HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #3 BLK 4 LT 23
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program `o menr
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 n
http://www.muni.org/onsite y
Departinenr
On -Site Wastewater Disposal System Permit
Permit Number: OSP221324 Effective Date: 8/31/2022
Work Type: SepticTank Upgrade - - -- - — Expiration Date: 8/31/2023
Tax Code Number: 05158242000
Site Legal Address: THUNDERBIRD HEIGHTS #3 BLK 4 LT 23 G:1865
Site Mailing Address: 24517 TEAL LOOP, Chugiak
Owner: BARKER RANDY D & MITZI C Lot Size in Sq Ft: 20000
Design Engineer: EKLUTNA ENGINEERING, LLC" Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field 2 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
:ecialProvisions:
For the IR, confirm that the deck supports are not directly over the tank.
Received B)
Issued By:
Date: 3 Z �—
Date: _ 2 Z
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. 051-582-42
Property owner(s) BARKER RANDY D & MITZI C Day phone
Mailing address 24517 TEAL LOOP CHUGIAK, AK 99567 5113
Site address 24517 TEAL LOOP CHUGIAK, AK 99567 5113
Legal description (Sub'd., Block & Lot) THUNDERBIRD HEIGHTS #3 BLK 4 LT 23
Legal description (Township, Range & Section)
Lot Size 20,000 Sq. Ft. Number of Bedrooms 4
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank
0
Upgrade
Duplex (D) ❑
Holding Tank
ElRenewal
❑
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 Municipal Codes. J
(Signaturebf property -owner or authorized age
Permit/Rush Fees: $ -az r,
Date of Payment: ���S�zZ
Receipt Number: 09 1/00 L?
Permit No. OD' #0 13 2,
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\FormsUient FormsTermit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221324, Deb Wockenfuss, 08/31/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221324, Deb Wockenfuss, 08/31/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221324, Deb Wockenfuss, 08/31/22
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'~ t MUNICIPALITY OF ANCHORAGE
' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
MAILING ADDRESS
~ DISTANCE TO:
~ Manufacturer
~ ~ ~ ~, ~ f No. o~partments
Liq. capacity in gallons Inside length Width Liquid depth
/ff~ IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation~ Nearest Iot~ P T NO,
~,~ No. of lines Length of each line Total length of~ines Trench wid?~I DiStance between lines
~ ~ Top of tile to finish grade Material beneath tile Total e~ct~e absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot llne
~ DISTANCE TO:
~ Class Depth Driller Distance to lot llne PERMIT NO.
~ DISTANCE TO: Ruilding foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE
MATERIALS
72-013'(~ev, 3/8)
PERMIT NO.
APPLICANT G.S.K. CONST.
LOCATION RAVENS LP.
LEGAL
SAR 6:1.05 R,-.3 PALMER RK.
LOT ~.~ BLK 4 THUNDERBIRD HTS,
LOT =,I~E ~o~00 5~URRE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NLMBER OF BEDROOMS
SOIL RATING
THE REGiuIRED ~.,I¢;.E~ "" OF THE SOIL RE, SoRPFION' ' ' ' '-'~TEM"" ' IS:
THE LENGTH DIMENSION IS THE LENGTH (IN FEET> OF THE TRENCH OR DRRINFIEL.D,
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFRCE OF THE
~ROUND RND THE BOTTOM OF THE EXCHVRTiON (IN FEET>,
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL. DEPTH IS THE MINIMUM DEPTH OF GRAVEL. BETWEEN 'THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET>, .
SEF"T ~ (;;
PERMIT APPL, ICRNT HFI~ THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
IN~TRLLRFION IN-,FECTIuNS OF' ANY WELLS ADJACENT TO THIS F'ROPERTY AND THE
Nt. MBER OF RE,_,IDENL. E~ THAT THE WELL WILL ~:,mw~
BBCKFILLING OF RNY SYSTEM WITHOIJT FINRL INSPECTION AND RPPROVFIL BY TMIS
r)EPRRTMENT WILL E,E SUB..EtLT TO PRO,.,ECU'f.[ON.
