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HomeMy WebLinkAboutT15N R1W SEC 9 LT 75 Municipality of Anchorage On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP211432 PID Number: 051-102-17 Dwelling: X Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New t❑ Upgrade Name Terry and Terri Rollie A SORPTION FIELD El Trench ❑ Wide Trench ❑ Bed ❑ Mound Site Address 20625 Starner St Chugiak ❑ Other Phone Number of Bedrooms Soil Rating Total depth from original grade 3 D/SF Ft. LEGAL DESCRIPTION Depth to pipe invert from origina de Gravel depth beneath pipe Subdivision Block Lot 75 Ft. Fill added above original grade G el length Ft. Ft. Township Range Section T15N R1 W 9 Gravel width Ft. Beds: Number of Lines Dis ce between lines Ft. SEPARATION DISTANCES To Septic Absorption Lift Station Holding Sewer Total absorption area Number of trenches Dist. between ches From Tank Field Tank Line Ft2 t. Well >100' NA NA NA >25 TANK 0 Septic ❑ S.T.E.P. []Holding ❑ Other Manufacturer Greer Capacity 1250 Gal. SurfaceWater >100' NA NA NA Material Number of compartments Lot Line >10' NA NA NA NA plastic 2 Foundation >10' NA NA NA L STATION Manufactur Capacity Remarks Gal. Alarm location Electn ailed by Installer PIPE MATERIAL House to tank 3034 drainfield Tank to 3034 CMM Construction Drainfield CO/MT 628 Inspector Curtis Townsend BENCH MARK (Assumed elevation) 100 ft Inspection 751 6/7/2022 2 a 6/23/2022 da:3i0 Location and description 4th bottom of siding by FCO ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp Conditional Approval: Date •q�fi� ���P,��,.. Date y ��� ;gats I- yo ��; Septic System Approved Date , jt`'�IF��No.CE 1C.. �`� ap��rr`c '''. Note: this appro I does not include well permit requirements. io.,.. ncinnia e Q z o Q 9 SCOPE OF WORK 1. REMOVED EXISTING SEPTIC TANK. 2. PLACED NEW 1,250 GALLON TWO-COMPARTMENT SEPTIC TANK AND TIED INTO EXISTING ABSORPTION SYSTEM. NEW TANK IS 5' AWAY FROM EXISTING FIELD. THERE ARE NO STEEP SLOPES TANK WAS PROVIDED WITH A MINIMUM 20" DIA RISER WITHIN 50' OF THE PROPOSED SERVING THE FIRST COMPARTMENT. DOUBLE TANK. CLEANOUTS PROVIDED DOWNSTREAM OF THE TANK. 3. THE OUTBUILDINGS ON THIS PROPERTY DO NOT CONTAIN ANIMALS. 4. ALL CONSTRUCTION WAS IN ACCORDANCE WITH ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL E CODE CHAPTERS 15.55 AND 15.65. NO WELL L OCA TED ON L 0 T 58B EXISTING 26' x 72" X 96" EFFECTIVE -,,,DEPTH TRENCH, HOLDING 21" OF WATER MAY 2022 �s T CO CLASS C WELL - LOCATED > 150' AWAY GARAGE DC01 A 2SSTANKMTFCOSLOPE 8��_ 3 BR �O HOME ORE?,,� �/ � � �_�, B f 1 E j f 1 r J � 100' TJ t rn 1 (GREENHOUSELQ CC) { I { OUTBUILDING — NO ANIMALS { Septic Record DroveiriQ Prepered `or TERRY & TERRI ROLLIE 20625 Starner St Chugiak, Alaska 99567 T1 5N R1 W SEC 9 LOT 75 EKLUTNA ENGINEERING, LLC 19162 MOUINTAIN ROAD GI-iUGIAK, ALASKA 99567 (9 07) "'06-1058 OSP211432 DATE: 2/08/2024 DRAWN: CLT SCALE: 1" = 40' PID: 051-103-17 SHEET 2 OF 3 J W 0 a*, N Cl) v 0 0 0 II /r------------------- N 89°57' E 330.20' (R BLM) ------------------ x30.00' Power N 89°56' 04' E 300.03' (M) W Et'c. \, Meter) I i Gravel I Fence IGravel 11.5'x13' 54` © Deck r-- 32'– i 10'x12' t1 Shed SPetp5 i m I r ---I pestic I Garage ' I II 1 good Guy © 5' 4,5 1 i I I 3�'� nce i _ – – S 4'x11' C/t7 House , 1 + — — % SelpH i J` Stairs OD 0 I 'i Ea es C1 1 I Drive 8' I 28' I 73'+a Deck NQ _ 12' 11' N+ Gravel 12'x25' / Green House Well / Wood 0 Gravel Fence i or' Flag I I Pole I I $ a I , 75, I ` I 3' j v22s Stable _ 1' I Eave I I Enve I Wood Fence t j 62_----- \___._ --- � --J L — Gravel_ Light Pole Potential M Patent M W Re erve i V �) W W = C__) I n h � I n r s i T StI eet Sign W i1 L--- Power Pole 2' Eave zo' I 1 