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HomeMy WebLinkAboutMOUNTAINSIDE VILLAGE BLK 4 LT 6Mountainsid Village Block 4 Lot 6 #020- ! 72-03 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 Permit Number: ~J-~ ~2~ _ O/{/? PID Number: ~HW ~ ~/~ ~ ~O /~( Wastewater System: ~ New Q Upgrade -- Address: ~ C~~b /~U¢ ~/? ABSORPTION FIELD PT~- ~ ~ Deep Trench ~hallowTrench ~Bed ~Mound ~Other Total Depth fro~riginal grade: LEGAL DESCRIPTION SoilRating: ¢, ~5 GPD/S,.Ft. -- L Block: Sub;iv,;i;.: ' Depth to pipe bottom I~ original g,ade: Gravel depth be~ath pipe , ,, ~'. /~' ¢ ,~,~ WELL: ~New ~ Upgrade Gravel ~ Number ~ines: Distance ~. Ii.es: ¢ ,t. : Total absorption area: Classification (Private, A,B,C): Total Depth: Cas;.d~ Ft. ¢ ~ ~ ¢ SQ. Ft. ~ ~ ~,. 'rANK ~PM Ft, SEPARATION DISTANCES ~p~i~ a Holding ~ S.T.E.P. sumac. ~J~ ~ LIFT STATION ~/~ Water Lot ~/~ / ~ i Size in gallo.s: ~ Manufacturer: Line ~ou~u~o.5' ~ / ~' ~ ~/~ , Cu~ain ~/~ __ ~ p~ Electrical Inspections pedormed by: Drain BENCH MARK Remarks: ,,, Location and Description: Inspections pe~ormed by: ~ ~5 Dates: 1st ~/~ Department of Health and Human Se~ices approval Reviewed and approved by: ~~ / ~ Date:/J-/"''~ Permit No, SW95-0167 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 Legal Description: MOUNTAINSIDE VILLAGE LOT 6 BLK 4 PID No.: 02:0-172-03 WELL SCALE 1" = 60' SWING TIES A-C = t54.5 B-C = 88.4 B-D = 77.51 B-E = t85.1 4,> - WELL · - MONITOR TUBE IIil~- SEWER CLEANOUT EXISTING LEACHFIELD EASEMENT ELEVAT}BNS (NBT TB SCALE) FINISH ELEV __ ! 106 1~_2.3 1.5' ADOED FILL 1~00 ' ' ~R~ 10~.4 TRa 104.4 ~MTI~ 100.3 NT2 [00.4  TOP OF FIE LOT CBR. RE,AR ASSUMED ELEV = 100.00 -~ ELEV ~¢¢¢ GRnUN]] 0 92 11/07/95 - £/2!/95 Material TVge ~n~ Go~' From To WELL DEPTH: '/ ,., DATE OF COMPLETI(LM Del0th of hale: /'_~_~' __ft Di~;~t H TO li*T&TI(~ WATER LEVEL,' METHOD 0t= D~ILLIqG: l~air rotary CI cable tool :oF WELL: ~g'~ornmstie ~ In-i~at~n ~ mo~tot I-I ~erf~'ated ~-ogen t~o{e Depths of oper~ngs: _ , to , t! AIVO V1EU:~g PUMP INTAIf,~ OF.J~fHt .._ fl: WELL Olb-~I~IFEGT1{D UPON COMPLLa'I'|ON? {~L.YI~{ C] NO 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:SW950167 DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES OWNER NAME:HAGMEIER JOHN C & JUDITH A OWNER ADDRESS:17621 MOUNTAINSIDE VILLAGE DR ANCHORAGE, ALASKA 99516 PAGE 1 OF \ © -,c~ DATE ISSUED: 7/18/95 EXPIRATION DATE: 7/18/96 PARCEL ID:02017203 LEGAL DESCRIPTION: MOUNTAINSIDE VILLAGE BLK 4 LT 6 LOT SIZE: 55368 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION 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 (18AA080) . 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 PROVISION,S/) RECEIVED BY: ISSUED BY: DATE: Louis Butera, P.E. Registered Civil Engineer June 23, 1995 Jim Cross, P.E. Manager, On-Site Services Municipality of Anchorage P.O. Box 196650 Anchorage, AK 99519 Re: Mountainside Village Lot 6, Block G Narrative Permit Application Dear Mr. Cross: The proposed well and septic systems will have very limited impact on adjacent properties for the following reasons: 1. The surrounding lots are large, allowing sufficient room for septic sites. 2. Immediate neighboring septic systems are all +30' distance. 3. Reserve space appears to be adequate, due to lot size available outside the well radius. 4. Drainage will not be affected and is not a major consideration in our design. If you have any questions please call our office at 694-5195. Sincerely, Louis Butera, P.E. If you have any questions please call our office at 694-5195. \G:\WPDOCS\1995\95-052A.NAR ~ 0 P.O. Box 773294 · Eagle River Alaska 995'/'7 . Telephone (907) 694-5195 · Fax (907) 694-3297 ~_~0'0 ~,~ TRENCHES C'"'l~,gx ~' 'gELL ~_ ~ I~ REPL.AREA I o I I - TEST HOLE - ~ONITO~ TUBE o SEWER CLEANOUT ~ - WELL NO SURFACE WATER ~ PROPOSED LEACHFIELD EXISTING LEACHFIELD NO KNOWN CURTAIN DRAINS EASEMENT WELL ~ SEPTIC SITE PLAN ~.?~'~~ u~o~u: ~oum~s~ v~uu~on uoT ~, ~u~ ~- ~..~X.~2% ~ONTRACTOR: HAGMEIER gTH uo~ ~-os:~l ~T~: ~/~s/~s I sc~u~ ~" = so' ~~"., P.O. Bo~ 773294 ~.~ . A'AOLE RIVER, AI(. 99577 '~ ~ SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM LEGAL: Monntainside Village Lot 6, Block G GENERAL 1. The well and septic plan are for a 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 Health requirements. 4. Excavation contractors are to be certified to work under the MOA DHHS certified contractor program. 5. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer. 6. All excavations and depths are advisory and are to be verified in the field by the contractor to meet Municipality of Anchorage requirements. 7. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any adjacent multi-family wells. 8. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer approval. 9. It is always recommended that a surveyor locate the nearest lot line position and the location of any easements. SEPTIC TANK 1. The septic tank shall be an Anchorage Tank 1250 gallon septic tank. 1. The drainfield is to follow the natural land contour to maintain uniform total depth of the drainfield bottom. 2. The bottom of the drainfield shall be level, plus or minus 1.5". 3. The total depth of the drainfield excavation is not to exceed 6' at any point. 4. The effluent line is to be 4" PVC. 5. The drainfield gravel is to be covered with typar 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 drainfield is to be finish graded to prevent ponding of surface water runoff. 8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any Class "C" well, or 200 feet to any community well. RECOMMENDED LEACHFIELD DIMENSIONS: TOTAL DEPTH = 6' GRAVEL DEPTH = 4' under pipe, 2" over pipe DRAINFIELD LENGTH = 133' DRAINFIELD WIDTH = 5' SOIL RATING = 0.45 GPD/ft2 BEDROOM CAPACITY = 4 SEPTIC TANK = 1250 Twenty-four (24) hours notice required for ali inspections. G:\WPDOCS\1995\95-052A.SPC ~ EAGLE RIVER ENGINEERING SERVICES P,O, Box 773294 EAGLE RIVER, AK 99577 (907) 694-5195 JOB SHEETNO. CALCULATED BY CHECKED BY SCALE OF. DATE DATE Mountainside Village Lot 6, Block G Single Fmnily 4 Bedroom Dwelling 4BR = 600gpd Soil rating = 0.45 gpd/ft: Required area = 1,333 ft: 5' wide trench with 3.5' gravel depth Length = 1,333ft2 + 5 x 0.54 --= 266' Reserve Area 4BR = 600gpd Soil rating = 1.2 gpd/ft2 Required area = 500 ft2 5' wide trench with 0.5' gravel depth · Length = 500ft2 + 5' = 100' \G:\WPDOC, ~,X. 1. 995\95.052A. cp~L 1 PERFORMED FOR: LEGAL OESCRIPTION: 2 3 4 7 8 10 12 14 17 20 COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST .... ,e- w/ Township, Range, Section: SLOPE SITE PLAN S IF YES, AT WHAT / 0L DEPTH? /zP p E Oeptl~ Io Waler Al~er ],~, / t Momtoring? Oale: ~/~'1/'~ Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE -~/¢" [)/Tz (minutes/tach) PERC HOLE DIAMETER TEST RUN BETWEEN z~, ~ FT AND ~::~' ~ FT PERFORMED BY: ~'/~' ~'~' I ~~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AN[;] MUNICIPAL GUIDELINES IN EFFECT ON THIS OATE. DATE; PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 7 8 9 10 ~2 14 17 18 20 Municipality ol Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHAT / L DEPTH? /~) O P OepLh {o water After / Monilorino? /~' Y hie: SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop ~ . ~:~t~ 30 $ ~Ii~" I~.I/~" ff ~ ~ : ~ ZO ,~ 7'1/0" /~ /i/~, PERCOLATION RATE 90, 0 ~m,.u,es,,~oh, PERC.OL~ DI^METER &'/' TEST R~N.ETWEEN :, 0 FTAND /';'0 COMMENTS PERFORMED BY: '~/~ ~'~' I ~~ CERTIFY THAT THIS TEST WAS PERFORMED iN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THiS DATE. DATE; -- PERFORMED FOR: LEGAL DESCRIPTION: 2 3 4 5 7 12 13 14 17 20- Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? S IF YES, AT WHA'r / DEPTH? ? p E Depth to Water Alter MoniterJnD? ~,( r~ Date'. SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ __ (m~nutes/inch) PERC HOLE DIAMETER __ COMMENTS PERFORMED BY: ~'/~ ~"S I '~~ CERTIFY THAT 'rills TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: Municipality of Anchorage Development Services Department Building Safety Division On-Sits Water & Wastewatsr Program 4700 South Bragaw SL P.O. Box 196650 Anchorage. AK 99519-6650 www.d.anchorage.ak.us (9O7) ~,3-7~04 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FORA SINGLEFAHILYDWELLING Parcel I.D. 020-172-05 HAA~ / 1. GENERAL INFORMATION Expiration Date:. Complete legal descflpflon ~! MOUNTAINSIDE VILLAGE SUBDMSION; LOT 6, BLOCK 4 Location(slta addrassordiractJons) 17621 MOUNTAINSIDE VILLAGE DR. ANCHORAGE, AK 99516 Current Property owner(s) Mailing address Lending agency Mailing address Real Estate Agent Mailing address RALPH &: CHARLO'I'I'E WESTOVER Dayphone 348-0102 17621 MOUNTAINSIDE VILLAGE DR. ANCHORAGE, AK 99516 Day phone DEBBIE CLOUTER Dayphone 265-9131 FORTUNE COLDWELL BANKER; 2525 "C" ST. ANCHORAGE, AK 99516 Unless otherwise requested, HAA will be held by DSD forpickup. 2. NUMBEROF BEDROOMS: 4 3. TYPE OF WATER SUPPLY: Individual Well r~ Individual Water Storage Community Class Well ~___ Public Water System 'I~PE OF WASTEWATER DISPOSAL: Individual On-site Individual Holding tank Community On-sita 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 cml engineer registered In the State of AJaska. Certificates of Health Authority Approval ara required for the transfer of title (except between spouses) for prepertJes served by a single family on-site wastawater 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 pdvate or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates may be reissued for a peflod of up to one year with valid water samples.) Certificates are valld 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 ougined 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 heroin. I further vedfy that based on the information obtained from the Municipalily 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. Name of Firm ALASKA WATER & WASTEWATER CONSULTANTS. INC. Address. 6901 DEBARR ROAD. SUITE 2B * ANCHORAGE. AK 99504 E~ineer's Printed Name JEFFREY A. GARNESS. P.E. Phone 557-6179 Date 'Ic~ I Engineer's (~omments: · In conducting this evaluation, AWWC, Inc. attempted to pmvfde a thorough, conscientious engineering analysis of the system In accordance with ADEC and MOA DSD Guidelines & Regulations. The reported results desctfbed the performance 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 _ copticsystemsdependonthefocalaoilscondition, greundwaterlevelsthatmay fluctuate dudng the year, and the water usage of the family being served by the system. These conditions are outside the control of the evaluator of the system. Satisfactory test results do not guarantee future performance of the system, nor do they guarantee that there ara no hidden defects or encroachments. AW1/VC, Inc. can therefore not provide * anywarrantyorfuture estimate ofhowfongthe system willcontinue tomeetthe 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 peraon or party ia not authorized, nor will it confer any legal tfght whatsoever. 5. DSD SIGNATURE ~ Approved for ~ bedrooms. Disapproved. Conditional approval for Attachments: HAA Checklist Septic System Advisory Well Flow Advisory bedrooms, with the fllowing stipulations' ~"?o~'v.' ...... '.'~0:~'~ 2.. Manitenance Agreements Supplemental Engineers Reod O~er (R~. 12.130) Original Certificate Date: Municipality of Anchorage Development Services Department Or-,-Slts Water & W~tewMer i~ P.O. Box 196650 Andxx~, NC 99519.6650 HEALTH AUTHORITY APPROVAL CHECKLIST Legal Oescflptlon: MOUNTAINSIDE VILLAGE S/D; LOT 6, BLOCK 4 Parcel ID: 020-172-03 A. WELL. DATA Well type Date completed 8/23/95 Toteldep~ 185 It. Date of test Static water level Well production If A, B, or C provide PWSID~ Sanitary seal (Y/N) YES Cased to fL FROM WELL LOG 8/23/95 16 10 '13 *CASED TO BEDROCK AT INSPECTION Well Log (Y/N) YES Wires properly protected (Y/N) YES Casing height (above ground) 18+ .in. 9/4/2001 .ft. 42 ff. .g.p.m. 6.7 + g.p.m. WATER SAMPLE RESULTS: Collfom~ 0 colonies/100 mi. Nitrate 3.8 mgJL.. Date of sample: 9/20/2001 Collected by:. Other bacteda 0 colonies/100 mi. AWWCI INC. B. SEPTIC/HOLDING TANK DATA Tank Type/Material STEEL Tanksize 125o gal. NumberofComparlments 2 Foundation cteanout (y/N) YES Depression over tank (Y/N) NO Date of pumping q Pumper Oatalnstell~ 8/18/95 Cleanouts(y/N) YES Hlgh wateralarm(Y/N) N/A A+ HOME SERVICES C. ABSORPTION FIELD DATA Date installed s/22/~ Soil rating (~r ~/bdrm)0.45 Length 134.,5 TOTAL fL Width 5 ft. Total depth e fi. Eft, absorpUon area 1345 ft' Monltedng tub~ YES Date of adequacy test 9/4./2001 Results (Pass/Fall) PASS Fluid depth in absorption field before test 0 in. Water added 682 gal. Bapsad Time: 10 min. final auld depth 0 Any mjuvenafion tmalment (past 12 mo.) (Y/N & [ype) in. Absomtten rote >= NONE KNOWN system type DUAL TRENCH Gravel below pipe 4 It. capm~sJon over field. NO For 4 bedrooms New depth 6 in. 600+ g.p.d, ff yes, give date - D. LIFT STATION Date installed Stze in gslions 'Pump on' ~ev~l et E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot 100'+ Absorption field on lot 100'+ Public sewer main Sewer/septic sen'ice line 25'+ High water alarm level et in. Meets alarm & circuit requirements? On adjacent lots 100'+ On adjacent ~ 100'+ Public sewer manhole/cleenout Holding tank N/A Absorption field 5'+ Surface water 100' + SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation 5'+ Property line Water main N/A Water service line 1 O' + Wells on adjacent lots 100'+ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Properly line 10'+ Building foundation, 10'+ Water sewlce line 1 O' + Surface water 1 o0'+ Curtain drain NONE KNOWN Wells on adjacent lots 100'+ Water main N/A Driveway, parldngNehlcle storage 10'+ F. COMMENTS G. ENGINEER'S CERTIFICATION I cer~y that I have detetrnlned through I~eld inspections and review of Municipal records that the above systems ere in conformance with MOA HAA guldelinea in effect on this date. Enginee~'e Prtnt~d N/sine Oate 1 o JEFFREY A. GARNESS HAA Fee S Date of Payment Receipt Number ~. ~) Waiver Fee $ Date of Payment Receipt Number $EP-28-01 17:31 FI~U-CT&£ ENVII~ONkENTAL SRV ,~?1~ CT&E Environmental ,Se~ices Inc. 9075615~01 T-959 P.02/03 F-340 CT&£ Rd.# Client Name Projeef Name/# Client Sample ID Matrix Ordered By PW$1D Sample Remarks: 1016392001 AK Water & Wastewatar Consultants l~c. Mountain Side Vilh~e L6, Blk4 Mountain Side Villiage L6 Blk4 Drinking Water Client PO~ Printad Date/Time 09/28/2001 13:43 Collected Date/Time 09/20/2001 13:35 Received Date/Time 09/'20/2001 15:30 Technical OIre,~ Stephen C. Eile. ,~ Rele~sed~ ~ Results PQL Units Method Allowable P~ep Anllysil limits [~nle ~nte Init l'latera Depa:'t~ent: Nitratc-N 3.80 0.500 mg/L EPA 300.0 (<10) 09/20/01 SCL lltcrobioloir/ Laboratory Total Coliform col/100mL SMI8 9222B (<1) 09/20/01 KAP '0X09/12 ~ 12:00 £,~T 907 276,1507 FORTL,'~'~ PROP. ~002 MOUNTAINSIDE: VILLAOE SUBDIVISION · LOT 6, BLOCK 4 '1 '. .' ..~'.: '~j .~'.~k' ..... :.- · ~ ,., i ,, · 1'~ ,r:'~ ' . MUNICIPALITY OF ANCHORAGE,'"?i '??,:,'i~' /'.~'~:" '.:D:PARTMEI~T OF HEALT~ &HUMAN sER~IcES;~',, ~ ~ ',: ":~;~J,'," ' .' ~'t~ ~' ' t%'." On-S te Serv oes Sect on · '~ - P.O, Box 196650'?Anchorage.'Alaska"~9951~'6650 :'~.~ ';:'.r'" .... , .: . , - .... ,. , ~Aq.A~A~..~t~~ ,..~ 7 ~,~t;~.~t;s~, , CERTIFICAT~ OF HEA~TH ~0TH'ORITy~ A P OVAL A FAM L DW UNO Parcel I.D. # 1, GENERAL INFORMATION Complete legal description Mountainside Village Lot 6, Block 4 Location (site address or cirections) 17621 Mountainside Drive, Anchorage Property owner John C. Haqme:~er Const.: Co., ,Inc. Day phone 248-6789 Mailing address _22J~ ~lmr~lanrt Av~m]e, Sui~ce 201, Anchoraqe, AK 99517 "Lending agency N/A .-Day phone_ Mailing address_ . Agent N/A - Day phone Address Unless otherwise requested, HAA will be held for pickup 2. NUMBER OF BEDROOMS: ~' : ' ~ : :" "'"":"""';" · ,. , ~ . ." :, 3. TYPE OF: WATER SUPPLY: '" ' ' Individual well x Community well Public water .... NOTE:: If community well system,'provide written confirmation from State ADEC attest, ,.,,. ' ' - lng to the leqality and : ,,'~. .' . . ' · ,.. . - :. ~: 4, TYPE OF WASTEWATER DIsPOsAL: ',!- ~ Individual on-site · . , Holding:tb'nk - . :.,,.,,,~ -.,:',:', ~., .,, :: CommL n ty on-s te..~ ~;,' ~:., :' ' ,. Public sewer ,', :,,~,., ...... : NOTE:"" If community, wastewatei' system, attesting to the legality and.~ !' "' .... ;,, .. 72-025 [Rev. 1/I)1) Front MOA #21 '~JOM S,.IBBU!BU@ I~UOjSSejoJd eql u! 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Aw woJj pub SOl!j ebeJoqouv jo Xl!led,o,un~ eql moji peujeiqo uoBe~Joiu! eq] uo peseq ]~ql XdJeA Jeqpnj I 'uleJeq pele3ipu. eJnionJls jo edXl pub smooJpeq jo Jeq~nu eq] Joj eienbape pub leUO!ioun] 'ejes s! mejsXs lesods!p JeleMelSeM Jo/puB Xlddns JeieM ei!S-UO eql ieql SMOqS uoqeO.ldd~ leAoJddv ~lpoqinv qlteeH s!q~ jo uojiebf~SaAU. ~ ]eqi ~JpeA I '~oleq UMOqS elep UoBBpIIBA eqi Jo se pub oieJe~ pex!j~e leas Xm Xq Pe!J!peo sv ~NIeN~ AB NOI&O~dSNI JO LN~&~&S .g MUnicipality of Anchorage DEPARTMENT OF HEALTH & HUMAN },~I~R~/49E8 Environmental Services Divisiq/Nvi~,ONMENIAL EERVtCES DIVt$1ON 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist R E £ E I \I E D Legal Description: A. WELL DATA Well type/D/d/l?/qft~ If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) )/g~ Date completed Total depth /YF) / Cased to ~:/' ~ Sanitary seal (Y/N) _ l./g~¢ Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform "~' Date o[ sample: FROM WELL LOG /0 Nitrate g.p.m. Collected by: AT INSPECTION Other bacteria g.p.m. B. SEPTICPtlOL-Ih'NG TANK DATA Date installed ~ 0~/~¢ Tanksize ,/750 Number0fCompartntents_ff.~ Cleanouts(Y/N). )/~S Foundatiou clcanout (Y/N) yff) ~ Depression (Y/N) .,.A/() High water alarm (Y/lq) /~//4 Date of Pumping /t/~P~ Pumper C. ABSORPTION FIELD DATA Date installed ~/~ Soil rating (g.p.d./ft2~:' fi2/l~m0 ~-), z./5 System type Length /.~Z/, 5 / Width ~ t Gravel thickness below pipe ~ / Total depth [~ / Effective absmption area/~q ¢ ~. Monitoring Tube present(Yin) ~Depression over field (Y~ Date of adequacy test ~/g4[~ Results (Pass*ail) ~-,~' For ff~' bedrooms Fluid depth in absoft,on field before test (in.); ~///4~ hnmediately after gM. water added (in.): Fhfid depth _~A//~ __(illS.) Miitutes later: Peroxide treatment (past 12 months) (Y/N) Absorptiou rate = If yes, give date g.p.d. D. Lllrf STATION Date installed Manhole/Access (Y/N) High water a~ *Datum Cyq~s..te~ E. SEPARATION DISTANCES SEPARA~ON DISTANCES ~OM WELL ON LOT TO: Septic/holdiffg tank on lot /~'0 ' Absorption field on lot /~/ Public sewer main /V/~ S~/septic se~ice line fi-/()O / Size in gallons ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Lift station "Punlp off" level at* SEPARATION DISTANCES FROM SEPTIC/HOL-DING TANK ON LOT TO: Building foundation ~ t Property line 7~ ~ O / Absorption field Water *mil-n/service line ~L~ / Snrface water/drainage ;,L/tOD/ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Receipt Nnmber cD N[~"'t(4Q / Rev. 8/95 OSS: haa.xvk.doc Waiver Fee $ Date of Payment Receipt Number Date of Payment HAA Fcc $ F. ENGINEER'S CERTIFICATION I cert~v that I have determined thrufield inspections and review in conJormance with MOA/fAA guide/'ne~ in effect on this date Signature~~ ~-~ ~ate /// Boilding foundation Surface water '4- Cortam drain Water raah'dservicc line ~./~> / Drive;vay, parking/vehicle storage area Wells on adjacent lots 7~//)O: Property line CT&E Re~.~[ ~ac~ix CTS~E Enviro.mental Services lac. "". ~°"'~":'- Laboratory Analysis Report: WAT~3R MOUR~£AII~S~DE ¥II~,~E 0/! C].iallg Name ]~GLE RI~R ~NG]~RiNG Ordered By ~AT3RA Projee~ dilution. CT = ~reaC~r Than ENVIRONMENTAL FACILiTIE~ IN AL/~KA, CAt.tFORNIA, Ft. ORIOA, ILLINOIS, MARYIJ~ND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO. WES]' VIRGINIA CT&E Bnvironmemml S~wi~; Ino, Te u];nica 1 Di~'~ctor Bample Remarks: 9k~PL~ CO~LECY'~D BY: