HomeMy WebLinkAboutNORTH WOODS BLK 4 LT 1North Woods
Lot 1
Block 4
#051-731-06
" Municipality of AnChorage Page / __of ~-~
, 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
Ueme: -.~Tb,~cJ ~ ~5~ Wastewater System: ~New ,,,~ Upgrade
Address:~Z ~O~ ~C~ Ai~ ABSORPTION FIELD
LEG Total Depth from original grade:
, AL DESCRIPTION SoilRating: O,~ GPD/Sq. Ft. ~'~ ~,~ ''
Subdivision: Depth to pipe bott0m~rom original grads: Gravel depth beneath p~pe
Township: ~ I Range: Fction: ~ ~,~ Ft. Grave' lengt~O Ft.
/~ , / ~ Fill added above original grade:
Gravel de?~ ~ ~ Number of lines: J Distance ~tw~n lin~:
WELL: ' Q New ~ Upgrade /~ Ft. ~
Classification (Priva[e, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe material:
Date msta~led:
Yield: I Pump Set at: J Casing Height Above Ground: TAN K
GPM~ Ft. I Ft.
SE PARATIO N DISTANCES ~ Septic ~ Holding ~S.T.E.P.
To Septic Absorption Li~ Holding Public/Private Manufacture~ ~ Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~f ~
~ Number of Compa~ments:
Material:
Sudace LIFT STATION
Water IOO~ Io~+ I0~ ~
Lot Size in gallons: Manufacture~
Cudain Pump Make & Model Electrical Inspections pedormed by:
BENCH MARK
Location and Description:
Assumed Elevation:
9epart ent of Hea m d Hu a e,vice appr vaV
Reviewed and approVed by:' '~;¢~
;2-o13 (1/91) MO,~, 25
P~rmit No. :5'~/ ~./~7S~ Page ~-- of. ~'-
Municipality of Anchorage
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 Ins pection Report
Legal Description:
PID No.: o 5-/- ~,/-~,,,
ORTH PAC
LECTRIC
LICENSED ' BONDED ' INSURED
Industrial - Commercial - Residential
3655 Ruth Drive
Wasilla, Alaska 99687-9201
(907) 373-4767
FAX 373-7035
To Whom It May Concern:
This is to certify that the liftstation installed
at Lot 1 Block 4, Northwoods, Norton Circle, moo'ts
NEC standards.
Signed,
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW940075
DESIGN ENGINEER:DAVID R. DAYTON, P.E.
OWNER NAME:JACOBSEN JOHN P &
OWNER ADDRESS:22532 NORTON CT
CHUGIAK, AK 99567
DATE ISSUED: 4/14/94
EXPIRATION DATE: 4/14/95
PARCEL ID:05173106
LEGAL DESCRIPTION: NORTH WOODS BLK 4 LT 1
LOT SIZE: 23387 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK 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:
EXCAVATE THE PEAT AND ORGANICS; INSTALL 2~EET OF APPROVED
F~LTER LAYER, AND INSTALL 200 FT. 0F WIDE'~i.~bRAINFIELD~n (TWO
TRENCHES) USING SIX INCHES EFFECYIVE GRAVEL BELOW THE
I T I UTION
RECEIVED BY:
Di R. DAYTON, P.E., R.LS.
· ~' Chugiak, Alaska 99567
20210 Donalar
[907) ~
696-2417
Lot 1, Blk 4, Northwoods Subd.
The design presented is an upgrade to replace a failed seepage bed.
The new system will be a pressurized shallow trench lOCated on the
rear of the lot. The septic tank will be ~eplaced with an Anchorage Tank/'
Orenco STEP tank.
The subdivision is served by a Public Water System, therefore well
contamination is not a critical factor.
The proposed system will have no measurable impact on reserved space,
surface or subsurface, or on drainage.
PERFORMED FOR: '-~
LEGAL DESCRIPTION:/~;r~'
1
2
3~
4
5
6-
7
8
9
10
· ..... 11
12
13
14
15
16
17
18
'19
20
COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
/
SLOPE
WAS GROUND WATER
ENCOUNTERED?
SITE PLAN
~lJ~ ,[~ IF YES! AT ~VHAT
S
c-~ ! 0
DEPTH?
7
P
E
Depth to Water After
Monitoring? Z~:Da,~ ~,I~v
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~ (,minutes/inch) PERC HOLE DIAMETER __
TEST RUN BETWEEN ' ~' FT AND :~ FT
' Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL D E,ORIPTION; L
1
5
6
'7
8
9
10
11
12
13
14
15
16
17
18-
'19 -
20-
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH? ~, ~ O
P
E
Depth to Water After /
Monitoring? ~', ~ Date:
DATE PER FORM E~~~~
Township, Range, Section: ~¢~
SLOPE SITE PLAN
A
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch) PERC HOLE DIAMETER ~' #
FTAND ¢0f FT
PERFORMED BY:: -~-"~-.,,.2,;~O I'~; ~:)~V2"~'J ~ I CERTIFY THAT "[:HI$ TEST was PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS'DATE. DATE:
72-008 (Rev. 4/85) - " ,:
D'. R. DAYTON, P.E., R.L.S.
20210 Donalar Chugiak, Alaska 99567
May 23,1994
Municipality of Anchorage
Dept of Health & Human Services
P.O. Box 196650
Anchorage, Alaska 99519-6650
(907) 696-2417
RECEIV ED
MAY ~ 4 1994
Municipality of Anchorage
Dept, Health & Human Services
Attn: Mr. Robert Robinson
Re: Revised Septic Ssytem for Lot 1, Blk 4, Northwoods Sub. Permit #SW 940075
Dear Mr. Robinson,
Due to the high water table found at this site when construction was
ready to start on the original design,'we have monitored the water table
through May 21, 1994. The highest water level was found on 5/2/94 at t.5'
below ground level.
We have performed additional percolation tests immediately below
the organic/sod layer and based the re-design on these results. Other
aspects of the design remain the same.
Please review the revised design and site plan and and advise us of
tour approval as soon as possible.
Sin~rely, ~
David R.Dayton
!
!
/d.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LE A' DESCR,PT,ON:
7
8
9
10
11
12
Township, Range, Section:
SLOPE
~o~s
WAS GROtJ ND WATER
ENCOUNTERED?
L
IF YES, AT WHAT O
DEPTH? P
E
Depth to Water Alter
Monitoring? Date:
13-
14-
15-
16
18
19
20
COMMENTS
SITE PLAN
Gross Net Depth to I Net
Reading Date ~3e Time Water I Drop
PERCOLATION RATE . -
TEsT RUN BETWEEN
{minutes/inch) PERC HOLE DIAMETER
FT AND I ~"z.._ FT
ACCORDANCE WITH ALL sTATE AND MUNICIPAL GUIDELINES ~N EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
~; /
PERFORM
DATE
LEGAL DESCRIPTION:~°f /J ~;;~-- '/~,~,.30.S' Township, Range, Section: .~
SLOPE SITE PLAN
1
2
3
4
5
6-
7
8
9
10
11
12
13-
14
15
16
17
18
19
WAS GROUND WATER
ENCOUNTERED?
$
IF YES, AT WHAT ~)
DEPTH? P
E
Depth lo Water After
Moniloring? Date:.
20-
Gross Net Depth to Net
Reading Date Drop
rc>r~_~ ¢>, i~Ti m~ Time Water
/ ~,/~, :,~ - ~,'m ~o ~?,- ~Y~
PERCOLATION RATE /'zZZ'° / (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN . ~'~- FTAND 1',-~ .FT
COMMENTS
~/~Z ~ CERTIFY THAT, THIS ~EST WAS PERFORMED I"
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: / ~/~/
72-008 (Rev. 4/85)
, MUNICIPALITY OF ANCHORAGE ~ I~G Pt $~' ~-
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS .~
J Wel, Absorpti~nqre~ Dwdling PERMIT N~.
DISTANCE TO: AO I '~
~ Man"facturer ~ Material ~ ~ ~°'°fc°moartme~ts~
Liq. capacity in gallons Inside length Width Liquid depth
lO O0 IF HOMEMADE:
~o ~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation Nearest lot line PERMI~ NO..
m ~ ~n~h o~ eac~liDe Total lengt I s Trench width __ Distance between lines
~ ~ ~ Top of tile to finish grag/ " Material beneath tile~ __ inches Total effec~bqr~, area
Length Width Depth PERMIT
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tan~ Absorption area(s)
~ DISTANCE TO:
OTHER ,~ ~ ~ ~ '
PIPE MATERIALS
SOIL TEST RATING ~ ' ~
APPROVED DATE LEGAL
..MUNICIPALITY OF ANCHORAGE ~.~ /~ ....