MINIMUM DISTANCE BETWEEN R WELL RND ANY ON-SITE SEWFIGE DISPOSAL SYSTEM IS
'&00 FEET FOR R PRIVATE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL. DEPENDING
UPON 'Fide TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM R PRI',/RTE WELL TO R PRIVRTE SEWER L~NE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET,
OTHER REr~UIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS PRE
AVAILABLE 'FO INSURE PROPER INSTALLATION.
I CERTIFY TI-IRT
i: I BM FAMILIAR WITH THE RE~;~.UIREMENTS FOR ON--SITE SEWERS AND WELLS RS SET
FORTW BY THE MUNICIPRLI'rY OF RNCHORRGE.
2; I WILL INSTALL THE S~TEM IN ACCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEHER SYSTE¢4 MAY RE(31JIRE ENLARGEMENT IF THE
RESIDENCE I5 REMODELED TO INCLUDE MORE THAN 4 BEDROOMS,
ISSUED BY .... ~; J:.~ ..D~TE .... V4. 0
O & E ENC,,NEERING & DEVELOPMENT CO.
Box 90, Davis St,, Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for:
Name' -'-'-'-'~"~'/'/~
SOIL LOG
Tel, No,
Earl Ellis
688-2280
Mailing Address'
Legal Description: ~o'?-
Depth (feet) Soil Characteristics
o ~L
11__
12
13__
14'
15__
16__
Ground Water Encountered: Yes
,ProP0sed Installation: Seepage Pit
Comments: ,, .,.
No ~ If yes, what depth
Drain Field
PLOT PLAN
PERC. TEST
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
~ S"/- $-~'3 -V~-
Parcel I.D. #
1. GENERAL INFORMATION
Complete legal description
Lot 23, Block 4, Thunderbird Heights, AAddition ~ 3
Locatior~.(site'add~ress or directions) 24517 Teal Loop Road, Chugiak, AK 99567
Property owner
Mailing address
Susan Anderson
Day phone
Lending agency
Mailing address ' .~'
Agent ,-'K~thJ Olmsted, Remax of Eaqle River
Address 16600 centerfield Dr., Eagle River,
Day phone
Day phone
Ak 99577
694-4200
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well X×X
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site xxx
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
724)25 IRev, 1/911 =font MOA#21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified By m / seal affixed hereto aha as of the validation date shown below, I verify that
~nvestigation of this Health Authority Approval &pplication shows that the On-site water supply
and/or wastewater disposal system is safe, functional aha adequate for the number of bedrooms
and type of structu re 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 ~n compliance with all Municipal and State codes.
ordinances, and regulations in effect on the date of this inspection,
S & $ ENGINEEEING
Name of Firm 17034 =ag~ RiVe. Loop Road No, 204 Phone _ ~ c(/./ . ~_ ~ ~, ~
Eagle Rive;-, Alaska
Address /.
Engineer's signature ~ _~/~ ~""~,¢,~_. Date_ '2/f6/"¢)'~''
DHHS SIGNATURE
-/J- Approved for _'T/CF~_~
Disapproved.
Conditional r 'roval -
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) i~sUes Health Authority
Approval Cedificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and sta{e reqUirements, Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
resPonsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIRI
Environmental Services Division
825 L Street, Room 502, Anchorage, Alaska 99501
Health Authority Approval Checklis~uNIC~PAuT¥ oF
ENVIRONMENTAL SERVICES DIVISION
Legal Description: ~.~..'7.~ '~q'~,~.J~D~-~-'i~,~Q~'[') ~,,. _. Parcel I.D.: ~)~'-/- -5~--~'~ --/'~ '
A. WELL DATA
Well type
If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Date completed
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
Cased to Casing height (above
Wires properly~Y/N)
FROM WELL LOG ~~NSPECTION
g.p.m.
