HomeMy WebLinkAboutVALLI VUE ESTATES #2 BLK 1 LT 64
'~-~UNICIPALITY. OF ANCHORAGE f-
l and Environmental ]?rote0' m~n
Heal
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
279-2511, x 224, 225
SEPTIC TANK:
DISTANCE ~ ~ ...~_.~LO___'~'_ NUMBER OF
EROM WELL_"~-Z_~ ~__)~ ' MANUFACTURER ____ I%~A'I'ERIAL ............. COMPARTMENTS
INSIDE LENGTH ......... INSIDE WIDI'H .... LIQUID DEPTH
LIQUID CAPACII'Y-/<¢~0 GALLONS.
TILE DRAIN FIELD:
TOTAL LENG1-H ~ ~-~ r
DISTANCE FROM WELL ....... FOUNDATION ........ NEAREST LOT LINE ....... OF LINE
# of Lines DIS'rANCE BETWEEN LINES TRENClt WIDTH .... ~'~'~ IN. TOTAL. EFFECTIVE
ABSORPTION AREA ~'~'~('121 _ SQ. Fr. LENGTH OF EACH LINE
DEPTtt OF FILTER I ~.~ I!
DEPTII: TOP OF TILE TO FINISII GRADE__ MATERIAL BENEATH T LE ~ __~, ABOVE TILE ...... IN,
SEEPAGE PIT:
Log Crib Rings
BUILDING FOUNDATION_
DIAMETER OR WIDTH__--, LENGTH ., DEPTH
C'~ib Size: DIAMETER___DEPTH_ , DISTANCE FROM: WELL__
TOTAL EFFECTIVE
NEAREST LO¥ LINE .... ABSORPTION AREA (WALL AREA)
_SQ. FT.
Well
Class: Dept~:
Well Distance To: Lot Line
Bldg: Sewer Line:
Pipe M~erials:
9 of Bedrooms:
Installer:
Remarks:
J /i
.... ~L_J .. .'
1
DATE
'l't..l!ii: I.Et'.,t[?i'i"FI B,Z!'"iEi'.4:F:;']:Ed'.,f :!:'Z THIE I..Ei"4GTH ,::]:N FtE!E'i"::, OF: THE Tt~IEI",!E:FI OI;;'.
-it..ll!i: [:)l:i!:l:::"]!.t O1::: F:I TI:RI!!i",!E:H E)F~: F::'ZT ]::!ii; THI:!: [:, ]: :E;TI::!i'-,ll;]:[~: E;i~TF!.,.IE!:EN THE :i!i;I..l[,~:l::"t::l(::[E OF THE
GI:,:-'.OIJi-,li) f:lh,lD 'l'Hiiii: [~::]::dl'TOl,'! OF 'I"H[:; Ei:::qCF!',,,'R'f'];OH ,:;:!:i'.4 F'EE:'T:).
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f::l I::'I::IC::k:Ft(3[~: F'I.F:I?',IT t"iF:l"r~ E:[{ :i: F,Ei!;TI:I!. .t .E[':' FIT "t'kl[i{ F:'EF;'.H]:TTE:E;':~ OF'T:[ON '_-'~;I...l[~:.:t'li!~l;::!" '1"O THE:
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FIEiFi:!EEi:HI~:i",Fi' ]:¢1; NEFf' I':::[¥::'T C:I.IF~:I:?.E:NT "¢OU HI:T-r' IiFJE: t:~'.!:::)::!Li]:F?.E:[) TO E::!",II..I::II.:-'.'CiiE: THE
f::IE~t~!;CIt:RF'T]:E!N :5"¢ZTI':::H F:ff',ff),.'"CI!:R ¥OLI tqFl¥ iEJE :iSI.IE~.]'!ECT TEl
/
LOCATION SKETCH ' TEST BOLE NO. 1
· . __Scale: 1"=3' ' ~' '"~ ~u
. · · ~,~.~, FILL - SILTY GRAVEL w/ ~"
~_~ TRACE SAND '
~ ~-~-'~'--,v~ Numerous Cobbles and
D~ Boulders
3'
SILT (~)
I,.~ Slightly Moist
SAND SILT AND
~'. - :.':~ GRAVEL (SM)
.~:':~....: Moist
~:"~' 8'
~ ROUND TREE / '.~
I 75,
Lot 64, Block 2, t [.o/. SANDY SILT w/ GP~\rEL (S~)
Valley View Add. No. 2, I ~--~ ~Moist
Anchorage, Alaska ~
Distances sho~,m are approximate and '...~ .
have not been measured by surveying ..~_~ .
methods. ~r7~.~ ·
Not to Scale.
