HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #3A BLK 4 LT 9Thunderbird
Heights 7 3A
Block 4
Lot 9
051-721-39
„\opm. MUNICIPALITY OF ANCHORAGE
• On-Site Water&Wastewater Program =5
�l r PO Box 196650 4700 Elmore Road
cl Anchorage,Alaska 99519-6650 Phone: (907)343-7904 Fax: (907)343-7997
.K Tar http://www.muni.org/onsite r
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On-Site Wastewater Disposal System Permit
Permit Number: OSP171203 Effective Date: 8/1/2017
Work Type: SepticTank Upgrade Expiration Date: 8/1/2018
Tax Code Number: 05172139000
Site Legal Address: THUNDERBIRD HEIGHTS #3A BLK 4 LT 9 G:1865
Site Mailing Address: 24853 TEAL LOOP, Chugiak
Owner: LAVIN GREGORY S & Lot Size in Sq Ft: 48766
Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 3
This permit is for the construction of:
❑ Disposal Field 0 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
•
Received By: Ott ,�,,I L /��� J Date: e a-
II V
Issued By: Date: /AV
MUNICIPALITY OF ANCHORAGE
r •
Community Development Department \: � Phone. t+ ; • •% 'O4
Development Services Division L-' F., . + - - '•,
•
On-Site Water & Wastewater Program 'O0
ON-SITE SEWER/WELL PERMIT APPLICATION a JUL 2 5 2017
IA. rt. ti
051-721-39 �� h
Parcel I.D. <<
Property owner(s) Gregory Lavin & Renee Hillier Day phone of 6 9 Lg
Mailing address 24853 Teal Loop Chugiak, AK 99567
Site address 24853 Teal Loop
Legal description (Sub'd., Block & Lot) Thunderbird Heights #3A B4 L9
Legal description (Township, Range & Section)
Lot Size 48,766 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) ❑X
(w/wo ADU)
Septic Tank ❑X Upgrade ❑X
Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: eAkS I. Waiver Fees:
Date of Payment: 1 194 Ii 1 Date of Payment:
Receipt Number: ( 661Receipt Number:
Permit No. OV1"1 12-1:33 Waiver No.
Permit App_- c
Pannone Engineering Services ac
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
July 24, 2017
Subject: Thunderbird Heights #3A B4 L9
Tank Replace Permit Request
Design Narrative
This is a design narrative for a permit to install an upgrade 1,250g Septic Tank to replace an existing
1,250g Septic tank to be issued for this property. The existing tank has completely failed. It will be
decommissioned per code. Currently the lot is developed. The proposed system will utilize a replacement
1,250g septic tank that will be connected to the existing drain field. The existing tank is located
approximately 100'+ from the well. The proposed tank will be placed outside the existing well radius. All
required separation distances will be met.
1. Upgrade Tank Design.
A foundation clean out installed if needed.
The tank will be located: 5'+ from any property line or building foundation ana Wastecrtf«
10'+ from any water line
100'+ from any surface water „v
100'+ from any private wells f/5.P
200'+ from any public wells
The proposed installation will not affect the future development of the surrounding or existing lots.
If you have any questions or concerns, please contact me at 907.272.8218.
Sincerely,
i... . •i �
•
t_
t : Steven R.Pannone IP
Steven R. Pannone, P.E.
Owner/Civil Engineer
Mailing: P.O. Box 100217, Anchorage. AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
· 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
PHONE .~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Manufacturer Mated I No, of compartments
Width Liquid depth
Liq..capacity in gallons Inside length
O Z ~ Manufacturer Material Liquid capacity in 9aBons
~ - DISTANCE TO: Well Foundation~ /--.~ Nearest lot line PERMIT NO.
Top of tile to ~nish~rade Material beneath tile Total effective ~sorp 'on area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter 3rib aepth Total effeotive absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ DISTANCE TO: Building foundation ~ Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
INSTALLER
72-013 3/78)
Permit
Applic~t:~C~,~¢
Location:
Legal Description: L~r 9
Type of Soil ~sorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms:
_~UNICIPALITY OF ANCHORAGE.
