HomeMy WebLinkAboutWOODBOURNE BLK 2 LT 81A a 1 24 21 ', u:2 z,, a Anchorage 1'!ell & Pi -in :� Ser
0722430742 p.1
De,eloprnent Services Department( Phone: 907-343-7904
On-Sito Water & Wastewater Section
Fax: 907-343-7997
Pump Installation Log
Well DTilbag Permit Ntunber:
Pit -cc]
Legal Description Block Lot.
woo
Puv'P Imstallaclon Date:
Date of Issue:
P perty Owner Na me. &, Address:
',.1,
Pump Intak-, Depth 6tl,;w Top af'8vell Casil1g.. k'�D feet
PUMP Name: —v4Pl
Pump Model;
PUMP Size-, --._hp
Pitiless adapter-Burial.Del.41:1g: feet
Pitle,is Name:
FlAess Adapter 1witailer--
Disinfeer"Ied ('11oll "'on. ction?
�M,effiod ofDIshiff-etiou:
Comwer-At"':
Pump Installer Narme: _, ANCHORAGE WELL & PL?Mp SERVICE
764',k) Bing Stre.,t
company., �och
-,rEge, AV 9�1516
243-074C
-N'INUiug Address -
city:
state:
Attention: i I e punj p jr.,it-djel- AaD PrOv] (h! u. Ta -MIT, installation log to 013 ir 30 da, , of pul-ap in S'ah &'Ton.
Municipality of Anchorage Page
DEPARTMENT OF HF_ALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wast~e, water Disposal System and/or Well Inspection Report
~Name:!t~ ._~--~/~C~-'ff'l~t Wastewater System: p New ~Upgrade
Phone: ~ ~ Ne. or.cms: ~ Deep Trench ~ Shallow Trench O Bed ~ound ~Other
LEGAL DESCRIPTION Soi,.~,n~: ~PD/Sq. Ft. TotalOepthf omoriginalgrade:
~ ~ Subdivision: Deplh to pipe bottom from odginal grade: Gravel depth beneath pipe
Township: I Range: Sect,o,,: Fill added above origina~a~. Gravel length:
Ft. Ft,
~t' Number of lines: I D,stance~en lines:
WELL: ~ New ~ Upgrade Graveldepth:
Classi~ation (Privat~ A,B,C): Total Depth: Cased TO: Total absorption are Pipe material: ~J
Date Drilled: S,aPc Water LeVehFt. Z~¢~ln r: ~ Date ,nst~d~
SEPARATION DISTANCES ~eptic ~ Holding ~ S.T.E.P.
TO Septic Absorption Lift Holding Public/Priwte Manufacturer: Capacity in~allons:
From Tank Field Station Tank Sewer Lines ~ [~~
Surface
w,ter ~ ~ / / / LIFT STATION
Lot
Curtain I Electrical
Drain ~ ~¢ / ~ ~ Pump M~ke & Model Inspections performed by:
Remarks: BENCH MARK
Location and Description:
ENGINF~8'S SEAL
Inspections performed by: i.~.¢e kl,ve. I.~p Rca. "0. 2~d ~-~L M~""
Eagle River, Alaska 99577 ~.~-~ I ¢ '::~ ' ¢ ~ ~ 2 ~ t.~
Department of Hea~ an~ Human ~ervices approval -~, '~'., ,.~. ~.:~ ~.. '~.,~
72-013 (1/91) MOA 25
Permit No. ,,~b.~lO~l'~ Page ~.-- of ~-
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SI:RVlCES DIVISION
P.o. Box 195650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well,Inspection Report
PID No.: ~1 ~'~' ~;'1'~..,~
72-013 A (2/91) MOA 25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERW[CES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW910211
DESIGN ENGINEER:S & S ENGINEERS
OWNER NAME:BOSWORTH GILBERT M &
OWNER ADDRESS:il701 WOODBOURNE DR
ANCHORAGE, ALASKA 99516
DATE ISSUED: 7/25/91
EXPIRATION DATE: 7/25/92
PARCEL ID:01535128
LEGAL DESCRIPTION: WOODBOURNE
BLK 2 LT 8
LOT SIZE: 102294 (SQ. FT.)
NUMBER OF BEDROOMS: 5 THIS PERMIT: 5
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.
1
SPECIAL PROVISIONS:
1. REMOVE ALL EXISTING LATERALS AND INSULATION.
2. DHHS WILL BE NOTIFIED AT TIME OF PIT RUN COMPACTION.
IN ADDITION TO REGULAR INSPECTION NOTIFICATION.
3. INSTALL ADDITIONAL PERMANENT MONITORING TUBE ADJACENT
TO NEW INSTALLATION FOR PURPOSES OF FUTURE MONITORING.
4. MAINTAIN PRO~R SEPARATION DISTANCE FROM CURTAIN DRAIN.
RECEIVED BY: ~& ~ ~ ~ DATE:
/
Tom Fink,
Mayor
Niunicipali :y of Anchorage
Department of Hlealth and Human Services
825 %" Street
P,O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
September 30~ 1991
Roger Shafer, P. E.
S & ~ Engineering
17034 Eagle River Loop Road
Suite 204
Eagle River, Alaska 99577
Subject:
Waiver Request for Lot 8 Block 2 Woodbourne Subdivision
Waiver Request #WR910045, PID #015-351-28, HA910356
Dear Mr. Shafer:
Your request for a waiver of the required 100 foot horizontal
separation of a septic system to the surface water has been
approved. The approved separation distance is 70 feet.
This waiver approval applies to the existing septic system to
surface water separation only. Any future upgrade to the septic
system will require ali. separation distances be met or another
approval from this department. Should the operation of the
subject wastewater disposal system cause any contamination or
degradation of the subject surface water, this waiver will
become void°
Sincerely,
Civil Engineer
On-site Services
//ohn Smi~th, P.E.~
~Program Manager
On-site Services
ljm:#5
HEALTH AUTHORITY
APPROVALS
SEWER &WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTIOR
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTE WATER
DISPOSAL SYSTEM
DESIGN
ROBERT SHAFER, P.E.
ROGER SHAFER, P.E.
September 18, 1991
CIVIL ENGINEERS
(907) 694.2979
FAX 694-1211
Mu~i~ip~ty of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ATTN: JOHN SMITH
825 L St~eet
P.O. Box 196650
Anchorage, Alaska 99519-6650
MUNICIPALITY OF ANCHOP~AGE
I!NVIRONMENTAL SERVICES DIVISION
SEP 18 199]
RECEIYED
REFERENCE: Lot 8; Block 2; Woodbourne Subdivision;
This l~ter is to address the two deficiencies to
d~posal system located on the referenced property as
l~ter of September 5, 1991.
the wastewater
noted in your
The depression around the groundwat~[ mo~toring tube located
adjace~ to the septic system, which occurred due to
se~ement, has been filled. The ground around the mo~toring
tube has been regraded to provide a positive drainage away from
the system.
o
We requeSt you issue a waiver for the horizontal separation
distance b~tween the septic system and the surface water source
originating from the ou~fall of a curtain drain. The
separation distance is 70 ft. The location of the curtain
drain outfall is depicted on the septic inspection as-built.
The main justification for the waiver is thai any sewage overflow which
may occur from the septic system would t~av~l down the d~uLveway as
opposed to across the driveway and down to the surface water. The
d~veway slopes toward the west at approximately 10% as depicted by the
septic as-bu~t.
If you have any questions or require add~tional inform~ion for your
review, please contact us.
Sincerely,
ROGER J. ~SHAF~R, P.E.
RJS/gm
17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
Tom Fink,
Mayor
September 5,
unicipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
1991
Roger Shafer, P.E.
S & S Engineering
17034 Eagle River Loop Rd,
Eagle River, Alaska 99577
Suite 204
Re: Lot 8, Block 2, Woodbourne
Dear Mr. Sharer:
Our office has completed its review of the recent Health
Authority Approval and wastewater system as-built inspection
report that was submitted by your office for the subject lot.
Based on our review and field inspection, we cannot approve
either of the documents until the following two deficiencies
addressed:
are
There is a significant depression around the groundwater
monitoring tube located adjacent to the system. This
depression must be filled in and the ground sloped to
provide positive drainage away from the system and
monitoring tube.
The existing curtain drain which out falls on the north side
of the driveway was observed to be discharging approximately
3 to 4 GPM to a surface drainage which discharges to Little
Campbell Creek. The horizontal distance between the surface
water and the new wastewater disposal system is
approximately 50 feet. Although the curtain drain was in
existence prior to the upgrade of the wastewater system,
this office issued the upgrade permit based on assurances
from your office that the flow from the curtain drain was
enclosed in solid pipe from the end of the drain to Little
Campbell Creek. This deficiency must be resolved by either
obtaining a separation distance waiver or by extending the
out fall to a distance that is 100 feet from the wastewater
system.
Sincerely, ~
f/Program Manager, Orl-s±te Services
ROBERT SHAFER, P.E.
ROGER SHAFER
July 14,
1991
CIVIL ENGINEERS
(907) 094-2979
FAX 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAINEXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERING STUDIES
ANOREPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SiTE
WASTEWATER
DISPOSALSYSTEM
DESIGN
Municip~ity of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
825 L Street
P.O. Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 8; Block 2; Woodbourne Subdivision;
PEPJ~IT REQUEST NARRATIVE
RequeSt you issue a p~rmit that will allow t~e upgr e' of an existing
absorption bed in accordance with ou~L design d~¢d~Ju~y 14, 1991.
The existing septic system was designed and installed under the
supervision of Alaska Enviro~entat Co~rol Services. In addition to
the septic system being installed a curtain drain was also proposed as
a part of the construction package.
Prior to perfo~ing an adequacy test a leachfield monitoring tube was
installed. Due to the excess ~ount of water encou~ered a water
monitorin~ test hole was also excavated w~t o~ the bed. It w~
determined from this mon~oring tube that the existing bed w~ in
non-compliance with the groundwater separation distance req~reme~
established by Municipal Ordinance and State Law.
An extension of the curtain drain was proposed. However, an
examination through excavation of the ex~sting curt~n drain revealed
that the drain had not been installed to the depths originally proposed
and therefore, was not fun~oning properly to lower the water table in
the seepage bed. The cost and e~fort~ neceSsary to reconstruct the
entire curtain drain does not appear warranted.
It is my opinion that the safest and most r~able alternative ~ to
constru~ a mounded, ~levated seepage bed. Due to the limited area
ava~able it is requested that the ne~ bed be constructed over the top
of the existing bed by removing organics, adding sand, and fill.
Upgrading of this septic system in it~ existing location will not have
an adverse effe~ on neighboring properties.
If we may be of further service or if you require
information ~or yogi review, please contact ~.
ROBERT A. SHAFER,._F~..E ....
~,,~ ...... '17~)3'4-E'AG LE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
~31 gm
add~o nal
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
p ER FORM ED FO R: ~(/~/,~:7 ,j~ O, ~" ~,~ ~)~
· EC^L DESOR'PT'ON:Z'~ /~ 2 ~¢/~O~r'~ Towns.,., .~.ge, S.ct,on:
2
13-
14-
15-
16-
17-
18-
19-
20-
L
:LOPE
WAS GROUND WATER
ENCOUNTERED?
Deplh to Waler Alter.,.~ !
Moflilering? Bate:
SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
COMMENTS '-S'~t ;~; ):'J~lt~lz~J,~!N(~ TEST RUN BETWEEN ~ AND ___. FT
AOOORBANOE WITH ALL STATE AND MUNICIPAL GUIDE~/CT ON THISDATE. DA~ ¢/¢/
72-008 (Rev. 4185} ¢/ / / /
WAS PERFORMED IN
SCALE
SCALE
MUNICIPALITY OF ANCHORAGE
DI:PARTMENT OF HEALI'H & ENVIRONMENTAL PROTECTION
I-"NVlRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
in gallons
PHONE
Dwelling .~ /
Absorption are_2a/~ ~ / ~ ~,~
NO. O F.~B~,/~DR CaMS
PER IT NO.
Liquid depth
IF HOMEMADE:
Well PERMIT NO.
Manufacturer Liquid capacity in gallons
DISTANCE TO:
Material
Foundati~.~0 /,.~ Neares~i?) /.~,
Total length of lines ~T/ert~)b widti~
Materla[ beneath ti}e ~ //inches
Top of tile to finish grade
Length Width
Depth
Total ~J)fe¢tive abs~rpt, J_/on area
PERMIT NO,
Type of crib rib diameter Crib depth Total effective absorption area
Well Building foundation Nearest lot llne
DISTANCE
TO:
F
Septic tank [
3lass Depth Driller Distance to lot line PERMIT NO,
DISTANCE TO: Building foundation Sewer line Absorption area(s)
[
OTHER
PIPE MATERIALS
SOl L TEST F~ATI NG ~.
INSTALLER
REMARKS
APPROVED
72-013 (Rev. 3/78)
DATE
LEGAL.
ALASKA ENVIRONMENTAL
CONTROl. SERVICE**" "NC;'
1200 West 33rd Avenue ~uite B
ANCHORAGE, ALASKA 99503
Phone 276-1361
CALCULATED BY /' L~¢' d
oF '~
CHECKED BY
DATE
SCALE.
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATUEAL RESOURES
Division of Geoiogicul ~ Geophysicsl SurvEys
Per~it IF
Applicant: ~/~.~ ~, ~cx~cod~l~ Mailing Address:
Location: Phone Number:
Legal Description: ~.o7~ ~/~? /~Jc0~ ~o~& Lot
Type of Soil ~sorption System Is:
Trench: Drainfield: Seepage Bed~ ~ Holding
Maxim~ N~ber of Bedrooms.: ~- Soil Rating(sq.ft/br)
Department · Health and Environmental rotecti~
825 L Street, ~_nchorage, AK. 9~501
5 HANDWRITTEN PERMIT
'' WELL AND ON-SITE SEWER
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH x/7~ GRAVEL. DEPTH o~ WIDTH ~0
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 and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimu/n depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /,$~,0¢~ _ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED *l ~ I
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a connnunity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31; 1 9 Q 3 * * *
I certify that:
(1) I am f~uiliar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
I wi~ install the system in accordance with codes.
I u~erstand that the on-§its sewer system may require enlargement if
theJ/resi~enc-e-~s remodel~ to include more that 3 bedrooms.
Applicant /
Date:
(2)
(3)
Signe~:
are
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[-~PERCO LATION
TEST
PERFORMED FOR: N
LEGAL DESCRIPTION: '~"'
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16-
17-
18-
19-
20-
SLOPE
O'
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
D~PTH?
SITE PLAN
Gross Net Depdl to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY:
72-008 (6/79}
CERTIFIED BY:
Job:
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1'- WEST 33RD AVE., SUITE B
· ANCHORAGE, ALASKA 99503
PHONE 276-1361
Soils Logs
ELEV. C~,~ o~-
TH i~
ELEV.
TH
3
4
5
6
7
8
9
10-
11
12
13
14-
15-
16
17
18
19
20
3
5
7
8
9
10
11
12
13-
14
15
16
17
18
19
20-
ALASKA I uIRO[Illl F1TAL COIqTF OL SE!I UiCE!$, I[/C.
~nqincerin9 $ ~nuironmcnlrJI $1udies
SPECIFICATIONS FOR SEEPAGE BED ALTERNATIVE WASTEWATER
TREATMENT SYSTEM AND CURTAIN DRAIN - LOT 8, BLOCK 2,
WOODBOURNE SUBDIVISION
1.0 GENERAL
1,1 THE DRAWINGS, SHEETS 1 THRU 3, SHALL BE A PART OF THIS
SPECIFICATION,
1.2 ALL MATERIALS AND WORKMANSHIP SHALL MEET THE
REQUIREMENTS OF ANCHORAGE DEPARTMENT OF HEALTH AND
ENVIRONMENTAL PROTECTION PERMIT AND REGULATIONS.
1.3 ALL EXCAVATIONS AND DEPTHS ARE ADVISORY AND TO BE
VERIFIED OR MODIFIED IN THE FIELD BY THE ENGINEE]t.
1.4 IT IS THE RESPONSIBILITY OF THE OWNER TO OBTAIN ALL
NECESSARY PERMITS OR EASEMENTS.
2.0 SEEPAGE BED
2.1 THE GRAVEL FOR THE BED SHALL BE SCREENED TO 0.5 TO 2.5
INCHES PER CODE.
2.2 THE BOTTOM OF THE EXCAVATION SHALL BE RAKED WITH THE
BACKHOE BLADE TO INSURE THAT THE BOTTOM }~S NOT BEEN
COMPACTED DURING EXCAVATION. THE BOTTOM ELEV~flON SHALL
BE PLUS OR MINUS 2".
2.3 THE DISTRIBUTION PIPE SHALL BE 4 INCH RIGID PVC OR
POLYETHYLENE. THE PIPES SHALL BE LAID LEVEL,
2.4 AN OBSERVATION PIPE SHALL BE PLACED AS SHOWN IN THE
DRAWINGS. IT SHALL BE RIGID PVC, ASTM 3033 D-3034. THE
SECTION SHOWN WITH HOLES MAY BE EITHER DRILLED 0.5"
HOLES @ 6 INCH CENTERS ON OPPOSITE SIDES OF THE PIPE
OR A REGULAR SECTION OF REGULAR PERFORATED SEWER MAY BE
CLAMPED TO THE SOLID SECTION WITH A NO HUB COUPLING OR
SOLVENT JOINT. A RUBBER RAIN-CAP (JIMCAP OR EQUAL)
SHALL BE PLACED ON THE TOP OF THE PIPE.
2.5 THE INSULATION SHALL BE DOW EXTRUDED BLUE STYROFOAM
BOARD, ARCO GEOFOAM ENBANKMENT INSULATION BOARD OR
WESTERN INSULFOAM II OF THE THICKNESS SHOWN ON THE
DRAWINGS.
2.6 THE TOP AND SIDES OF THE BED SI{ALL BE PLANTED WITH A
WHITE CLOVER AND RED FESCUE MIX OR BLUEGRASS,
3.0 CURTAIN DRAIN
3.1 THE PIPE FOR THE CURTAIN DRAIN SHALL BE RIGID PVC
PERFORATED PIPE ASTM D 3350 LO6K2B.
3.2 THE ROCK FILL SHALL BE 1/2" - 2 1/2" WASHED GRAVEL,
3.3 THE ENGINEERING FABRIC SHALL BE TYPAR, MIRAFI OR
FIBERTEX,
3,4 THE SLOPE OF THE DRAIN SHALL NOT BE LESS THAN 0.45
FT/IO0 FT,
3.5 THE CURTAIN DRAIN SHALL NOT BE PLACED CLOSER THAN 20 FT
TO ANY SOIL ABSORPTION SYSTEM.
~200 ~UCsl 33rd Aucnu¢, SLJil¢ J~ · Anchoraq¢, AI~sJ(o 99503 · {907) 276-1361
ALASKA ENVIRONMENTAL
CONTROL SERVICEr "NC.
1200 West 33rd Avenue ouite B
ANCHORAGE, ALASKA 99503
Phone 276-1361
SHEET NO. / OF
CHECKED BY DATE
SCALE_
I/Jo ,~t~ ~'~
b/e l de ,~
L
ALASKA ENVIRONMENTAL
CONTROL SERVICEr 'NC.
1200 West 33rd Avenue .,uite B
ANCHORAGE, ALASKA 99503
Phone 276-1361
SHEET NO
CALCULATED BY /' Yr ,~'/
OF__
DAtE
CHECKED BY
DATE
SCALF
'1. GENERAL INFORMATION
Complete legal description
MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage; Alaska" 99519-6650 '
CERTIFICATE OF HEALTH'AUTHORITY ..
APPROVAL FOR A SINGLE FAMILY DWELLING
Lot 8; Block 2; Woodbourne Subdivision
Location (site address or directions) 11701 Woodbourns, Anchorage, Alaska
Property owner
Mailing address
Gib and Edie Bosworth
Day phone
Lending agency NORTHRIM BANK
Mailing address_ Anchoraqe, Alaska
Ag e n t2C~Q0~RE~LT~err~ £Pisa
Address 2600 D~n~]~, Fourth Floor, Anchora~ge, Alaska
Unless otherwise requested, HAA will be held for pickup.
Day phone
Day phone 276-2001
99503
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
............. Community_welt
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and ~tatus of system·
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
X
Individual on-site ,: ,
Hoidi'ng tank ' .:
community on-site
Public sewer
If community Wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system,
72-025 (Rev, 1/91] Front MOAIf21
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JeTeM e3!s-uo eq~ 'uo!leedsu! pus uo!leSp, se^u! ,~u~ u~oJj pus Sel!J eOgJoqeu¥ ,to/q!led!e!unbJ
u Jo4 peu!e~]o uop, guuo,tu! sql uo pes~q 3gq~, ~,tpe^ JeqMnj I 'u!eJeq pe~,ea!pu! eJnTonJls,to adh pug
suaooJpaq jo JeqLunu eqT Joj e~gnbep~ pug leuo!~eunj 'ejes s! uue~s,~s I~sods!p Je3gMe3S~M Jo/pug
~lddns Je~gM e~!s-uo eq~ lgqT sMoqs uogge!ldde I~^oJdd¥/qpoq3n¥ qTleeH s!q~ ,to uo!~gS!~se^u!
~uu lgq~ ~jpe^ I 'MOleq UMOqS e3gp uoi~gP!lg^ eq~ jo sg pug o~eJeq pexgjg IgeS ,~uJ ~q pe!j!~Jeo s¥
~NION~ A8 NOliO~dSNI dO IN~lVl$
WELL DATA
Well type~'¢'~//~*~¢~ If A, B, or C, attach ADEC letter.
Log present O~N) ~'/ . Date completed /
Total depth ~,-z=~ Cased to _ \'~
Sanitary seald~N) ~
Municipality of Anchorage ~
Department of Health & Human Services M~j~iT¥ OF ANCHORAGE
HEALTH AUTHORITY APPROVAL CHECKLISTENVI~T^LsERvlcEs DIVISION
SEP 18 1991
Parcel I.D.
RECEIVED
ADEC water system number
/ ~ ~ ~'~ Driller
__Casing height \,.~. d
Wires properly protecteq[J~N) V
FROM WELL LOG
Date of test _
Static water level ~[ !
Well flow "7
Pump level t,..)~(_~
g.p.m.
AT INSPECTION
SEPARATION DISTANCES FROM WELL '1"O:
Septic/hekf~g tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS: ~/,~
Coliform (~ ~'~'b,,~l ,,~-~ ~v~ Nitrate __ ~::~' ~
Date of sample: '~'~'~'~'~'~'~'~'~'~ ("¢'~"¢~,) Collected by:
Other bacteria
R. SEPTIC/HOLDING TANK DATA
Date installed
Tank size / ~"-~=dP Compartments
Cleanouts~N) y Fo u;d~"O n clea n ou tdC~N) y Dep ress[~? (Y,~:I%~
High water alarm (Y/N) /~ Alarm tested (Y/N)
Date of pumping ~¢;~' ~ '~ A ~ ~ ~ ~
SEPARATION DISTANCES FROM SEPTIC/HOI_DING TANK TO:
Well(s) on lot / ~ On adjacent lots
To property line lot Jr- Absorption field
Surface water/drainage / ~1 j~
Foandation _ ~
Water main/service line
72-028 (Rev. 3/91) Front MOA 21 CONTINU ED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Manhole/Access (Y/N)
Vent (Y/N)
"Pump on" level at
"Pump off" level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacentlots
Surface water
D. ABSORPTION FIELD DATA
Date installed ~ I E:)- ~
Length '~¥'~ Width
Total absorption area
Depression over field (Y~)
Results(pass/fail) /'~'_~ ~//--~-~
Peroxide treatment (past 12 months) (Y~
Soil rating \'~'~ .4~/.'¢-rz-- System type
Gravel thickness
Cleanouts present ~:¢~7N)
Date of adequacy test
for
'A,// If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot \ .~.1 On adjacent lots ~ <~tC'r'r~''~
To building foundation
On adjacent lots '¢'~¢:~
Cutbank
Surface water
Curtain drain
Property line
T/e existing or abandoned system on lot
N" 0'N/¢ Water main/service line /~.~
Driveway, parking/vehicle storage area ~ t ~_~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect,~?h¢~date of this inspection.
S & S ENGINEERING
Signature !7e34 Eag[~ River L~ Read No.
Eagle River~ Alaska
Engineer's Name
HAA Fee $ ;~--~'~ Waiver Fee: $
Date of Payment _~ "' /-¢- c// Date of Payment
Receipt Number ,:::~..3~ 774~ ~ ? ~"7~ Receipt Number
72-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY'
A DIVISION OF COMMERCIAl. TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
AHALYSIS HEPOHT BY SAI~LE fox WOBKordo~ 36970
Date Report Printed: AUG 7 91 @ 16:37
Client Sample ID:L$ B2 NOODBOGHHE
PWSID :UA
Collected AUG 6 91 0 14:30 hrs.
Reeeivad AUG 6 91 0 iS:lO hrs.
Preserved with :AS REQUIRED
Client Name :$ & S ENGINEEEIHG
Client Acct :SNSENGP
B?O # PO # NONE RECEIVED
Ordered By :H. SHAFEE
Analysis Completed :AUG 7 91 Send Reports to:
Laboratory Supervisor :STEPHEN C. EDE 1)S & S ENGINEERING
...................
Chemlab NeE #: 913936 Lab Smpl ID: 1 Matrix: ~ATEH
Allowable
Parameter Tested Result U~ts ~ethod Limits
HITHATE-N 0.46 m~/1 EPA 353.2 10
Sample ROOTINE SAMPLE COLLECTED BY:
Remarks:
1 Tests Por£ormed ' See Special Instructions Above UA-Unavailable
ND~ None Detected *' Nee Sample Remarks Above
NA= Not Analyzed LT-Less Than, GT=Greate~ Than
~.~Sr~S Member of the SGS Group <Soci~t¢ GOnOrale de SurveUlance)
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTN
DEPARTMENT OF EEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR tlEALTH AUTHORITY APPROV~ CERTIFICATE
1. General Info~ation Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name~(~L~L~ Telephone - Home ~usiness
(c>Applicant is (check one) Lending Institution
Buyer 2] ; Other [~[ (explain);
(d) Lendiug Institution TeJ.e~one
Address
(e) Real Estate Co. & Ageat
Address
Telephone
(f) Mail the HAA to the following address:
'2. ]~yp.~e o~f Residence
Single-Family ~_~[
Number of Bedrooms
3. Water Su2~_~Z..'
Individual Well .__~]
Multi-Family ~--~
Other (describe)
Commnnity []~ Public
Note: If commueity well system, must have written confirmation from the State
Department of Environmental Consorvation attesting to the legality and status,
Sewage____Dis__p~osal
Note: If community well system, must have written co~rfirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
Engineering_g_ Firm Providin_g~.Insp_ections, Testsn~File Searg_h_~ 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 oa-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the aumber of bedrooms and type of structure indicated herein. I further verify that,
based on the info~ation obtained from the ~nicipality 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-
tions in effect on the date of this inspection.
Name of ~irm~~ ~;~l~ ~.~' ~ ~/~,,j~.5~j.~_ Telephone 5~/'.5~ ~J
(ENGINEER
pH__ LuEp p_/_ov al
Approved for -~--~J bedrooms
Approved ,~ Disapproved
Terms of Conditional Approval
CAUTION
TRE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DtlEP) ISSUES IH~ALTH AUTHORITY APPROVAL CERTIFICATES BASED ~_'O.]~_L_Y. UPON TIIE REPRESEN~f-
ATIONS GIVEN IN PARAGP~kPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN T~U{ STATE OF ALASKA. THE Dt[EP DOES Tills AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. F~MPLOYEES 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.
(DtIEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
As
WElL [~%TA
Well Log P~esent G/N)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Lega% Description:
MUNICIPALITY OF ANCHORAQ~
DEPT, OF HEALTH &
I!NVIRONMEN'[AL PROTECTION
AUG ~ 0 I984
R[C[IV[ D
If A, B, O~ C, D.E.Co Approved(Y/N). ~/-~-------z~
Date Completed 1 ~/~ yie~7~
Total ~p~ /~ ~ Card to
Static Wate~ ~], ~[/~ ' ~ ~ At ~O"~f~,[ /o~
Casing ~ight ~~nd ~3 ~.~ Sanit~y ~a% on Casing ~)
Elec~ical Wi~ing in ~nduit ~) ~ession ~ound ~l~ead
'~p~ation Distances f~ ~11:
To ~ptic~olding Ta~ ~ ~t
To ~a~st F~ge of ~so~ption Field on ~t,.
To Newest Public ~ Line
Clean, t/MaXcie ~/~ ,,
Wate~ Sable Collected By ~, ~~ ,
Wate~ S~le Test ~sults
B. SEPTIC/HOLDING TANK DATA
Date Installed /~/~'~/~I~ _ Size /~O~
Standpipes ,~N) Ai~-tight Caps ~N)
Dapl~ession over Tank (Y~_} Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~ .;
No. of Compartments O_
_Foundation Cleanouh~N)
Holding Tapk High--Wate~ Alarm (Y/N) 7~/~/7~ Temporary Holding T~nk Permit (Y/N)__~/~_
Separation Distances f~c~ Septic/Holding Tank:
To Water-Supply Well l~Pl/~'
· o opert 16 +×
TO Water Main/Service Line _ ~/~.
cou~ ( 004`/~
TO BuiJ.ding Foundation ~/~
TO Disposal Field '~,~-/~F-
TO Stream, Pond, lake, c~ Major' D~ainage
[Page 1 of 2]
2-15-84
C. A~SORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field '~l FAc
~ ~- Type of System Desi~gn
Depth of Field /~ %/2-/ ~
Gravel Bed Thickness }/~_/ ~y
of
~p~ession eve= Field (Y~ ~te of ~st A~a~ ~st ~/~
Results of ~st ~a~ ~st ~j,~ ,~
~paration Distan~ fr~ ~s~ption Field:
TO ~te~-Supply ~11 ~7 ~ f ~ To ~o~rty Li~ I C)'~/ ~
To Building Foun~tion l( [ d ~ To Existing or ~ndomd System
Lot ;~;/~ ; ~ ~joining ~ts (~+ / ~
To Wate~ Main/~vi~ Li~ ~/~ To ~t~(if preset) ~/~
To Stre~ond~ke/~ ~jo~ ~aina~ C~ //)~/o
To ~i~way, P~ki~ ~ea, ~ Vehicle St~a~ ~ea ~ ~ ~ o
Counts ~ ~ ~.~ ~J
D. LIFT STATION
Date Installed
Size in Gallohs
"Pump On" Level at
High Water Alarm Level at
Tested for ~ing Cycles~X~ing Adequa~
Electrical Co~s(Y~)/
Co~m~nts ~. x~
~ Dimensions ~
/ x~ Vent (Y/N)
Test o
Meets MOA
** Check Permitted Bedroom Rating Against HAA t~quest
I certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed ~ ~/~ ~4/~./~ Date .~z~//~/~
Company
KB1/d5/s
[Page 2 of 2]
MOA NO.
2-15-84