HomeMy WebLinkAboutKNIK VIEW BLK 2 LT 11Knik View
Block 2
Lot [!
#051-031-4;?
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: -~i4¢~(¢ olr~ PID Number: ~5~1 .- o'~j - ff
Name:
L~o~ ~~ Wastewater System: ~ New D Upgrade
Address:
Phone: No. of Bedrooms:
'~ ~ ~ ~ OO ~ ~ Deep Trench '~ShallowTrench D Bed Q Mound ~ Other
LEGAL DESCRIPTION Soil Rating: Total Dep(h from original grade:
Lot: Block: Subdiv~ion: Depth to pipe bottom from original grade: G ravel depth beneath pipe
Township: Range: Section: Fill added above ¢riginal grade: Gravel length:
WELL: ~T,¢~ New D Upgrade / Gravelwidth: ~ I Ft. Number of lines:l Oistancebe~weeslines:~ Ft.
Classification (Private, A,B,C): Total Depth: ~d To: Total absorption area: Pipe material:
Driller: ~ Drilled: Static Water Level: installer: Date installed:
~~Pump Set at: Ft. Casing Height Above Grou;:: TANK
SEPARATION DISTANCES ~ Septic D Holding D S.T.E.P.
To Septic Absorption Lin Holding ~ublic/Private Manuf¢cturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~ (,)~O~A ~ ~ J
Well' ~el~ ~ · ~.~ I~ MateriEl: Number of Compadments:
su~aoe ~ UFf
Water 100 I OOI ~ .... ~_
Lot ~ Size in gallons: Manufacturer:
Foundation ~ O ~ ~ "Pump on' level at: I "~~ High water alarm at:
Cu~aiR ~-- ~ja¢~ Pu~~ectrical Inspections pedormed by:
Drain
Remarks: BENCH MARK
Location and Description:
I Assumed
Elevation:
ENG~ SEAL
170~4 Eagla Eiver Loop B~ad, No, 204 2nd. II - 3~ -
Department of Healthand Human Services approval '~?., ....
72-013 (Rev. 9/91) MOA 25
Permit No. SW960134. Page 2 of 2
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
LOT 11 BLOCK 2, KNIK VIEW S/D 051-031-42
Legal Description: ' PID No,:
~il ~0.5' 18.0'-
m----_._____..___~ ST2 -: 6.5' 1
/ ~ OBL1 -~.5' ~0.0'
/.~~ 3DL2~O.O' ~,.0~'-
~~ / oo~--~.o, ::.~
' ~ ~02 --e6.O' 40~v
~ ~ ~~ E5.5' 40.0'
~w lOOO o~/ t'.~o~-,-~_
s~,~ ~co /
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72-013 A (Rev. 9/91) MOA 25
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 PERMIT
PERMIT NUMBER:SW960134
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:SCHMELZER FAMILY TRUST
OWNER ADDRESS:P.O. BOX 670045
CHUGIAK, AK 99567
PARCEL ID:05103142
DATE ISSUED: 6/21/96
EXPIRATION DATE: 6/21/97
LEGAL DESCRIPTION:
KNIK VIEW BLK 2 LT 11
LOT SIZE: 20000 (SQ. FT.)
NUMBER OF BEDROOMS: ~THIS PERMIT: Mid$
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
3 o
4 o
THE ATTACHED APPROVED DESIGN.
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) .
THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL, ONLY PERMIT)
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
THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS
RECEIVED BY: /?
DATE:
DATE:
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
June 14, 1996
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECFION
& FLOW TEST
SITE pLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ONSITE
W,'~STEWAT ER
DISPOSALSYSTEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: :Lot 11, Block 2, Knik View Subdivision
Request you issue a permit ins%all a septic system to serve
proposed four bedroom house on %he referenced Property.
A test hole was excavated and percolation test performed.
The approximate location of the test hole is located on the
attached site plan.
At the time of excavation no wa%er was encountered in the
test hole. The monitoring tube within the test hole has
been checked and found to be dry.
This property has enough area for a future septic upgrade
which can be seen on the attached site plan.
This property is served by a Community Water System.
We dc) not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
If you require additional information, please contact us.
Sincerely,
n~,
RCC/gk
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
= 50'
SCALE
SITE PLAN
DE.:,IGN
HEAL'r H AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER&WATER
INSPECTION
ENGINEERINGSTUDIES
AND REPORTS
WELL INSPEC lION
& FLOWTEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
iNSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
ON-SITE WASTEWATER DISPOSAL SYSTEM
and
MATERIAL SPECIFICATIONS
ROBERTC. COWAN, RE.
ROBERTA. SHAFER, RE.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot 11, Block 2, Knik View Subdivision
June 14, 1996
SENERAL:
1.
e
The scope of this project includes the installation of
a 1250 gallon septic tank and a leachfield trench to
serve 'the proposed four bedroom residence located on
the referenced property.
Construction shall be in accordance with the approved
site plan and design drawings, Municipal permit with
any special provisions or conditions, and all
applicable State and Municipal Wastewater Disposal
Regulations.
The contractor shall be responsible for obtaining any
necessary underground utility locates.
Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
Contractors installing wastewater disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
SEPTIC TANK INSTALLATION:
A septic tank is 'to be constructed by a certified
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
The septic tank shall be sufficiently bedded to
prevent settling or shifting of the tank.
Ail standpipes on the septic tank shall extend a
minimum of 12 inches above final grade.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 ' EAGLE RIVER, ALASKA 99577
Page Two
Lot 11, Block 2, Knik View Subdivision
June 14, 1996
Septic tanks installed with less than 4 ft. of cover shall
be insulated.
A foundation cleanout shall be installed one to four feet
from the building foundation° In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. i The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENC~/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed~-up) before
gravel (sewer rock) placement.
Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 11, Block 2, Kink View Subdivision
June 14, 1996
Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (56) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
The following pipe materials are approved for use in septic
system installations in the Municipality of Anohorage:
Type of Pipe
Perforated Solid
Cast Iron
ASTM D3034 (PVC)
ASTM FS10 (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other -than listed above must be
approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and 'the native soil backfill.
Ail leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the ~200 sieve.
When sand is being used as a filter material, its gradation
specifications must conform -to current M.O.A. or D.E.C.
requirements.
Page Four
Lot 11, Block 2, Knik View Subdivision
June 14, 1996
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of 'the wastewater disposal
system. These inspections will occur as follows:
The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
e
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre-construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way -the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and wJ. ll inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.i
Page Five
Lot 11, Block 2, Knik View Subdivision
June 14, 1996
S & S Engineering shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for 'the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
PERFORMED FOR:
LEGAL DESCRIPTION:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
-"'~ ¢' , ............. ?,
::': .,' .," I\ ",.
'~, ~,~ RO~ c. COWAN ],~ ~
DATE .~,,,-~, ...... :,~ i.-, ,,? .... .~,..N- ~.
Township, Range, Section: :
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
18
19-
20
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT / 0L
DEPTH? M & p
E
Deplh 10 Water Alter
Monilori,o? OP-Y _ Dale: (~-,
SITE PLAN
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE - '~"~- (mmutes/~nch) PERC HOLE DIAME'rER ~ ~1_ .~ f*
TEST RUN BETWEEN ~ FT AND ~;' FT
PERFORMED BY: ' CERTIFY THAT T/HIS TE/ST WAS
/ ?O;'~j ~gle River Loop Road N~. ~g~ .... ~ //~/. / ¢.~ ~
ACCORDANCE WITH A~ ~/~,/~I~JI~J~IC)~J~J~L GUIDELINES JN EFFECT ON THiS DATE. DATE:
72-008 (Rev. 4/851 :
PERFORMED IN
T E S T L A B
A r~iviaion of [:30Wi., Incorporated
S & S Engineering
17034 Eagle Rivet' Loop #204
Eagle River, Alaska 99577
Attention: Mi'. Collin Williams
AASHTO ACCREDITED
CONSTRUCTION
MATERIALS TESTING
LABORATORY
w.O.#A26842
June 12, 1996
Subject: Particle-Size Analysis
Lot 11, Blk 2, Knik View
Dear Mr. Williams:
The particle-size distribution of your soil was measured in tile laboratory. The published methods for
this test are:
· ASTM C 117, "Material Finer Than 75-gm (No. 200) Sieve in Mineral Aggregates by Washing;"
· ASTM C 136, "Sieve Analysis of Fine aod Coarse Aggregates;"
· ASTM D 422, "Particle Size-Analysis of Soils;"
· AAS[ 1TO T-11, "Ivlaterial Finer Than 75-jun Sieve in Mineral Aggregates;"
· AASHTO T-27, "Sieve Analysis of Fine and Coarse Aggregates;"
· AASHTO T-30, "Mechanical Analysis of Extracted Aggregate;"
· AAS[ITO T -88, "Particle Size Analysis of Soils;" and
· AK DO'ITPF ATM T-7, "Sieve Analysis of Fine and Coarse Aggregates."
Alaska Testlab's standard procedure is in conformance with these standards, witli the following
descriptions:
· The coarse fi'action of oon-extracted soils is not washed unless the coarse particles appear to be significantly coated
with fines;
· The fine fi'action of the soil is ah4,q?s washed;
· The plus 3-inch fi'action is not routinely included in the test due to tl,e la'ge sample mass reqnired:fer a representative
sample; The estimated percentage of plus 3 inch material in the sample is shown on the test report;and
· The mass of the coarse and fine test fractions are reported. :
The soil is classified in accordance with ASTM D 2487, "Classification of Soils for Engineering
Purposes (Unified Soil Classification System)." The fi'ost classification is identified in accordance
with Corps of Engineers and Municipality of Anchorage (MOA) procedures.
The test results are attached. If you have any questions regarding the test procedures or the results,
please call.
Sincerely,
ALASKA TESTLAB
4040 B STREET" ANCHORAGE · ALASKA · 99B03-5999 · 907/5G~'-EO01:) · FAX SO7/~E$:~-r~SB~
Percent l'assing by Weight
/2"
~'h
tl 16
# 30
No. 40
No. 60
# 8O
No.10
No.200
0.O2mm
'
Vt
kid
dY',
Municipality of Anchorage
Development: Servlces DepdHment
Building Safety Division
On-Site Water and Wastewaler Program
~,700 Soulh Bragaw St.
P.O. Box 196650 ,~mchorage, Al< 99519-6650
www.cLanchorage.ak.tJs
(907) 343-7g04
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-031-42
t, GENERAL INFORMATION
Cor~pl~lele'galdescri~tion'Lot ll; Block 2; Knik View S/D
Location (sile';~dress °~ir~clions) 22400 Inlet Vista Dr. ~ Chugiak,
Cu?e6t Proped~ owner(s) Donna Alderman
Mail!n. gaddress 'PO Box 670045,
Lending '"" ' " Day phone
agency
Expiration Date: ...~"" ,-q',-~- ~ ,~
Mailing address
Real Eslale Agent
AK, 99567
Dayphone688-3403
Chugiak, AK 99567
Day phone
Mailing Address
Unless olhenvlse requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Slorage
Communily Class A
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ~
Individual Holding lank []
Community On-sile
Public Sewer []
'1'he Municipalily of Anchorage Developmenl Services Deparbnent (DSD) Issues CertiAcales of Health .Authority
Approval (HAA) based only upon the representations given tn paragraph 5 by an Independent professional civil
engineer registered In the Slate of Alaska. Certificates of Heallh Aulhority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-siIe wastewater disposal and/or waler
supply system· DSD also Issues HAAs upon request to homeowners. Certi~cates of Health Aulhority Approval are
wild 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. (Certificales may be reissued for a period of up to one year with
valid water samples.) Certificates ere valid I'o~' 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 or omissions in the professional
engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seat affixed hereto and as of Ihe validation da~e shown betow, I verity Ihat my Invesllgalion,
based on procedures outlined In the Heallh Authorlb/Approval Guidelines for this application, shows that Ihe
on-site water supply and/or wastewater dlsposat syslerri Is(are) safe, l'uncfional and adequate for the number of
bedrooms and type of struclure Indicated herein. I furlher Verify Iha{ based on the Information oblained from the
Municipality of Anchorage files and from my Invesfigalion and Inspection. the on-site water suppty and/or
wastewater disposat system Is(are) In comptiance ~Nilh all applicable Municipat and State codes, ordinances,
and regulations In effect at the time of installation.
5. DSD SIGNATURE
t/'" Approved for
Disapproved.
Conditional approval for
NameofFirm S & S EnRineerinR Phone 694-2979
Address 17034 N. EaRle River Loop RD..E.R.. AK 99577
!
Engineer's Printed NameR°bert C. Cowan Date ~-/Q
~ EOBE~ ~ COWAN
bedrooms. 't, ~, '... ~.'
bedrooms, with the following stipulations:
Additional Comments
Attachmenls:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Repod
Other
Original Cedi[icale Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bregaw St.
P.O. Box 196650 A~chomge, AK 99519-6850
wv~w.ct~nchorege.ak.us
(SO7) ~43-7S04
Legal Desc31ptJon:
A. WELL DATA
HEALTH AUTHORITY APPROVAL CHECKLIST
ff A. B. or C provide PWSID # /~
weil type ..~,,,,/
Date completed Sanitary s~*(Y/N)
Total depth' ft. Cas/~e" , fl.
FROM ~,,L~LOG
Date of test
Static water level / ft.
Weil production / .g.p.m.
WATER SAMPLE/p~SULTS:
Coliform .~7~colonles/100 mi. Nitrate
Date of sample: C~ected by:
SEPTIC/HOLDING TANK DATA
Tank.'f~:~terlal. , ~
'l;'a~k' 'ize' /~ 0 gal Number of Compartments
Foundation cJeanout (Y/N)
Date of pumping ~ Pumper
C. ABSORPllON FIELD DATA
' DMeinstalled~'~ So, rating (J~or~/'odrm, /o Z,-"
Well Log (Y/N) /
Wires properly pmtect~/~
Casino height (abo~mund) in.
AT INSPEG7
fther bacteria colonies/100 mi.
Cleanouts (y/N). y
High water alarm (Y/N) ,4,./
System type
ft. Gravel below pipe ~' fl.
Total depth /q_.~. ff. Eff. absorptionarea~:~ft2 Monitoring tub, '~ Depression over field
Dateofadequacytest~'/¢,'~-/~.- FJ.utts(Pass/Fall) /1~S$ For 5 bedrooms
· . ./. '/, - ·
t,..e, depth L Z.. Z so.p.o. rete >=
g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)/ / If yes, give date
UFT STATION
Date ins~iied ~ Size in gallons
"Pump on level at ~_ tn. 'Pump off' level at
Datum [ . Cycles tested _
Public sewer main _
Sewer/septic service line
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lilt station on lot _ /'i
Absorption field on lot
On adjacent lots
Public sewer ,manhote/cteT°ut
. Holding t~lnk'
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~' I ~- Property line ~ ~ ~' Absorption field
Water main / (~ ' J'-
Wells on adjacent lots ~
I
Water service line /' O + . Surface water
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO' !
I
Property line I 0 f-/-- Building foundation [~) *+ Water main
=
Water Service line /O I"t- -
Surface water / (~ ! '~- D6veway, pafldng/vehicie storage
Curtain drain/~'~'~- ~--~'0~-~/ Wells on adjacent lots ~C)O
In.
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections a. nd
review of Municipal records that the above systems am
conformance ~ MOA HAA guidelines in effect on this date.
Engineer's Printed Name
Date
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12J00)
Waive~ Fee $
Date of Payment
Receipt Number
CE-8801
Parcel I.D. #
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
~r~ICIPALITY OF ANCHo,,~,AG,~
~j~j NMENTAL SERVIcEs DIVI$10N
RECEIVED
GENERAL INFORMATION
Complete legal description
Lot 11; Blpck.2; Knik View Subdivision
Location (site address or directions)
NHN Inlet View Drive
Chugiak, AK
~ropert'; owner
Mailing address
Lerov Alderman dba M2C1 Constructi~y phone
P.O. Box 670045 Chugiak, AK 99567
223-8100
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well
Community well ×xx
Public water
Niumc~paik¥ ot Anchorage
Dept. Health & Human Services
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
xxx
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
o
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.
Name of Firm $ & $ ENGINEERING .
17034 Eagi~ River Lump P~v~:; ?-.'~,. 2&4 Phone ~' ci¥ _ >9 -7 ~/'
Address Eagle River, Alaska 99577
DHHS SIGNATURE
~'%--Approved for ~-~L?~?--('~)
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a 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. 1191) Back MOA fY21
~N~NO/CIPA~tTY OF ANQ-i
Municipality of Anchorage ' ~Et~7~,t s~. ~
' VICE8
DEPARTMENT OF HEALTH & HUMAN SERVICES : ~)
Environmental Services Division MAY2 1 1qo
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) ~43-4744 '~
A, WELL DATA .:;
Well type (~l ~S ",A" If(~B, or C, attach ADEC letter. ADEC water system number 'CPi
Date completed
Log present (Y/N)
Total depth Cased to Casing he
FROM WELL LOG
protected (Y/N) =
AT INSPECTION
Sanitary seal (Y/N)
g.p.m, g.p.m.
Date of test
Static water level
Well production
WATER SAMPLE
Coliform
/..D. at~of sample:
B. SEPTIC/HOLDINGTANK DATA
Date installed Jl -%0 - ¢/~_Tank size __
Foundation clea~0ut(~)
C. ABSORPTION FIELD DATA
L¢'ngth ~,5' 'Width
Nitrate
Collected by:
1ooo
Depression (Y~'~
Pumper
Other bacteria
Number of Compartments
High water alarm (Y/N)
_ Soil rating (g.p.d./fF or fF/bdrm) },
Gravel thickness below pipe
System type
Total depth
72-026 (Rev. 3/96)*
Fluid depth (ins) Minutes later: Absorption rate = ; .g.p.d.
Peroxide treatment (past 12 months) (Y/~.'..~ /J If yes, give date
Effebtive absorption area ~:'7_~ ¢' Monitoring Tube present'q) Y¢.S Depression over field (Y(~ /(Jo
Date of adequacy test_ /~/~ ~/'./~--~,.[ Results (Pass/Fail) For ~----- _ bedrooms
Fluid depth in absorption field before test (in.); ~ immediately after ..... ~-al. water added (in:).~ ....
LIFT STATION
Date installed
Manhole/Access (Y/N) ~
High water ~ *Datum
Cy~d
Eo
Size in gallons
"Pump off" level at*
R C IV D
SEPARATION DISTANCES FROM WELL ON LOT TO: ~'t_y_o.f Anchorage
_~....~---"~aept, Health &Human 8er¢ce8
Septic/holding tank on lot .,~(~'F'~-~'acent lots -
Absorption field on lot ~ On adjacent lots
Public sewer main ~ Public sewer manhole/cleanout
e line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ tcF Property line I O
Water main/service line ~O ~- Surface water/drainage )OO
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line I O ~ 'P Building foundation
Surface water ~
Curtain drain ~//~
Absorption field ~"
Wells on adjacent lots
Water main/service line
Driveway, parking/vehicle storage area ~ ~+~
Wells on adjacent lots '~(--~O,I ~
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records their, e, ~l~s are
in conformance w~h MOA HAA~uidelines in effect on this date.
Date :~- / al / O 7
HAA Fee $. ~
Date of Payment
Receipt Number ¢::~7.~_~.~(/~ .~.~j
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number