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Home My WebLink AboutT15N R1W SEC 5 LT 21 Municipality of Anchorage Page I of 2_ 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: ~W'c/c~0.~Z-7 PID Number: ,,"~5"/~.~2. ll Name: ~-¢~'~7' ~ ~ur~ /~ ~ ~ Wastewater System: ~ New ~ Upgrade Address: ABSORPTION FIELD ~o. ~ox ~7o~q ~U~/~, ~ ~ a Deep Trench ~ShallowTrench aBed DMound aether Total Depth from original grade: LEGAL DESCRIPTION ~ SoilRating: /.2 GPD/Sq. Ft. Lot: ~ S~n: ]epth to pipe bottom fram original g~ade: Gravel depth beneath pipe Ft. Township:/~ ~ I""""> ~ Filladdedaboveoriginalgrade:. '', 7 Ft. Gravollength: *~ Ft. ~ ~ New ~ U pg rede Srave~ width: Number of lines: Distance etweea lines: ~Ft. / J ~ Ft. WELL: Classification (Private. A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: F~/~ -- ~ V~ Ft. Ft. ~1~ SQ. Ft. Driller: Date Drilled: SlaticWater Level: Installer: Date installed: Yield: GPM IPump setat: Ft. ICasing Height Ab°ye Gr°und:Ft.TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. To Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity iQ From Tank Field Station Tank Sewer Lines ~C/~ ~ ~ Surface '~ ' I ~ LIFT STATION ~ Water /~ /~ ~ ~ ~ Lot , ~ ~ Size in gallons: ~ Manufacturer: Line /~ ~ /~ ~ I Foundation ~/, 7/1 ~ ~ ~ 'Pump on" level at:~ level at: J H,gh water alarm at: CudainDrain '~0~ ~ ~ J Electrical lnspections performed by: Remarks: BENCH MARK _ I Assumed Elevation: 17034 Eagle River Loop Road, No. 2~ inspections performed by: ~.1~ Liver. Alaska 995~ Dates: 1st /~ -Zo-e9 Department of Health,a ~H ceD approval '~;:': ...... ~ · Reviewed and approved by: ate: -*,:-~ z,:: 72-013 (Rev. 9/gl) MOA 25 Permit No. SW940327 Page 2 of 2 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 Descriptionl~OT: 21, SECTION 5, RIW, T15N PID No.: 05103211 Legal C01i C02 N~W lq00 GAL SEPTIC TA~K N;T:S'." A B FCO 8.7 2,1 C01 5.9 2.8 C02 29.0~ 25.8 C03 34.~ 93.0 .CO~ 53~ 48.5 C05 53.~ 54.8 MT1 50,~ 57.9 50' E.0.~W. ESMT NEW NEW 1000 GAL. SEI~TIC LOT 21i ~¢~ · FINAL GRADE co~& MT ii C04 )4.5' CO4& 91i5 · 85.~' NO WATER FOUND lID ~o ~ PAGE 1 OF 1 MUNICIPALITY OF ANCHOKAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PER~4IT. ,olz 3:ooem PERMIT NI/MBER:SW940327 DATE ISSUED: 8/31/94 DESIGN ENGINEER:S & S ENGINEERING EXPIKATION DATE: 8/31/95 OWNER NAME:SOUTER ROBERT D & OWNER ADDRESS:P.O. BOX 670994MIELKE ST CHUGIAK, AK 99567 PARCEL ID:05103211 LEGAL DESCRIPTION: T15N R1W SEC 5 LT 21 LOT SIZE: 108900 (SQ. FT.) NUbK~ER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL 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 AIqD 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) 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 RECEIVED BY: ISSUED BY: ROBERT SHAFER, P.E. ROGER SHAFER, P.E. August 12, 1994 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 SOIL TEST PERCOLATION TEST STRUCTURAL & ~IECHANICAL INSPECTIONS Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES 825 'L' Street P.O. Box 196650 Anchorage, Alaska 99519-6650 REFERENCE: Lot 21, Section 5, T15N, R1W Request you issue a per~it to drill a well and install a septic system to serve theproposedthreebedroomhouse out he referenced property- A test hole was excavated and a percolation test performed. The approximate location of the test hole is located on the attached site plan. The monitoring tube within the test hole has been checked and found to be dry. There are no protective well radii which encroach upon the property. There are no points of contamination within the proposed well radius which can be seen on the attached site plan. The proposed 1000 gallon septic tank is to be placed outside the well protective radius. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. If you have any questions, or require additional information for your ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 NORTH EAGLE RIVER LOOP ° SUITE 204 ° EAGLE RIVER, ALASKA 99577 0 +,OOI 0 d I I I OVO~] q~AV~[D N¥'ld 311S ,og =: ,,!- U ]I¥.L3(]/NOIIO3S-XI g L~ 'S'I'N ON-SITE WA~T~NA~'~ DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MA~'~LIAL SPECIFICATI(XE%~ R~F~f~NCE: Lot 21, Section 5, T15N, R1W The scope of this project includes the installation of a 1000 gallon septic tank and a five foot wide drainfield to serve the proposed three bedroom residence for the referenced property. Construction shall be in accordance with the approved site plan and design drawings, Municipal permit with any special provisions or conditions, and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. SEPTIC ~ 1. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 3. Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. 4. Septic tanks installed with less than 4' of cover shall be insulated. Page Two Lot 21, Section 5, T15N, R1W August 12, 1994 A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10' from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. 6. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. ABSORPTI(~ TRENCH/DRAINF~.D INST;~LLATION: Excavate the proposed trench to the dimensions shown on the design. The bottom of the excavation shall be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (roughed-up) before gravel (sewer rock) placement. Once the gravel is installed, the distribution pipe is to be installed level with the perforations faced downward. Gravel is then to be placed over the distribution pipe to provide a minimum of 2 inches of cover over the pipe. o A silt barrier must be installed between the final gravel layer and the native soil backfill. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter and installed approximately in the locations shown on the design. The portion of the monitoring tube extending through the gravel shall be perforated from the bottom of the trench to the invert of the distribution pipe. This is equivalent to the effective depth of the gravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finish grade over the trench must be mounded to prevent the formation of a depression after settling. MINIMUM MAT~LIAL SPECIFICATIONS: 1. Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. Page Three Lot 21, Section 5, T15N, R1W August 12, 1994 2. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. 3. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the #200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.O.A. or D.E.C. requirements. INSPB~L-I~3.0NS: Typically there will be a minimum of three (3) installation of the wastewater disposal system. follows: inspections required during the These inspections will occur as 1. The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. 2. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. Page Four Lot 21, Section 5, T15N, R1W August 12, 1994 3. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required, especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractor's activities. The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractor's activities. Final acceptance of the contractor's work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 1 2 5 6 ? 8 9 10 PERFORMED FOR: ~- '~ DATE LEGAL DESCRIPTIoN:L(~)"~'O'~ !/ S~---~-- ~,/7'/~A-~./~l~J,T°wnshiP;LRo;r~ge' Section: 12 13 14 15 16 17 18 19 20 COMMENTSf~)~SM ~,. '~'~ (ENGINEER'S SEAL} SITE PLAN WAS GROUND WATE~ ENCOUNTERED? IF YES, AT WHAT .~ 0 DEPTH? Pm Monitoring? ~,-) Date: . Gross Net Depth to Net Reading Date Time Time Water Drop ~:d~ ~ ~YY : f~ ~ ~ ~'/~ (y?" ; 2fl ~- ~" lye" PERCOLATION RATE . TEST RUN BETWEEN (minutes/inch) PERC HOLE DIAMETER -- $ & S ENGINEERING PERFORMED BY: 17034 Eagle River Loop Road NO. '~0~ CERTIFY THAT THIS TEST WAS PERFORMED IN Eagle River Alasl(~ Y~tf~ll ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) 10/10/1094 15:49 90?6941211 S AND S ENGINEERING PAGE 02 10/19/1994 15:49 90?$941211 S AND S ENGINEERING PAGE 03 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 I LEGAL ~ESCR I?TJ ON ' -~ DISTANCE TO: , ~ ] Well Dwelling PERMIT NO. O Z ~ I Manufacturer Material Liquid capacity in gallons ~= ~jJ NO. of Ii.es / Length ~a~e Total ,~ ~nes Trench w~o' Mches" ~ : Top of tile to finish graOe~ -- Material beneath tilo /~ Cinches Length Width Depth PERMIT NO, ~ ~ Type of crib Crib diameter C~i~ept~ I Total effective absorption area m Well Building foundation Nearest lot line ~ DISTANCE TO: ~ ~ C~/~/~_ D~/~ ~ 7 ~ ~er Distancetolotline PERMITNO. ~ DISTANCE TO: ' ~ilding foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS 72-013 (Rev. 3/78) DEF'ARTMENT OF HEALTH AND ENVIRONMENTAl_ F'ROTECTION 8:-25 L o]REE], ANCHORAGE, AK 99501 ,~64- (]tXl---~_-~ ]~ ]'E SIEI~J~ZF~ WELt.- PER~'~I ][ -F PERMIT NO: DATE ISSUED: 8426~7 07/26/84 APPLICANT: BOB SOUTE~ ADDRESS: % S&S ENGINEERING EAGLE RIVER, AK 99577 CONTACT PHONE: 694-2979 LEGAL DESCRIP: SUBDIVISION: NA. SECTION: 5 TOWNSHIP: LQT SIZE: 2.5A (SQ.FT. OR ACRES) MAX BEDROOMS." 3 LO"r: 2. 1 ~.,~..Obl ....NA :L5N RANGE: Listed below are th~=_ optior~s available to you system. Choose thR option that best DEF:'TH 'TO PIPE BOTTOM (FT.) 3.0 ** 3.0 GRAVEL DEPTH (FT.) 0.5 1.0 TOTAL DEPTH (FT.) 3.5 4.0 GRAVEL WIDTN (ET.) 14.0 5.0 GRAVEL LENGTH (FT.) 28.0 45.0 GRAVEL VOLUME (CU.YDS.) 14.5 12.5 TANK SIZE (GAL_S) ~000.0 .~,~ 1~000.0 SOIL RATING (SQ. FT./BR) 85 85 in designing your septic fits your site,, ~,'~ DEPTH TO PIPE BOTTOM --':: 3.5 FT. REQUIRES INSULATION · ~ DEPTH TO PIPE BOTTON < 4.0 FT. MAY I~~E:[..UII~E~ ' ~ ' ~' A LIFT STATION ~ TANK MUST NAVE AT LEAST TWO COMPARTIdENTS I certi£y that: 1..I ,=nm £amiiiaP with the requiremenLs ¢or on-site sewers and wei].s as set £orth by {he Municipality of Anchorage (MOA) and tine State oF Alaska. 2. I will ins{all tine system in accordance with all MOA codes arid reguIations~ al~d in compliance wi'Lb the design cPJ. tepia o¢ this per'mit. 3.' I wilI adhere to a].I MOA a~'~cl Gtat. e of Alaska requirements Cop the set back distances Crom any existing welI wastewaten di. sposa] system of public sewerage system on this or any adjacen~ or nearby lot. 4. I undenstar~d that this permi{ &s valid ¢o~ a maximum of 3 bedPooms arid any enlargement will nequine an addi{ionaI 0epmit. SIGNED APPI_ICANT: ISSUED BY IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, ]FWEN (1) AN ELECTRICAL PERMIT AND INSPECTION NUST BE OBTAINED; (,'-2) AS-BUILTS WILL NOT BE APF'ROVED WITNOUT AN ELECTRICAL INSPECTION REPORT; AND (3) TI4E ,~.LE[,TRICAL WORI< MUST BE DONE BY A LICENSED ELECTRI[,.[AI,I. ............................. ..... NUN X DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE~ AK 99501 264-4720 PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: ~]N---S ~ TE SE~ER ~-~- ~gEL. L. F"E~R~d I ]" 840627 k~ 07/26/84 CONTACT PHONE: BOB SOUTEC % S,~o ENGINEERING EAGLE RIVER, AK 99577 694-2979 I_EGAL DESCRIP: SUBDIVISION: NA. SECTION: 5 TOWNSHIP: 15N LO]' SIZE: 2.5A (SQ.FT. OR ACRES) MAX BEDROOMS: Listed below are the options available to you system. Choose the option that best fits your LOT: 21 RANGE: BLOCK. NA. ~n designing your septic site. DEPTH TO ~IPE BOTTOM (FT.) GRAVEL D~FTH (FT,,) ' TOTAL DEFTH (FT.) 7.0 - 8.0 GRAVEL LENGTH (FT.) 34 0 66.0 TANK SIZE (GALS) 1~000;0 ~'~ 1~000.0 SOIL RATING (SQ. FT. /BR) 125 125 TANK MUST HAVE AT LEAST TWO COMPARTMENTS I certify that: 1. I am ¢amiliar with the requirements {or' on-site sewers and wet'ls as set ¢opth by the Municipality oF Anchopage (MOA) and the State o£ Alaska. 2. I will install the system in accordance with all MOA codes-and regulations~ and in compliance with the' design cpiteria oF this permit. 3.. I will adhere to all MOA and State o£ Alaska pequipements fop the sel back distances Fpem any existing well~ wastewaten disposal system ep pwblic sewerage system on this or any adjacent or n'earby lot. 4~ I understand, that this permit is valid Cop a maximum o£ 3 bedrooms and any~enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES, ]'HEN (1) AN ELEGTRI~E~-~ERMIT AND INCPECTION MUST BE OBTAINED~ (2) ~S-BUILTS WILL ~.OT BE A~PRO~E~.D W¢~:~O_UT AN ~//TRICAL INSPECTION REPORT;' AND (.~) THE ....... MONIClPALITY OF ANCHORAGE 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LO~ -- PERCOLATION TEST 2 8 11 13- 14- 15- 16- 17- 18- 19- 20- SLOPE SITE PLAN WAS ~ROUND WATER A JO S ENCOUNTEREd? L O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) COMMENTS TEST RUN BETWEEN FT AND , FT CEflT, FI ED I~n¢~~ 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL MEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date (a) Lega%.Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicants (c) Applicant is (check one) Lending Institution Buyer~; Other~-~ (explain); (d) Lending Institution /OL~--;_~- Telephone - Home Business ~--~ ; Owner/builder ~ Telephone Address (e) Real Estate Co. & Agent Address (f) Telephone ~f't~he HAA to the following address: ~'& ~ £M8INE~RINM SR~ 19S~, · 2. Type of Residence Single-Family.~. Number of Bedrooms Multi-Family Other (describe) 3. Water Supply Individual Well ~ Community ~--~ Public ~--~ 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, 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 ehows 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 wast,water disposal system is in compliance with all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection. Name of Firm Telephone DHEP Approval -~. ~'~.~ ~.~"~ Approved for/~Z~(~y bedrooms By~~ ~ Date ./ Approved ~ Disapproved __ Co~ition~ 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 $ ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTEEED 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 DEEP 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/Di8 [Page 2 of 2] 7-19-84 A® MUNICIPALITY OF ANCHORAGE (McA) HEALTH AUTHORITY APPROVAL (HAAi CHECKLIST - FEBRUARY 1984 Well Log P~esent/ (Y~) Total Depth ~ ~x , Cased to Static Water Level 3~ Casing Height Above Grc~nd 30 *' Electrical Wiring in Conduit (~ Separation Distances f~om Well: MUNI¢ PA~, I'IY OF ANC:HOPAG~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTIOIq Legal Description: ~E~D ~-~ If A, B, ~ C, D.E.C.~ / ~/~Pr°~d(Y~~---/-~YieldF ~ ~te ~leted /~ Pump Set At Depth of G~outing Sanitary Seal on Casing~/~) Eep~ession A~ound Wellhead (Y~) To Septic/N~ Tank on Lot To Nearest Edge of Absorption Field on ~ot/~ ' To Nearest Public Hewer Line ~J /~ To Nearest Public Sewer Cleanout/Manhole ~r ~ f~_ To Nearest Sewer Service Line on Lot Water Sample Collected By~I~ C~4~/~4~'~//O~; Date Wate~ Sample Test Results ~F~} ~[~ ~z~4~-~ To/'~? C~tu~nts ; On Adjoining Lots /OO ; On Adjoining Lots Be Date Installed /O/~ Size /~_~ No. of C~%~a~tm~nts Standpipes~ / ' . Ai~-ti~t ~ps~ Foun~tion Cloanout~) ~ession o~ Ta~ (~ ~te ~st P~d ' ~ P~ing~intena~ ~n~a~ ~~/File .(Q~ ; fJ ~ ~ ~--~/, Holding Ta~ High-Wate~ ~a~ (Y~ ~ Holdi~ Ta~ ~t (Y~/~ ~p~ation Distan~s ~ ~ptic~olding Ta~: To Water-Supply ~11 /~ ~ To ~ilding F~ndation To ~o~ty Li~ /d ~ To Dis~al Field To ~ter ~ip~Se~vi~ Lir~ /~ ~ To S~e~, ~nd, ~e, ~ ~jor ~aina~ ~ ~ ~ ~ Receipt # Date Paid: Amount: [Page 1 of 2] 2-15-84 ABSORPTION FIE~LD DATA Soils Rating in Absorption, Strata Date Installed Width of Field Square Feet of Absorption A~ea Dep=ession ove= Field QY~ Results of Last Adequacy Test t~ of Last Ad~=quacy Test Separation Distance from Absorption Field: To Weter-Supply Well //~3 ~ To P=operty Line /~P Type of System Design Length of Field ~5~ Depth of Field Gravel Bed Thickness Standpipes P~esent To Building ~ion Lot ; On Adjoining Lots To Water ~J~c. ln/Be~vice Line /O 7L To Cutbank( if present) TO Stream/Pond/Lake/or Major D~aina~e Course TO Driveway, Pa=king Area, c~ Vehicle Storage Area ComTe nts /~3 o ~ ~ To Existing or Abandoned System cn D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Weter Alarm Level at Tested fo= Electrical Codes(Y/N) "Pum~/Q~" Level at Vent (Y/N) Pumpxng Cycles during Adequacy Test~ Meets MOA Con~aents ** Check Permitted Bedroom Rating Against HAA Request ** I (~rtify that I have checked, verified, or eonforr~d to all MOA HAA on the date of this inspection. KB]./d5/s Date MOA No. [Page 2 of 2] in effect 2-15-84