HomeMy WebLinkAboutSOUTHPARK #2 BLK 3 LT 35Onsite File
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MuniciPality of Anchorage Page
DEPARTMENT OF HEALTH AND HUMAN SERVICES .
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-~,744,
'On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~'~'J'J ct ~'~)0 ~' 0 PID Number:
.a~: ~G ~ ~',~ ~'~ Wastewater System: ~ New ~Upgrade
Phone: ~-- ~J ~No.o~drooms: ~ DeepTrench ~Shall0wT~ench .~Bed ,~ M0~n~, DOther
LEGAL DESCRIPTION so,.~i.~:, ~GPD/Sq. Ft.
Subdiv~ion' Depth to pipe bottom from original grade; Gravel deCh beneath pipe
Township: '(~ IRange: N/~ ISecti°n: ~ ~;~,, ,~ F',l added ore originalo,_~~rade: Ft. Gravel lengt,:, , ~ Ft.
~ ~ New ~ Upgrade~ Gravelwidth: / Numberoflines: Distanceb twee~lines:
Ft.
Yield: Pump Set at: Casing He bore G¢ound:
TO Septic Absorption Lift Holding 'ublic/Private Manufacturer: ~ ~ns:'
From T~nk Field Station TanA Sewer Lines
Surface ~]~ ~ LIFT STATION
Water
Line
"Pump on" level at: "Pump off" level at: High water alarm at:
~ump Ma~e &Model ~ Electrical Inspectio~ edormed by:
Drain
Remarks: Z~/ ~ ~% = S~P~ BENCH MARK
Location and Description:
I Assumed Elevation:
Inspections performed by: 4¢ ~5 Dates: 1st
Department of Heal. and Human Services app vel
Reviewed and approved by: / Date: 7 7-~
72-0t 3 {Rev. 9/91) MOA 25
'" '
CE-7953
I'OO
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Permit No. ~vJc:t~-°O~'O Page ~ of
Municipality of Anchorage
DEPARTMENT OE HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephgne: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description'. uo~- ~) ~--~, ~ /¥o0,-~. ~'~
i .
io
is4-,
72-013 A (1/93) *
INSPECTI{ N REPORT
MUNICIPALITY OF ANCHOBAGE, t)UIL1]ING .SA1T~TY I[IIlVISION
2500 EAST ~.IBOB ~OAD
i:NSPEC~IONS: (907) 563-.3464 INfORMATIOn4: (907) 786-821]
~!AME: ELEC CONGT AND CONSULT/LARr~Y T'E~MIT ~: 95.-YF24
~,[~DKLJS: 1570] S~ANWOOD CIB DA~L~ 0~,/05/95
f.'HONE ~l.: :]44-5130 ~HONE 92:3~5-87~1
~.i]T: 35 BLOCK: 9 SUBDIVISION: Si)II~H BARI.(
,,OHHEN~. LIB~ S~ATION UB HOOK/ASK FOB LARRY/THIS IS FOB
KELLY LO[<AN/INSPECT. ON T!I~S:~'UNE ,G /D~TWBEN 8;00
AND NOON HAVE. ABRANSB WITH OWNER-CBAIG BONNING
TYPE OF INSPECTION: REINSPEC~ION:
'l: ~leotrieal Pinal 2: ,~- .
r~ NO NONCOMPLIANCE OBSERVED [ ] CO[{BECTIONS ESSENTIAL AS EXPLAINED BELOt
~: ] WILL ~EXAMINE AT NEXT INSPECTION ~' ] O0 NOT CONCEAL UNTIL ~EINSPHCT~D
~,OMMENTo:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.0. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT ~ER:SW950050
DESIGN ENGINEER:ALASKAWATER & WASTEWATER SERVICES
OWNER NAME:RONNING CRAIG O & KIM T
OWNER ADDRESS:15701 STAi~WOOD CIR
ANCHORAGE, AK 99516
DATE ISSUED: 4/18/95
EXPIRATION DATE: 4/18/96
PARCEL ID:02005240
LEGAL DESCRIPTION:
SOUTHPARK ADDN 2 BLK
3 LT 35
LOT SIZE: 25149 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
2.
3.
4.
o
SPECIAL PROVISIONSa~
RECEIVED BY:
ISSUED BY:
THE ATTACHED APPROVED DESIGN.
ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 ~ THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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
THE FOLLOWING SPECIAL PROVISIONS.
DATE:
Alaska Water & Wastewater Services
"Preserving The Last Frontier"
April 9, 1995
MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
1995
RECEIVED
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Ref: Septic System Upgrade for Lot 35, Bk 5, South Park S/D,
Addition
To whom it may concern:
Attached is the application, site plan,
for the subject septic system upgrade.
the proposed system are as follows:
and design drawings
Comments regarding
1. TRENCH DESIGN: As can be seen from reviewing the
attached percolation test results, the soil "perked" at 16
minute/inch at the location proposed for the system upgrade.
This corresponds to an application rate of .6 gpd/ft2.
Since the existing home has 4 bedrooms, the total design
flow is 600 gpd. Based upon this, the minimum amount of
absorption area is 1000 ft2. The proposed trench is 5 feet
wide, 4 feet deep and i00 feet long, providing an effective
absorption area of 1000 ft2. A lift station will be
installed so that pressure distribution can be utilized. An
alternator valve will be installed so that flow can be
diverted to either the old or new trenches.
2. SURFACE WATERS: Per the HAA dated 9/6/90 there are no
surface waters within 150 feet of the existing septic tank
and trench. If this is the case, there are no surface
waters within 100 feet of the proposed system. Currently
there is snow on the ground, making it difficult to assess
the situation. According to the homeowner, and based upon
what I can see at this time, there are no surface water
concerns. The proposed upgrades will not be done until some
time in May~ after the snow has melted. At that time
separation distance requirements will be verified.
5. SLOPE CONCERNS: On the site' plan I noted the
approximate location of a cutbank adjacent to the new
trench. The slopes were shot using a surveyors rod and a
hand held level. In short, they are approximate. The
Telephone: (907)337-6179 · Fax: (907)338-3246 · 8471 Brookridge Drive · Anchorage, Alaska99504
existing trench is only about 15 feet from the 57~ cutbank.
I am unaware of any problems associated with wastewater
daylighting (the existing trench is operating in a
surcharged condition). I will evaluate this situation once
the snow has melted, and prior to performing the upgrades.
If you would like to be present for this site visit, please
state so on the permit. The north end of the new trench
will be about 20 feet from a slope which varies from 25-35%.
If it turns out that the existing surcharged trench is not
daylighting then the potential for the new trench to
daylight should be minimal. In addition, due to the fact
that we will now be alternating flow between the old and new
systems, the potential for daylighting will be further
diminished. It is my recommendation that the separation
distance to the cutbank be waived to 20 feet, with the
stipulation that the existing trench be evaluated for
daylighting once the snow has melted. If necessary, the
design can be modified at that time.
I am unaware of any negative impacts that this installation
would impose on adjacent wells, or septic systems. If you
have any questions, please call me a 337-6179.
Sincerely, ~
Ronning4.NPS
lO-r
(~)
O~' D~'c~~ I00,00
/
/
CE-7953
Municipality o! Anchorage
,DEPA.R,,T..MENT OF HEALTH & HUMAN S
' 825 L Stre(~t, Anchorage, Alaska 9950
sOiLS LoG - PERCOLATION'
=_RVICES
!-0650
'EST
PERFORM'~=DFOR: LOT ~j ~"~ 1
LEGAL DESCRIPTION: ~--C3~t'~C"P~ ~-~'~ ~ J ~3)O~,~ ~ ~ Township, R nge, Section:
SLOPE
8
9
10
11
12-
13-
14-
15-
16-
17-
.18-
19-
20-
WAS GROUND WATER
I~.NCOUNTER ED?
,p yES.^TW.AT
DEPTH?
E
·
Monitoring? .oa{~ ; ,. ~ ,.
Reading Date T, ime Time Wete~ : Drop
~. .~/~/,~ '.~,~ ~o ~/,~ t '~"
pE~CO~TiON HATH ~ ~ (~[nut~inch) PHRC HOLE DIAMETER
TEST RUN BETWEEN ~ {,-FTANO ~'~'"FT "
ACCORDANCE wITH ALL STATE AND MUNICIPAL GUIDEL N ~ '
72-~8 (Rev, 4/~) ;
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
~) EE~ I~M$ /M tAJoop ~ Tn SEPTIC ABSORPTION
AddressFROM~" WELL
~ TANK FIELD
Phone(s) Permit NO. NO. o~edrooms WELL
LEGAL DESCRIPTION
Township, Ra.ge. Section
AS'BUILT DIAGRAM (Show location of well, seplic system, prope~y lines, founda[ion,
S ,5 '~1/~ ~ ~ ~ driveway, water bodies, etc.)
