HomeMy WebLinkAboutT15N R1W SEC 19 LT 13TISN
Section
Lot 13
#051-241- $.2
Municipality of Anchorage Page // of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: C)14)~-¥5" PIDNumber: ~5'/-
N,~.e: ~r Wastewater System: ~New ~ Upgrade
P~one: ~Z,~Oi ~eepTrench ~ Shallow Trench ~Bed ~Mound ~Other
WELL: ~;,~,u~__ New ~ Upgrade Gravelw,dm: Numbet Of lines'
SEPARATION DISTANCES ~Septic ~ Holding ~ S.T.E.P.
/~ ~ / / Mamnal: Number of Compa~men~s:
Surface LIFT STATION
Line /~ /o
Inspections peHormed by: ~ g.~ Dates: 1st ~/=~,
Department of Health and Human Services approval
Reviewed
and
approved
Permit No. SW010245
Page 2 of
2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 1966,50 Anchorage, Alosl<o 99519-6650 Telephone: 343-4744
On-Site Wostewoter Disposal System and/or Well Inspection Report
Legal Description:
GLO LOT 13, T15N, R1W, SEC. 19
/
Spruce Drive
No.: 051-241-12
A,/B,
C 4.3.5 ~37.5,
D 90.8 ~82.5
T~ST
· MONITOR ~JBE~
9/14/01
EN~NEER'S
MUNICIPALITY OF ANCHORAGE
Development Sen/ices Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Jul 17, 2001
Expiration Date: Jul 17, 2002
Permit Number: SW010245
Legal Description: T15N R1W SEC 19 LT 13
Design Engineer: 0024 Eagle River Engineering Services
Owner Name: Ronald E. & Eva F. Bryant
Owner Address: 19511 Klondike Dr.
Chugiak, AK 99567-
Parcel ID: 051-241-12
Site Address: 019511 KLONDIKE DR
Lot Size: 42488 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of:
[] D~sposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
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 noti~ DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day,
B. Covered, sealed, and heated to prevent freezing.
Date:
Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWERfVVELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel
Permit N u m b e r SW_..~.O_/_.~_~
Propertyowner(s)~'~O~c~lc~ /-~ (~
~U~
Mailing address (1) 1~5 ~1 ~l~ncl,'~
Mailing address (2)
Legal description (Lot, Block & Sub'd,) ~)"~
Legal description (Section, Township & Range)
Lot Size 25 ,~ OC) Acres/q.~
THIS APPLICATION IS FOR:
Sewer Only [~]
Sewer and Well
Sewer Upgrade ~
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Zip Code
Number of Bedrooms
Well Only I-~
Water Storage []
Jacuzzi '
Water Softening Unit
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of proped7 owner or authorized agent)
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
Date of Payment:
Receipt Number:
I~Z-17-2~1 ~9:26AM FROM E.R. Engtneerin9 S~c~. TO 249~
,Eagle River!Engineering Services
EaSe River, AK ~9577 3294
July 17, 2001 I
Jim Cross, P.Ei
Municipality o? Anchorage
P.O. Box 196650
Anchorage, A~ 99519
Re: OLOL t 13, TISN, RIW Sec.l~9 SM
Narrative & P~ rmit Application
Dear Mr. eros;
louis Butera, P,F,.
(907) 694-519.5
(907) 694-32~7 fax
The proposed kv¢ll and septic :.system!will have very limited impact on adjacent proper~
following reasSns:
1. The surrounding lots ~ large, this lot fronts the'300 foot Glenn Itigh~ay
dth the septic system !n that location as far away as possible .from neighb~
dlowing sufficient roo~ for septic sites and therefore not affecting ihe deval,
lcighbors lots. The well is already existing in place.
2. ;mmedlate neighboring I,septic system are all +30'. distance from this system.
3. Fhe soil permeability is ~dequatc.
4. ~)rainage will not be aff~cied and ~s not a major considera~on m our deslgn.
This was previ, msly p~-mit~ecl as a 3 b~lr. oom dwelling in 1974. A new 4 bedroom home is c
and thc ~xistin ~railer is to be r~movcd and old septic system properly abandoned. The new
is in a higher lbcalion on thc lot and in[ludes a reserve ~ We will be disconn¢ctlng
the Iraller and rov~dmg n new waterl to the new h me.
If you have an~ questions please call otir office at 694 5195.
Sincerely,
Louis Butera, P.E.