Nitrate Other bacteria
Collected by:
g.p.m.
SEPTIC/HOLDING TANK DATA
Date installed ~""~ ~ Tank size [~-5--o Number of Compartments __~ Cleanouts~N)~
Foundation cleanoUt(~N) "-( Depression (Y~ ~-~ High water alarm (Y/N) t-)~. /
Date of Pumping "7~ 7 ~~ Pumper
ABSORPTION FIELD DATA
Date installed 5- - ~
Length "~P ~ Width
Effective absorption area
Date of adequacy test '~
Soil rating (g.p.d./fF or fF/bdrm) ~o~+/~ System type
Gravel thickness below pipe ~ ! Total depth
Monitoring Tube present~)~ Depression over field (Y~
Resu~ail) ~ For ~
'3 ~¢. O~edroOms
Fluid depth in absorption field before test (in.); ~:>'~' Immediately after~° gal. water added (in.):
Fluid depth ~ (ins) Minutes later: ~.- ~.,..o Absorption rate = .g.p.d.
e~o~£ IZ-~c~)'') Ifyes, givedate '"'~&
Peroxide treatment (past 12 months)
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" level at*
~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
On adjacent lots
On adj~
Public sewer main
Sewer?'septic service line
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation t.~~ Property line \ ~ Absorption field
Water main/service line ~E:;> ~''~- Surfacewater/drainage \ ~o t~. Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ~'~- ~'+ Building foundation ~ ~ ~ Water main/service line
Su~ace water ~ ~ Driveway, parking/vehicle storage area
Curtain drain Wells on adjacent lots
F, ENGINEER'S CERTIFICATION ~-~~.
I certify that l have determined thru field inspections and rewew of Municipal r~.~at the-~'y~tems
in conformance with MOA H~ guidelines in effect on this date. ~/-~- ~. . o-~
HAA Fee $ ~-C'.'.%~,
Date of Payment '~- '~
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. # ~ ~"') ~
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~ ~ ~'~' ~ ~ HAA# ~
1. GENERAL INFORMATION
Complete legal description
Lot 23; Block 4; Thunderbird Height~ #3
Location (site address or directions)
24517 Tezzl Loop
Chugiak, AK
Property owner
Mailing address
Frank & Reb¢,kah Baker
Day phone
24517 Te~ Loop Chugiak, AK 99567
688-4388
Lending agency
Day phone
Mailing address
Agent Caroline Greiner/ Re~ax of Eaqle River Day phone 694-4200
Address 16600 Centerfield .Drive Eagle River, AK 99577
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well XXX
Public water
If community well system, provide Written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72K)25 (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 flies 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.
S & S ENGINEERING
Name of Firm 17034 Eag;e A;vur L~p Road No. 2~4
Address Eagle RiYer,, Alaska. . 9957~r~ ,?
Engineer's signature ~/:/~ . -.
Phone
Date _'~ /2- i / ~/6
DHHS SIGNATURE
Approved for J~
Disapproved.
Conditional approval for
bedrooms.
. R C] cowAN ,r ,.~.
C~ - 880 ..' .: ..
bedrooms, with the following stipulations:
Additional Comments
The Municipality of A~chorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their !ending 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
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744
Health Authority Approval Checklist
Legal Description: Lo-r 2~ t g~'v" u~i TtlcelO~,~,~ 14~'~. Parcel I.D.:
A. 'WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitmy seal (Y/N)
Date of test
Static water level
Well production
IfA, B, or C, attach ADEC letter. ADEC Water system number
Date completed
Cased to
FROM WELL LOG
Casing
Wires
g.p.m, g.p.m.
