HomeMy WebLinkAboutT15N R1W SEC 5 LT 74 W2TISN
Lot 74
#051-081-23
Municipality of Anchorage Page I of 5 ..
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650-e Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number:' c~-'g)j~-' PID Number:
.~m~: ~ + ~ ~ ~1~ Wastewater System: ~w ~ Upgrade
Address:po. ~X ~70~5' ~, AI~ ABSORPTION FIELD
""°"":4bb-iCSU ,o.o~.O,oom.: ~ Deep Trench ~ShallowTre,ch ~ OUound ~Other
LEGAL DESCRIPTION Soilaaling: .~ GPD/Sq. Ft.' T°talDepth fr°m°risinalsrade:
Lot: ~ ~ Subdivision: Depth to pipe bottom Imm original grade: Gravel depth beneath pipe
Range: / ~ :iii added above original grade: Gravel length:
Number of lines: ~ Distance baleen ~ines:
WELL: ~w D Upgrade' Grovel width: /~ FL ~ 4 Ft.
~r/~ / ~1 Ft. /~1 .t. ffOO SQ.F~. ~--~/~
Oate in tulle
SEPARATION DISTANCES . ~ptic ~ ,o~di,g ~ S.T.~:P.
TO Septic Absorption Lift Holding ~ublic/Private Manu~scturer: Capscity in
From Tank ~ield Slalion Tan, ;ewer Lines ~~ f~l~
~/ Number of Compartments:
Surface >/~0' ,>,00' ~ ~'~ LIFT STATION
Water
Manufacturer:
Curtain Drain ~/~ ~ / ~ Pump Mske~ectrical inspections performed bY:
Remarks: Zu ~Su~iOM P~ BENCH MARK
~ 5~ P Ii ~ S / S~, Assumed Elevation:
ENGINEER'S SEAL
Inspections performed by://~r~A Dates: 1st
Department of Hca , es approval
Reviewed and approved .- _ : , . -7-
72-013 (Rev. 9~el) MOA 25
Municipality of Anchorage Page ~'
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: ~L~Ol ~ PID Number:
Municipality of Anchorage Page ;~
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
PermitNumber: 5',~J cJ~O l ~ ~' PID Number: O.~-j ."'O ~,J - ~--'~
. of $
RECEIVED
NOV ~ 1995
--. , ,.n oe~ices
RECEIVED
NOV 8 ~g~35
Dept. Health & Hurm~e
FROM : MMM CONTRACTING PHONE NO. : 68812~8 Nov. 10 1995 0g:SOAM Pi
MM&M CONTRACTING INC.
P.O. BOX 670495
CHUGIAK, AK. 99S67
PHONE698-1236
FAX 6B8-1238
November 10, 1995
Mr, Mike Anderson
Anderson
P. O. Box 240773
Anchorage, Ak, 99524
Re: W~t 1/2 I.~t 74 8~tion 5 T15N, R1W
'I~ lct~r ~ m a~e ~t M ox~a~tMg ~d pu~ in lbo sopfi~ ~t~ at ~o a~ve
~foroncod looafion we ~d make ihin a~s~m 18' ~do ~& tho ~p~ layod at
We h~O ~ ~fion is helpS.
Sinc~oly,
SupPOrt
FROH :
CONTRACTING
PHONE NO. : 6881238
Aug. 23 1995 08:46AM P1
SULLIVAN WATER WELLS
I~om. . .FI, to~Ft- , ' _._
Fret6, . _Ft, to. Ft.__.
Fr om -.-.-,,.~. Ft, tO~ Ft, - __. - ~.
From _FI, to~Fl .... .--
" ' ' ~D~ept, Health &'Fiuma-n ~ervi~es '
Pont-It'" brand fax tranemitt[d memo 7,071
MUNICIPALITY OF ANCHORAGE
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 PERMIT
PAGE 1 OF 1
PERMIT NUMBER:SW950185
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:KRETSINGER MILLARD D & ALICE E
OWNER ADDRESS:8401 LONGHORN ST
ANCHORAGE, AK. 99516
PARCEL ID:05108123
LEGAL DESCRIPTION:
T15N R1W SEC 5 LT 74 W2
LOT SIZE: 54450 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
DATE ISSUED: 8/01/95
EXPIRATION DATE: 8/01/96
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 AND THE S.TATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AA~80) .
