HomeMy WebLinkAboutT15N R1W SEC 5 LT 33 S110' Municipality of Anchorage 'i. Page I
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: .~U qloOl~O PID Number: ~'~')\ ~{~)~'~,%
*ddr*";Po /[OX (. 717/I ~.~UCv,ee~_
Phone: N °' c ~_8 e;l~/c~m s:
LEGAL DESCRIPTION
· o,: $$ S-'/~ .look:
Township: i~,/~I
WELL: [] New
[Private. A,B,C):
~xl $-r'taJ ~.
Driller:,
Subdivision:
r-I Upgrade
Total Depth;
Drilled:
Yietd; GPM Pump Set at:
of -~
We,
Surface
Water
Lot
Line
Foundation
Cu~ain
Drain
Remarks:
Inspections performed by: ~-~'rul~" ~=.~,i~Z'P.x Dates: 1st 2nd
Department of Health ~ Huma.,,r~ervices approval
Reviewed and approved by: .~~ Date: F~L/~.?z~
Ft.
Height Above Ground;
Fl.
SEPARATION DISTANCES
E] DeepTrench r~ Shallow Trench ~Bed E] Mound [] Other
Soil Rating:.. , ~) GPO/Sq. Ft. Total Depth from,, original, grade:g~, ~ I
Depth to pibo bottom from original grade: Gravel depth'beneath pipe
ed aPove original grade: Gravel length:
Ft.
~r of lines: Distance be[ween lines:
Pi · material:
Date installed:
TANK
[] Holding
~f~'S.T.E.P.
Capacity in gallons:
Number of Compartments:
~/00f
"Pump on" level
LIFT STATION
"Pump off" level at: High water alarm at:
,~-7" ~/7'
performed by:
BENCH MARK
Location and Description: ~'~) [~ bl~ ~'..~'~' G/'7..A J ~'"il~
lOO -
ENGINbI=A;;~ SEAL
43Bf - ~
Wastewater System: [] New ~Upgrade
ABSORPTION FIELD
MuniciPality of AnchorageI''''' Page 7-
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION '
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ,~J °/~, O J$ 0 PID Number.
of -~
Municipality of Anchorage'.'." Page ~ 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:. ,~v,J cf ~. O J :~O PID Number:.
08/26/1996 19:00 6947112 S6TECHNIC~L P~GE 83
CCC Construction Date: 06-26-96
POB 7 70r~7
~agl,.~ Rive~ ~ 995~7
Lt. 335 ,TlbN,RIW,S5
22307 Day i~on Dr. chugiak
at ~bove ment.!oned property has been wired in accordaNCe w~th
the National t,:Leotrlcal Code and ~anufaoture~
Systems were che0ked and Performed as ~pecifted
the ~stems
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW960130
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:RUSSI HAROLD J & KAREN S
OWNER ADDRESS:22307 DAVIDSON DR
CHUGIAK, AK 99567
DATE ISSUED: 6/21/96
EXPIRATION DATE: 6/21/97
PARCEL ID:05103223
LEGAL DESCRIPTION:
T15N R1W SEC 5 LT 33 Si10'
LOT SIZE: 36155 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK 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 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 SPEgAL PROVISIONS.
SPECIAL PROVISIONS":/ __ ~ /~
RECEIVED BY~"~ ~~/~
DATE ~i-~/~'' ~
DATE: ~//~
June 7, 1996
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 33S, T15N, R1W, Section 5
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
The absorption bed on the subject property has failed and must be replaced. We are
therefore applying for a permit to upgrade the septic system. The attached site plan shows
the location of the new absorption bed. The testhole placed on the lot revealed a clean well
graded sand approximately 4.5' below the surface. The bed will be constructed atop this
material. Groundwater was found at 10' below the surface and stabilized at that level.
A pressure distribution system will be required due to insufficient fall from the house. The
existing septic tank will be removed and abandoned. The new bed will be constructed a
minimum of 10' from the old bed.
The surface
maintained.
made:
of the lot is fiat
If the new system
and all separation distances from adjacent wells will be
is constructed as designed the following statements can be
The system, if constructed as designed, will have no adverse impact on the wells in
the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on existing septic
systems in the area or those to be constructed in the future.
