HOLE OIAMETER --
TEST RUN BETWEEN ~'~ FTANO ~" FT
PERFORMED BY: $ & S ENGINEERING i ' ~ ~..~k CERTIFY THAT THIS TEST WAS PERFORMED
17034 Eagle River Loop Road NO. 204~
ACCORDANCE WITH A~,~i~,e~/[~i~:gaC~J~L7~UIDELINES IN EFFECT ON THiS DATE. DATE:
72-008 (Rev. 4/85)
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
NAME
/vi A ~.'T H iq
MAILING ADDRESS
LEGAL DESCRIPTION
~'A RE hi LAFC, C-&N'T
] Well
DISTANCE TO: I
Manufacturer G R 4~
Liq. capacity in 9a OhS ~
DISTANCE TO: I Well
LOCATION
Absorption ar M at~!j.~ ~_~
Or-'-- '7 ~a Dwelling ~
I. nside length~ W dth ~
Dwelling
Well
DISTANCE TO: Length
No. of lines of each llne
PHONE
g~-o~i8 I ~NEW
[~]UPGRADE
Top of tile to finish grade
Length8, ~'
Nearest lot
Trench w_~dth
Width
Foundation
Total length of lines
Material beneath tile
Depth ~j~ ,~
Type of crib Crib diameter Crib depth
Well ~°l-~ ~,~C- Building founda ion
U.~ A 'r E I~
Depth ~ Driller
Building foundation
DISTANCE TO:
inches
NO. OFBEDROOMS
PE MIT NO.
~r,¢o ~+6~$-
No, of comp~.~ments
Liquid
Liquid capacity in gallons
PERMIT NO.
Dist a n c e~be't~ween lines
Total effective absorption area
PE IT N .
Total effective absorption area ~/~ J'l~ '2 /L~ I /
Nearest lot line
sEiSpttll i~i~;t li'~ne
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
MI_I~ICIPSLITY OF 8NCH~
DEPFIRTMENT OF HEFILTH 8ND ENVIRONMENTFIL PROTECTION
825 L STREET, FINCHORFIGE, FIK 9950t
264-4720
PERMIT NO:
DRTE ISSUED:
849455
067±4d84
FIPPLICFINT
ADDRESS:
CONTFICT PHONE:
MFIRTHR KRREN LRRGENT
82~0 SERCLIFF
FINCHORFIGE.. FIK 99502
248=09iB
LEGRL DESCRIP:
LOT SIZE:
LOT LOCFITION:
MRX BEDROOMS:
SUBDIVISION: SOUTH PFIRK Sl LOT:
SECTION: 3 TOWNSHIP: tin RFINGE:
32536 (SQ. FT. OR FICRES)
BFIUGH CIRCLE
BLOCK:
LISTED BELOW 8RE THE OPTIONS FIVFIILFIBLE TO YOU IN DESIGNING YOUR SEPTIC
SYSTEM. CHOOSE THE OPTION THFIT BEST FITS YOUR SITE.
DEPTH TO PIPE BOTTOM (FT.) 3. 5
GRfiVEL DEPTH (FT.) 0 5
TOTRL DEPTH (FT.) 4 0
GRRVEL WIDTH (FT.) tD.O
GRFIVEL LENGTH (FT) 36. 0
GRBVEL VOLUME (CU YDS.) 25.3
TRNK SIZE (GFILS) 1,000, 0
SOIL RRTING (SQ. FT. ?BR) i50
i, 0
40
5.0
79. 0 m~
~L., 000. 0 mm
±50
DEPTH TO PIPE BOTTOM ~ ~. 5 FT. REQUIRES INSULFITION
DEPTH TO PIPE BOTTOM < 4.0 FT. MFIY REQUIRE B LIFT STRTION
GRFIVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT.
TRNK MUST HRVE 8T LEFIST TWO COMPRRTMENTS
ERCH)
CERTIFY THFIT:
i. I RM FFIMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS
RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORFIGE (MOB) RND THE STRTE OF RLRSKR.
I WILL INSTFILL THE SYSTEM IN FICCORDFINCE WITH FILL MOB CODES FIND REGULFITIONS,
RND IN COMPLIRNCE WITH THE DESIGN CRITERIR OF THIS PERMIT.
I WILL FIDHERE TO FILL MOB RND STRTE OF RLRSKR REQUIREMENTS FOR THE SET BFICK
DISTFINCES FROM RNY EXISTING WELL, WFISTEWFITER DISPOSRL SYSTEM OR PUBLIC
SENERFIGE SYSTEM ON THIS OR FINY FIDJFICENT OR NERRBY LOT.
I UNDERSTFIND THFIT THIS PERMIT IS VRLID FOR R MRXIMUM OF ~ BEDROOMS RND
FINY ENLFIRGEMENT WILL REQUIRE RN RDDITIONRL PERMIT.
IF FI LIFT STRTION IS INSTFILLED IN FIN RRER COVERED BY MOB BUILDING CODES,
THEN (i) RN ELECTRICRL PERMIT FIND INSPECTION MUST BE OBTRINED; (2) RS-BUILTS
WILL NOT BE RPPROVED WITHOUT RN ELECTRICRLx INSPECTION REPORT; RND (~) THE
ELECTRICRL WORK MUST BE DONE 89 R LICENSED ELECTRICIRN.
8PPLICRNT: M8RTHR KRREN LRRGENT U
ISSUEC BY ~ ~, -- - :
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
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
DATE PERFORMED:
SITE PLAN
TM
11
12
13
14
15
16
18
19
2O
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER I~_
E
IF YES, AT WHAT ~ ~
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEStaT, UN B.~ETWE~E~.~Nr FT AND FT ,
CERTI FI ED BY: DATE:
•
•
Municipality of Anchorage eG'
On-Site Water and Wastewater Program <` 1�V
(907) 343-7904 SA El
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 020-491-41 Expiration Date: adu, .2 I / 017
1. GENERAL INFORMATION
Complete legal description SOUTHPARK#1 BLOCK 3,LOT 15
Location (site address) 16221 BAUGH CIRCLE,ANCHORAGE,AK 99516
Current Property owner(s) NANCY P.&WILLIAM J.OLZACK Day phone
Mailing address 16221 BAUGH CIRCLE,ANCHORAGE,AK 99516
Real Estate Agent Day phone
2. TYPE OF DWELLING:
Z Single Family (w/wo ADU)
0 Duplex
0 Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well 0 Individual
Individual Water Storage ❑ Holding Tank 0
Community Class_Well 0 Community 0
Public Water System ® Public Sewer 0
WaiverNariance request for: Distance:
Received by: Date: B/Zi//S
COSA to be released o th ineer,unless otherwise requested by the engineer.
COSA Fee $ 5244. Waiver Fee $
Date of Payment - I Date of Payment
Receipt Number - l 0t.3 Receipt Number
COSA# 06 C le l,S3o Waiver#
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,
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.
Name of Firm ANDERSON CONSTRUCTION& ENGINEERING Phone 345-3377
Address 4640 SHOSHONI DRIVE,ANCHORAGE,AK 99516
Engineer's Printed Name MICHAEL N.ANDERSON,PE Date 07/19/2018
•
dr/ `"a°
c°,4 j
6. DSD SIGNATURE
System #1 Approved for 3 bedrooms. 0.
MICHAEL .DE•Ic • et•
_-
System#2 Approved for bedrooms. �c�-a° C` ��4�9
Disapproved. hP �'°/� �'` ;'i`•"
Conditional approval for bedrooms, with the following stipulations:
r�r A G•iio
ON\140�Rp,Npy
'9(> `1`1N OGRP
QR
n W�'�o �
By: 'RAW l AOriginal Certificate Date: ?•/2 1 i 3
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 Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other •
COSA blue sheet 10-10-12.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system _
Certificate of On-Site Systems Approval Checklist
Legal Description: SOUTHPARK#1 BLOCK 3,LOT 15 Parcel ID: 020-491-41
A. WELL DATA - PUBLIC WATER
Well type If A, B, or C provide PWSID# Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate_ mg/L
Arsenic: ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material STEP!STEEL Date installed 811 512 01 8
Tank size 1250 gal. Number of Compartments 2 Cleanouts (Y/N) Y
Foundation cleanout(Y/N) Y Depression over tank (Y/N) N High water alarm (Y/N) Y
Date of pumping NA-NEW TANK Pumper
C. ABSORPTION FIELD DATA
Date installed 5/6/1993 Soil rating (g.p.d./ft2 or ft2/bdrm) 0.5 System type MOUND
Length 50 ft. Width 10.30 ft. Gravel below pipe 0.5 ft.
Total depth *2-3.1 ft. (Measured 7/13/18) Eff. absorption area 1000 ft2Monitoring tube Y Depression over field N
Date of adequacy test 713/2018 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 500 gal. New depth 3 in.
Elapsed Time: 1260 min. Final fluid depth 0 in. Absorption rate >= 450 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N &type) N If yes, give date
D. LIFT STATION
Date installed 8/15/2018 Size in gallons 1250 Manhole/Access (Y/N) Y
"Pump on" level at 44 in. "Pump off' level at 42 in. High water alarm level at 48 in.
Datum BOTTOM OF TANK Cycles tested 2 Meets alarm&circuit requirements?Y
E. SEPARATION DISTANCES
WELL ON LOT TO: - NA/ PUBLIC WATER
Septic tank/lift station on lot On adjacent lots _
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas — Manure/animal excrete storage areas ^_
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10' Property line 10'+ Absorption field 5'+
Water main 10'+ Water service line 10'+ Surface water 100'+
Wells on adjacent lots 200'+
ABSORPTION FIELD ON LOT TO:
Property line 10' Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water 100'+ Driveway, parking/vehicle storage 10'+
Curtain drain 50'+(None Known) Wells on adjacent lots 200'+
F. COMMENTS
*Majority of field has 2.5'+of cover with the lower SW corner less than 2'with no known frost issues.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in O F Az�>,,
conformance with MOA COSA guidelines in effect on this date. , .
'• k
's
�.•' •• 'F
Engineer's Printed Name MICHAEL N.ANDERSON.PE 49TH , .•;7•
r�
Date 08/20/2018 % 0
A•. MICHAEL N. AND SON ;
rrjtltk/PC\
CE- �6 ��
COSA canary sheet 2-6-15.doc PR.0F $$1� +
Municipality of Anchorage
Development Services Department
Building Safety Division =. _
On -Site Water and Wastewater Program
4700 South Bragaw St. s `�
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. GZO —OSI -ss HAA #_kd%��/�
Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lot t.S 0le-c l2 3 SG,4fi` eet ' k SIb f do * /
Location (site address or directions) 162 2 / 8au!74 (fire le
Current Property owner(s) CAr cf E Tulle Mar hf) Day phone SSZ-9066
Mailing address
Lending agency
Mailing address
122/ I3auUti Ctrtic /}n�i �}Gc 99S/l
Day phone
Real Estate Agent None. F.S. 130. Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
❑
Individual On-site
S]
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System +wwCC
HCl
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. 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 Health Authority Approval Guidelines for this application, shows that the
on-site water supply and/or wastawater disposal system is(are) safe, functional end 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
wastewatar disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm ic[,,,t ~./o.r, 7'e~A,,,, ¢,~ / ...('~'~",.',; ¢e¢ Phone
Address I'Y5'$~
Engineer's Printed Name -/7,,~,¢,~or~ ~.. ,~-~o,.-~. Date
DSD SIGNATURE ~~~ '~
~ Approved for ~ bedrooms. ~.~.'~, '. C~- 3Ss~ .~.;~-' ~
Conditional ,pproval [or bedrooms, w~ the followm~ ~bpulations:
Additional Comments
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Da
/ ,
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastowater Program
4700 South Bragaw St.
P.O. Box 196650 Anchomga. AK 99519-6650
www.ci.anchorege.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L~/ /~-..
A. WELL DATA N. ~,
Well type
Date completed
Total depth ft.
If A, B, or C provide PWSID #
Sanita7 seal (Y/N)
Cased to ft.
FROM WELL LOG
Parcel ID:
~o -05'/ -~-s-
Well Leg (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
in.
Date of test
Static water level ft. ft.
Well production g.p.m, g.p.m.
WATER SAMPLE RESULTS:
Coliform __.cotonias/100 mi. Nitrate
Date of sample: Collected
B.' SEPTIC/HOLDING TANK DATA
Tank TypeJMateri~l 5'epic /.g/e4, /
Tank size t OO~ gal. Number of Comparlments
Foundation cleanout (Y/N) Y'
Date of pumping ~/~ 7/'O /
mg./I.
Depression ova' tank (Y/N)
Pumper A '+
Other bacteria
colonies/100 mi.
Date installed
Cleanouta (y/N)
High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date installed 5-/0' / 93 Soil rating (g.p.d./fl2 or ~/bdrm) p,
Length 5"C~ ft. Wklth lO ~ - 3'~:~ ' ft.
Total depth 6 ff. Eft. absorption area ttn2~ Monitoring tube __
Date of adequacy test ~' / ~- / / O ~_ Results (Pass/Fail)
System type /~omn ~
Gravei below pipe O, ~" ft.
y' Depression over field
For ~ bedrooms
Any rejuvenation treatment (past12 mo.) (yIN & type) I~lonz I,<,~¢~..,~, Ifyes, givedata ,v. 4,
Fluid depth ln absorption field before tast b in. Water added -/ 'f Tgal. . Nowdepth A in.
Elapsed Time: ~L~ min. Final fluid depth /t in. Absorption rate >=
O. UFT STATION
Date instalted 5'/e" / ) 3
'Pump on" level at 3-~" in.
Datum ~./~,,,.* ~,/ ~.~'
Size in gallons
'Pump off" level at
Cyales tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: N'. ~'.
Septic tankJtilt station on lot
Absorption field on lot
Public sewer main
On adjacent lots
On adjacent lots
Public sewer manhole/cteanout
Building foundation
Water main ~ I~
Wells on adjacent lots
Sewer/septic service line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Property line
Water service line
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'
Water Service line · *'¢, *
Curtain drain M,,^~
Absorption field
Surface water '~ ,'c,o'
Building foundation 3 $ ' Water main ~. ,,o ~
Surface water ~, ~o~, D~eway, pe~ng/vehide storage
Wetls on adjacent lots A./. 4 ~> Zo~ '~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date
HAA Fee $ ~
Data of Payment
Receipt Number ~
(Rev, 12/00) "
Waiver Fee $
Date of Payment
ReCeipt Number
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
1. GENERAL INFORMATION
Complete legal description
Lot 15; Block 3; Southpark ~I
Location (site address or directions)
16221 Bau~h Circle
Anchorage, AK
Property owner Tom & Deanna Field Day phone
Mailing address C/0 State Farm Iru~urance R~ocat~on Svc. Attn: Miche.¢.l~ Custe~
61709
Lending agency
Mailing address
Agent
Address
2702 Ireland Grove Road
Bloomington, Illinois
Day phone
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3 \,
NOTE:
Individual well
Community well XXX
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
7:~-O25 (Rev, 1/91) Front MOA~I
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 inves~ation 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
Address
Engineer's signature
S & S ENGINEERING
17034 Eagle River Loop Read No. 204
Eagle River~ Alaska 99577
Phone
Date
,OF ..~
DHHS SIGNATURE
~. Approved for ~
Disapproved,
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
..~'"~2
By: / .
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.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744
Health Authority Approval Checklist
Legal Dcscription: LoT' If'"
A. WELL DATA
Well type C
Log present (Yfi',l)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level /
Well production J
WATER S~L~TS:
~n~le .' - Nitrate
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to Casing ~round)
Wires ~erly protected (Y/N)
FROM WELL LOG //'~ AT INSPECTION
Collected by:
Other bacteria
B. SEPTIC/I-iGLD~',iG TANK DATA
Date installed ~'/t0/~' ~/ Tank size
Foundation clea.nou~t (~,(N)
,l~a. ie o~iPumping i0 [~l/q
C~ ABsoRPTiON FIELD DATA
Dateii~stalled ~'/6 / ~/'~
· Leng4h : 30 .' Widflt
Effective ~bsorption h/ea ~ 00 0
Date of adequacy test I o
Fluid depth in absorption field before test (in.);
Fhfid depth ~ .(las.) Minutes later:
/ o o O Number of Compartments ~ Cleanouts (.~r/N).__
Depression (Y/~) /v 6 High water alarm (Y~fi}). ~' 0
Pumper /toro
rating~r fi:/bdm0 (9. ~ System type /~ & O
Soil
~ 0 Gravel thickness below pipe O. g- Total depth ~
Monitoring Tube present{O/N) Y/'J' Depression over field (Y/0) ~' o
Results ~_.~'Fail) /°`4 ~..f For ~ bedrooms
O Immediately after//-]Jgal, water added (in.):
}1 Absorption rate = /45'-0 '/- g.pd.
Peroxide treatment (past 12 mouths) (Y/N) /v°"/'L tc/vo~v~ If yes, give date --
LIFt STATION
Date installed 5 / 6 / ~/ 'J
Mauhole/Acccss (~/N)
lfigh water alarm level at*
Cycles tested ~
Size in gallons
"Pump ou" level at* ',,3.. g
,5'00
'~Pulnp off' level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ; On adjacent lots
Absorption field ou lot ~
Poblic sewer main ~ Public sewer manhole/cleanout
SeLw,,cgsepl~crvice liue Lift station
SEPARATION DISTANCES FROM SEPTIC/IIC. LDI-NG--TANK ON LOT TO:
Baildiug fouudation ,i' /'-b t
Property line / o 9- Absorptioa field
Water nmin/servicc line :~ 5'/Y' Surface water/drainage ! 00 C/_ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Bailding foundation '~ $' ! '/--
Surface water / 0 0 'P
Curtaiu drain
Water main/service liae
Driveway, parking/vehicle storage area
Wells on adjacent lots ,'v /.4 Property line
F. ENGINEER'S CERTIFICATION '"
Waiver Fee $
Date of Paymeut
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
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
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL. FOR A SINGLE FAMILY DWELLING
Parcel I.D. # (").t~/~)_,('"~\-~h~ NAA#
~- ~,'~
Lot 15; Block 3; '~'S~vision Ad~on
Location (site address or directions) 16~¢7 Bm~gb Rx',~o,~,_; A~ohm~g~.; A,~Aka
Property owner
Mailing address
Lending agency
Mailing address
Chuck Webster
Day phone
16221 Bau~h Cir~e~ Anchorage, Alaska 99516
Day phone
345~4094
Agent Bonnie Hockstein/JACK WHITE COMPANY Day phone
Address ~¢fll P~--.9~D~.A~,~.gn.[:[-~ lflfl~ An,,bn~,~g~ A£,~/,b~ 99~fl3
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: $ '~
TYPE OF WATER SUPPLY:
NOTE:
562-5500
Individual well
Community well ~x,~
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community onTsite
Public sewer
If community wastewater system, provide written confirmation from State AD£C
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA #21
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 Murdcipality 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.
Phone ~ ~'~-'Z_ ¢'2 ~
Name of Firm
Address
17034 Ea~l~iYer/~oop Eoa~l No. 204
Engineer's signature ~
Date
DHHS SIGNATURE
Approved for ~'~ __
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragrapl~ 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does th is 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
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /,.../E.~,, ~(~,, ?.¢~T~,~f_,c- ~,/~, :/¢-( Parcel I.D.
Well
~' If A, B, or C, attach ADEC letter. ADEC water system number __
Log Date completed Drill(
Total depth __Cased to Casi ht
Sanitary seal (Y/N)
Wires propel (Y/N)
FROM AT INSPECTION
Date of test
Static water level
Well flow
Pump
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot O'~C~-~
Absorption field on lot 200
Public sewer main '~)/'~
Sewer service line
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cteanout
Petroleum tank
g.p.m '~ :¢ >
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate /k.~/~ Other bacteria A"/~'~
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~--Id-~--(d~L~
Cleanouts Y~q) ~
High water alarm (Y/I~
Date of pumping
Tank size /~(-~(~ C~/~'-~--~Compartments ~
Foundation cleanout Y~) ,Y Depression (Y/~) ~'~-~h
~f/,/~ Alarm tested (Y/I~ /~//,,z).
, ~ 7 - Pumper -
SEPARATION DISTANCEs FROM SEPTIC/HOEu~NG TANK TO:
Well(s) on lot
TO property line
Surface water/drainage
On adjacent lots
Absorption field
Founu:'Jon
Water main/serv; ~e line
79-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes(~/N)
Manufacturer
Manhole/Access ~N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot ~//~¢ On adjacent lots
~ ~'/' Surface water /,~d %
Date installed
Length
Total absorption area
D, ABSORPTION FIELD DATA
Width
Depression over field (Y/~
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/~
Soil rating
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for ~
System type (~'~
Total depth
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~///~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots (~,02 '¢- Property line
~'(~' To existing or abandoned system on lot ~,~
Cutbank /t/f/'/./. Water main/service line .~; r~.
Driveway, parking/vehicle storage area
E, ENGINEER'S CERTIFICATION
I certify that I have ch~~formed to all MOA and HAA guidelines in effect on the date of this, inspection.
Signature.
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Paymert
Receipt Number
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
1. GENERAL INFORMATION
Complete legal description
Lot 15; Block 3; Southpark Subdiv~ion No. I
Location (site address or directions) 16221 Bauqh
Property-own~" '" Karen Larg~nt
Mailing address "~¢¢~'-~;'- ~'~ %0, ~/
..; -i;.. Day phone 5'-¢~ ¢ 5'5% o
Lending agency
Day phone
Mailing address
Agent
Day phone
Address
.Unless ot~-erwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well XX
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.
72~25 (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 Phone '; ¢, ~ ENGINEERING
, Eagle River, Alaska 99577
Engineer s signature .
DHHS SIGNATURE
Approved fo r ~/~/~ ~,)
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By: /¢~-¢~ ~_/c4.,~,._Z-~:
Date %--~/ 6, - ~//
The Municipality of Anchorage Depadment 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
Municipality of Anchorage
Department of Health & Human Ser~,ices
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: /--/~.' 5! K'..~; .-.%,~J~ /3R¢~" _~ _~_.~ Parcel I.D.
A. WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
If A, B, or C, attach ADEC letter. ADEC water system number Date completed ?)/~ Driller
Cased to
Casing height
I
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main *J/IA
Public sewer service line
; On adjacent lots Z. 0(:2 ~'
; On adjacent lots ' 2.00 -f
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/IO/f~ Tank size /0C~2 ~/ Compartments
Cleanouts (Y/N) t~ Foundation cleanout (Y/N) ~1 Depression (Y/N)
High water alarm (Y/N) ~/~ Alarm tested (Y/N) k.)/~
Date of pumping ~'-- ~' - ~ {
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~- OO On adjacent lots
To property line ~ Absorption field .~,
Surface water/drainage ,/'f) O '~
/ '~- Foundation
Water main/service line
72q)~6 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
\ ·
SEPARATION DISTANCE FROM LIFT ST~TION TO:
Well on lot ~__ On adja~t lots
D, ABSORPTION FIELD DATA ~
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at __
Cycles tested
Surface water __
Soil rating ,/ A~t3 ¢/~,~ System type
Gravel thickness I' ~ /' Total depth_
¢
Cleanouts present (Y/N)
Date of adequacy test .~.--_
for ,_-~ bedrooms
~',.~/(/~ If yes, give date
Date installed
Length ~, _¢~ ~z_ Width 2
Total absorption area ~;~z~
Depression over field (Y/N)
Results (pass/fail) /')~
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water /
Curtain drain J~)/~"l
On adjacent Pots_ ~-'~' Property line
,
To existing or abandoned system on lot
Cutbank /k) Water main/service line
Driveway, parking/vehicle storage area O
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature ~-;,.~:~.~ !~. ;Hv~. I_oo~
Ea( le Eivor, Alaska
Eng neer s Name
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/91 ) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
WALTER J. HICKEL, GOVERNOR
563--6775
March 19, 1991
FOR: Kim Watson
NBA
PWSID #213475 South Park S/D--(Anchoraqe)
My review of the records on file in this office reveals that the
South Park S/D Class A Public Water System is in compliance with
the provisions of 18 AAC 80.060, State of Alaska Drinking Water
Regulations.
Sincerely,
_Timo. t~ A. Karnowski
Environmental Engineer
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF MEALTH AND ENVIRONMI~NTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. C~neral Information Application Date
(a) Legal Description (include lot, block, subdivision, section, township,
range)
Location (address or directions)
(b) Applicants Name t<~r~,~.~ I.,~f,,~Telephone - Home~_~f~CB~b~ess
Applicants Address
(c) Applicant is (check one) Lending Institution ~--~ ; 0wner/bulld~r~
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f)
Mail the H~ to the following address:
C
Type of Residence
Single-Family~
Number of Bedrooms
Multi-Family~--~
Other (describe)
Water Supply-
Note: If community well system~ must have written confirmation from the State
Department of Environmental 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]
Engineering Firm Providing Inspections~ Tests, File Search~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is ih compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
6. DHEP Approval
Approved for ~ bedrooms
Approved /~' Disapproved
Terms of Conditional Approval
(ENGINEER SEAL)
B~ ' Conditional
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT I~SPECTIONS 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.
(DHEF SEAL)
RR4/eJ/D18
[~a§~ 2 of 2]
7-19-84
ao
MUNICIPALITY OF ANCHORAGE (~gAgCmAU~ OF
HEALTH AEYI~ORITY APPROVAL ([~/)RONM[NTkt~ROT~CTIOi~,~ GI~,_i~-
CHECKLIST - FEBRUARY 1984 OCT 2 6 I984
,RECEIVED
Well Classification I~_L If A, B, o~ C, D.EoCo Approved~)
Well LoG P~esent (Y/N) ~ Date Cc~pleted ~ ~ Yield ~/__~
Total Depth "~ caSed to ~(~ Depth of G~outin~. ~ ~
Static Wate~ Level ~ ~ Pump Set At
C~.sing ~ight Above Ground t~%~% Sanitary Seal on Casing (Y/N)~
Electrical Wi~ing in Conduit (Y/N) ~{~1~ Depression Azound Wellhead (Y/N~
Sepazation Distances f~cm Well:
To Septic/Holding Tank on Lot ~Q-O~ ;') ; On Adjoining Lots ~
To Nearest Edge of Absorption Field on Lot ,~ ?_o~.
; On Adjoinin~ Lots ~
To Neazest Public Sewer Line I~ ~ To 'Nearest Public Sewe~
cleanout/Manhole 1~ To Nearest Sewe~ Service Line on Lot
Wate~ Sample Collected By ~ ; Date
Water Sample Test Results
To P~opert¥ Line
TO. Wa~ Mair~/Service
:.
SEPTIC/HOLDING TANK DATA
Date Installed C¢/10/~ Size IC~C) (-3 NO. of C~mpa~tments
Standpipes~"; ' ' ~Ai~-ti~ht Caps )~_~__ Foundation Cleanou _t~/N)
Depression over Tank (Y~ ~ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~x;/~ ; for
Holding Tank High-Water Alarm (Y/N) jv~ Temporary Holding Tank Permit (Y/N)
Separation Distances f~om Septic/Holding Tank:
To Water-Supply Well C.c,~,v~'~ ~/~OO~ TO Building Foundation
To Disposal Field ~ -~ c~~
To Stream, Pond, Lake, c~ Majo~ D~ainage
~'~[Page 1 of 2] 2-15-s4
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~ - to - '5'~
Width of Field ~ ~-' ~'
Square Feet of Absorption A~ea
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System
Length of Field
~p~ of Field
Grail ~d Thick.ss
~ stan~i~s P~esent
~te of ~st A~a~ ~st
Separation Distanoe from Absorption Field: ·
To Water-Supply Well ~OO/ ~ To P~operty Line
To Building Foundation I C~~ TO Existing o~ Abandoned System on
not /~/~ ; on Adjoining Lots /~Z~-I
To Water Main/Service Line /~/~ To Cutbank(if present) /~
To Stream/Pond/Lake/c~ Major D~ainage CoL~se /D C~ ~ ~'~
To Driveway, Pa~king A~ea, o~ Vehicle Storage A~ea
D. LIFT STATION
Date Installed
Size in Gallons
"Pump on" L~vel at
High Water Alarm Level at
Tested for
4~/
Pumping Cycles du~ing Adequacy Test. Meets MOA
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Ccr~nents ~,~
** Check Permitted Bedroom Rating Against HAA Request
I c~rtify that I have checked, verified, or confc~med to all MOA HAA Guidelines in effect
on the date of this inspection.
Company / ,-~ ~- MOA No.
KB1/d5/s
[Page 2 of 2]
2-15-84
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA g9501
RILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
According to records on file in this office the
Water System is in compliance-with the State Drinking
Water Regulations