10'x24' i Barn 1Conc Pad 1 a i Pad ------------- S 89°57' W STARNER Fence 50' Potential BLM Patent Edge of Pavement ROW Reservf I 330,20' (R BLM) I hereby certify that I have surveyed the following described property: BLM Lot 75, Sec. 9, T. 15 N., R I W., S.M., as per recorded plat T. 15 N., R 1 W., S.M., Dependent resurvey and Section Subdivision, dated May 13, 1955 and that no encroachments exist except as indicated hereon. This As -built will only show the easements as noted on this As -built: under no circumstances should this data hereon be used for the construction or establishing boundary or fence lines. 0 25 so T. 15 N., R 1 W., S.M., Sec 9, Lot 75 6 mmmd FEETAs Depicted on: SCALE IN T. 15 N., R. 1 W., S.M. 1"= 50' Dependent Resurvey and Sec. Sub'd Dated May 13, 1955 Surveyed: June 9, 2022 GRID: NW1359 FD 3 1/4' Almon ii 0 0 0 a W W o W 0 N o co 3 � tC r 3 1 I I I I I i i FD 3 1/4' Almon W i o I o t 0 STREET of AQ T—H rr; •' r rr • Antiony P. Boneta rrc,• LS -10393 rrro • . 7/ Z tom° r r 1 l l p"OrPSs\CAA�� ASBUILT SURVEY Terry L & Terri D Rollie PO Box 671162 Chugiak, Alaska 99567 ENT-M.,;a APB Land Surveying 12204 East Prince of Peace Drive Eagle River, Alaska 99577 (907)227-1361 MUNICIPALITY OF ANCHORAGE On€ite Water & Wastewater Pr.ogram ,, PO Box 136650 470O Elmore Road Anchorage, Alaska 99519-6650 Phons (907) 343-7904 Far (907) 343Jgg7 http://www. muni. org/ons ite On-$ite Wastewater Disposal Permit Number: OSP211432 Work Type: SepticTank Upgrade Tax Code Number:: 051103-17000 Site Legal Address: T15N R1W SEC I LT 75 G:1359 Site Mailing Add.ress: 20625 STARNER ST, Chugiak Owner: ROLL]E TERRY L & TERRI D Design Engineer: EKLUTIIA ENGINEERING, LLC* System Permit This permit is for the construction ofi I Disposal Field M Septic Tank fl Holding Tank E Privy fl Private Wetl I WaterStorage All construction shall be in accordance with: 1. The attached appioved desiEn. 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 wastewater code requires inspections during the installation. The engineer shall notifu the Developmerrt Services Department,p.er AMC 15.65, Provide notitication by calling (907) 343.7904 e4n.4. From October 1 5 to April 15, a subsurface soil absorption system unde r esnstruction during freezing weather shall be eitherl a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing Received By: Effective Date: Expiratidn Date.: Lot Size in Sg Ft: TotalBedrooms: Date: Date,: fi/1?J2021 ffi|12na22 1CI8900 q el)irrtrncnt lssued By: MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On -Site Water & Wastewater Section '--' Fax: 907-343-7997 ON-SITE SEPTIC/WELL PERMIT APPLICATION Parcel I.D. 051-103-17 Property owner(s) ROLLIE TERRY & TERRI Day phone Mailing address PO Box 671162 Chugiak AK 99567 Site address 20625 Starner St Chugiak AK Legal description (Sub'd., Block & Lot) Legal description (Township, Range & Section) T1 5N R1 W SEC 9 LT 75 Lot Size 108,900 Sq. Ft. Number of Bedrooms 3 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (N all that apply) Absorption Field ❑ Initial ❑ Single Family (SF) El Septic Tank El Upgrade 0 (w/wo AD U) Holding Tank ❑ RenewalDuplex (D) E]❑ Multiple Dwellings ❑ Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable M icipal Codes. I k ) D/ S / 2_-�)? � (Signature of property owner or authorized agent) Permit/Rush Fees: -#Z25 Waiver Fees: Date of Payment:/O/6'A ( Date of Payment: Receipt Number: OyO� y D Receipt Number: Permit No. 05821 / LI32 Waiver No. GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc Eklutna Engineering, LLC curtistownsend @gmail.com October L],2027 Subject: T15N R1W Sec 9 Lot 75 OSP2LL432 New Septic tank permit request This is a design narrative for a permit to instail a new septic tank on this property. The existing tank is 42 years old. The homeowners are desiring to replace the tank' The proposed system will serve an.existing 3 bedroom house. The existing septic tank wiil be removed and disposed of and a new 1'250 gal septic tank will be installed. The homeowners desire the larger tank size' Double cleanouts will be provided downstream of the tank' 1. Soils. The soils in this area are composed of sands and gravels' A test hole had previously been dugto16,duringthemonthofJune.Nogroundwaterwasfound' Z. Soil Absorption System. The existing soil absorption system will not be upgraded at this time' lt has less than 2' of water in it' 3. Wells. This lot is served by a private well. The subject property septic field is > 100' from the water well. The sanitary seal on the well casing is functioning correctly' 4. Neighboring wastewater systems. lmmediate neighboring septic systems are all +30' distant' S.SurfaceWater:Surfacewaterisgreaterthanl00'away' 5. Topography: The existing topography in the area of the tank has a slope of 8%' The proposed installation will not affect the future development of this or the surrounding lots' For the above reasons, we request that a permit be granted to replace this septic tank' Sincerely, Curtis L. Townsend, P.E. Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211432, Deb Wockenfuss, 10/12/21 F-Iql IY N(n IV LU-IY SNl/) I fr Y I THERE WITHIN TANK. ARE NO 50' oF STEIP SLOPES THE PROPOSED SCOPE OF WO.RK1.REMOVE EXISTING SEPTIC TANK.2.PLACE NEW ,I,250 GALLON TWO-COMPARTMENT SEPTIC TANK AND TIE INTO EXISTING ABSORPTION SYSTEM. ENSURE NEW TANK IS 5' AWAY FROM EXISTING FIELD. TANK IS TO BE PROVIDED WITH A MINIMUM 2O'' DIA RISTR SERVING THE FIRST COMPARTMENT. PROVIDE DOUBLE CLEANOUTS DOWNSTREAM OF THE TANK,3.ALL CONSTRUCTION TO BE IN ACCORDANCE WITH ALL REOUIREMTNTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65. NO WELL LOCATED LOT CLASS C WELL ---> LOCATTD > 150' AWAY EXISTING 26' x 72" X YO E.T T LU IIVL DEPTH TRENCH GARAGE rF-l= iL!/>'lLltr)/S /r\J / a'b Lr) PROVIDE NEW SEPTIC TANK Septic Design Prepored for TERRY & TERRI ROLLIE 20625 Starner St Chugiak, Alaska 99567 T15N R1W SEC 9 LOT 75 osP211432 I a'; ;#',3 ;il ;,;;ffi .r,&,t&Hni?K- 'i?ms.$. EKLUTNA TNGINTIRING, LLC 19162 MOUNTAIN ROAD CHUGIAK, ALASKA 99567(e07) 406- 1 OsB DATE:101612021 DRAWN:CLT SCALE:1" = 40' PID: 051-103-17 SHEET 1 OF 1 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP211432, Deb Wockenfuss, 10/12/21 I r' N4!p`s7�'— 33o.d h r` M .r0�pf .Sd •Q6ry �S`1t � 8" ASSUILT ,09 JGWAKU N ASSULIATES LAND SURVEYING 694-0829 1 HEREBY CERTIFY THAT I HAVE SURVEYED THE SCALE: FOLLOWING DESCRIBED PROPERTY `��\ •� OF AC \� Col 7S SFz 9 TiS.f/.rr.'Gc� s-�°'> DATE, i • . 9 AND THAT NO EN6ROACHMENTS EXIST EXCEPT AS 0 INDICATED. IT IS THE RESPONSIBILITY OF THE OWNER TO DETERMINE THE EXISTENCE OF ANY GRID _H �""' �• ...... EASEMENTS, COVENANTS, OR RESTRICTIONS iY4i /ern WHICH DO NOT APPEAR ON THE RECORDED SUBDI- •,• M VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD FB / •• ANY DATA HEREON BE USED FOR CONSTRUCTION OF FENCE LINES, l5- t �� OR FOR ESTABLISHING BOUND- DRAWN; ARY LINES. 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 MAILING ADDRESS PHONE [~I~EW 'ZT~"~ [~UPGRADE LEGAL DESCRIPTION LOCATION DISTANCE TO: Iwe'' ~-~4' IAbs°rp;~-~)a~ea Liq. capacity in gallons Well Inside length g'DISTANCE~[]('"~ TO: IF HOMEMADE: Dwelling NO. OF BEDROOMS PERMIT NO. No. of com.~rtments Liquid depth PERMIT NO, Manufacturer Liquid capacity in gallons DISTANCE TO: Well /~.~ / No. of lines/ Leng~o,~:~e~ch ne Top of tile to finish grade Material .oundat,o , Total~.n~h,of Ii nes / Tren.