HomeMy WebLinkAboutLITTLE BEAR BLK 1 LT 11Little Bear
Lot 11
Block 1
#014-061-28
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MINIMUM [.',ISTRNCE BETHEEN R HELL RND RN'¢ ON-SITE _,E!-IHbE "-'"- "
~.OO FEET FOR FI PRI',,,'FITE WELL OF,' 2¢30 FEET FOR IR PUOLIC NELL
L4ELL LOGE; RRE F.:EQUIRED RND MUST BE RETURNEE:' TO THE [:,EPRRTHENT k~!'FHIN
OF THE I.,.IELL i]:OHPLETION. ' ,- -, PI4"]F'ER
SPEC:IFICFITION.'F., FINE:, CON~TRLIC]"ION DIFfGRFIP1S FIRE RVR:!:LRE;/.E TEl
I NLC.,TRLLFIT I ON.
I CERTIF"r' THRT
t: ! RH FFIHILIRR WITH THE REI;!UIREi'"iENTS FOR ON-SITE SENERS Ri",l[:' NELLS
FORTH E:'¢ THE HUNIL':IF'FILIT'¢ OF RNC:HCIRRIZiE.
: I HILL I~THLL THE _-,~r_-,TEi'~ II,t 1=IIT-:E:OF-:[:'FI'I'"IL-:E NITH THE F':FI[:,EE;
:S I GI'.,IEr.[~: ~ ~--
RF'F'L ICRNT E[:, RINNER
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Parc~l I.D. #
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, A~aska 99519-6650
(9071 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
1. GENERAL INFORMATION ..... -
Complete legal description LFFrLE BEAR SUBDIVISION:· LOT 11, BLOCK 1
Location (site address or directions) 6621 BABY BEAR CIRCLE
Property owner ROBERT LAMIE Dayphone (907~ 257-0177
Mailing address c/o DAN & KRISTI WOLF. REMAX PROPERTIES
Lending agency Day phone
Mailing address
Agent DAN &: KRISIT WOLF. REMAX PROPERTIES Day phone (907) 276-2761/276-4429
Address 2600 CORDOVA STREET. ANCHORAGE. AK 99505
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 5
3. TYPE OF WATER SUPPLY:
Individual well PRIVATE
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:-
Individual on-site
Holding Tank
Community on-site
Public sewer xx
NOTE: If community wastewater system, provide written confirmation from State ADEC
lng to the legality and status of system.
72-025 (Rev, '~/91) Front MOA ~1 Computer Vemion
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $1720.00 at,
or prior to, closing for the engineering services provided.
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 the number of bedrooms and type of
structure indicated herein. I fudher verify that based on the information obtained from the Municipality of
Anchorage files and from my investigation and ins )ecl:ion, the on-site water supply and/er wastewater
disposal system is tn compliance with all Municipa nd State codes, ordinances, and regulations in effect
on the date of this inspection. ~ .
Name of Firm ALASKA ~ & ~'A.ER/~gA' _R CONsuLTANTs, INC. Phone (907) 337-6179
Address 6901 DEBARR//ROAE/, ..~ FE/'.~ANC-loP'AGE, ALASKA 99504 . / .__
Eng,neer's S,gnature (..._.~,, ~,, / ~(~/~'"~. -Date
In conducting this ~Valuaflon, AWWC,~/c.~tt~ lpted to provide a thorough, conscientious engineering analysis of the
system in acCOrdance with ADEC andlMOA D, '-IS Guidelines & Regulaflons~ The reported results described the
performance of the system under the conditions encountered at the.time of the test, and separation distances
measured to readily identifiable features. The operational life of all wells and septic systems depend
on the local soils condition, ground water levels that may fluctuate during the year, and the water
usage of ~h~ family being served by the System, These c°nditiees are outside the control of ·
the evaluatOr of the system. Satisfactory test results do not guaTantee future performance
of the system, nor do they guarantee that there are no hidden defects or encroachments.
AWWC, Inc. can therefore not provide any warranty for future estimate of how long the
system will continue to meet the operational requirements of the ADEC Or MOA DHHS.
The content of this report is for the sole benefit of the owner listed above. Any
reliance upon or use of this report by any other person or pady is not authorized,
nor will it confer any legal right whatsoever.