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 ~O APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
Bo COVERED, SEALED AND HEATED TO PREVENT FREEZING
5o THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE~ ALASKA 99524
July 18, 1995
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 74B, T15N, RIW, S5 Subdivision
Well and Septic System Installation
Impacts to Adjacent Properties
Dear On Site Services Engineer:
We hereby apply for a permit to install a well and septic system on Lot 74B, T15N,
RlW, S5 to serve a three bedroom home. The location of the facilities are shown on
the attached Site Plan. The lot is surrounded on three sides by vacant lots and on the
west by an existing home. The ~rotective setbacks for the well can be maintained
from existing septic systems.
Soils encountered on the lot are excellent for an onsite system. Testholes were
placed in mid May and minor seeping was noted in one of the holes. No accumulation
of water was noted, however, during the monitoring period. A well and septic system
can be placed on this lot with little or no impact to adjacent properties.
If the systems are placed as shown the following statements may be made:
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
SCALE
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Lot 74B
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Three Bedroom Home Shallow Bed System
Perc. Rate: 12 Min./Inch 1,000 Gal. Septic Tank
Application Rate: .6 GPD/SF Min. 2' Accepting Soils
3 Bdrms. X 150 GPD / .6 GPD/SF = 750 SF of Absorption Area
750 SF / 18 LF Width = 42 LF Length /5 · ~
Therefore: Construct a Shallow Bed System 18' Wide X 42' Long
the Location Shown on the Site Plan. Distribution Pipe Placed
1.5' Below Original Ground Surface.
at
at
'///\~Xl/l?X./l/\x~./i/~xAi4 x,,Xl// ~,,Xl//
NOTE:
TYPICAL SHALLOW BED SYSTEM
(NO SCALE)
Maintain 4' Vertical Separation From Bottom of Trench
to Groundwater Table.
Grade Area Over Bed to Drain Away.
Mound Over Bed or Provide 2" of HI Direct Burial
Insulation To Achieve 3' of Cover.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
.ERPO. EOPOR: M HM nT -TId
LEGAL DESCRIPTION: ~'~' 7'-/--
DATE PERFORM
Township. Range. Section: 'T"'I ~'/~,
SLOPE SITE PLAN
ENCOUNTERED?
DEPTH?
Depth to Watr. r After ~;~ ~/y.,,/~,~,
Monitoring? Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
~:~ ~ ~,1~
PERCOLATION RATE I ~' (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN '~'?-~" .FTAND .~l FT
COMMENTS
/
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE' DATE;'
72-(308 (Rev. 4/85)
PERFORMED POR
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE
Towns.ip, Range, Section: 'w/fi/q, ~ l ~d, $ C~
SLOPE SITE PLAN
1
2
3
4
6
7
8
9
10
11-
12-
13
14
15
16
17
18"
19-
20-
COMMENTS
H/HL.-
WAS GROUND WATER
ENCOUNTERED?
DEPTH?
E
Depth to Water After ~,/~../~.
Mofli~odng? ~ Da~
Reading Date Time Time Water Drop
~ I~ ~, ~,'z~ 1.1'~
1,~ ~.1~ ~.~
PERCOLATION RATE ~ ~ (minutes/~nch) PEflC HOLE DIAMETER ~ ti
TEST RUN BETWEEN ~'~ FT AND ~ ET
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~1//'~
72-008 (Rev. 4/85)
Municipality of Anchorage
On-Site Water & Wastewater Program
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-081-25
'1. GENERAL INFORMATION
Expiration Date:
Completelegaldescription T15N, R1W, SEC 5, LOT 74 W2
Location (site address)
21514 TORKELSON CIRCLE *CHUGIAK ~ AK 99567
Current Property owner(s) JILL DEAN
Day phone 865-1952
Mailing address
PO BOX 672513 *CHUGIAK ~ AK 99567
Real Estate Agent
JOHN ERKINS W/ REMAX
Day phone
808-298-8861
2. TYPE OF DWELLING: · Single Family (w/wo ADU)
[] Duplex
[] Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 5
4. TYPE OF WATER SUPPLY:
Individual Well ·
Individual Water Storage []
Community Class Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ·
I~dividual Holding tank []
Community On-site []
Public Sewer []
Received by: ,/~,".*, . _
Date:
/ /
Waiver Fee $
Date of Payment
Receipt Number
Waiver Cf ·
5. STATEMENT OF INSPECTION BY'ENGINEER
As certified by my seal alT~xed hereto and as of the validation date shown below, I vedfy that my
investigation, based on procedures outlined in the Certificate of On-Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address :3701E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Phone 337-6179
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a therough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local so/ts condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future pedormance of the system, nor do they guarantee that
there are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
OPerational requirements of the ADEC or MOA DSD The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
DSD SIGNATURE
V'/'' System #1 Approved for
System #2 Approved for
Disapproved.
