HomeMy WebLinkAboutHYLEN CREST #1 BLK 3 LT 7Hylen Ceest
Block 3
Lot 7
#050-474-03
" 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
Permit Number: ~L. LJ O/~OO~-~ PIP Number: O~-"O ¢?/7,'~) ~
Name: L ~_ ~ ~o~J-5'r"~.~6;~a,,J Wastewater System: .,~New [] Upgrade
i Address: /~ .¢¢/¢--' ABSORPTION FIELD
Phone: ~/~...~..~1' No. of Be~oms: /~DeepTrench ~ Shallow Trench ~Bed ~Mound ~Other
L E G AL D ES C R I PTI O N so, Rating: Total Depth from original grade:
/, ~ ~/sq. ~.
Lot: Block: Subdivision: Depth Io pipe bottom from original grade: Gravel depth beneath pipe
Range: Section: ~ Fill added above original grade: Gravel leng~
Number of lines: Distance betwsen lines:
WELL: B New Q Upgrade Gravel width: ~ Ft. / ~ Ft.
Classjfica.~ion (Private. A.B.C): Total Depth: Cased To: Total absorption area: Pipe material:
Driller: Date Orgled: Sta,,c Water Level:Ft. Installer:~~ ¢,¢~¢ Date instal[ed:¢/~¢ --
Yield: Pump Set at: Casing Height Above Ground:
o*~ ~,. ~. TANK
SEPAHATION DISTANOES ~eptia ~ Holding ~
TO Septic AbsoCpllon Lift Holding ~ublic/Private Manufjcturer: Capacity in gallons:
Material: Number of Comp~ents:
Well ,~ ~ ~ ~ ~ ~ ~
Surface
Wate~ i~,~ I~+ .-- ~ -- LIFT STATION
LineL°t ~ ~ ¢ ~ ~ ~ Size in gallons: Manufacturer:
Foundation /~ J ~ ~ ~ ~ "Pump on" level at: "Pump of~" level at: High water alarm
CurtainDrain .... ~ Pump Make & Model Electrical inspections performed by:
Remarks: BENCH MARK
Location and Description:
Assumed Elevation:
ENGINEER'S SEAL
Inspections performed by: ~. ¢- ~ *¢ Bates: 1st ¢/"~ ~, *~~% '
.
~S Dawd R. Dayton
Department of Health and Human Services approval ~),,, ....:.s~%o
Reviewed and approved by: .~c~t4~ ~ Date~ ~ ~.-u~, ..~
72-013 (Rev 9/91) MOA 25
Permit No.
~,'OJ ~ ~ O O Z..c.~' 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 Inspection Report
Legal Description:
PID No.:
ENGINEER'S SEAL
72-013 A (2/91) MOA 25
PermitNo, _,.,~OJ cl' "~OOZ~' Page ~:~ of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Rox 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
LegalDescription: /..~Y~ ~c~ /'-~/,u-~'-~,"~':/ PIDNo.:
Dept.
.F~N~C~N~F~.J~ ~.S SEAL
¢~'~'"[ ..... ~"'" .....
David R, Dayton ~ ,~
NO. 2205-E ,, ~
72-013 A (2/91)MOA25
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF 1
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930028
DESIGN ENGINEER:DAVID R. DAYTON, P.E.
OWNER NAME:L & B CONSTRUCTION INC
OWNER ADDRESS: 14828 TERRACE LANE
EAGLE RIVER, AK 99577
DATE ISSUED: 3/15/93
EXPIRATION DATE: 3/15/94
PARCEL ID:05047403
LEGAL DESCRIPTION: HYLEN CREST #1 BLK 3 LT 7
LOT SIZE: 20000 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
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 (iSAACS0).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 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:
THE TRENCH MUST BE 9.5 FT DEEP WITH 6.0 FT OF GRAVEL
BELOW THE PERFORATED P//~E. / /
/
, ?
Municipality ot Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
7'-/'/- ~¢/
PERFORMED FOR:
LEGAL DESCRIPTION: '¢"'~' ~'' ./~'~,~4J ~'~7"
lO
11
12
13
14
15
16
17
18
19-
20-
DATE
PERFORMED:
·
SLOPE SITE PLAN
- f
WASGROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth Io Water AFter v'/
Monitoring? ,A~a' ~.A~ Dale:
I'
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE __ tm~nutes/~nch) PERC HOLE DIAMETER
TEST RUN BETWEEN -"'(""" FT AND ~ FT
COMMENTS
PERFORMED BY: '--"~, ~., · '~'¢~ '"4"~'::~'~ I ~ ,~/~'~--CERTIFY THAT THIS TEST WAS PERFORMED tN
/_../_
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/85)
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
Township, Range, Section: ~ ~/ ~t ~/~
1
2
3
4
5
6
7
8
9
10
12
~4
16
17
18
19
20
COMMENTS
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT 0
DEPTH? p
E
Monitoring? ~x'r~' Date: ,
Gross Net Depth to Net
Reading Date
Time Time Water Drop
/ ,, i/? /o ,, /o?,~
PERCOLATION RATE ~/,T-/j~ lmlnutes/mch) PERC HOLE DIAMETER __
TEST RUN BETWEEN '~-- FTAND ~ FT
PERFORMED BY: ~ "~"~~ I -~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AN DMUNICIPALGUIDELINESINEFFECTONTHISDATE. DATE:
72-008 (Re,,'. 4185)
MUNICIPALITY OF ANCI..~yRAGE
D~PARTMENT OF HEALTH AND ENVIRO,NMEI'4?Ai. PROTECTION
SOILS LO'~ - PERCOLATION TEST
, o.,, ..,o..,o, Cz/..,/,.,- _
6
7
8
9
10
11-
12-
13-
15-
16'~
17
18
19
20
COMMENTS
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
R~dt~ D~te Time
, FT ^1
p~ RATE
SITE PLAN
PERFORMED BY:
72.006 (6/70)
£agle ~lver, AK g9577
GO4-SIg5
P.O. BoX 6650
ANCHORAGE. ALASKA 99502-0650
(907) 264-4111
TO~~, Y ~' NOWLES.
DEPARTMENT OF HEALTH & HUMAN SERVICES,
January 10, 1986
TO: Permit Applicant
Subject: Permit # 850729
Lot 7 Block 3 Hylen Crest Subdivision
A permit issued by this Department for an individual well and/or on-site
sewer system has expired as of December 31, 1985.
Permits are issued on a calendar year basis by authority of Municipal
Ordinance. A new permit must be obtained from this Department for any
well and/or on-site sewer system not installed by the expiration date.
If you have drilled the well, a well log needs to be sent to this
Department for documentation of the installation and to close the permit.
If a private engineer inspected the installation of the on-site sewer system
the original as-built inspection report(three part form) must be sent to
this office for review and approval,and for documentation.
If there are any further questions, please call this office at 264-4720.
Sincerely,
Susan E. Oswalt
Program Manager
On-site Services
SEO/ljw
enc: Copy of Permit
LILT: '7 BLOCK:~ 3
RANGE: :I.W
I...:ils't'..(.:.~cl t;::,elc)~/,~ a~'(l"(.:;.~ 'l'.l"li:,? clp'I:..i.c)FiS available 't'.(:) 'you in d6?s:i.l.:]r'l:i.r'ig yl])Lll'" sep'l:.:ic
systl..~.mi. []l"ic)c,!~=i(.::,, 'l:..h¢:~ Ol:rLior'l tl')ai', best l':ii:.s yot..ir, s:i. te,,
'T IF;i,". IIEE: !l"ql E:]: II.-..'11 b,,,!l .... :Eli, IF;i: ¢'::'.~h % II"dl
:OIEI:::"I'H '1"O F;]:I:::'E BJ]'T']'[)i¥I (F:"t".)
GRAVIEI.... DE]::'-FH (I="T.
TOTAL. DIEF'TH (I='T,,)
GRAVI:ZI_ M ;1: DTH , ,; F:'T.
[.:.~RCrtVEI.... Lliii:NE.)'I"H (I:::"F,,)
GF;.'AVliE]...VOLLJME ,;CU,, YDS,,' )
'r'AI',IK S I Z!..~: (GAI....S)
SO :1: [.. I:RATI NG ¢, !:.<;! ,, F:'T ,, /BI::~ )
¢,'..x. TANI::: M,US'T HAVE A'f' I...I:fi:AS]' "l'l,,.J[I C,[IMI:::'ARTr,IENTS
I c (.'.~r' 'L :i. ~:' y 't.l"l a t:
f'c~r'.th by 'Ll'~e Iqlr.U]:i.c:J.'pE~l&ty C:)f' Aricl"u::irage (MOA) and the State of' Alaska,, :
2. :l: v~:i.;I. 1:i.r'is't'.al]. t'..I-ie sys'Lem in ac:ccir~dance wi'Ll~ all I"IOA cc:ides ar'id r'egulat:i, or'u~i~
,:~r'l(::J :i.l"t cl::)ml;)].~.ar'tc(.:~;, with 'L J"/ E.:.:, des;i, lj.:jl"i (::r'i'LE~r':~a I:i¢ tl]:i.s j:)er'rliJ.'tL.
3,, :1: v¢:i. ll adhere 't:.c:i all MOA and State c:ll' A:laska r'equ:i.r, emen'Ls Fop the s6rL back
c:l:i, stanc:o:,s ¢Porn al'ty ~:~;4is'L:J. ng we].l~, was'Lewater' d:i. spc~sa]. ~ys't:.em i:3i" pt..d:)].i(:::
sE.~/,~6..:r'age systo~ltl Cll'] 't'..l't:i.s o1' ar]y ac:l.jac:ent (:)p near'by
4.. :[' t.q"l(::J(;.]r'~i~t¢:u]d tl'ta'[, th:i.s j::) (:9., p /fl i '[ :J.s v~'~].J:d ~'op (:?~ IfJE&x~liiLt/fi E)J' 4 bedr~;~oms
any eE~:t, arger/l(~,~ni:, wiJ. 1 r'equ:i, re ar'l addit:i, cn"~al peJ"m:i.t,,
:IZF' A I...IF:'"f' S'I"ATI£1N ]:S INS"f'AI.J....ED II',.l AN Al:REA COVERED BY HOA BLJIL. D):I',JG
THEIxl (1) AN EI....ECTI::;;]:CAI.... I:='EI::;;MZ[T AND ]:I;.tSPI~Z[TT'Z[]I',I' MUST BIE OBTA.!;NED; (2.) AS.-..EIUII.TS
MILL NO'f: BIE AF'I::'F;;OVEO WITH[0UT AN IELECTRI:[;AI... ]:I'qSF:'EC'f't[)N F;;I:i::PUR'I"; AND
I!!i:LI!ii:CTF:;;]Z[i;AL MORI< MUEN' BE DOI'41E BY A I...]:[]i'~ZIxlSIE]) IEI...E]:;"I'R ]: [; ]Z AN .
AI='FI... I CANT: [..OVIEI....ACIE E XCAVAT
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 254-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR;
LEGAL DESCRIPTION:
SLOPE
DATE PERFORMED: /:/
SITE PLAN
5
6
7
8
9
10
11
12
13
15
16
17
18
19
20,
COMMENTS ~-~¢ ~'~ -"~,~' ,'~; ,~
Gross
Reading Date Time
WAS GROUND WATER
ENCOUNTERED? .
L
O
P
E
IF YES, AT WHAT
DEPTH?
P E ~%C G'~-A~T1OI~ RATE
TEST RUN BETWEEN FT Al
PERFORMED BY:
72-O08 (6/79)
Eagle River Engineering Services
P, O, Box 773294
Eagle River, AK 99577
694-5195
CERTIFIED BY:
MgNI~.IPALIT¥ OF ANCHOP, AG,~
I~I~J~T, C.I~ HEALTH &
t[N¥1t~NMENI'AL PROTECTION
ECEIVED
LO'T c,,
..t.
P 'OF FOUNDATION WALL ELEV.. IT SHALL SE TNE RESPONSI'BILITY OF ..THE
· ':~ C3.~:)~:3. BUILDER OR OWNER TO VERIFY THAT
£VATIONS BASED ON/"'%'~'Or't~"~;~) BUILDING LOCATION SHOWN MEET8 ALL
~ OD · C~,C:~ DATUM. SUBDIVISION COVENANTS AND LOCAL
EPARED FOR: ZONING CODES AND ORDINANCES,
LOT PLAN
. .LOT-7 , BLOCK
,,,o,T ,jO_l
hdC,
AWN .DATE
ECK J GRID
J k-I '~.',.' c~-/
), BK, J JOB NO.
I HEREBY CERTIFY THAT ALL PROPERTY
CORNERS EXIST THIS DATE AS SHOWN.
Municipality of A.chorage
Development Services DeJJdrJment
Building Safety Division
On-Site Water and Wastewater Program
~J700 South Bragaw St.
