HomeMy WebLinkAboutNORTH WOODS BLK 4 LT 5No th Woods
Block 4
Lot 5
#051 -731 - 10
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
~ ~ SEPTIC ABSORPTION
Address WELL
Permit No. IND. of Beams
Township, Range, Section
AS-BUILT DIAGRAM (Show location of well, septic system, properly lines, foundation,
~~ ~ ¢[~ , ~ ~ driveway, water bodies, etc.)
XTANKSI
Manufacturer Capacity in gallons ~ ~ · ~ ~ ~ 7
TYPE OF SYSTEM
~ TRENCH ~ED ~ W. DRAIN ~ OTHER ~ ~'~G ~ j
Depth to pipe bottom from Total depth from original grade ~ ~.* ~ . ~ ~j ~.
original grade ~1 ~ ET ~ t ~ FT
Fill added above original grade Gravel depth beneath pipe
Gravel length Gravel width
Total absorption area Distance between lines ~
Number of lines ~ ~ ~ )
Soil rating Pipe material
~nstt!er ~yB~~ /~ Datelnstalled
Claxification (A.B,?~~ TotalDepth I, '~'~ 811111
~ ~ ~ ~~ ~ ~ Inspections Pedormed by:
S & S ENGINEERiN~
Health Depa~ment Approval: Date: '~~-
72-013 (3/85)
M U N I C, J: F:' A L. I T Y 0 F::' A N C. H O R A G E
Depar'tment of Health,.:~. ~ Human Serv:i. ces
F::'erm:i.'L Number' :~ 89" :1.86
Da'Lc ]:ssued :~ ()8/[?'?/89
A NCI'"I, AK 9 9 5 () 3
Day F'hor'~e:.:
F'a r c e I I d :,' () 5 :L ~,...'7 :]; I ..,,. 10
Sec:: t :i. on: 4 't"own sh i p: :L 5N Ran g e: :t.W
l....c)t Size 20500 (sq, Ft,, or. ac:roes)
Max Bed r'. c:,c:,ms ~ 't'h :i. s t::'e r-m i 'L ~ 3 To'La 1 Capac i'L y: 3
'Lar~k mt.Lst ha'.v.'.ce at ].cea!!~,t ~,2 C:£:)!IJI:i~'.'U"'t..~'fiE,~I'I~,L'~,, Dep'l:.h 'Lo top c)F septic tarJl.:: (s) < 4.0
· [' 6'~et i" e clt..~ J, i" (,,',)>~ :i. J"~ SL.~ ]. at :i. (:)r~ OV(.:';.? P t afl I.i: ( s ) ,,
Of'" [..,~ ~....J.I'::T ~::~ I ~..,I .FL)I,t N, L.I.. t"d:..,U.t.l'd::. 'I"HE AF::'PRC)PRIATIE ELb:CTRICAL.. 11,1"
, -I.t,,f I[.tl. 'TH]:S SYSTEM MUS]" BE iih::~]AL.L[:.D IN ACCORDANCE WI"f'H 'T'HE
t::.No.I. NI.I::.I-, ,~ 1)t:., .I.['N,, INS]"AL.L_A'T'IOIq OF A L. IF'T STA]"ION NIL. L.
........ ~ ......... ' .................... 1 ::~F'OR A ":"
]'HE Al F ROI I,i~.~tt:. t.L.E..,fI,,J.L, AL. INSF::'IECTION. THIS PERMI] ....... ...:,
.] ....... ~. r' v "'" % "' "~' ' '''~ /':"
).:'.t:::.Dt' 00fl c .I. II(;:4.J::. F'AMILY RESIDENCE: ONLY, AND IEXF::'IRIES C)N .I.,: ....... 1./89,
CEI:;'.'T'IF'Y THAT:
]: am {am:i.t:i. ar' w:i. th 't:.he r'equ:i.r(~.~mer~ts For or,-site sewer's and we].ls as set
f'or"Lh by the l"h.,u"~icii::~ality of' Anchor'age (MC)A) and the Sta'Le of' A].aska,.
I ~,,~:i.:t.:t. :i.r"~s'l:.all 'Lhe sysitem in acc:ordance w:i, th all MOA codes and Pegu].ations,
and ir'i .compl:iance ~.t.h the design cPit~[~r'.ia oF 'Lh:i.s permit,.
]: ~,~:[].i ;¢,t(::lhepe to al.I. MOA and State oF Alaska r, equSrements for' the set bac:k
d :i.s'Lar'tc:es { r'om any ex :i. sFL:i, ng wel ]., i,~as'Lewat, el" d:i. sposal syslLem
this pepmit, is valid f'of a max:i, mum
at the capacity o~' the t,c)taI sy~st, em is :]~; bedr, ooms~ and
:I.:I. requ:LF-e an ac:h::l:i, ticd"~al per. mit,,
DA ]"E ,",
D A T E:
SCALE
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: '"'~"~
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
12
13
14
15
16
17
16
19
~,,~ ~ Township, Range, Section:"'~
V,-~:Z:~ ~"'1SLOPE S,TE PLAN
ENCOUNTERED?
DEPTH?
Depth t° Water Alter '~:~ tMonitoring?
Gross Net Depth to Net
Reading Date Time Time Water Drop
20 PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER ~ ~' I-~
TEST RUN BETWEEN __ FTAND FT ~ ~r
PERFORMED BY: '~.~N,~:~f~NI~'~, I~',,,-¢j ~, ,,~~~"~'CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANt. W~L~'C~.W~i~k~¢~,~A. ~U~D.'~S,~F.BOT ON T.~S D^TE. ~ATE:
72-008 (Rev. 4/85) ./
May 15, 1989
ROBERT A. SHAFER
CIVIL ENelNEE~
694-29,79 ,
HEALTH AUTHORITY
APPROVALS
,SMEWER & WATER
iSEWER & WATER
iINSPEC~ION
ENGINEERING STUDIES
AND RE.ORTS
WELL INSPECTION
& FLOW ~ST
SITE pLANS
ROAD DESIGN
Ms. Eva Loken
RE/MA× OF EAGLE RIVER
~6600 Centerfield Drive
S~t~ 201
Ea~£¢ River, Alaska 99577
REFERENCE:
sincerely,
)BERT A. SHAFER, P.E.
PERCOLATION /SS
TEST
Lot 5; Bloc~ 4; North Woods Subdivision #I
NHN Norton Court, Peters CreeK, Alaska
AHFC #65502
Dear Eva,
A goundwater monitoring tube was installed on the referenced property
on May 8, 1989 as recommended in our letter to you d~ed May
1989. The tube was installed approximately 15
septic system servin~ the referenced property.
On May 13, 1989 th~ ~roundwater within the moni~o~ing tube was m~asurcd
~ 4 ~eet bel~' Th~ b~ttem of the leachfi~d
surface. From this information
~~3~ee ow'the gr%n~oot above the groandwater
it appears the septic syst~ is only
table as opposed to the required 4 feet separation.
Prior to obtainin~ a Health Autho~ty Approva~ (HAA) for the referenced
property the septic system will need to be up~raded at a distance
of 4 feet above the groundwater. The upgrade would consist of a
mounded type of absorption~ed with an effluent, lift station.
Please notify us if you wish us to proceed with the wor~ necessary
to obtain an up~rade permit ~rom the Municipality of Anchorage.
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTE wATER
D!SPOSAL SYSTEM 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577
D~SIGN
MUNICIPALITY OF ANCHORAGE
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
NAME
~'~ q~ 0C2~/~;~/ [] UPGRADE
LOCATION -- /~ [rO. OF BEDROOMS
] Well ! I Absorption area Dwelhng ~ERMJ.T.-.~;]O
~ ~ I Manufacturer ~ Material No, of compartments
~ Liq. capacity in gallons ~ ............ [ Inside length ~ Wi~h Liquid depth
~ ~ I I~,, I Dwelling ~-~ PERMIT NO
O z < I Manufac~ ~' /~ Material /~*~ Liquid capac ty n gallons
O I Wel~ ' Foundation t ~Nearestlotline ~ PERMITNO.
~ I DISTANCE TO: ~ ~ ~ ~ *17
~ ~ ~ No~f lines ~ ~ kength of each line ' Total length of lines .,~rench width Distance bet~e~lines
g ~ TOp of tile to finish gr, ~e~ Material beneath tile/~ ' ~ ~ ~ ' Total effective absorption area
~ , ,a ( ~, I ,.~h., I/7¢
m Length Width / ~ ~ PERMIT NO.
~ ~ I Type of crib/ ~rib diameter / Crib depth I T~ive absorption ar a
OTHER
PIPE ~ATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
/
AP~¥~ ED ~ DATE
LEGAL
PERMIT NO.
APPLICANT
LOCATION
LEGAL
PJ&S
NORTON CT.
LOT 5 BLK 4 NORTHWOOD SUB
,{
[:,EF'RRTMENT ~;~,HERLTH AND ENVIRONMENTAL ~OTECTION 825 '"k STREET, RNCHORRGE., PK.
, ,-,-.~,-,=, .
&8~O~SLRL. OM DR. ~44-8~D%
LOT SIZE 20500 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT?BR)= 225
THE REQUIRE[) SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[)EF"-FH= 5. 5 L..iE~"~I]TH= tE;~: f3RR%,"EL. C, EP'I'{4= ]:. 5
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
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 DEF'TH OF GRAVEL BETWEEN THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
PERMIT APPLICANT HAS THE RESPONSIBILIT~ 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.
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
±00 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.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGR8MS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'E~:M I T E~',-~F' I RES DEC:E~'IE:EF.: _~-": ::1, .. :ikL~8~_
I CERTIFY THAT
±: t RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND HELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I MILk. INSTALL THE SYSTEM IN RCCORDANCE WITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
APPLICANT PJ&S
I =,=,LIED B'¢_ [:'RTE --
V4. 0
· ' MUNICIPALITY OF A~C/C~Icg~la~: ^NC~O~^G~
DEPARTMENT OF HEALTH AND ENVI'~i~N"E~I-~T~"
~ ~, ~, ~~~f.~oT~C
~ILS L~ - PERCOLATIO~F/~Ts 19~1
PERFORMED FOR:
R F C
SOILS LOG
PERCOLATION
TEST
April 7, 1981
LEGAL
~ESCm~TION: Lot 5r Block 4, Northwood Subdivision
D~Organics and organic silt,
dark brown, top frozen.
~?(4'J~ ( Pt-0L )
Gravelly-sandy-silt, brown to
red-brown, moist, firm, contains
some organics, rounded'gravels.
(GM-ME)
Silty-gravelly-sand, gray,
compact to dense, moist, rounded
and sub rounded particles to
boulder size.
(GM-SM)
9
10
11
12
13
SLOPE
WAS GROUND WATER yes
ENCOUNTERED?
IF YES. AT WHAT
DEPTH?
SiT~: PLAN
RI)AD
I'~
SO;L rES" -,~
! I .
Gro~ Net Depth to Net
Reading Date Time ' Time Water Drop
2 4-10-81 2:39 pM 20 Min. 12 3/8 3/8
3 4-10-81 2:49 PM 30 Min. 12 1/2 1/8
4 4-10-81 2:59 PM 40 Min. 12 3/4 1/4
5 4-10-81 3:09 PM 50 Min. 13 1/4
6 4-10-81 3:;9 PM 60 Min. 13 3/16 3/16
PERCOLATION RATE - 5 3 . (minutmli~)
TE~ RUN .~mEN 4 FT AND ~ ;T
COMMENTS
PERFORMED BY: Howard Grey & Assoc., Inc. CERTIFIEOSY:,
DATE: April 8, 1981
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Ar~chorage, AK 99519-6650
www.cl.anchorage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL.
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
1,
051-731-10 HAAS /-J/~ t~/~///O'7 ' ': '
GENERAL INFORMATION Expiration Date: ~ .- ,,.O..' -' '~) ~ '
Completelega!descdption ~ NORTH WOODS SUBDMSION; LOT 5, BLOCK 4
Location (site address or direc'dons) 22430 NORTON COURT * CHUGIAK, .AK
Currant Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
UARCIA GRABARFFS Dayphone 688-744~
c/o CAROLYN GREINER w/ REMAX PROPERTIES
Day phone ·
CAROLYN (;REINER w/ REMAX PROP. Day phone 696-0592
16600 CENTERFIELD DRIVE '~ EAGLE RIVERr AK. 99577
Unless otherwise requested, HAA w/Il bo held by DSD for plckup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class A 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 Certficates 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 AJaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for proposes served by a single family on-site wastawatar 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 cf 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 may be reissued for a period of
up to one year with valid water samples.) Certificates are vaIid 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 or omissions In the
professional engineer's work.
Note: Alaska Water and Wastewater Consultants, lnc. shall be pald $810. OO at, or pdor
to closing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGI'NEER:
Invest/gab'on, based o~ proc~dureg outli~d In thd Health Authori~, Appro~l Guidelines for this application,
shows that the on-site water supp~/ and/or wastewater disposal system Is(are) safe, f~nctional and adequate
for the number of bedrOOms and type of Structure indicated herein. I furthe[' verify that based on the
Information obtained from the Munlclpality of An~horage files and from my Investigation and Inspection, the
on-site water supply and/or wastewater disposal system Is(a're) in compliance with all applicable Municipal
and State codes, ordinances, and regulatio..ns In effect at the time of installation.
NamoofFirm ALASKA WATER & WASTEWATER CONSULTANTS, INC. Phone 337-6179
Address. 6901 D£BAI~I~ ROAD, SUITE 2B.* ANCHORACE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments: ............
In conducting this eyaluation, AWWC, Inc.'attempted to provide a thorough,
consclen#ous englnsedng analysis of the system In accordance with ADEC and MOA
DSD Guidelines & Regulaffcns. The reportod results described the pedorrnance of the
system under the conditions encountered at the #me of the test, and separation
o?stances measured to readi~, IdentiEable featores. The operational life ef all wells and
septic systems depend ~n the local soils condition, groundwatsr levels that may ·
fluctuate dudng the year, and the weter usage of the fam#y being se~'ved by the system.
These conditions are outs/de the conkol of the evaluator of the system, satisfactory test
results do not guarantee fufure performance of the system, nor do they guarant~e that
there are ne I~fdden defects or encroachments. AWWCo Inc. can therefore not pre,ldo
any warranty or future ese'mate of how long the sYStem will continue to racet tho
operational requirements of the ADEC or MOA DSD. The content of this report Is for
the sole benefit of the Owner listed above. ,any reliance upon or use of this report by any
· other person or ~ is not authoflzed, nor will It confer any legal #ght whatscover.
Date ' ."
't !
5. DSD SIGNATURE
["/ Approved for ~ bedrooms.'
Disapproved.
Conditional approval for __
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
bedrooms, with the tllowing stipulations: k~L~.~'{'~ OF A'~?~ .; .'.