6. DHHS SIGNATURE
-~' Approved for ,~ bedrooms
__ 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 carb~in 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. 1/91 ) Back MOA #21 Computer Version
,JUN 06 £000
Municipality of Anchorage _
DEPARTMENT OF HEALTH & HUMAN $ ~(~t~t~s~vlc~
Environmental Se~,Jces Division
825 "1." Street, Rm 502 Anchorage, Alaske 99501 (907) 343-4744
Health Authority Approval Checklist
Legal Description: LITTLE BEAR SUBDIVISION; LOT 11, BLOCK 1 Parcel I.D.:
014-061-28
A. WELL DATA
Well Type PRIVATE
Log present (Y/N) Y Date completed
Total depth 85' Cased to 85'
Sanitary seal (Y/N). YES
If A, B, or c, attach ADEC letter. ADEC water system number
1/8/77
Casing height (above ground)
.Wires properly protected (Y/N).
18'+
YES
Date of test
FROM wELL LOG
1/8/77
AT INSPECTION
5/12/00
Static water level 24'
25'
5.8
Well prodUction 12 g.p.m.
g.p.m.
WATER SAMPLE RESULTS:
Coliform 0 Nitrate 0.5 mg/L Other bacteria 0
Date of sample: 5/23/00 Collected by: A.W.W.C., INC.
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size Number of Compartments ~
Foundation cleanout (Y/N) ~rm (Y/N)
~~ Pumper
C. ABSORPTION FIELD DATA ~
Date installed__ .Soil rating (g.p.d./fl2 or ft2/bdrm) _ S~
Length Width Gravel thickness below pipe / Total depth
EffectiVe absorption area Monitoring Tub~ Depression over field (Y/N)__
Date of adequacy test ~/.~su~(Pass/Fail)__ _ For __ Bedrooms
Fluid depth in ab~n.); Imm.e. diatel~ after, gal. watar added (in.):
Fluid depth ~ ('~atar: Absorption rate = _
~ent (past 12 months) (Y/N) If yes, give date
72-026 (Rev, 3/g6)* Computer Version
D. LIFT STATION ~
Date installed Size in
Manhole/Access (Y/N) ~ew~l at* "Pump off" level at*
High wa~~Datum
__Gyc:,les-f6ste d
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot N/A
Absorption field on lot__ N/A
Public sewer main 25'+ - WAIVER REQUESTED
Sewer/septic service line 25'+
On adjacent lots N/A
On adjacent lots N/A
Public sewer manhole/cleanout 100'+
_ Lift station N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Property line __ ~
Water main/service line __ ~ter/drainage Wells on adjacent lots
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property
line Building foundation ,Wate~
Surface water ~--------~~ing/vehlcle storage area.
Wells on adjacent lots
F.
DateEngineor'~:~/O ~JJEFFREY A. GARN SS
H~ Fee
Receipt Number ~-~'~'./~ ~,~'b~//~
72-026 (Rev. 3/96)* Computer Vomlon
Waiver Fee $
Date of Payment
Receipt Number
Rick Mystrom.
Mayor
Mtmic pality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
http://~www.cLanchora§e.ak.us
June 21, 2000
Jeffrey Gamess
6901 Debarr Road, Suite 2-B
Anchorage, AK 99504
Subject:
Waiver Request for Little Bear, Lot 11, Block 1
Waiver Request #WR000035
Parcel ID #014-061-28
HA000227
Dear Mr. Gamess:
Your request for a waiver of the required 50 feet horizontal separation from the
public sewer trunk to private well has been approved. The approved separation distance
is 25.0 feet. The required separation distance from the sewer line to the well was 50 feet
at the time the well was drilled.
This waiver approval applies to the existing public sewer trunk to private well 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
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
On-Site Services
Waiver Review Worksheet
WR#: WR000035 PID#: 014-061-28 HA#: HA000227
Date Received: June 6, 2000
Legal Description: Little Bear Subdivision, Lot 11, Block 1
Permit~:
Engineer: Alaska Water & Wastewater Consultants, Inc.
690t Debarr Road, Suite 2-B, Anchorage, AK 99504
Applicant: Robert Lamie
Waiver Requested: 25 foot waiver from the private well to the public sewer line
Criteria: 1. Geology Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
2. Special Conditions:
3. Other:
Total:
Waiver is Granted:
Waiver is not Granted:
List Conditions or Reasons for above: ~ ,E~ ~:~ ~
Date: ~--21 '-OO
Re¢#: 05905 Amount: $0~0.00
Name of Reviewer
Date Paid:. §-6-00
_]
S. of Zt, 9, E. C, s. P. w. 6-, fo~ s. £,
/.7
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LO~OOOO~B
ALASKA WATER & WASTEWATER
June 2, 2000
Municipality of Anchorage
Department of Health and Human Services
Attn: Dan Roth
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 11; Block 1; Little Bear Subdivision Little Bear; Waiver request for
separation distance between well and the public sewer line.
Dear Mr. Roth,
The referenced property is a three bedroom residence served by a private well and public
sewer. There were two previous Health Authority Approvals issued on this property. One
in 1989, submitted by Brace Corwin, P.E. and the most recent one by Tobben Spurkland,
in 1994. Neither engineer addressed the separation distance to the sewer main running
along the north property line. Records fi:om your department indicate that the well was
permitted in June, 1976 but not drilled until January, 1977. Per Anchorage Water and
Wastewater Utility (AWWU) records, the public sewer was installed in 1976, prior to the
existence of the well. Based on our field measurements, the well is approximately 27.5
feet fi:om the public sewer nmin that runs along the north property line. (see attached
drawings). The required separation distance requirements in 1977, between a private well
and a sewer main was only 50 feet. We are requesting that your department waive the
subject separation distance to 25 feet. Justification for the waiver is summarized as
follows:
1) The existing encroachment has existed for 24 years with no adverse impact to the
aquifer. Recent water samples indicated no bacteria and nitrate levels of .5 mg/L (see
attached water analysis)
2) The driller's log for the referenced well indicates that the aqtfifer is confined by layers
of brown sand to gravel and gray clay to 18 feet and hard pan from 26-80 feet (well log
attached). These confining layers act as a protective barrier between the sewer main and
the aquifer.
6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * website - akwwc.com
Page Two
Waiver request
Little Bear S/D Lot 11; Block 1
Based upon the facts, it appears that there is minimal risk in granting the subject waiver.
If you require any add~ional information for your review please contact us at 337-6179.
Sinc;e&e ~ /'~,/~ l
6901 Debarr Road, Suite 2-B * Anchorage, Alaska 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * website - akww¢.com
05/17/00 10:00:33 AM
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~.w.~.
ALASIC& WATER & WASTEWATER ~o~: //~.." 4 ~:~-, ~ '~";,'~
CONSUVr^NTS,~NC., ....... 1 : 100 ~/'::':"
ROBERT LAMIE (907) 257-0177 1 OF
LITTLE BEAR SUBDIVISION; LOT 1 1, BLOCK 1 '4[~_
riPE Of WOR~:
SITE PLAN
~DING STA. O+O0(A) TO STA. 26+14.04(A) WITH A.C.
)DING STA. O~-O0(A) TO STA. ~6+14,04(A)WITH D,I.
_~ _ E-I-H SUB. TRUN~
RW _._ PLAN AND PROFILE
............ ~ ..... :: ~ ..................... -f, ..... ~ .....................
~PRUCE
SWAMP
ICO
9O
80
'RUCE
N
NOTE= D.I.
CLASS B BEDDING STA. O+O0(A) TO STA 26+14.04(A) WITH A.C.
CLASS C BEDD NG STA. O~-O0(A) TO STA, 26<.14.04(A} WITH
26
Sent By: Rema× Propertlee~ Dan Wolfj 'go7 258 4687j
FIRST P~F_.RICAM TITLE Ot HLHD~
//~.
May-lO-O0
1:24PM;
Page 2/2
~T
~ASEMENT$ OF I;'ECO~D, OTHER THAN
THOSE SHOWN ON THE R~CORDED
PLAT, ARE NOT SHOWN Hr'R~ON,
0 ~ i 3. gO?5~;L~SaO PAGE. 02
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
(*)ILl- (J&~l- 7-8 HAA#
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner ~rq~-/
-!
Mailing address
Lending agency
Mailing address
Agent ~'~'- ~- ',.~-~',
Address ~2.~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
Day phone }~q-5717
Day phone
Day phone ~ - ~(
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.
72-025 (Rev, 1/91) Front MOA #21
STATEMENT OF INSPECTION B~Y 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.
NameofFirm t ~'~l~l~e~"l ~,-P~{,~¢(¢ -~-L~ Phone ~L~_~ ~/~
Address ,¢~¢ :¢ ~' I,I- ~,z~ ¢ ;,z_o "~
Engineer's signature
DHHS SIGNATURE
Approved for ~'~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
Date
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 engineeCs work.
72-025 (Rev. 1/91 ) Back MOA ¢Y21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Well type ~.
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Parcel I.D.
Date of test
Static water level
Well flow
If A, B, or C, attach ADEC letter. ADEC water system number
"-/ Date completed I/'~/7'7 Driller '-~,
~:~ ¢ Casing height
'Wires properly protected (Y/N)
Cased to
?
FROM tNELL LOG
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot W/,~
Public sewer main
Sewer service line
.g.p.m.
AT INSPECTION ,~
g.p.m. ~ r,o ,.. ~'
· , On adjacent lots ~/A z~ m
; On adjacent lots ~/~
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ¢
Date of sample: g/~' ,%/~]
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Nitrate
Tank size
Foundation cleanout (Y/N)
~ ~ T~ .Other bacteria
Collected by: ~ ~
Compartments
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Sudace water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (3/93)° Front CONTINUED ON BACK PAGE
C. LIFT STATION ~'~//~
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LiFT STATION TO:
Well on lot
On adjacent lots
Sudace water
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absorption area
Date of adequacy test
Soil rating (GPD/Ft2)
Gravel thickness
Cleanout present (Y/N)
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type
Total depth
Depression over field (Y/N) .
for Bedrooms
After test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Sudace water
Curtain drain
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect On.the date of this inspection.
Engineer's Name
Date G
HAA Fee $ ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ~) l Z'/-~ ~ -'~ ~ HAA# J°l ~(~~]¢'~ ~ ~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section,'township, range)
Location (address or directions)
(b) Property owner P~::~ ~"~ f~*~'
Mailing Address ~ ~
(c) Lending Institution ~ ~
Mailing Address ~ )~
/-
(d) Real Estate Company and Agent
(e)
Business
Telephone ~L/)/q-
Telephone
Mail the HAA to the following address: (or check here~if hold for pick up.)
List contact person and day phone number below:
TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
WATER SUPPLY
Individual Well 5~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
SEWAGE DISPOSAL
On-site [] PublicJ~ Community[] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88} Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my sea~ affixed hereto and as of the validation date shown below, Iverifythat my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional ~tnd adequate for the number of bedrooms and type of structure indicated herein. I further verify th~:
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 ~Or~/1 ~ ~ ~ ~ ~ ~ ~ Telephone ~-~-~---/~/I
6. DHHS APPROVAL
Approved for ,~
Approved ~X~
' Disapproved
Conditional
Engineer's Seal
Terms of ConditionafApproval
The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval
cerificated based only upon the representations given in paragraph5abovebyan independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending
institutions inordertosatisfycertain federal and state requirements. Employees of DHHSdo not conduct inspections
oranalyzedatabeforeacertificateis issued. The Municipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
~ _~I~IICIPALITY OF ANCHORAGE (MOA)
IP CHCw.~.
MUNIC ~/~~S PlY S'~,Ith Aulhorily Approval (HAA)
~NVI~ONME~' CHECKL ST- FEBRUARY 1984
R£CEtVED
WELL DATA
Well Classification :~"~/" J I/eL
Well Log Present (Y/N) '~/ Date Completed
Total Depth OO~ ~ Cased to __
Static Water Level /~ ~ t
Casing Height Above Ground 2. ~"
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~ ..~'O
To Nearest Sewer Service Line on Lot
Water Sample Collected by k). L ~'n ~
Water Sample Test Results -~"~-'T/S
Comments
343-4744 ~
Legal Description: L I"/-'¢'/'~.. /.7~..~_ ,¢~:~./..- ,,.~'~)(_~.
/-¢'f'- / / ¢c/<. /
If A, B, C, D.E.C. Approved (Y/N)
~ /e/ 7~7 Yield
Depth of Grouting /3/
Pump Set At (-Cf~ /
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; on Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Oleanout/Manhole
;Date
B, SEPTIC/HOLDING TANK DATA h/
' '/~o. of Compartments
Standpipes (YTN~__ Air-tight Caps (Y/N) Foundation Clea ou ( / )
Depression over T~ __~ Date Last Pumped .____
Ppmping/Maintenance Contac~File (Y/N) ~; for ____
Holding Tank High-Water Alarm (.Y7N~ Temporary Holding Tank Permit (Y/N)
~ PwAa~eAr~ IsOu ~p~ S:e~iN C ES FROM SE PTI ~I_.~N G TToABN~:ding Foun dar ion
1 Field
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C, ABSORPTION FIELD DATA
So. rig in Absorption Strata
Date I nsta'l'~%__
Width of Field %--..~.~.
Square Feet of Absortion Ar~
Depression over Field (Y/N) "'"'""%
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FI"EbD:
To Water-Supply Well
To Building Foundation
Lot
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
'"'~e..~o p e r ty Line
~ To Existing or Abandoned System on
; On Adjoining Lots~',,,
To Cutback (if preshe%
Size in G~G~r~s~ .-~
"Pump On" Level at -------~
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
High Water Alarm Level at ~--~---~ Vent (Y/N)
Tested for % Pumping Cycles during Adequacy Test,
Meets MOA Electrical Codes (Y/N)
Comments
m ~r~ '"~
Bedroo Against HAA Request**
fied, or conformed to all MOA and HAA guidelines in effect on the date of this
/ ,---.---~
**Check Per m i~e~/~
I certify that
inspection.
Signed
Corn
Engineer's Seal
-
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
CORWIN & ASSOCIATES, INC.
4790 Business Park Blvd.
Building E Suite 1
ANCHORAGE, ALASKA 99503
Phone 561-6151
JOB
SHEET NO.
CALCULATED BY
CHECKED BY
SCALE
OF
DATE
DATE
MUN CIPALITY OF ANCHO~
DEPT: OF HEALTH &
~NV RONMENTAL PROTECT ON
AU~ 1 4 lgSg
RECEIVED
· ~, D/~TE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
MUNICIPALITY OF ANCHORAGE:xn, DEPT. OF I;-ALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~IRONM~T't'L
825 L Street- Anc,orage, Alaska 99501 MAR 2 8 I980
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
PROPERTY OWNER
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) / ' ' PHONE
~. BUYER PHONE
MAI LING ADDRESs
3, LE~DI~GI~STITUTION ~ PHONE
I
~AILING ADDRESS ' '
4. REALTOR/AGENT PHONE
~AIkl~G ADPRESS
SI L ~GA L DEscRIPTION
E. TYPE OF RESIDENCE NUMBER OF~BEDROOMS
[] One [] Four
~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY J~ Three [] Six
[] Other
7, WATER SUPPLY
INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOGi A well Icg is required fQr all wells drilled
since June 1975. For wells drilled prior to ~l~ta~ ]d~ate, give well
depth (attach Icg if available.) ~1~~4, U~l-~,w, -
s. SEWAGE D,SPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
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 UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or []HoldingTank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
[~'"~APP ROVE D FOR ,~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[~] DISAPPROVED
DATE BY ~,~
~=MUNICIPALITY OF ANCHORAGF~<
c [!~ '~E. PARTMENI ,~F HEALTH AND' ~NV~I.RONMENTAL ,-'ROT:EO'T~ON::: %": '~'~;..~ : ~' .
825
Da~e Received: ~arch 21, ~977
1st Inspection: Time 1:30 p.m.
2nd Inspection: Time
Date 3-22-77 Tues. Date
Inspector Dixson
Inspector
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
1. Lending Institution Request: National Bank of Alaska
Mailing Address: Post Office Box 3-3859 99509 Phone: 279-2506
2. Property Owner: Donal Dahl/Dahl Construction
Mailing Address; Star Route A Box 79 99507
Phone: 344-57'20
3. Legal Description: Lot 11 Block 1 Little Bear Subdivision
4. Single Family Residence: (x~ Number of Bedrooms: 2
Multiple Faraity Residence: ( ) Number of Bedrooms:
Permit ¢76312
5. Well Data: Type Individual
Construction
6. Sewage Disposal System: On-site system ( ) Public Utility
Permit Installed
Installer
Depth 83'
Bacterial Analysis
Well Log Fi~ed (~
(x)
Septic Tank Size
Manufacturer
Absorption Area
Soils Rate
Material
Distances: Well to Septic Tank
to Sewer Lines Nearest Lot Line
Absorption Area to Nearest Lot Line
to Absorption Area
Page T~o
~ , !Depa~tmen~ 0f Health and Environmental Protection
· ~ ~' Request for'ApprovaI of'Individual Sewer and Water Facilities
Legal Description: Lot 11 Block 1 Little Bear Subdivision
Comments:
Affadavit Attached: )
Approved:
Disapproved
Letter Attached: ( )
Date:
Date:
Department Worksheet: