HomeMy WebLinkAboutT13N R1E SEC 10 NE4NW4NW4SW4
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
[] UPGRADE
LEGAL DESCRIPTION
LOCATIONk-~/~--d /O / ~l~/ ~/~ NEb UW~ NW~ SWh NO. OFBEDROOMSj
Dwelling
Well ; ~ Absorption area PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
[ DISTANCE TO: //~ ~ //Y ' Trench widt~~ Distan
~.~ [ ' No. of lines Length of each line ' Total tength of lines . c~
Total effective ab rption rea
,' Top of tile ,o finish grade ¢, Mateda] beneath'tile____~ inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib Total effective absorption area
~ Well Building foZndation Nearest lot llne
~ DISTANCE TO:
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
REMARKS ~
~ 8~B 198X
72-013 (Rev. 3/78)
MUNtr C I PAL I T'~¢ OFr ANC~-~ORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE~ AK 99501
264-472()
F'ERMIT NO: 840610
DATE ISSUED: 07/25/84
SEWER & ~4ELL F"Ef-i:M I T'
qPPL I CANT:
ADDRESS:
CONTACT PHONE:
CHUCK BARR
% S&S ENGINEERING
EAGLE RIVER, AK 99577
694-2979
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
SUBDIVISION: NA LOT: NA
SECTION: 10 TOWNSHIP: 15N RANGE: 1E
2.5A (GQ. FT. OR ACRES)
3
BLOCK: NA
Listed below are the options avaiIable to you in designing your septic
system. Choose the option that best fits your site.
TREI4~CH BED ~ ~ DRA
DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0
GRAVEL DEPTH (FT.) 6.0 0.5 3.5
TOTAL DEPTH (FT.) 10.0 4.5 7.5
GRAVEL WIDTH (FT.) 2.5 19.0 5.0
GRAVEL LENGTH (FT.) .38.0 36.0 49.0
GRAVEL VOLUME (CU.YDS.> 22.8 25.3 36.-2'
TANK SIZE (GALS) 1~000.0 .~ 1~000.0 ~ 1,000.0 ~'~
SOIL RATING (GQ.FT. /BR) 150 150 150
~'~. TANK MUST HAVE AT LEAST TWO COMPARTIdENTS
certify that:
1. I am familiar
3.
with the requirements For on-site sewers and wells as.set.
forth by the Municipality o~ Anchorage (MOA) and the State of Alaska.
I will install the system in accordance with ali MOA codes and regulations
and in compliance with the design criteria oF this permit..
I will adhere to all MOA and State Of Alaska requirements For the set back
distances' From any existing well, wastewater disposal~ system or public
sewerage system on this or any adjacent or nearby lot..
I understand that this permit is valid ~or a maximum oF 3 bedrooms and
any enlargemeot will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
]'HEN (1) AN ELECTRICA~MIT AND INSPECTION MUST BE OBTAINED; (2) OS-BUILTS
si G NED DATE, '¢
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~ SOILS 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
19
20
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
O
P
E
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION R ATE ~' ~'~ (minutes/inch)
TEST RUN BETWEEN FT AND -- FT
COMMENTS
PERFORMED BY: /~'V CERTI FI ED BY:
DATE:,
72-008 (6/79)
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
Parcel I.D. 05-0 -°J ~'1 -0 ~
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
HAA# OM
GENERAL INFORMATION
Complete legal description NE4:
Location (site address or directions)
Expiration Date: ~- I- (~) ~
NW4: NW4:~Sec 10: T13N: R1E
32909 Cumulus Rd.
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Billie Kehr
same
Day phone 696-1911
Day phone
e
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 3
Day phone
TYPE OF WATER SUPPLY: '
Individual Well 3[~]
Individual Water Storage I-I
Community Class __ Well I--]
Public Water System I--I
TYPE OF WASTEWATER DISPOSAL:
'Individual Omsite
Individual Holding tank []
Community On-site []
Public Sewer r'-I
I
The Municipality of Anchorage Development Services Department (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 pdvate or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a pedod 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,
Phone 6q/4-2q70
20/* Ea?le River, AK 99577 ,~
Date 5"/"x-~/o '/'
_-.,,.. ~,, ; ......... :.'_~,~
~'~ \,:,.,"
~ ~9 .-' iA -',. 'IL.'A.