I
I
for ih~
ht of way
,ring lots,
rment of
nstmeted
eachfield
terline to
TOTAL P.E~2
Lot 214 /Lot 21'~ NO S~P~C +30' Lot 216
~ ~1 ~- IO'R.O.W. ~t ~ "
.~s +,~ ~ ~ /~" ~ ',~ ~ /
/ / /~ / · -
~EUENT
NO SURFACE WATER PROPOSED L~CH FIELD
NO KNOWN CURTAIN D~IN5 --- EXISTING L~CH EIELD
WELL/SEPTIC SITE PLAN
LEGAL: GLO, LOT 13, T15N, RIW, SEC 19
~ ~' .. .... ;..: '~'/+
OWNER: BRYANT ~ ,,' ~'.~
CONTRACTOR: N/A ~'.'~9~ ".
Jo.fo -o20ws/9 TE: s/26/0 I SCAL[ =50'
EAG~ RIVER E~G/~EER[~G S~RVICES
P.O. ~o~ ~73294 '~/
EAG~ RIVER, AK. 995?7
(90~) 694-5195 tAX: (90~) 694-329~
· , ..Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
LEGAL:
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
GLO Lot 13, TISN, RIW Sec.19 SM
June 27, 2001
A. GENERAL
1. The well and septic plan are for a 4 bedroom single family residence only.
2. The drawing and or site plan shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of tlealth and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Department of Environmental Conservation requirements.
6. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval. Contractor is to provide a current MOA certification to install septic systems.
7. Any remaining open test hole excavations shall be filled and graded with monitor pipe removed.
8. Construction inspections as per MOA guidelines are required. Waterline is to be inspected prior to
backfill.
B. WATERLINE
I. A new I' K copper waterline is to be installed starting at the existing well pitlcss adaptor and
connecting to the existing waterline stub under the new house foundation. Waterline is to be a minimum
of 10' depth below finished grade or insulated until it can provide that depth. Existing waterline to be
abandoned in place.
B. SEPTIC TANK
!. A new, MOA approved septic tank is to be installed, the existing septic tank is to be pumped,
crushed and buried in place onsite.
C. TRENCH LEACtlFIELD
I. The trench is to be located in the location as'shown on site plan, this will be staked by engineer.
2. The bottom of the trench excavation prior to rock placement shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 12' at any point roferencing ground surface.
4. The 4" effluent line within the trench shall be laid level within 0.03'.
5. The trench gravel is to be covered with typar non woven fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoff.
RECOMMENDED LEACtlFIELD DIMENSIONS:
TOTAL DEPTH = 12' GRAVEL DEPTH -- 8' under pipe, 2" over pipe
TRENCtl LENGTtl = 47' TRENCti WIDTtl = bucket width (+2')
SOIL RATING = 0.8 GPD/ft2 BEDROOM CAPACITY = 4
SEPTIC TANK = 1250 gallon MOA approved.
Twenty-four (24) hours notice required for all inspections.
k2001\Ol-020spc
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 01-020
Calculated By: LB
Date: 6/26/01
Legal: GLO, LOT 13, T15N, R1W, SEC 19
Single Family 4 Bedroom Dwelling
TEST HOLE 1
Deep Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom
Percolation rate
Wastewater application rate
Required absorption area
Trench width (W)
Gravel depth (D)
600 gallons
13.3 minutes per inch
0,8 gallons per day per square foot
750 square feet
3 feet
8 feet
Required length = Required absorption area 12 / D
Required length = 750 / 2
Required length = 47 feet
Total Excavation Depth = 12.0 feet
/ 8
01-020.xls 11:14 AM6/26/01
PERFORMED FOR:
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
lEGAL DESCRIPTION: GLO.. t01' ~3 Township, Range, Section: Tim'/t/,
SLOPE ill'rE PLAN
3
4-
CO
I
N
/
?
' ~ IF YES, AT WHAT
!2 ' ),.j E
Oepth to Water ~er
15 ~ ~ Time Time Water Drop
PERCO~TION RATE ~ (mmut~mc~) PERC HOLE DIAMETER
TEST RUN I[ETWEEN ~ FT AND ~ FT
COMMENTS
PERFORMED BY; F.R_ J::.S 2. ~&~te~'~ I ~
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON'THIS DATE.
72-008 IRev. 4,85)
CI[RTIFY THAT THIS Ti[ST WAS PERFORMED IN
DATE: 7-- '*~ -- C~ /
? ·
) 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 '~ PHONE
NO. OF BEDROOMS
LOCATION ~( ~ ~
~ DISTANCE TO: I Well / ~e' ] Absorpt';~ ~rea ~ ~,~Dwelli PERMIT NO.~
Manu,ac,urer ~ M at e~ ~m o,~m~artments
~ Liq. capacity in gallons Inside length Width Liquid depth
~ ~O~ IF HOME.DE:
O ~ Manufacturer Material Liquid capacity in gallons
~ DISTANCE TO:Iq~I ~~1~ Nearest Io line
Length of each line Total len th of lines Tren~w~dth Distance between lines
-- No. of lines ~ ~1 ~'"~ inches m°taT~Tve ~ti~ea~
"~ Wop of tile to finish grade ~.~ , .aterial beneath tile /~4 inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot llne PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
RE ARKS
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
PERMIT NO.
DEF'FIRTMENT OF' HERLTH RND ENVIRONMENTRL. PROTECTION
825 '"L'" STREET., RNCFIORRGE., RK.
2E4-4~2~
( 79E~47(~ )
EIPPL I CRNT
LOCRT I ON
LEORL
FIL LFIRSON (RUSTIC HOMES
B I RCHNOOD
L:I.i: S:t9 "f':LSN R::L!.,.I SM
PO BOX 594 ERGLE RIVER
LOT SIZE
694
Sg!URRE FEET
TYPE OF SOIL RBSORBTION SYSTEM IS: TRENCH
P'IRXtMtJM NL.IMBER OF' BEDROOMS
SOIL RRTING (SQ FT?BR)= 224
THE REQUIRED SIZE Of:' .;'HE SOIL. RBSORPTION S'¢STEM IS:
THE I_ENGTFI DIMENSION IS TNE L..ENGTFI (IN FEET) OF TNE TRENCH OR DRRINF'IEL.D.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETNEEN THE SUR. FRCE OF' THE
GROUND FIN;:, THE BOT'rOM OF THE EXCRVRTION (IN FEET).
]'HERE IS NO SET 14IDTH FOR TRENCHE:S.
';'FIE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL E,'ETklEEN THE OUTFRLL PIPE;
RND THE BOTTOM OF' .;'HE EXCRVRTION (IN FEET).
PEF..'MIT RF'PLICEINT NRS THE RESPONSIBILITV TO INFORM THIS DEPFIRTMENT DLIRING THE
INS]'RLLRTION INSPECTIONS OF RNY NELLS RDJRCENT TO THIS; PROPERT'¢ RND THE
NUNBER OF' RESIDENCES THFIT THE NELL NIL. L SER',/E.
L::RCKFILLING OF RN'¢ S'¢STEM NITHOUT FINRL INSF'EC:TIOI',I RND RPPRO',,,'RL BV THIS
DEF'RRTi'dEIqT NIL. L E:E SUSJEC:T TO PROSECUTION.
MII",IIMUM DIS'TRNCE BETP.IEEN R NELL RND RNY ON-SITE SENRGE DISPOSRL SYSTEM IS
±E;EI FEET FOR FI F'RIVRTE I.,.tELL.~ OR
:t50 TO 2E~0 FEET FROM R PUBLIC NELL DEPENDING UPON THE .['VPE OF PUBLIC k!ELL..
OTHER REQUIREMENTS MR', EIPPL'¢. SPECIFICRTIONS FIND COIqSTRUCTION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
I
J.:
FORTH B'¢ THE MUNICIPRLI.["¢ OF RHCFIORRGE.
2: I P.IILL INSTRLL TNE SYSTEM IN RCCORDFINCE I.'.IITH THE CODES.
2: I UNDERSTRND THRT THE ON-SITE SEWER S'¢STEM NR'¢ REQUIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODEl_ED TO INCLUDE MORE THRN ]: BEDROONS.
S I GNE[:,: ..._~__~~ ...............................
I:~PF'L~Fff,~ RL. LFtRSON (RLISTIC HOMES)
..... ,,,_:.
ISSUED E, : .... [:RTE .::..
CERTIF:'Y THAT
I RM FrRFIILIRR klITkl THE REQUIREMENTS FOR ON-SITE SENERS RND PtELI...S RS SET
O & E ENG,NEERING & DEVELO, MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
SOIL LOG
Performed for: Name:
Mailing Add ress,~ <~ .~
Legal Description: ~ ~
Earl Ellis
688-2280
Depth (feet)
Soil Characteristics
1__ "~/-
2__
3__
5
PLOT PLAN
12__
13__
14__
15__
;16 __ ~ /..,j~,.~ _..~.~,,,~,.u~ <G~
Ground Water Encountered: Yes '" No
Proposed Installation: Seepage Pit
If yes, what depth
Drain Field /
PERC. TEST
Comments;
Performed by: ~.~
{gerl fiei Drilling
by ENVIRONM[ NT,'\L d;:o ;ECTION
[DOC Co. dba
JUN 4
SULLIVAN WATER WELLS
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION .' , ,
DATE - Started Ended
PERMIT NUMBER
DEPTH OF WELL ~ ~, -
/ / V:i /', STATIC LEVEL OF WATER FT.
