HomeMy WebLinkAboutVALLI VUE ESTATES #2 BLK 1 LT 55
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: ~' Pc/~ ¢ O~ ~' ~/ PID Number: ~2/,5- - / 7--3' - /~
Name:
Po? ~ ~,~ ~/,~ Wastewater System: D New ~ Upgrade
Address:
~¢ 7o ~ %~ p~,~ A~4 ¢~-/¢ ABSORPTION FIELD
Phone: ~--~0~ No. of B~rooms: ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other
LEGAL DESCRIPTION sci, Rating: ~ ~ ~, To~al Depth from origmal grade:
LOL Block: Subdiv~ion: Depth to pipe bottom fro~ or,hal grade; Gravel depth beneath pipe
TOWnShip m Range: m section: Fill added above original grade: Gravel tength:
WELL; B New ~ Upgrade Gravelwidth: Number of lines: [O~s~a~ce~etweenlines:
Classifica~io~ (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material: ~
Driller: Date Drilled: Static Water Level: Installer: I ~ Date instafled~
Yield Pump Set at: Casing Height Above Ground:'
SEPARATION DISTANCES ~ Septic U Holding ~ S.T.E.P.
TO Septic Absorption Lift Ho~din9 Public/Priv¢te Manufacturer: Capacity in gallons:
Material: Number of C~padments:
Sudace
Lot Size in gaJlons: Manufacturer:
Line I% y -- -
Cu~ain ¢ump Make & Model ~ Electrical Inspections pedormed by:
Drain -- --
I
Remarks: ~yf ~¢~ ~¢ 4¢¢r%,~¢~ ~ BENCH MARK
Location and Descr[ tion:
AssUmed Elevation:
/ ~ ~ ENGINEER'S SEAL
Inspections pedormed by: :/o>~p ~¢44,c¢¢%~( Dates:lst ¢l/Y/e~ : ""
Department of Health and Human Sewices approval
PERMIT NO: SW990034
PID NO: 015-123-10
PAGE 2 OF 2
NEW 1250 GALLON
SEPTIC TANK
O
SWING TIES:
FROM: COR. "A"
TO:
S.T.C.O. "D"
S.T.C.O. "E"
DBL. C.O. "F"
TR. C.O. "G"
TR. M.T. "H" 65'
TR. C.O. 'T' 78'
TR. M.T. "J" 63'
TR. C.O. "K" 50.5'
COR. "B" COR. "C"
12' 36'
37' 63'
63'
54.5'
50'
4 BEDROO
HOUSE
LOT 55
55' LONG SOIL ABS. TRENCH
LEG WITH 10.2' EFF. GRAVEL
~ T.H.
#1
22' LONG SOIL ABS. TRENCH
LEG WITH 9.1' EFF. GRAVEL
PLAN VIEW
SCALE: 1" -- 30'
2' SOIL COVER
PROFILE VIEW
NOT TO SCALE
BOTTOM TRENOH
T.H. #1 BOT. ELEV. 79.5'
~/~M.T. DRY 6/14/99
BOT. TRENCH
ELEV. 86.5'
LOT 55, ELK, 1, VALLI VUE EST,, UNIT #2
SEPTIC SYSTEM UPGRADE
AS-BUILT INSPECTION REPORT
FLATTOP TECHNICAL SERVICES SCALE: AS NOTED
14530 ECIIO STREET DRAWN BY TFM
ANCllORAOE, ALASKA 99516 SEPTEMBER, 1999
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Roam 502
P.O. Box '196650, Anchorage, AK 995'19-6650
(907) 3#3~4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Mar 17, 1999
Expiration Date: Mar 16, 2000
Permit Number: SW990034
Legal Description: VALLI VUE ESTATES #2 BLK 1 LT 55
Design Engineer: 0019 Flattop Technical Services
Owner Name: Doug & Ginny Davlin
Owner Address: 6670 ROUND TREE DR
ANCHORAGE , AK 99516-6815
Parcel ID: 015-123-10
Site Address: 006670 ROUND TREE DR
Lot Size: 20073 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well [] Water Storage
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
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Issued By: / Date: 7
Rick Mystrom,
Mayor
Mun c paHty of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Ancilorage, Alaska 99519-6650
http://www.ci.anchorage.ak.us
March 17, 1999
Ted Moore, PE
Flattop Technical Services
14530 Echo Street
Anchroage, Alaska 99516
Subject:
Waiver Request for Lot 55 Block 1 Valli Vue Estates #2
Waiver Request #WR990018
Parcel ID #015-123-10
SW990034
Dear Mr Moore:
Your request for a waiver of the required 10 feet horizontal separation from the
absorption field to property line has been approved. The approved separation distance is
2.0 feet.
This waiver approval applies to the existing absorption field to property line separation
only. Any future upgrade to the on-site wastewater disposal system will require all
separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-4744.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Water Quality Program
Date Received:
Legal Description: Lot 55 Block 1 Valli Vue Estates #2
Engineer: Ted Moore, PE, Flattop Technical Services
14530 Echo Street, Anchorage, Alaska 99516
Applicant: Dough & Ginny Davlin
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
Waiver Review Worksheet
PID# 015-123-10 HA# Permit #
March 9, 1999
Waiver Requested:
of 2 feet.
Lot line waiver of the new trench to the south property line
Criteria: 1. Geology:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
Points:
3. Other:
Waiver is Granted: X Waiver is NOT Granted:
List Conditions or Reasons for above:
ate: ??
Rec #: 04721/1456 Amount: $ 115.00
Name of Reviewer
Date Paid: March 9, 1999
CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS
THEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 March 8, 1999 ANCHORAGE, ALASKA 99516
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
The purpose of this letter is to provide the required design narrative in support of our application for a
permit to upgrade the wastewater disposal facilities on Lot 55, Block 1, Valli Vue Estates, Unit #2, located at
6670 Round Tree Drive. The original seepage pit is no longer able to absorb septic tank effluent at an adequate
rate. Soils logs, perc test results, a site plan, design drawings and specifications are enclosed for your review.
We are also requesting a lot line waiver allowing the new trench to be constructed within 2 feet of the south
property line. The purpose of the requested waiver is to allow greater flexibility in siting the upgrade trench to
maximize use of the limited space available on the lot within the constraints of topography. Granting the
waiver will have little or no impact on the ability to construct future upgrades to the soil absorption system
serving the residence of Lot 56.
The proposed system will be constructed in the vicinity of test hole #1. As can be seen from the soil log, the
native material between 3' and 8' below ground level is a variable somewhat silty sand with a measured perc
rate of 2 minutes per inch. It is proposed to utilize a somewhat conservative soil application rate of 0.8 gpd/sq.
ft. for the upper portion of the trench that lies in this stratum. The native material below 8' is a silty gravel with
a measured percolation rate of 44 minutes per inch, which corresponds to a soil application rate of 0.45 gpd/sq.
t~. The proposed 50 foot long trench with 10 feet of gravel extending to 13 feet below ground level has 5 feet
of sidewall in each stratum. This yields a design capacity of(50 x 5 x 2 x 0.8) + (50 x 5 x 2 x 0.45) - 625
gallons per day.
Since this upgrade project increases the bedroom rating of the residence from 3 to 4, a site for a replacement
trench of the same dimensions is designated on the site plan. The topography of the lot in the vicinity ofthe
proposed construction slopes down towards the west at approximately 5%. The topography in the vicinity of
the future replacement site slopes downwards at approximately 20% and will require the installation of a lift
station to pump effluent up to that site.
The proposed project will have no significant impact on present or future water supply and wastewater
disposal systems serving adjacent properties, nor will it have any significant impact on reserved space-surface
and subsurface, or on drainage. Please give me a call at 345-I355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
LOT 38
INSTALL NEW
1250 GALLON -
SEPTIC TANK
LOT 54
HOUSE
~ONCRETE RING
-~-~, ABANDON / SEEPAGE PIT
,' EXISTING
,' 1000 RETAIN FOR POSSIBLE
,, SEPTIC TANK FUTURE RECONNECT
~ , C.O. o
LOT 37
STING
BEDROOM
OUSE
DECK
CONSTRUCT ~C.O.
50' LONG SOIL
T.H.
ABS. TRENCH #1~
W. 10' GVL.
LOT 55
DRIVE
SITES FOR FUTURE
REPLACEMENT
SOIL ABS.TRENCHES
(LIFT STATION NEEDED)
LOT 36A
NOTE: ALL LOTS IN THIS SUBDIVISION
ARE SERVED BY A COMMUNITY WATER
SYSTEM. NO WELLS WITHIN 200 FEET.
LOT 56
0
SEPTIC
SYSTEM
0
L55, BLK. 1, VALLI VUE EST. #2
SEPTIC SYSTEM
SITE PLAN
FLATTOP TECHNICAL SERVICES 1 INCH = 30 FEET
14530 ECHO STREET DRAWN BY TFM
ANCHORAGE, ALASKA 99516 MARCH, 1999
NOTE: THIS IS NOT A SURVEYED PLAT.
ALL LOCATIONS SHOWN ARE APPROXIMATE.
ASTM D-3034
WASTE LINE
FROM HOUSE ,
CONSTRUCT NEW 50 LONG SOIL ABSORPTION TRENCH
WITH 10.O FEET SEWER GRAVEL BELOW DISTRIBUTION PIPE
INSTALL NEW
1250 GALLON / ASTM F-810 DIST. PIPE ~
C.C. __ C.C.
DBL. C.O,
PLAN VIEW
SCALE: 1" = 10' - 0"
MONITOR TUBE
CLEANOUT
MOUND BACKFILL 12"
ORIGINAL GROUND
FILTER FABRIC
ASTM F-810 PERF. PIPE
1/2" - 2 1/2" SEWER GRAVEL
-BOTTOM OF EXCAVATION
SECTION "A" - "A"
SCALE: 1" = 5' - 0"
LOT 55, BLK. 1, VALLI VUE EST. #2
SEPTIC SYSTEM UPGRADE
PLAN AND CROSS-SECTION
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, AK, 99516
SCALE; AS SHOWN
DRAWN BY: TFM
MARCH, 1999
Flattop Technical Services
14530 Echo Street, Anchorage, Al{ 99516
Phone (907) 345-1355
Lot 55, Block 1, Valli Vue Estates, Unit #2
6670 Round Tree Drive
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of abandonment of an existing 1000 gallon septic tank and installation
of a new 1250 gallon septic tank followed by a 50 foot long soil absorption trench containing a total of 10.5 feet
of sewer gravel.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor deviations
from these drawings may be allowed or required by the engineer conducting the inspections. All construction
procedures and material specifications shall conform with Municipal and State requirements. All separation
distances shall be in conformance with Municipal requirements, unless specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around any
buried utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system components to
ensure that proper drainage is achieved after settlement and that there are no residual depressions. Insofar as
possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after the
soil is compacted, as well as placement of topsoil and reseeding ail areas disturbed by the construction.
1.6 If the two west lot corners are not readily locatable at2er the snow melts, the homeowner shall arrange
with a surveyor to locate and mark these corners prior to the start of construction.
2.0 Septic Tank:
2.1 The existing septic tank which is located underneath an extension of the building must be properly
abandoned by hand digging down to expose and remove the manhole covers. This is to be followed by a
thorough pumping of the tank and backfilling it with concrete slurry.
2.2 The new 1250 gallon, 2 compartment septic tank shall be Municipally approved and shall be set level
on undisturbed soil in the approximate location shown. Each compartment shall be equipped with a watertight
manhole cover and a 4" cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of
approved burial type, rigid insulation.
2.3 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The trench
for the waste line from the residence to the septic tank will probably have to be dug by hand and shall have a
minimum slope of 1/4'" per foot. The waste line between the tank and the soil absorption system shall have a
minimum slope of 1/8" per foot. A cleanout shall be installed within 5 feet of the building foundation, and
immediately prior to any other 90-degree bends. A double cleanout shall be installed within 5 feet downstream
of the septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by excavating a 50 foot long trench to a depth of 13 feet
in the location shown on the site plan just east of an existing 10 foot utility easement.
3.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces shall be raked to
allow proper infiltration.
3.3 A total of 10.5 feet of approved sewer gravel shall be placed in the bottom of the excavation with the
perforated distribution pipes laid level such that the pipe inverts are no less than 10.0 feet above the bottom of
the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the #200 sieve.
3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on the
design drawings. The portion of the monitor tube extending through the sewer gravel shall be perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum of 2
feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet, two inches
of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in addition to the filter
fabric.
3.6 The top surface of the cover material shall be raised a minimum of 12 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill slopes shall
be no steeper than 3:1.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have the site
finish graded after the backfill material has stabilized, and for placement of adequate topsoil and seed to
promote rapid revegetation of all areas disturbed by the construction.
4.0 Inspections:
4.1 A minimum of 4 engineering inspections will be required during the course of the project: (1) initial
stakeout with the contractor to establish the location of the system and to discuss the plans, specifications and
construction procedures, (2) after the native material has been excavated to expose the infiltrative surface to
ensure that it is level and at the right elevation, and conforms with the soil test information, (3) after the sewer
gravel is in place and the distribution pipes have been laid and connected up to the septic tank, but prior to
placement of insulation or filter fabric, and (4) after rough backfill and grading is complete. The septic tank
requires one inspection after it is set level and the piping connected, but prior to backfill. This inspection may
be incorporated with any of the above inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in advance
to ensure the availability of the engineer.
TEST HOLE
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99515
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: Lot 55,B!ock 1, Valli Vue Estates, Unit #2
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(~et)
3
4-
5
7
8-
10
1~-
Februaw 2~2,1999
Doug and G nny Davlin
Pt,
SM Reddish gravellyloam
SP/SM Gray, somewhat silty sand
Dry, variable, lenses of GP/GM
SLOPE
GM Gray silty gravel
Dry, dense
Depth to Groundwater Date
No Groundwater 2/22199
_M.T. DW~ 3/2/99
SITE PLAN
2o%~
5% ~
16-
17-
18-
19-
COMMENTS:
Clock Net Time Percometer Net Drop
Date Reading Time (minutes) Reading (inches)
2~22 12" Presoak
Start _J 1:46 23 3/4
#1J 2:16 30 23 3/4
Add water 2:16:15 23 3/4
#2_ 2:46:15 30 23 3/4
Add water 2:46:45 23 3/4
#3 3:16:45 30 23 1/16 11/16
BH
PERCOLATION RAT( 44 (minutes/inch) PERC HOLE DIAMETER 6
TEST RUN BETWEEN 9.5 FTAND 10.0 FT
See Io.q entitled T.H. la for second perc test conducted between 3,5 and 4' below.ground level.
PERFORMED BY FLATTOP TECHNICAL SERVICES. I ~"..~.~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: .~ ,/' ~ ./~.¢'
ITEST HOLE
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
LEGAL OESCRIPTION: Lot 55,Block 1, Valli Vue Estates, Unit #2
DATE PERFORMED: Februais, 22, 1999
PERFORMED FOR: Doug and Ginny Davlin
DEPTH Pt.
(feet)
1
SM Reddish gravellyloam
SLOPE
2
SP/SM Gray, somewhat silty sand
Dry, variable, lenses of GP/GM
SITE PLAN
GM Gray silty gravel
Dry, dense
Depth 1o Groundwater Date
No Groundwater 2/22/99
~M.,T, Dry 3/2/99
20%~~
BH
Clock Net Time Percometer Net Drop
Date Reading Time (minutes) Reading (inches)
2/22 12" Presoak
Start 1:33:20 10 1/8
#1 1:38:20 5 13 1/2 3 3/8
Add water 1:39:30 9 3/4
#2 1:44:30 5 12 3/4 3
Add water 1:45:30 9
#3 1:50:30 5 .__ 12 3116 3 1/16
PERCOLATION RATE 2 (minutes/inch) PERC HOLE DIAMETER 5"
TEST RUN BETWEEN 3.5 FT AND 4.0 FT
COMMENTS:
PERFORMED BY FLATTOP TECHNICAL SERVICES. I ~'"~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 3/,~:~' ./' ~)~.~
I
ANCHORAGE AREA
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME ~J). W'
LOCATION
SEPTIC TANK:
DISTANCE ,
FROM WELL~/,?
INSIDE LENGTH
/// ~L/~ //~; ~pg !
MAILING ADDRESS /~ ' ~ '
LEGAL DESCRIPTION /(~'~-
MANUFACTURER~/~ ~- ~<~-C
NUMBER Of
MATERIA~COMPARTMENTS ~
INSIDE WIDTH
LIQUID DEPTH ~ .LIQUID CAPACITY /~() GALLONS.
SEEPAGE PIT:
NUMBER OF PITS / DIAMETER '-~
LINING MATERIALt;~ ~/:.d?~'~t ~Pi~{£R B size:
BUILDING FOUNDATION
OR WIDTH /~)
, LENGTH ~, DEPTH
DIAMETER//I . I '/:~'
DEPTH'~Ctt'DISTANCE FROM: WELL (¢/~;_~¢¢¢/¢z'~¢*//_
/ TOTAL EFFECTIVE
NEAREST LOT LINE -~) ABSORPTION AREA (WALL AREA) ~/ ~// SQ. FT.
ADDITIONAL ABSORPTION
WELL:
TYPE (~t~/~4~;/;;I
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION ~DEPTFt- DISTANCE FROM:
NEAREST NE~ARE'ST SEPTIC SEEPAGE
LOT LINE .,~'~'~-FwSEWER LINE TANK SYSTEM
DISAPPROVED REMARKS
DISTANCES:
DIAGRAM OF SYSTEM
INSTALLED BY: '~'0~¢/.; /OQf~~'
PIPE MATERIAL:
LOT SLOPE:
REMARKS: ,/~'?~4¢¢x L~ g¢~,½ZUY[,¢-/~ ~.:~
G.A.A.B.
GREATER ANCHORAGE AREA BOROUGlt
DEPARTMENT OF ENVIRONMENTAL QUALITY
3330 "C" Street
ANCHORAGE, ALASKA 99503
Case #
9--
lO-
ll-
12--
Performed For ~[~c:~/~' %C~Ut~.
Legal Description: Lot~ Block.
This Form Reports Soils Log_fl
Soil Test Must Be Logged To
Depth
Dated Performed ~,~-/~ ~//~
/ Subdi'vision_ IJ~//i ~_~'~ "
Percolation Test
4' Below Proposed Seepage System -
Feet Soil Characteristics
4--
5m
7--
Was Ground Water Encountered?
If Yes, At What Depth?
_J F_-
Reading
Date
Gross Time Net Time Depth to N20
Net Drop
Percolation Rate Minute
Proposed Installation: Seepage Pit
Depth of Inlet .Depth to
COMMENTS:
Drain Field
Bottom o~Pit Or Trench
Date:
"tment of Environmental Qualit
.... cer and Sewer Questionnaire
Subdivision '~-~LL~d;
Owner's Name:
Mailing Address:
Date
, Time
, Block ~.,.~/:
Questions:
1. How many bedrooms are now in your house?.
2. How many bedrooms were in the house at the time of purchase?
3. Were the basement bedroom walls "roughed in" at the time of purchase?.
4. Was the basement bathroom plumbing "roughed in" at the time of
purchase?
5. Did the realtor or builder inform you that you would have to enlarge the
existing sewer system if you finished the basement bedroom (s)?
6. If on a public water supply, do you always have an adequate supply of
water? ~ ~"2~ ~' /~'~/c-, ~-~.
7. Is the pressure always adequate?, ~.~
8. Who was the builder? ~,~ Y~,/z~.~.
9. Who was the home purchased from? [~,'t [~ ~
OTHER COMMENTS:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St,
P,O. Box 196650 Anchorage, AK 99519-6650
www,ci,anchorage,ak.us
(g07) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. etS' -I 7-3 - lC)
1.
GENERAL INFORMATION '
Complete legal description
Location (site address or directions)'
HAA # HA
Expiration Date:
Current Property owner(s)
Mailing address
Lending agency ~ t<,
Day phone
Day phone
Mailing address
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ~/
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~A Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of AJaska. Certificates of Health Authority Approval ere required for the transfer of
title (except between spouses) for properties served by e single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval ere
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days eld. (Cer'aficates may be reissued for a period of up to one year with
valCd water' samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors er omissions in the professional
engineer's work.
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.
based on procedures outlined in the Health Authority Approval Guidelines for this application, show~; that the
on-site water supply and/or wastawater disposal system is(are) 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 suppIy and/or
wastewater disposal system is(ara) in compliance with all applicable Municipal and State codes, ordinances.
and regulations in effect at the time of installation.
Name of Firm ~'t~t {--~or~ -7-e~/~;¢~! .~'~,-,.,,', ~' Phone
Address 1~/5'So
· V
Englneer's Printed Name, "7-A to,~Cor~ ~. /"¢0o,'~ . Date
5. DSD SIGNATURE
~ Approve,d for L~
Disapproved.
Conditional approval for bedrooms
with Ihe following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastawater Program
4700 South Bragaw St. ..
P.O, Box 196650 Anchorage, AK 99519-6650
www.cLanchomge.ak.us
(907) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescdptlon: /-ef$-~'., ~lk ~.
WELL DATA
w~ type ~
Date completed
Tota~ depth
ft. Cased to
FROM WELL LOG
IfA, B, orCprovkJePWSID# ?~/O&"O$-- WeilLog(Y/N)
· Sanltay seal (Y/N) Wires properly protected (Y/N)
ft. Casing height (above ground)
AT INSPECTION
Date of test
Static water level ft.
Well production g.p.m.
WATER sAMPLE RESULTS:
Coliform colonlas/100 mi. Nitmie
Date of sample: Collected by:
SEPTIC/HOLDING TANK DATA
TankType/Matertal ..~ .~_~/'~c //
fto
g.p.m.
in.
mgJI. Other bacteria __ colonies/100 mi.
Tank size IZS'~? gal.
Foundation deanout (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
System type
Gravel below pipe I~'. Z., 9. I ff.
__ Depression over field
For z,/ bedrooms
New depth in.
~' ~O g.p.d.
If yes, give date A/./~.
Dateinstailed ~'//~/~ Soilrating (g.p.dJft=or~/t)drm)¢~',~
Length '7 7 ff. Width ~. ~' ft.
Total depth I~ ft. Eft. absorption area Iv~Z.~, · Monitoring tube.
Date of adequacy tast ~.,~. 4 ~..1~'~ ,~,Z Results(Pass/Fail)
Fluid depth in absorption field before test in. Water added gal.
Elapsed TIme: min. Final fluid depth in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Number of Compa.'tments ~
Depmesion over tank (Y/N) N
Pumper .,~'$~=~c-c
Claanouts (Y/N) 7'
High water alarm (Y/N)
· · Date installed
O. LIF'r STATION
Data installed
'Pump on" level at in.
Datum
E. SEPARATION DISTANCES
Size in ga,ms
'Pump off' level at in.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO: ~/. ~.
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic sewlce line
Manhole!Access (Y/N)
High watar alarm level at
Meets alarm & cimult requirements?
in*
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
Properly line I ~
Watar se~ce line '~'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Absorption field '2 o '
Sudace watar · I~0 ~
Building foundation ~
Water main '~ ~.O ~
Wells on adjacent lots · ?..oO '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line
Water Sen/ice line
Curtain drain
F. COMMENTS
Building foundation I~ Water main ~, .'¢, '
Surface water '~, ioo' Driveway, parking~ehictestorage
Wells on adjacent lots ~, ?..¢a~ '
--
G. ENGINEER'S CERTIFICATION
con~an~ ~ M~ ~ gu~elines
Engin~r's PHnt~ N~e ~A ~
HAA Fee $
Receipt Number
Waiver Fee $
Data of Payment
Receipt Number
, DA~T~R EC ElY E D
INSPECTION APPOI NTM ENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSPEC-T-~R __
MUNICIPALITY OF ANCHORAGE MUN[CIPALI~ OF ANCHO~GE
PROTE · ~EPT, OF I~;AI.]H &
DEPARTMENT OF HEALTH & ENVIRONMENTAL ~MENT,qL ;:, {qECTION'
825 L Street - Anchorage, Alaska 99601
(ENVIRONMENTAL SANITATION DIVISION APR 1 4 1980
Telephone 264-4720
~r~ ~r~
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed, Please allow ten (10) days for processing,
PROPERTYOW ER PHONE
PROPERTY RESIDENT (H different from ~bove) PHONE
PHONE
MAILING ADDRESS
3, LENDING INSTITUTION ~/~ PHONE
4, REALTOR/AeENT I PHONE
I
MAILING ADDRESS
5, LEGAL DESCRIPTION
STREET LOCATION
b ¢'70 'T-'t'o u.. ro :[:) ~ ¢,~s _.~. i vt.
I Lo-k 5~
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
~"~ING LE~ FAMILY [] One [] Four
[] ._~Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
[] Other
7. WATER SUPPLY
[] INDIVIDUAL* * ATTACH WELL LOG. A well log is required for aH 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
I~-'-INDIVIDUAL/ON-SITE** /(¢'~7~- .YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
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
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: /~)~)~ If Tank is homemade SOiLS RATING -
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL ~
4. DISTANCES Septic/Holding Tank Absorption Are~ Sewer Line I Nearest Lot Line
WELL TO:
I
Absorption Area to noarest Lot Line
5, COMMENTS
~]~APPROV ED FOR , ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
/
72-010 (Rev, 6/79)