Conditional approval for __
bedrooms. ,~
bedrooms.
bedrooms, with the following stipulations:
The Municipality or Anchorage Develop, emi Se~/ices Division (DSD) issues Ced/f/cares of On-Sita Systems Approval (COSA) based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in tbe professional engineer's work.
7. ATTCHMENTS:
COSA Checklist
Septic System Advisory
(Rev. 11/05)
Nitrate Advisory
Arsenic Advisory
Other
Original Certificate Date:,
If more than 1 septic system is on the lot:
COSA Checklist # of
Structure served by this system __
Certificate of On-Site Systems Approval Checklist
Legal Description:
A. WELL DATA
Well type PRIVATE
Date completed
Total depth 121
8/95
ff.
T15N, RlW, SEC 5, LOT 74 W2
Date of test
Static water level 47
Well production 8
WATER SAMPLE RESULTS:
Coliform 0 colonies/lO0 mi.
Arsenic: ~It~ ugJL.
B. SEPTIC/HOLDING TANK DATA
IfA, B, crC provide PWSID# N/A
Sanitary seal (Y/N). YES
Cased to 121 ft.
FROM WELL LOG
8/95
g.p.m.
Tank Type/Material SEPTIC/STEEL
Tanksize 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) *YES Depression over tank (Y/N) NO
Parcel ID:
051-081-23
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
t /lo/ 2
38 _ft.
5.88 g.p.m.
Date of pumping
C. ABSORPTION FIELD DATA
YES
Nitrate(~.~O(omg./L. Collected by: GEO. Ltd,
Date of sample: 11./8./12
*UNDER DECK (BOARDS HAVE ACCESS HATCHES)
Date installed 8/23/95
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
YES
12+ in
8/11/12 Pumper. SANITARY PUMPERS
r,BELOW EXISTING GRADE TO BOTTOM OF MTI
Date installed 8/25,/95 Soil rating~oQ 0.5 System type
BED
Length 50 .ft, Width 18 .ft. Gravel below pipe 0.50 .ft.
Total depth .2.16 ft. Eft. absorption area 900 ft2 Monitoring tube YES Depression over field NO
Date of adequacy test 11/10/12 Results(Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 0 in. Water added 530 gal. 0 in.
Elapsed Time: 0 min. Final fluid depth 0 in. g.p.d.
Any rejuvenation treatment (past 12 mo.) (YIN & type) -
SOIL COVER OVER TOP OF DRAINFIELD IS APPROXIMATELY 12-18". DRAINFIELD HAS 2" OF INSULATION.
New depth
Absorption rate >= 450+
NONE If yes, give date
D. LIFT STATION
Date installed Size in gallons ~ ~
"Pump on" le~ High water alarm level at__
~ ~ Cycles tested Meets alarm & cimuit requirements?.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
Septic tank/lift station on lot
Absorption field on lot. 100'+
Public sewer main N/A
Sewer/septic service line 25'+
Animal containment areas 50'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout N/A
Holding tank N/A
Manure/animal excreta storage areas 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation *5.7' Proper'q/line 5'+
Water main N/A Water service line. 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water service line 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
F. COMMENTS
PER MIKE ANDERSON, P.E. 1995 COSA & INSPECTION REPORT.
Absorption field *5'
Surface water 100'+
Water main N/A
Driveway, parking/vehicle storage 10'+
G. ENGINEER'S CERTIFICATION
I cerSfy that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
(Rev, 11105)
75A
NOTE:
BAD GRID NW1457
TORKELSON CIRCLE
N8g° 58' 18"W 165.18'
45.7'
.Os
74E2
N89° 58' 18"W 165.18'
UNDER NO C~RCUMSTANCES SHOULD AN AS-6UiLT BE USED FOR CONS~UCTION OR FOR ESTABUSHING BOUNDARY OR FENCE LINES.
THE SURVEYOR TAKES RESPONSIBIU)'Y FOR ~HE INITIAL TRANSACTION ONLY A~O ASSUMES RNANCIAL UABI[JTY ONLY FOR THE COST OF THE SURVEY.
LISTED DISTANCES PREVAIL OVER SCAUNG. REPRODUCI~ON MAY CAUSE ERRORS IN SCALE.
[] LOT SURYEy SURVEY TYPE
PLOT PLAINS & LOT SURVEYS
IT IS THE RESPONS(BiLITY OF ~tE BUILDER OR OWNER, PRIOR TO
CONSTRUCTION, TO VERIFY PROPOSED BUILDING GRADE RELATIVE
TO FINISHED GRAOE AND UTILITY CONNECTIONS ANB TO DETERMINE
THE EXISTENCE OF' ANY EASEMENTS, COVENANTS OR RESTRICTIONS
WHICH DO NOT APPEAR ON ~tE RECORDED SUBDIVISION PLAT.
SURVEY CERTIFICA'~ ON
BLOT PLAN
SYMBOLS
FOUND REBAR o o ,3 W~)O0 FENCE
ASSUMED ELEV. X × × METAL FENCE
ASPHALT
NOTE:
Prepored by
Robert E. Johns, Jr. &
Professionol Lond Surveyors
1700 Brink Drive.
ANCHORAGE, ALASKA 99504
Assoc.
Scale: 1" = 60' Rec, Lot S.F. Rec. Plot File No.
Dote Surveyed: 8/26/12 Brow. b~. REJ c.~.. ~MK
DOt~ Drown: 8126/12 ~'~: 1457 W.O. 12-355
Legal Descdption:
LOT 74 W2
T15N R1W SEC 5
Page 1 of 1
Sonja Blewett
From: John Erkins [johnerkins@yahoo.com]
Sent: Thursday, November 29, 2012 7:03 AM
To: Sonja Blewett
Subject: septic system
John Erkins
RE/MAX
(907)257-0116 office
(808)298-8861 cell
The greatest compliment I can receive is to be referred to your friends, family, and business
associates.
Sent £rom my iPhone 4Gs
Begin forwarded message:
From: "Jill Dean" <,~illdean(¢mtaontine.net>
Date: November 29, 2012, 6:55:14 AM AKST
To: '"John Erkins'" <johnerkil~s,r~;~ab_qo.:coln>
Subject: septic system
Dear John, This message is to inform you and whoever else may be concerned that I have
owned and lived in the house at 21514 Torkelson Circle in Chugiak, Alaska since it was built
in i995. During that time the septic system has never frozen or given me any problems of
any sort. Please let me know if you need any further information.
Jill Dean
11/29/2012
Parcel I.D. #
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
1. i GENERAL INFORMATION · ~ ~-.- '
· Cornl~'lete leg;I de;c; ;; ~ ,"
~.. pt
_..-~:'. . . :: . :: .:. . .: . :~'. '.?: .......... ~_,,.
...... Location (site address or directions)_
- , . .".. .. * ~-.;~ _ .-
. . .... -., Property owner ~L~t.T'l Day phone
:' . Lending agency '
'
- .~!~;~.?.~ Agent - ' - :' :; -' - "'-?::"? ~ ;:Day
.: ...... r :- ::,;::~.,~,~, c ~:, Address
. :{..~?..
: i : :. NOTE: ' If commUnity wastewater System?prOvide written confirmation from State
: ~ ~ ;.~ ;: :,: .... :,~
: · ' t , ':;;~3' ::,::t attesting to the legah~ and status of system.
