HomeMy WebLinkAboutSPRING FOREST BLK 2 LT 13
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
iPHONE ~
~J~N EW
UPGRADE
MAILING ADDRESS
EGAL DESCRIPTION
LOCATION
I ] Well ~4~E.~ '~ I Absorption area
DISTANCE TO' ~' '~ i " ' '
I-- ~ Manufacturer
~ [Li~. ¢,apa?__ty in g~,ons I ,~side length
' ' r~ I I Well yI , Foundation
~h- I DISTANCE TO: ~,.~__..~) ,~L, /~
~ ~, ~O No. of )ines. Length of each lin~._ Total length of lines
~- Top of tile to finish grade Material beneath tile
~ b [ Type of cri~ Erib dia~mete~ Crib deptl~--
Class Depth Driller
; _
__,~ DISTANCE TO: Building foundation Sawer line
Dwelling
Width '
IMaterial
Nearest, ~t~l~n e
T re ncl~,,~i~d t h
NO. OF BI~DROOMS
inches
No, o f.~l~,?~.~mst s
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT N.I:~- ~
Distance between lines
PERMIT NO.
inches
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOl L TEST RATING
INSTALLER
REMARKS
APPROVED DATE LEGAL
....
72 013 (Rev. 3/78) ~ I'"
DEPARTMEIq'I" (]F HIEAL"I"H AND ENV]:RONMEIqTAL I::'ROTEE:)TION
82.5 I.... STREE"I", ANCHE3RAGE, Al< 9950
2.64-4'72.0
I::'ERM I T NE]:
DA*YE ], ,:~,:~UE:.D:
8,,J. 4,.~ 7 HAIqD WR I 'I'TEN
() 7 / .?. ce / 8 '5
AI:::'PL I C',ANT:
CONTAC'I" 1' ~'IUNE.",
I..EGAI.,. DES(]RIP: SUBDIVISION: E~PIR.~NG FOREST L.(]"I"~
.~E.C~ ION: 14 'I"[]WI~SI-"I:[F':~ 12N RANGE: ,z,W
LOT S:I: ZE: :1 ........ A (~3Q. F:'"I". OR ACRES)
BLOCK.." .~.
]: ce~tif'y that:
1. I am f'amilJ, aP ~it, J"~ the i"equir, emen'~.s fcip on-site ~eweps al'id wells as se{
t'{:)r"Lh by the Mun'.~c, il:~ality c){' Anchol"age (MOA) and the State of Alaska.
2. I will inst. all the system :i.n acccmr:lar~ce with all MOA codes and r'e~}lulat:i, ons,
~lad :i.r'i cc:)r~l:~],iance with the desicjr] cPitePia of this pepmi'l:.
3., ]: w~,],], adl]ei',e to) a].]. ME)A ar'id State (::I~' Alaska p~(~uil-elilen'['..s t'I]p 'l:.h~D set back
distances ~'l"om any existing we].l, wastewatei' disp:~sal system or public
~;l~W~;~l"~/g{~ ~y~S~'..{):~lli C)I"I 'Lh:i.s or' ar]y adjacent ~oP t']ear'by 1cit.
]:F A L, IF"I" STATION IS ]]IqS]"ALLED IN AN AREA E~E]VE.~E.D BY MOA BI.,III,..I)ING
.'T'HEIq (~.) AN IE],..E[]TRI[:AL, F:'ERPIIT AND INSF:'E[',"I"iOIq I~ILJ~T BE E)B'I'AINED; (.::.) A,.~-BU].I...t,..~
W'[II,.,.,,, I',IFYI':.~]E, Ai~.BE..wORI<.AF:'F:'R]V~D.~,.i.. ~I'l"},'[ J~" Ax ELE[T":~[CA[ [~3PEC'I"IOx :~EF'ORT~, AIqD (3) 'T'HE
..... ............................................................................... .............................
AF:'PL I CAIqT: DENN I S SM :I'. "I"H
Permit No:
Date Issued:
Appiicant:
MUNICIPALITY OE ANCHORAGE
Departmen~ ~f Health and Environmenta Protection
Pouch 6-650, Anchorage, AK 99502
264-4720
On-site Sewer/Water Permit
HANDWRITTEN
Legal Description: S/D: ~pm,~-~, ~-~-~-~4-
Section: [~ Township:
Lot Size: /~ 7~- /~ (Sq. Ft. or Acres)
Lot: 1'7~ Block: '2-
I ~/kJ Range
Lot Location:
Max Bedrooms:
Listed below are the options available to you in designing your septic
system. Choose the option that best fits your site.
TRENCN BED W. DRAIN
Depth to pipe bottom(ft.)
Gravel depth (ft.)
Total depth (ft,)
Gravel width (ft.)
Gravel length (ft.)
Tank size (gal.)
Soil rating (sq. ft./br)
-~*~ Gravel length > 75 feet requires multiple runs (not exceeding 75 feet each) ** Tank must have at least two compartments
I certify that:
1. I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage(MOA) and the State of Alaska,
2, I will install the system in accordance with all MOA codes and
regulations, and in compliance with the design criteria of this permit.
3. I will adhere to all MOA and State of Alaska requirements for the set
back distances from any existing well, wastewater disposal system or
public sewerage system on, this or any adjacent or nearby lot.
4. I understand that this permit is valid for the maximum number of bedrooms
stated above, and any enlargement or modification wi].], require an
additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, THEN
(1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS WILL
NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED: DATE:
Applicant
issuED
SWP/024 rev.1/85
DATE:
,dUNICIPALITY 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
3
4
?
DATE PERFORMED:
SITE PLAN
/
/ _
10
11
12
13
14
15
16
17
18
19
20-
COMMENTS
PERFORMED
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
~" 1/()
.p
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch}
~ SOILS LOG
[] PERCOLATION
TEST
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PFRFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16-
17
18
19
20
I S'L-~O p E
A
c~I
,/~/t/~L..~ ENCOUNTERED?
SITE PLAN
I
I
S
Gross Net Depth to Net
Reading Date Time Time Water Drop
COMMENTS
;~ { 4
PERFORMED BY: I~,,~/HA~ .~
72-008 (6/79)
PERCOLATION RATE
(minutes/inch)
ALASKA eilUIROI mEI TAL COF1TROL S RuIC S, linC.
July 2, 1985
Municipality of Anchorage
Department of Health and Human
Services
825 L. Street
Anchorage, Alaska 99501
NOTE TO FILE
RE: Design for Deep Bed Type Absorption System completed for
Dennis Smith on Lot 13, Block 2, Spring Forest
Subdivision, T12N, R3W, Section 14
Mottled soil, possibly indicating seasonally saturated soil was reported
at 12 feet in a perc test on the subject lot performed January 30, 1985.
A water monitor tube was installed to 18 feet in the same testhole on
February 13, 1985. A bed type sysem for the lot was designed utilizing
four feet of sand fill to provide separation from the possible high
water table. The water monitor tube was checked on February 20, 1985
and found to be dry. It was again checked on June 21, 1985 and water
was observed at 18 feet. Therefore, it appears the four feet of sand
~ill is unnecessary, and the system can be installed at 12 feet.
Revisions have been made on the attached percolation test form.
It this office can be of further assistance please contact us at
561-5040.
Sincerely,
Dennis Roe
Soil Scientist
Approved by:
1200 LUcsl 33r,~ Aucnu¢, Suile ~. Anchor(~(l~, AIosko 99503 .(907) 561-50/40
ALASKA e dlROFIITlelqTAL COFITROL Se[ ulCES, IFIL
~n§Jn~¢rinq 6 ~nuJronmcnl~l Studies
SPECIFICATIONS FOR BED WASTEWATER TREATMENT SYSTEM -
DENNIS SMITH, LOT 13, BLOCK 2, SPRING FOREST SUBDIVISION
1.0 GENERAL
1.1 THE DRAWINGS, i THRU 3, SHALL BE PART OF THIS
SPECIFICATION.
1.2
ALL MATERIALS AND WORKMANSHIP SHALL MEET THE
REQUIREMENTS OF THE MUNICIPALITY OF ANCHORAGE,
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
(DHEP), THE CONDITIONS OF THE PERMIT, AND ALL
APPLICABLE RULES AND REGULATIONS CURRENTLY IN EFFECT.
1.3
ALL EXCAVATIONS AND DEPTHS ARE ADVISORY, AND ARE TO BE
VERIFIED OR MODIFIED IN THE FIELD BY A DHEP APPROVED
INSPECTOR.
1.4
IT IS THE RESPONSIBILITY OF THE INSTALLER TO
ADHERE TO APPROVED DESIGNS FOR INSTALLATION, TO MAIN-
TAIN THE SPECIFIED SEPARATION DISTANCES, AND TO HAVE
APPROPRIATE INSPECTIONS.
2.0
2.1
2.2
2.3
2.4
SEPTIC SYSTEM
THE SEPTIC TANK SHALL BE A UPC APPROVED TWO COMPARTMENT
TANK, CONSTRUCTED OF 12 GAUGE STEEL WITH BITUMASTIC
COATING, SET LEVEL ON UNDISTURBED SOIL, AND INSULATED
WITH AN OVERLYING LAYER OF 2 INCH BURIAL TYPE
POLYSTYRENE.
THE SEPTIC TANK SHALL BE A MINIMUM OF 5 FEET FROM THE
HOUSE FOUNDATION, AND A MINIMUM OF 5 FEET FROM THE
ABSORPTION AREA.
THE SEPTIC TANK AND BED SHALL BE A MINIMUM OF 100 FT.
FROM ANY PRIVATE WELL OR BODY OF WATER, 150 FEET FROM
CLASS C WELLS, AND 200 FEET FROM CLASS A OR B WELLS,
UNLESS OTHERWISE SPECIFIED. LESS THAN THE REQUIRED
SEPARATION DISTANCE MUST HAVE PRIOR APPROVAL OR WAIVER
BY ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
(ADEC).
PIPING SHALL BE FITTED WITH A MECHANICAL WATERTIGHT
CAULDER COUPLING ON THE OUTLET AND INLET OF THE
SEPTIC TANK. PIPING SHALL BE 4 INCH SOLID PVC ASTM
1200 LUesl 33rc[ J~ur;nu¢, $Lli1¢ 6, Anchoreqe, J~laska 99503,[907) 561-50~,0
2.5
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7
D3034 OR CAST IRON, SLOPED A MINIMUM OF 1/4 INCH PER
FOOT WITH A MINIMUM OF 4 FEET OF COVER. IF LESS THAN
4 FEET, PROVIDE 1 INCH OF DOW EXTRUDED BLUE POLYSTYRENE
FOR EACH FOOT OF COVER LESS THAN 4 FEET.
(ADEC).
CLEANOUTS SHALL BE INSTALLED AS DESIGNATED AND CAPPED
WITH AIR-TIGHT JIM CAPS (OR EQUIVALENT), AND EXTEND A
MINIMUM OF 2.0 FEET ABOVE GROUND LEVEL.
SEEPAGE BED
THE GRAVEL FOR THE BED SHALL BE 0.5 TO 2.5 INCH,
SCREENED ROCK WITH LESS THAN 3% PASSING #200 SIEVE
RESIDUAL. ALL SUBSTITUTES MUST HAVE PRIOR DHEP
APPROVAL.
THE BOTTOM OF THE EXCAVATION SHALL BE LEVEL AND RAKED
WITH THE BACKHOE BLADE TO INSURE THAT THE BOTTOM HAS NOT
BEEN COMPACTED DURING EXCAVATION.
THE DISTRIBUTION PIPE SHALL BE 4 INCH RIGID PVC WITH
A MINIMUM CRUSH STRENGTH OF 1500 LBS. OR EQUIVALENT.
ALL PIPES SHALL BE LAID LEVEL, AND SPACED ACCORDING TO
THE DRAWINGS.
TWO MONITOR STANDPIPES SHALL BE PLACED AS SHOWN IN THE
DRAWINGS. THEY SHALL BE RIGID PVC ASTM D-3034,
OR 4" DIAMETER CAST IRON. THE SECTION SHOWN WITH
HOLES MAY BE EITHER DRILLED 0.5" HOLES ON THE 6 INCH
CENTERS ON OPPOSITE SIDES OF THE PIPE OR A SECTION OF
REGULAR PERFORATED SEWER PIPE MAY BE CLAMPED TO THE
SOLID SECTION WITH A NO HUB COUPLING OR SOLVENT JOINT.
A RUBBER RAINCAP (JIM CAP OR EQUAL) SHALL BE PLACED ON
THE TOP OF THE PIPE.
IF THE FINAL GRADE OVER THE BED IS LESS THAN 4 FEET
ABOVE THE GRAVEL, INSULATION IS REQUIRED. IT SHALL BE
DOW EXTRUDED BLUE STYROFOAM BOARD (1" PER FOOT OF SOIL
LESS THAN 4 FEET OVERLYING THE BED.)
IF INSULATION IS NOT PROVIDED, THEN THE GRAVEL MUST BE
COVERED WITH A LAYER OF A NONWOVEN FABRIC (SUCH AS
MIRAFAI, FIBRETEX 200 GRADE, POLY-FILTER X, OR EQUIVA-
LENT). A MINIMUM OF 4 FEET COVER MUST BE PROVIDED.
RECOMMEND THAT THE TOP AND SIDES OF THE BED SHALL BE
PLANTED WITH A WHITE CLOVER AND RED FESCUE MIX OR BLUE
GILASS.
3.8 THE SAND FILL SHALL BE CLASSIFIED SP (UNIFIED SOIL
4.0
4.1
4.2
CLASSIFICATION SYSTEM), WITH LESS THAN 5% PASSING
#200 SIEVE.
INSPECTIONS
IF AECS DOES NOT INSPECT THE INSTALLATION OF THE
SYSTEM, WE SHALL NOT BE RESPONSIBLE FOR ANY PART OF
THIS DESIGN.
THREE INSPECTIONS ARE REQUIRED:
THE FIRST INSPECTION SHALL BE PERFORMED WHEN THE
EXCAVATION FOR ABSORPTION AREA IS COMPLETE, BUT
PRIOR TO THE PLACEMENT OF THE SAND FILL.
THE SECOND INSPECTION SHALL BE PERFORMED AFTER THE
SAND FILL IS PLACED, TO INSURE PROPER TYPE AND AMOUNT.
THE THIRD INSPECTION SHALL BE PERFORMED PRIOR TO BACK-
FILL OF THE SYSTEM, AFTER SEWER ROCK, LEACH LINES AND
SEPTIC TANK ARE INSTALLED.
ALASKA ENVIRONMENTAL
CONTROL SERVICE INC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 561-5040
SHEET NO
CALCULATEDBY ~ ~
CHECKED BY
SCALE /qT5
DATE
15o0
ALASKA ENVIRONMENTAL
CONTROL SERVICE 1NC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 561-5040
SHEET NO.
CALCULATED BY
CHECKED BY.
SCALE
--OF
DATE
DATE_
ALASKA ENVIRONMENTAL
CONTROL SERVICr INC.
1200 West 33rd Avenue Suite B
ANCHORAGE, ALASKA 99503
Phone 561-5040
SHEET NO.
CALCULATEDLY .g. K
CHECKED BY
SCALE f ~
DATE
DATE
7.0
O
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
f.21 c.-~ .? Y )- - :)- %"' HAA # ~.~¢~,o~ ~('x,,~.~-h-~ ~'%
1. GENERAL INFORMATION
Complete legal description
Lot 13; Block 2; Spring Forest
Location (s, ite address or directions) 6131 West Tree Drive
/-'. · ~. Anchoraqe, AK
:~ 346-1939
~, Propei~ty owner ,Anthony & Para Schwarz Day phone
C/O.HFS Mobility Services Attn: Lorena Osornio
· - Mailing~ddress P.O. Box 4039 Concord, CA 94524
.... Le~ding agency Day phone
'~. Mailing address
Agent Jack Blair/ Remax Properties Dayphone 257-0159
Address
Unless otherwise requested, HAA will be held for pickup.
5
NUMBER OF BEDROOMS:
TYPE' OF WATER SUPPLY:
Individual well
Community well
NOTE:
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.
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEER.
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
$ & $ ENGINEERING
NameofFirm ~?n~4.r:.~,..~,; ~:,~?1_0,,?~.~,4~n,204 Phone ~
Eagle River, Alaska 99517
Address
Engineer's signature ~"~/"~ 7/~'w-~"*~--~ Date
DHHS SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
Date
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 DH HS 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 engineeCs work.
72-025 (Rev. 1/91) Back MOA ~1
Municipality of Anchorage
MUNICIPALITY OF ANc
DEPARTMENT OF HEALTH & HUMAN SERVICB~vIRoNMENT^LSERWC
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-~42 9 1~)~)~----
Health Authority Approval Checklist E C E l V E D
LegaIDescription: /~o~' J~ ~/[.~ ,'~ ,¢?lt,,,vC ?~.~. 7' ParcelI.D.: 01.£- -7~z.i~
A, WELL DATA
Well type A
Log present (WN)
Total depth
Sanitary seal (Y/N)
Date of test
If A, B, or C, attach ADEC letter. ADEC water system number
static water level ~
Well production
WATER SAMPL~ULTS:
C~liform ~ Nitrate
Date/4~sample:
Date completed ~
Cased to ~(above ground)
,,~res properly protected (Y/N)
FROM WELL LOG J AT INSPECTION
g.p.m, g.p.m.
Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ¢I/~ 3/~'s''- Tanksize
Foundati0~ cli~tn(~Uf ~fN).
Datq of~ Pumping q/~ G
C. AB~dRPTION FIELD DATA .
Leng'th ~ f Width
Effective absorption area
Date of adequacy test ~t '~ '~
I f~'~) o Number of Compartments ''~ Cleanouts~_.~N) ¥~-J'
Depression (Y/(~_~ ~' ~ High water alarm (Y/(~ /,/0
Pumper
Fluid depth in absorption field before test (in.); Immediately after~¥& gal. water added (in.):
Fluid depth. ~J ~/ (ins) Minutes later: ~ 3 5'- Absorption rate = '? 5'0 +-- g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~,o,~. ~ *'~"~ If yes, give date
Soil rating (g.p.d./fF or~2~r.~ ~;~ E-- System type T,4 ~,v c f/
Gravel thickness below pipe ~ ¥ Total depth ! I
Monitoring Tube present (~N) ¥~--)" DepresSion over field (Y,¢,.) /v ,~
Results (Pass/Fail) /¢/hJ $ For '-~
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at* ~
E, SEPARATION DISTANCES
Size in gallons
"Pump on" level at* f ~ff" level at*
SEPARATION DISTANCES FROM WELLON LOT TO:
On adjacent lots
Septic/holding tank on lot
On ad~lcertt-fd?~
.~'~ Public sewer manhole/cleanout
Absorption field on lot
Public sewer main
Sewe~
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ 'y- Property line 6~ ''/-
¢ /
Water main/service line I 0 ¥ .Surface wateddrainage / Oo q~
!
Absorption field &- "'~
Wells on adjacent lots '~ o ~ ~/-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line I 0 ¢- Building foundation I
Water main/service line
Surface water 1 o o ~-- Driveway, parking/vehicle storage area
Curtain drain ~vo,,.,~ ~.v~ ~ ~ Wells on adjacent lots
ENGINEER'S CERTIFICATION
Signature
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/96)*
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. #
CERTIFICA'rE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 13; Block 2; Spring Forest Subdivision;
Location (site address or directions) 6131 W~st Tree Driv~
Property owner
Mailing address
Lending agency
Mailing address
Dennis A. & Lynn~t~ J. Smith
6131W~st Tr6¢ Drive, Anchorage,
Day phone ,
Alaska 99516-6710
Day phone
Agent Barbara Parker JACK WHITE COMPANY
Address 3201 C S~¢e.% #100 Anchora~j6~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 5
TYPE OF WATER SUPPLY:
Individual well
Community well XX
Public water
NOTE:
Day phone 563-5500
Alaska 99503
If community well system, provide written confirmation from State ADEC attest- --
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
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.
NOTE:
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 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
Address 17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
,'~Dd ~__,,~ 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 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 ~t21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed /u//t Driller
Cased to /~,,~/J Casing height
~u/Ill Wires properly protected (Y/N)
ADEC water system number
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTION
g.p.m.
S~ PAR~.~ON DISTANCES FRO/~WELL TO: ~0/~./v&LLRj I '(%/~ -_
Septic/holding~---(~7~__._____ ;On adjacent lots
Absorption field on lot ¢-~0C1 ~ ~'7'~---~ ; On adjacent lots
Public sewer main Public sewer manho"~"~nout
Sewer service line Petroleum tank
WATER SAMPLE RESULTS: //~
Coliform ~--~--~ ~7~/'/~-~-N~ t r a t e
Date of sample: Collected by:
Other bacteria
B. SI-'PTIC/HOLDING TANK DATA
Date installed
Cleanouts(~N)
High water alarm (Y~.?
Date of pumping
Tank size I.~(~ ~-A-Lr_ Compartments
_ Foundation cleanout ~__~N) ~'/(~=-% Depression (Y/~
/~J/,/)- Alarm tested (Y/~J~)
SIEpARATION DISTANCES FROM SEPTIC/HGrLd~N~ TANK TO:
Well(s) on lot /h~//Z~ On adjacent lots d;¢~0 (3 'iLFoundation '~)-(~ 7L~
To property line 'l 0 1~/~ /
Absorption field I~l~) 4- Water main/service line ~L') '/'
l
Surface water/drainage [/(~-~
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE:.
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "P~
High water alarm level Cycles tested
Meets MOA electrical codes (Y/N) _.~
SEPARATION DISTANCE FROM LIFT STATION. 70: ~.
Well on lot On adjacent lots S~r
D. ABSORPTION FIELD DATA
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Date installed ~:~'-'°~-~ Soil rating 1,;~--~ &F//¢. System type
Length ~1' Width ~' /
Total absorption area
Depression over field (Y/~
Results (pass/fail)
Peroxide treatment (past 12 months) (V,~
Gravel thickness ¢73, I
Cleanouts present
Date of adequacy test
for
~O0~ r._, If yes, give date
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots c9,~0 ¢- Property line
To existing or abandoned system on lot
Cutbank /L/'//~' Water main/service line
/60 ~ ~ Driveway, parking/vehicle storage area
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
Engineer's Name
Date
S & S ENGINEERING
Eagle River, Alaska 99577
HAA Fee $ '//~'~
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA
Waiver Fee: $
Date of Payment
Receipt Number