HomeMy WebLinkAboutTUXEDNI PARK BLK 2 LT 6Tuxedni Perk
Block 2
Lot 6
#041-022-21
Municipality of Anchorage Page I 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: --~u=l~°O 8°~ PID Number: O~J --- O7.7..-Z.
Name:
~.~. ~ O~s~ ~ ~~G Wastewater System: ~New D Upgrade
Address:
IN°'°fBe~OOms: ~DeepTrench ~ Shallow Trench ~Bed ~Mou~d BOther
Total Depth from original grade:
LEGAL DESCRIPTION Soil Rating: J.~ GPD/Sq. Ft. ~.~
Subdiv~ion: Depth to pipe bosom from original grade: Gravel depth beneath Ripe
Township: j~n0o= Js,o,ion: Fill added above original grade: Gravel length: 50'
Number of lines: ~ Distsnc~een lines:
WELL: ~New D Upgrade Gravelwidth: ~ '~ Ft. I Ft.
Cl~ssificstion~t~ ~(Privste' A,B,C): Totalj~Depth: Ft. Cased~To: Ft. Total absorption~ooare~ · SQ. Ft. Pipe~¢~material:o~
Driller: Date Drille~ Static Water Level: Installer: ~.[~ Date instage~
Yield: Pump Set at: I Casing Height Above Ground:
SEPARATION DISTANCES ~s~ptic ~ Holding ~ S.T.E.P.
TO Septic Absorption Li~ Holding >ubfic/Pdvate Manufacturer: Cap8cityin gallons:
From Tank Field Station T8.k Sewer Lines ~o~ ~
Material: Number of Compartments:
Sudace
w~ /oo~+ /oo~ -- ~ ~ LIFT STATION
Foundation IO ~ ~ ~ ~ "Pump on" level~h water alarm at:
CudainDrain ~.~ j(~ ~ 3~del J Electrical Inspections pedormed by:~
Remarks: BENCH MARK
Location and Description:
E~EA~J
Department of Health and Human ~e~ces approval ~, ~,'%, ...'~
72-013 (Rev. 9191) MOA 25
ERM,T .o. AS-BUILT DRAWING PAR°EL ,0
SW980089 041-022-21
94,~6
¢OMf
J 2.¢'W
'.-[~2rfOM ¢
NEW
97.70*
AflNb~f -96,67,~'-J J
/ ~IN?~,
¢ 100.7~*
COVER -, 4' +
fOP O~ fANg,
~f - ~.7~
12¢0 ~ON ~
N~W
u 9~,99
ALTERNATE SITE~ / / f ~ '-"" '"" % %
A B
ST1 16.0' 38.5'
ST2 22.8' 39.2'
DBL1 25.3' 39.9'
DBL2. 26.7' 40.4'
C01 64.3' 29.5'
C02 33.3' 52.7
MT 38.1' 45.5'
\
LNEW 1250 GALLON
SEPTIC TANK 'x
ALASKA WATER AND WASTEWATER CONSULTANTS, INC.
7320 E. CHESTER HEIGHTS CIRCLE, ANCHORAGE, AK 99504-
PHONE: (907) 337-617g/FAX: (907) 338-3246
LEGAL DESCRIPTION:
TUXEDNI PARK SUBDIVISION, LOT B, BLOCK 2
TYPE Of WORK:
AS-BUILT DRAWING OF SEPTIC SYSTEM UPGRADE
PREPAREO FOR: PHONE NUMBER:
R.W. BALES DESIGN & CONSULTING 522-3338
IDRAWN BY: SCALE: PAGE:
DATE:5.27.99// J.L.M./A.C.G. 1 = 50' 2 OF 2
WELL
Prom : ALP,N~ DRILL 90? 345 0202
LOCATION OF WELL
LOCATION/SKETCH=
D~EpTH$ MEASURED FROM,,~asing top ~ground surface
BOREHOLE DATA: Depth
Material Type and Color From To
Aug, 13, 19'9,° 10:.22 AH
STATE OF ALASKA
DEPARTMENT OF: NATUR,~,L R£$OURCES
DIVISION OF MINING
WATER WELL R~CORD
W~LL OWNER:
WELL DEPTH; ~ DATE OF COMPL~IO~
Depth o~ hole:_~
DEPTH TO STATIC WATER t.F-/EL~
.,,,/,~)._~.~___ft below ~.'top of casing D ground suHaee
M~HOD OF DRILLING~ ~air tot~ty~ oabte tool
~ other ....
USE 01; WELL: ,~domestic ~ irrigation ~ monitor
D Public ~upply [] other_
CAS[NO 8TICK-[ fi, Diem: ~ in. to~ft
C~sing tVpe: .~,i~, to Z~ft
WELL INTAKE OPENING TYPE:~ open end ~ sofeened
~ perforated ~ Open hole
Dept. Health & H
ces
Depths of openingm to ft
SCRI~EN TYPE: OJam: in.
SlotlMesl~ Size: Length:.
GRAVEL PACK TYPE:
Volume used; Depth to top:
G~OUT TYPE:
Depth', from ft to ft
Duration~ ~
PU~PING~VEL AND YIELD'
~ ft 8t~ ~_ h ~ ~umplng~gpm
PUMP INTAKE DEPTH: ~ fl Ho~epowen
WELL DISlNFECTEO UPON CO~PL~ION? ~YEB ~ NO
CONTRACTOR INFORMATION: REMARKS:
Reg'eg~,..~jrd B~J~ine,~, Neme ..,,/ -'-7--'l '~ -
"/~ ~ ~ ~_.c~ ~ PLEASE MAIL WHITE COPY OF LOG
~~~~ ~ ~o DNR/DfVlSION OF MINING ~ WATER
~gnature~nze~ Hespresentat~ ~te 3601C St, Bulie 800
ANCHORAGE AK 99~03-59~B
PAGE 1 OF i
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW980089
DESIGN ENGINEER:ALASKA WATER & WASTEWATER SERVICES
OWNER NAME:RW BALES DESIGN & CONSULTING
OWNER ADDRESS:10096 WASHINGTON CIRCLE
ANCHORAGE, AK 99515
DATE ISSUED: 4/30/98
EXPIRATION DATE: 4/30/99
PARCEL ID:04102221
LEGAL DESCRIPTION:
TUXEDNI PARK BLK
2 LT 6
LOT SIZE: 63408 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 ( 24 HOURS ) {NOT REQUIRED FOR WELL ONLY PERMIT)
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:
RECEIVED BY: ~~ ~- ~~J~ DATE:
Alaska Water & Wastewater
7320 East Chester Heights Circle - Anchorage ~ Alaska 99504
(907) 337-6179 ~ Fax (907) 338-3246
Consulting Engineers
April 14, 1998
Municipality of Anchorage
Department of Health & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Reft Well and Septic Design for Lot 6, Block 2, Tuxedni Park S/D.
To whom it may concern:
The proposed 4 bedroom house will be served by a private septic system and a private well.
Comments regarding the proposed design are summarized as follows:
1. SOILS: Attached are logs which shows the soil profile, and the percolation test results. Test
hole #1 will be used for the primary site. The soils below the silt/loam layer are primarily well
graded gravel with some fines to a depth of 8 feet. The soils below the GW to GW-GM that
transition to a sand with some fines (SW to SW/SM) to a depth of 13.5 feet. No groundwater was
encountered during the excavation, or after monitoring. The percolation test was performed
between the depth of 7.5 feet to 8 feet and the rate was 1.7 minute/inch. No bedrock, or
impermeable soil was encountered. Test hole #2 had similar soils characteristics.
2. TRENCH DESIGN:
a. Percolation Rate: 3 minutes/inch
b. Allowable Application Rate: 1.2 gallons/day/ft2
c. Number of Bedrooms: 4
d. Design Flow: 600 gallons per day
e. Minimum Absorption Area: 500 fi2
f. Total Depth: 9 feet (max.)
g. Effective Depth: 5 feet
h. Width: 2 feet minimum
i. Minimum Length: 50 feet
j Effective absorption area = 500 fi2
3. SURFACE WATERS: There are no surface waters within 100 feet of the proposed
upgrade.
4. TOPOGRAPHY: From the road (Haida Circle), to the test holes, the lot is generally flat. At
the test holes the lot slopes downhill from east to west at 15% to 20%. There are no slopes,
downhill, and within 50 feet of the proposed trenches, that exceed 25%. In short, there are no
slope concerns.
I am unaware of any adverse impacts this installation would have on adjacent wells or septic
systems. If you have any questions, please contact me at 337-6179, or 244-9612. Thank you
for your assistance.
~~Sincere'lY' a
Principal ness,QFC., ~4.S.
PRBPB~ED 2.5 FBBT ~IDE DEEP TRENCH
9 FOBT DEEP (MAX,) ~Y 50 FBDT LBN6,
2 FOBT OF SE~ER DRAINROBK, TRENOH
TB BE INST^LLED PARRALEL TO
ALTERNATE SITE---~ /' ,~
INSTALL D~L
UTILITY
WELL AND gEPTIC DESIGN~ LBT 6, BLBCK 2, TUXEDNI PARK
PREPARED FDR~
PREPARED BY'
)ATD 4/9/98
R.~/, BALES DESIGN 8, CDNSULTING
ALASKA ~¢ATER & ~/ASTE~/ATER
NV/N tlYi J,L.M, SCALE~ 1" = 40'
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14-
15~--
16-
17-
18-
19-
Municipality of Anchorage. 4~."~'~"' -~l,~'2k '.~4;~/;,.~ ~
825 "L" Street, Anchorage, Alaska 99502-0650 ~~" ........ ~'t.~~'~*" ~'' ' ' ~
SOILS LOG -- PERCOLATION TEST ~ 5 J~ES ~WlL~S ~ ~
.~'. N ~0. =.~
~~,C~ ~ ~'i ~:.. C.E....~, ,
~ ~/p, ~, ~ Township. Range. Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Monitoring? Oate:
S
Reading Date Gross Net Depth t~e~ Net
Time Time Water Drop
PERCOLATION RATE /~'~bF (minutes/inch) PERC HOLE DIAMETER
TEST RUN aETWIEEN ~'~' FTAND ~0FT
COMME.TS ~ ~ n ~ ~ ~ '
PERFORMED FOR:
LEGAL O E SC R I PTIO N :'~( J ~/~/~/~-
~,.~ ~,.~, (ENGINEER'S SEAL)
· . . ~ ~*' %~ ~
Municipality of Anchorage. ~* ~ ~, ~ *~
DEPA~ENTOFHEALTH&HUMANSERVI~/49~J ~
825 L Street, Anchorage, Alaska 99502-06~'''~'''
- E.CO T, ON
"~R94(, ;L~ , ~-- Township, Range, Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
s
E
Monitoring? 'Z Date:
Gross Net Depth I:~ Net
Reading Date Time Time Water Drop
/.'~ - ~" -
~',m I~.~,~, /.5" ~,S"
: ~ Io~,~ ~,~" ~,~"
PERCOLATION RATE Z-~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN '~'~'~ FTAND ~.0 FT
2
4
§
7
8
g
tO
tl
1:2-
14-
16-
17-
18-
19-
20-
ACCORDANCE ~19'" ALL STATE AND MUNICIPAL GUIDELIN.~S iN EFFECT ON THIS DATE. DATE:
72-008 {Rev. 4/85)
Municipality of Anchorage
Development Services Department
Building Safely Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
~USH www.ci.a nchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Parcel I.D. 041-022-21 HA/~
1. GENERAL INFORMATION Expiration Date:
Completelegaldescdption TUXEONI PARK SUBDIVISION; LOT 6~ BLOCK 2
Location (site address or directions) - 6658 HAIDA CIRCLE * ANCHORAGE~ AK 99507
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
ROBERT &: APRIL JULIUSSEN Day phone 244.-5881
6658 HA1DA CIRCLE * ANCHORACE~ AK 9950'~
Day phone
BECKY POWELL w/ REMAX PROPER~ES Day phone 244-5881
2600 CORDOVA STREET * ANCHORAGEt AK 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OFWATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 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) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. 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 samples. (Certificates 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 of Anchorage is not responsible for errors er omissions in the professional engineer's
work.
Note: Alaska Water and I/Vaslewater Consultants, Inc. shall be paid $1,245.00 at, or p#or
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedrooms and type of strocture 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 wastewaler disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS. INC. Phone
Address 6901 DEBARR ROAD. SUITE 2B * ANCHORAGE, AK 99504
Engineer's Printed Name JE~-KEY A. GARNESS, P.E.
Date
337-6179
Engineer's Comments:
In conducting this evaluation. AVt~VC, Inc. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the peffon'nance 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, groundwater levels that may
fluctuate during the year, and the water usage of the family being sen/ed by the system.
These conditions ara outside the control of the evaluator of the system. Satisfactory test '
results do not guarantee futura performance of the system, nor do they guarantee that
there ara no hidden defects or encroachments. AWWC. Inc. can therefora not provide
any wamanty or future estimate of how long the system will continue to meet the
operational raquirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance [/pon or use of this report by any
other person or party is not authortzed, nor will it confer any legal tfght whatsoever.
5. DSD SIGNATURE
[,,'""' Approved for L.~ bedrooms.
Disapproved.
Conditional approval for __
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
bedrooms, with the fllowing stipulations:
-..
~'~
~: WAiER AND
..
Manitenance Agreements
Supplemental Engineers Reo~
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
aulld~ng Safety
On-Site Water & Wastewater Program
47O0 Boutll Bragaw
P.O. Box 196650 Anchorage, AK g951g-6650
www.cLanchorage.ak.us
(O07) 343.79O4
Legal Descflptlon:
WELL DATA
Well type ~/A~ IfA, B, or C provide PWSID/t
Date completed 5/18/20~ Sanltap/seal (Y/N) YES
Totaldepth 159 It. Casedto 159 fl.
FROM WELL LOG
Date of test 5/18/lgg8
Static water level 107 fi.
Well procluctlon 20 g.p.m.
WATER SAMPLE RESULTS:
Coliform ~ colonies/100 mi.
Ameni~ tJJ,~, mgJL.
B, SEPTIC/HOlDING TANK DATA
Tank Type/Material ~l'l~.L
HEALTH AUTHORITY APPROVAL CHECKLIST
TUXEDNI PARK S/D; LOT 6t BLOCK 2 Parcel ID:
041-022-21
wen Log (Y/N)
Wires propedy protected (Y/N)
Casing height (above ground)
AT INSPECTION
6/1~/2002
Nib'ate mgJg
5.26 g.p.m.
YES
YES
18+ in.
Other bacterla.._~_colonies/100 mi.
AKWWCm INC.
Date of sample: 5/13/2002 Collected by:
Date installed 5/1gg8
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
McDONALD'S PUMPING
Tank size 1250 gal. Number of Compartments 2
Foundation deanaut (Y/N) ~ Depression over tank (Y/N) NO
Date of pumping 6/4/2001 Pumper
¢. ABSORPTION FIElD DATA I~J~_Ea~9_.~E~
Date installed ~5/~gga Soil reUng ~ fl~/'odrm) 1.2
Length 50 ft. Width 2.5 +/- fl.
Total depth e.4 ff. Eft. absorption area 500+ fl~ Monitoring tube YES
Date of adequacy test 5/13/2002 Results (Pass/Fall) PASS
Fluid depth in absorption field before test 0 in. Water added 737 gal.
Elapsed Time: 0 min. Final fluid depth 0 in.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
System type TRENCH
Gravel below pipe 5..36
Depression over field~
Newdepth
Abeorptlonrate>= 600+
NONE KNOWN ffyes, glvedate
NO
For 4 bedrooms
0 in.
g.p.d.
D. LIFT STAT]ON
Date instelled Size in gallons
"Pump on" level at in. "Pump o~ ~n. High water alarm level at ~ in.
~ Cycles tested. Meets alarm & circuit requirements?.
Septic tank/lilt station on lot
Absorption field on lot
Public sewer main
Sewer/septic eendce line
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
100'+
100°+
N/A
25'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 10'+
Water main N/A Water Bewice line 10'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+
Water service line 10'+
Curtain drain NONE KNOWN
F. COMMENTS
Building foundation. 10'+
Sun'ace water 100'+
Wells on adjacent lots 100'+
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manholo/deanout N/A
Holding tank N/A
Absorption field 5'+
Surface water. 100'+
Water main N/A
Driveway, parldng/vehlcte storage 10'+
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Pl'int/~ Na~le
Date
d~eeREY A. OARNESS
HA.a, Fee $
Date of Payment
Receipt Number
(R~.
Waiver Fee $
Date of Payment
Receipt Number
I~Y°I?-OZ 04:50PM FROU-CT&E ENVIRONI~NTAL SRV
Zt~__ CT&E Environmental Services Inc.
9075615]01
T-891 P.OZ/03 F-344
CT&£ Ref.# 1022'~47001
Client Name AIC Water & Waslcwatt'r Consultan~ Inc.
Project lqameAt Tuxe~i Park
Client Sample ID Lot 6 Block 2
Matrl, Drinking Watcr
Ordered B)'
PWSID 0
Sampte
paramclct Resu~ PQL
Unlt~
All Dates/Times are Alaska Stand~'rd Time
Printed Dar e~Tlme 05/17/2002 15:44
Collected Dale,Time 05/13/2002 12:45
Received DalWTIme 05/13/2002 15:10
Technical DIr~~
Released By
Allowable PJ~p AnaTysia
LimiLq Date Date Init
N~t~t~N
1.38 0.200 mg/L EPA 300.0 (<10) 05/13/02
JDT
M:L c rob:L o 1 o!~/' Laborat;oxT'
Total Colit'onn O
col/100mL SMI8 9222B
(<11
05/I 3/O2 KAP
~0T ~RV~Y CERTIFICATIO~ LE~/ND
Scale ~. , Dcte Prepa,ed ~: ~ L. BUT~O/t
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
ParcelI.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
041-022~21 HAA# ~:'~ ~C~0~
1. GENERAL INFORMATION
Complete legal description
Lot 6; Block 2; Tuxedni Park
Location (site address or directions)
NHN Haida Circle
Anchorage, AK
Property owner
Mailing address
Robert Juliussen
6658 Haida Circle
248-0188
Day phone
Anchorage, AK 99507
Lending agency
Mailigg address
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
XX
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:
xx
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev, ~/91) Front MOA#21
o
So
STATEMENT OF INSPECTION BY ENGINEER
As ce~ified 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 effe~l~e~t~le~this~n~pection.
' Z/ l~ /
]~7-~/7~
Address :: ~ ~e/~ ~
EngineeYs signature ~.;~ ~~~t.r~ Date
Alaska Water
Wastewater Consultants,
Ir~
Shall be PAID $ ~ et,
or prior to, closing for the
l~l~.~Hna 9~r~i¢~s Provided.
DHHS SIGNATURE
J/// Approved for .F'(~ ~.//'~. bedrooms.
Disapproved.
Conditional approval for
bedrooms, with th-e 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 DH HS 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.
MaY 2 ? 999
Municipality of Anchorage
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
2 ,.D.: 1
A, WELL DATA
Well type ?f' L) ~'~
Log present{~N)y
Total depth /~.~' ?
Sanitary seal ~)N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
!
Cased to / ,~ ~' / Casing height (above ground)
7 Wires properly protected Y~q)
FROM WELL LOG
AT INSPECTION
g.p.m,
Nitrate /, '~ ¢'1,'3~/L Other bacteria
Collected by: A J/i/~/~/~, ~ ¢----'
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~
Date of sample: ~"-'~ .¢~ -
g,p,m.
B. SEPTIC/HOLDING TANK DATA
Date installed
Foundation cleanout
Date of Pumping
ABSORPTION FIELD
Date installed '~'/
Length ~'O Width
Soil rating (g.p.d./ft~ or fF/bdrm) /o 'Z- System type "-['~?-'~--'~
"Z~'(-~/'~ Gravel thickness below pipe ~"'~ Totaldepth
Effective absorption area ~ 'f- Monitoring Tube present (Y/N) y Depression over field (Y/N) __
Daf~~j Results (Pass/Fail) tkJ'{~''~/ For ~
¢luid depth in absorption field b~ _ Immediately after gal. water added (in.):
Fluid depth (ins) Minutes later: ~ g.p.d.
Peroxide treatment (past 12 months) (Y/N)
NO
bedroom~'-'~
If yes, give date
72-026 (Rev, 3/96)*
D. ~
Date installed~'"'"---~ Size in gallons
Manhole/Access (Y/N) ~~
High water alarm level at* ~ "Datum
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ~,OO/~ ~, ;' On adjacent lots
Absorption field on lot [ COI'(- On adjacent lots
Public sewer main kl' Public sewer manhole/cleanout
Sewer/septic Service line ~.~- *' .F.- Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:'
Foundation ~' £'~'' Property line ,.~/'4- ::,
. AbsorPtion field,
Water main/service line /~/'~ Surface wateddrainage/oO /'~
Wells on adjacent lots /00/'f~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: = ' -
Property line
Surface Water
4- Driveway, parking/vehicle storage area /
Curtain drain A) O ,A/~.-- ,/~---,'J ° ~-~'''g/
F. ENGINEER'S CERTIFICATION
.. /
I ce~i~ that I h ~ ned , inspections and review of Municipal re~t~¢~Jj ~ms are
in conforma~~/~/~ effect on this date.
Signature ~
Engineer s Name ~~
Date ~/~/~
HAA Fee $
.ate of
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
J~-OlI~9 ]~:15 FRO~,-CT£ ~NVIRONM~NTAL
~1~ CT&E Envi,onmen~al Serv/ce~ Inc.
T-gg4 P.02/03 F-428
CT&~? Ref.#
Matri~
Ord~r~ By
~WS~
'.~mplg Remzrks;
992300001
AK W~er & W~srewaTer Comult~[u Inc.
Tux~dm Park L~ B2
0
Clien~ ~
~l'inted [/8~e/l'ime
06/01199 11:06
Collected l~.~elTtme 05/25/99 16:15
l~eiv~x~ D~e/'l~e 05/26/99 11