HomeMy WebLinkAboutTHUNDERBIRD HEIGHTS #3A BLK 4 LT 12
Municipality of Anchorage
On-Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP221267
PID Number: 051-721-36
Dwelling: ❑®" Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New Q Upgrade
Name
SOMERSET & JANCY JONES
ABSORPTION FIELD
ElD Trench El Wide Trench ❑Bed El Mound
Site Address
24823 Teal Loop Chugiak AK 99567
❑ Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
PD/SF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from originrade
t.
Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Thunderbird Heights #3A 4 12
Fill added above original grade
Ft.
ravel length
Ft.
Township Range Section
Gravel width
Ft.
Beds: Number
of Lines
istance between lines
Ft.
SEPARATION
DISTANCES
To
Septic
Absorption
Lift Station
Holding
Sewer
Total absorption area
Number of trenches
Dist. be n trenches
From
Tank
Field
Tank
Line
Ft2
Ft.
Well
7j(Jv'
NA
NA
>/00'
TANK ❑® Septic ❑ S.T.E.P.
❑ Holding ❑ Other
Manufacturer
Greer
Capacity
1000 Gal.
Surface Water
> 100'
NA
NA
Material
Number of compartments
Lot Line
>10'
NA
NA
NA
plastic
2
Foundation
> 10'
NA
NA
LI STATION
Manufacture
Capacity
Remarks new steel pipe was driven as MT
Gal.
tank insulated
Alarm location
Ele installed by
PIPE MATERIAL House to tank D3034 Tank to D3034
drainfield
Installer
Dean Construction & Development
Drainfield
CO/MT D3034
Inspector Curtis Townsend
BENCH MARK (Assumed elevation) 100 ft
Inspdection 15' 8/4/2022 Zia 8/9/2022
Location and description
3'd 41h
garage slab
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval:
l\0
t
Date
... �••••
.a'q�
j Date � �'
�(��`°Cj •, No. CE 11 �
Septic System
Approved
Date 2 Z
6
�� pF. • • • • •.. `�-
l '9PROFESS0�
Note: this approval es not include well permit requirements.
krncv vorvcI 1 o/
/ SCOPE OF WORK
l. REMOVED EXISTING SEPTIC TANK.
/ 2. PLACED NEW 1.00OGALLON SEPTIC TANK AND TIED INTO
c>�
EXISTING ABSORPTION SYSTEM. THE TANK WAS PROVIDED
/
WITH A MINIMUM 20^ 0 MANWAY RISER SERVING THE
/
FIRST COMPARTMENT. \
/ 3. INSTALLED DOUBLE CLEANOUTS UPSTREAM AND
/
DOWNSTREAM OF TANK.
/ 4. PROVIDED 2" OF INSULATION OVER TANK.
5. STEEL MONITOR TUBE WAS DRIVEN GO" INTO THE
�
EFFECTIVE DEPTH.
. / O. ALL CONSTRUCTION WAS IN ACCORDANCE WITH ALL
REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE
/ / CHAPTERS 15.55 AND 15.65.
Septic €onk Record Drawing Prepared for
N
SOMERSET AND JANCY JONES
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24823 Teal Loop Chugiak, Alaska 99567
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DATE: 7/11/2023
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Septic €onk Record Drawing Prepared for
SOMERSET AND JANCY JONES
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24823 Teal Loop Chugiak, Alaska 99567
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THUNDERBIRD HEIGHTS #3A BLOCK 4 LOT 12°'N
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OSP221267
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EKLUTNA ENGINEERING, LLC
DATE: 7/11/2023
19162 MOUNTAIN ROAD
Ci1UG1AK,
DRAWN:
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ALASKA 99561
(907) 406-1058
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PID: 051-721-36
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP221267
Work Type: SepticTank Upgrade
Effective Date
Expiration Date
Tax Code Number: 05172136000
Site Legal Address: THUNDERBIRD HEIGHTS #3A BLK 4 LT 12 G:1865
Site Mailing Address: 24823 TEAL LOOP, Chugiak
Owner: JONES SOMERSET O III & JANCY B
Design Engineer: EKLUTNA ENGINEERING, LLC*
This permit is for the construction of:
� C 'l.�,i,i 3 K'��il I ��pi���f�•
n ^
Uepartrnent
7/25/2022
7/25/2023
Lot Size in Sq Ft: 21333
Total Bedrooms: 3
❑ Disposal Field Z 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 B)
Issued By:
Date: Z 6 L Z
Date: 2Z
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. 051-721-36
Property owner(s) JONES SOMERSET O III & JANCY B
Mailing address 24823 TEAL LOOP Chugiak
Site address 24823 TEAL LOOP Chugiak
Day phone
Legal description (Sub'd., Block & Lot) THUNDERBIRD HEIGHTS #3A BLK 4 LT 12
Legal description (Township, Range & Section)
Lot Size 21,333 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field
❑
Initial ❑
Single Family (SF) 0
(w/wo ADU)
Septic Tank
El
Upgrade ❑ x
Duplex (D) F]
Holding Tank
El
Renewal El
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. /
/ '1/ 2-0 Z
(Signature of property owner or authorized agent)
Permit/Rush Fees: _ Waiver Fees: --- -
Date of Payment: i /1 5b-022 Date of Payment:
Receipt Number: 6 7 33 2D Receipt Number:
Permit No. 0S P a 2 1 '� % "I Waiver No.
G1Development ServiceslBuilding Safety\On Site Water and WastewaterTorms\Client Forms\Permit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221267, Deb Wockenfuss, 07/23/22
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221267, Deb Wockenfuss, 07/23/22
FRI 15:37 FAX 6896'09 r
VISTA REAL
ATE
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As 'the.respOns`ibi.l ity. of the'.oner -
EASEMENTS Q RECORD OTHER THA he ,existence of. any.easemelitS,.. covena�i �s
THOSESHOWN THE RECORbED ' strict ons which, do not: a4peidr: on 'the` pec;,
' -
PLAT, ARE PHOTS HEREOP�• �' ' sion.plat, Under�no`circumstances'-s
d
D ; hereon' be used, for. cons t'ruc" on;•cr jr e,
7ish boundary orence'1.iries: rhe su�ra��r
respons.�i,t�o�: the..ittiti a1 tansacr;c^ cr.
is LEGE.............
ND:
PRM CAP HONUMeNT
LOT SURVQY
Q MON PIPE
LO i BLOCKS L1 svavCr Hua a TACK
.;
ANCHORAGE RECORDING DISTRICT ' REVISIONS
�R_vApto aY: OOWLING >3 ASSOCIATES
804 :AST 16th ave• 9cF'fe'.:2..,ef�:;:;;:
-9 950
~ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PH,,.O.N E [~[EW
MARLING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Well h
~ ~ Manufacturer , · M~ter~l No. of compartments
~ ~ Liq. capacity in gallons Inside length Width Liquid depth
J~O~ IF HOMEMADE: ~
~ ~ DISTANCE TO: Well Dwelling PERMIT NO~
O ~ ~ Manufacturer Material Liquid capacity in gallons
~ Eoundation Nearest lot line~ / PERMIT NO~/O~
No. of lines Length of each Ii e Total lan th of lines Trench width
-- T f I /* ' ¢~z Total effective absorption area
~¢ opo ti e to finlsn grade ¢/ Material beneath tile O/ m
Length Width Depth PERMIT
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot llne
~ DISTANCE TO:
~ ~a~ ¢~ / Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer llne Septic tank Absorption area(s)
~ DISTANCE TO: -~ '¢~OO ~ ~OO ~
OTHER
PIPE MATERIALS
SOfL TEST RATING ....
72-013 (Rev, 3/78)
DEPFIi;~FFid,r._:]',Ff' OF i-.!EFII_TH FIND Ei'.,!VIRONf,!ENTP/I... PRO'T'ECTZON
~25 -"L." STREET., ANCHORFiCiE., ¢I,K. 5~95Ei::L
;264-.-472Ei
S2Et;[.02 ) ~
PO BO:-";; D C;HUG!F!I< 688-28E::J.
LO]" SIZE 4EiCtgE~ S';;!URRE F'EE'F
TRE':NCH
S;OZL RFITING (:~.;¢! F]'/BR:: .... 85
TPIC" ,~.}.E(;!U [[ Ii:El) ' ........OF '::;fi T I
;THE LENGTH Dti'dENSZON !S 'THE LENGTH (IN FEET) OF THE: TRENCH OR DRR!hiF!EL..D'..
'Tide DEPTH OF R TRENCH OR PiT IS THE DZS;TR!qCE E;E'THEEN THE S!..IRFRCE OF THE
GF~p:]LIF~D RN[) THE BOTTOM OF THE E::.,;CR',,,'RTION ,::ZN FEET).
THERE Z:.-; NO SET !.,.III)TH FOR TREI'.,~CHES.
'THE GRR',/EL. DEPTH IS 'THE r,'i;[!'.~Zl'lUrd DEPTH OF' GRRVEL. BE]"!,.iEEN THE OLr!'FFILL F:'ZPE:
Rhi[:, TP!E DOT'TOM OF THE EXCF!"/F~/I"iON (IN FEET).
F'ERMZT FIPF'L.!CRh!T HFiS THE F:ESF'ONSIS!L. ZT'¢ TO ~ - "~ _ ............. DURING THE
!~.,_~u.L. FJ. LN_ OF Fll".!'¢ ~'~-~1c R[:.;FR]ENT 'I'Ct l,~I: ..... · .
iNS'FRLLRTION -*~':~; ........... " . ......... '~ ': F'm'"F'EI~'T'¢ FIN[) THE
b!ijMEIER OF RE?Ijr2EF,!C;ES THF!T -~ ...... ~= I,'$:. L,!ELL. 1.4ILL' ...E~ ........
EI¢~CKF!I._LING OF RH',. S'T'S"I"EM .,lITI-Ir.ll IT FINRL ~.,,::C,F,-'TT-~'.I ................... FIN[:' H,'"[' ":""' I..'..,-, HL" ~,rF'' ]'HIS
: [:,EF'FiR-!'MEI'.,!T I.,.! i LL ............ F F ':;IIE IF:' "]'T "r,', ~ PROSECI..I"i' I
MIF,I!!',ILIM DiS"FRNE:E 8ETHEEN Fl., HELL Fff,-,'E) RN"r' ON-SiTE SEt,.!FIGE DISPOSRL S"?STEP'! IS
Lt_E~I2f FEET FOR R PRi',,,'FIT.IE.': HEL. L OR '1_50 TO ;:}':I-Z~C~ FEET FROM i:~ PUBL. IC HELL DEPEND!h!G
UP(3t",I THE 'TYPE OF PUBLIC NELL.
MZNZMUM DISTRNCE FRC$1 F! PRIVR'T'E IqELL. TO R PRIVFITE SE!,~ER L_;f_NE iS ;25 FEET RF,ID
TO R COMMUNZT'?' SEP.!ER LINE Z'S 75 FEET.
OTHER RE6:!UIREt"IENTS MffT' RPP!..."¢. SPECZFZCRTIC~h!S RI'4D COf'.,12Ff'RLJCTIOH E:,ZFIGRRMS RRE
R',/RZL..RBLE TO !N'_E';URE F'ROF'ER Ii',!STRLL. RTION.
I '3[:',L-}TIF'T' THF!T
'ri.: ! Fib1 FFff'liLI£:IR I.,.I!TH THE RE[;P._IIREMEN"I"S F'OR :I'-,I--'STTE SEI..IERS; F~N[:' P]E!...I_S
F .Z R~ F~ ~'r' THE MUN I C ~ PRL ~ T"¢ OF' R!",E:HORROE.
2: I I.,.!ILL. ~i~F!:ILi... THE S"FSTEM Zhl RCCORDFINCE W~'FH THE CEE:,IES.
Ur4L.,LK~,! ~M}_ IHr~, ~[~1~ U,,I .... ~ ..... E.!..,~ .............. Eh I,H~ ............ .'"R'*' ENL.FIRGEMENT ~F THE
I:~ESI[:'ENC:E ~i~ REHOC, EL~6et/r'O ~NCI._U[:,E P1ORE 'THF!N 3: BEDROOMS.
' F, PF,.... I,]:,:ih'.' .~;'i'E~¢',i I ....
F,~.~ , , - o ~ 4 ~ /~' 'fire
~SSUED ................. ~ .......................................... - ............ M ..........................................
O & E ENG,NEERING & DEVELO,..MENT CO. :
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280 '~
Russell Oyster Earl Ellis
694-2774 SOIL LOG ~ 688-2280
Depth (feet)
Soil Characteristics
11__
PLOT PLAN
12__
13__
14
PERC. TEST
15__
16__
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit__
Comments:
No t-- '~' If yes, what depth
Drain Field
Performed by:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Envirc nmental 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. # ¢5~/- ?~-/-
1, GENERAL INFORMATION
Corn Dlete legal description
Location (site address or directions) ~/'/~ --~
Property owner
Mailing address
Lending agency
Mailing.'~ddress.
Day phone
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS;
TYPE OF WATER SUPPLY:
Individual well
Community well
Pu 01lc water
NOTE:
tf 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 affi~ed 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 Municipal!ty 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 Eagle ~-,J.vaz' ]~ngJ.~ee~trt~ Sez'~r~.eee Phone
P.O. t~ox ~:~t~, ~agle River, AK 99577-329~
Address
Engineer's signature
Date ~-/4-?'7
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By: . ,:-~: _ . -
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given ir~ 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.
72~025(Rev, l/91) Back MOA~21
Municipality of Anchorage ,JUN 'J 7 l~m,~x~.l,.~=.~
& HUMAN SERVICES ; '~
DEPARTMENT
OF
HEALTH
Environmental Se~ices Division ~ ~ J ~/d~
825 L Street, Room 502 * Anchorage, Alaska 99501 * (907) 343:~ a VL U
Legal Description:
Health Authority Approval Checklist
'~'~/,,.,~/~-~;.,~.-~./' ///~ ~.~ ParcelI.D.:
A. WELL DATA
Well type ~¢'~,~Z~_ -/~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date completed
Cased to
FROM'X~ LOG
Nitrate
Collect~
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Other bacteria
Date installed /~'~.3_ Tank size ,/42~' Number of Compartments ~ Cleanouts (Y/N) .
Foundation cleanout (Y/N) Y "~ ¢/~""°-~Depression,(Y/N) /~J High water alarm (Y/N) Al/4
Date of Pumping /~'¢' !~f~?7 Pumper J--~ ~' ~'~P'~
C. ABSORPTION FIELD DATA
Date installed /~'~' ~
Length ;2 ~ ~ Width
Effective absorption area ..~ 7~ ~'
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 (g.p.d./fF or fF/bdrm) ~5- ~'~,tSystem type
~' Gravel thickness below pipe ~ / Total depth / o
Monitoring Tube present (Y/N) ~ Depression over field (Y/N)
Results (Pass/Fail) /~ r.r For '-~ bedrooms
Immediately after ~J7 gal. water added (in.):
Absorption rate = '7' z~j--~ g.p.d.
If yes, give date '
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
;'~eWs itee; ~ Idarm level at*
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
E. SEPARATION DISTANCES
Septic/holding tank on lot ~%~/' On adjacent lots
Sewer/sophie line %'~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ ~, / Property line /-/~, / Absorption field
Water main/service line /-/~' ~¢,/.,~urface water/drainage
Wells on adjacent lots ./-,a~,.¢ ,'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propertyline f-/~' / Building foundation 3,, / Water main/service line
Surface water ,'-,',¢~ / Driveway, parking/vehicle storage area
Curtain drain
Wells on adjacent lots ¢- ¢~',~"
F. ENGINEER'S CERTIFICATION
I certify that I have
in conformance with MOA HAA guidelines in effect on this date.
Signature
Engineer's Name
Date ~ ~ / ¢ -
HAA Fee $
Date of Payment ~//~7/~.~
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
1. GENERAL INFORMATION
Complete legal description Lot 12; Block 4; Thund~bird H6~g/~:s Subdivision #3A
Location (site address or directions) ¢,~8¢3 T~ Lon?; ¢.~u.gx'ak; A£a~ka
PropertY owner
Mailing address
Lending agency
Mailing address
Kar6n Findling Day phone 688-3966
H~ 7q Box 117 Tcn~ Innp; Ch.g/nb. A~Abn qq567
Day phone
Agent
Address
Day phone.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ',4
TYPE OF WATER SUPPLY:
Individual well
Community well XXX
Public water
NOTE: 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 XXX
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.
724)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 investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S & $ ENGINEERING Phone
17034 Eagle River Loop
Eagle I~iver. Alasl(a
Address
Engineer's signature
bedrooms.
DHHS SIGNATURE
¢/t~'_ Approved for
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The 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
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lo~\'L- ~ ~ ~'~,o~¢~-~,~.t~ Parcel I.D.
A. WELL DATA
Well type
If A B, or C, attach ADEC letter· ADEC water system number
Log present(Y/N)
Date completed Driller
Total depth
Cased to Casing height
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
g.p.m.
; On adjacent lots
; On adjacent lots
g' ~c; ~z
Z
Public sewer main
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 ~ oc~o L¢7~.~ Compartments
Cleanouts ~tN) X/ ~ Fo'undation cleanout(~N) D*pression (¥~
High water alarm (Y~J~) ,~t ~ ~"
Alarm tested (Y/N)
Date of pumping J/-~'~/ ~'~ Pumper -.~./~.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on 10t 2.-,PO ~;P On adjacent lots
To propertyline /~) / ~ Absorption field
.~2.o Surface Water/drainage /D~ /
Foundation 2--~ ' ~
Water main/service line / o ~ /'-
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrica~
TANCE FROM LIFT STATION TO:
On adjacent lots
Manhole/Access (Y/N)
"Pump on" level at .---~--'~;~"Pump off' level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length %~2' Width
Total absorption area
Depression over field (Y~)
Results(~/fail)
Peroxide treatment (past 12 months) (Y~
Soil rating ~ ~/~¢~ System type -'["'¢~¢-¢q c-~\
Gravel thickness ~¢ ' Total depth /~ /
Cleanouts present ,~/N) \/ ~
Date of adequacy test /~ ~ ~
for '~/~--~-~ ~/"~ ) bedrooms
,x////~ /<'/'/'=' '~ If yes, give date /"/~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot '~'oo~
Surface water
Curtain drain
To building foundation
On adjacent lots
On adjacent lots '~)~ Property line
~c~ ~'~'~ To existing or abandoned system on lot
Cutbank ~ / A~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA g,
Signature
Engineer's Name
Date
S & S ENGINEERING
17034 Eagle River Loop Road No. 2_0~
Eagle River, Alaska 99577
HAA Fee $ / 7
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91 ) Back MOA 21
,~4UNICIPALITY OF ANCHORAGE
~ DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HE~TH
DEPAR'Z~NT OF HEALTH A~ ENVIRONMENTAL PROTECTZONr. iii/ 2 6 1984
AJ~PLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE~
1. General Information Application Dat~E~y~/~L
(a) Legal. Description (include lot, block, subdivision, section, to%mship, range)
Location (add}gs~or d~ections)
(b) Applicants Name C~/:~/%1 ~, O/-/)~,}/--~lephone - Home 'Business
Applicants Address fy~_ ~)oX //? ~/~.~/g~-~f Z._~¢%~
(c)Applicant is (check one) Lending Institution ~ ; ~er/builder.~ ;
Buyer ~ ; Other ~ (~plain);
(e) Real Estate Co. & Agent a~ C~& :f~
(f) Mail the HAA to the following address:
Type of Residence
Single-Family~
Number of Bedrooms
Multi-Family~--~
Other (describe)
3. Water Supp1z-
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.
' 0nsite~ Public ~ - Community ~, Holding Tank~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to th~ legality and status.
[Page 1 of 2]
5. Engineering Firm Providing Inspections~ Tests, File Search~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that'the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein° I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm~9 ~ ~ ET~I!~P~M~
Address
Date
DHEP Approval
Approved for__.~ bedrooms
Approved ~ Disapproved
Terms of Conditional Approval
Telephone
· . ~.~ ~, ~...~ ~
Cond~tSon~
CAUTION
%HE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFES~IONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES ~ND
THEIR~LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE tLEQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
ae
MUNICIPALITY OF kNCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCHORAG~
DEPT· OF HEALTH &
ENVIRONMENTAL PROTECTION
Jill 26 ' 984
RECE[VE
Well Classification
Well Log P~esent (Y/N)
Total Dept~.
Static Water Level
A
Cased to
Pump Set At
Casing HeightAbove Ground
If A, B, c~ C, D.E.Co Approve~(_(__Y~N)
Date Completed Yield
Depth of Grouting
Sanitary Seal on Casing (Y/N)
Eledt~ical _W~ring in Conduit (Y/N! :' I / Depression A~ound Wellhead (Y/N)
Separation Distances f~om Well: .-
TO Nearest Edge of AbS0~ption Field'on"E~ ~)6) (7~ ; On Ad]olnlng Lots
To Nearest Public Sewer Line
Cleancut/Manhole ~
Water Sample Collected By'
Water Sample Test P~sults
TO Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
C~t~t~nts
Bo
SEPTIC~N~ TANK DATA
Date Installed ¢/7/~ Size /~9~ No. of Ccmpartm~nts
Standpipes~N); '-- Air-tight Caps ~/N) Foundation Cleanout (YA~
DePression ove~ Tank (Y&~J~ Date __I~.stL~e~ d ?/~-~/~¢
Pumping/Maintenance Contract on File (Y~N)'~/~ ; for - ' '
Holding Tank High-Water Alarm (Y/N) 7/¢ Temporary Holding Tank Permit (Y/N)//4
Separation Distances f~om Septic~ Tank:
TO Building Foundation ~ /~
To Disposal Field ~ !
TO Stream, Pond, Lake, c~ Major D~ainage
To Wate=-Supply Well
To Property Line
To Water Main/S~rvice Line
Course
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Pating in AbsorptiDn ~t~ata
Date Installed
Width of Field
Date of Last Adequacy Test
Square Fee% of AbsorptionArea
Depression over Field
Results of ~st Adequacy Test
/
Separation Distanc~ f~omAbsorption~_m~Fiel~:
/
To To
Length of Field ~3 ~
Depth of Field ~--0 /
Gravel Bed Thickness ~_ /~
Standpipes P~esent ~/N)
To Building~oundation ~ /~ To Existing Or Abandoned System cn
Lot /~/~ ; On Adjoining Lots 3~
To Water Main/Service Line J~ b To Cutbank{if present)
To Stream/Pond/Lake/o~ Major Drainage Course
To Driveway, Parkin~ A~ea, or Vehicle Sto~age A~ea /c"~ /~
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested fo~
Electrical Codes(Y/N)
Comments
Dimensions
. Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
du~ing Adequacy Test.
Meets MOA
Company ~'~'
KB1/d5/s
** Check Permitted Bedroom Rating Against HAA Request **
I c~rtify that I have checked, verified, o~ confo~ed to all MOA
on the date of this inspection.. 'Date
/
[Page 2 of 2]
2-15-84
Time Time .he
Date Date Date
Inspector Inspector Inspector
Comments Conditional Approval
Date Sswer installed Permit No. Septic Tank Size
~ ~ ~. Holding Tank Size
Soils Rating Well To Absorption Area Well Log Received
Well to Tank
APPLICANT FILLS OUT LOWER HALF ONLY
Property Owner ~ & ~ Co~s~ac~o~ Phone
Mailing Address ~ox 252~ ~a~me~ ~ 99645 745-273~
Buyer Patricia J. & Clifton M. Olmstead
Address 3129 Lockwood C~e~Anchorage, AM 99504
Lending lnstitution Alamka Pacific Ba~k Phone
Address 101 W. Benson Blvd, Anchorage, AK 99503 276-3110
Realty Co. & Agent Totem Realty, Inc./William J. Schlegel ~- Phone
Address 724 E. tSth Avenue, A~chorage, AK 99501 272-0571
LegaIDescription Lot 12, Blk 4, T~umderbird Heights
Street Location Teal Loop
Type of Residence
~ Single Family
_ ~ ~ultiple Family No. 0f Bedrooms 3
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A'well log is required for all wells drilled since Juhe
~ Community 1975. For wells drilled prior to that date, g;ve well depth (attach ~g if
~ Publio Utilit~ available.)
Sewage Disposal
. ~ Individua~ Year Individual Installed: ~982 .
~ Public Utility When Connected to Public Utility:
~ Holdin~ Tank
. N~TE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.