HomeMy WebLinkAboutSUNSET HILLS BLK B LT 28
Mumcipal'ty of Anchorage Page_ / of
DEPARTMENT OF: HEALTH AND. HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 9951~6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Ins. pection Repor~
Permit Number:.. ~AJ c}~7OI7 ? __ PID Nun~ber: ' O! ~ 7-D/~
~°: /Z~----/~ £, ' ,~.~z~:~" Wastewater System: [] New ~Upgrade
P~a~: IN°'°~ 8~raom= ~ ~ D~p Trenc~ ' ~Shallow Trench [3 Ba~ Q Mound ~ Other
LEGAL DESCRIPTION so,,,.u.,: /' ~ GPD/Sq. Ft. -
Subdivision: ~ I D~ to pi~ ~m from o~n~ g ~ e: Grav~ depth benea~ pi~e
T~n~tp: J fl~ga: S~tlon: Flit add~ a~ova odglnal grade: Grovel length:
WEL~ ~ New ~ Upgrade er~vmwlum: ~ m.
SEPARATION DISTANCES ~s.,,= ~ Holding
LOt ~ f ~
Remark.: ~A~/0 ~ ~-~)m V ~ BENCH MARK
Depa~ment of Heal~ and Hurna~Se~ices approval
LOT 28, BLOCK B, SUNSET HILLS
PERMIT NO. SW970179
PARCEL ID NO. 01820145
I, ObO ~'&'
I
PLAIN AS BUILT
SCALE 1" = 20"
:' M-W DRILLING INC, DAT[ ~'! ' '¢ ,
PAGE 1 OF
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH kND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW970179
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NANE:CARLE ROBERT C & KAREN L
OWNER ADDRESS:14201 SUNVIEW DR
ANCHORAGE, ALASKA 99515
DATE ISSUED: 7/08/97
EXPIRATION DATE: 7/08/98
PARCEL ID:01820145
LEGAL DESCRIPTION:
SUNSET HILLS BLK
BLT 28
LOT SIZE: 15500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION 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 A_ND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80) .
3. 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)
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:
RECEIVEDBY:
June 24, 1997
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 28, Block B, Sunset Hills Subdivision
Septic System Desk. In
mpacts to Adjacent Properties
Dear On Site ServiCes Engineer:
The existing absorption trench On Lot 28, Block B, Sunset Hills Suodivision
will not pass an adequacy test. A testhole placed on the lot found
groundwater at 15' below the surface and since the bottom of the existing
trench is 13.5' below the surface it encroaches into the required 4'
separation. A aew absorption system is therefore necessary. The
attached Site Plan indicates the proposed location for the new trenches
and identifies all components of the existing system. The e×isting septic
tank wil be inspected and verified for continued use
A testhole on the property revealed clean poorly graded gravels and sands
which percolated between 1.5 and 5 minutes per inch. No groundwater was
encountered during .placement of the hole, but was noted at a depth of 15'
during the monitoring period. The system s designed to maintain 4'
separation from the groundwater,
The ground surface of the lot is relatively fiat in the area of the new
trench. A minor grade is noted from south to north, but will have little
mpact on the new system. If the system is constructed as designed the
following statements can be maae:
The system, if constructed as designed will have no adverse mpact
on the wells in the area or those to be cOnstructed in the future.
The system, if constructed
on existing septic systems
the future.
as designed, will have no adverse impact
n the area or those to be constrt~cted in
Lot 15, Block 2, Cinerama Terrace Subdivis on
June 24, 1997
Page Two
J
The system, if constructed as designed, will have no adverse
impact on 'eservee space, either surface or subsurface on any lots
located in the area,
The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area. The current drainage pattern w il
be maintained.
Sincerely,
Michael E. Anderson, P.E
Attachments
C
$0
NOTE:
AREA MAP
SCALE 1" = 100'
No Wells in the Area Are within
100' of the Septic System.
LOT 28, BLOCK B, SUNSET HILLS
SUBDIVISION
DESIGN FACTORS:
Three Bedroom Home
Perc. Rate: 1.5 to 5 Min./Inch
Application Rate: 1.2 GPD/SF
SYSTEM REQUIREMENTS:
Wide Trench System
Verify Existing Tank
3' Drainfield Rock
3 Bedrooms X 150 GPD / 1.2 GPD/SF = 375 SF of Absorption Area
375 SF/5 LF (Trench Bottom) X .58 (Red. Factor) = 44 LF Trench Length
Therefore: Construct a 5' Wide Absorption Trench With Two Laterals
Each 22' In Length. Distribution Pipe In Trench Placed at 7.5' Below
the Original Ground Surface. Place Trenches 10' Apart With a Flow
Splitter Valve Between.
NOTE:
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away.
Maintain 4' Vertical Separation From Ground
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PER,-'ORMED'.OR= ~O/X C~ e-~'
DATE PERFOR~
10
11
12
13
15
16
17
18
19,
20-
COMMENTS
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
~%
Gross Net Del)th to Net
Re~dlng Date Tired Time Water Drop
=-/ ~/;,? ,/..~ ~/ .- ,,,,/,~,,
_- ./: ~'z. $ /. y~:" Z"
I~ERCOLATION RATE /' ~'' Iminutesllnch) PERC HOLE DIAMETER ,~ vi
TEST RLJN BETWEEN ~ FT AND -- ~ ~
72-008 (Rev. 4/85}
Municipality of Anchorage .'
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOIL,S LOG -- PERCOLATION TEST
1
3-
4
6-
7
1(
11
12
13
14
15
17-
18-
DATE PERFORMED:
Township, Range, Section:
SLOPE
WAS GROUND W.ATER
ENCOUNTERED?
s
IF YES, AT WHAT ~
DEPTH? p
E
OePUI t° W~t~'r N!~/,~'~ /Z /
SITE PLAN
Reading Date Gro~ Net Depth to Net
Time Time Water Drop
TEST RUN BETWEEN -- FT AND
PERCOLATION RATE ~" ~ (minute~nch} PERC HOLE DIAMETER ~//
.(~ MUNICIPALITY OF ANCHORAGF
DFPARTMENT 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, fl
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
01 8201 45 HAA# 1'~°~,'~
1. GENERAL INFORMATION
Completelegaldescription Lot 2R.. R'lc~c,k ~¢ S~nset Hills Subdivision
Location (site address or directions) 1 4281 .q,~nv~ Cw F~'ive
Property owner
Mailing address
Lending agency
Mailing address
Agent R~'i- h ,q~ top-on
Address
Robert C. Carle Dayphone
42.01 ~"nview Drive
Day phone
Day phone 261-7689
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
Thr~
Individual well xxx
Community well
Public water
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:
XXX
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
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.
563-7155
Name of Firm Anderson Engineering Phone
Address P.O. Box 240773 Anchorage, AK 99524
Date 7/15/97
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates' based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer% work.
Municipality of Anchorage l~.t~
DEPARTMEN'r' OF HEALTH & HUMAN SERVICES R E C E IV E
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 34~t¢'¢441 5 ~9c.
Municipality of Anchorage
Health Authority Approval Checklist Dept, Health & Human Se~ioes
Legal Description:
A. WELL DATA
Well type Private
Log present (Y/N)
Total depth 11 7 ~
Sanitary seal (Y/N)
Lot 28, Block B, Sunset Hills ParcelI.D.: 01820145
N
Date of test
Static water level
Well production
WATER SAMPLE RESULTS;
Coliform O
Date of sample: 7/14/97
a. SEPTIC/HOLDING TANK DATA
Date installed 7/14/97
Foundation cleanout (WN)
Date of Pumping New
C. ABSORPTION FIFLD DATA
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to 1 1 5 '
Y
FROM WELL LOG
10/04
98'
15
10/84
Casing height (above ground) 2 '
Wires properly protecteo [Y/N) ¥
AT INSPECTION
6/10/97
96'
g.p.m. 7.7 g,p.m.
Nitrate o / /v~'//_ Other bacteria
Collected by: MEA
Tank size 1 , 000 Number of Compartments 2 Cleanouts (Y/N)
Y Depression (Y/N', N High water alarm (Y/N) N
Pumper Construction
Date installed 7/14./97 _ Soil rating (g.p.d./ft2orfF/bdrm) 1 ,2
Length ~,4 ¢; ' .Width __ 9 ' _ Gravel thickness below pipe
Effective absorption area 4g ~ gP . Monitoring Tube present (Y/N) y
Date of adequacy test. ~,~ ¢,,~,~ ~- _ Flesults IPass/Fail) _p a .~ .q
Immediately after
Absorption rate =
If yes, giva date
Fluid depth in absorption field before test (in.); _ 0
Fluid depth . (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N). N
72-026 (Rev. 3/96)*
GPD System type Wide Trench
2 ' Total depth ~ 11 '
Depression over field (Y/N) N
For 9 bedrooms
gal, water added (in.):_ 0
;, 4 9 ~ _g.p.d.
