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HomeMy WebLinkAboutVALLI VUE ESTATES #2 BLK 4 LT 7 Municipality of Anchorage Page 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: SLO 4t~-0'~ t ~ PID Number: Name: i~./~i~j~.~ ~. ~~ Wastewater System: D New ~Upgrade A~, ~. ABSORPTION FIELD Phone: ~ G-- ~0 ~] [No. of Bedrooms: H ~ Deep Trench ~ Shallow Trench ~ed ~Mound ~Other LEGAL DESCRIPTION ~ Soil Rating: ~,~ GPD/Sq. Ft. Total Depth from original~, grade: Subdiv~ion:~ Depth to pipe bottom from original grade: Gravel depth beneath pipe Lot: ~ Block: ~ ~A~I ~ ~ ~,~' Ft. 0.~' Ft. Township: I Range: I Section: Fill added above original grade: Gravel length: t Gravel width: Number of lines: I Dis[ance betwee~ lines: WELL:~tST~ New ~ Upgrade / 16' ~. Classification (Private, A,B,C): ~,, Total Depth: C~ Total absorption area: Pipe material: ~ Driller: / ~ ~taticWater LevekFt. Installer:~ ~T~ Date installed: ~/~ Yield: ~etat:Ft. IC~singHeightAb°veG~°und:Ft. TANK SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P. TO 'Septic Absorption Lia Holding )ublic/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines ~O ~ ~ [~ Well- ~ ~o~ ~ ~ g~ Materiak ~ E S..a~ LIFT STATION Water f~ ~ [~ t~ ~ ~ ~ Lot , ~ s~=. i. g~bo..: Line ~ ~ ~ ~ ~ F°undati°n ~o~ ~ __ ~ __ "..m. CudainDrain ~ ~ /~ ~ ~O~ / ~Electrical Inspections pedormed by: ~*~ BENCH MARK Remarks: ~ v~1~A~C~ ~Al~ ~o Location and Description: S~ INSTALLED O~ ~ / ~ ~ ~i~l~- ~ , I Assumed Elevation: / S & S ENGINEERING , 17034 Eagle Rive~ Loep Leaa, Ne. $04 mspecbons performed~ie ~[v~-, A[~ =~=~ Dates: 1st Department of Health ~d Hum~ervices approval ~,~,~ .... ,,;~ ~ Reviewed and approved by:_ / 72-013 (Rev. 9/91) MOA 25 Permi~ No. $W95021.5 Page 2' of 2 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 Legal Description: LOT 7, BLOCK 4, VALLI VUE ESTATES //2 PID No'01554150 :03 MT1. C01 CO~ 97.4' / FINAL GRAD~ 96.2'~ /-] IN.aL GRADE S.T. 92.2' 9[.7 ?-~8=95 , · ~ B FCO 51 10' ST1 2; 58' ST2 2~,' 62' NEW BED CO1 31' 64'  C02 5~' 65' ~ MT1 5( ' 62' SYSTEM C04 6;' 100' ~ MT2 71 108'  uTx~- ~ [ NEW 12~ ) GAL ,'~~ 5SEPTIC ,ANK (Rev. 9/91) MOA 25 / A MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF 1 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950213 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:BRUNNER KENNETH J OWNER ADDRESS:6203 GREEN TREE CIR ANCHORAGE, AK 99516 DATE ISSUED: 8/10/95 EXPIRATION DATE: 8/10/96 PARCEL ID:01534150 LEGAL DESCRIPTION: VALLI VUE ESTATES #2 BLK 4 LT 7 LOT SIZE: 29452 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK 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 (18AACS0) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISION~ _ ~ RECEIVED BY: ~--~./ '~)~Q~'J~/~-~ 3t ~ ISSUED BY: DATE: DATE: Rick Mystrom, Mayor Municipality of Anchorage Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 August 14, 1995 Robert Cowan, P.E. S & S Engineering 17034 Eagle River Loop Road Suite 204 Eagle River, Alaska 99577 Subject: Waiver Request for Lot 7 Block 4 Valli Vue Estates ~2 Waiver Request ~WR950037, PID ~015-341-50, SW950213 Dear Mr. Cowan: Your request for a waiver of the required 10 foot separation between a septic system and a lot line has been approved. The waived distance is 2 feet between the bed and the property line. This approval applies to the existing septic system lot line separation only. Any future upgrade to the septic system will require all separations be met or another approval from this department. Robert W. Robinson Civil Engineer On-site Services RWR/ljm MUNICIPALITY OF ANCHORAG~ Department of Health and Human Services On-site Services Section Waiver Review Worksheet WR~ WR950037 PID~ 015-341-50 HA# Permit ~ SW950213 Date Received: July 31, 1995 Legal Description: Lot 7 Block 4 Valli Vue Estates 92 Engineer: Robert Cowan, P.E., S & S Engineering 17034 Eagle River Loop Road, Suite 204, Eagle River, Applicant: Ken Brunner Alaska 9957' Waiver Requested: Lot line waiver of 2 feet from the bed to the property line. Criteria: 1. Geology: Points: A. Water Table B. Soil Sorption C. Permeability D. Water Table Gradient E. Horizontal Separation TOTAL: 2. Special Conditions: 3. Other: Waiver is Granted: so/ns~~ Waiver is NOT Granted: List Conditions or Re for above: Date: /Name of RevieWer Rec ~: 01149/1907 Amount: $ 115.00 Date Paid: 7-31-95 SEWER&WATER INSPECTION ENGINEERING STUDIES AND REFORTS WELLINSPECTION & FLOWTEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCTURAt & MECHANICAL INSPECTIONS ONSITE W~TEWATER DISPOSALSYSTEM DESIGN ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. CIVIL ENGINEERS July 27, 1995 (907)694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services P.O. Box 196650 Anchorage, AK. 99519 REFERENCE: Lot 7;Block 4; Valli Vue Estates #2 Request you issue a permit to upgrade the septic system serving the four bedroom house on the referenced property. Also requested is a waiver for the separation distance between the bed and property lines of 2 feet. A test hole was excavated and a percolation test performed in the area of the proposed upgrade. The approximate location of the test hole is located on the attached site plan. At the time of excavation no water was after seven day ground water monitoring, tube was found to be dry. encountered and the monitoring Attached is the proposed upgrade design. This property is served by a Community Water System. This property has enough area for a future septic upgrade which can be seen on the attached site plan. We do not anticipate any adverse effects on neighboring wells, septic systems or drainage patterns by the installation of the proposed septic system. If you require additional information, Sincerely, Robert C. Cowan, P.E. cc/gk please contact us. Enclosure 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 1"=50' SITE PLAN UPGRADE 'T' ill O1-- m :~,~ :z:: o ~ZO~ ~~oo, lO' UflLI~ EASEMENT ' N'.T.S. DETAIL SCALE © PROFILE 5' DEEP Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: Township, Range, Section; 7 8 9- 10- 11 13L 14- 15- 16- 17- 18- 19- 20- SLOPE SITE PLAN WAS GROUND WATER ENCOUNTE.ED? IF YES, AT WHAT DEPTH? pO Monitoring? (]ate: ~ Gross Net Depth to Net Reading Date Time Time Water Drop COMMENTS T~'$~ ~'co ~ ~ OqC $ & S ENGINEERING' ~ CERTIFY THAT THIS TEST WAS PERFORMED PERFORMED BY:i/o~4 Eagle River coop Road NO, 2~ '-'E-7 ~ · v ~ /~ ~ / ~ ~ ACCORDANCE ~I~I~~PAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72~8 (Rev. 4/~) PERCOLATION RATE ~' -) (minutes/inch) ~.ERC HOLE DIAMETER TEST RUN BETWEEN ~ )'' ' FT AND G.~" FT ROBERTC. COWAN, RE. ROBERTA. SHAFER, RE. SEWER&WATER INSPECTION ENGINEERINGSTUDIES AND REPORTS WELLiNSPEOTION & FLOW TEST SITE PLANS SOILTEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS ONSITE WA~TEWATER DISPOSAL SYSTEM OES[GN ~EFERENCE: Lot GENERAL: 1. ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION PRACTICES and MATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 7, Block 4, Valli Vue #2 July 27, 1995 2e Se The scope of this project includes the installation of a 1250 gallon septic tank and absorption bed to serve the four bedroom residence located on the referenced property. The existing septic tank is to be excavated, pumped, crushed, and abandoned in place. The existing leachfield is to be abandoned in place. Construction shall be in accordance with the approved site plan and design drawings; Municipal permit with any special provisions or conditions; and all applicable State and Municipal Wastewater Disposal Regulations. The contractor shall be responsible for obtaining any necessary underground utility locates. Unless specifically agreed otherwise, the property owner shall be responsible for final grading areas subsequently depressed from soil settling. On all leachfield mound systems, the property owner shall be responsible for ensuring a satisfactory vegetation growth over the mounded area. Contractors installing wastewater disposal systems must be certified by the Municipal Health Department for system installations. Owners installing their own systems must also receive prior approval from the Municipal Health Department. ~EPTIC TANK INSTALLATION: me A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. 2. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. 17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577 Page Two Lot 7, Block 4, Valli Vue July 27, 1995 ~2 J 6o Ail standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Septic tanks installed with less than 4 ft. of cover shall be insulated. A foundation cleanout shall be installed one to four feet from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (unless an effluent pumping system exists within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10 ft. from the tank. The first cleanout, in line, shall be to clean toward the leachfield. The second cleanout shall be to clean toward the septic tank. Final grading over the septic tank shall be such that a positive slope exists away from the septic tank. LEACHFIELD BED INSTALLATION: Excavate the proposed Bed Area to the depth shown on the design. The bottom of the excavation shall be within 2 inches of level. If the bottom of the excavation becomes smeared, it must be raked or scratched (ruffed-up) before gravel or sand placement. So If a sand layer is required, place sand over entire excavation to the required depth shown on the design. The top of the sand layer must be within 2 inches of level. Sewer rock shall be placed uniformly throughout the entire bed. Perforated distribution pipe must be installed level with perforations down. Gravel depth below the perforated pipe shall be a minimum of six (6) inches. Gravel depth above the perforated pipe shall be a minimum of two (2) inches. The total gravel depth throughout the entire bed shall be a minimum of twelve (12) inches. The perforated distribution pipes must be as shown on the design but, no more than six feet apart. The distance between the outermost perforated distribution pipes and the sidewall of the absorption bed must be no more than three feet. Page Three Lot 7, Block 4, Valli Vue July 27, 1995 #2 Silt barrier material must be installed between the final gravel layer and the native soil backfill, unless insulation is used, then the silt barrier should be installed over the insulation. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tubes shall be of four (4) inch diameter, installed at the locations shown on the design, and extend a minimum of 12 inches above final grade. The portion of the monitoring tube extending through the gravel depth shall be perforated six (6) inches below the bottom of the horizontal distribution lines. The monitoring tube should not extend below the bottom of the gravel surface. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The finished grade over the bed must be mounded to prevent the formation of a depression after settling. MINIMU~MATERIAL SPECIFICATIONS: Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. The following pipe materials are approved for use in septic system installations in the Municipality of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Yes ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) Yes Yes Use of a type of pipe other than listed above must be approved by the inspecting engineer. Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Company Styrofoam HI or equal). 4. Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Fernco, or equal). Page Four Lot 7, Block 4, Valli Vue July 27, 1995 %2 A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. 6. Ail leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3% passing the ~200 sieve. 7. When sand is being used as a filter material, its gradation specifications must conform to current M.0.A. or D.E.C. requirements. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wastewater disposal system. These inspections will occur as follows: The first inspection must be conducted after the excavation of ditches, pits, trenches, or beds and before the installation of any gravel. A septic tank may be set in place, but may not be backfilled before this inspection. The second inspection must be conducted after the placement of the silt barrier, gravel, distribution lines, standpipes, cleanouts, and insulation, but before the placement of any other backfill. The final inspection is to occur upon final grading of the property. Often there will be more than these 3 inspections required. Especially with the installation of multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or control in any way the contractors activities. Page Five Lot 7, Block 4, Valli Vue 92 July 27, 1995 The owner shall contract with the contractor to perform the work outlined in these specifications and plans and in accordance with the attached M.O.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be the owner's representative and will inspect the work as stated above to document the contractors activities. Final acceptance of the contractors work rests with the owner and the M.O.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any other persons performing work on this project or the failure of the contractor to carry out the work in accordance with these' construction documents. S & S Engineering's inspecting engineer will not be responsible for the construction means, methods, techniques, sequence, procedures or the safety precautions incident to this project. CONTRACTOR/INSTALLER GRE/-,,ER ANCHORAGE AREA BOF,., JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION MAILING ADDRESS L~O< -,~,]~'-/ PHONE '~-~' ,/~'..2. ~- LEGAL DESCRiPTiON /___ '7 ~'~' ~-'/¢~*--' ~)~ SEPTIC TANK: DISTANCE FROM WELL',.~ rP INSIDE LENGTH MANUFACTURER ,~ MATERIAL NUMBER OF COMPARTMENTS INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY?g'O~ GALLONS. TILE DRAIN FIELD~'~¢ DISTANCE FROM WELL NUMBER OF LINES ABSORPTION AREA ~'("~"~( FOUNDATION DISTANCE BETWEEN LINES TOTAL LENGTH NEAREST LOT LINE OFLINES ~"-~'- TRENCH WIDTH ~N. TOTAL EFFECTIVE Sq. FT. LENGTH OF EACH LINE DEPTH OF FILTER DEPTH: TOP OF TILE TO FINISH GRADE MATERIAL BENEAT~t TILE IN. ABOVE TILE IN. WELL: TYPE BUILDING FOUNDATION CESSPOOL APPROVED CONSTRUCTION NEAREST NEAREST LOT LINE__, SEWER LINE__ OTHER SOURCES __ DISAPPROVED REMARKS DEPTH SEPTIC SEEPAGE , TANK SYSTEM DISTANCE FROM: DISTANCES: DIAGRAM OF SYSTEM INSTALLED BY~-~ ~ SEWER LINE DEPTH: PIPE MATERIAL' ~ LOT SLOPE: REMARKS: Form EQ-032 DATE~ APPROVED G,A.A,B. PEF.'.M I T NO. [:,EPARTMENT L,F HEALTH AN[:' EN'v'IRONMENTFIL ,-'ROTECTION 25±6 E. TUDOR RD., FINCHORRGE, FIK. ~507' ;276-2;22i 76786 ::' HF F L I _.HN"[ LOCAT 1 ON LEGAL ~' I i','IE:ER ENTERPRISES GREEN TREE CIRCLE L7 E:4 VALLI ',,,'tJE P 0 AL,..., 325:1. LOT :~49-2L922 ~:=:._-_,b .:,~:.IjHRE FEE']- I:,. TRENCFI TYF'E OF =,OIL RBSORE:TION S'¢STEM '-' MR:-'<IMUM NIJME, ER OF E:EDF.:OOM~ = ~ _- ' F' ,::S~::! ' ..'", ,' ..... ':,AIL RRTIN-~ FT. E,R. - THE REQUIRED _,I~E OF THE SOIL HE,=,uFFTI~N _,r_,TEI] IS: [:,EF'-rFI= i0 [_EI"-.~i]TI4 .... =:"'=',=_ ~F.H , EL [.. E.F TH-- THE LENGTH DIMENSION IS THE L. ENGTH (IN FEE7') OF THE TRENCH OR DRAIIqFIELD. THE DEPTH OF A TRENCH OR PIT IS ]"HE DISTANCE BETWEEN THE SURFACE OF' ]'HE GROUND FIND THE BOTTOM OF THE EXCAVFITION (IN FEE7'), THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEF'TH OF GRAVEL BETI,.IEEN ]'HE OLrTFRL. L PIPE AND THE BOTTOM OF THE ENCR'¢ATION ,::IN FEET). THI_ E, HuKFILI_INb OF RN"r' :"r:]EI1 WITHOUT FINAL II'.4SF'EC:TION AND RF'F'F.'.O',,,'FIL E:'¢ [:,EPARTMEi',IT WILL E,E :,UB,.E_.T TO PROSEC:LITION. _ ,- " ,- ' :,EI,.IPIbE [. I:,Fu:,HI_. :Jr: FEll IS r,iINIMIJM DIC~TRNCE EETWEEiq R WELL AND AN'¢ LN-=,t FE "'", .... '-"-'-' ¢' "- .... :1.00 FEET FOR A PRIVATE WELL ]R 2E~0 FEET FOE: R F'UBLIC 14ELL ,FECIFIL. HTIuN-, AND FANC, TI~'t F:TIAN DIAGRAMS FIRE FI,,MILI-IE, LE TO IN_,JFE F'I:~:OPEF..'. l NS]'AI_LFIT 1 ON. I CERTIF'¢ THAT i: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS FIS SET FORTH 8%' THE MUNICIPALITb' OF ANCHORAGE. 2: I WILL INSTAl_[_ THE S'gSTEM IN ACCORDRNCE WITH THE CODES. 2: I UNDERSTAND THFIT THE ON-SITE SEWER S'¢STEM MA'¢ REQUIRE ENLFIRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 5: BEDROOMS. S I GNED: ..... ~- .............. APF'I_ICFINT TIME:ER ENTERPRISES~'~'- ,, . -. ..... :. · SI)II,S I,()(i - Iq~I{OI,A'IUON TI'i,";T Performed for ~imber Enterprises ' ' · ke,ja~ l)c$cr~pLlon. Lot v B1~- j, 4._~.~_=.~ ..................... Dage Perfon;.~d 9/1~/76 · i/ds form reports: S~i-9;' l'~--'"'i .............................. Percolation Oep ti~ Iree t Gw (85) ow ow (85) OW (85) m~ (85) ~q (85) GW (8~) e~ (85) m~ (8~) ~ (8~) 5- 6- ?- 8- 9- 12- Flat Was ground water encountered? -~i~o ....... If yes, at what depU~? ~roposed.lnsLallatlon. .~et'l)a!lc Pit Urain Field I,y. ~ ~ ~ ,:r' r~,l By- · , , .... 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 O ~ S'- -- 3't1- ~ 0 HAA# L-~'~.c~-~,~.~'~;~ 1. GENERAL INFORMATION Complete legal description Lot 7; Block 4; Valli VueL#2 Location (site address or directions) 6203 Green Tree Circle Anchorage, AK Property owne~ Mailing address Sh~ryl & Ken Brunner Day phone 346-2087 6203 Green Tree Circle Anchorage, AK 995~6 Lending agency· Mailing address Day phone Agent '- Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 '"' TYPE OF WATER SUPPLY: 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. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer XXX 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 STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my inves_tLgation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, Phone ordinances, and regulations in effect on the date of this inspection. S & S ENGINEERING Name of Firm 170_~4 _~?..-~ ~...o- L _,',.~,_ ?--"~-~ toe- ~_.m~. Eagle River, Alaska 99577 EngineeCs signature '~'~ bedrooms. DHHS SIGNATURE /~ Approved for ~ Disapproved. Conditional approval for Date 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 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 ~ztSl~ Environmental Services Division ~ q-' 825%" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744 t-fl ~ Health Authority Approval Checklist Legal Description: Loc '7, ',',',~u~c~ t~, kfAUL~ k,/v~' ~-5~r. ¢1;02 Parcel I.D.; A. YVELL DATA Well type (qov~v~o~.,i-r~V If~ B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth / Satfitary seal (Y/iq) / Date completed / / Cased to f Casing height (above ground) Wires properly protected (Y/N) I~ROM WELL LOG AT INSPECTION Date of test Static water level Well production g.p.m, g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC~TANK DATA Number of Compartments ,~ Cleanouts {~q) V~s Depression (Y~ Pv/o High water alarm (Y~ ~q/C) Date installed '~-/~' - ~57 ' Soil rating~r ft2/bdrnl) O,'7 System type ~ Length ~'q ~ Width:: /~- ~ Gravel thickness below pipe O. ~" Total depth "2. Effective absorption area ~'~ ~ Monitoring Tube presenq~q) ~/E~ Depression over field (Y(~ Date of adequacy test ¢ ~ ~ 5~eo~-~- Results (Pass/Fail) For / bedrooms Fluid depth in absorption field before test (in.); Immediately after gal. water added (in.): Fluid depth Minutes later: Peroxide treatinent (past 12 months) (Y~j) (in.) Absorption rate = If yes, give date g.p.d. D. LIFt STATION Date installed Size in gallons Manhole/Access (Y/N) ~'Palnp on" level at* .~r~mp off' level at* High water alarm level at* Cy~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/huldii~g tank on lot Absorption field on lot __ Public sewer main Sewer/septic service line ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC~ TANK ON LOT TO: Fouudation ~e:, t Property line ~ ' Absorption field -] / Water main/service liue to ~ Surface water/drainage /oo 9 Wells on adjacent lots /-,///I SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation Water main/service line Surface water I oO /4- Driveway, parking/vehicle storage area Curtain drain Wells on adjacent lots F. ENGINEER'S CERTIFICATION >A--- ~,~ /~ q ~"Oo '~ '? ~.~~ ' lcertifytha,, havedeterminedthrufieldinspectionsandreviewofM'unicipal~"'d¢~,~f~"sare in conformance wit~MQ~ I~tid~es in effect on this date. ~,~ ~.,.~ v~ Signature .......................................................................... HAA Fee $ ~ ' ~ W~ver Fee $ a oemaym u Receipt Number ./~ ~ ~~) Receipt Number Rev. 8/95 OSS: haa.wk.doc MUNICIPALITY OF ANCHORAGE . ..~' ~ DIVISION OF ENVIRONMENTAL HEALTH DEPART~NT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information (a) Legal Description (include lot, block~ subdivision, Location (address o~ direc~i~) (b) Applicants Name Application Date section, township, range) Telephone - Home Business (c) (d) Applicants Addrese Applicant is (checko_~ne) Lending Institution Buyer ~ ; Other~__~ (explain); Lending Institution Owner/builder~; Telephone (e) Real Estate Coo & Agen~ Address Telephone (f) Mail the HAA to the following address: Z..~¥pe of Residence Single-Family~ Number of Bedrooms 3. Water Supply Individual Well[~ Multi-Family~ Other (describe) Community~ Public~ Note: If community well system, must have ~itten confirmation from the State Department of Environmental Conservation attesting to the legality and status° 4. Sewage Disposal Onsite ~ Public ~ Community ~ Holding Tank ~ Note: If community well system, must have writteu confirmagion from the State Department of Environmental Conservation attesting to the legality and status° [Page 1 of 2] 5. ~gineering Firm Providing Inspections~ Tests~ File Search~ Data and Informat_~io2~ As certified by my seal affixed hereto and as of the validation date shown below: Verify that my investigation of, this Health Authority Approval shows that the water supply and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms and ~ype 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- riots in effect om the date of this inspection. Name of 7-eC,t,',c,d bedrooms Disapproved __ DHEP Approval Approved for Approved ~ Terms of Conditional Approval CAUTION T~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTLFICATES BASED SOLELY UPON THE REPRESEI~T~ ATIONS GIVEN IN PARAG~kPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED IN 1'~ STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND '.'~KIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS° EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE IS ISSUED° THE MUNICIPALI'i"f OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK° (DHEP SFJ~L) RR4/eJ/D18 [Page 2 of 2] 7-19-84 A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ~Oli9]lO~d q¥1N]~NO~IAN~ ~ Mll~H ~O 'ld~G Legal Description :it0~:~¥"~/1'1~ ~ Well Classification /~ --~TWell Log P=esent (Y/N) oral Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances f~cm Well: To Septic/Holding Tank on Lot To NeaEest Edge of Absorption Field on Lot To Nearest Public Se%~r Line C leanout/Manhole Water Sample Collected By Water Sample Test Results If A, B, c= C, D.E.C. Approved(Y/N) )" Date C~leted Yield Depth of G~outing. Pump Set At Sanitaz-/ Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nea=est Sewer Service Line on Lot ; Date C~=,=nts B. SEPTIC/HOLDING TANK DATA Date Installed ~/'F6~ Size I~'~'~I No. of C~,~artments ~ Standpipes (Y/N) ~' Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N) ~' Depression over Tank (Y/N) ~ Date Last Pumped ~6'/~/~$- Pumping/Maintenance Contract on File (Y/N) N,~. ; for Holding Tank High-Water Alarm (Y/N) ~,/~. Tempo~az-/ Holding Tank Permit (Y/N) Separation Distances f=cm Septic/Holding Tank: To Water-Supply Well ~/~. To Building Foundation ~' To Property Line ,~/~' TO Disposal Field ~' To Water Main/Service Lir~ g~'.l~ I~#~ To Stream, Pond, Lake, c~ Major D~ainage Course ~ ~' Comments Receipt $ A~-~,°~%-~ Date Paid: ~'~-/~-~5~-- Amount: d/5, O~ [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption St2zata Date Installed Width of Field Square Feet of Absu~-ption A~ea Depression over Field (Y/N) Results of Last Adequacy Test ~ , Type of System Design Length of Field ~' Depth of Field I~ ' Gravel Bed Thickness Standpipes P~esent ~) Date of Last Adequacy Test Separation Distance f~om Absorption Field: To ~ate~-Supply Wall N,/L To P~operty Line ~ ~ To Building Foundation ~' To Existing Or Abandoned System cn Lot ~o~Y ; On Adjoining Lots ~4-~' To Water Main/Service Line g~' /~ ,~/-~To Cutbank(if present) To Stream/Pond/Lake/o~ Major D~ainage Ccu~se To D~iveway, Pa~king A~ea, o~ Vehicle Sto~age A~ea ~ C~,~ents D. LIST STATION Date Installed Size in Gallons "Pump On" Level at High Water Alamu Level at Tested for Electa~ical Codes(Y/N) Diwensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Conments ** Check Permitted Bedroom Rating Against HAA Raquest I certify that I have checked, verified, o~ confc~m~d to all MOA HAA Guidelines in e~fect on the date of this inspection. Company Date MOA No. KB1/d5/s [Page 2 of 2] DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE/WESTERN DISTRICT OFFICE 437 "E" STREET, SUITE 303 ANCHORAGE, ALASKA g9501 BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 To Whom it May Concern: According to records on file in this office the ~i$/'o~ Water System is in compliance-with the State Drinking Water Regulations Sincerely, MUNICIPALITY OF ANCHORAGE MUNICIPALITY O~: ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~pT' ©;- :;: ':.~[l 8, 825 L Street - Anchorage, Alaska 99501 J~i~/IR©~MENTAL I-';OTgCTION ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 SEP ? F{EQUEST EOF{ APPF{OVAL OF INDIVIDUAL WATEF{ AND DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. JPHONE MAILING ADDRESE PROPERTY RESIDENT (If different from above) MAI LING ADDR ESS PHONE PHONE 4, REALTOR/AGENT MAI LIng ADDR ESS PHONE 5. LEGAL DESCRIPT ON STREET OCl TIO 6. TYPE OF RESIDENCE [~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATER SUPPLY [] INDIVIDUAL* ~ COMMUNITY [] PUBLIC UTI LITY NUMBER OF BEDROOMS [] One [] Four [] Other [] Two [] Five .~ Three [] Six * ATTACH WE LL LOG, A well log is required for all wells drilled since June 1975, For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM I~ INDIVIDUAL/ON-SITE~ ~lf individual/on-site, give installation date ~(~ ( r~ . If system is over two (2) years old an adequacy test is required [] PUBLIC UTILITY by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY DATE RECEIVED INSPECTION APPOINTMENTS TIME TIME TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR DIRECTIONS: 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE E;~J OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] iNDIViDUAL DEPTH OF WELL [] COMMUNITY DATE DRIP-LED [] PUBLIC UTi LITY Connection Verified LOG RECEIVED 3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER []INDIVIDUAL/ON-SITE DATE INSTALLED [~] PU SLIC UTILITY (-~ Connection Verified INSTALLER []Septic Tank °r [~] H°lding Tank4 ,¢.~ ,c~ if Tanl< is homemade Size: /(~/~ O SOILS RATING '.. give dimensions:' TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: 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 acco~y certificate) °DISAPPROVED DATE BY (Titly) LEGAL DESCRIPTION 72-010 (Rev. 3/78)