20'
:" SAND W/ TRACE SILT AND
A ~'~ ~ T~CE G~VEL (SP-SM)
':~ Moist
~/':: 23'T.D.
-~r-~ !i~i-i~-~ -..}.w ].--. i "'.r;i].'-'iT. Ji~-' withinThisGr~undwate~l°gthedepictStest~as' n0~hol~SUbsurface en'coun~er ed .'at_the soilSlocationObServed' '"':~' -shown.'-' /-
See Drawings B-01 and B-02 for explanation
of.-symbols. ' - ~-'
ow~, VEZ ~-~ 50CAT~O~ Sr,~TCH AND ' ~'~'
CKD:' SMH ; ' R&M CONSULTANTS INC:, ' - TEST HOLE LOG NO, ~1 ,-:.:.. GRID: . :r. '
DATE:' 7-18-77 ' ................................... : "'. GARY ANDERSON ': 3'~ji~"i."!_' PROJ. NO. 751190
SCALE: see above
July 18, 1977
R&M No. 751190
Mr. Gary Anderson
P.O. Box 4-1143
Anchorage, Alaska
99509
Subject: Soil Znvestigation for Sanitary Sewer System, Lot 64,
Block 2, Valley View Addition No. 2, Anchorage, Alaska
Dear Mr. Anderson:
At your request of July 6, 1977, we conducted a subsurface soils invest-
gation at the proposed location of the sanitary sewer system on the
subject lot. The investigation complied with those procedures required
by the Municipality of Anchorage Department of Health and Environmental
Protection.
This investigation, which was accomplished on July 13, 1977, consisted
of a test hole drilled to a depth of~23 f~ below the existing ground
surface. The test hole was sited according to your instructions and its
location is shown in attached Drawing A-01. Drilling was accomplished
with a rotary drill rig using continuous-flight solid-stem auger with an
outside diameter of 6 inches. Samples were taken at the depths shown on
the soils log in Drawing A-01. The samples will be held in storage at
our lab for approximately six months. In addition, all material brought
to the surface by the augers was continuously monitored by an experienced
engineering geol.ogist.
The topography at the drilling site is generally horizontal. At the
time of the investigation the lot had original vegetation consisting of
birch and spruce. The top of the test hole was located on fill material
approximately 3 feet above original ground surface.
The soils encountered in the test hole are shown in the test hole log in
Drawing A-01. The symbols used in Drawing A-01 are explained in Drawings
B-01 amd B-02. This log displays specific conditions encountered at the
test location. However, subsurface conditions may vary in other parts
of the lot without any apparent surficial evidence of the change.
Groundwater was not encountered. Bedrock was not encountered. At the
time the hole was drilled, seasonal frost was not present and permafrost
was not encountered ....
A percolation test was perfomed within the test hole at the depth shown
in the attached Table 1. All depths were measured from the top of the
hole. The data in Table 1 show average infiltration from the depths
indicated to the bottom of the hole. The measured percolation rate was
0.77 minutes per inch.
July 18, 1977
Mr. Anderson:
Page 2
We appreciate this opportunity to be of service to you. Please contact
us if you have any questions concerning this letter or if we can be of
additional service.
Very truly yours,
R & M CONSULTANTS, INC.
Michael Mitchell, Jr.