Department~r ~f Health and Environmenta~-~protection~~-~
. ~ 825 ' ~ Street, Anchorage, AK. ~9501 ~ /~ ~.
264-4720
' ~",~ * * * HANDWRITTEN PERMIT * * *
Permit ~ ~
Applicant: . .~~ ~
Location:
Legal Description: Z ~ / ~/~
Type of Soil Absorption System Is:
ON-SITE SEWER PERMIT
Mailing Address:
Trench: Drainfield: _ Seepage Bed: /~ Holding Tank:
Maximttra Nu/~ber of BedroGms: ~ Soil Rating(sq.ft/br) /.~ ~..~ ) ~~/ ~/
The Required Size of the Soil Absorption System Is:~9
'/~W~,~ t
DEPTH ~ LENGTH ~ / GRAVEL DEPTH ~ .~ WIDTH ,~0.
The length dimension is the length(in feet) of t~~ ~r drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the exCavation(in feet). There is no set width for trenches.
The gravel depth is the minim~ depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDIN6) TANK SIZE = / ~OO GALLONS * ~
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS AR5 REQUIRED * ~ *
Backfilling of any system without final inspection.and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minim~ distance from a private well to a private sewer line
is 25 feet and to a co,unity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days Of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 3 * * *
i certify that: -
(1) I ~ f~iliar with the requirements for on-site sewers and wells as
set forth'by the MuniCipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that %he on-site sewer system may require enlargement if
the residence is remodeled to include more thak 3 b~ro~m~.
Applic~ Date: ~--/~&S '
O & E ENC, .NEERING & DEVELO'"~VIENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
Russell Oyster
694-2774
Performed for:
Name: ~;~
Mailing Address: /~,
694-2774 or 688-2280
SOIL LOG
Earl Ellis
688-2280
Legal Description:
Depth (feet)
0
Soil Characteristics
4 v ~-T~
5__
6__
7__
9
10
11__
12__
13__
14__
151
16__
Ground Water Encountered: Yes
If yes, what depth
Proposed Installation: Seepage Pit.__
Drain Field
Comments:
PLOT PLAN
PERC. TEST
~'~'~ MUNICIPALITY OF ANCHORAGE ~"~'~ ~il~' ~T
DEPARTIVlENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE ,J~NEW
4~ 2-~Si E~ UPGRADE
MAI LING ADDR~ESS
LEGAL DESCRIPTION
LOCATION
NO, OFBEDROOMSj
I Well
DISTANCE TO: (..~OI13 r~
Manufacturer
I Absorption area
Liq. capacity in gallons
I il500 IF HOMEMADE:
DISTANCE TO: IWell
Inside length
Dwelling
DISTANCE TO:
No, of lines ~
Lenath of each line
Top of tile to fTh.~g~de
Length
Width
F°unda~.~b
Total len gtf I~.~i nes
Material beneath tile
Depth
Type of crib Crib diameter Crib depth
Well Building foundation
DISTANCE TO:
Class Depth Driller
DISTANCE TO: Building foundation Sewer line
Dwellin~ ~ %/'..Z.
Materia]~,~
Width
Material
Nearest lot
Trench wi~..h~) inches
inches
PERMIT NO. ·
No, of comp~.ments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Distance between lines
Total effectiveg.J;~gp~l~O~ area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO,
I Septic tank I Absorption ~rea(s)
OTHER
PIPE MATERIALS
SO] L TEST RATING
INSTALLER
REMARKS
APPROV Ef 7 - ~"
DATE
LEGAL
72-013 (Rev. 3/78)
J MUNICIPALITY OF ANCHORAGE ~..A /.,~ ~
, Department/~ Health and Environmenta]~rotection~'~'~~
-- 825 ~. Street, Anchorage, AK. . ~i501 ~
264-4720 ~
' ~ f * * * HANDWRITTEN PERMIT * * *
Permit ~ , ~
)~ ON-SITE~SEWER PERMIT
Applicant: -~_~ Mailing Address:
Location: Phone Number: _
Legal Description: ~0~ ~ ~/~~ ~ Lot Size: '
Type of Soil Absorption System Is:
Trench: Drainfield: ._ Seepage Bed: ~ Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) ~O
The Required Size of the Soil Absorption System Is:'
DEPTH ~ LENGTH .~/ / GRAVEL DEPTH ~ ~,/~WIDTH
The length dimension is the length(in feet) of the ~rencn or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
· * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~OO GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to ~nsure proper installation.
~ * ~ PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familiar With the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand chat the on-site sewer system may require enlargement if
the residence is remodeled to include more th~3 bedroo~s/
Appli~an~ ~ ~ ~--~
Date: ~2~
O & E EN~.~NEERING & DEVELC~'MENT CO.
Box 90, Davis St,, Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
SOIL LOG
Performed for: Name:
Mailing Address: ~' ~ ~ ~/~ ~~, ~--~7
Legal Description: ~ ~t ~~ ~ ~ ~0~ /
Depth (feet)
0
2
5
6__
7__
8__
9 '
10__
Soil Characteristics
Earl Ellis
688-2280
Tel. No. f~ ~-- ~'5/
PLOT PLAN
11
12__
13__
14__
15__
16__
Ground Water Encountered:
Proposed Installation: Seepage Pit
Comments:
Yes__._..__~No If yes, what depth.
Drain Field.__
PERC. TEST
I
Date: JA~( ~,~ /?~,,~
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.oi.ancho rag e.ak.us
(907) 343-4744
Parcel
1.
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Expiration Date:
GENERAL INFORMATION
Complete legal description ~..~-/
Location (site address or directions)
Current Property owner(s) ,~)(~[
Mailing address '_/~/~.--'~.' Z 1. ?L-tA?/?; .'.J ~/~7,~
Lending agency
z- ~.~- 7/v ~- Day phone ~/'~.¢!,.¢-'- -- / ~-f c?
Day phone
Mailing address
Real Estate Agent_ //\/,.)"/
Mailing Address//¢// [¢
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site
[] Individual Holding Tank
[] Community On-site
Public Water System
[] Public Sewer []
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Cedificates 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 Alaska. Certificates of Health Authority Approval are
required for the transfer of title (except between spouses) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
Certificates of Health Authority Approval are 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 old. Certificates
are valid for one year for propedies served by Class A or B wells or a public water system. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
-2 025 ~Rev. OI 00]'
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
based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval
application show 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 wi[h all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm
Address
S & S ENGINEERING
Eagle Eive~', Alaslca 99577
Engineer's Printed Name /;~
DHHS SIGNATURE
L.-'"' Approved for "~
Disapproved.
Conditional approval for
Phone (-.°' ~''$ ¢/ - -~'? 7 ?_ _
bedrooms.
Date
bedrooms, with the following ~tipulations.
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
/-/:
Expiration Date:
Original Certificate Date:
Reissue Date:
75 025 ~Rev 01 001'
Legal Description: ~ /,'
A. WELL DATA
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Municipality of Anchorage "~ ~ C E ! U ~' ';/~
DEPARTMENT OF HEALTH & HUMAN SERVICES JUL ~9 ~)
Environmental ServiCes Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (~7~4~o~ A~c~o~
· ~krMENTALSERVIC~SDivp._'
Health Authority Approval Checklist
Date of test
Static water level
Well production
WATER~ SAMPLE RESUUr~
Coliform
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~'
Cased to Casing hei.~'(above ground)
W~y protected (Y/N)
FROM WELL LOG~ AT INSPECTION
g.p.m. '~
g.p.m.