DepartmentC f Health and Environment~/'~?rotectiOn
825 ~ Street, Anchorage, AK. ~9501
264-4720
* * * HANDWRITTEN PERMIT * * *
~0N-SITE SEWER PERMIT
Phone Number:
7-~~, Lot Size:
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br) '//~
The Required Size of the Soil Absorption System Is:
- W DTH
DEPTH LENGTH L~ GRAVEL DEPTH 2 ! ~
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(H~-DIq~G) TANK SIZE = /~D~ 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 am 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 un~z~tand that the on-site sewer system may require enlar/~ement if
include more tha~ 3 bedroomF./.~
theodore is~ A-~------rem°deled to ~~~~
Signe~: mi~ant~~ ~.~ , Issued by:
A Date: ~//~/~ C/
SWP/024(1/81)
,~-'~ ,~'~h .~ SO~LS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
LEGAL DESCRIPTION:
2
3
4-
5-
DATE PERFORMED: ~-~/L?F
SLOPE SITE PLAN
77~/ ~-
10-
11
13-
14-
15-
16-
17-
18-
20-
WAS GROUND WATER ~/
ENCOUNTERED? ~5 0
P
f E
rF YES, AT WHAT
b~'PTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~ (minutes/inch)
COMMENTS
PERFORMED BY:
72-008 (6/79)
-- FT
/
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel i.D. ,,"D 'D'-'/
1.' GENERAL INFO'~AIION
ComPlete. legal descdlStion
kocation (site address pr di~'ections) ~.~4~-'~
HAA# C) /-/- O ,,~.. ~/"/-"
Expiration Date: (~ - / ~ "' ~) ~
Current Property owner(s),,~v,~.,,~ ? ~.,~,¢~ ~~.4,t-,~ Day phone
.Mailingaddress ,,~'¢-~'~"...,~"',-~ ..-'~,,~z .~',~,~ ~'~-~-..~...f.~-
Lendin[j agency Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~
e
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
. Individual On-site
[] Individual Holding tank []
[] Community On-site []
/]~ Public Sewer
The Municipality of Anchorage ,Development Services Depadment (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
' engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year With valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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,
based on procedures outlined in the Health Authority 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 ~"'~o-~,,~
Address/,~.//,.~/ /~,(,~"~."
Engineer's Printed Name~..~,<.,~',,~,,"~p~ ~ .,~-~'~
DSD SIGNATURE
~ Approved for
Disapproved.
Conditional approval for'
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow AdvisOry
X
(Rev. 01/02)
Maintenance Agreements
Supplemental Engineer's Report
Other
original Certificate Date: - / ('- 40
Municipality of Anchorage
Development Services Department
Building Safety Division
"'On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage,AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
' '
HEALTH AUTHORITY APPROVAL' CHECKLIST
Legal Des( ription:
A. WELL DATA
Date completed
Total de~th": ft.
. : .~'
Date of test
~ 3'1'
Static wa{~r' level
Well production
WATER SAMPLE RESULTS:
c61iform~ ~ !~·
Arsenlc:~ ~ mg.ll.
Parcel ID:
Well Lo~ iY/N) .
IfA, B, or C provide PWSID #
Samtary sea! (Y/N) W!res pr.operiy~Y/N)~:
Cased t° ~ ft. . Casing he~hY(a~ve ground).
g.p.m. - ~ ~'~ g.p.m. -
Nitrate mg./I.
Date of sample: __
SEPTIC/HOLDING TANK DATA
Other bacteria
Collected by:l';
colonies/100 mi.
Tank/ype/Material :':~ ,..~',,~'_/~".,~'.,,' · · .--. -.
~Tank size ............. ?,,~ ~ gal. . .:,,NumberofCompadments~ Cleanouts~). ~, ,~
Foun~dat!on]cleanou~N) '~ Depression over tank (~ ~: High water alarm (Y~
Date.of pump~ng . ~ ~/~ Pum per ~ ~ .~~~/~'
C.
Date installed
ABSORPTION FIELD DATA ·
Date ~nstalled ~~ .So~l rating (g.p.d.lft2 or ft2/bdrm)/,~4''~ System tPe /,~/~
Length :I !i !~.,~-ji~'.'"-::"fl. Width' ~ .fl. Gravel ~Jow pipe ,~. - ft.
Total dep!h :,~ ft. '~ff. absorpbon area ~5,'.d"'ft Monitoring tube ~/~ (,/JDepression over field
Date of ade,quacy test ~/.."~.//./'~f.,'~, Result~ail) /z=,_.,,.~_.~.~. ~ i: '"~For_,.-~' bedrooms
Fluid depth m~absorption field before test ,~ in: . .' Water added ~Ogal'. - i: - New depth/p'" in.
Elapsed.ffim&i' '~ min. ; Final fluid depth .~' in. Absorption rat~ ,;>= ~ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) .,~,',,-~.,¢~ If Yes, give date
Ee
LIFT STATION
Date installed Size in gallons . ~ ' e/Access (Y/N)
a in. ,High water alarm level at
"Pump on" level at ,n.. t
Datum .._._....--'"~Cycles tested ' ' .' ~ Meets alarm & circuit requirements?
sEpARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
:'septic tank/lift station on'lot L: ~ i L" '.;' O~ ;~ :'.:-'; :'-"'
AbsorPtion field on lot__, i ~--. ,;~,,~.........."~n adjaCent lots ',._-'~-"
~ ~ ' : Public sewer manhole/cleanout
~ublic sewer main 'i , ~ : Public sewer man
Sewer/septic s~ .
SEPARATION DISTANCES FROM 'SEPTIC/HOLDING TANK .ON LOT TO:
Building foundation ,,,",¢~" ' ProPerty line ~"~,~' / "Abso~:Ption~ field ~'¢ · : . ..
Water main ~' ~',~ ' .Water service line 2'/,.~) · Surface water ,,"',.',~ / '" :' ' '
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: .
Property line ,~',,..-3
Water service line
Curtain drain '/'.~'-(:::)
Building foundation ' ,/,,~ / Water main .
· Surface water -~-,,"~---~) / Driveway, parking/vehicle storage
Wells ~n adjacent lots ~. ~ '
cOMMENTS .......
G. ENGINEER'S CERTIFICATION ' .. " ' ' ' ' ~"-,~ ~"~:,'
,cedi~thatlhavedeterminedthroughfieldinspectionsand :-:' '1--*~~
review of Municipal records that the above systems are in . ~~~~
~o,fo~,o~ ~ith MOA ,~ ~d~,~ i, ~t o,'~ d~t~. . . ' : ~-
.... · . . ~~;"-...
HAA Fee $
Date of,Payment
Receipt Number
(Rev. 12/01)
Waiver. Fee $
Date of Payment
Receipt Number
OG/l~/200~ 12'4U FAX BO? 222 8801
RESIDENTIAL MDRTAAE
1~002/002
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· ..,. ~ o~"~.,.;-,.- t... ~ ...... ~ . -.
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88517 flO7-243..d,21~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHOR. ITY APPR, OyAL ·FOR A Sii ( EE 'FA'U'iLy''. .. . .DWELLING' . "'.. '"; ':'
Parcel I.D.
Expiration Date:
1. GENERAL
' Complete legai~escription
Location (site address or directions)
Current Property owner(s) Jim.~',~ .{, ~re~d~ /Y,~v~he~ Dayphone
Mailing address 2~'~'3
Lending agen~ ~ ~ ~,;<~ Dayphone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROO~IS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site [~
Individual Holding tank
[] Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/ar water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for ene year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not respcnsible for errors or omissions in the professional
engineer's work.
4. 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,
based on procedures outlined in the Health Authority 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.
Phone ~'q/.¢'- EI15'
Ea¢le River En ineerin Services '
P.O. Box 7~3~4, Eagle Ri~r, AK 99577-3204.
Name of Firm
Address
Engineer's Printed Name ,~,~,...-~r ~,,-~,.,-~-,
5. DSD SIGNATURE
.. I,-'"" Approved for
Disapproved.
Conditional approval for
bedrooms.
Date ~'/.Z 3/of
bedrooms, with the following stipulations:
· Additional Comments
Attachments:
HAA Checklist
' Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Budding Safety Division
On-Site Water & Wastewater Program
4700 South Bmgaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
LeoalDescription:'[~fl~ev J~r~ I~]',.~ ~3-R;i. effl: 0lo~, q'PercellO:
A. ~NELL DATA
D~t~a. elltype ~bl;c wqt¢~' ffA, B, orCp~ePWSlD# Wall Log (Y/N)
~mple~ S~ s~) ~ p~ pmt~ ~IN)
T~m~ep~ " ~s~ ~". ~ ~ight (able g~nd), in.
~ FROM WELL LOG ~ AT INSPECTION
D~e of t~st ~ ~
S,fic,~l~ fl' ~ '
CoI~ ~i~1~ mL Ni~e .. ~-~ ~r ba~ ~lonie~100 mi.
- Date ~ sample: ~ . ~l~ ~: %.
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material .~"~e~. J
Tank size !,1, 5 O gal. Number of Compartments
Foundation cteanout (Y/N) Ye
Date of pumping ~'--D. 5'o~ a
C. ABSORPTION FIELD DATA
Date installed ~
Length ~ 3'1 ft.
Depression over tank (Y/H)
Pumper ,7'~ ,~-,,,~,,~,~'
Soil rating (g.p.d./ft~ or ~/bdrm) I I 5
Width ,,g' / fl-
Date Installed ~'/2 ~' / ~ ~
cleanouts (Y/H))'¢5
High water alarm (Y/N) ..~
System type ~,Jlow "[~a~h $/w;~lp.,
Gmval below pipe '~ / ft.
Total depth
Date of adequacy test ~'/,~ ;~ JO l Results (Pass/Fail) P~I $ $
Fluid depth in absorption field before test 0 in. Water added,95'0 gal.
Elapsed Time: "-- min. Final fluid depth ~ in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (YiN & type) ~V/,~
ft. Eff. absorptionerea 3~t~ ft2 Monitoring tube Y__e,_5_. Depression over field
For 3 bedrooms
New depth (~ in.
/-~.C'~ g.p.d.
If yes, give date
O. ~IFT STATION
D~U~e installed
"Pu~ on' level at __ in.
Datun~
Size in gallons
'Pump off' level et in.
Cycles tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES /14//:)
SEPARA'~N DISTANCES FROM WELL ON LOT TO:
Septic tank/lif~tetion on lot On adjacent lots~
Absorption flald~n lot On adjacent lots
Public sewer mallt~ Public sewer manhole/cl~out
Sewer/septic servt~ line Holding lank ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation I0 / Property line + ~4)' Absorption field ~"
Watermain ~'/0' Water service line ~O/ Surface water +loQ/
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~ I o ~ ' ' Building foundation I ~' ' Water main -t' l0 ~
Water Service line +'T07- Surface water '1' lo0 ~ Driveway, paddng/vehicie storage
Curlain drain /V//~ Wells on adjacent lots ~ I~ ~
F. COMMENTS
G. ENGINEER'S CERTIFICATION
review of Munid~l ~ eat ee a~ sy~e~ am ~
~n~ance ~ MOA H~ gu~elines ~ e~ on e~ date.
Date ~12 ~101
HAA Fee $
Date of Payment
Receipt Number
(Rev. 17./00)
waiVer Fee S
· 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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description ~UNDERBIRD HETGHTS #3A, ~ 9, BLOCK 4
Location (site address or directions) 24853 TEAL LOOP
Property owner GR~G & SUE; DOC.~;ETT Day phone
Mailing address 24853 TEA~ D~OP, CHUGIA~, A~ 99567
Lending agency CITY MORTGAGE
Mailing address EAG~ RIVER, A~
Agent KATHERINE DONOHUE
Address
PRUDENTIAL VISTA REAL ESTATE
4241 B STREET, ANCHORAGE, AK
99503
Day phone
Day phone 244-6939
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
NOTE:
Individual wetl ;;:~
Community well
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
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~)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 files and from my inves_tLgation 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.
Eagle R ver Engin . ng Serv ce
__~,.~,,,,, ~ .~ ~. Phone
Name of Firm P.O. ~ .....
Address
Engineer's signature ~~, ,~'~ ~--~
Date
8-8-97
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 Cer[ificates 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.
Municipality of Anchorage E C [!1 V 997 E
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ,
825 L Street, Room 502. Anchorage, Alaska 99501. (907) 34§-"4"74~4
Municipality of Anchorage
Health Authority Approval Checklist Dept. Health & Human Services
LegalDescription: ~/~¢ ~'/',4¢~// ~"¢/¢'"~{~-~",~f"~¢¢/,/-/'/-' ¢.:~..4 ParcelI.D.: ~:.~5-'/ ~,~[_7~
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 Cased to
Casing height (above ground)
Sanitary seal (WN).
Wires properly protected (Y/N)
FROM LL LOG
AT INSPECTION
Date of test
Static water level
Well production g.p.m, g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate
Other bacteria
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed 4~'- ~._~ Tank size
Foundation cleanout (y/N)
Date of PumPing
Number of Compartments ~L_ Cleanouts (y/N)__
Depression (Y/N) /t) High water alarm (Y/N)
Pumper O';,,~C, ~'
C. ABSORPTION FIELD DATA
Date installed ~ - o~-~
Length z-/,F / Width E' /
Effective absorption area ~, ~'5" ~
Date of adequacy test ~- ? ~ '7
Fluid depth in absorption field before test (in.); ~-~
Fluid depth ~' (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Soil rating (o~r fF/bdrm) //.S-
Gravel thickness below pipe
Monitoring Tube present (Y/N) ~
Results (Pass/Fail) ~',~ ¢.r'
System type -~'
~ / Total depth
Depression over field (Y/N)
For
Immediately after~'oD gal. water added (in.):
Absorption rate = ~- ~'~'~ g.p.d.
If yes, give date
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed ./ Size in gallons
Manhole/Access (Y/N) J "Pump on" level at*
High water alarm level a/t~/'/ *Datum
Cycles tested
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot J
Absorption field on lot J
On adjacen/~
On a~t lots _
/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation //~ / Property line /-.~¢ ' Absorption field 2(¢' /
Water main/service line ¢'-/~" Surface water/drainage ~'/'~'~ ~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ?'-/¢' / Building foundation ~-~ ' Water main/service line
Surface water '/- ~'¢'~" Driveway, parking/vehicle storage area
Curtain drain ,¥/4-
Wells on adjacent lots ~ .z ~, ,.~
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections
in conformance with MOA HAA guidelines in effect on this date,
Signature
Engineer's Name
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
APPLIC""~IT FILLS OUT UPPER HAL'-r:',ONLY
Phone
I5'roperty Owner t~.~CI ~ '
Mailing A(~?ess ~a~lG Ri¥'er~ AK t zip Code ~9~77
G_egoTy ?~. Do~xgect & Sue C. Ower
A~m~2201 W. g~6th Ave.~ Anchorage~ AK z~pCo~o 9~507
Phone
Lending lnstitutyn First Federal Sqvings & Loan
Address Zip Code
RealtyCo.&A~nt R~J/,,~AX o~ ~{~o ~-o~ I~c (~rll i,lO~l[~[le) Phone
Address ~0 ~O~ 8~8, ]~}~e R~O~ ~K ZipCode
Legal Description Lot 9, Block /~, Thunderbird Heights Subdivision
mreetLocaU~ NHN Teal LOOO Road
Type of Resi~nce
~ Single Family
~ Multiple Family NO. of Bedroo~
~ Other ' ~-
Time Time Time Time
Date Date Date Date ,~
Inspector Inspector Inspector Inspector
., MUNICIPALITY OFt ~NCHORAGE
Field Notes: ~ "~_~C-O.~~'~'-'V~' ~ ~["'~ -~ -~:~- ~ , .... ~ j ~, T~ ~'~ ~NVIRONMENTAL DEPT. OF H~A~TH &PROiECTiON
O~c~~ ~ ~- SEP i
RECEIVED
)APPROVED ~EDROOMS *CONDITIONS OF APPROVAL
Soil;Rating Date ~wer Installed Welt To Absorplion~ ~/ Well Log Received
j j ~ ~--~, WelltoTank Septic T~k Size