... . . :'v .
· · 'ON-SITE
~~ [ WASTEWATER : :
Manltenan~ Agreemen~
Supplemental Engineer's Reort
Other
Odglnal Certificate Date:
Municipality of Anchorage
Development Sen/Ices Department
On-SM Water & Waslawster Pmgfmn
4700 ~oulh 8ragew St
P.O. Box 196850 Anchorage, AK g9519-6650
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescdptlon: NORTH WOODS SUBDMSION; LOT 5, BLOCK 4 ParcallD: 051-731-10
A. WELL DATA
Welltype ~e~c IfA, B, orCprovldePWSlD# ~l~ ~
Date completed ~ Wires propedy protected (Y/N) _
ff. Cased to ft. Casing halght (above ground) .In.
AT INSPECTION
Date of test ~
· ,~.Wefl'lS-roductlon g.p.m. ~P.m.
WATER SAMPLE RESULTS:
B. SEPTICRJOLDING TANK DATA
Tank Type/Material STEEL
Tank size 1000 gal. Number of Compa,'lments 2
Foundation d, eanout (Y/N) *YES Depression over tank (Y/N) NO
Date Installed 7/6/1981
Cteanouts (Y/N) YES
High water alarm (Y/N)
Date of pumping
C. ABSORPTION FIELD DATA
Date Installed g/29/~gsg
Pumper
Length 43
· Total depl~ ~
*[LEVA110N 5HOTS SHOW MONITORING IUB[ ~ INST. a I rn Dru-u~ 1HAg I
BOTTOU OF BED. NO WA*IZ:R, AT ANY POINT. CAME BITO 'file ~ [
,Son rating (~.p.d~:)r ~/txJrm) 225 System type BED
Width 24 ft. Gmval below pipe 0.5 ft.
Eff. absot'ptlon ama1032 R~ Monltmtngtube YES Depresslonoverllald NO
Date ~' adequacy test 7/19/2001 11.5~esults~ass/Fal0 PASS
Flulddeplhinabsorptlonflaldbefomtest 5.5 In. Wateredded 710 oal.
1 270 13/2.5 In. Absoq~lJon rate
Elapsed Time.-~ 920 min. final fluid depth 1~15'75/6
NONE KNOWN
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
For 3 bedrooms
'17.5/
Newdeplh15.5in.
450+ g.p.d.
yes, glv~ date -
D. UFT STATION
Date Installed 10/2/1989
· Pump on" level at _~._in.
Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se~c tenk/~tt station on lot.
Abeorption field on lot
Publla sewer main
Size in gallons 500
"Pump off' level at..ZZ_ln.
Cycles tested ~
Curteln drain * 50'+
F. COMMENTS
Manhole/Access (Y/N) YES
High water alarm level at 37 In.
Meets alarm & circuit requirements? YE~
WATER
PUBLIC
On adjacent lots
Holding tank
SEPARATION DISTANCES FROM SEP'nC/HOLDING TANK ON LOT ~
Bulldtng foundation 5'+ Property Ilne 5'+ Absoq~on field
Water main 10'+ Water een4ce line 10' + Surface water.
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
PropeAy line 10'+ Building foundation 10'+
Water ee~ce line 10'+ Surlace water 100'+
Wells on adjacent lots 200'+
5'+
100'+
Water main. lO'+
.Driveway, parldngNehldestorage 10'+
* PER 1989 $&:S ENGINEERING
ENGINEER'6 CERTIFICATION
I cerfffy that I haw determined through field Inspec#on$ and
review of Municipal records that the above
conformance wflh MOA HAA gufde#nes in effect on this date.
HAAFee$ '~OC~ . ~
Date of Payment
Receipt Number
(Rev.
Waiver Fee $
Date of Payment
Receipt Number.
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
(~,,~ \ "'-)~\- \('~ haa# t
GENERAL INFORMATION
Complete legal description
Lot 5= Block 4: No~hWoods
Location (site address or directions)
Property owner
Mailing address
J~ff Blackman
22430 Norton Court
22430 Norton Court
Eaql~ River, AK 99577
Day phone 688-0391
Ea~l~ Riv~, AK 99577
Lending agency
Mailing address
Day phone
Agent
Ad dress
Day phone
w
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water
XXX
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
NOTE:
XXX
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
5. STATEMENT OF INSPECTION BY ENGINEER
As Certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I 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
Address
Engineer's signature
$ & S ENGINEERING
17034 Eagle River Loop Read No..2~
Ea~lle River, Alaska 99577
Phone
Date
Sm
Approved for /~'/'~"~---'--~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The 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,
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription:~T-¢~' [~,,4Z. J~c>C,tl-~¢~,5 IParcell.D.
A. WELL DATA
Well type k
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 prope~
FROM WELLLOG ~~ ' AT INSPECTION
Date of test
Static water lev~
g.p.m.
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot '~.~,> c=, ~ ~
; On adjacent lots
g.p.m, m ~ ,-. n
Absorption field on lot
Public sewer main
; On adjacent lots
Public sew~
Other bacteria
Sewer service line
WATER SAMPLE ~
Coliform Nitrate
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed '7 - ~' ~ ~ ~
Cleanouts (~YN) ~
High Water alarm (Y~J~)
Date of pumping
Tank size \ ~ o Compartments
Foundation cleanout ~/N) '~/ Depression,(Y~)
J Alarm tested (Y/~)
Lo ~ ~ ~o~-~ r:'; Pu:mp~.r ,,
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~ 0 L ~ On adjacent lots
To property line ~¢3 ~' Absorption field
Surface water/drainage ~C~ c~
Foundatio:;
Water main/service liqe
~+
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent ~)/N ) ~/
High water alarm level
O~ ~' "~ Manufacturer
~'"0 0 Manhol~/,Access ~N)
"Pump on" level at ~ ~ "Pump off" level at
Cycles tested
Meets MOA electrical codes l¢~'/N) ~
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot d.V-o p On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length '¢~'~ ~ .Width
Total absorption area
Depression over field (Y~:~)
ResultS/fail) ~¢<¢5
Peroxide treatment (past 12 months) (~-~ l,~ C~% ~k~,\-~,,-k
Soil rating '~--?-' ~'~
Gravel thickness
Cleanouts present~/N)
Date of adequacy test
for
System type
Total depth
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot "]~ c~ On adjacent lots Property line
To building foundation ¢'~ ~ To existing or abandoned system on lot
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I havec~/fied, orconformed to all MOA and HAA guidelines in effect on the date, of this inspection.
Signature
Engineer'seqame
HAAFee$ /7~)
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, ALASKA 99515
WALTER J. HICKEL, GOVERNOR
" (907) 349-7755
June 4,1993
Mr. Ray Shafer
S & S Engineering
SUBJECT: Lot 5, Block 4, (22430 Norton Ct.); Northwoods Subdivision
Class "A" Public Water System, PWSID 213001
Dear Mr. Shafer:
I have completed a review of this office's files concerning the monitoring status of the
above-referenced Class "A" Public Water System and found the following:
The last satisfactory Total Coliform Bacteria Sample results was submitted
to this Department on May 11, 1993. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last inorganic Chemical Contaminants Sample results were submitted
to this Department on April 21, 1992. This does meet the provisions of 18
AAC 80.200(a), of the State Drinking Water Regulations.
The last Radioactive Contaminants Sample results were submitted to the
Department on April 11, 1993. This does meet the provisions of 18 AAC
80.200(a), State Drinking Water Regulations.
The last Organic Chemical Contaminants/Volatile Organic Chemical (VOC)
were submitted to this Department on June 2, 1992. Based on analysis of
the previous VOC samples results have been satisfactory. This does meet
the provisions of 18 AAC 80.200(a), State Drinking Water Regulations.
Issuance of this letter does not imply that the above-referenced Class "A" Public Water
System is in compliance with other provisions of the State Drinking Regulations. Unless
otherwise noted, this letter is valid for 30 days and is for the specified legal description
noted above only.
If you have any questions on the above information, please do not hesitate to contact this
office at 349-7755.
Sincerely,
Michael Lu
Environmental Eng. Asst. II
STATE OF ALASKA
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
APPROVAL OF ON-SITE RESIDENTIAL WATER AND SEWER SYSTEMS
PROPERTY DESCRIPTION
Lot, Block & Subdivision or U.S. Survey
LOt 5, Block 4 (22430 Norton Ct.)
Northwoods Subdivision
PWSID no. 213001
This approval does not constitute a guarantee of any kind, explicit or implied, as' to the performance
of the water supply and wastewater disposal systems.
WATER SUPPLY
A recent watersamp ewastested and found to meet Department of Environmental Conservation drink-
ing water standards for total coliform bacteria.
ti~nvironmental Da~une 3, '93
WASTEWATER DISPOSAL
The domestic was~( system was:
[] inspected by
applicable
artment of Environmental Conservati¢
ts of 18 AAC 72;
[] inspected by a al Engineer who
quirements of 18 AAc 72
found to be in compliance with
[] installed by a Certified
of 18 AAC 72; or
ifies that the system complies with applicable requirements
[] tested by a Professi( Eng
and that the complies with
that the performance of the system is satisfactory
~inimum separation distances specified in 18 AAC 72.
Thisapp~ is valid for a [] single family l~-family unit with a total of bedrooms.
Date
18-0404 (Rev. 8/85) DISTRIBUTION: WHITE--BANK/LENDING INSTITUTION; CANARY--APPLICANT; PINK--DEPARTMENT
that the system complies with applicable re-
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Lot 5; Block 4; North Woods
Location (address or directions)
22430 Norton Court
(b) Property owner
Mailing Address
(c) Lending Institution
Mailing Address
Telephone: (home)
Telephone
Business
(d) RealEstate Company and Agent Re/Max of Eagle River ATTN: S/'mron Minsch
Address 16600 Centerfield Drive Suite 201 Anchorage, Ak. 99577
Telephone 694-4200
(e) Mail the HAA to the following address: (or check here~, if hold for pick up.)
List contact person and day phone number below:
S & S ENGINEERING
Eagle River, Alaska 99577
2. TYPE OF RESIDENCE
Single~Family~ Number of bedrooms 3'"
3. WATER SUPPLY
Individual Well []
Community [~X Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation'attesting toth legality and status. '
4. SEWAGE DISPOSAL
On-site J~3( Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality andstatus.
72-025 (Rev, 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation or this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functional end 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 S & -~ EN~IkI~I~RING Telephone
17034 Eagle Ri~er Loop Road No. 204
E~!e ~!v~r: Alaska 99577
Address
Date
6. DHHS APPROVAL
Approved for ~ bedrooms by
Approved ~/ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88} Back Page 2 of 2
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
MUN~CIPALITY OF ANCHORAC-~43-4744
ENVIP, ONMF-NTAL SERVICES DiViSION Legal Description: Lo-
AUG 91990 I o.
A. WELL DATA
Well Classification
Well Log Present (Y/N) __
Total Depth_ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
mECEIVED
Date Completed
Depth of Grouting
If~, B, C, D.E.C. Approved ~)/N)--/~---
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot '~-~o~ ~
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~, L...L~ . ~ , \ '~, '-~
; On Adjoining Lots
'z.-,~o ~- ; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed 7-(°-~ [ Size
Standpipes (~N) y
Depression over Tank (Y/~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Air'tight CaPs (~N)
No. of Compartments
y Foundation Cleanout ,~N) y
Date Last Pumped ~ ' 7- ~ o
, for
Temporary Holding Tank Permit (Y/N) ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ~c,
To Property Line '1~
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
t
Comments ~-~--~ ~--~::;~-~?~ c:~.
To Building Foundation
To Disposal Field
72-026 (Rev. 7~88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed \Q ~ 'Z~ - ~
Width of Field 7~-~~
Square Feet of Absortion Area
Depression over Field (Y/~
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~
To Building Foundation
Lot "~ ~'~-
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field 4% ~
Depth of Field ¥- f
Gravel Bed Thickness ~ ~/~
Statndpipes Present.N) y
Date of Last Adequacy Test .'~'/~
To Property Line ]~ ~
To Existing or Abandoned System on
; On Adjoining Lots '~"
To Cutback (if present)
Comments
D. LIFT STATION
Date Installed lo ~ ~ ¢'1 Dimensions ~- \ "~.
Size in Gallons
"Pump On" Level at
High Water Alarm Lev/el at ~ ~ [~ Vent~)N)
Tested for ~///~
Meets MOA Electrical Codes~C~N) y
Comments
Y
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed $ & $ ENGINEERING
Compan~._-,.l~ River, Alaska 99577
Date %~'/7/ ~0
MOA No. ~ ~o ~ ¢o ~
Receipt No. ~.~0.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE WESTERN DISTRICT OFFICE /
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
June 12, 1990
STEVE COWPER, GOVERNOR
563-6775
S & S Engineering
17034 Eagle River Loop, Suite 204
Eagle River, Alaska 99577
Attn: Roger Shafer
PWSID: 9213001
According to the records on file in this office, the Chuqiak
Utilities/N0rthwood Deerhorn Subdivision Water System is in
compliance with the State of Alaska Drinking Water Regulations.
Sincerely,
Richard Sunder
Environmental ~ield Officer
RS:bas
* '~'~ "~'~ ~4UNICIPALITY OF ANCHOP, AGI~
', DEPT. OF HEALTH &
I~ICIPALITY OF ANCHORAG~ ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL X~.~LTH
DEPARTMENT OF ~ALTH AND ENVIRONMENTAL PROTECTION r JUl ~, 6 1984
APPLICATION FOR B~ALTH AUTHORITY APPROVAL CERTIFICATE
(a) Le.g~ Description (include lot, block~ subdivision, section, township~ range)
Location (address or directions)
Applicants Address
(c) Applicant is (check o.~ne) Lending Institution
Buyer ~-~ ; Other I I (explain);
(d) Lending Institution
Address
Telephone - Home Business
Telephone
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. TTpe of Residence
Single-Family~
Number of Bedrooms
3. Water Supply'
Individual Well[-----1
e
Multi-Family ~-~
Other (describe)
Community~-~ Public.~.
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewage Disposal
0nsite~ Public ~-~ -Community ~ Holding Tank ~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
5. Engineering Firm Providing Inspections~ Tests~ File Search~ Data and Information
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 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 Mnnicipality 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 regula-
tions in effect on the date of this inspection.
Name of Firm ~ ~ ~ ~ ~,:~IN~[N~,~ Telephone
Address
. -
Terms of Litional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN. PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS -AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP 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.
(DHEP SEAL)
RR4/ej/D18
7-19-84
[Page '2 pf 2]
MUNICIPALITY OF ANCHORAGE (MOA) MUN}ClPAUTY OF ANCHORAGE
DEPT. OF HEALTH &
HEALTH AUTHORITY APPROVAL (HAA) ENVIRONMENTAL PROTECTION
C L'rS - F RU Y ].98,t JUL 2 6 1984
m.,. RECE! ED.
Well Log P~esent (Y/N) Date Completed Yield
Total Depth Cased to Depth of G~outing
Static Water Level Pump Set At
Casing Height Above Ground / Sanitary Seal on Casing (Y/N)
Electrical Wi~ing in Conduit (Y/N) /~ // Depression A~ound Wellhead (Y/N)
Separation Distanaes f~cm Well: /C/ /
Tank on Lot '/ / / ; On Adjoining Lots
To
Septic/Holding
To Nearest Edge of Absorption Field o~Lot/~/~ ; On Adjoining Lots
To Nearest Public Sewe~ Line To Nearest Public Sewe~
Cleanout/Manhole To Nearest Sewer Serviae Line on LOt
Water Sample Collected By ; Date
Wate~ Sample Test Results
Be
Date Installed .(~/~Z)/~./_ __ Size - /~ No. of Cc~rga~tments
Standpims ~) Ai~-tight ~ps ~) F~ndation Cleanout
~ession o'~ Ta~ (~ ~te ~st ~?
P~ing~intenan~ ~n~a~ ~ File (~)'/~, fo~
Holding Ta~ High-Wate~ ~a~ (Y~) ~ ~a~y Holdi~ Tank ~it (Y~)
~ation Distan~s ~ ~ptic~olding Tank:
To Wate~-Supply~We 11
To P~ope~ty Line
To Wate~ Main/Sexy/ice Line
Course .~/'/~
./
To Building Foundation
To Disposal Field ~
To Stress, Pond, Lake, c~ Major D~ainage
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Abso~pt$on Strata
Date Installed.
Width of Field / '~ /
Square Feet of Absc~ption A~ea
Depression over Field (Y~
Results of Last Adequac~ Test
Length of Field
Depth of Field
Gravel Bed Thickness
stan ims
Date of Last Adequacy Test
Separation Distance f~c~ ~Absc~ption Field: /
To Water-Supply W~ll :', .>~
~ ,,~ To Existing ~ ~ndo~d
Lot ' /~ ' ~ ~. ;~ ~joi~ing ~s ~O ~
To Wate~ Main/~vi~' Li~ ~ , To ~t~(if ~e~nt)
To St~e~ond~ke/~ ~jo~,~ai~ C~ ~
To ~i~way, Pa~ki~ ~ea, ~ Vehicle St~a~ ~a ~ ~
System.. cn
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested fo~
Electrical Codes(Y/N)
Cc~a~ents
on the date of this inspection.
Company .,, ~ ',g$.7
Dimansions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
~ing Adequacy Test.
** Check Permitted Bed~ocm Rating ~gainst HAA Request
I certify that I have checked, verified, o~ ~onfc~mad to all MOA
* Date ~/~.~ ~
KB1/d5/s
M~ets MOA
HAA _C~_ '~ [~n effect
[Page 2 of 2]
2-15-84
DEPT. OF ENVIRONMENTAL CONSERVATION
SOUTHCENTRAL REGIONAL OFFICE
437 "E" STREET, SUITE 200
ANCHORAGE, ALASKA 99501
BILL 5~EFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
DATE: 7 ' ~-- ~,. ~' ~
To Whom It May Concern:
Acc r ,i,ng to records on file in this office the ~a ~(~
,.'
Water System is in compliance with the State'Drinkin9
Water RegUlations..
~incerely,
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1 General Information Application Date
(a) Legal Description (include lot, ~block, subdivision~ section, township, range)
Location (address or ~irections)
(b) Applicants Name
Telephone - Home
Bus ines s
Applicants Address
(c) Applicant is (check one) Lending Institution
Buyer ~ ; Other ~ (explain);
(d) Lending Institution
Owner/builder [---~ ;
Telephone
Address
(e)
Real Estate Co. & Agent
Address
(f) Mail the HAA to the following address:
Type of Residence
Single-Family~
Number of Bedrooms
/[ulti-Family
Water Supptz
Individual Well ~ ~_G~munity ~
Other (describe)
Public
Note: If community well system, must have written cor~irmation from the State
Department of Environmental Conservation' attesting to the legality and status.
~ewa~
No~e: If community well system, must have written confirmation from the State
Department of Environmental Conservation a~testing to the legality and status.
[Page 1 of 2]
E~ineerin8 Firm Providin~ Inspections~ Tests~ File Search~ Data and Information
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 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 regula-
tions in effect on the date of this inspection.
Name of Firm ~ ~ ~ ~' ~=,.~,=~ Telephone
Date ~~ .
/~/ (ENGI~ER SEAL)
DHEP oval ~
' - //
Te~s c ~Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIDNS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. ~MPLOYEES OF DHEP 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.
(DHEP SEA1. )
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
Well Log P~esent (Y/N)
Total Depth Cased to
St~atic~er Level Pump Set At
Casing ~Heig~7~iAbove Ground
Eleefi~i.eal' Wi~'~i~.~in Conduit (Y/N)
Sepa~a'~ion Distan~s f~om Well:
TO"Sept~c/Hd!d~Tank on Lot 2~0 ~-
TO: Nearest ,Edgei?~ Absorption Field on Lot ~ ~-
To Nearest Pfiblic'S~we~ Line
Cle anou t/ManhO le
Wate~ Sample Collected By
Wate~ Sample Test Results
If A, B, o~ C, D.E.C. Approved(Y/N)
Date Cc~pleted Yield
Depth of G~outing.
Sanitary Seal on Casing (Y/N)
Depression A~ound Wellhead (Y/N)
; On Adjoining Lots ~D
; On Adjoining Lots
To Nearest Public SeweE
To Nearest Sewer Service Line on Lot
; Date
Co~ents
Be
SEPTIC/HOLDING TANK DATA
Date Instal~ /~~/ Size /~O~ No. of Cc~pa~tments ~
Standpipes((Y~ ~a Ai~-tight Cap~/Y~/~ Foundation C/eanout/Y~)
~p~ession~ Ta~ (,~ ~to ~s~d ~/Z ~/~ ~ ~
Holding Ta~ High-Wate. Ala~ (Y~)~/~---- ~a.y Holding Ta~k ~rmit (Y~) ~/~'
Sep~ation Distan~s ~ ~ptic~olding Ta~:
To Water-Supply ~11 ~ ~ To ~ilding Foundation ~ /
To Property Line
To Water Main/Service Line
Cour se
To Disposal Field O~- /
To Stream, Pond, Lake, c~ Major D~ainage
Cor~aents
Receipt $
Date Paid:
Amount: c(~
[Page 1 of 2] 2-15-84
Ce
~ABSORPTION FIELD DATA
Soils Rating in Absorp. tio~ Strata
Date Installed y/~/~ /
Width of Field '~' /-- ~ /
./
~'-~ Type of System
Length of Field /~
Depth of Field ~'--
Gravel Bed Thickness
Square Feet of Absorption A~ea //7~ Standpipes P~esentdY~
Dep~tession over Field (~ Date of Last Adequacy Test ~./~/~7 Cf
/
Results of Last Adequacy Test ~'~/t-F'/.~/~W~o~ 7
Separation Distance from Absorption Field:
To k%ter-Supply Well ~
To Building Foundation
Lot
TO Water :~;bn/Service Line
To Stream/Pond/Lake/c~ Major Drainage Cou]tse
To Driveway, Parking Area, or Vehicle Storage Area
Comments
~- To P~operty Line . /O ~
~-d) To Existing or Abandoned System cn
; On Adjoining Lots M//F~
.~ /i To Cutbank(if present)
D. LIFT STATION
Date Installed
Size. in Gallons
"Pulrp On" Level at
High Water AlarmLevel at
Tested for
Electrical Codes(Y/N)
~ets MOA
Con~uents
Check Permitted Bed~ocm Rating Against FJkA Request
I certify that I have checked, verified, or conformed to all MOA HAA C~%idelines in effect
on the date of this inspection.
Cc~any ~ P~: ~9~979 MOA
KB1/d5/s
[Page 2 of 2]
..; O~.Al -~%
2-15-84
~ Db,~ RECEIVED ;
,. , INSPECTION APPO NTMENT.,S '
DATE DATE~ [',, ~ / DAT ~ · .
I NSPECTO~ ' ~ '
INSPECTOR INSPECTOR~__~ :
MUN C PALIT~ OF ANCHORAGE MUNICIPALIw OF '~CHO~GE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT OF
ON
ENVIRONMENTAL SANITATION DIVISION AU~ 2
Telephone 264-4720
DIRECTIONS: Complete all parts on page 1. IncomPlete requests'will not be proce~ed. Please allow ten (10) days for prodessing.
PHONE
1. PROPERTY OWNER ·
MAILING ADDRESS ~ ~ .
PR~RTY R~IDENT~If different from above) ' PHONE
2. BU ' PHDNE
MAILING ADDRESS / I I
3. LENDING iNSTITUTION ~ PHoN[
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One [] Four
,~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~ Three [] Six
[] Other
WATER SUPPLY -"1 INDIVIDUAL*
COMMUNITY
[] PUBLIC UTI LITY
* ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED,
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQU EST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
:.~:T~pEOFR;$1DEN~E~ ' .. ':,:.:.,,,, '.- . '~ - .~LNUi~,BE~',~.DROOMS' ' : .
~.: SINGLEFAMI~..- ~ : .- . - . --,- _. · ·
~onneedon Vedf~d _ . LOG R~ECEIVED ~ · . - ' .'
UT I~ TY _, : - -¢ ---(- -- --' - '
Con~ctiSn V~¢i¢ied iNStALLER · ' -' r _-
-D-I~A~ ;- ' . ~ .Sbptic/Holdlng ~ahk' A~soiptl0n Area . Sewer Line Nearest
AYea to heare~t~Lot ~ine ' - _ ' ' '
:B, FC~MMENTS- . ·_. - - - _ F .
~ ,CONDtTION¢ ~APPROVAL (le~tCm. ust accompany certificate)