Senior Geologist
Head, Earth Science Department
MM:JMB/sl
Attachments: Drawings A-01, B-01, B-02 and Table 1
NO. 751190
TABLE 1
PERCOLATION TEST
GARY ANDERSON
TIME
10:41
10:42
10:43
10:44
10:45
10:46
10:47
10:48
10:49
10:50
10:51
10:56
11:01
11:06
11:11
11:21
11:31
11:41
ELAPSED
TI~
0
1
2
3
4
5
6
7
8
9
10
15
20
25
30
4O
5O
60
INCHES
42.0
43.75
45.0
46.25
47.75
49.0
50.0
51.0
52.0
53.0
53.75
58.0
63.5
68.5
73.0
80.75
85.0
88.0
DROP IN INCHES
0
1.75
1.25
1.25
1.5
1.25
1.0
1.0
t.0
1.0
0.75
4.25
5.5
5.0
4.5
7.75
4.25
3.0
46 INCHES TOTAL DROP
0.77 MINUTES PER INCH
~0.0~
N 02° I~' 00" W - 14-'7.55'
b 3o.o'
0
Z
z
;0
30.0'
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
GENERAL INFORMATION
Complete legal description
. C( ,t
Location (site address or directions)
I~roperty owner -~"~'~ ~
Mailing address
Lending agency
Mailing address
Agent [~o ~,
Address'
Unless otherwise requested, HAA will be held for pickup.
_CA'~ e/~ Day phone
~,'~e~ t,~l ~o~'~¢~ Day phone
Ro PA~ Pr~n ~/ V~. Day phone
NUMBER OF BEDROOMS:
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:
NOTE:
Individual on-site
Holding 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~J1) 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 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.
DHHS SIGNATURE ;'
v'/ Approved for THR£ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
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 courtesyto purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DH HS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or oi'nissions in the professional engineer's work.
I~ IE ', E I V I'* L)
OCT 04 1999
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVIC~iRON~eNT^~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744
Health Authority Approval Checklist
Legal Description: /-o~ ~'~ .G/lc !, ~/~11; //~ # ~
A. WELL DATA
Well type ~'(~z_~_r ",~" If A, B, or C, attach ADEC letter. ADEC water system number "~ ! o ~'~.5--
Log present (Y/N)
Date completed
Total depth Cased to
Casing height (above ground)
Sanitary seal (Y/N)
Wires properly protected (Y/N)
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
g.p.m, g.p.m.
Coliform Nitrate
Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/2-.3/77 Tanksize
Foundation cleanout (Y/N)
Date of Pumping IdJ/!
C. ABSORPTION FIELD DATA
Date installed ~/2._T/77
Length ~'7 ' Width 5' /
Effective absorption area ~'7~ ,~-~H' Monitoring Tube present (Y/N)
Date of adequacy test ~) (' Z ~,/?~ Results (Pass/Fail)
Number of Compartments
Depression (Y/N) h/ High water alarm.(Y/N) /v.
Pumper /~- ~'' iLJ~"~ -~ ~ ~'~
N~ ~/ c.~, /~11~ ~
Soil rating (g.p.d.~orff~d~) ~o~ System~pe
Gravel thickness below pipe ?' Totaldepth (~' ~,~ ¢'~,~-~.~
~ Depression over field (y/N) A/
For ~ bedrooms
Fluid depth in absorption field before test (in.);
Immediately after~2¥$~'gal, water added (in.):
Fluid depth 0 (ins) Minutes later:
Absorption rate = ~ 5'.~-~ q.p.d.
Peroxide treatment (past 12 months) (Y/N) N~ /<:no ~,~
72-026 (Rev. 3~96)*
If yes, give date A/. ,4
D. LIFT STATION ~J' '~.
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
Eo SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO: M.
Septic/holding tank on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation 15-' Property line '~ ~ ' Absorption field
Water main/service line '> ~o ' Surface water/drainage ~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Wells on adjacent lots
Water main/service line ~> / ~'-' '
Building foundation ~ O '
Driveway, parking/vehic e storage area
Wells on adjacent lots ';> ~oo '
Property line ~' ! ¢ '
Sudacewater ':> /~o'
Curtain drain /~/on ~
F. ENGINEER'S CERTIFICATION ·
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA guidelines in effect on this date.
Signature ,,~'")~ ~. ~
Engineer's Name -/-4~, ~'o~ ,~. /wo~ ,~_
Date C~c/o~r V., /~?~
are
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description /.¢ ~ d"/., /~/~,c/< _¢, b'~/ll ¢",~ E_c~/~_r ~:~.
Location(siteaddressordirections) (~770 Ro~.,,~:.f' Tr~ Pr,;.(.
Property owner
Mailing address
Lending agency
Mailing address
Agent No,~ ~
Address
Day phone
0"'770
A/ ~,8 (' P'~/' /)-7¢'""'"~ Day phone ~'7 -33Oo
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~ '/
TYPE OF WATER SUPPLY:
Individual well
Community well ~,~
Public water
NOTE:
RECEIVED
APR 2,9
Municipality of Anchorage
Oept. Health & Human Services
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ¢" ·
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
724)25 (Rev. 1/91) Fronl 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 thi~ Health Authority Approval application shows that the on-site water supply
and/or wastewate(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
sup'ply 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 F/~/'J-o£ 7-ec,5~/ -q e,' ~,,',-.~J Phone :~ ~,~-- 1_75-~-- __
Address 1~t.5-.YO ,5~ cAo ..C.¢,.. ~ cA o,',~,~ ~ ,3~
Engineer's signature ~'~-e.¢,-¢._ ~, ~ Date
DHHS SIGNATURE
('~ Approved for ~:~]) bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Heelth 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 D H HS 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.
72~25 (Rev. 1/91) Back MOA#21
Municipality of Anchorage ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division MUNICIPAU~y OF ANCHORAG~
825%" Street, Room 502 · Anchorage, Alaska 99501· (9L~)l!~;r~4r~L SERVICES DIVtSI(
APR 2 9 997
Health Authority Approval Checklist
LegalDescription: .L. ~'~, ~-.'1, l/all; ~o~ I~S /" ~4~ >~ Parcell. D.:
A. WELL DATA
Welltype CIa.o' ~'A~
IfA, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/IN) Date completed
Total depth Cased to
FROM WELL LOG
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Sanitary seal (Y/Iq)
Other bacteria
Number of Compartments ~ Cleanouts (Y/N) 'r (0
High water alarm (Y/N) Itl. ,~.~
Date of test
Static water level
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform Nitrate
Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~/~ 7 Tank size I ooo ?
Foundation cleanout (Y/N) Y Depression (Y/N)
DatcofPumping ti/Z6'/97 Pumper ~4-/'
C. ABSORPTION FIELD DATA
Date installed 8/77 Soil rating (g.p.d./ft2orll2/bdrm) ~3'0
Length 6' 7' Width 5' ~ Gravel thickaess below pipe '7,
Effective absorption area ~/~ a;-b/,t Monitoring Tube present(Y/N) ~' Depression over field (Y/N)
Date of adequacy test ~/g~- 79 2 Results (Pass/Fail) t~,~rj For ,9 bedrooms
Fluid depth in absorption fleld before test (in.); ~ Immediatelyafter~/gal. water added (in.):
Fluid depth C2 (ins.) Minutes later: 5" Absorption rate = ~> q~-~ g.p.d.
Peroxide treatment (past l2 months) (Y/N) Ma,,a ~,,a,*^ Ifyes, givedate t~. A.
System type ~-re ,, c 4
Total depth Ia ' tn ea~.
D. LII~T STATION N.A.
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump off" level at* __
High water alarm level at*
*Datum
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: /V. A- ·
Septic/holding tank on lot
,; On adjacent lots
Absorption field on lot
; On adjacent lots
Public sewer main
Public sewer manholc/cleanout -
Sewer/septic service line
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation t g ' Property line E 6' Absorption field
Water main/service line ;> ~o Suffacewater/drainage > too Wells on adjacent lots > ~oo .
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Property Line ~ I,~ ' Water main/service line ) to '
Surface water ~ e o o'
Driveway, parking/vehicle storage area
Curtain drain t%~,e xea,, Wells on adjacent lots ~> ~o '
F. ENGINEER'S CERTIFICATION ..:. ~. .,.; ,.
I certify that I have determined thru field inspections and review of Municipal recot;ds.thfi~ tho ;db~ve' ;aYStemg,are
in conformance with MOA 1t~ guidelines in effect on this date~- : . . ,~ ,~ .~,,:,- ~, .
Engineer's Name
Date
· Ep'g~neenng:Sea! Here
.[% 5.~ C;. - ,~.>~'9 /.
HAA Fee $ .~ Oo ~ Waiver Fee $
DateofPayment /%q/q ~ DateofPayment
Receipt Number ,.~.?.e~e/~ ~ /~9 /to ) Receipt Number
,,..
Rev. 8/95 OSS: haa.wk.doc
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
.~.; >,~. - '. ~:...,?-.')T;~.!*.t,I--c'~,.-·
1, GENERAL IN E'~)RMA'~IO N
~ .G~. pl~e.l~gal description
Location (site address or direc,t, io~). '
Property owner
Mailing address
Lending agency
Mailing address
Day phone '~4-G--"~' 17..O
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~ '-4
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: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
sTATEMENT OF iNsPECI'tON BY ENGINEER
as of the validation date shown betoW, I verify that mY
As certified bY mY seal affixed heretlsa~ale, functional and adequate for the number of bedrooms
investigation of this Health Authority Approval application shoWS that the on-site water supPlY
on ..__ ,h,, on-S te water
· . . erein.~ furthervedfythatbased theinformati°n obtained from
and/Or wastewater disposal system . . and inspect uu, ,, ,v
.. -~ structure indicated h -- from my invest~gabOn and State codes,
theMuniC~p¢l~tY°~' ..... , ,~ date of th ,-,, --, L "...~ &~°_
wCsteWater ~ispoS~l system is in compliance with
supply and/or is inspeCtiOn( .. ·.
. -~ and raguiati°ns m eiiect on u~ ~ ~' ' ' ~hone ~
. .
Name of Firm
-- ' Engineer s ~,u-
~.O~ AL4
-, " '"'
6. DHHS siGNATURE
_~ Approved for
Disapproved.
conditional apprOval for
bedroomS.
bedroomS, with the following stipdationS:
Additional comments
Date
Health and Human Services (DHHS) issues Health Authority
Anchorage Department of in paragraph 5 above by an independen!
The MuniCiPalitY of 'rementS. EmptoyeeS of DHHS do not
ApprOval Certificates based only upon the representations given ..... ,~urtesytopurchaserSOfh°met~
professional engineer registered in the State of Alaska. The DHHS does tnls a~
is issued. The Municipality o! Anchorage is not
and their lending institutionsin order to satisfy certain (ederaI and state reqUl
conduct inspections or analyze data be(ore a certificate
responsible for errOrS or omissions in the professional engineer s work
Legal Description:
A. WELL DATA
Well type A
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
~,oT' ~-~', ~LO~, [ Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number
'~/(~ Date completed ~ (*4 Driller
~/~ Cased to ~ Casing height ~
Wires properly protected (Y/N)
FROM WELL LOG
Date of.test
Static water level ,
Well flow,, ~ .~../f// g.p.m.
Pump level
SEPARATIO,~q DI-S. TANCES FROM WELL TO:
Septic/holding tank on lot
; On adjacent lots
Absorption fiel~.o.n, lot / ,!,,, ';~ ,..~, ,:~, ; On adjacent lots ~ ..
Public §,ewer,main~ ,., Public sewer manhole/<~le~nout
Sewer service line , Petroleum tank .~ ·
WATER SAMPEE RESULTS:
Coliform Nitrate Othe~.badteria
Date of sample: '"-'- Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed "~'/'~7 Tank size [~) ~ Compartments
Cleanouts (Y/N) . ~ ' Foundation cleanout (Y/N) ~/ ' ' ',D~pressiOn (~Y}~)
High water alarm (Y/N): i~/[~r Alarm !este~,,(Y/N) ~'
Date of pumping ~'! Pumper /~ C,,A/_.7,~ ~~ '~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /L)/,~. ' ' On a~jacen, lots
To property line ~ ~
Surface water/drainage
72*026 ~Rev. 7/911 Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Sizein gallons
Vent(Y/N)
· ~lPump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION D~ST. ANCCE FROM LIFT ST~;'TIO~ TO:
D. ABSORPTION FIELD DATA
Date installed 8/ "~"7
Length ~ '~ ! Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
On adjacent I'0ts"
Peroxide treatment (past 12 months) (Y/N)
Manufacturer
Manhole/Access (Y/N)
' ." ".~'~-~Pt4mp Off" i~v~r
¢'-*'~ Cycles tested
Surface Wa'ter
Soil rating'., ~'~ ~ ~ystem type
Gravel thickness '"~ ! Total depth /~"
Cleanouts present (Y/N)
Date of adequacy test _ /~--~1
for ~ bedrooms
"'- ~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellonlot /O' /¢~, On adjacent lots ~
To building foundation
On adjacent lots /%
Cutbank
Property line
To existing or abandoned system on lot
~ ~ Water main/service line
Surface water
Curtain drain /~]/~
!
Driveway, parking/vehicle storage area ~ ~' ~' !
E. ENGINEER'S CERTIFICATION
I certify that I ha, v.e checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date l
HAA Fees
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Beck MOA21
Waiver Fee: $ '
Date of Payment
Receipt Number
KNIEFEL ENGINEERING
8451 MILES COURT
ANCHORAGE, ALASKA 99504
(907) 337-6560
HEALTH AUTHORITY RESULTS AND ANALYSIS
Date of Testing: December 21, 1991
Legal Description: Lot 64, Block 1, Valli Vue ¢2
Street Address: 6770 Round Tree Drive
Number of Bedrooms: 3
Welt Flow Test: Public Well, See ADEC Letter, PASSED
Results of Septic System Adequacy: PASSED
Total Gallons into system: 650 gals. in 127 minutes
Comments:
The absorption system worked properly with no rise noted in the
oleanouts at the end of the field or at the tank. The system was
tested in accordance with MOA policy and regulations in force at
the time of this test.
The Health Authority test passed for this system. The tank was
pumped within the last four months, see attached receipt.
51~/~0~S5%.¢~' ~'
MOA CE 90-030
' MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE/
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DFPT. OF HEALTH &
825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION OCT 9 1978
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWERt~I[!J]-~[D. , .
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTYOWNER ~ ~
MAILING ADDRESS
PHONE
PROPERTY RES[DENT (If different from above)
2. BUYER
PHONE
PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
MAILI G~ADDRESS ~
4. REALTOR/AGENT
MAI LING ADDR ESS
PHONE
PHONE
5, LEGAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
~ SINGLE FAMILY
[] Two [] Five
[] MULTIPLE FAMILY ~ Three E~ Six
[] Other
7. WATER SUPPLY
[] INDIVI DUAL* * ATTACH WELL LOG. A well log is requ'ired for all wells drilled
~ COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
_~_ INDIVIDUAL/ON-SITE** **If individual/on-site, give installation date ~L"~'~ ~ .
If system is over two (2) years old an adequacy test is required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72~10(3/78)
THIS sIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
tNSPECTOR INSPECTOR INSPECTOR
DIRECTIONS;
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
'~ SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
~ 2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
-~ COMMUNITY DATE DRILLED
[] PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
'~ I NDIVI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY ~2-~ 3-'~'~
Connection Verified _ INSTALLER
~J~]SepticTenkor []HoldingTank ~J~t. ~,.~L.~.,~/~I~/- &~'x"/,~-,'
Size: I~:)ED~) __ if Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTIQN AREA MATERIAL
L'/"~D' Nearest L.(~t Line
4, DISTANCES Septic/Holding Tank Absorption Area Sewer Line
WELLTO:
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR ,~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
LEGAL DESCRIPTION
72-010 (Rev, 3/78)