Nitrate Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed (~/~4/¢~- T~anksize
Foundation cleano~/N) L~.~
/~/"~" Number of Compartments z~ Cleanouts.~)N)
Depression (Y~)' ~/~2 High water alarm ~JN)
/
C. ABSORPTION FIELD DATA
Date installe~ ~/,~'~'/¢"~ 'Soil rating (g.p.d./fF or fF/bdrm) ~ ~
Length ~ Width ~/-~ Gravel thickness below pipe
Effective absorption area ¢~ .Z~ Monitoring Tube present~) ¢'Z Depression over field (Y/N)__
Date
of
adequacy
test
Fluid depth in absorption//field before test (in.); r/ '~ Immediately after'~?'gal, water added (in.):
Fluid depth ~ ~--" (ins) Minutes later: ~/ Absorption rate -- _/z z/~"-~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) ,/~/~.,1/~~/~'~b/A/ If yes, give date
System type ~ -'~'~'~
~. (.. ~'o~r~ ~:~-~
Total depth
bedrooms
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Manhole/AccessL~N) ~z/~5,
High water alarm level at* {;~ '~'
Cycles tested ~-~--
Size in gallons ) ~ 5'- o
"Pump on" level at* '? ~ "Pump off" level at*
*Datum.~.,~ ("~/~ /4'//~fZ
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
Absorption field on lot OQj:padj~nt lots
Public sewer main ~ Public sewer manhole/cleanout
Sewer/septic service line ~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation /,~/¢- Property line ~ /
~ Absorption field
Water main/service line /~ ~- Surface water/drainage //~ ,/¢- Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
/
Property line ,./~'~ /- Building foundation //~/'~ '/- Water main/service line
Surface water /O~ /+ Driveway. parking/vehiclestorage area
Curtain drain ,/&/~/¢~ //'~/¢'-//U~/ Wells on adjacent lots /-zA'/,~_! C
/0
F.
HAA Fee $
Date of Payment
Receipt Number
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal recor~,~ ~t~¢l,f-C~¢tems are
in conformance with MOA HAA guidelines in effect on this date.
Signature
Date 7//*/oo
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
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
0~'| -"/~ I- ~ HAA# \~"~°t'~(('~*~3 ~,
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) 'Zz~.~,Z. /~T¢~ ~--___~,~.~..~-'
m
Property owner
Mailing address
Lending agency
Mailing address
~ow-~ -,,T'~_.~,~ Day phone
Day phone
!
Agent Z~/l~/t,Ar~ o ~- -~::~,~,--~:
Address ~' t
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
NOTE:
Day phone r--~¢-5~--~ ,~w- 2.30
Individual well
Community well
Public water ~
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 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.
David R. Dayton P.E. Phone
Name of Firm z~i0 [mna]ar
Ch~iak, ~laska 9~567
Addre~
Engineers signature . . . ~ ~ Date
DHHS SIGNATURE
/-//Approved for ~
Disapproved.
Conditional approval for
bedrooms.
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.
72-025(Rev, I/91) Back MOAiI21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~o~3'W~.~$ ~ ~.~ Parcel I.D.
o~-I- ?5/- 04.,
A. Well Data
Well type P~5~ c
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC watersystem number
Date completed Driller
Cased to Casing height
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Wires properly protected (Y/N)
AT INSPECTION
g.p.m.
g.p.m.
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:.
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
Compartments ~--
Depression (Y/N) /%/
Alarm tesied (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Foundation ~
Water main/service line
Well(s) on lot
To property line
Surface water/drainage
On adjacent lots
Absorption field
CONTINUED ON BACK PAGE
72-026 (3/g3)* Front
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) y
High water alarm level
~/~/~ Manufacturer
t' ~ ~-~"--C~ Manhole/Access (Y/N)
"Pump on" level at .z/z.._ "Pump off" Level at
Y Cycles tested ,..:2 .
Meets MOA electrical codes (Y/N) ~.--
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot /~o/J ~: On adjacent lots ~ '~' '-~
Sudace water
Date inStalled
Length ./5'
Total absorption area
D. ABSORPTION FIELD DATA
Width
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Cleanout present (Y/N)
Results (pass/fail)
Soil rating (GPD/FF)
Gravel thickness Total depth
~ "~' {d Depression over field (Y/N)
for
After test
If yes, give date
System type /~b~ ~ '~
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~o ,v C~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots /./o ~C'~- Property line /'~-)
~ c5"- To existing or abandoned system on lot
~,o ~ Cutbank ,4.,)?.~/- Water main/service line
/ oo ~-- 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.e~e~t On the date of this inspection
Signature
Engineer's Name
Date
David R. Dayton P.E.
20210 Donalar St.
Chugiak, Alaska 9956!
HM Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
APPLI '"NT FILLS OUT UPPER
HAL'"I ONLY
Phone
F~operty Owner ~TSK
zip Code 745-2553
Mailing Address
Buyer Kenneth R., ~ Alice ~. Smart
Address 1001 Boniface Pkwy #13J, Anchorage, AK ZipCode 99504 '
Lending lnstitution ~i~st ~tiO~ ~k O~ A~oho~ (~'~LI~oo~ ~no~) Phone
Address ( ~ ~'~ ) Zip Code
RealtyOo.&A~nt ~]~AX o~ e~le ~i~er, I~o. (Jim Mont~He) Pho.e
Address PO ~O~ 848~ ~e ~iVe~ A~ ZipCode99%77 694-4200
Legal Descdpt~n Lot 2~ B~OO~ ~ NoPt~oo~ffi S~b~ivi~io~
Street Locati~ z'~ ~'OZ'tO~l ~O~$
Type of Resi~nce
~ Single Famiiy
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~ Individual A~ACH W~LL LOG. A w~l Icg is required for all wel~s drilled since June 1975.
~ Community /~0 ~ For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal
~ Individual Year Individual Installed:
~ Pubtic Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
~'-- I' ~.~',.,' ~ '~-~' / ~'-m~JTime
Time
Time
Time
Date Date Date Oa,e /0~._.,/L7~ ~.~.,
Inspector Inspector Insp~tor Insp~tor
Field Notes: ~ ~ ~ · MUNiCIPALiTY OF ANCHO~GE
DEPT. OF HSALTH
RECEIVED
( ~ APPROVED BEDROOM8 'OONDITION8 OF APPROVAL
(~) DISAPPROVED
( ) OONDmONAL APPRO~L~
I
Soils Rating Date ~wer Installed Well To Absorption Area~ Well Log Received
~OC[ C -- ~ 7-- ~ ~ WelltoTank ~~ Septic T~k Size ?
72-023 (3182
APPLI?~NT FILLS OUT UPPER HA~'~'' ONLY
%~ ' -' Phone
Property Owner {2~':: ,)Q.~" ~/}Or";'.~) ~ L'~{}/~t ~'~£'
Buyer
Address Zip Code
Phone
Lending Institution
Address Zip Code
Phone
Realty Co. & Agent
Address Zip Code
Street Locat,o. /')<~/-~-,,, d;,, ,.,,'.~
Type of Residence
~gle Family
[] Multiple Family No. of Bedrooms
[] Other
Water Supply
[] Individual ATTACH WELL LOG. A wail Icg is required for all wells drilled since June 1975.
[~,~Community For wells drilled prior to that date, give we depth (attach Icg if available).
[] Public Utility
Sewer Disposal
Year Individual Installed:
[~ndividual
[] Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time
Time
Date Date Date Date~/~
Insp~tor Insp~tor Insp~tor Insp~tor
Field Notes:
( ~PPROVED BEDROOMS ~ *CONDITIONS OF APPROVAL
( ) DISAPPROVED
~ ~'-- ~ JUN 2 7 1983
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
[~/~% Well ,o Tank Septic T~k Size
72-023 r31~)
Scmic
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APPLI:' FILLS OUT UPPER HA ONLY
Property Owner Phone
GSK Construction
Mailing Address Zip Code 7 ~+ 5- 2 5 5 3
Buyer JOH~T P., & KATHLEEN R. JACOBSEN
Address Zip Code
Phone
Lending lnstitution Lom~,~ ~ Nettleton Co
Address Anglo Bldg Anchorage Zip Code 27/+-7661
Phone
Realty Co. & Agent RE/MAX of eagle river, Inc, (Jim Montague)
Address PO Box 8/,8, Eagle River, AK ZipCode 99577 69/,-/*200
Legal Description LO~3 l, Block /+, Northwoods oubd:Lvlslon
Street Location NHN Norton Court
Type of Residence
[] Single Family ~ , ~' ,.
[] Multiple Family No, of Bedrooms ~ '
[] Other
Water Supply
[] Individual ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
[] Community ' For wells drilled prior to that 8ate, give well depth (attach og if available).
[] Public Utility "~" "-
Sewer Disposal
~ Individual Year Individual Installed: 1983
[] Public Utility .f,..~, When Connected to Public Utility:
[] Holding Tank t [, ~
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
(~) APPROVED BEDROOMS.~ *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
DATE
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size /~j~