TANKS
Manulac[urer
Material No. of Compa~ments
TYPE OF SYSTEM
~ TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to pipe bottom from To[al depth from original grade
original grade ~ [1 ~ [~
/ /50 SOFT D B03¢
WELLS
PRIVATE ~ OTHER {Identify)
REMARKS:
72-013 (3/85)
Id U N :[ C I P A L I T Y 0 F A N C: 1'"[ 0 F;: A G E
De~par. tmer~t, of' !...leal'Lb & Human SePvic:os
8~;~5 L. S'Lr-,~::~e)t.~ Anchopag(;;,, Alaska 99501 34:3-.4720
,'-.}aC~! J. ssu.(:.~d ~ 06, ,/()E~/9() li!:ng ± r',,eE, r'. Des i gned
F) E Fi'. M
DESIGNS IN WOQD
7021 DR t F"[ WOOD
ANCFIE)RAGE, Al< 99-518
!:)ay l:::'l"~cln e!:
:349-.8C) 14
M a x
Pa~ce:l. Ida 0,'..?.0-052.....Zl.0
L(::r~- I...E~.ga 1 ::Subd ivi!~,ior'l: SOUTHF'AFd< NO, 2 Lot.
Section: 3 Township~ 1iM Range:
Lot. S:[.xe 2.5149 (sq. ft.. or act. es)
B(::,dPc~oms: '[h:Ls~ F'er'mit: 4 'r'c)tal Capacit. y~ 4-
,%F: :::' I' '[ 3 ~x ..... ' =' -
....... IArll .... M:Er~imum L-.)t. al s~:?p'L:i.c t. ank c:apac:ity: J ..... ~ ..ual. lor'lE¢. Each Eiept. ic:
tank must. I'h'aV~e at. :l.~!:east. ?.'. i:::c~mpar, tmr. ants. Dep'!:.h 'Lo t. cip of' ~.~ep'L:i.c rani< (s) < 4,,0
~'~':eet. i~equ±Pe!s irl!_=.,u].at:i, cn"~ over t. ar~k('.-':¢).
J: E;EI.-Tf'.,':F:Y THA'I".~
i. ]: am 'l'ami!iar' with t.h.e r'(.~!ciuiPemen!.s
f'cmf't'~ by t. he i'dur',,ic::i, pa].:J, ty c:,[ Ani::l"ic~i"age (MOA) an(:! the State o[
2~ ! ~,,~J. ZlZ! :i.i]s't..~./]l.] 't.h~i;) f~iyE~tiE~ill J.l"iac:c:orclanc:0.) !~tJ.'l.l'i ail IdEIA cc~de~i and r'.egulaLions,
3. I ~/4J:t.:l. a(::lhe["(e to ail [¥!E)A and Stat. e) (::~{' AJ. aska i-ecju:i.?emsnts {'ol" the set. back
dist. anc:es5 ~ Porn any ~;~x :i. st.:i, ng ~e~]. J. ~, (.~as'Le~atet* d J. sj3osa], systetm of pub ].
/.J.. Z t,u~d~:?r'fE, tE:dlf:J that, 'L:.!~zs [~SPfTUJ, t J.~B val:i.d f'or a maximum of 4 I:~edr'c')om~al.
· ,.~:,, r ......... xtb.~ .... ~.~
........ ......................................................................... 0
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION: (... ~"" t~ ~.~
DATE PER
WAS GROUND WATER
ENCOUNTERED?
Township, Range, Section:
SLOPE
4-
5-
6-
7-
8-
9-
10-
11
~ITE PLAN
/,,JO
IF YES, AT WHAT
DEPTH? ~J//~ pO
E
Oeplhto Water Nter .,, _
Monilorino? ~"'" ~ Date;
'~ h
Gross Net Depth to Net
R~a~.~l Oate Time Time Water Drop
d?, ..~"-0 $-/c..-%' i ,'~-~ /0 , '~ ,/~-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS .~
P~RFORMED BY:
ACCORDANCE WITH ALL STATE AND MUNICIPAL
T~ST RUN BETWEEN '~ ~ ~T AND ;5 .9. ~T
I t~, {~'A/t ~-"~"~'~,.~ CERTIFY THAT THIS TEST WAS PERFORMED IN
GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
~~. //, /
l. System Size = 4 Bedroom ~ 200 sf/bed. X 1.5= 1,200 sf
2. Reserve ~rea = 4 Bedroom ~ 2,000 sf/bed. = 8,~0g sf
3. Tank Size = two compartment 1,250 gal. minimum
q. Co--unity Water provided to all adjacent lots
5. Ail materiais and construction methods to follow MOA regs.
6. Bed Size = 24' X 50~ = 1,200 sf
(4 lines,~ 6' spacing ~ 50' length)
SEPTIC SYSTEM DESIGN .......
DATE PREPARED FOR: ~.¢.,.::;'%,
' ~-/~- 9o ~A~ ~y~5 ,.,~,,t ............