72~25(Rev, 1/91) Front MOA~I
STATEMENT OF INSPECTION BY ENGINEER
As certifiea by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application snows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the n umber of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
tiqe Municipality of Anchorage files and from my investigation and ins0ection, 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 T~"O,
Engineer's signature
Date
6.. DHHS SIGNATURE . .. .
Y Approved for ~-~ :' bedroo'ms.
.. ' .: Disapproved.
The Municipality of Anchorage Departmen~ of Health and Human Services (DHHS) issues Health Authorit'
Approval Certificates based 9nly upon the representahons g~ven in paragraph 5 above by an ~ndependent ,. '~
professional engineer registered in the State of Alaska, The DH HS does this as a courtesy to purchasers of homes ;::~i~ .!.~'~
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 ~m~ss~ons in the professional engineer's work, "- -~ ' .~_:'.-':
RECEIVED
Municipality of Anchorage NOV 8 1995
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ':" '~ ~a! ~v ot Anch.~0rege
825"L" Street, Room 502 · Anchorage, Alaska 99501 · (90'~)~4:~;;,~4'lin r,a~' '..
Health Authority Approval Checklist
A. WELL DATA
Well
Log present (YfN)
Total depth I~-I i
Sanitary seal (Y/N)
IfA, B, or C. attach ADEC letter. ADEC water system number
Date completed
I
Cased to ]Z I
¥
Casing height (above ground)
Wires properly protected (Y/N)
Date of test
Static water level
FROM WELL LOG
AT INSPECTION
Well production
WA~ER SAMPLE RESULTS:
Coliform O
Date of s,'mtple: I ~/Zr~ / ~ ~
Nitrate
o{~5 P/I..~/L.-- Other bacteda
Collected by: /~- ~/'J-/L¢~ C~
B. SEPTIC/HOLDING TANK DATA
Date installed ~/t[3/q~'
Foundation cleanout (y,rN)
Date of Pumping IQ ~*~d
Tank size [t Ot)l~ Number of Compartments _~ Cleauouts (Y/N)
x(~ Depression (Y/N) P,J High water alarm (Y/N) '1/
Pumper ffOto ~tsd Cr*lO,'J
Fluid depth in absorption field before test (in.);
Fluid depth ,,,4//~ Minutes later: O
Peroxide treatment (past 12 months) (Y/N)
C. ABSORPTION FIELD DATA
Date installed ~/Z~'/c]~ Soil rating (g.p.d./fi2 or fl2/bdrm) e ~ System type ~/4~
Length Width / ~ Gravel thickness below pipe · ~ ~ Total depth
Effective absorption area 6~0 F'~"~, L~Monitoring Tube present(Y/N) "1/ Depression over field (Y/N) IXJ
Date of adequacy test A,~O ~Os3 ~7 Results(Pass/Fail) ~P~.$5 For ~ bedrooms
O Immediately after t4//l- g~l. water added (in.):
(in.) Absorption rate = ~/~'0 g.p.d.
A If yes, gl,ye date ~
Date ms!ailed Size in gallons
HM:'li:i I:i51eAr i iCiim( ~)1.* ~ "Pump off level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank ou lot / lO t
Absorption field on lot [ 2[/.) t
Public sewer main /x'/I 1 61550
Sewer/septic service line ~2 t'O0t
; On adjacent lots '~ 100
; On adjacent lots
Public sewer manhole/cleanout P4 t/...~5~
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation .$*, ') / Property line c't~.~t Absorption field
Water main/service line >' g-O/ Surface water/drainage _ ~/OO ! Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building fouudation
!
Surface xvater
Curtain drain
Water maia/service line >
Driveway, parking/vehicle storage area
Wells on adjacent lots
ENGINEER'S CERTIFICATION .,, "":'v ~
I certify that I have detern~med thrufield respect!ohs and review of Municipal records, th'at the above ~ystems are
in conformance with MOA HAA guidelines in effbct on this date. / ~ ~
Signature
Eugineer's Name
Date
HAA Fee $ Waiver Fee $
Date of Payment
Date of Payment
Receipt Nulnber
Receipt Number
Rex,. 8/95 eSS: haa,wk.doc