HomeMy WebLinkAboutTURNAGAIN BLK 1 LT 1 S100'123
/0
i-'% MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska §9501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAILING ADDRESS
LEGAL DESCRIPTIQN
~ /Oo~
LOCATION
' O O F HOMEMADE:
Well
DISTANCE TO:
Absorption area
PHONE [~rg EW
~i~---D'Fq I [] UPGRADE
DISTANCE TO:
No. of lines
/
NO. OFBEDROOMS
PERMIT NO.
No, of compartments
Liquid depth
Total length of lines
Material beneath tile
Inside length
Dwelling PERMIT NO,
Material Liquid capacity in gallons
Well/~/~ Foundation L I Nearest lot line PERMIT~D'N~"S
Length of each ne Distance between lines
~/,~
Top of tile to finish~a~e
Width
Length
Type of crib
Depth
Crib diameter Crib depth
Well Building foundation
DISTANCE TO:
Depth Driller
DISTANCE TO: Building foundation Sewer line
Trench width
+ .~O inches
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
Total effective absorption area
PERMIT NO.
Total effective absorption area
Nearest lot line
Septic tank Absorption area(s)
Distance to lot line PERMIT NO,
OTHER
REMARI<S
APPROVE DATE~ LEGAC~
72-013 IRev. 3/78}
~ ' ONMENTRL , /:OTECTION ~
. E:'EF'RRT~]E~T' HEALTH AND EN"/~
PERMIT t4J ( 82:8Z42~"
HFFLI_.HNr CHRRLES H =M,¢LII[~I ~RR B0;:.~ 908 D9502
LOCRTION SINGLE F~MILM DNELLING
LEGRL 9!00" L&E:Z TLIRN~GRIN L0T SIZE 999999
'=- - ":' '' - IS:
TYF'E OF ..,uIL HB_uRFTIUN GYSTEM TRENCH
tJH,',IItUft NUME:ER OF BEDROGM9 3: :,JIL RATING ,::%Q FT/'BR)=
THE REQUIRED SIZE OF THE SOIL 8BSORF'TION SYSTEM IS:
[:,E F'T K4 = ~2 LE~-~I3TH= 27- ~3RR %.'E L [:.E F" TH =
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 SURFRCE OF THE
GROUND RND 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 EXCRVRTION (IN FEET).
F-:EL---!LI :~ RE[t-, 5EF"T ][ C: T F-! ~'-&F---: '_--] I ZE= 1.~]-~E~ £~ GRLLOI'-~-c-,
PERIdIT APPLICANT HAS THE RESPONSIBILITY TO iNFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF RNY WELLS ADJRCENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TL4C, (2) ~ ~-~_C.F'EC:TZC,~--c- RF:E F:E~2~IJZ F:E[:.
BACKFILLING OF ANY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEPARTMENT WILL DE SUBJECT TO PROSECUTION.
blINIMUM DISTANCE BETWEEN A WELL AND RNY ON-SITE sEWRGE DISPOSAL SYSTEM IS
±00 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.
HELL LOGS RRE REQUIRED AND MUST BE RETURNED TO THE [:,EPRRTMENT WITHIN ~0 [:,ASS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIAGRAMS RRE
AVAILABLE TO INSURE PROPER INSTRLLATION.
F'E F-.' f-1 Z ]- E::-::F" I F~:E$ [:,EE:Ef4E:EF: --==:1.. t9,~2J----::
t CERTIFY THRT
t: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPFtLITY OF RNCHORAGE.
2: I HILL INSTRLL THE SYSTEM IN ACCORDANCE ~.~ITH THE CODES.
]:: I UNDERSTAND THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ]: BEDROOMS.
,= .... c~ ~ "~ ~ ............
_, I bNE[-' .............................
RPPLICANT C~RLES W SAVOINI
I=,=,UE[. BY ......................................... ',,,'4. 0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99§01 264-4720
SOILS LOG - PERCOLATION TEST
XSOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17,
18-
2225-E
20 - 25. 1971
COMMENTS
DATE PERFORMED:
SLOPE SITE PLAN
WAS GROUND WATER~[~1~ S
ENCOUNTERED? ~}
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
,(minutes/inch) '
TEST RUN BETWEEN FT AND -- FT
PERFORMED BY: ~~~d~ CERTIFIED BY:
72-008 (6/79)
POtJCH 6-650
ANOlflORAGE, /d ASK/", !-if,; ':';
(907) 26.'1-4 I I 1
DEPARTMENT OF HEALTH AND ENVIRONMEN rAL ?[~OTEC lION
January 4, 1982
Charles Savoni
SRA Box 908
Anchorage, AK
99507
Permit ~ 810493
Subject: S100 of L 1.B 1 Turnagin SB
A permit issued by this department for a well and/or sewer
system has expired as of December 31, 1981.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent to
this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for our
files.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Sewer and Water Program
Enclosure: Copy of Permit
L~ ]'-.[ -- .-. :I TE
PERMIT NO. ,' 8±0493 ',
FIF'PL I CFINT
LOCF!T 1 ON
LEGFIL
'DEPFIRTMENT OF: HERLTH I-:NE:, ENVIRONMENTFIL PF:OTECTION
825 *L'" STREET., RNCHORRGE., FtK. 9950&
254-4720
..HII[~ L,_- SRVON I
MRTL"¢ Rk,'E OFF KLFtTT
S±000F L± B± TLFNRuIN .:,E,
B,.., '.¢0_
SRR ' ' '- '='
LOT =,I~E
079t.
'~,l..] U R R E FEET
T'¢PE OF .=,uIL FIBSORPTION =~_lEfl I=,. TRENCH
- , ., ,-~ ,,=' = - c:F~IL RFtTING ('-]FJ FT,. ~,F...- :L40
MR;:<IMUM NLIM6ER OF EE[.RUUfl_, e ...... 'F ")-'-
'THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
C, E F" T ~-t =: :;L2 LE~'-aLSTH,=.= 5~=- ~3 R !-~ '...' E L [:.EF'TI~=
THE LENGTH DIMENSION IS THE LENGTH (IN FEET.'.', OF TNE TRENCH OR DRRINFIEL, D,
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND FIND THE BOTTOM OF THE ENCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRMEL DEPTH IS TNE MINIMUM DEPTH OF GRRMEL BETWEEN THE OU'T'FRLL PIPE
RND TFIE BOTTOM OF THE ............. (IN FEET).
PERMIT RPPLICBNT HRS THE RESPONSIBILIT'¢ TO INFORM THIS DEPRRTMENT DURING THE
INSTRLLRTION INSPECTION% OF RN'¢ WELLS RDJRCENT TO THIS PROPERT'¢ RND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
........ - - - . ,.::1-. -- ~ .... F-" E L----.~ IL.It ][ .IF--: E [CE:,
E, HE. KFILLING OF FtN'¢ :,~_,TEM WITHOUT FINFtL IN_~FEL. TI.N RND RPPROVRL E,~' THIS
DEPFIRTMENT WILL BE _,UE, JEL. T TO FF..u=,EL-UTI-N.
MINIMUM DISTRNCE BETWEEN R WELL RND RN'¢ ON-SITE SEWRGE DISPOSRL S'¢STEM IS
· 00 FEE]' FOR R PRIVRTE WELL OR ±50 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING
UPON 'THE TYPE OF PUBLIC WELL.
MINIMUM DISTRNCE FROM R PRIVRTE WELL TO FI PRI',,,'RTE SEWER LINE IS 25 FEET RND
TO R COMMUNIT'¢ SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MR'¢ RPPL'¢. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
FI',,,'RILRBLE TO INSURE PROPER INSTRLLRTION.
I _.EFTIF TFIRT
'- ' :' ' '- H_, _,ET
±: I FIM FBMILIFIR WITH THE REL.]UIREMENTS FOR ON-SITE .:,EWER_, 8ND WELL--, :': ':
FORTH B'¢ THE MIJN!CIF'~L!T'¢ OF BNCHORRGE.
~°'. I 1.4ILL ~N_,TBLL THE _,~_,TEM IN BCCORD~NCE WITH THE L. OCE_,.
- --c :,T_.,TEM M~N'
3: I UN[:,ERSTFIND TFIBT THE uH _ITE SEWER '-'": REQI_IIRE EM_BRGEMENT IF THE
RESIDENC:E !S REMO[:,ELE[:' TO INCLIJE:,E MORE THR[~ ~[:,RO0,MS. f~1 ~
RFFLICRNT CHRRLEE :R,]NI ~
'CONSTRUCTiOIxl AND OPERATION ,._.i::RllJ' CATE
ALASKA DEPARTMENT OF ENVIRONMENTAL 30NSEaVATION
PUDLIC WA1-ER SYSTEM
':' (onditionalty approved /¢~*-'~" ?J t ached conditions).
.1., no~ slaJted within two yems of the a!)p~oval (lab;, this (e~ti[icate is w~id and new
plans and spemfications must be submitted for review and apt>r,aval ,r , , ~, ,- ,
I ' , ~, Approvc'd bt Da le
/e "APPR()V,':,I ~O tJPEF,t\qL section must
il' e publ lc.
~ he consti'uction of the public
.,gte~ sS, s(em was completed on .................................
~ant~xJ interim apl;royal to operate fo~
, MUNICIPALITY OF ANCHORAG
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
GENERAL INFORMATION
(al
lb)
(c)
Lega Descr pt on (include lot, block subdivision, section, township, range)
Location (address or directions/
Applicant Address ~O_ ~0~ ~O~S ~
Applicant is (check one): Lending Institution ~; Owner/b'x~d~' ~; Buyer ~: Other ~ (explain);
(d) Lending nstitution (-~.'~-~'~ . L,]~__,¢"[ J"'I¢¢¢¢~_ Telephone
Address ~ ~ ,./. [4 '
(e)
Real
Estate
Company
and
Agent
£
Address
Telephone
(f) Mail the HAA to the following address:
-TYPE OF RESIDENCE
Single-Family/~ Multi-Family []
Number of Bedrooms ,~
Other
WATER SUPPLY ' '; :.-
Individual Well'~ Community [] Public [] ·"
Note; If community well system, must have written confirmation from the State Department of Environmental Conservation
attesbng to the legality anu status.
SEWAGE DISPOSAL ~'
Onsite~' Public [] ' Community [] Holding Tank []
Note:~'lf community well system, must have written confirmation from the State Department of Enwror~mental Conservation
attesting to the legality ano status· .
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM. PROVIDIh~'i INSPECTIONS,~TESTS,.FILE SEARCH, DAiA AND INFORMATION
As-certified by my seal affixed hereto'and as of the val~dahon date shown below, I verify that my r nvest;gahon 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 flies and from my investigation and inspection, the on-site water auppry and/or
wastewater disposal system is n compliance ~ith all Munici pal and State codes, ordinances, and regulations in effect on
the date of th s nsP~bton - '.' 1.-~.-~ ~-,:' ' ;..;.}:i:.;,: ~,,~,:~:. ,~-::.:. : ..'.~ ,; .
Name of F rm ? ¢.',Telephone i! -- · ¢ ·
Engineer's Seal
DHEP APPROVAL , ,
Approved for ~'~g'~'(~}bedrooms by
Approved' ~ ' Disapproved
Terms of Conditional Approval
Conditional
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 DEEP do no[ 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'.,
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Descript on'
Well Classification
Well Log Present (Y/N)
Total Depth .~/~ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
If A, B, C, D.E.C. Approved (Y/N) ¢~_ ./~_~ ~"
Date Completed ~/_~¢/~,~ Yield '~~//)
. /- /~-
Depth of Grouting .~
Pump Set At ~
Sanitary Seal on Casing (Y/N) ~
Depression Around Wellhead (WN) ~
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Mar~hole /~L¢~
Water Sample Collected by ~
Water Sample Test Results
Comments z'~:~v~'~ ~ /-' ~,,~,;/~-"¢?
-/
; On Adjoining Lots '~,,'/~¢
/'/':'~_~ ; On Adjoining Lots %/h[,)
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~/~
Date ~ ¢-/~ ~
B. SEPTIC/HOLDING TANK DATA
Date Installed /"~.,~?x~
Standpipes (Y/N) ~ ~'
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) /~'/~'-
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line >' [0
Course
Size ,/¢~ No. of Compartments
Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N)
/y Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page i of 2
72~026(~1/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /y¢~
Width of Field ,..~ (.)~l
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
57?
Separation Distance from Absorption FielO:
To Water-Supply Well
To Building Foun, d/ation __
Lot ! .Y~.d~'
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments _/~:¢ .~'~_¢, ,~ ,.'
Type of System Design
Length of Field ~,'~/ / ~',--~'
Depth of Field /'C'~
Gravel Bed Thickness 2/
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To/Cutbank (if present)
D. LIFT STATION
Date Installed //~/¢JV~'~
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 thot I hav,~.checked, verified, J;;~conformed to all~MO~A end HAA guidelines in effect on the date of this inspection,
Signed ~: ~ Date ~/~/~1~,~
/
Company MOA No.
Receipt No. ~
Date of Payment
~, ~ , ,
Amount:$ ~ ~ ~.4~TI~ ~...~ '.~, Engineer's Seal
Page 2 of 2 ~O~.
CON'SULTING ENGINEER ~ ~ ~ ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
RESIDENTIAL WELL INSPECTION
LEGAL:
LOCATION:
OWNER:
TYPE OF WELL:
WELL LOG AVAILABLE:
S 100' LOT 1, BLOCK 1,
11501 CORNELIA
DEBBIE STRUTZ
SINGLE FAMILY
YES
INSTALLATION REQUIREMENTS MET: YES
WELL YIELD FROM WELL LOG: 40 GPM.
PUMP YIELD:
DATE OF INSPECTION:
TEST PROCEDURE:
TURNAGAIN
5 GPM.
JULY 2, 1986
WELL WAS PU PED AT A CONSTANT RATB
GALLONS PER MINUTE WHILE THE DRAWDOWN ~WT~S
MONITORED WITH AN ACOUSTIC PROBE. THE WELL WAS PUMPED TILL THE
DRAWDOWN STABILIZED. STATIC WATER LEVEL WAS FOUND AT 170 FEET
BELOW TOP OF CASING.AT A PUMPING RATE OF 5 GPM. WATER LEVEL
STABILIZED AT 188 FEET AFTER 30 MINUTES OF PUMPING. THE WELL WAS
PUMPED FOR AN ADDITIONAL 30 MINUTES WITHOUT ANY FURTHER DRAWDOWN.
WELL RECOVERED TO 171 FEET WHITIN 10 MINUTES AFTER FLOW STOPPED.
TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM BACTERIA ON
JULY 4, 1986. TEST WAS NEGATIVE.
TEST RESULT:
THIS WELL MEETS THE REQUIREMENTS OF THE
MUNICIPALITY OF ANCHORAGE.
The Municipal requirement for well flow is 150 gallons of water
per bedroom per 24 hours.This well surpasses this requirement.
The assessment of the condition of this well applies only to the
conditions as of this date. The flow rate of the well may change
due to subsurface conditions that may not be observed from the
surface, and changes in land use and other factors that may
impact~n~,:bb~.tions of the aquifer feeding the well.
.... ~-o. ..... .~.-,, ~. ~
· ~'.' A .~ ~
CONSULTING ENGINEER TELEPHONE: (907) 279-3916
SEPTIC SYSTEM ADEQUACY TEST
LEGAL: S 100' OF LOT 1, BLOCK 1, TURNAGAIN
LOCATION:
11501 CORNELIA
OWNER:
DEBBIE STRUTZ
RESIDENCE:
SINGLE FAMILY, THREE BEDROOMS
SEPTIC SYSTEM:
FROM MUNICIPAL RECORDS:
TANK: GREER STEEL, TWO COMP. 1000 GAL.
ABSORPTION SYSTEM: TRENCH
ABSORPTION AREA: 512 SQ. FT.
SOIL RATING: 140
INSTALLATION DATE: OCTOBER 1983
DATE OF PUMPING: JULY 3, 1986. ANCHORAGE CESSPOOL PUMPING
DATE OF TEST: JULY 2, 1986
TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED. TANK WAS FOUND
WITH 7 FEET OF COVER. LIQUID DEPTH WAS 50.5
INCHES. TRENCH MONITORING TUBE WAS FOUND 12 FEET DEEP WITH 5 FEET
OF LIQUID.
WATER WAS ADDED TO THE TRENCH AT A CONSTANT RATE OF 5 GALLONS PER
MINUTE. THE WATER LEVELS IN TANK AND SUMP WERE MONITORED. A TOTAL
OF 300 GALLONS AS ADDED. THE WATER LEVEL IN THE TRENCH ROSE 3
INCHES TANK LEVEL ROSE 1 INCH. WITHIN 10 MINUTES AFTER THE WATER
WAS SHUT OFF THE WATER LEVELS WERE BACK TO THOSE AT THE BEGINNING
OF THE TEST.
TEST RESULT:
THIS SYSTEM MEETS THE CODE REQUIREMENTS OF
THE MUNICIPALITY OF ANCHORAGE.
The operational life of all septic systems depends on the local
soil conditions, groundwater levels that may fluctuate during the
year, and the water usage of the family being served by the
system. These conditions are outside the control of the evaluator
of this septic system. We can therefore not give any estimate of
how long the system will continue to meet the operational requi-
rements of the Municipality and State.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONiVtENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-,3720
/~'~ I ¥ ! '~ ~ 5
Application
Date
t
GENERAL IN'FORtV]ATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
~ $1oo~ ~,~ ~_oT_!,g~l_, q-'or~zA~,/4-~
Location (address or directions)
Applioanl Name ~k ~1~ J Telephone: Home ~/ [~ Business
Applicant Address Il ~0 I Co ~N~ ~J~
Applicant is (check one): Lending Institution ~; Owner/b~ ~; Buyer ~; Other ~ (explain);
(d) Lending Institution }'~ ~ 1~4, ~
Address
TeJephone
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~i~ Multi-Family []
Number of Bedrooms__ ~
Other
WATER SUPPLV
Individual Weli~ 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,J~ Public [] Community [] Holding Tank []
Note:('''^If corem unity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status. [
72-025 (11i84)
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 ail Municipal and State codes, ordinances, and regulations in effect on
the date of this
~lame of Firm
Address
Date
Telephone
Engineer's Seal
DHEP APPROVAL y~/~.~t
Approved fo~'~-~--~¢-~::~ bedrooms b e
Approved ~.'~__ Disapprove~" 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 o[ 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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~ ~f'~'
Well Classifi'cation ~'~ ~: '~
Well Log Present (Y/N) ~
Total Depth ~/O Cased to
Static Water Level / ~'('~
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Ii A, B, C, DiE.C. Approved (Y/N)
Date Completed 8 --,~-O-- ~ '~ Yield
~ /O ' Depth of Grouting
Pump .Set At ~.e
/~, ~ Sanit~iry Seal on Casing (Y/N) ~/'
/~/ Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments::~ .,,~,.,¢,"f~ f,,'~,~44~.~ ,~2
; On Adjoining Lots ,,~ /~'~
/~-,~ ; On Adjoining Lots '~/~
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ~[ ~
; Dat r
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) ~ c¢'¢.~ Air-tight Caps (Y/N)
Depression over Tank (Y/N) ~
Pumping/Maintenance Contract on File (Y/N) ~'//A
Holding Tank High-Water Alarm (Y/N) '~///'A
Separation Distances from Septic/Holding Tank:
Size /~ NO. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped ~/~
;for
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line
To WaCer Main/Service Line
Course
To Building Foundation ~ ¢ ~
To Disposal Field ~ ~
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
Date Installed ~)~_. 7-'-
tf
Width of Field
Square Feet of Absorption Area -~/r~
Depression over Field (Y/N) ~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well /,¢~- ~
To Building Foundation ~2~
Lot ~ 0 N '~
TO Water Main/Service Line ~> / O
To Stream/Pond/Lake/or Major Drainage Course
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N) K
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~'4' L2 ~LI ACFJ¢!/-T.S
LIFT STATION N ON ~
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
Page 2 of 2
72 026 (11/84)
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verifie¢~ or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed "~. G,~d~.~ ',~, Date
Company_ %..~z./~ MOANo."~O~-O[/_,.
Receipt No. ~.~ ~ ~-~
Date
of
Payment
Amount:$ 45.{~ ~"~' :;7$Yi/~ ~ Engineer's Seal
,LI(?'""~'NT FILLS OUT UPPER HAI":ONLY
' : :! Phone
, __~:~z~_n, >. - ~ .
Water Supply ~~~~ ~
~ Individual Year Individual Installed: / ~, %
Time ~ i lille
Date Date Date Date /
Inspector Inspector Inspector Inspector
Field Notes: ~ ~ ~. (~~../ MUNICIPALITY OF ANCHORAGb
ENVIRONM~NTAL pEOTEGTiON
gECEiV_ED.
(~APP~OVED BEDROOMS ~GONDITION8 OF APPROVAL
( ) DISAPPROVED
( ) GONDITIONAL APPROVAL'
BY:
Well TO Absorption Ar ~ Well Log Received
Soils Rating Date ~wer Installed