HomeMy WebLinkAboutVALLI VUE ESTATES #2 BLK 4 LT 6
Municipality of Anchorage Page [ of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: -,¢~...[~1 '~ ['Z....~ RID Number: ~ ~'~ ~
Name:' ~pgrade
~,0 ~ ~ ~~ ~. ~~ WastewaterSystem: BNew
Address:
~o. ~ tt~)~ ~c~ ~i~t} ABSORPTION FIELD
Phon~~ No.~edrooms: ~eepTrench B Shallow Trench BBed BMound BOther
LEGAL DESCRIPTION Soil Rating: ¢.~ GPD/Sq. Ft. Tota[Depthfromoriginalgr~d~:/
Lot: ~ Brock:~ ~tSubdivisi°n:~u~ ~ Depth to pipe bottom from original~gradej Ft. Grave[ depth beneath pipe ~
Township: ~ Range: I Section: Fill added above original grade: Gravel length:
Number of lines: I D[stance r~tween lines:
WELL: D New D Upgrade GraveJ~:~ ~/Ft. [ ~ ~ ~t.
Classification (Private. A,B,C): ~ / Total Depth: Cased To: Total absorption area~ ~ ~Q. F~. Pipe material: ~ lO ~
Drifter: ~ Date Drilled: StaticWater Level: InstalJer:
Date installed:
Y[eld: Pump Set at: J Casing Height Above Ground:
~.~ ~. ~.TANK
SEPARATION DISTANCES ~s~.~i~ ~ Ho~in. ~ S.T.E...
To Septic Absorption Lift Holding 'ublic/PrNate Manufacturer: Capacity in gallons:
From Tank Field Station Tank 'SewerLines ~C ~6 ~ 1~
Well ~ ~ ~ ~ ~,~ Material~~ NumberofC~a.ments:
Surface
w~t~ I~'+ I~'+ -- ~ ~ LIFT STATIO~
LineL°t ~/ I~' ~ ~ -- ~ Size in galIons:
CuHainDrain ~ ~e J~ ~ Q O~ J ~ ~ Pump Mabel Electrical Inspections peHormed by:
Remarks: OL~ T/Z~ ~~t BENCH MARK
Location and Description:
~CH~ T~, Assumed Elevation: ~
ENGINE~ SEAL
S & S ENGIN~RIN~ ~ ~Gv~ ~ ~
. , .
Inspections performed b :~oa4 ~.~ ....... Dates: 1st I~ ~
Y Eagle River, Alas~ ~-~',
~j ~ ~ ROGER J,~HAFE~
D parlment of Health $ervic approval ....
Reviewed and approved by: ://~
72-013 (1/91) MOA 25 ~
PermitNo. '~l,'~J~'¢~-~l'~'-- Page ~ of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Lega{Description: '"'~b'4:2~"t'/--" ~ ; ~ (~' PIDNo.:
72-013 A (2/95) MOA 25
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920312
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:ABRAMS DAVID E & SHIRLEY A
OWNER ADDRESS:P.O. BOX 111421
ANCHORAGE, AK 99511
DATE ISSUED: 9/29/92
EXPIRATION DATE: 9/29/93
PARCEL ID:01534149
LEGAL DESCRIPTION: VALLI VUE ESTATES #2 BLK 4 L
T 6
LOT SIZE: 20886 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
THIS IS THE REISSUANCE OF PERMIT SW910315 WHICH EXPIRES ON
THIS REPLACES PERMIT SW910315 WHICH EXPIRES ON 10/02/92.
THE SYSTEM MUST BE INSTALLED IN ACCORDANCE WITH THE APPROVED
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910315
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:ABRAMS DAVID E &
OWNER ADDRESS:PO BOX 111421
ANCHORAGE, AK 99511
DATE ISSUED:10/02/91
EXPIRATION DATE:10/02/92
PARCEL ID:01534149
LEGAL DESCRIPTION: VALLI VUE ESTATES #2 BLK
T 6
4 L
LOT SIZE: 20886 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD SYSTEM
ALL CONSTRUCTION MUST 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 FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: /~ ~ i~.~. ~_3~[j~;~
DATE:
DATE:
' /
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
CIVIL ENGINEERS
(907) 094-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
September 24, 1991
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
Anchorage, Alaska 99501
REFERENCE: Valli Vue Estates #2, Block 4, Lot 6
Request you issue a permit to upgrade the septic system
serving the referenced property.
An adequacy test was performed on the existing system and the
absorption capacity of the system was found to be less than
adequate.
A test hole was excavated and a percolation test performed in
the area of the proposed upgrade. Attached is the proposed
upgrade design.
Since the subdivision is served by a Class 'A' water system,
there are no protective well radii which encroach upon the
property. We do not anticipate any adverse effects on
neighboring properties by the installation of the proposed
septic upgrade.
If you have any questions or require additional information
for your review, please contact us.
Sincerely,
RJS/lsu
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
3--
4
5
6
7
8
9
10
11
12-
13-
14-
15-
16-
17
18
19
20
WAS GROUND WATER , ~
ENCOUNTERED? ~.~,
S
L
IF YES, AT WHAT 0
DEPTH? p
Monitoring?
E
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ll~) (minutes/inch) PERO HOLE DIAMETER ~'/2 //
TESTRUN BETWEEN (~¢ FTAND -~'~ FT
COMMENTS
S & S ENGINEERING
17034 Eagle R~ver Loop Road NO.~--
PERFORMED DY: Fn.l~ I~v~. At~eb~ Oa~ I ~ -~, [\/~"~ ~- CERTIFY THAT THiS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
GREA? R ANCHORAGE AREA BORC GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME "TJJ~,~-/~ ~T~-F~'~/-J'~'MAILING ADDRESS ~ ¢). /~ ~q 3~'~ /2~-~-/ PHONE
LOCATION ~/~- "~"//~' /~'*'~-~) LEGAL DESCRIPTION
SEPTIC TANK:
DISTANCE ¢ NUMBER OF
FROM WELl ~¢)~'] ~'~ . MANUFACTURER --~A/'£~z ' MATERIAL - /~//~F_~2(:~./'~-~ COMPARTMENTS
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
LIQUID CAPACITY/g:~(-~ GALLONS.
TILE DRAIN
DISTANCE FROM WELL ~'~ FOUNDATION
NEAREST LOT LINE
TOTAL LENGTH
OF LINES ~/
NUMBER OF LINES / DISTANCE BETWEEN LINES A/~ TRENCH WIDTH '~IN. TOTAL EFFECTIVE
ABSORPTION AREA z~d~ SQ. FT. LENGTH OF EACH LINE ! ~ "~ / /
/D~2"~' <~.~ '~/2~/~/-/ /~2./ DEPTH OF FILTER
DEPTH: TOP OF TILE TO FINISH GRADE /-/ / ~:~ !
MATERIAL BENEATH TILE ~ ABOVE TILE
WELL:
TYPE ~'/(~'~'~/~ CONSTRUCTION
BUILDING NEAREST
FOUNDATION__ LOT LINE
CESSPOOL OTHER SOURCES
APPROVED DISAPPROVED
NEAREST SEPTIC
SEWER LINE TANK
REMARKS
DEPTH
SEEPAGE
SYSTEM
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL: (~7--
~' P~_. ,~,~ ~_
LOT SLOPE:
REMARKS:
DIAGRAM OF SYSTEM
Form LQ-032
GrEATEr ANCHORAGE ArEA E~OROUgh
DEPARTMENT OF ENVIRONMENTAL QUALITY
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
I NSYALLATION LOCATION ~
INSTALLATION OF: ~EPTIC TANK
FINANCED THROUGH
COMPLETION DATE ANTICIPATED
PERMIT NO.
PIT ., DRAIN FIELD
TO BE INSTALLED bY
RIOTE~ THIB PERMIT IS NOT VALID WITHOUT BOIL TEST
FINAL INSPECTION: 24 HOUR NOT~CE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES, REOUIBEMENTS
SEPTIC TANK ~j I SEEPAGE PIT
DRAIN FIELD
DRAIN FIELD
WELL TO SEPTIC TANK
WATER MAIN TO SEPTIC TANK
f
DRAIN F"ELD /~
TO RiVER, LAKE, STREAM.
· SEEPAGE PIT
ALSO CONSIDER AREA WELLS.
SEEPAGE PiT
/Or> ~ D~A~N ~'~LD jot> /
DIAGRAM OF SYSTEM
CAST IRON INTO AND OUT Of SEPTIC TANK AND INTO CRiB CROSSING GAP OF
EXCAVATION 5 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PIT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
G~AVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
I CERTIFY THAT [ AM FAMILIAR WITH THE R]~QUIREMENTS OF GREATER ANCHORAGE A~EA BOROUGH ORDINANCE NO. 2~-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE W~TH SA~D CODE.
Test Hole 10
Lot t6, Block
Depth in Feet
From
0.0'
0.5'
To
0.5'
6.0'
6.0' 16.0'
Elevation:
Existing Ground
#17378
Soil Description
Vegetation, roots, some silt.
F-2, Silty Gravelly Sand, SM, gray
· damp, Group C.
NFS, Sandy Grave%, G~M, gray, damp,
trace of silt, Grou~ D.
Bottom of Test Hole:
Frost Line:
Free Water Level:
Sample
1
2
3
1.07
None
None
Type of
Depth M% Sample Group
5.0'- 6.0' Damp G C
8.0'- 9.0' Damp G D
15.0'-16.0' Damp G D
Remarks:
Type of Sample, G = Grab.
Group refers to similar material, this study only.
4040 "B" STREET,
ANCHORAGE, ALASKA 99503
PHONE: 907-279-2581
October 14, 1975
WO #17563
Mr. Dave Burlingham
Timber Enterprises ''
P.O. Box 3351
Anchorage, AK 99501
Subject: Percolation Rating for Soils on Lots
Block 4,.Valli-Vue Estates
5 and 6,
Dear Mr. Burlingham:
This letter is an addendum to our report, to you, dated
July 21, 1975. Enclosed with this letter are copies of the
test hole logs and soil gradation from~that report.
Using the Hazen emperical formula for permeability of fairly
uniform, cohesionless soils, the computed permeability of
the material, represented by the encl~ gradation, is 1.3
minutes/ inch. Because of the uncertainties involved in
using formulas to compute percolation rates, we suggest a
more conservative design value of 5 minutes/inch.
Utilizing the data published in Table A "AbsorPtion Area Re-
quirements for Individual Residences" on page 8, of the
"Manual of Septic Tank Practices" published by the.U.S.
Department of Health, Education, & Welfare, the required
absorption area, for such soils, is 125 square feet per
bedroom.
We hope this information is satisfactory to your present
needs. If we can provide clarification of the data pre-
sented, please do not hesitate to contact us.
· Very truly yours,
Melvin R. Nichols, C.E.
Laboratory Supervisor
MRN:rb
cc: Mr. Rolf Strickland, DEQ
g o o g
~o g g
o
0
April 15, 1980 R&M No. 051001'20
Jack ~ite Co.
3201C. Street
Anchorage, Alaska 99503
Attention: Joe Babka
Re: Adequacy Test on Existing Sanitary Sewer System; Lot 6~ Block 4~ Valley
View Estates, Anchorage Alaska. For Services Rendered through April 15,
1980.
Dear Mr. Babka:
The following is our invoice for professional services rendered on the above
ref&renced project.
Invoice No. 051001-20
Professional Services
Fixed Fee
Total Invoice No. 20
Please note our invoice ntunber on your
questions concerning this invoice, please
Ms. Janice Cecere.
Thank you:
R&~ CONSULTM~TS, INC.
C. J. Phrisena
Anchorage Office Manager
CJP/djj/I2-X
$175.00
$175.00
remittance. Should you have any
contact me or the Project }~anager~
April 15, 1980 R&MNo. 051001-20
Jack ~%ite Co.
3201C. Street
Anchorage, Alaska
99503
Attention: Joe Babka
Re: Adequacy Test on Existing Sanitary Sewer System; Lot 6, Block 4, Valley
View Estates, Anchorage, Alaska
Dear Mr. Babka:
Per your request of April 8, 1980, we conducted a test of the sanitary sewer
system on the above described property]
During this test the liquid level in the septic tank was monitored as water
was added to the system. The measurements are sunmmrized in the following
table:
Time
Liquid Level Below Top
of Standpipe
Total Gallons
Added
10:30 7.75
10:42 7.75
10:55 7.75
11:06 7.75
11:15 7.75
11:25 7.75
11:35 7.75
0
30
80
130
180
]80
180
The meter used during the test ~'as a Rockwell 5/8" standard water meter
had previously been calibrated by Rgffi Consultants Inc.
which
April 15, ]980
Jack White Co.
Page.-2-
If the 3 bedroom residence on the property is to house 6 people, the average
load on the system can be expected to be 450 gallons per day or .31 gallons
per minute. During the test, the system accepted 180 gallons in 45 minutes.
This indicates an average effluent acceptance rate of approximately 4 gallons
per minute at the time of the test.
Because the house on the lot is occupied, we assume that the leach field was
at its normal degree of saturation. We can therefore conclude that the
system is disposing of effluent at an adequate rate for a 3 bedroom resi-
dence.
We appreciate this opportunity to be of service to you. Please contsct us if
you have any questions concerning this test or if we can be of additional
service.
Very truly yours,
R&M CONSULTANTS, INC.
Ernest R. Rahaim
Staff Geologist
ERR/JC/dj/AT&SI-C
Parce D #
· 1: GENERALI
(Sit~ ~88resS 0r direction's)
Mailing address ~'~-~ 6P-~----~,~ '-~E=F-_ ~---~1.
Lending agency ~
. L:.Mailing address . '~
Address ~ '
Unless othe~ise requested, HAA will De held for pickup.
2. NUMBER OF BEDROOMS: ~ ~
. 3. TYPE OF WATER SUPPLY: ·
Individual well
Community well
Public water
Day phone ,¢O.z~ -~,~o
Day phone
Day phone
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WAS EWATER DISPOSAL.
· .'." "· "' Individual Or
Cpmmuni' , . ,.- ;~:' :,
POl:iiic Sev . :~..,.,.:: ,-::: ,.: :~- i ,. ' - .-i:: :..::' ~.'.: ·
mmur~ity Wastewate~'syst~m, p~ovide Writte~ ~Onfi~mation from state ADEC '
a~esting to the legality and ~tartus of s~stem. ~.
) Front MOAa21
STATEMENT,-'iOF INSPECTION BY,ENGINEER, '~"-;!. ·
As ce 'dried by my seal affixed hereto and ~s of the validati(~n date shown De,ow, I verify tlnat my
~nvestigatipr) of ~his Health .Authority Approyal ap~l~c.at~n' SHOWS that ~. onFsite,w~te.~- ~uBply
and/or ~astewa(~¢ discos'al s~stem is safe, fu'ncti~al ~nd a~Sq~'ate,fOr'th~ ~u~e(¢ b~d~0ms
an~ ~ype of structu re indicated her~ n. I fu~he¢.verify t~at B~se8 o.n t~e infermation' 0btain;eS.from
the.Mun cipality Cf Anchorage file~ and from my investigation and inspection .~he ~nrsffe'Water
supply and/or waCtewater disposal Sys~e'~ is in com¢l'ia~ce Wit~'all Mun'ic~ pal'a~d St~e co~es;
ordinances, and regulations in effect on'the date of th~ inspection.
DHHS SIGNATURE
///' Approved for 'Z'~l,
Disapproved
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given m paragraph 5 above by an independent
professional engineer registered in the State of A aska 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 eng~ neer's work,
RECEIVED
Municipality of Anchorage _/~Jl~,~
DEPARTMENT OF HEALTH & HUMAN SERVlCEBN 1 6 1998
Environmental Services Division MUNICIPALITY OF ANCHORAGE
825 LStreet, Room 502 · Anchorage, Alaska 9950'I~'N,,~TAEeD~A~'~'~&s
Health Authority Approval Checklist
Legal Description: ..T_ ~E ~,'~.,. ~.OT~", ~-,/4'/-// Parcel I.D.:
A. WELL DATA
Well type ¢~0.44,44~,1
Log present (Y/N)
Total depth
Sanitary seal (Y/N) J'~/,~-
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed /~///~'
Cased to JU///L Casing height (above ground) /~///~
Wires properly protected (Y/N) ,AJ//~
Date of test
Static water level
Well production
FROM WELL LOG AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate /'J/~ Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed lO I-~-I~:2-
Foundation cleanout ~/N)
Date of Pumpin~ ,'~ II;~'J~
Tank size ](~6/t'~ Number of Compartments c~ Cleanouts(~N) ~,,
Y.~ Depression (Y/~) ~-)o High water alarm ~/~
C. ABSORPTION FIELD DATA
Date installed [o/z~- [ ~ '1_ Soil rating~or ff2/bdrm) (~), c~ System type ~'~--~ ~
Length ~ ~' Width ~ ~ Gravel thickness below pipe ~ ~ Total depth / ~ ~
Effective absorption area ~O~ 3~ Monitoring Tube Present ~/N) ~ Depression overfield (Y/N) ~
Date of adequacy test ~/JbJ~ Results(Pass/Fail) ~ For ~~ bedrooms
~Fluid depth in absorption field before test (in.); ~ ~' · Immediately affer~0~ gal. water added (iL.): ~ [(
Fluid depth ~/~ (ins) Minutes later: ~/~ Absorption ra~e = ''~ ~'~ g.~.d.,, , ~'
Peroxide treatment (past12 months) (Y~ ~ ~ ryes, gi~6aate., ' ):".'~ '~'~ ~':~'
72-026 (Rev. 3/96)* ~ ~/~,¢ C~U~L ~/Z T~C~ ¢''¢ ~% C~
LIFT STATION
Date installed
Manhole/Access (Y/N) ~///~
High water alarm level at*
Cycles tested
"Pump on" level at*
*Datum
Size in gallons
/J/~ ,,Pump off" level at* /0/'~
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ~/~
Absorption field on lot ~d//~-
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation I Cb '4- Property line /0 "/- Absorption field
Water main/service line /O '-,~ Sudace water/drainage /OO ',,L Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Surface water
Curtain drain
ENGINEER'S CERTIFICATION
I cerlify that l h/aC~et~r~Cined/th/~ie~ inspections and revie'
in conformance wit~/t~/~,,~fllesin effecton this date.
/0 Building foundation / (~ + Water main/service line
/ (~6) "/- Driveway, parking/vehicle storage area
~h~O~-'~,-, Wells on adjacent lots
HAA Fee $.
Date of Payment '~/'~ ~/6~ (~
Receipt Number ~~' ~)~ 7(-/~ ~/oC" V Z ,)
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 rJot 6 Blk 4
Valli Vue ~2
Location (Site address or directions)
6243 Greentree Circle
Property owner
Mailing address
Lending agency
Mailing address
shirley Abrams
PO Box 111421 Anchorage, AK 99511
Day phone
907-277-4223
Day phone
Agent ' Sammy Boyd
Address c..~1 c]we] 1 Ran]~¢,r
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well
Community well XXX
Public water
NOTE:
4. TYPE OF WASTEWATER DISPOSAL:
Day phone 907L338-7768
Individual on-site
Holding tank '
' Communit~ on-site
----: :-:Public sewer
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
,,,"':.i
,,,, .~.'>'~ ; .... ,, ,, "L/ ,
,,' ~ ~ ~.- . :J .', . ~. ~
· '"',~ ' ;~ ~/:; ' '-'7
NOTE: If community wastewater system, provide written confirmation from State ADEC
' ' . . attesting to the legality and status of system. ~
72-O25{Rev. 1fgz) Front MOA~'~I
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 all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection..
NameofFirm s & S Rng~n~e~Hng Phone 694-?qTg
17034 Eagle River Loop, Suite 204, Eagle River, Alaska 99577
DHHS SIGNATURE
~/ Approved for '~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the folloWing stipulations:
Additional Comments
Date /,2 ~ ~' - ~")z~
· ,~,~,p' royal C~rtifiCat~.'S, IJase~ on y p -.
' %r~e~i{)~al e 6'~i~.'~ei"registered in the State of Alaska. The DHH.S do. es th,s .as a co~;SmY t ~oPv~h~fs; ~ ~t ~d°or nne~
r- n '~sttutionsinordertosatsfycertainfedera anostaterequ~remen · P ~
and(heirlendi g' . ......... '~*'~ - issued The Municipa ty of Anchorage is not
conduct inspections or analyze clara De,ore a uu[um,~,~ ,o ·
responsible for errors or omissions in the profess onal engineeffs work.' ' :
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription= ~..~")-~ /~.'~'~ ~//,~C~T.- (//o~ ParcelI.D.
A. Well Data
Well type ~-c,/c~//l o4J(~-'T' If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Date completed Driller
Total depth .Cased to Casing heigh~--
Sanitary seal (Y/N) __ Wires prope~N) __
FROM WELL LOG ~AT INSPECTION
Date of test
Static water level
Well flow g.p.m, g.p.m.
Pum. m~ll
SEPARATION DISTANCES FROM WELL TO:
,--,
; On adjacent lots
; On adjacent lots
Septic/hc.~J{~ tank on lot
Absorption field on lot
Public sewer main
Sewer service line
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform Nitrate
B. SEPTIC~ TANK DATA
Date installed
Cleanouts(~l)
High water alarm ('v~.
Date of pumping
Collected by:
Tank size /~L~ 0 ~-v-~ C.._
Foundation cleanout(~N) ~,~
Compartments "~
Depression (Y/{~ ~-~'~
Alarm tested (Y/N) ,/u//
Pumper /Z3j .-'r-
SEPARATION DISTANCES FROM SEPTIC/ ........ '~:-TANK TO.
Well(s) on 10t ,,,L,'//,~
To property line
Surface water/drainage
On adjacent lots ~. o ~ ('/"--
Absorption field .~' ~
Foundation 2 r'
Water main/service line /0
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
"Pump on" level at
Manufacturer
Manhole/Access
....~P~ump off" Level at
~ested
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTA~STATION TO:
Wo~ On adjacent lots
D. ABSORPTION FIELD DATA
Date installed //O /~
Length 4~ '~
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Surface water
Soil rating (GPD/Ft2) (~' ~¢
Width ~ Gravel thickness
~;~4~) ~-- Cleanout presenh~,N)
System type ~'~//~ ~CCL-C/7/
Total depth // /
Depression over field (Y~_~ -.-~'
(~ After test 14 ~
~ K~,~J~J If yes, give date ,'/(///~-
Bedrooms
SEPAFIATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Sudace water /(.~') f '~-
Curtain drain
On adjacent 1ets ~ C~o [-~ Property line //3f- r
To existing or abandoned system on lot ~O r./_-
Cutbank .~-O t../¢.~ 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
Signature
Engineer's Name
Date
CE - 8801
HAA Fee $. ~
of Payment
Date
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
· ~ DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE MUN ..... L."HOP, AGE
) DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT[ONDEpT' OF
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ~; C'fECTION
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 [ PR 1 1980
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEV~I~
1. PROP/ER*TY OWN E~ , f .~ /. PHONE
AILING ADDRESS ] / J
PROPERTY RES DEN]- ( f d fferent from above) ~.) PHONE
2. BUYER PHONE
MAILING ADDRESS
4. REAL~OR/AGENT ~ I PHONE
- . ' ~L. '- t I -~'
MAI LING ADDR E~,S/~ /I ~-'/ ~ ~r / ~ ~ '
£
5, LEGAL DESCRIPTION
STREET LOCAT[ON
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four [] Other
~ SINGLE FAMILY
[] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
7, WATER SUPPLY
[] I NDIVI DUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
I~ COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[~ INDIVIDUAL/ON-SITE** /?~" YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010
(Rev.
6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FiVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL 3EPTH OF WELL
E3 COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or []Holdln§ Tank
Size: ,/~)(~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELLTO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL {letter must accompany certificate)
[] DISAPPROVED
DATE BY
72-010 (Rev. 6/79}