"'"; / t:, ',.~, DRAW DOWNFT
GALS. PER HR ; ~'
KIND
OF
CASING
KIND OF FORMATION:
From Et. to Ft
From Et. to . Ft.
From. Ft. to · . Ft.
From Ft. to Ft
From .Ft. to Ft.
From__ Ft. to.__ Ft.
From Ft. to .Ft.
From Ft. to__Ft.
From___Ft. to Ft.
From__ Ft. to Ft.
From__ Ft. to Ft.
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft.
From __ Ft. to Ft.
From Ft. to Ft.
From Et. to Ft.
From Et. to Ft.
From Et. to Ft
From Ft. to Ft,
From Ft. to Ft
From Et. to Ft
From Et. to Ft.
Frpm Et. to Ft
From Et. to Ft.
From Et. to Ft.
From Ft. to__.Ft.
From Ft. to Ft
From Ft. to Ft.
From Fi. to Ft.
From. Ft. to Ft.
From Ft. to Ft.
From Et. to Ft,
MISCL. INFORMATION:
DRILLER'S NAME ; ' " ' .... ( ; ' '
[)EPFII;?.THENT OF' HEF:ILTH F¢',ID ENS,~IRCINI'"IEF~TFIL I::'RCITEC'I"~Of,I
825 "L." STF;?.EET., FINE:HOF~:FIGE., F:ff;::.
I!.,,.1~ ~!~ L.. L.. IF::" [~;[ F-L." ~"1 ;i[T 'l'
I:
[...OI~:FIT I
I...[}XSF:IL..
FIE L.I: R...:,C L
KL_OI',!D ]: KE ST
['"llhl):MUi¥1 [)iSTF:I[',!ISE: BETI.,.IE[EN FI NEI..L. FIN[) FINY
:t. Ei~il FEET F'OR FI F'I:~::[',/FITE NELL..;
:tSF:i TO 2E)el FEET FF~'.O['"I I:;I F'LIBLZC ~.IEL./_ E:,F_F'EN[.':':[t",!C~ UF'ON TIqE TYF'E OF F'UE:[_ :[ C: I.,IE':L..[
I.,.IE!...L I..OGS FI[;?.E F,.':EL::!IJ):F?.E;[) RND i'qLIS;T E:F_' R_F. XTI..IF~:i'.,I['}':D TO TH['£ D[_£F'~F~'.TMEN'F I,~:I:TI'.I:[N Z}~:Ci DFIY'..:-':
01':" THE{ NEL.L COIdF'LETICII'-,I.
OTHEF?. I::?.ECIU.'[I4:E-:ME3qTS; M,'::IY FIF'F'L.Y. '_:;P[.:.'CZFZC:FIT}X)NS F:IND C:ON'.STF,'.LICTZON
F:!',,/I::I ]: LFIBLI!.~: '['O I ['.,ISl..IB'.E Ix'F~:OPEF~: :[ I',I:STFILL FI'i'Z ON.
J: CEF?.]"]:FY THFIT
:L: i FIM F:'FIMZL. ZFiI:;:: WITH TNE RE6!UIREI"IEi',!T5; FOR OI",f-%ITE 5;E!-,IERS F~lq[:' !.4EL.I..S FIS SET
F'CIF::T!-I BY THE: P'iUI"~:£ C: I PF:IL.. I TY OF' FII',!CHORFIC'iE.
2: I I-,.t];I.._L ]:i'-,I:iSTRI._I... THE; '.E;'T~;'I'E:I'"I].'t",I F:iCCOF::F;,FIi",IC:IE !.,.Ii:TH THE: L-O[)E'.~:;.
FIF'F'L :[ CFliqT FIL. LFIf;;:SON
J...-.~.,,UL.[. [iP'rL- [:'F:I~[ E
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEAL.TH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Expiration Date:
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Current Property owner(s) ~o~,~l~
Mailing address
Lending agency
Day phone
Mailing address '
Real Estate Agent
Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: .