The system, if constructed as designed, will have no adverse impact on reserved
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 will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
RECEIVED
22556
ALDER LEAF CT
DAVIDSON
BLM 46
BLM 54 BLM 55
THIS PROJECT
LOCATION MAP
--
305
Bk 256 Pg 365
R.0.W Esmt
330.86
220 P~ 329 t o
//
/ ....?
330.79
330. 79
'49"W 334.57
I INLET
AREA MAP '
SCALE 1" = 100'
SITE PLAN
~SCALE 1" = 40'
NOTE: NO WELLS WITHIN 100' OF NEW SEPTIC SYSTEM
REMOVE AND DISPOSE
EXISTING SEPTIC TANK
APPROXIMATE LOCATION
OF FAILED BED
R.O.W. EASEMENT
,500 GALLON
S.T.E:P. TANK
15' X 50' BED
LOT 33S, T15N, RIW, SECTION 5
DESIGN FACTORS:
Four Bedroom Home
Perc. Rate: I Min./Inch
Application Rate: .8 GPD/SF
SYSTEM REQUIREMENTS:
Shallow Bed System
1,500 Gallon S.T.E.P. Tank
Pressure Distribution System
4 Bedrooms X 150 GPD ! .8 GPD/SF = 7S0 SF of Absorption Area
750 SF!15 LF (Width) = 50 LF (Length)
Therefore:' Construct a 15' Wide X 50' Long Shallow Bed System with a
1,500 Gallon S.T.E.P. Tank and Pressure Distribution Piping. Bed to be
Placed AtoP SW Material Approximately 4.5' Below Surface.
NOTE:
TYPICAL SHALLOW BED SECTION ~,-.~.~ .... ;o,-~.
(NO SCALE) ~, ,, '~,-
Bottom of Bed to be 4' Above Groundwater.
Grade Area Over Bed to Drain Away.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
:~E~G NEER'$ SEAL
PERFORMED FOR: /~/~/.~ ~* ~"~-,,~"~ ~S~I
LEGAL DESCRIPTION: ~97"3~1T/~'/~) J~-I~ ,~' Township, Range, Section:
I
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-
20-
$~J
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
I
N
DEPTH?IFYES'ATWHAT lO' pO
E
Depth to Water Althr/~) '
Monitoring? Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch) PERC HOLE DIAMETER __
__~TAND ~'~ FT
ACOORO^NCE W,TH ALL STATE AND ~N'OIPAL~U'C~'N~$'N ~CT ON TH'$ O^TE' O^TE:
72-008 (Rev. 4185)
ANDERSON ENGINEERING
.~ ~/~/) .^~. ~'/~/~- c,,~.?
CHKD. BY DESCRIPTION
SHEET ! OF --/-.
JOB NO. - .............
(~r'=~. = 717 x~
cji ~ /~, 7..~
· i; 1~"~' ' ;; ~ EFFLUENT PUMPS
,,, i i,wr' ~ ~ ~ 1/2Hptoll/2Hp
120OSI15HHF-9stage~- ;il i .~. ii
~ .... ,T'i"".'t' ~
' ~ "* ~ .... *"'" '""' '~"*"*"~" "'Pr'i'!"
?.~- ~- i-~.4-.-~--.p,- ~.~ --~, 'i i : iii , , ~: i Ii !.
...... i.. ~--.+ ....... ~..~ ~. ?--..+-r "~" . . .
..~...~...~...~ .... i..t..J...
'~. ~-.' !+]~ ' ii, zOO IOSHHF-5
~~: -~..~H-..~ ~-~' :: ::~-"'~i~ '~'~;
,.-i ..... i..;..~.- -+-.~--FT ~.~ -~-i-~i- . -~"~ ...... ~ 'T" "~ ......... ~"
-4.4..~..F' -.~. 4~ - ~.~ ..... ' '- :::~ '~"
· 40 OSI 05 HH - 2 stage
... ' ' '..- --i.4... 4.....i...i...P.P .~..~..i-..¢ ..i....4-,i..,h+--i ..... ~..i...i..+ -~..~ .....
.i_~...i .... ~..
~ ~. ,.~. M-~,-! : ~.. ::: ~ ~' , ..
:; i :: ........... I ~.
,;:~ 0OSI05HHF-Ss age: ~i i
i: -N~lllw / 114 flow controller ' ~ ~ ~ ~ , , ~ , , -L
t~I- ,,,,
0.~ 5.~ 10.~ 15.~ ~,~ ~,~ 3),~' ~,~: ~,~ 45.~
N~ DIVERGE GPM
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: Lot 33S, T15N, RIW, Section 5
GENERAL:
The scope of this project includes the removal and disposal
of an existing 1,000 gallon septic tank and the procurement
and installation of a 1,500 gallon S.T.E.P. Tank with a lift
station and the construction of a 50' long X 15' wide
absorption bed.
Construction shall be in accordance with the approved site
plan, design drawings, Municipal Permit with any special
provisions or conditions, and all applicable State and
Municipal Wastewater Disposal Regulations.
The Contractor shall be
underground utility locates
system.
responsible for obtaining all
and for the layout of the septic
Unless specifically agreed otherwise, the contractor shall
be responsible for final grading areas subsequently
depressed from soil settling. The property owner shall be
responsible for revegetation of affected areas unless
specifically agreed otherwise.
Contractors installing wastewater disposal systems must
be certified by the Municipal Department of Health and
Human Services for system installations. Owners installing
their own systems must receive prior approval from D.H.H.S.
before beginning system installation.
LIFT STATION INSTALLATION
1. The lift station is to be constructed by a certified tank
manufacturer. Construction shall include an 18" manhole
fob access to the lift station.
Lot 33S, T15N, R1W, Section 5
June 7, 1996
Page Two
2. The lift station shall be sufficiently bedded to prevent
settling or shifting of the tank.
All standpipes on the lift station shall extend a minimum of
12 inches above final grade.
4. Lift stations installed without 4' of cover shall have a
minimum of 2" of direct burial insulation.
A foundation cleanout shall be installed one to four feet
from the building foundation. No cleanouts are required
between the lift station and the drainfield in a pressure
distribution system.
Final grading over the lift station shall be such that a
positive slope exists away from the septic tank.
ABSORPTION BED CONSTRUCTION:
The absorption bed shall be constructed to the dimensions
shown on the design. The bottom of the bed shall be within
2" of level.
Distribution piping must be placed level with perforations
down atop a level bed of drainfield rock. Rock should then
be placed over the pipe to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between
the drainfield rock and the natural soil backfill.
Monitor tubes must be 4" in diameter and installed at the
locations shown on the design. The portion in the drainfield
rock must be perforated.
5. Direct bury insulation must be placed over the distribution
system when less than 3' of backfill depth is available.
Lot 33S, T15N, R1W, Section 5
June 7, 1996
Page Three
Finish grade over the trenches must be mounded to prevent
settlement or depressions.
MATERIAL SPECIFICATIONS:
1. The lift station must be constructed by a Municipally
approved septic tank manufacturer. An Orenco 20 OSI 05
HHF - 5 is recommended.
2. The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C.
(perforated and solid), ASTM F810 or H.D.P.E. (perforated, but
not solid) and ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial
polystyrene (Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
A permeable geotextile fabric (Typar, Mirafi or equal)must
be installed between the final drain rock layer and the
native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than
3% passing the #200 sieve.
INSPECTIONS:
A minimum of two inspections are required by Municipal
Ordinance. These inspections must be conducted under the
supervision of a professional engineer registered in the State
of Alaska. The first inspection must be conducted after the
excavation of trenches, beds or pits and before the installation
of any gravel. A septic tank may be set in place, but may not
be backfilled.
Lot 33S, T15N, R1W, Section 5
June 7, 1996
Page Four
The second inspection must be conducted after the placement
of the geotextile fabric, gravel, distribution piping,
standpipes, cleanouts and insulation. No backfill should be in
place at the time of the second inspection.
The contractor is responsible during the layout of the system
to assure that all separation distances from adjacent wells in
the area are met.
~ 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 P~_~qONE [~N EW
MAIL,N~p~RESS
LEGAL DESCRIPTION ) '
LOCATION NO. OF BEDROOMS
~ DISTANCE TO: 5-
~ ~ Manufacturer Material No, of compartments
7~ Inside length Width Liquid deptb
~oZ DISTANCE TO:
~ Well Foundation Nearest lot line PERMIT NO,
~ ~ ~ Typtof cri~ Crib diameter Crib depth area~
~r~H~r Distance to lot line PERMIT NO.
OTHER
REMARKS
(Rev. 3/78)
. , ~UNICIPALITY OF ANCHORAGE~
Depagtmeht? ~ Health and Environments '?rotection
825 ~ Street, Anchorage, AK. 79501
~~ 264-4720
· ~// * * * HANDWRITTEN PERMIT * * *
Permit #~I~ /~?WELL AND/OR ON-SITE SEWER PERMIT~ ~ ,(-~ / /
Applicant: ~ ~]~? ~ c~ 3'~ Mailing Address/O '~ ~ ~ ~/~////~
Location: Phone Number: / ~Z~'7,~<
Legal Description: Z ~ ~ ~? ~ ~/~ /~ot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed:/~ Holding Tank:
Maximum Number of Bedrooms: ~ soil Rating(s~.ft/br)
The Required Size of the Soil A~sorption System Is: /(
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimtum depth of gravel between the outfall ~ipe and
the bottom of the excavation(in feet).
· * REQUIRED SEPTIC(HOLDING) TANK SIZE = , GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that'the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution·
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days Of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
· * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
i certify that:
(1) I sum familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 ~drooms.
Applicant "
Date: ~ ~ ~ [~
SWP/024 (1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Ataska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7 /2.0c~/~--- 'TO 1/~ ~
SLOPE
SITE PLAN
10 /.~
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATER \/~..~ S
L
ENCOUNTERED? o
P
IF YES. AT WHAT , E
DEPTH?
COMMENTS
PERFORMED
72-008 (6/79)
Reading Date Time
PERCOLATION RATE
TEST RUN BETWEEN FT Al
Permlt ~ '~
Applicant
~-~IUNICIPALITY OF ANCHORAGE,~-~
Environmenta] }rotection
Department~ ' Health and
825 Street, Anchorage, AK. 3501
264-4720
* * * HANDWRITTEN PERMIT * *
WELL A ._. ~' ~.~- PERMIT
?,~;m ?~ Mailing Address: Pa
Location:
Phone Number:
Legal Description: 7-7S-/~ ~/~d ~Gy~
Type of Soil Absorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms:
Lot Size: ~//~
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br)
DEPTH
The Required Size of the Soil Absorption System Is:
~/~ LENGTH ~/~- GRAVELDEPTH~/~ WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet). ~!
* * REQUIRED SEPTIC(HOLDING) TANK SIZE =/~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee~
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers
set forth by the Municipality of Anehorage.
(2)
(3)
S igne~:
and wells as
I will install the system in accordance with codes.
I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 bedrooms.
k~pl~cant ~ ~ ~/~/~ ~
Date:
SWP/024 (1/81)
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR a SINGLE FAMILY DWELLING
Parcel I,D. # ~) ~\ - (~-- '~,-"~ HAA # ~'~ ~
GENERAL INFORMATION
Complete legal description $'iil2
Location (site address or directions) ~-~-~0-/
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
&7i7il
/'~ 55, i Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
MuNtC. JpAgT~ OF ANCI'~I~AGE
{~,Vi~.ONMENTAL SERV ~--.S gl'VISION ~
,}UN 27 996
iH I,I' ,.
RECEIVED
If community well system, provide written confirmation from State. A.,DEC. attest-; . ·
lng to the legality and status of system.
'"~
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 ~i~posal 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 /~,--~,J § ~-/Z~O ~J ~:"~J ~ / ~J ,~"~'-/'~ ~J ~ Phone
Address P~) ~O~ ~YO~7~ ~~G~
Enginee¢s signature ~ F- ~ Date
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 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 engineer's work.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ..........
p r. Jl~ ANCHORAGE
dUN 2 7 1996
Health Authority Approval Checklist
Legal Desctiption: 5Y$/-~>- ~ r~-'/~'A/, ~--t~I 5~ Parcel I.D.:
A. WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitmy seal (Y/N)
RECEIVED
IfA, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to ~4~. ~ Casing height (above ground)
y Wires properly protected (Y/lq)
FROM WELL LOG AT INSPECTION
I
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Colffom O
Date of sample:
Z,~ g.p.m. /~ g.p.m.
Nitrate I~ 0~ Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ~/,~'/~] ~,
Foundation cleanout (Y/N)
Date of Pumping t~J~
Tank size I~0 0 Number of Compartments ~- Cleanouts (YPN)
Depression (Y/N) /~1 High water alarm (y/lq)
Pumper
-y
C. ABSORPTION ]cl~LD DATA
Date installed b/Zta / ~/~ Soil rating (g.p.d./fta or tt2fodrm) ' ~' Systemtype R~-'~
Length ~,/~ t Total depth
Width ] ~ Gravel thickness below pipe e 5 I ~, ~- t
Effective absorption area c]]~" f:y,~;-Monitoring Tube present(Y/Iq) y Depression over field (Y
Date of adequacy test /~ (~ o$'r'Results (Pass/Fail) '~AS-~ For [=~ ¢/1.. bedrooms
Fluid depth in absorption field before test (in.);
Fluid depth O (ins.) Minutes later:
Peroxide treatment (past 12 months)
Immediately after gal. water added (in.):
Absorption rate -- g.p.d.
Ifyes, give date A//~
D. LIFt STATION
Date installed
Manhole/Access (Y/N)
High ~vater alarm level at*
Cycles tested
Size in gallons
"Pmnp on" level at* qU.,,q
*Datum ~Ewr/-O t~
"Pump off" level at*
E. SEPARATION DISTANCES
Absorption field oa lot
Public sewer main
Sewer/septic service line
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot '>'! O 0 t
>/00
; On adjacent lots
; On adjaceot lots
Public sewer manhole/clemmut
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building fom~dation ~.~'- / Property line >/0 ~ Absorption field
!
Water main/service line '> / 0 Surface water/drainage ~/0 0 Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building fomldation '~/O t Property Line ~>/0 t Water main/service line
Surface water '>/0(9 t Driveway, parking/vehicle storage area )'
Curtain drain A]0 M ~' O ~1 ~_~O'C' Wells on adjacent lots ~ l0or
F. ENGINEER'S CERTIFICATION
I certiJy that I have determined thru field inspections and review of Municipal records .th6~ t~;e ab'&'oe byo~tems are
in conforntance with MOA J-[AA guidelines in effect on this date. , /?,,,~,~,, ,
Date of Payment
Receipt Number
Rev. 8/95 eSS: haa,wk.doc
Waiver Fee $
Date of Payment
Receipt Number
84/15/1996 19:28 6947112 SGTECHNICAL PAGE
zTL'
CT&E Environmental Services Inc.
Laboratory Division r~'JJJJJ~'J~'~'~'.~-~e-j~-~-.~-fjffjj~j~fjj~~~
Laboratory Analysis Report
CT&E Ref.# 962552.962552001
Client Sample ID 22307 Davidsonl 0!
Matrix Drinking Water
PWSID 0
Collected Date 06/25/96
Technical Director: Stephen C. Ede
Sample Remarks:
Nitrate-~
Nitrite-N
Total Coliform
Results QC
Qual
PQL
Units
Method Allowable Prep Analysis Init
Limits Date Date
1.08 0.100 mg/L EPA 353.2
0.100 U 0.100 mg/L EPA 353.2
0 0 cot/lOOmL SM18 92228
06/26/96 Elizabeth
06/26/96 Elizabeth
06/25/96 TAV
U - Undetected
LT - Less than
GT - Greater than
D - Secondary 0ilution
J - Belo~ the calibration range
200 W. Potter Drive, Anchorage, AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 561.5301
3180 Pager Road, Fairbanks, AK 99709-5471 -- Tel: (907) 474-8656 F. ax: (907) 474-9685
ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA. FLORIDA, illiNOiS, MARYLAND. MICHIGAN, MISSOURI. NEW JERSEY, OHIO, WEST VIRGINIA
CT&E Environmental Services Inc.
Laboratory Division
Drinking Water Analysis Report for TOtal Coliform Bacteria 200 w. pott.r Orlve
Aschotage, AK 99518-1605
READ I?,'STRUCTIOA:$ O?/ R. EVER~E SIDE BEFORE CO£LECTI.'.YG SA:!TPLE Tel: (907) 552.2343
MUST BE COMPLETED BY WATER SUTPLIER
PUBLIC WATER SYSTE3! I.D.
t::g~RIVATE WATER SYSTE.:'~I
Send R~ults 0 Send lnvolce
Month Day
SAMPLE TYPE:
[~Routine
O Repeat Sample (for routine sample
with lab ref. no. )
0 Special Purpose
Year
Treated Vv'a ter
Untreated Water
Time
SA~WLE LOCATION Collected
Collected
By
Fax: (907) 581.5301
TO BE cOMPLETED BY LAflBORA. TOKY
Aaa ys s shoWS this Water S.&MPLE to be:
.<~ SatisfaCtorY :
o Unsadst'actoLy
O Sample over 30 hours old, results may
be unreliable
o Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via special deliveo' mail.
Date Received (~/2- 5--
Time Received .[~,"50
Analysis Began [ ('' a.~
Aaa ytlcal .,X'lathod: ,~Membrane Filter
g MMO-NIUG
· Numberofcolonies/100 mi.
96. 2552 t
Sent to A.D.E.C. Anch . Fbks Jun
Analyst
Client notified of unsatisfactoc,.' results:
Phoned Spoke with
Date: (~ ,....o...,, Time:
Faxed
[]
Faxcd
BACTERIOLOGICAL WATER ANALYSIS RECORD
;Xl~IO-MUG Result: Total Coliform E. Co[i
:Membrane Filter: Direct Count L'~ Colonies/100 mi
· Verification: LTB BGB COLIFIRM
Fecal Coliform Confirmation
Final Membrane Filter Resu~ls
Reported By _IS~ [,]5~j-~
Coliform/100 mi
7ART ONE C7
~'~ sCS Member of the $G$ Group ISoci~t& G~n6r.le de Surveillance)
f~*" MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range){/,..~ 6')
Location (address or directions)
(b) Applicant Name /~.~,/'~'," Telephone: Home Business ~'Z/-~'~/'~
ApplicantAddress /~/'~'~ I/J, .~-/v"$d.&,/ .¢l~17~ B~/¢- .,~Z//,,, 2¢*~
(c) Applicar~t is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
Address
Telephone 2-Z/~'- .%-SC ~/'
(f) Mail the HAA t . ¢
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well~J~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite~[J' Public [] Community [] Holding Tank []
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/§4)
~'~, -r ~ ~--'-~J ,~. / u~ -~-~ ~'"
ENGINEERING FIRM PROVIDIN. ,NSPECTIONS, TESTS, FILE SEARCH, DA . AND INFORMATION
As ce~ified 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 Js safe, functionsl 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 ~ Telephone '~/->~
Address 1~ ~ ~-~ /~ ~/~- i~ ~/ ~- ~
Date ~ -/~ '-¢¢
OHEP APPROVAL
Approved for ~-"~'C'~.)bedrooms by ~ ,,4~, '~/~-..~.~
App~:oved f Disapproved Conditional
Terms of Conditional Approval
,
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 requirements. Employees of DHEP 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.
Page 2 of 2
72-025 (11/84}
ENGINEERING FIRM PROVID. .~ INSPECTIONS, TESTS, FILE SEARCH, [... ~'A 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 1~"~¢ /'J ~-~
Date ~ -/O -¢7
Approved for '~'~w~'~'~)bedrooms by
Approved '~ Disapproved Conditional
Date ,.~ --/c, - ~'=~'
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 requirements. Employees of DHEP 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.
Page 2 of 2
72-025 {11/84)
/~, MUNICIPALITY OF ANCHORAGE ?~%'
DEPART~,.4T OF HEALTH AND ENVIRONMENTAL Pn~TECTION
DIVISION OF ENVlRONI~ ENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-StTE SEWER AND WATER FACILITY
264-4720
Applicabon Date ~Z~
1. GENERAL INFORMATION
(a) Legal Description (: nclude Iot,'~ff~-ck, subdivision, section, township, range)
koeatton .radrlre,ss or, d~rect~ons)
Business
...... ~ 2"/. ~- Telephone: Home
'b¢~ 'A~ ca~Name" '
-~,;' ~'(~E"~ii~fifi~' ch~ec~ dfi~)?ff86ding Institution B; Owner/builder; Buyer B; Other D [explain);
. , . .........
" .-' (d) Eefl~jng Institution .'~0~ ~¢~ Telephone
(ei' Real Estate Company and Agent ,'~57~;~'f
Telephone
ii:" (~' Mail the HA~ to the following a~dr;ss ' '~" . ,/
2. , 'TYPE OF RESIDENCE ..... '
;. 6;.';: Single-Family'~ Multi-Family [] Other
' '" Of Bed O
-.,.. :::,Number r ems
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
Onsi~e~[~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Deeartment of Environmental Conservation
attesting to the legality and status.
72-025 (11/84]
Page 1 of 2
ENGINEERING FIRM PROVID', /INSPECTIONS, TESTS, FILE SEARCH, D. .~ AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Healt,h
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 ,/~-~--5 Telephgne
Address
Date
DHEP APPROVAL
Approved for '¢"~"'~ (E,) bedrooms by,~4v'-: ~' ~ Date
Approved Disapproved Conditional
Terms of Conditional Approval ~ ~ ~
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 JR order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
72-025 {11/84}
A, WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MO
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: Z~"-
If A, B, C, D.E.C. Approved (Y/N) /~'///'~
Well Log Present~. )/
Total Depth ~/'~ Cased to ~//'o /
Static Water Level ~J) /'~-'~/ /
Casing Height Above Ground /" ~
Electrical Wiring in Conduit(~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot //~
To Nearest Edge of Absorption Field on Lot
Date Completed ¢-z~ -¢¢/$ Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casin~N)
Depression Around Wellhead (Y~
; On Adjoining Lots
/2-0 ~ ; On Adjoining Lots
To Nearest Public Sewer Line /J/~ To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected by /~"~ 5 ~ /-J/~/' ; Date
Water Sample Test Results
Comments (~ ~.J~'ZL_ ~
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes~N) Air-tight Caps(~N)
Depression over Tank (Y/~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
Size /~ No. of Compartments
Foundation Cleanout(~)
Date Last Pumped
,,~,'/~ ;for ,'~//~
Temporary Holding Tank Permit (Y/N) /-J,~
To Water-Supply Well
To Property Line
To Water M~in/Service Line
Course'
Comments
/
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field /'~
Type of System Design
Length of Field
Depth of Field
Square Feet of Absorption Area
Depression over Field (Y(/~).
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot /¢,///q
To Water Main/Service Line
Gravel Bed Thickness E~,
Standpipes Present (Y4t
Date of Last Adequacy Test
To Property Line /0 4-
To Existing or Abandoned System on
; On Adjoining Lots /0 / -/
To Cutbank (if present) /,///4
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION
Date I nstalled~""---.
Size in Gallons ~
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
'"'"'"'"'~ _ Vent (Y/N)
~mmping Cycles Meets MOA
~ during Adequacy Test,
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have ¢)~ecJccd, verJfi~ed, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~"2.~-----('//C~f'~' Date ~' ;-Z -~'
Company ,"~¢ ~' MOA NO. ,.~, -dZ/' ~._~.~__~.~'~,~,~,.
Date of Payment
Amount: $ //~ ~ d ~
Page 2 of 2 6NVIRONMENTAL $ERWCE ,~.
MAR 31987
RECEIVED
October 13~ i983
~,,iay ne Cousineau
Po O, Box '163
~3agle River, Alaska
S~bject: ~R J. WSM Silo Pt
App.-oval ~~dfvidual sewer and wa%er facilities casnot
be granted until ~he following items have been completed:
.o (A well log submitted to this office for our files and
~ ~review. This ~epar~'~3nt has no record of any on-site per-
~t for this-~hi~lon. ~x soils lo~ must be sub~itted,
~/~ a permit oDt~l ~engineer agybuilts submitted
~?lease notify this Department for a reinspection when the
noted dlscreparlcies have been correcued. If there are any
further questions, please call this office at 26,1--4'720.
Sincerely,
CW70/E2/s
Cory Willis
~ssoclate ~nv iro~i~le ntal
Specialist
- ~ ' ' APPLIC>NT FILLS OUT UPPER HAI.,~ONLY
~roperty
Phone
Owne~
Address /r~y/,.~ & ~' 7 ~'{ Zip Code
Street
Type of Resi~nce
~ Single Family
~ Multiple Family No. of Bedroo~
Water SupCy
: Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
[~) ~"' O) MUNICIPAUTY
Field Notes: ~ , ~ O~ ,A~NCHORAGE
:~:'~\ / ~ -~1 DEPT. OF
~ ~ ~ ~ ~NVIRONM[NTAL PROT~C[ION
RECEIVED
( ~) APPROVED BEDROOMS "~NDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
S Date ~wer Installed Well To Absorption Are~ /~ O t~ Well Log R~ceived
~ ~~ Well to Tan' /a*t~ Septio T~k Size