~'~dth Depth Crib depth Building foundation Length Type of crib Width Crib diameter Well PERMIT NO, Distance between lines Total effective absorption area PERMIT NO. Total effective absorption area Nearest lot line DISTANCE TO: ;lass Depth Driller Distance to lot line DISTANCE TO: Sewer line Building foundation Septic tank OTHER PIPE MATERIALS / SOIL TEST RATING INSTALL~~ REMARKS APPROVED 72-013 (Rev, 3/78) DATE LEGAL PERMIT NO. ( HUNICIPi:tLIT¥ OF RNCHORRGE DEPARTMENT OF HERLTH RND ENVIRONMENTRL PROTECTION 825 'L' STREET~ RNCHORRGE~ AK. 9~.)501 264-4720 ON--S I TE SEWER PERM I T 790~0~ > RPPLICRNT LOCRTION LEGRL JERRY JRCOBSON OLD GLENN HWV L?5 N SEC ~ TISN RiW SN TYPE OF SOIL RBSORBTION SYSTEM IS: PO BOX R-46 CHUGIRK LOT SIZE TRENCH I'I~BQUflRE FEET MRXlMUM NUMBER OF BEDROOMS SOIL RRTING (SQ FT/BR)= 1~5 THE REQUIRED SIZE OF THE SOIL RBSORPTION ~*~STEM IS: DEPTH= i~ LENGTH= ~6 GRAVEL DEPTH= THE LENGTH DIMENSION IS THE LENGTH (IN FEET> OF THE TRENCH OR DRRINFIELD. THE DEPTH OF 8 TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE GROUND RND THE BOTTOM OF THE EXCAVRTION (IN FEET>. THERE IS NO SET WIDTH FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCRVRTION (IN FEET). REQU I RED SEPT I 13 TA:tNK S I ZE= '~ OOe GRLLON~ PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE INSTRLLRTION INSPECTIONS OF RNY WELLS RDJRCENT TO THIS PROPERTY RND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. ------ TWO ( 2 ) INSPECT IONS ARE REI3U I RED BRCKFILLING OF RNY SYSTEM WITHOUT FINRL INSPECTION AND APPROVRL BY THIS DEPARTMENT WILL BE SUB..?ECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWRGE DISPOSRL SYSTEM IS 100 FEET FOR R PRIYRTE WELL; OR i50 TO 280 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL, OTHER REQUIREMENTS MAY APPLY, SPECIFICRTIONS RND CONSTRUCTION DIRGRRM~ RRE RYRILRBLE TO INSURE PROPER INSTRLLRTION. PERM I T EXP I RES DECEMBER ~l., 1~79 I CERTIFY THRT l: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORRGE. 2: I MILL INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 3: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THRN 3 BEDROOMS. SIGNED:_~ ............... GE(" ~'ECHNICAL 8' DEVE 3PMENT CO. Box 9(], Davis St., Eagle Rivet, Alaska 99577 694-2774 or 688-2280 Russell Oveter Earl Ellis 69..2774 SO[L,, ,LOG ~8-22a0 Soils ~t Foundations Land Development Perfomed for: Name: ~r~-~ ~/~£~ ~/L~Jr~, Tel. NO. Hatling Address: Legal Description: Z~r 7~-~/~,~/~ '~-/J-~/~ ~/w/~ Depth (feet) So~l Characteristics 3 5 7 8 Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No ~ If yes, what depth Drain Fteld _3 PERMIT NO. MUNIC:IP L. IT¥ DEPARTMENT OF HEALTH 8ND ENVIRONMENTAL PROTECTION 825 ~L~ STREET., ANCHORAGE, 2~4-4720 &-JIEL. L PERM I T APPLICANT LOCATION LEGAL JERRY JACOBSON PETERS CREEK TISNRIW S. 9 L?5 PO BOX A-4~ CHUGIAK LOT SIZE 272--5226 108900 SQUARE FEET MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELL~ OR i50 TO 200 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 20 DAYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY 8PPLY. SPECIFICATIONS 8ND CONSTRUCTION DIAGRAMS 8RE AVAILABLE TO INSURE PROPER INSTALLATION. PERMIT EXPIRES DECEMBER I CERTIFY THAT 1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE FORTH BY THE MUNICIPALITY OF ANCHORAGE. T IN ACCgRDANCE WITH THE CODES. SI~NED: ......... J Af UCAN *ACOBSON ISSUED BY .... ATE .... SEWERS AND WELLS AS SET by OOC Co. dba SULLIVAN WATER WELLS P.O, BOX277- CHUGIAK. ALASKA 99567 · -ELEPHONE688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started PERMIT NUMBER Ended DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From Ft. to Ft. From Ft. to . Ft. From.__Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From Ft. to Ft. From___.Ft. to From Ft. to Ft, From__.Ft. to Ft. From__.Ft. to _Ft. From Ft. to.__Ft. From__.Ft. to Ft. From Ft. to___.Ft From Ft. to .Ft From__Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft. From Ft. to ____.Ft. From Ft. to_ Ft, From Ft. to Ft, From Ft. to FL From Ft. to __Ft. From Ft. to Ft. From Ft. to Ft. From_ Ft. to Ft. From Ft. to Ft. From Ft. to Ft From Ft. to Ft. From Ft. to Ft. From Ft. to_ Ft From Ft. to Ft. From Ft, to Ft. From Ft. to /V~I~[Ci~ALIT',' or ~'~'~^~ DEFT. G7 ;::-ALT;I & MISCL. INFORMATION: ENVIRONMENTAL pRO'rECTION AU8 9 1979 RFCEIVED DRILLER'S NAME 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.# GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address. Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well 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: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm I'-"~ J~ ~,.c ~ ~~.~ _ Phone Address ¢¢-o ,7~ Engineer's signature DHHS SIGNATURE Approved for 3 Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: , / Date / '2 -/dj- c7~8 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 ragistered 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. 72q)25 (Rev, 1/91 ) Back MOA ~21 RECEIVED Municipality of Anchorage NOV 2 DEPARTMENT OF HEALTH & HUMAN SERVICES J ...... MUN aP^UT OF ~-nwronmemal ~erv~ces u~vlmon ENVIRONMENTALSERVI~[~I 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist LegalDescription: ~-"/~: c>~-c_°t,Tl~N; t~.~ ParcelI.D.:. A. WELL DATA Well type ~-. Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Static water level Well production Cased to FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~ ~-- Casing height (above ground) .~. Wires properly protected (Y/N) AT INSPECTION ~:~C) g.p.m. ~, ..~ g.p.m. WATER SAMPLE RESULTS: Coliform ~ Nitrate ~), ~ '~ ~ Other bacteria ! Date of sample: Jill ~, [ ~ o~ Collected by: ~. ~ B. SEPTIC/HOLDING TANK DATA Date installed '7/?/?,~ Tanksize IC,-c~ Number of Compartments ~ .Cleanouts[Y/N) Foundation cleanout (Y/N) I,,.t Depression (Y/N) ~- High water alarm (Y/N) Date of Pumping ''\/'~ r/~r Pumper 3 ~ C. ABSORPTION FIELD DATA Datelnstalled 7/7/7~ Soilrating (g.p.d./ft~or~/bdrm) /~ Systemtype '~-~--4 Length ~ Width ~, / Total depth Gravel thickness below pipe ~ ~ Effective absorption area /-~///~ Monitoring Tube present (Y/N) y Depression over field (Y/N) Date of adequacy test 'l/l~'//~E' Results (Pass/Fall) -~"~ For ~, bedrooms Fluid depth in absorption field before test (in.); -' ~ -- Immediately after ~,~ gal. water added (in.): -' e -"' Fluid depth --o -- (ins) Minutes later: Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Absorption rate = '"/ If yes, give date D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Size in gallons "Pump on" level at* *Datum "Pump off" level at* Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON .LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/sePtic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation /.-~ Property line ,'.%> / O Absorption field Water main/service line ~ ~' o Surface water/drainage ~ ~ o SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ,~, /~ Building foundation ~- .~ Surface water Curtain drain /D Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area -~. Wells on adjacent lots ~> I ~ ENGINEER'S CERTIFICATION I certify that I have determined thru field Inspections and review of Municipal recOfds that the above systems are in conformance with MOA HAA guidelines in effect on this date. Signature 'Y--.~_~ -. ~ Engineers Name ] ~ ~.,-~-t ~, ~- Date [1 ~1 ~ '~ ~,"~ ~ · HAA Fee $ '~ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/'96)*