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
[]
[]
TYPE OF WASTEWATER DISPOSAL:
Individual On-site' []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Cedificates 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 sample results less than 30 days old. (Certificates may be reissued for a period of up to one yesr with
valid water samples.) Certificates ere 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 or omissions in the professional
engineer's work.
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 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations In effect at the time of installation.
]~a~]e ]~{ver ]~n~ineel~ J~ervlces
Address
E~gineer's Printed Name
DSD SIGNATURE
~ Approved for ,L/..
Disapproved.
Conditional approval for
bedrooms.
Phone ~,F4,'-J'-/~'j'- ,
Date
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
By:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastawatar Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription: Z~"~/v) /~T 7-/.,-*,~ ,~'/~' £~c /? ParcellD:
A. WELL DATA
Well type /~.,~/e Ifa, B. orC provide PWSID # /via
Date completed /~ 77 Sanitary seal (Y/N) ~.
Total depth 4/,~. ff. Cased to ~7'eZ ft.
FROM WELL LOG
Date of test .,4-- ,~
Static water level ~ 7 ft.
Well production 6 g.p.m.
Well Log (Y/N) Y
Wires properly protected (Y/N)
Casing height (above ~(~nd)
AT INSPECTION
7-
31 ft.
,~ · 5- g.p.m.
y,
~.~' in.
WATER SAMPLE RESULTS:
Coliform ~ colonies/100 mi.
Date of sample: =~ -//- ~ !
Nitrate /t~? mg./1.
Collected by:
Other bactana ~ colonies/100 mi.
B. SEPTIC/HOLDING TANK DATA
Tank Type/MateriaJ S'">,-,e~ /
Tank size / ''~ r~' gal. Number of Compartments
Foundation cleanout (Y/N) ~F' Depression over tank (Y/N)
Date of pumping /v'~,,/:7'a..-,~ Pumper ~//~f
Date installed
Cleanouts (Y/N).
High water alarm
Length
Total depth /.~ ft.
Date of adequacy test
ABSORPTION FIELD DATA
Date installed ~-~'-,/ Soil rating ~r~/bdrm)
ff. Width 4/' ft.
Eft. absorption area 7,~'"& ~ Monitoring tube _
Results (Pass/Fail)
Fluid depth in absorption field before test ~ in. Water added
Elapsed Time:~ min. Final fluid depth ~ in.
Any rejuvenation treatment (past 12 mo.) (YiN & type)
System type ,¢~,=, ~',"~"-.~,'
Gravel below pipe ~ ft.
~,' Depression over field
For .-' bedrooms
"{Iai. New deptE-' in.
Absorption rata >= ' ¢~;:=~:¥.2 g.p.d.
If yes, give date
D. LIFT STATION
Date installed ~ Size in ga~.
'Pump on" level at lo.'~ 'Pump off' levl~
Datum '~ycles tested
iN.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot /.~
Public sewer main ,~/,e
Sewer/septic service line / ~'~
Manhole/Ac. ce~,~./N )
On adjacent lots -d-,,~,,.~ '
On adjacent lots F,',~'p z
Public sewer manhole/cleanout
Holding tank ,,,V/.4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Property line ./J' · Absorption field 5' ·
Water service line ?'~" Surface water ,,",'~--',~ '
Building foundation
Water main ,~'/"~
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /,~ / Building foundation ,3"-~ ' Water main
Water Service line v'~ ~ · Surface water ~/~,g / Driveway, parking/vehicle storage
Curtain drain ,~/.4 Wells on adjacent lots. '~','~,~ /
F. COMMENTS
Jn.
Waiver Fee $
Date of Payment
~_ '~. Receipt Number
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
G. ENGINEER'S CERTIFICATION ; ~.. e~,,~,~.~,~~~.
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 Printed Name ~--~,~./.[ ~.~ ,-c~r,-,
90T5515301 T-393 P.OI/OZ F-'597
C'T&E Refer 1016164001 Client
Cli~t Name .F. agl¢ IUvc~ ~ngin e c~i~ g ~in~ Datc~lme ~8~001 7~4
Pro~ ~m~ ~a ~ Da~ ~ I~1 13:35
Mat~ ~[nk~ Wat~ T~bnlcal
~llD 0 ~
Results PQL Uni~ Me,hod Llmil.s ~"~e D~ Init
Nitr~tc.-~ 1.~9 0.500 m~/L £PA 300.0 (<10)
I~/IZ/~I SCI.
Total ~olifi)~m
ml/lOO~L 8MIg _97~n
MUNICIPALITY OF ANCHOP~RGE
DIVISION OF ~NVIRONMEN'fAL HEAL%~
DEPARTME~I' OF HEALI~H AND ~KrIRONMENTA£ PE~IfECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1.__C~-~neral__-~ ~- ~Inf°rmati°rk- ~--'-- Application Date _7_~/,/~'7/~7./
(a) I~g~/~r~pt~on_ (includ~ lot, block, subdivision, section, township, range)
(b)
__7~n°cati°n~ (_a~dck, ess or di~ections~ ~/ ~7~ff /~fi ~)y<~/fo ~'
Applicants Address__
(c) Applicant is (check one) I~onding Institution ~; Owner~builder/~;
Buyer~ ; Other~(explain);
(d) I~nding Institution Telephone
Address
(e)
t~al Estate Co. & Agent
Address'
2. ~ of Neside~ee
Single-F~uni
Numbe~ of
3. Water ~
Multi-Family
Other (describe
Note: If corn,unity v~ll system, n~st havre written confirmation frc~ the State
Depar~Tsnt of Envirop~rental Conservation attesting to the legality and status°
Is the well adequate fo= the number of bedronms specified in this HAA ~
4o S__ew.a.~e Disposal
Onsite Public ~ Community ~ Holding Tank ' ' .
Is the wastewater disposal system adequate for the number of b~dr
[Page 1 of 2]
2-15-84
5. Enm i~.in~__q Firm I>rovidin I~ctions_~ Tests, Data and Information
I certify thct~have checke~, ver.ified, or confornred to all MOA [t~A Guidelines in
effect on ,~ d~/~f,_~ihi, s/fnspectlon.
SJ 9ned~~ Da te~_~~/
Naun~ ~f~irm_ _ Te_l. ephone
Address .~ ~ ~ ~6J~N~(~ :.:~a-~--- "'
Sigr~d by ~ ~, ~' ,~-,, - '
.~i...~ , 7 .....
Date __ ;';q;
( ENGINEER SEAL)
6.DHEPAp~roval
Approved for ~ bedrccms
Approved ~ Disaplmzoved E~
Terms of Conditional Approval
By ~ ~(~,~'",¢'¢-¢~'¢- Date
Conditional L---~
The Municipality of AnchoraGe Department of F~alth and Envirop~ental P~otection does
not guarantee the continued satisfactory performance of the water supply and/or the
wastewater disposal system. This approval indicates that~ as of t.~ validation date
shc~za above, based on the data and information furnished by an engineer registered in
the State of /klaska, the water supply and wastewater disposal system is safe and func-
tional for the number of baclrocms and type of structure indicated.
( DHEP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
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2-15-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
ae
Well Classif icat ion~Q~
~11 ~ ~esen~~ ' ~te ~d ~/~ ~ ~ Yield~
Total ~p~
Static Wate~
Casing ~ ight ~ G~nd ~ --~O Sanlt~ ~al on ~slng~
~p~essi~ ~nd ~l~ead (~
Elect~ical Wining in Condui ~t~]~
Separation Distances fnom Well:
To Septic/~ Tank on Lot /~ /
To Neanest Edge of Absonption Field on Lot /~ ¢
; On Adjoining Lots
; On Adjoining Lots
To Nearest ~ Sewe~ Line /J~//d To Nearest Public Sewen
Cleancut/Manl~ole /~///~ To Nearest Sewe~ Service Line on LOt
Wate~ Sample Test Results ~'~ ~7-//-=/R C ~o~f_ 7
C~t~t~ nts
B. SEPTIC~ TANK DATA
Date Install~ /~D--ZO ~7~ Size /~00 NO. of Cc~pa~tr~nts
Standpi~s ~ Air'tight Caps~ Fo~n~tlon Clean~
~ ~ / /~ · ' / ~//~
P~ing~inte~n~ ~n~act ~ File .~Y~/~ , fo~_ ~'~/
Holding Ta~ Hiuh-Wate~ ~a~ (Y~ ~ra~ Holdi~ Tank ~ (Y~"--
Sep~ation Distan~s ~ ~ptig~Ta~- .
To Water-Supply ~11 /~ f To ~ildinu Foundation
TO ~o~rty Li~ /~ ~ To Dis~sal Field //' f
To ~ter ~/~vi~ Li~ ~ ~ To S~e~, Pond, ~e, o~ ~jo~ ~aina~
Counts
[Page 1 of 2] 2-15-84