P. :. · .:.
;.. .... ....
%% '4"'." '~'-:,.-. ,.~' ,,.. %.
"'k'4'c ;4 ?,:~7--~' .'
bedrooms, with the following stipulations:
and regulations in effect at the time of installation.
NameofFirm $ ~ .q ~..5~.,,,.,-~,~E
Address 1_703/, ~. Ea~].e Eiver Loop Ste.
Engineer's Printed Name Robert: C. Cowan
bedrooms.
DSD SIGNATURE
~' Approved for ~
· Disapproved.
Conditional approv_a.I for
Additional Comments
Attachments:
HAA Checklist
SePtic System Advisory
Well Flow Advisory.
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~'-' / - 0 Z/
(Rev. 01~2)
· wlumc~oalitv of
Anchorage
Development- "services Department
Building Safety Division
On:Site Water & Wastewater Program
4700 South Bragaw St.
P.O. B6x 1196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak:us'
-. (907) 343-7904
: ! HEALTH AUTHORITY APPROVAL CH'ECKLi~
Legal Des~'ription. A/. ,'/V~. ,
A, WELL DATA ::
;' .~:"rti~r i - - -
Well t~pe -?--~, ::- If A, B, or C provide PWSl D # ":"'
Date Completed/~ c~ ~
.... , .... . ary seal (Y/N) '7
: I ~; : ' ..:-cl3"'f- ' ' i : ,;+-
Total depth'U~' ft.-: : · cased to: ~r-O: ft
i I ii ' FROM wELLLO~;
Date o! testli' :
Static ~atl;i ;level
Well P'r~d~iion
WATER 'SAMPLE RESULTS:
Colifor'm 1'?~ ''
O colonies/100 mi.
Arsenic: I"T' mg./I.
B, SEPTIClHOEDING TANK DATA '
Tank TypeiMaterial"~j"~-~ C / ~'C-~*L..- ! :
Tanks. iz~!~ga'. !- ~'.?~;uml~erofC~r~partments ~"~
,'. 1+, I :~ :~ ,/ ~ '.~ '
Foundation Cleanout (Y/N) .~,'
.. =., .,.. ...-.,.-. ,: . ., ... .._.....,....,...
Date of pu~ ing
C. ABSORPTION FIELD DATA' ': .'~ ' '
Well:L:~g !(Y/N,
Wires proper!y Protected (Y/N) '"/ -
C'" ' 'i.:'l ,~: , 2../-
asing height (above ground) ( in.
AT INsPECflOiN!''
'' ~, ~'::~i, ' g.p.m.
6!her ba~teri~ ~ colonies/100 mi.-
Collected .by: "~',~..~,
ft." . Gravel belowpipe ~ ft
Total depth ,l~ ft. ;~Ef[.-ab~orption a~ea'~.~t~ :Monitoring tube ~ ' Dep~es'Sio~ over field ~'
ate of ade quacy test d/~ l~4 , Resuts(PasslFafl)~ : :'For 3
Elapsed T,r ,e ~Om,n.. . F,nalflu,dde thy~:~,n.' "' .... " ~ '~ Absorpt,on:?::~ ' ::~ Z
D. LIFT STATION
Size in gallons
Date installed//z)//,/~
"Pump on" level atT~_ in. "Pump off" !evel at ~
Datum // Cycles tested
/
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Manhole/Access (Y/N) '
septic iank/ili'[ stat;on on lot
Absorption field on lot
in.
On adjacer{t lots'
On adjacent lots'~
'High water alarm levelat ; '.! in.
Meets alarm & circuit requirements?
Public sewer main Public Sewer 'manhole/cleanout
~wg~-Tseplic service line ' ~- Holdingtank
SEPARATION DISTANCES FROM SEPTIC/~. TANK ~N LOT TO: -. :... ~!:. :i:~
Building foundation .z~ '+. . Property line ~'
Water main ~]/~- Water service line
Wells on adjacent lots /~L"P /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
4--
Property line / 0 /4--- Building foundation / 0 /
Water Service line / LO' (0(9 t
']--' Surface water 4'-
Curtain drain ~t,/c,U~K"A/,,-,,., ~J Wells on adjacent lots /'~ ~
Absorption field
Surface water
COMMENTS
ENGINEER'S CERTIFICATION
I certify tl~a~ I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name /~)O/~.,,z,~---
Date S-/~-
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/01)
waiver Fee $
5'-//~- '7/o 9" ; Date of Payment
Receipt Number
05/19/04 ~FED 12:10 FAX 0898499 VISTA REAL ESTATE ER ~002
ASBUILT
I HEREBY CERTIFY .THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
ND nAT HO ~.N~OAC,~ENTS EX~ST ~XCE.T AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS: COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDE~ SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOUU)
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
ARY LINES.
SEWARD &
SCALE:
'OR'ID: -,,
ASSOCIATES LAND SURVEYING 6 9 &- 0 8
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.#
1. GENERAL INFORMATION
Com plate legal description
Sec 10: T13N: R1E; NE¼; NW¼;~NW¼ ~%~%~
Location (site add tess or directions)
2410 Eagle River Road
Eagle River, AK
..p..ro~9-.owh-er,, Stuart Hirsh
Ma ng'address.' %9630 Basher Drive
....... bend lng' agency ....... ~,
~Mmhng address.: ~
' ;:/:~' 'Agent
Add ress
Anchoraqef
Day phone
AK 99507
Day phone
Day phone
564-4841
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individua well
Community well
Public water
NOTE:
ing to the legality and status o~ system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site ~
Holding tank '~
Community on-site
If community well system, provide written confirmation from State ADEC attest-
NOTE:
Public seWer ,
If community wastewater system, pr6vide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front ~OA#2'
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 Munici pality of Anchorage file~ 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 S & S ENGINEERING
17034 Eagle River t.oop R. oad I~o. '-'(~4 Phone ~'
Address Ea.qle River, Alaska 99~7.,
Engineer's signature ~YZ_ &~ Date
DHHS SIGNATURE
Approved for ,~
Disapproved.
Conditional approval for
bedrooms·
bedrooms, with the following stipulations:
Additional Comments
?., ~,'
The Municipality of Ar~horage 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
profees]onal engiH~er registered in the State of Alaska. The DHHS does this as a courtesy to purchasers :)f 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.
ENVIRONMENTAL BERVICE8
Municipali~ of Anchorage BAY 2 9 1997
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division ~ E C E J
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description: ~;~-.
A. WELL DATA
Well type
Log present (Y/{~
Total depth:
Sanitary seal ~YN)
Health Authority Approval Checklist
/,J eye' Parcel I.D.:
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Pe. to~. J
Cased to ~o 1 4- Casing height (above ground)
Wires properly i~r~{ected (~N)
FROM WELL LOG
Date of test
Static water level
Well production' '
WATER'SAMPLE RESULTS:
Coliform ~
Date of's~a~nple: ~ - 2.~
SEPTIc/HOLDiNG TANK DATA
Date installed -/-~l~U¢' Tanksize
g.p.m.
Nitrate
,~ooo
Collected by:
Other bacteria
S & $ ENGINEEEIN(~ "~
17034 Eagie I¢ive.r gaap
Eagle River, AI&sE~ 99577
Number of Compartments
High water alarm (Y/~).
Foundatioq,~cl,e~'no. ut.~/N): ~.~ E-s Depression
DateofCumping .Io/~6, r '' : ; Pumper '.,)J~
ABSORPTION FIELD DATA.
Date i'~s~t'ailed . '"/- -~] ' ~5~ ~ Soil rating (g.p.d./fF or f~
: ~ ~ Gravel thickness below pipe
Length Width ~ '%~ ~
Effective absorption area ~'~¢ Monitoring Tube present (~N) ¥~-~
Date of adequacy test ~ - ~o - ~J (,, Results (~Fail)
Fluid depth in absorption field before test (in.); (~
Fluid depth ~) (ins) Minutes later: C) ~'
Peroxide treatment (past 12 months) (Y/N)
Total depth
__ Depression over field (Y,~) __
For ~
Immediately after ~,C, gal. wateradded (in.):
Absorption rate = /"~OH .g.p.d.
~¢,%~¢ If yes, give date
System type
bedrooms
72-026 (Rev. 3/96)* ': ' : ·
D. LIFT STATION
Date installed Size in gallons ..
Manhole/Access (Y/N) ~"Pump off" level at*
High water, alarm level a~..--.----'-""~* , , *Datum ~ . _ =
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM.WELL ON LO,T TO:
L.S_~p~t-~i, holding tank on lot 1~2I
Absorption field on lot ~o 6~
On adjacent lots
On adjacent lets
Public sewer main 14/A Public sewer manhole/cleanout ~/~
Sewer/septic service line -, ,.~,~L+ Lift station /4 /A
SEPARATION DISTANCES FROI~ sE~oLDING TANK ON LOT TO:
Foundation lc, 14- Property line IO ~ + Absorption field ,.,5' I
Water main/service line lo 14- Surface water/drainage ~0o~4- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ) o~'4- Building foundation I o I..p Wa'(er main/service line Io I.f_
Surface water lo oIA Driveway, parking/vehicle storage area .~ I+.~
Curtain drain ~q/A Wells on adjacent lots )c,~ L+
CERTIFICATION
ENGINEER'S
I cert~ that I have determined thru field ~nspect¢ons and, rewew of Mumc~pal re~ ~t the a~¢b~s are
in conformance with MOA HAA gUideJines in effect on this date. ~ ~' '~ '~
Signature "/~ ~- ~/~
' '
_. , -, .
HAA Fee $_ ~
Date of Payment ~-i/:z~/~ 7
Receipt Number ,'2-~-(¢~;~ ~L--~//~ ~'~/'~ :~ "~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receip, t 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
Parcel I.D. # (~'?',(- ~,--~%\ - ( ')~
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) 7--~ I c~ ¢~-~-~, L~ ~--~,U ~ ~'~:~.
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
2. NUMBER oF BEDROOMS: '
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well -~ -~
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system,
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.
5. STATEMENT OF INSPECTION BY ENGINEER
Address
Engineer's signature
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and reguJations in effect on the date of this inspection.
.5 & $ ENGINEERING
Name of Firm ~.70'~4 1=~,91. i~v.~- L~p ~. ~ Phone ~ ~ ~ - ~I ~ ~
~le River, Alalka 9~577
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 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.
724)25 (Rev. 1/91) Back MOA #21
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: ¢6t/~, ~-' 'lq, ~ ~ t]q, ~ ,.t '['t Parcel 1.D.:
~. ~ ~.~ .... .
A. ~LL DATA
Well type
Log present (YI~
Total depth
If A, B. or C. attach ADEC letter. ADEC water system number
Date completed ~g~o~ ~
Cased to "~o ~ 4~ Casing height (above ground)
Sanitaw seal
Date Of test
Static water level
Well production
FROM WELL LOG
Wires properly protected
AT INSPECTION
g.p.m. ~ .ff'-
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed "/~1 CaotJ Tamk size
Fouudation cleanout~l~N)
.Date of Pumping
Nitrate /,'2-
Collected by:
Other bacteria
S & $ ENGINEERING
Eagle River, Alaska ~¢577
I e. om Number of Compartments 'Z-- Cleanouts~i~N) 7
Depression (Y~ ~ High water alarm ('~ ~
pumper
C: ABSORPTION vIELD,DATA
. Date installed '~ -- 3 I ~ ~ d[
Length ~ q~ ' Width
Effective absorption area ~ ~'0
Date of adequacy test. t~'~ o.~1
'~t~ uGravel thickness below pipe
Monitoring Tube presenl~N)
Resultsdi~il)
Fluid depth in absorption field before test (in.);
Fluid depth t9 (ins.) Minutes later:
Peroxide treatment (past 12 months) (Y/'~
~.L
Soil rating (g.p.d./fi2 or fl2/bdrm) ~'a, q/~'& System type
Total depth
Depression over field (Ytt~
For '~ bedrooms
Immediately after{.~50 gal. water added (in.):
~ Absorption rate q/~-O 4-
= g.p.d.
/~-~)o~J~3If yes, give date
D. Liirf STATION
Date installed
Size in gallons
Manhole/Access (Y/N) "Pamp oil" level ' *._g~
High water alarm level at* *Datum
~ted
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic se~ice line
; On adjacent lots
; On adjacent lots
Public sewer ~nanhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation lc>/V Property line ~to 14 Absorption field
Water main/service linc t.¢, vk Surface water/drainage ~c~,.~ ,.,t- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~, ~> ~ .k
Surface water \ ~ ~,
Curtain drain r~ [ p~
Water main/service lille \o t &
Driveway. parking/vehicle storage area ~
Wells on adjacent lots ~oc, ~'~ . Property line
F. ENGINEER'S CERTIFICATION
I cert~V that ! have determined thrufield inspections and review of Municipal records ~ff~-t~e~v~t~v~,~. are
in conJbrmance w/th MOA II~ gKidelines i~ effect on this date. ~, ~ ...............
............................................................................................... :-"e~:
OO '.'<. ........ .
HAAFc~ $ ~ ~0 WaiverSee$
Date of Payment ~'~/¢~-~¢ ~ ~ Date of Pay,nent
Receipt Number ~O 7 Receipt Number
Rev. 8/95 OSS: haa.wk.doc
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF NEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SiTE SEWER AND WATER FACILITY
264-4720
App cation Date~
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Loc~ion (address or directions)
Applicant Name F.'~
Applicant Address
Applicant is (check one): Lending institution []; Owner/builder []; Buyer []; Othe.~J~ (explain);
(d) Lending Institution ~J~c-~--~z-¢~¢f/ ¢.¢~¢~t~- - Telephone
Address ~ ~J~-~ ~ ~ /~ ~c-~. ~/(~ ~
(e} Ream Estate Company and Agent 2~.~ /~-~ /
TCephgne
(f) ~AA to the following address:
TYPE OF RESIDENCE
Single-Family"~ Multi-Family []
Number of Bedrooms J
Other
WATER SUPPLY
Individual Wel~/ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsiie~/ 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.
Page 1 of 2 72~025 ¢~,84)
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 regulations in effect on
the date of this inspection.
Name of Firm Telephone
Approved for ~'-/,~z~¢ edro ~
Approved J Disapproved/":~c~L~gAJ '(?'"~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
A. WELL DATA
Well Classificati~n,
Well Log Present (Y/~)
Total Depth ~./, K
static water Level
MuNiCIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720 NOlJD~,tO;~d 1V-[NgWNO~I,~j
Legal Descriptiop: ~
Casing Height Above Ground
Electrical Wiring in Condui~t ~.N)
Separation Distances from Well:
To Septic/l~ Tank on Lot
If A, B, C, D.E.C. Approved (Y/N)
Date Completed .i~C¢~_ I~.~' Yield
Cased to _ ~ ''~ Depth of Grouting
~ Pump Set At /¢ K,
~¢" Sanitary Seal on Casing CN)
Depression Aroupd Wellhead.(Y/~'
To Nearest Edge of Absorption Field on Lot ? OL~
To Nearest Public Sewer Line f'J//~
; On Adjoining Lots
On Adjoining Lots
To Nearest Public Sewer
Cleanout/Manhole ~J//,/l To Nearest Sewer Service Line on Lot
Water Sample Collected by .~ '~ ~ ~'-~(" ~ ~ I~Date ~ ~ ~
Water Sample Test Results ~ ~
Comments ~ ~ ~ ~ ~~ ~ t~L-
B. SEPTIC/I,14~-'BfN~ TANK DATA
Date Installed ~-~/
Standpipes~N)
Depression over Tank (Y,~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Ho!d~J Tank:
To Water-Supply Well /~
To Property Line ) ~ 1'4-
To Water ,M~r~r/Service.I]in~ . , O
Course
Size ¢'~ No.~)f Compartments ';Z-
Air-tight Caps4~N) Foundation Cleanout (~N) ~_
Date Last Pumped ,"'~/~=-~"J ~
¢~")/~ ; for
Temporary Holding Tank Permit (Y/N)
. To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments-..
Page 1 of 2
72-026(11184)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y~)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
Type of System Design
Length of Field ""~ "'"'"'"'"'""~
Depth of Field I ~
Gravel Bed Thickness ~7 'Z~ '~
Standpipes Present(~N)
Date of Last Adequacy Test ,/~..~
To Water-Supply Well
To Building Foundatioo
Lot
To Water ,Maffl'/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Property Line'
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) l'3//%
D, LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensiorfs '
Manhole/Access (Y/N)
p/"PumpOff"Levelat "'
/~ yent (Y/N) .
J ! ' 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 M CA and HAA g uidelines in effect on the date of this inspection.
Signed "~ ~'~ ~1~X:~'"~¢4 Date
Page 2 of 2
72-026 (11/84)
~--~ ,~; APPLI¢-~NT FILLS OUT UPPER HAP'~ ONLY
PropertY, Owner. ~_~_.~/.~,~/~. ~}_~ /30~j~~ ~y~ ~ Phone
Buyer
Address // Zip Code
mreet Locati~ _ ~ ~.~ ~ ~/~../~.~,~ ~ ~)
Type of Resi~nce
~ Other
Community For wePs drilled prior to that date, give weg depth (attach log if avaHable).
~ Public Utility
Sewer Disposal Year Individual Installed:
Individual
~ Public Utility When Connected to Public U~iity:
~ Holding Tank
Time Time Tirne Time
Date Date Date Date
Inspector Inspector Inspector: Insp~ct,~.r~
Field Notes: MuNICIpALITY OF ANCHORAGE
?/~.p~:,l.~;./,~- I ENVIRONMENTAL pROTECTION
t~AR 1 6 ~g83
( ) CONDITIONAL APPROVAL'
Soils Rating Date ~wer Installed Well TO Absorption Area~ / WelJ Log Received
72-023 (3/~)
~tarch 22, ].983
~dwa~c, and Donna }~,arrett
2410 Eagle River Road
Eagle River~ Ak 99577
.~J/4, Sect Township 13Nt RIE
Subject: NE~i, NWJ/II~ NW-I/4, "'" 10,
Approval for the individual sewer and water facilities cannot
be granted until the following items have been completed:
The top o[ the well casing s.~oul~ o~ sealed so that it is
water tight.
The well casing needs to be extended twelve (12) inches
3above 9round level.
The water analysis report needs to be submitted to this
<~. ~ ' review.
office from the Che~ Lab, 5633 B ~tr~.et, for onr
Expose the well for our isspection to determine proper
construction, also to insure minimum distance requirements
are met between the well and sewer system.
The septic tank pumped with a receipt submitted to this
department, The total number of gallons pumped needs to be
on the receipt and verified by a regis'~ered engineer as to
the actual number of gallons pumped. ~33his is to veriiy the
size of the septic task.
Locate and expose the cleanout to the seepage pit and/or
leaching area ~or our inspection, i~his is to insure the
minimum distance requirements are met between the well and
sewer system,
A four (4) inch cleanout needs to be installed to the se~--
tic tank.
Ed~;ard and Donl%a Barrett
1,1arch 22, 19°o3
Page 2
An adequacy test needs to De performed on the existing
leaching area. ?his test will determine if the system is
adequate according to National Standards° A listing of
private firms perforl~ing the test is enclosed. ~his report
needs to be submitted to this office ~or our review.
machine
to
be
Your "gray ~-~ater" from n~. waon~nt3
plumbed into the "sootic system". ~his material is to
treate~ as sex~age.
b~
Please notify this D~partment for a reinspection when tile
noted discrepancies have been corrected. II-; there are any
further questions~ please call this office at 26~-4720o
Sincerely,
Jli197/e j/E1
Enclosure
Jim Roberts
ssoczate Environmental