D. LIFT STATION -
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
None on Lot
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot > 1 00 '
Absorption field on lot ;* 1 00 '
Public sewer main > 1 00 '
Sewer/septic service line > 5f) '
"Pump off" level at*
On adjacent lots > 1 00 '
On adjacent lots > 1 00 '
Public sewer manhole/cleanout > 1 00 '
Lift station N~ on
Wells on adjacent lots > 1 00 ~
Water main/service line > 20 '
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation > ~; ' Property line > 5 ' Absorption field
Water main/service line > 20 ' Surface water/drainage > 1 00 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
PropertY line > 1 0 ' Building foundation > 1 0 '
Surface water > 1 00 ' Driveway, parking/vehicle storage area
Curtain drain _None on Let Wells on adjacent lots > 1 00 '
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections
in conformance with MOA HAA guidelines in effect on this date.
S,gnature
Engineer's Name Michael E. Anderson
Date 7/15/97
are
>50'
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
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. ~ ~"'~ ~ - -g~\ - ~-~---~ NAA # MI ~"~ \ L~.~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
5or 28; Block B; Sunset Hills Subdivision
Location (address or directions)
14201 Sunview, Anchorage,
(b) Property owner Fannie Mae
Mailing Address Loan ~107476
Alaska
Telephone: (home)
Business
(c) Lending Institution Seattle Mortqaqe
Mailing Address A~ENTION: Dick Dolman
Telephone
(d) Real Estate Company and Agent SELECTIVE REAL~Z'/Msj~ne Geils
Address 3305 Arctic, Suite 203, Anchor&ge, Alaska 99503
Telephone 562--2221
(e) Mail the HAA to the following address: (or check here B), if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING/694-2979
17034 Eagle River Loop Road, Suite 204
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single-Family [~ Number of bedrooms 3
3. WATER SUPPLY
Individual Well E~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site ~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
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
Address -, ,, ,..i J¢.r LoOp Road
EaUL~ t~;'~-r, ,~laska 9~577~
Date
Telephone ~ f ~"~7 ~J
6. DHHS APPROVAL
Approved for ,~___bedrooms by
Approved ,~/ .__ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88) Back Page 2 of 2
,JAN 0
Mun!cipati y ef A ~c~ ora a
Dept. Health & tturoan o .
A. W~LL DATA
Well Glassifioation ~,~[~ ~ ~'L/~
Well Log Present (Y/N)
Total Depth~ Cased to~J/~Depth of Grouting
Static Water Level
MUNICIPALFrY OF ANCHORAGE (MOA) ~
Health Authorlly Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: ~o_-./~ .~.~i ,~_/cC &~. ,r.~ ,,j.
Ioo f
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N) ~J
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot / O0
To Nearest Edge of Absorption Field on Lot
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At ~ /
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
7.0 ¢/,PM .
; On Adjoining Lots [ CO G
; On Adjoining Lots [ ~O
To Nearest Public Sewer Line ~/~____ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot _ ,2- ~v /-iL
Water Sample Collected by ~:~5L ~.~ ;Date
Water Sample Test Results ~%~'~5,'/~c,"~o'¢u. -~ ~:~¢r(%'~-~_,Fi~-
B. SF. PTIC/HOLDING TANK DATA
Date Installed ~-!-¢4 Size /Z~i~frLNo. of Compartments
Standpipes (Y/N) ~{ _Air-tight Caps (Y/N) bi
Depression over Tank (Y/N) h,J
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~,l LA
Foundation Cleanout (Y/N) _~
Date Last Pumped %["- ~4 -C~ J
/~/~ ,'for ~, ,/(Ar
Temporary Holding Tank Permit (Y/N) ,g/¢
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ___..~OO
To Property Line ( D
To Water Main/Service Line __J
To Stream, Pond, Lake or Major Drainage Course
Comments .~E J ! ~O ~A-LI%¢ CJ b
To Building Foundation
To Disposal Field
i oo -/-
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~'*- / - ~:~/'¢
Width of Field .~,
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness ~ (¢
Square Feet of Absortion Area 2 ~2/-/ ~ Statndpipes Present (Y/N)
Depression over Field (Y/N) /,J Date of Last Adequacy Test
Results of Last Adequacy Test ~../-~q?,_¢.,~c.-~,-~¢'~ - ¢
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot ~ / ~
To Water Main/Service Line I
To Stream, Pond, Lake, or Maior Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line
; On Adjoining Lots
To Existin~ or Abandoned System on
To Cutback (if present)
IOO
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at "~
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed
Company
Date
MOA No.
L~ & $ ~NGINEERING
t~agle River, Alaska 99577
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) 88ck
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL itEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH Ab~i'HORITY APPROVAL CERTIFICATE
/
1o General Information Application Date /. '7~,~
(a) Legal Description (include lot, block, subdivi~ion, secti.on, township, r~ange)
Location ~(address..o~ directions)~
(b) Applicants Name~.-_f~z:~__~.)'f~.'7--- Telel)bone - Home.~/O-.3/'~/Business.'.?7~.T~/.f.~'~
Applicants Address / c/ ~._f~/ 5'~ ....... ~ ~,~- ,~
(d) Lending Institution __.//~"~"
Address
(e) Real Estate Co'o & Agent
Address
Telephone
(f)
Mail the HAA to the followin~
~._~'pe of Residence
Single-Family~
Number of Bedrooms
Multi-Family~
Other (describe)_
~jater
Individual Well
Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status°
Sewage Disposal
Onsite~ Public ~_~ Community ~j~ Holding Tank [[~
Note: If commnnity well system~ must have ~itten confirmation fr'om the State
Department of Enviromnental Conservation attesting to the legality and status°
[Page 1 of 2]
5. Eng~ineerin~g_ Firm Providing In.p_p2[ctions, 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 iavestigation 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 MunicipaIity of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal~
system is in compliance ~ith all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this ins~pection.
Name of Firm~_~'_a~/Zq;.fL~j~i/~ -- ~_~._~'
Telephone
Date _.~[~ I q f:z 'J
(ENGINEER SEAL)
Approved Z~~ Disapproved ~/~ ~/Conditio~7---
Terms of Conditional Approval
CA~fION
THE MUNICIPALITY OF ANCIIORAGE DEPARTMENT OF [LEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES REALTIt AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON Ti{E REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAl, ENGINEER REGISTERED
IN THJ'] STATE OF ALASI(Ao THE DHEP DOES %~IS AS A COURTESY TO PURCttASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDEthU., AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHE]? 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.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
I-IEALTH AUTHOP~ITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
~LL DATA
Well Classification
Well [~g P~esent (Y~
Total Depth //? /
Static Water [~vel ~7c~ / Pump Set At_
Casing He ight Above Ground __
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
MUNICIPALF~Y OF ANCHORAC-,]]
DEPT. OF nI!ALTH &
ENVIRONMENTAL PROTECT ON
RECEIVED
Legal Description: ~r/ ~
~/~ If A, B, ~ C, D.E.C. App=o~d(Y~)
~d~ :Z~/~---/A~ ~ptn of Grouting.
/
Sanit~y E~al on CasingS)
~p~ession ~nd ~l~ead
~/~ ; On A~joining Lots/~/~,~ ~
To Nearest Edge of Absorption Field oD Lo~/~j~; ~ Adjoining l~tq/~ /~
To Newest Public ~ Line. //~ _ To ~est Public ~%~r /
Clea~t/Ma,~ole ~ ~ ~a~est ~ ~y].~ L~ on I~ ~
Wate~ S~le Collected By ~ //~/_, ~te __~ ~ ~ /~/ _
Wate= S~st ~sults ~j
B. SEPTIC/HOLDING TANK DATA
Date Installed .~ /., ~/'_ Size t(~.~
Standpi~s~) Ai~-tight Caps') Foundation Cleanout~)
~ession o~,~ Ta~ (Y~ ~te ~st P~d
P~ing~aintenan~ Cont~a~ on File (Y~.) ; fo~
Holding Ta~ High-Wate~ Ala~ (Y~) ~
Separation Distan~s ~ ~tic~olding Tank:
To Water-Supply Well//7~ /~-~-~- 7~
To P~operty Bins ~
Cou~seT° Water Main/S~/~_ Line_
/
Comments
To Building Foundation_
To Disposal Field_ ~
To Stream, Fond, Lake, o~ Major D~ainage
C. ABSORPTION FIELD DATA
Date Installed
Width of Field
Soils Pating in Absorption Strata ~?-~/~C/~/3,.~z~ Type of System
.~ /, ~/ / ~ng~ of Field ~./ ~ _'
~p~ of Field ~ -
Grail ~d ~ick~ss ~
~J~ ~ . Stan~ims ~e~nt
te of ~st A~a~ ~st ~/~ ~/~
ld:
~ To ~o~rty Li~ ~ ~/~"
To Building Foun~tion ~ ~/' To Existing ~ ~Ddo~d System
Lot ~ · ; ~ ~joining ~ts
To Wate~ Main/~v~ Line. ~ /~ ~ To ~t~(i~re~nt)
TO St~e~ond~ke/~ ~jo~ ~aina~ ~ ~
To ~iveway, P~ki~ ~ea, ~ Vehicle St~a~ ~ea ~' ~
Co, t~l~ts
Square Feet of Absomption A~ea
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance f~om Absorption
TO Weter-Supply Well /~J ~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Dimensions
Manhole/Access (Y/N)
"Pum~ Off" Level at
Vent (Y/N.)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Co~%~nts
** Check Permitted Bedroom Ratin~ A~ainst HAA R~quest **
certify that I have checked, verified, c~ confo~n~d to all MOA HAA Guidelines ih effect
on the date of this inspection.
KB1/OS/s
[Page 2 of 2]
2-15-84