',. (.i q'
8GALE PREPARED BY:
i"=~O~ Kniefel Engineering MOA CE 90-030
oi
May 29, 1990
,.r To:. -WHOM IT NAY CONCERN
400~ZT[,ao~a,: ~*m~. Re: Ou~ Escrow ~90~1146
~ncnorage, &K995ot $~arr/D~ig~s in Wood
-:~' m~ ~74~ Lo[ 35, Blk 3~ Sou~hpark
qO/ ?05:
907 224.3 ~':
FAX 22-~
3670 lake
90?
F~,X 235-5203
Sub, ~2
Please be ad'v%sed that we are currently in the process
.;f closing escrow~for the above referencod rea] property
waerein title will transfer from Dennis I
Deann S~arr to Desigas iq Woods Ltd
.... 'ALASKA TITLE
/
STEWART
-<c?o~ Off%cer
INS U..AN~,~ AGENCY,INc.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN.SERVICES
825 "L" Street, Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: I~. ~ .~ ~/_ ~
1-
2-
4-
5-
6-
7-
8
9
10
11
12
13-
15
16
17
18
19
~O~.,.tl~ ?4r~ 7-.- Township. Range. Section:
SLOPE
SITE PLAN
WAS GROUND WATER ,/~,~
ENCOUNTERED?
IF YES. AT WHAT
OEFTH?
PERCOLATION RATE
TeST RUN eETWE~
STEVE COWPER, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE WESTERN DISTRICT OFFICE
'3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
September 4, 1990
563-6775
Attn: Wayne ~.'cFaden
PWSID: ~213475
According to the records on file in this office, the South Park
Subdivision Water System is in compliance with the State of Alaska
Drinking Water Regulations.
Sincerely,
Environmental Spe%~ialist
VEC:pf
* ~ . ' VIUNICIPALITY OF ANCHORAGE .
(~'~i~'~l. DE?ARTMENT 0F HI'AL:i'll'& HUMAN ~ERVICES~
.~. ?::= : ~=~ '~ .Division:of Environmental Services
- .~ :~ i~ri~ .':'i:~i On-Site Services Section ·
P O. Box 196650 ;f~nch0rage'Alaska ~'99519-6650
: ~), . ~. "~ .... 343-4744 '
-" CERTIFICAT~ OF HEALTH AUTHORITY
. ~ APPROVAL FOR A SINGLE FAMILY DWELLING
' · :' · ~-~-~-~: ~ .... ? ~r · ~
P~rce D ~ ~~~.~. :..~ ."'~:~?::~HAA~
-- . ' ' . ~ : . ' ,..~-,,,,~;C.'
1, GENERAL INFORMATION '.'.'" , .' ' · ~'¢,~i:~ >~¢';'¢u
Complete legal descnpbon J
Lo,c, at!on (Slt~ ad,d[ess o,~ dl[ec,tlons) ~' /~ 5 · ,.,. ,
· .? '"'~ ~" '?~.~ 2'
Prone~¢o~n~r ~, '~
Ma hno address ,.~,'
'kending agency . ~ ~:'"t~'~ ~ Day phone
Mailing address
Agent .....
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY: .......
Individual well
Public water
NOTE:
lng to the legality and status of systam,- ,- ;'.
TYPE OF WASTEWATER DISPOSAL:
Individual-- on-s?te .,' .,:,.
7</
. Hodngtank ..........
Public sewer....: ....... . , ·
NOTE;
If commUnity W~ll 'system, provide w~itten confirmation from State A~EC~ attest-
If community wastewater system; provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025(Rev, I/91) Front MOA#21
STATEMENT OF INSPECTION BY: ENGINEER ..., .~/....~,....~ : ~, ~ ....
.... ,~: ~t~ · .~ ,, ~. · :' ~,;~ '~?: ~'~ ~2'. ~ i : ,. r.~,/. ,
As certified by my seal affixed hereto and as o} the validation,date shown b__o, I verify that my
investigation of this Health Author!ty Approva. I appl!ct~!l,~n~ sb~s !t~at the omsite water supply
and/or wastewater disposal ~ystem IS Safe, functional and ~de~t~ fo~ the number of bedrooms
and type of structure indicated herein. I fu~her verifY~that based on the information obtained from
the Municipality of Anchorage files and from my Ipvestigatlor and inspection, the on-site water
supply and/or wastewater disposal system Is in compliance ~lth all Munlc~ ~al and State codes,
ordinances, and regulations in effect on the date of this io~p~c~0~,
Alaska Water &
Wastewater Se~vl~s
NameofFirm ~.. ~.~.,.~.n, ~// Phone ~ 7- ~/7~
. ,77 II .
Address
~ ~~~ Date
EngineeFssignature ~7~/~ ~ ,~ ~
DHHS SIGNATU RE
X' Approved for 4
Disapproved.
Conditional approval for
bedrooms ..... ,., - ~
, ~"',"~ ~ ~ ~ l~:!'~, ./! ~'?,"!.~u'.~1'l:~;'~ :,~ ~- -
b~roon~e ' With the following' stipulations:
. .~ ., . ~ 1~ ~
Ad~lJtional comments
~rage Department of Health a,nd Human Sea. ICe8 (DHHS) ssues Hea Autho 'fy
.=d only upon the rePmsenti~tlons given .!n pqragraph § above by an independent
'~ : registered In the State Of Alaska, The DH HS dbms this as a courtesy to purchasers of homes
;i~ndlr~g tutions in order to satisfy certain federa 8nd Sta~e r~qulr, ements. Employees of DHHS do not
conduct inspebtions or analyze data before'a'eertlflcate I~'lssU~d,'t*he;Municipality of Anchorage is not
responsible for errors or omissions In the professional engineer's work.','! ~' -
Municipe~litY ~of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A, Well Data
Well type Co
3resent (Y/N)
Sanitar
Parcel I.D.
o%0
I~)B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
-2.
FROM WELL LOG
ATINSPECTION
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM
Septic/holding tank on lot
g.p.m.
lots
EIVED
JUL 5 1995
Municipality ot Anchorag. e
Dept. Health & Human Serwces
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE
Coliform
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N) "~ ~-~--~%
Nitrate
; O'h-a~ent lots
P Upb~i;;:2rt~e/clea n ° u '
Tank size I '7_,.~'E) Compartments
Foundation cleanout (Y/N) ",/:F---~5 Depression (Y/N)
Highwater alarm (Y/N) ~/~- Alarm tested (Y/N) f,j
Date of pumping ~'/6/~Z~--- ?/~--~'~-
_~_~ -~ Pumper ~--
To property line ~ 9,/+'_
Sudace water/drainage
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 1,3/~' On adjacent lots hJ/~
Absorption field ~/-I-
72-026 (3/93)* Front
Foundation I O
Water main/service line
CONTINUED ON BACK PAGE
Size in gallons. ~ O Manhole/Access (Y/N) '~-I ~, ~
Vent (Y/N) ~ ~ % "Pump on" level at z3¢ I" "Pump off" Level at ~ I"
High water alarm level .z3r-/" Cycles tested hJ ~
Meets MOA electrical codes (Y/N) 'q,~---- ~,
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot ~J )A On adjacent lots
D, ABSORPTION FIELD DATA
Date installed ,~-/1 ~/~/~' Soil rating (GPD/FF) -
Length I ~-7 / Width ~ / + Gravel thickness
Total absoq3tion area \c~c~o -g'.-tz Cleanoutpresent(Y/N) ~,,~"r. ~1,~
Date of adequacy test tJ ~ Results pad.fail)
Water level in absorption field before test ~ I ~'
Peroxide treatment (past 12 months) (Y/N) ~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots ~ to
Surface water
System type
Total depth
Depression over field (Y/N)
for ~ Bedrooms
After test r,J/(~-
If yes, give date
Well on lot I'~ I~, On adjacent lots hJ ,A Property line ~D -~
To building foundation lC) To e-xistJ,'~g or aba,";dc,,'~ed system on lot I0
Cutbank ~-~ ± Watermain/service line ~ Io/ o,-- ,+.~,~
Ddveway, parkin~vehicle storage area --7O ~ ~-~ ~
Sudace water
Curtain drain
E, ENGINEER'S CI--RTIFICATION
I cerb'[y that I have checked, verified, or conformed to all MOA and HAA guidelines in effe~
bnglneers r~ame
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3~J3)' Back
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Location (address or directions)
/.5' 7,~ / _5 77//,4///d ,~ d
(b) Propertyowner ¢ECS i ¢ /J 5 2,'.7
Mailing Address
(c) Lending Institution
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone: (home)
Business -¢5/?- 842
Telephone
Telephone
(e) Mail the HAA to the following address: (or check here ~ 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 we[I system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE ~OSAL
On-site, S" 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
5. 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 in compliance with all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm 'Z~"JO¢Or') ~b,,,/,b.'127~rJ(~ Telephone ~ 3 '7~(¢L~ 5~..~~
Address
Date
Engineer's Seal
6. DHHS APPROVAL
Approved for ~ bedrooms by , '- ~'~Date
Approved Disapproved Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph $ above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev 7/88) Back Page 2 of 2
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