Coliform
Nitrate Other bacteria
Collected by:
B. 7~YTOIOLDING TANK DATA
Date installed 5'- ~, - ~,~ Tank size
Foundation cleanout {~/N)
DateofPumping 3 ~'lq -
C. ABSORPTION FIELD DATA
Date installed ~ ' '~
Length ~o~ ' ' Width
Effective absorption area /400
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fhlid depth 0 ~ (ins.) Minutes later: Io
Peroxide treatment (past 12 months) (Y(~)
l'zSo 6a~.. Number of Compartments ')- Cleanouts (Y/N)' ']
Depression (Y/~ /q High water alarm (Yff~) /~
Pumper -3 ~, ¢orqeMc...
Soil rating (g.p.d./ft2 or fi2podrm) ~oo ¢/'/Ig¢. System type 'T~K~.~C 14
Gravel tlfickness below pipe °r ~ Total depth ~ ~
Monitoring Tube present(~q) ¥ Depression over field (Ytl~ Iq
Results {~/Fail) {0A,~5 For 'Yr tt. bedrooms
Inunediately allerqqo gal. water added (iu.): ~"
Absorption rate = (:, oo '~
~d Ifyes, give date b]//~
g.p.d.
D. LIFT STATION
Date installed Size in gallons
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank oil lot i __ On adjacent lois
Absorption field oil lot : "" " ; On adjacent lots
Pubfic sewer maio ~eanout
~oevmq-tS'rept~c sm-ace line Lift station
SEPARATION DISTANCES FRO~HOLDING TANK ON LOT TO:
Building foondatiol~ (,:- ~ Property line I o I 4- Absorption field
Water lnailYscrvicc line I o I + Surface water/drailmge ] OO I + Wells on adjacent lots
"2o0
SEPARATION DISTANCE FROM ABSORPTION mELD ON LOT TO:
Boilding foundatioa ~ (o ~
Water maiWservice line
Surfime water I oo ~ 3'
Curlain drain t~/A
F. ENGINEER'S CERTIFICATION
Drive,wry, l~arking/vehicle storage area I O
Wells oo adjacent lots '7__ oo t 4- Propel~, line
I certify that I have determined thrufield inspections a ~d 'ev ew of Municipal records that~.~~ns are
m cmgormauce w~th MOA /t~ gutdehnes in effkct on this date. ~.~:.~}2
/; .,_~ / ~ ............
Eugineer's Name J/~ O~ ~ ~ - - (a,~,~ ~' ~~g~":'
............................................................................................................ ~2:'~,~
HAA Fcc $ ~0~/ Waiver FeeS
Date of Payment ~ o ~ ~ ~ Date of Payment
Receipt Nunlber ~ 4 fi~/ Receipt Nunlber
~v. ~vs oss: fiaa.wk.aoc ~ ¢ / 7 0 ~
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
Lot 23; Block 4; Thunderbird Heiqhts Subdivision #3
Location (site address or directions)
Property owner Tom and _Cynthia Jensen
Day phone 694-9035
Mailing address
Lending agency
Mailing address
Day phone
Agent Lola Pederson/DON MCKENZIE REAL ESTATE Day phone
Address lqlq~ dlrl Glenn R4gh~my: R~gl~, ~'~?.~"~ AI~ QQ577
Un/ess otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ",
TYPE OF WATER SUPPLY:
NOTE:
694-9035
Individual well
Community well xxx
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:
NOTE:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
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 ~2f
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 flies 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.
17034 Eagle Eiver Loop Read Ne. 204
Name of Firm
Address
Phone
Engineer's signature
DHHS SIGNATURE
~ Approved for ~//~ ~"~'~) bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72~25 (Rev. 1/91) Bsck MOA ~1
Legal Description: ~,'¢'~"~ ~-v.-~ ~l~O~O~.?'~ Parcel I.D.
A, WELL DATA
Well type
Log present(Y/N)
Municipality of Anchorage /~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Total depth Cased to
Casing height.
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
Wires properly protected (Y/N)
AT INSPECTION, UNtCIpAUTY OF ANCHORAGF:
s .wc s
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~..~ t~-
Absorption field on lot '7.-o~ ~
Public sewer main
; On adjacent lots
; On adjacent lots
Public seWer manhole/cleanout
Sewer service line
Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~"'~ ~ ~ ~ Tank size ~ 'Z.~-O (.~.--~-~ Compartments
Cleanouts ~/N) y' Foundation cleanout (~N) V Depression (Y,~
High water alarm (Y~) )'-[ Alarm tested (Y/N) ~J L
~' ' t ~ "c'/?-- Pumper '~. t~-,
Date of pumping
To propertyline [O ' +
Surface water/drainage
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well~s) on lot ¢4:'o t'F~ On adjacent lots '~' '~
Absorption field ~ t -
Foundation
Wate'r main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (YJ~I~""~
S EPhOR OM LI FT STATION TO:
W'b-II on lot On adjacent lots
Manhole/Access (Y/N)
sted
Surface water
D. ABSORPTION FIELD DATA
Date installed
Soil rating fC, o ~//~'~.- System type
Length ~-D / Width '~¢ j Gravel thickness ~' ~ Total depth
Total absorption area ~¢O ¢ Cleanouts present ~f/N) '¢
Depression ever field (Y,~.) ~ Date of adequacy test ~' - / ~
Results ~fail) ¢/~ for ~- ~>0¢- ('/-/)
bedrooms
Peroxide treatment (past 12 months) (Y~ ,/~,'~"~ /~',4Jo !.~ &.(' If yes, give date
PARA'FION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot .~¢P ¢ ~' On adjacent lots '"J/~/ Property line
To building foundation "~ fcc ' To existing or abandoned system on lot
On adjacent lots .T, ~ / ¢' Cutbank #//~ Water main/service line
Surface water ! ~ ~ ¢'~ Driveway, parking/vehicle storage area
Curtain drain /'//~-
E, ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA
date of this inspection.
Signature
Engineer's Name
Date
S & $ ENGINEERING
17034 EaCe R yet Loop Ro~d NO, ¢[1~
Eagle ~iver, Alaska 995~'
HAA Fee $ /'~O o o
Date of Payment ~' [~" ¢/~
Receipt Number ~/~¢? ~I
72-026 (Rev. 3/91) B~¢k MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
- * ,~IUNICIPALITY 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)
Location (address or directions)
Telephone: Home ~J2oc'""="~~,''1' Business
t
(c) Applicant is (check One): Lending Institution []; Owner/builderJ~'; Buyer []; Other [] (explain);
(d) Lending Institution ~ ../~~ Telephone
'-Address ' ~'~-/-~t'~-~/~c"z~'~///.~
(e)Real Estate company and Agent
Address
~hone '
(f) ~t'~t'the HAA to the following ,address:
. u
TYPE OF RESIDENCE
Single-Family~' Multi-Family []
Number of Bedrooms -50
Other
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 .
Onsite~[/ Public [] Community [] Holding
Tank
[]
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDING INsPEcTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my sea~ 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 Oll 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 inspect[on.
Telephone
Name of Firm
Address
Date
Approved for ~/~' ~"J "~-~ b ed r o o m s by~'l~ ~/~ ~E)
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 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 (MOA/
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL DATA
' WelI.Classifieatio n'~-~/L'~
MUNICIPALITY OF ANCHOI~AGE
DEPT. OF HEALTH &
ENVIRONMENTAl. PROTECTION
MAR 2,5 lg8
264-4720 I: IV F D
o-r z')
Legal
D e s c r i p t i o~o~o~o~o~o~o~o~o~:
Well Log Present (Y/N)
Total Depth
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
'To Septic/Holding Tank 9n Lot
KA, B, C, D.E.C. Approved (~/,N~
Date Completed I Yield
Cased to D~4~{h Jof Grouting
tC~mp Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
.To Near~st Edge of Absorption Field on Lot ~-~-~C:~ t -t-- ; On Adjoining Lots
TO Nearest Public Sewer Line
Clean0ut/Manhole
Water Sample Collected by
Water Sample Test Results
Comments '""~>.',~,.~ ~ ~i~''~''' Z.~\ '~ ~ ~'-'C~
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~%"'~ '~) i
Stand pipes ~'A~ Air-tight Caps
Depression over Tank
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) '~,~
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~<~2~ ~ '~'
To Property Line
To Water Main/Scrv!cc Line ~ "''+'
Size /Z-~° No. of Compartments
Foundation Cleanout ~
Date Last Pumped ~'~"-~ ~ ~'
/V/z- ; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation ~'¢ ~
To Disposal Field ~ ~
Course
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata \Oo4 \~:~-- Type of System Design
Date Installed ~'~, '-~::~! Length of Field ~:b'--O
Width of Field 4_//I Depth of Field ~:~
Square Feet of Absorption Area ~/o[::;:~¢ Gravel Bed Thickness ~ z~/!
Standpipes Present
Depression over Field (.'Y¢i~ Date of Last Adequacy Test
Results of Last Adequacy Test ~_~/&-~._%r~/7~¢~L_~/¢. r¢
Separation Distance from Absorption Fie d.L~
To Water-Supply Well ~-o4> i 4-- (--~4.~LAd-- To Property Line
To Building Foundation To Existing or Abandoned System on
Lot /"Jf/~' ; On Adjoining Lots ~
To Water Main/8~vi~e Line ~ ~ '~- To Cutbank (if pres~,~
To Stream/Pond/Lake/or Major Drainage Course ' '/~
To Driveway, Parking Area, or Vehicle Storage Area ~,o ~
Comments-~ ~'~-~K-.~ ~/"~ -'-%¢--"¢'~'~-1~¢--~'~-~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ & $ Etl_oi~-,~r~ Date ~-.~/'~ ~ ,/~ ~
Company~l,~ ~b¢~, ~la~a ~
Receipt No. '~"? ~ -7 ~
Date of Payment ~ - :~;;~-~'~
Amount: $ (~ ,-,~ ~--
Page 2 of 2
72-026 (11/84)
i NSPECTiON'~APPOiNTMENTS
TIME TIME TIME
DATE DATE DATE·
INS.ECTOR INSPECTOR INSPEOTO5
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEI~'r~ONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION AUG 1 3 !981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SE~fAEC~ILVITal E~s
DIRECTIONS: Complete all parts GU page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
G. S. K. Construction 745-2553
MAILING ADDRESS
SRA 6105 A-3, Palmer, AK 99645
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER PHONE
Thomas B. & Cynthia Jensen 349-4176
MAILING ADDRESS
911 Jayme Ct., Anchorage, AK 99502
3. LENDING INSTITUTION I PHONE
Alaska National Bank of the North; Attn: ClaudiaI 278-4581
MAILING ADDRESS
3301 C Street, Anchorage
4. REALTOR/AGENT PHONE
Totem Realty, William 3. Schlegel 272-0571
MAILING ADDRESS
724 E. 15th Avenue, Anchorage, AK 99501
5. LEGAL DESCRIPTION
Lot 23, Blk 4, Thunerbird Heights
STREET LOCATION
Raven Loop Rd.
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One E] Four [] Other__
[] SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY [] Three [] Six
7. WATER SUPPLY
[] INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For w~lls drilled prior to that date, give well
[] PUBLIC UTI L1TY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM /=~-g-2 I t L~
[] INDIVIDUAL/ONrSITE** 1981 YEAR ON-SITE SYSTEM WAS iNSTALLED.
[] PUBLIC UTI LITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev, 6/79)
THiS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2; WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] ~NDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY ~ .~. _~J
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
live dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[~;]'"~APP R OV E D FOR '~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED