HomeMy WebLinkAboutGREENBROOK BLK 1 LT 2
"" 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: ~~:~ c~'TJ ' ' ~-- PID Number:
-, Wastewater System: ~ New ~Hpgrade
Address: '
~¢~ ~~ ABSORPTION FIELD
Phone: ~ ~ No. of Bedrooms: ~eep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
LEGAL DESCRIPTION so, Rating: Total Depth from original grade:
Lot: ~ Block:~ ~ ~Subdivisi°n:~o~ ~ Depth to pipe bottom from original
Ft.
Township: Range: ] Section: Fill added above original grade: Gravel length:
Number of tines: Distance baleen lines:
WELL: D New . ~ Upgrade Grave[~~ ~ Ft. / ~ Ft.
Classification(Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Drilled: Static Water Level: Installer: ~ ~ Date in,tailed:
Yield: GPM Pu~p Set at: Ft. Casing Height Above Gr0u~d:Ft. , TAN K
SEPARATION DISTANCES ~pt,c ~ Ho~d~.g ~ S.TZ.P.
TO Septic Absorption Lift Holding Public/Private Manufacturer: Capacityin gallons:
From Tank Field Station Tank SewerLines Material: ~,'/~ NumberofCo--ments:
Surface ~ ~ ~ LIFT STATION
Water
Lot Size in gallons: Manufacturer:
"Pump on" level at: "Pump off" level at: High w~ter alarm at:
CudainDrain ~ ~ Pump Make & Model Electrical Inspections pe~ormed by:
Remarks: BENCH MARK
~ ~ ~,~ ~ Location and Description~
Rewewed and approve -. Date:
72-O13 (1/91) MOA 25
/
/
N
gO 75 100
SCALE; I' = SO FT,
J
TDBBEN SPURKLAND P,E,
203 ~ 15TH, AVENUE
ANCH, AK, 99501
SEPTIC SYSTEM AS BUILT
DATE, Nov, 16, 1993
SHEET, £/3 GRID, £839
Monitor
Cleon ~Tut
50' Long
11' Deep
6' Sewer rock
5' Covem
53
EXISTING TRENCH
BULL RUN
Mira £! 140
6 £t oF' Septic Rock
ND SCALE
80
· -rn
I850 gal. septic tank
Anchorage Tenk Steel
BENCH MARK; TDP DF BECK
ASSUMED ELEVATIUN: ]00.00 FT,
OBBEN SPURKLAND P.E,
203 W15~h Ave
Anchorcge Ak 99501
BLDCK ] GREENB£DDK
[DY LEWKII~/SKI
6900 CALLAWAY CIR
SEPTIC SYSTEM AS gUILT
D^TE, No~ l~ 1993
SHEET, 3/3 G~,~839
------PKGE ...... ~"'OF 1
MUNICIPALITY OF ANCHORAGE ///',/~ - F3
DEPARTMENT OF HEALTH AND HUMAN SERVICES,,//~ '~ .
P.O. BOX 196650, 825 "L" . STREET, ROOM 502/, ~'-C~/['/ /~7
ANCHORAGE, ALASKA 99519-6650 ~-~ ~
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW930471
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:LEWKOWSKI ANTHONY J &
OWNER ADDRESS:6900 CALLAWAY CIR
ANCHORAGE, ALASKA 99516
DATE ISSUED:il/08/93
EXPIRATION DATE:il/08/94
PARCEL ID:01702351
LEGAL DESCRIPTION: GREENBROOK BLK 1 LT 2
LOT SIZE: 60321 (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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
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 PROVISIONS:
RECEIVED BY: ~,-- '~~'~~
Lt~T
SF~UR~LA~D F'. E.
205 W 15th. Avenue, Suite 206
ANCHQRABE, ALASKA 99501
(907) 279-5916
SEPTIC SYSTEM DESIGN
2 FI:~L OC ~-~ J.. GREENBii:OOK SiD
TONY LEWKOWSKI
No Ground Water or Impervious Layer to 16 ft.
Use Standard Trench
Soil Rating. From test October 11, 1995
5 min/in = 1.2 gal/sq.ft.day
Required Arem per Bedroom:
150/ 1.2 = 125 sq.ft..
Tank total depth
Less 4.3 feet
Min. Depth to Bottom of pipe
Testhole Total Depth
Less 6 feet
Less 4.3
8.5 ft.
4.2 ft.
4.3 ft
16 ft
10 ft
5.7 ft
Reck Depth 5
Number of Bedrooms 3
Min Length of Trench 125 x 3 / 10 = 57.5
Use 50 ft.
SYSTEM CONF I GIUiRAT I ON
STANDARD TRENCH
TOTAL LENGTH
TOTAL WIDTH
TOTAL DEPTH
RDCK DEPTH
COVER
SEPTIC TANK
50 FT.
2 FT.
10 FT.
5 FT.
5 FT.
1250 GAL. Existing
Install diYerter valve between
existing trench and new trench
There are ne developed or natural surface / sub surface drainage
courses on this or the adjacent lots.
The proposed septic system will not change the general slope of
the area. Pending and/or concentration of surface runoff will not
result from this installation.
Sep'l: i c Sys'l:em D~,~si gn
SCALE: I* = 100 FT,
LDT £
A
DEA£MDUN £DA9
LDT 10
~ LO? II I c:q
'DBBEN SPURKLAND P.E,
203 ~ 15TH, AVENUE
ANCH, AK, 99501
LOT ~ ~L£CK I G£EEN~B£DDK $/~
TDNY LEWKDWSKI
6900 CALLAWAY CIR.
SEPTIC SYSTEM I)ESIGN
DATE, OCT, £5~ 19~$
SHEET, 1/2 GRID, ~859
££ALD 1' --- 50 FL
I
I
I
I
I
I
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J
I
I
I
I
I
I
I
I
E03 ~/ 15TH, AVENUE
ANCH, AK, 99501
SEPTIC SYSTEM DESIGN
DATD [7£~ £S, 1993
SHEET, 2/3 GRID, 2839
Nonltor
Clean
Clean Out
Standard [renche :
50' Long
10' ~eep
S' Sewer rock
5' Cover
_1
Cleon Out
53
EXISTING TRENCH
I0
"l
new cleanout
BULL RUN
Clean outs after tank
not required,
Access to al( Nnes
through dlvertervalve
140
7 £t o£ Sep~ic Rock
iCleanouts ~
ND SCALE
Exist, Ground
4' kiln Cover
~over Tank
]250 9al, septic tank
Steer Steel
]BBEN SPURKLAND P,E,
803 ~15th Ave
Anchorage Ak 99501
LZT? £ BLDCK 1. 5£E£N££DDK
TOY LEWKDW'SKI
6900 CALLA ~/A Y CIR
SEPTIC SYSTEM DESIGN
])ATE, L/C~, 26, 1993
SHEET, 3/3 GR.[]], £839
He~j:h and Environmental Protq ,ion
Fourth Floor West ~'-~
825 L Street
Anchorage, Alaska 99501
264-4720
........ IN'SP~cTION REPORT ON-SITE SEWAGE DISPOSAL SYSTL~M
SEPTIC TANK:
FROM Wi_LL ......... MANUFAC7URER_~- ~---- MATERIAL
NUMBER OF
COMPARTMENTS
LIQUID CAPACITY_~ ~,S~D_ GALLONS.
TILE DRAIN FIELD:
TOTAL LENGTH
DISI/;,N('E FROM WELL .... FOUNDATION *~-~ NEAREST LOf LINE_..~.O~ ..... OF LINE .~'~) ....
/;,[~SORFIION AhIEA ..'~O ....... SQ. FT. LENGTH OF EACI{ LINE
DEPTH
OF
FILTER
DEPIlI: iOP OF TILE 10 I-iNI5tl GRAF)E
__ MATERIAL BENEATH TILE Q:~O IN. ABOVE TILE'~%_ .__.IN,
SEEPAGE Pl']':
Log Crib ___
Rings
DI.,VV1E-FER __ OR WIDTH __. LENGTH. DEPTH
BUILDING FOLJNDA1 ION .....
Crib Size: DIAMETER ...... DEPTH.____ DISTANCE FROM: WELL
TOTAL_ EFFECTIVE
NEAREST LOT LINE __ ABSORPTION AREA (WALL AREA)
,SQ, FT.
~ass: Depth:
~ell Distance To: Lot Line
~ldg: Sewer Line:
~ipe Materials:~Te~t
~ of Bedrooms: ~ %~.
~emarks:
APPROVED
F'EF::f'I :[ T
t::[F'F'I.... ]: CI::INT L ",7::K1.,.I[:,3[:, HOI'IE'::!; I NC
L L":I ] I.:1 ]" t: Ftt'-,I .I-. L I.. H..,.I- T E: I I::~:
LEGFI[... L..;E: E::'L '~iI::;'EEI'.IEF".:'ICd'(
"r'.r'F'E Ol::: :E;O l L. [:t[i'~LSEdq:[irl~ I ON ?:;'¢:ii;'T'Eiff'l 1:5: Tlq:ENE:H
'601L. lq.'.liT I NEi ,:: :ii;Ii:! FT,-."E:I:~: :: .... :1.7!5
'THE [...Ei'.,IEiT[4 D :t: HE:i',t:i'~; :!: ESI I E; 'THE LEt",I(!i!'H ,:.' I N I::'EE:"f' ::, OF:' THE Tlq':IiEt'.,IC:H O,'-'~: [.':,lq:F:l:!: NF: ]: E:L.[.':,.
THE I:>EI::'TH Ot::' R TIq:EI',ICH Olq'. F'IT IE; THE: [:, :I: ?,TRIqCE E~ETHE."EI",t THE: '."~;IJlq'.l:::i:!OE OF THE:
Glq:OUl',![.', I::IND THE EJO'T'TOM ElF' THE IE',:-':CR',,,'II'T' I ON ,'.: I I",! FE:ET).
THE[;.'E :TEl; I',10 ?.;ET 14:[DTH I::'F)F~:
THE GRF:IVIEI_. [:,EI::'TH I¢5 THE I"'IINIMUM DEPTH O1:: GRII',,,'EL. [II:ETHEE:N THE OUTF'F:IL.L F'IF'E
Iai'.4[:.', TIdE ['%)TTOM O1:::' THE E::.:;C.'FI',/RT 1 O1'4 ,.'.' :f: N I:.":EE'r >.
;:-:-- ................................................ F::" F:II Iii;;: E:::: ~:=~ iC~ E:
F! PIIIT_:I<:FIGE: PL.I::INT Hl::t"r' 1!3E IN'.:!!;TFIL.,I,...E[:' R'T'
FOI...L. EIt41NG
'.'L. IEITHEI:;;'. FI CL. RE;:'ii; .l: OR II
2:. FI CONT I N[..ICIt..t:!i; I"ll'q I N'T'EN
FK:~lq:EEHENT I E; i'.,IEIT
F:IE:SORPT I ON
I"'/"tEE '" :E; OF'T l :51JE:.irECT 'T'O THIE
::iF,r/"
l :!::; I::~:E:QL
t'11:::t"r' E:E
Ml:a'.r' I!i~E E;
N :i:.:; T li L..[.. E E:,.
F' li HFItI",!'T'ENFINCE
TO ENL. FIRGE THtE :ii;OIL.
!::'E;IEC::[J T :[ ON.
E~F.:If_":I<:F: ILL :[ NEi OF'
DEF:'FIF.'.TMEI'-,F!" I.,.I :[ I_L E;UE',.:rE
E C:-IF' %
OIJT F ]: i'-,ll:':tL I
!C:'l"I ON FII'-,!E:, F:tt::'P'I'i: ::: 'v'FIL E:"r' TH I :E;
M I N I HUM [:' I E;"FRIqCI
::i..E~C~ FE:ET I::OR F!
OTHEt~: lq'.E Q
!:~',,,'t:'~ ! L.F'IE',L.E TO ]: NE;Ulq:
I::1 I.,.IE:LI~. liNT>
!L.L. OR 2E:.lEI FEE:!" t::'O[4: FI F:'UE',L. ZC 14EL..L.
~:;F:'EE: I I::' I CRT I I]fl'.,IS liNE:, C:Oi'.,IS"FI;UJE:T !' ON [::, I [:tG:lq.'RH'.:+.'; lIRE
>lq:EIF'Elq'. l N:!:.:;TIIL. L.FFt" 1' ON.
I _.EN I 11- r TH[:IT
J.' .T FIM FIIMIL. IFtlq: I,I]"T'H THE RE6!U:r. lq'.E:HENT:':~; F:'Ellq: L"IIN.-E;ITE '.'SEHER'}.'i; liND 14EL. L:i.:; iI:.'.':: :5lET
FOI.:.:TH :, "Fl-liE HUN I C: I F:'IIL.:t: T'./ Olq' F:tNF:HOI:;~:f-~[:~iE.
· 2-.::: I H'[LL. :[?.,t2;TIII_L. THE: ::, r.:, t El1 'll',t RCCCd::~:L":,FINCE !-,.II:TH TI-IE '"OF:,I:E:E;.
::~:: I Ijt'.,II::,Elq:E;TFINI) THliT "['HIE EII'.,I.-E; l TE ':'i;EHER .:, :: -I I::11 MR'T' F.'F'¢:,LI ]: RE ENLFIR[3EHE:NT I F' TFIE
F:E'.::;IDIEI'-dCE" ]:E; _IREI"~:E.',EI~" T'O ~L.[J[::,E h'lOl:;i:E THliiq :~: E',EDlq:C,3M2;.
E; I GNEC,: ..~~ ....................
' · ~ Pot~j 6-650, 99502~- - '2518 E. Tudor. ~
, ., . ~ Anchorage, Alaska.
Legal Descript'i"on:z~?- Z -_~'z_~ / ~~_~. ~u~.
'~'his form reports: Soils log ~ P~'co]ation test ~ J4/. m~ /-///~-z~/~---)-i--~---
Depth
Feet <
4-
5-
6-
11
]3-
14 -
Was'ground water encountered? //~/~'
Reading
·Date
If yes, at what depth? ' ' '
Gross Time
Net Time
Depth to H2O
I
Percolation rz
Net Drop
te minute
installation':" seepage Pit ..... Drain Field '
Proposed
IlePth of Inlet . Depth to bottom of pit or trench .
¢r,ormed By. ~o ~ /~~ Certlfled By:~ ~ .~ Date: L2'I - 77 . · ~/~ i~~
,/
MUNICIPALITY OF ANCHORAGE Z~,
DEPARTMENT OF HEALTH & HUMAN SERVICES .I
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # (-~'\'-'~ - (L~-~'~,~3 -'-~'\ NAA# ~-~,
1. GENERAL INFORMATION
Complete'legal description
Lot 2; Block 1; Greenbrook Subdivision
Location (site address or directions)
6900 Callaway
Anchorage, AK
Property owner
Mailing address
Lending agency
Mailin. g address
Agent Beckie
Address
Troy Hayes & Joann Sullivan-~Dayphon
6900 Callaway Anchorage,
348-6150
Day phone
Brocies/ Dynamic Properties Dayphone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ~r
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
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
NOTE:
xx
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
5. 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 [he number of bedrooms
and type of structure indicated herein. I furtherverifythat 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 rec~ulations in ~ffec~orLthe date,
Name of Firm
Address ,
EncneeFs signature [ .... ~//
bedrooms.
DHHS SIGNATURE
P~ Approved for
~ t,his inspection.
Phone
Date /0/,2'-~?///~:
q~ ruFESS~0
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-O25(Rev. 1/91) Back MOA~21
Legal Description:
WELL DATA
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 ·
' 'V~ONMENTAL
Health Authority Approval Checklist,
,.~, or C, attach ADEC letter. ADEC water system number
Well type
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
(Y/N) Date completed
_ Cased to __
Date of test ~
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform Nitrate
g.p.m.
Date of sample:
Collected by:
SEPTIC/HOLDING ~?NK DATA
Date installed t/f~ ~ Tank size
Foundation cleanout (Y/~A~'T
Date of Pumping ~!_~)_rg_ [c/~
f~3..~ Number of Compartments'~- Cleanouts~l)
Depression (Y/N) /~J/z} High water alarm (Y/N) /V'
Pumper /~'~-)~
ABSORPTION FIELD ~ATA
Date installed ///~ Soil rating (g.p.d./fF e~-ft%'Sdrm) /' ~-
Length ~)/' Width --~ [ Gravel thickness below pipe
Effective absorption area '~)~ Monitoring Tube present (Y/N) y
Date of adequacy test f~,,~r/./~/X~'d,Jg;,,, ~/L~'/~27 /' ~' ¢'~
¢,f2ry./A/. ,~,~_~. Results (Pass/Fail) /9'A"J"~
Fluid depth in absorption field before test (in.); /~)/r~- Immediately after
Fluid depth ~ (ins) MinuteS later:
Peroxide treatment (past 12 months) (Y/N)
System type
Total depth
_ Depression over field (Y/N)
For / bedrooms
72-026 (Rev. 3/96)*
"'""gal. water added (in.):
Absorption rate = ~-~ .g.p.d.
If yes, give date ~
O/'J
L,F
Dat installed ~'-----~.. Size in gallons
Manhole/Access (Y/N) ~Pump off" level at*.
High water alarm level at* ,...-.- *Datum
SEPARATION DISTANCES
SEPA Nq2t~TANCES FROM WELL ON LOT TO:
Septic/holding tank on Iot~-~-~ On adjacent lots
Absorption field on lot
Public sewer main _.~._.~.-.--~'-""~ Public sewer~
Se~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ l,f., Property line ~--/4- Absorption field ~
Water main/service line /0 t4' Surface water/drainage /~)C~/4.- Wells on adjacent lets
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
P¢opertyline
Surface water
Building foundation /~) ~/~ Water main/service line
/',/- Driveway, parking/vehicle storage area
Curtain drain
inspections and review
~es in effect on this date.
ENGINEER'S CERTIFICATION
I certify that l hav~c.dcter/r}//ne/dfhr~
in conforrnaywith~7/~oid
Signature
Engineer's Na~
Dato
/.f_
Wells on adjacent lots
of Mumc,pal rec~t'¢, ~ are
HAA Fee $. "--'~ ~/~"¢-' ~
Date of Payment /
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Parcel I.D. # ~--~
MUNICIPALITY OF ANCHORAGE ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section M ]TY OF ANCHOP, AGE
P.O. Box 196650 ' Anchorage, Alaska 99519-6~L,clNE/iRONMENTALSEI~VICE$ DIVISION
343-4744
SEP 18 1997
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~ '-7 -- (~ :~ ~ -- ~-/ '~ NAA # ~ ~C~ "-'1 (-~ L.t ~1 ~
GENERAL INFORMATION
Complete legal description
Location (site address or directions) /o?OO ~_4LLz~//dR-,y' ~_~./~,
Property owner '~o~, ~ ~pE_~F~ ~Ew~.ou~&~:~ Day phone
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
'~,'~.SF-.~' } %~'~-~ ~"'-+-'-P~ Day phone
Un/ess otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State AD£C attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
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
5. 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/orwastewaterdisposal 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
Address
Engineer's signature
Wa~iewa!er Services
847! ,91'O0k/icae Dr.
Ascii., AK 9,'-3504
Phone
Date ~ .///7/~-~
DHHS SIGNATURE
Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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.
72-025 (Rev. 1191) Back MOA ~Y21
Municipality of Anchorage MUNlaPAU'n' OF ANCH~
DEPARTMENT OF HEALTH & HUMAN SERVICFa~mON~EN'r~s~RVlCES{~,~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343,~4] 8 't99 P'"" '-"
Legal Description:
Health Authority Approval Checklist
~--(~FJ~rJ~ ~ ~]0 Parcel I.D.:
RECEIVED
A. WELL DATA
h-~...Well type ~/?0~/f//~/~/'f7 If~ B, or C, attach ADEC letter. ADEC water system number ~. I(-_)'-~ ~'¢° ~/
...... Date completed _ ~
Total depth ~,_ Cased to ~ __ Casing height~abdve ground). __
Sanitary seal (Y/N) ~ W~rotected (Y/N)
FRO~AT INSPECTION
Well production ~ g.p;m, g.p.m.
Bo
C=
WATER SAMPLE ~ULTS:
Coliform ,~
D e~of sample:
SEPTIC/HOLDING TANK DATA
Date installed Jl/l¢/~.,, ~3o~E. Tank size
Foundation cleanout (Y/~
Date of Pumping o[/[ (:> / °l '~
ABSORPTION FIELD DATA
Date installed ///[~ /~}
Length ~ ~ Width
Effective absorption area ~(~0
Nitrate
Collected by:
Depression (Y/~) /k.~o High water alarm (Y/N)
Pumper b~AL~.~L- r~f~/¢¢2. 'M(7
Number of Compartments. ~ Cleanouts~N)_ ~
Soil rating (g.¢.d.//ft2 or fF/bdrm)
~ ' Gravel thickness below pipe
Monitoring Tube present (~N) y
System type ~*"~C::::~:~¢
Total depth
Depression over field (Y/~__~
Date of adequacy test c~ / [~/c['~ Results(Pass/Fail) ~S% For ~O~P.- bedrooms ,,
Fluid depth in absorption field before test (in.); ~(>~-" Immediately after~¢'O gal. water added (in.): ~/J.~O,
Fluid depth /_./! ~l (ins) Minutes later: J(:,O ,MI~ Absorption rate = ~)0 ~ g.p.d.
Peroxide treatment (past 12 months) (y(~/)~ ~ K/[/~Mr~ Ifyes, givedate
72-026 (Rev. 3/96)*
D. LIFT STATION
Absorption field on lot
Public sewer main
~ervice line
Da-'~ee ihstalLed Size in gallons~ ~-~--~
Manhole/Access (Y/N) -~ ~ "P~~~
High water alarm level at* ~ *Datum
SEPARATI~~S FROM WELL ON LOT TO:
Septic/holding tank on Iot~ On adjacent~~
~n~ lots
~ Publ~~hole/cleanout
Lift station~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation
Water main/service line _
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line
Sudace water
Curtain drain ~6r~-
"Pump off" level at*
Absorption field
Wells on adjacent lots
Building foundation /5 ',/- Water main/service line /O
Driveway, parking/vehicle storage area
Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that I have det, ecnined t~u field inspections and review of Municipal records
in conformanc~::/A~/ui~linesin effect on this date. ('~
Signature ~~{~'- ~'-"'-'
Engineer's Name/~' '//J~-Z..~ ,~- ~,~,¢__~----~' :' '
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
},.__/ D~.-,.E RECEIVED
~ INSPECTION APPOINTMENTS
MUNICIPALITY OF ANCHORAGE MUNICIPALI~ OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
ENVlRONMENTALSANITATION DIVISION JUL A 9 1981
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER A
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow tel~0) days for processing.
1 PROPERTY OWNER . .,,, / PHONE .
pROPER~Y RESIDENT (If dif~ent from above) ~ .~ ~. ~.. /PHONE
MAI LING ADDRESS
3. LE~.I,~ I~STITUT'O~ -, C~ ~ / ..~H O N E
4. REALTOR/AGENT/), .
6. TYPE OF RESIDENC~F~
[~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF BE~S
[] One LJ Four [] Other
[] Two [] Five
j~ Three [] Six
7. WATER SUPPLY [] INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
*ATTACH WELL LOG. Awell 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
~ INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INST~L-'L'-~D,
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE ~IATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1, TYPE OF RESIDENCE NUMBER OF BEDRODMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDtVl DUAL/ON -SITE DATE INSTALLED
Connection Verified INSTALLER
[~]Septic 'rank or [] Holding Tank
Size:_/--~- ~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Ta~ orption Area Line '~ Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
¢ APPROVED FOR F BEDROOMS
[] CONDITIONAL APPROVAL (letter must a~compan¥ certificate)
[] DISAPPROVED /' (,~/2~..