P.O. Box t96650/~nchorage, Al( 995 t9-6650
www.cLanchorage.ak. Us
(907) 3,J:~-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-474-03
1. GENERAL INFORMATION
Complele legal description Lot 7;
Location (site address or directions)
Expiration Dale: /-J o ,~' O - O 3
Blnrk q; RylPn
10136 Loon Circle
Current Property owner(s) Sharon Cardoma
Day phone 580-1400
Mailing address
Lending agency
10136 Loon Cir. Ea~le River. AK 99577
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: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site
[] Individual Holding tank
[] Community On-site
Public Sewer
'l'he Municipality of Anchorage Development Servlces Departmenl (DSO) Issues Certificates of Health Aulhorily
Approval (HAA) based only upon the representations given In paragraph 5 by an Independent professional civil
engineer registered In Ihe Stale of Alaska. Certificates of Health Aulhorlty Approval are required for the transfer of
ti!le (except between spouses) for propedies served by a single [emily on-sHe wastewater disposal and/or waler
s.pply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
volid for 90 days from Ihe date o[ issue for properties served by a private or Class C well and may be reissued with
new waler sample results less than 30 days old. (Certi[icates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality o[ Anchorage Is not responsible for errors or omissions In the professional
engineer's work.
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewator Program
4700 Soulh Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ct.enchorage.ek, us
(~07) ~-?~0~
HEALTH AUTHORITY APPROVAL CHECKLIST
A. WELL DATA
Well type
Date completed
Total depth
Data of test
Parcel ID ~2:~:~
ff A. B. or C provide PWSlD # J Well Log (Y/N)
Sanita~ seal (Y/N) / Wires properly protected (Y/N)
ft. Cas. to y Cas. lng he,bt (above ground)
FROM WELL LO~,/// AT INSPECTION
Static water level / ft.
Well production / g.p.m.
WATER SAMPLE RESULt.'
Coliform ,~esJl00 mi. Nitrate
Date of sample: ~ Collected by:
B. SEPTIC/HOLDING TANK DATA
g.p.m.
mgJI. Other bacteria __ colonies/100 mi.
Tank Type/Materiel ~
Tank size ~ gel. Number of Compadments ~
Foundation cteanout (Y/N) '7/ Depression over tank (Y/N) /~
~;l~;Io( ~ ~'~
Data of pumping
ABSORPTION FIELD DATA
Date installed ~..~ Soil rating (g.p.d./fta o~ ~/bclrm)
I.
Len~h ZJq' '.. w.~th ~ ft.
To~l d,pth I~Y ft. E,. apso~,on araa.¢~ ~ Mon,o~.g ~,be '/
Fluid depth in absorptiou field before test ¢~ in. Water added~,'gal.
Elapsed Time:/~4 min. Final fluid depth ~ in. Absorption rata >=
Any rejuvenation treatment (past 12 mo.) (Y/N & type) ¢~J
Data installed
cteanou= (Y/N)
High water alarm (y/N) /'"J
System type
Gravel below pipe ~- ~ ff.
Depression over field ~,,!..
F~ ~ b~moms
N~ dep~-~n.
~ g.p.d.
If yes. g~e da~ '
T'~.~ 15:34 FAX 907 258 0005
\
Agent Service center
~]005
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
Lot 7, Block 3,
Hylen Crest S/D ~ /
Location (site address or directions)
10136 Loon Circle
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
,.Charles Clanton
Day phone 696-0651
10136 Loon Circle, Eaqle River, AK 99577
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: z~ -~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
X~L~
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.
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.
S &S ENGINEERING
Name of Firm ........ ,. ,~: .... , ...... u ,,_ ,,,,,,
Address Eagle River, Alaska 99577'
Phone ~-)-¢1-7¢
Date
DHHS SIGNATURE
Approved for /r~ [y/~ 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 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.
72q325 (Rev. 1/91) Back MOA ~21
Municipality of Anchorage JUL 0 1999
DEPARTMENT OF HEALTH & HUMAN SERVICES
..... ~4UNICIPALITY OF ANCHURAGE
Environmental
Service8
Division
F' VIRONMENTAL SERVICES DlVISl~lt~l II._J.~
825 L Street, Room 502 · Anchorage, Alaska 99501 ~:~g07) 343-4744
Health Authority Approval Checklist
Legal Description: ~T g/ ~'L~¢/'(' ~,J ~//,Y'/cg¢/C~/ Parcel I.D.: 05-0- 4'~Z:~--O~.=.~
A. WELL DATA
Well type'~/.,//~L,/C If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Cased to
FROM WELL LOG
Date of test
Static water level /
Well production / g.p.m.
WATER SAMPLE RE~:~'. · ·
Coliform ~ Nitrate
Date s~ample: Collected by:
Date completed
CaS~ve ground)
Wire~p'roperly protected (Y/N)
AT INSPECTION
B. SEPTIC/HOLDING TANK DATA
g.p.m.
Other bacteria
Date installed z¢-///~_:~ Tanksize /2~----~)~'' Number of Compartments ~ Cleanouts((~'N)
Foundation cleanout ~N) ~ S Depression (Y~ A/O High water alarm (Y/N)
Date of Pumping ~ / ~ ~ Pumper ~ ~
C. ABSORPTION FIELD DATA.
Date installed ¢/~5 '" : _
Soil rating (g.p.d./fF or fF/bdrm) /, 2 System type
, _
Length "T-! Width Gravel thickness below pipe ~': ~" Total depth /~-
Effective absorption area -'~'-'¢8 ¢ Monitoring Tube present (~;//N) 1~--~ Depression over field (Y~
Date of adequacy test ~//¢0//~'+ Results (Pass/Fail) ~r~ For ~ bedrooms
Fluid depth in absorption field before test (in.); ////// Immediately after~ZZ/~'gal, water added (in.): 2/~'//
Fluid depth Z",-~ ~'
(ins) Minutes later: Absorption rate = ~¢?(:~ ~ g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~//~)K//~, ~/f~¢~lf yes, give date
72-026 (Rev. 3/96)*
LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
/~//,~c .~'¢zeq~al Ion s
",~mp on" level at*
~ *Datum
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /~//1//P¥' ~/_..//'~/-~(-' On adjacent__~ _ lots
Absorption field on lot _ .OfYa-dja~cent lots
Public sewer main ~'~ Public sewer manhole/cleanout
Sewer/septic serviced:re~'~''~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /(~ /~' Properly line / (~/'~ Absorption field
Water main/service line ,//'~ ~ Surface water/drainage //~2 ~' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /(~) t"/-' Building foundation
Surface water /f~"~/7/.
Water main/service line
Driveway, parking/vehicle storage area
Curtain drain A/(~/V~ /~,A,/~/'v",/V/ Wells on adjacent lots
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal record, /,,F'.; .....,..'., d,~_i,s are
in conformance with MOA HAA guideli~nes in effect on this date. ~,~ ~ .,.,,, ~,,,,,.q-..?~
Signature
Engineer's Name /~ 0/3 ~,'¢~- (~". ~"0 ~
Date ~/'~ / ~ ~ '1'~" 6E'880i /~
HAA Fee $
Date of Payment- "~/~ /~/-~
Receipt Number
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # O 5'0 ~7 4fo5
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) (_~.~, ~J (?,~fzo. t.~ ~ ~ ~.~r ~v,~,"~
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
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:
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.
72-025 (Rev. 1/91) Front MOA ~21
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Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A, Well Data
Parcel I.D.
RECEIVED
~jl'U[.. 1 1993
Municipality of Anchorage
Dept, Health & Human Services
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
MUNIOP^LITY OF ^N6HOPC~GE
Date of test
Static water level
Well flow
Pump level1
FROM WELL LOG
.g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
AT INSPECTION
J[NVlRONMENTA~ SERVICE8 DIVISION
JUL 0 2
g.p.P E. CE VED
; On adjaeent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Col'iform
Date of sample:
Nitrate Other bacteria
Collected by:
S. SEPTIC/HOLDING TANK DATA
Date installed ~/ t / ~ b
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size i ~"-') Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N)
/k'///dr Alarm tested (Y/N)
/~/C-~u' ~'V 5 ~3'44'~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /U///~- On adjacent lots /(///~L Foundation i 7..
TO property line ~'/'S-' Absorption field J¢~ Water main/service line
Surface water/drainage J ~ ~
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed /f'"////~
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
Well on lot
Date installed
Length ¢~
Total absorption area
Date of adequacy test
On adjacent lots
D. ABSORPTION FIELD DATA
Width
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Surface water
Soil rating (GPD/Ft2) (// Z....
Gravel thickness
Cleanout present (Y/N) Y
Results (pass/fail)
After test
If yes, give date
System type
Total depth
Depression over field (Y/N)
for
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation / '~-
On adjacent lots ,,~"b .-/:-
Surface water
Curtain drain
On adjacent lots /~¢'~/z.,¢r~ Property line
To existing or abandoned system on lot
Cutbank A.//,~ 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 c
David R. Dayton P.E.
20210 Donalar St,
Signature Chuglak, ~a~,~ 99567
Engineer's Name ,,(//~ //~",,--------~
Waiver Fee $
Date of Payment
Receipt Number