HomeMy WebLinkAboutWELLMAN LT 2Onsite File
Wellman
Lot 2
#018-281-24
PIPE MATERIAL House to tank Tank to
Installer D3034 drainfield D3034
A+ HOME SERVICES Drainfield D3034 co/MTD3034
Inspector MOA AND GEG BENCH MARK (Assumed elevation) 100.00 ft
Inspection 15` 7/14/2022 2�d 7/15/22 Location and description
3'd 7/15/22 4m 7/18/22 BACK DOOR THRESHOLD
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp
� Foop
Conditional Approval: Date o �� '" jt;
Septic System .J f y A, Garn ss:
CE -79
Approved Date Z 2 O��s
Note: this approvalfiles not include well permit requirements. ��pap,ofessto"'O\
#AECC884
:v 05/02/18)
Municipality of Anchorage
On -Site Water and Wastewater Section • (907) 343-7904 Page 1 of 3
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211324 PID Number: 018-281-24
Dwelling: 0 Single Family (SF)
❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New 0 Upgrade
Name
PATRICK NELSON
ABSORPTION FIELD EAST/WEST
❑ Deep Trench X Wide Trench ❑ Bed ❑ Mound
Site Address
3540 TWILIGHT LANE *ANCHORAGE, AK
❑ Other
Phone
Number of Bedrooms
Soil Rating Total depth from original grade
1-509-378-5266
3
1.2 GPD/SF 6.74/6.75 (MAX) Ft
LEGAL DESCRIPTION
Depth to pipe invert from original grade JGravel depth beneath pipe
SEE DWG. Ft. 0.52/0.52 Ft.
Subdivision
WELLMAN; LOT 2
Block Lot
Fill added above original grade
Gravel length
Township Range
section
SEE DWG. Ft.
40/40 (80 TOTAL) Ft.
Gravel width
5/5 Ft.
Beds: Number of Lines
Distance between lines
SEPARATION DISTANCES
To Septic Absorption
Holding Sewer
Lift Station
Total absorption area
Number of trenches
Ft.
Dist. between trenches
From Tank Field
Tank Line
400 Fe
2
6'+ Ft.
Well
100'+
100'+
25'+
TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other
Manufacturer Capacity
GREER TANK 1000
Surface Water
100'+I
100'+
Gal.
Material
Number of compartments
Lot Line
5'+ I
10-+
NA
PLASTIC
2
Foundation 110,+1
10,+
LIFT STATION
Manufacturer
Capacity
Remarks PER CONTRACTOR, THE OLD TANK WAS DECOMISSIONED PER UPC
Gal.
OLD DRAINFIELD WAS ABANDONED IN PLACE
Alarm location
Electrical installed by
PIPE MATERIAL House to tank Tank to
Installer D3034 drainfield D3034
A+ HOME SERVICES Drainfield D3034 co/MTD3034
Inspector MOA AND GEG BENCH MARK (Assumed elevation) 100.00 ft
Inspection 15` 7/14/2022 2�d 7/15/22 Location and description
3'd 7/15/22 4m 7/18/22 BACK DOOR THRESHOLD
ON-SITE WATER AND WASTEWATER SECTION APPROVAL Engineer's Stamp
� Foop
Conditional Approval: Date o �� '" jt;
Septic System .J f y A, Garn ss:
CE -79
Approved Date Z 2 O��s
Note: this approvalfiles not include well permit requirements. ��pap,ofessto"'O\
#AECC884
:v 05/02/18)
PERMIT NUMBER:
OSP211324
NOTE: PIPE LOCATIONS ARE
SHOWN PER GEG SHOTS
TAKEN WITH LEICA DISTO
S910 LASER DISTANCE
METER. SWING -TIES TO
HOUSE CORNERS WERE
GENERATED IN AUTOCAD.
WELLMAN; LOT 1 1
I
APPROXIMATE LOCATION OF I
100' WELL RADIUS
/
/
a? : V, s -7')I / z
RECORD DRAWING
/ TWILIGHT LANE
\ B
\ NEW 1000 GALLON HDPE GREER TANK
NEW DRAINFIELD
- / ffAF Ao. 7.71 \�C
GARNESS ENGINEERING GROUP, Ltd
ENGINEERING SALES CONSULTING
3701 E. TUDOR ROAD, SUITE 101 -ANCHORAGE, AK 99507 - PHONE (907) 337-6179 -FAX (907) 338-3246 -WEBSITE: -gemessengineenng.com
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
PATRICK NELSON 509-545-3772 2 OF 3
LEGAL DESCRIPTION: DRAWN BY.
WELLMAN; LOT 2 D.J.G.
TYPE OF WORK: DATE:
�,_ RECORD DRAWING OF SEPTIC UGPRADE 7/26/2022
PARCEL ID NUMBER:
018-281-24
/.q�0 0 60
N
SCALE:
!!Nm -
1.1 = 40'
�. rey A. Gayness =
♦ 79 3
%Sz4 it
Z:: .
LICENSE VA
� \\S\� ••••
#AECC884 /
PERMIT NUMBER:
OSP211324
RECORD DRAWING
TOP OF TANK AT INTLET = 91.75
TOP OF MH = 96.97
/--- FINAL GRADE = 96.21-96.24
MH ST2
TOP OF TANK AT OUTLET = 91.74
INVERT OF BUNG AT INLET = 91.07-/ \
Doo �--
NEW 1599 GALLON H.D.P.E.
GREER SEPTIC TANK RATED FOR
10' BURIAL - NO GROUNDWATER
ENCOUNTERED IN TANK HOLE
EAST
ORIGINAL GRADE ATTO� FINAL GRADE = 96.46-96.78
HIGHEST POINT = 96.44
2022 T.H.
FILTER FABRIC
INVERT OF PIPE = 90.22
0.52'
�5'~I
BOTTOM OF
TRENCH = 89.70
RELATIVE ELEVATION OF BOTTOM OF T.H. = 79.94
(GROUNDWATER ELEVATION AT 83.44 ON 7/14/22)
ORIGINAL GRADE AT
HIGHEST POINT = 95.86
0.52'
F i
PARCEL ID NUMBER:
018-281-24
INVERT OF BUNG AT OUTLET = 90.92
910
WEST
FINAL GRADE = 96.56-96.76
2022 T.H.
FILTER FABRIC
INVERT OF
PIPE = 89.63
BOTTOM OF
TRENCH = 89.11
RELATIVE ELEVATION OF BOTTOM OF T.H. = 79.36
(GROUNDWATER ELEVATION AT 82.86 ON 7/14/2022)
GARNESS ENGINEERING GROUP L
FNr:INFFRINr- cAI FC r.r)MCl IITIAIrl ' ��
3/U1 L. I UUUR RUAU, SUI I E 101 - ANCHORAGE, AK 99507 - PHONE (907) 337-6179 • FAX (907) 338-3246' WEBSITE: w .gamessengineertng=m
PREPARED FOR: PHONE NUMBER: PAGE NUMBER:
PATRICK NELSON 1-509-545-3772 3 OF 3
PROJECT/LEGAL DESCRIPTION: DRAWN BY:
WELMAN; LOT 2 D.J.G.
TYPE OF WORK: DATE:
� SEPTIC SYSTEM PROFILE RECORD DRAWING 7/22/2022
All.'�•
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effr�.y,. Garness .:.cvi
4-10 AN
4E-71953 AV
AW
LICENSE
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MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP211324
Work Type: Septic Upgrade
Tax Code Number: 01828124000
Site Legal Address: WELLMAN LT 2 G:3135
Site Mailing Address: 3540 TWILIGHT LN, Anchorage
Owner: NELSON PATRICK L
Design Engineer: GARNESS ENGINEERING GROUP LTD
This permit is for the construction of:
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy
Effective Date:
Expiration Date
�r�nt
X04 S�,
o
Department
Lot Size in Sq Ft
Total Bedrooms:
8/26/2021
8/26/2022
❑ Private Well ❑ Water Storage
All construction shall be in accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations (18AAC72) and Drinking Water Regulations (18AAC80)
3. The wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
I Special Provisions: 100 ft separation between the proposed septic system and the well on the lot to the east
shall be confirmed prior to construction.
Received By:(r Date:
Issued By: 2 OG 2nt 6'5 Date: $ 2 b ocD
3
'.
TYPE OF DWELLING:
wG�j;t �1 S1 Li+tA P
ar �S ANCHORAGE
va �a
F
y } i u52& 5 ai �`�n
aY u :� Y`` :
Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Privy ❑
Multiple Dwellings ❑
(SF and/or D)
Private Well ❑
Development Senjices Depa!
i!-nent
�_ - -
Phone- 907-343-790
On -Site Water & Wastewater Section
Distance:
Pax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 018-281-24
Property owner(s) PATRICK NELSON
Mailing address 3540 TWILIGHT *ANCHORAGE, AK
Site address
Legal description (Sub'd., Block & Lot) WELLMAN; LOT 2
Legal description (Township, Range & Section)
Lot Size
Day phone 509-545-3772
Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN:
TYPE OF DWELLING:
(® all that apply)
Absorption Field 0 Initial ❑
Single Family (SF) x❑
Septic Tank Q Upgrade x❑
(w/wo ADU)
Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Privy ❑
Multiple Dwellings ❑
(SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
Gzvn_,�
�-
(Signature of property owner or authbzDzed agent) (
�1�---'
Permit/Rush Fees: 5q 5 Waiver Fees:
Date of Payment: A d2 I Date of Payment:
Receipt Number: 0329 (V C-2 Receipt Number:
Permit No.OS%�2 1 /l C-1 Waiver No.
G:\Development Services\Building Safety\On Site Water and Wastewater\Forms\Client FormsTermit Application.doc
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211324, Rebecca Carroll, 08/26/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211324, Rebecca Carroll, 08/26/21
DESIGN CRITERIA:
NUMBER OF BEDROOMS: 3
GALLONS PER DAY (GPD): 450
PERCOLATION RATE/S: 2.8 MIN/INCH
PROPOSED APPLICATION RATE: 1.2
MINIMUM DRAINFIELD SQ.FT.: 375 FT'
DRAINFIELD DESIGN:
MAXIMUM DEPTH: 6.75 FEET
WIDTH: 5 FEET
LENGTH: 40 & 40 FEET (80 FEET TOTAL)
EFFECTIVE: 0.5 FEET
REDUCTION FACTOR: N/A
ACTUAL SQ.FT.: 400 FT'
CONTRACTOR TO HAVE ALL 100' WELL RADII
FLAGGED BY A PLS PRIOR TO CONSTRUCTION
GEG, Ltd. HAS AN 8 PAGE SPECIFICATION LETTER
THAT PERTAINS TO THIS DESIGN. BY PROCEEDING
FORWARD WITH THIS INSTALLATION, THE
ENGINEER, WELL DRILLER, CONTRACTOR AND
PROPERTY OWNER AGREE THAT THEY HAVE
READ THESE SPECIFICATIONS AND AGREE TO
ACCEPT THE TERMS AND CONDITIONS OUTLINED.
PROPOSED 1000 GALLON HDPE GREER TANK; INSTALL
DOUBLE CLEANOUTS BEFORE AND AFTER TANK
lZi
/
/ I
!j
!! I
5'+ FROM TANK
APPROXIMATE LOCATION OF EXISTING I
TRENCH TO BE ABANDONED IN PLACE
L c
#1
Q s
GARAGE
EXISTING
HOUSE j
00
�l
�O�GN
T.H,#\\\ L2'
L2 '
A '-11-
WELL ON LOT 134: PER THE CONTRACTOR (JASON WITH A+ HOME SERVICES), HE MET WITH THE HOMEOWNER OF LOT
134 AND DETERMINED THAT THE WELL IS LOCATED INSIDE OF A WOODEN BOX (NEAR THE SOUTHWEST CORNER OF THE
HOUSE). GEG WAS NOT ABLE TO CONTACT THE HOMEOWNER ON 7/14/22 TO CONFIRM THAT THE WELL IS LOCATED
INSIDE THE BOX, HOWEVER, IT WAS CONFIRMED BY GEG THAT THE BOX IS 100'+ FROM THE LOT LINE. IN SHORT, IF THE
WELL IS LOCATED WHERE THE HOMEOWNER TOLD THE CONTRACTOR IT WAS LOCATED, THERE ARE NO CONCERNS.
19
DRAINFIELD
1klFkI TA
ARNESS ENGINEERING GROUP, Ltd
3701 EASTTUDOR ROTb'19EIOIE'ANCAl2E-,ASLISKAE PtrONE tf-0ij337-61i9i Y. 55 -v,:�w.gzmessengieering.nm :.... ..+ :.. . ......................�. .0
PREPARED FOR: PHONE NUMBER: PAGE NUMBER: f � J ej�+A. Ga ness Q a
PATRICK NELSON 509-545-3772 2 OF 2 �# C g -_Ar
PROJECT/LEGAL DESCRIPTION: DRAWN BY: •#�� • Qi� Z2 \e"
WELLMAN; LOT 2 D.J.G. SIF•••''••• ( �'i
TYPE OF WORK: DATE: ♦,111NOi E,SS\ '
DESIGN OF SEPTIC TANK UPGRADE7/14/2022 # ICENea
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211324, Rebecca Carroll, 08/26/21
ELECTRIC
PEDESTAL
-----TWILIGHT LANE ----------
0
EAST 164.82'
i..
w DRIVEWAY'
w'.
r�
v GARAGE
l WELL
41.0' v '
23.0'
10.0' 07 ATTACHED
Cd N 9 5, COVERED
SHED
DECK
45.9' 24.0' ; - o
i SEPTIC rNn
CLEANOUT N SHED
Z 4.0' ^ 1.5'
C) 4.0' M 1 -STORY LOG
0 vN AND FRAME
w 616.0' HOUSE
—� DECK
LOT 1 SEPTIC
STANDPIPES
w
0
0
LOT 2
49,466 sq, ft.
l
S 89058'39" W 164.82'
LOT 155
0 20' 40'
EASEMENTS OF RECORD, OTHER THAN THOSE SHOWN ON THE
RECORDED SUBDIVISION PLAT (79-75) ARE NOT SHOWN HEREON.
THIS DOCUMENT DOES NOT CONSTITUTE A BOUNDARY SURVEYAND
IS SUBJECT TO ANY INACCURACIES THATA SUBSEQUENT BOUNDARY
SURVEY MAY DISCLOSE.
UNDER NO CIRCUMSTANCES SHOULD ANY OF THE DATA HEREON BE
USED FOR CONSTRUCTION OF FENCES, IMPROVEMENTS, OR FOR
ESTABLISHING PROPERTY BOUNDARIES.
JOB # 21091 NO CORNERS SET THIS DATE I SCALE 1"= 40'
0
N
0
w
C = LOT 134
m
t
CD
o
CD
�E OF
A Bfi
7i� JJ •• LS -14837
r��rFPFO 6/302021 QSJQ�
AS -BUILT
I HEREBY CERTIFY THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY:
LOT 2, WELLMAN SUBDIVISION
ANCHORAGE RECORDING DISTRICT, ALASKAAND THAT
THE IMPROVEMENTS AS DEPICTED HEREON EXIST AS
SHOWN IN RELATION TO THE PROPERTY LINES.
DATED THIS 3rd DAY OF JUNE, 2021, AT ANCHORAGE,
ALASKA.
FIXED HEIGHT, LLC C.O.A.122554
Land Surveying Services 907.290.8949
225 W 23rd Ave., Anchorage, AK 99503 WWW.FIXEDHEIGHT.COM
%,./ MUNICIPALITY OF ANCHORAGE ,,~./
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
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
_o~ I DISTANCE TO: ]Well
Manufacturer HOME~DE
t~in gallons I? :
Well /.~g) I
Length of e~ci~ I~eo~ ~
IAbsorption area
Inside length
PHONE ~NEW
E]UPGRAOB
Dwelling
Mater'a
Total length of lines
Material bene~t~hi~le'
NO. OF BEDROOMS
PERMIT N~.~.~ ~~~,0~,.
No, of compartments~.~
Material
Nearest lot line
Trench wid~ inches
Liquid depth
Dwelling PERMIT NO.
Manufacturer Liquid capacity in gallons
Foundation PERMIT NO. '2
DISTANCE TO:
No. of lines
Top of tile to finish grade
Width
Total effective absorption area
Length Depth
,e of crib Crib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot line
DISTANCE TO:
Depth
Building foundation
DISTANCE TO:
Driller
Sewer line
PERMIT NO.
Distance to lot line
Septic tank
OTHER
PI PE MATER IA L~).~ .
SOILTESTRATING /F~
2-~0"13 (Rev. 3/78~ (~
DATE
LEGAL
DEPARTMENT OF HEAL. TH AND ENVIRONMENTAL PROTECTION
825 "L" STREET, ANCHORAGE, RK. 9950-1
~64-4, ~0
O~I--S I TE '__~E[.]EF-.' PER~ ][ T
PERMIT NO. ( ?905:88 )
RF'PLICRNT TED WELLMRN ,...~.-490 E ~RR ~ ~ '-~
LOCATIGN [.ICM N
LEGAL
TYPE OF SOIL RBSORBTION SYSTEM tS: TRENCH
54450 SQURRE FEET
MRNIMUM NUMBER OF BEDROOMS
SOIL RATING
THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
E'-" E P 'l" H .~- dL:-l- ~__E~GTH: 3~ f3~ R fi"," E L. ~-'E F' T ~ = 7
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 SURFACE OF THE
GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF ]'HE E~CAVRTION (IN FEET).
F-: E r_-.. IJ I RED SEPT I C: TF-II'-tI~-:] S I ZE= .-1~_ O,L:~ E-! GF~LL~]~-t~
;PERMIT RPPLICRNT HRS THE RESPONSIBILITY TO INFORM THIS DEPRRTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
]-b~C~ (2) I ~SF'ECTIO~S RE:E REC~LII E:E[:.
BRCKFILLING OF ANY SYSTEM WITHOUT FINRL INSPECTION RND RPPROVRL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DtSPOSRL SYSTEM IS
100 FEET FOR A PRIVATE WELL; OR
i50 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING L~'ON THE TYPE OF PUBLIC WELL.
OTHER REQUIREMENTS MBY APPLY. SPECIFICATIONS 8ND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'ERI"I I T E.S'-~ F' I RES DE~CEIF-'IBER
I CERTIFY THAT
i: IRM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: t WILL INSTALL THE SYSTEM IN RCCORDBNCE WITH THE CODES.
3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENL, RRGEMENT IF THE
SIGNED: ...... ;:; .....................
APPLICANT TEE) WELU1RN
..... .........
Perfformed for ,t
Le_oal Descnpt~or
This form reports:
Depth
Feet
3-
4-
5-
6-
7--
8--
12'--'
14--
'18-
GR¢..rER ANCHORAGE AREA
BOROUCk~
Dep~nrr;ent of Environmental Ou~liw
' · ' 3330 "C" Street
,' sOiLs LOB--
Soils log .~ , Percolation
Was groundwater encountered?
''I
.............. ,4,:,%,
~'"'~'~//~ ~
yes, at what depth?
; I
Reading
Date Performed
. D~te ' Gro~ Time t Net Time I Depth to Water
~H;Iqt '/:5~ ¢/~ t 0 ~ o.q/
/ ' '1 ~:~ ~5 ~ ~.1'
f I ?. 4~ i//5 ~ ~ .~- ,
~ t,x , ,,I ,,,/4 I
rercolation r~te ' ""'~/" ~ :
Proposed.installation: ~:.~age Pit . -- Drain Field
Depth of Inlet , ~ '~--f' ,/ ,... DeRth~to.b?ttom of pit or tI%nc~h' --
COMMENTS: /~¢¢'¢'~// I0 ~,~//~¢x.~ ~ , /~ ~
....... ~ ~,.. ~m ~11~ ~mi~i~R~. ~ . _ Date:
LOCATION
..... ~-Ir'ALIT '
¥ Or- aNCHoRAGp~
FOSS DRILLING 8F_,p
13~6 I~ra Street .
~l t~,,,~ 1
USE OF~'
SIZE OF CA~ING b"' DEPTH OF HOLE/_~PT. CASED TO / -~ 2
FEET OF DRAWDOWN.
REMARKS
DATE COMPLETED
PUMP TO BE SET AT
AA Ve
/~t~/~ . q~ ~
__t o
' __t~__
__t6
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SiTE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~ II~ ~1~-3 Telephone: Home ~- tqm7 Business ~qff' '7~/~
Applicant Address ~YO ~, lt~h~ ~, ~4c~or~ /
(c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
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 I~ 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'
Onsite [] 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.
72~025 (11/84)
Page I of 2
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 r~'{cz ~,/~ 7~c ,~ ~ ~'c,~f ~'~,~-¢~,(',:~' Telephone
Address I~'tb'-.?O ~-cA~ 5"~,..,., ,,~'ncl~rc~L/q~? ]t-~
Date c~',z ,~ ! / 8('
~pp:;:::~ ,or~¢__------t~ Disapprov~dd . . Condition,~//
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
72-025 (! 1/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
A. WELL DATA
Y
Cased to ~ 6'~'
If A, B, C, D.E.C. Approved (Y/N) ~ ,~'.
Date Completed ~.lh~l 7/ Yield
Depth of Grouting
Pump Set At _~.
'~S" Sanitary Seal on Casing (Y/N)
Y Depression Around Wellhead (Y/N)
Well Classification
Well Log Present (Y/N)
Total Depth [~£1
Static Water Level 7~'
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
N
To Septic/Holding Tank on Lot Ill' ¢-~ ¢'. c,. ; On Adjoining Lots ~. too '
To Nearest Edge of Absorption Field on Lot ~' I ~5' ' ; On Adjoining Lots '~ coo '
To Nearest Public Sewer Line ~,/J. To Nearest Public Sewer
Cleanout/Manhole N, 4. To Nearest Sewer Service Line on Lot N,,4.
Water Sample Collected by "T'~ ,~/ ; Date
Water Sample Test Results
Comments C -J-~ c~/ ~ c~ m,~, ~,'
,8' / ,'5'
B. SEPTIC/HOLDING TANK DATA
Date Installed "7/E-¥/7,~ Size
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 I! I ~ ~o~ ¢, ~',
To Property Line ~, ~o '
To Water Main/Service Line
Course ~> I
No. of Compartments ~--
Air-tight Caps (Y/N) ~' Foundation Cleanout (Y/N) N
Date Last Pumped ~/'[¢'/~9'(¢
; for N,~.
Temporary Holding Tank Permit (Y/N)
To Building Foundation '~0 '
To Disposal Field ~c¢- d~'/'a~ce' ~,:/- ..¢Ao,,.,,~ o~
To Stream, Pond, Lake, or Major Drainage
Comments H~z~,y ..Cecum [~,~r ~adtc~/~c.(
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field ~6"
Square Feet of Absorption Area 5-q~
Depression over Field (Y/N) N
Results of Last Adequacy Test /'~¢,¢~a ~¢
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ~ +70 '
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments .~'~ ~t '~ ~2{c¢~ (,~c~.(
Type of System Design
Length of Field ~¢ /
Depth of Field Il* - I'~.~
Gravel Bed Thickness '7 ¢
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~ lO '
To Existing or Abandoned System on
; On Adjoining Lots ~ -~ /
To Cutbank (if present) ~I,A.
D. LIFT STATION ~h ,'~,
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
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Date
MOA No.
Signed ~~
Company
Receipt No.
Date of Payment
Amount: $ '~'~,'b%~
Page 2 of 2
72-026 (11/84)
Engineer's Seal
'~UNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE DEPT. O? }!:Ai. TH &
DEPARTMENT OF HEALTH IA ENVIRONMENTAL PROTEC[~i,~ONMF. NTAL ,r, kOTECT[ON 825 L Street JAnchorage, Alaska 99501
JUN 1
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720
FIEQUEST FOB APP.OVAL OF INDIVIDUAL WATER AND SE~ FA~L~/T~)
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed~ Please allow ten (10) days for processing.
MAI L~ING ADDRESS
PROPERTY RESIDENT (If different from above)
2. BUYER
~AI LI N~ ADDR ESS
3. L lNG INSTITUTION
MAILING ADDRESS
PHONE
PHONE
5, LEGAL DESCRIP ON ~ ,
TREET LOCATION
6. TYPE OF RESIDENCE ~.~..~ /NUMBER OF BE~OOMS
· ~ ~ One ~ Four ~ Other
~ SINGLE FAMILY ~> /~ Two ~ F,ve
~ MULTIPLE FAMILY ~ Three ~ Six
7. WATER SUPPLY
~ INDIVI DUAL* * ATTACH WELL LOG. A well (o§ is required for all wells drille"~--~'
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if availab)e,)
**If individual/on-site, give installation date
If system is over two (2) years old an adequacy test is required
by this Department.
8. SEWAGE DISPOSAL SYSTEM
'~--I N DI VI DUA L/ON-SITE~
[] PUBLIC UTILITY
NOTE THE INSPECTION_FEE MUST ACCOMPANY. ~~.~ORE PROCESSING. CAN BE INITIATED.
.2:30
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
I NSP ECTOR I NSP ECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE · NUMBER OF BEDROOMS
~ SINGLE FAMILY [] ONE ""EZ] THREE [] FIVE [~] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY -~C'~
~] INDIVIDUAL DEPTH OF WELL
~ COMMUNITY
DATE DRILLED
Conn'ection Verified LOG RECEIVED
PERMIT NUMBER
3. SEWAGE DISPOSAL SYSTEM ~O[
~ INDIVIDUAL/ON -SITE DATE INSTALLED
~PUBLIC UTILITY ~-~
Connection Verified
~N~TALL~
~Septic Tank or ~ Holding Tank ~ ~ ~j~_
Size:/~(~ . If Tank is homemade SOILS,RATING
give dimensions: ~ ~ .
TOTAL ABSORPTION AREA ~RI~L
4. DISTANCES ~ Septic/Holding Tank Absorption Area Sewer Line [ Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
~ CO~DITIO~A~ A~PBOVAL {letter must ack,pang cortificato}
~ DISAPPROVED
DATE ~ ~ ~t ~ BY(Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
BASIS OF REARINGS EAST (ISI9.01' REC.) (lll, B.SB'
ACCEPTANCE OF DEDICATION
LEGEND
~URVEYOR'S CERTIFICATE
VICINITY MAP
SCALE , MILE
CERTIFICATE OF OWNERSHIP & DEDICATIOI~
I(WEi, HEREBY CERTIFY THAT I AM (WE ARE) THE OW#ER{S) OF THE
NOTARY' ACKNOWLEDGEMENT
LOTS I G 2
BLN LOT 1:55
BOMHOFF & ASSOCIATES, INC.
Engineering' Planning' Surveying
102OWES1 INTERNATIONAL AIRPORT ROAD
ANCHORAGE A L ASK A