HomeMy WebLinkAboutHERITAGE PARK BLK 2 LT 4H
Pitage
Pa k
Block 2
Lot 4
#050-211-76
l,,,,/ 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
Dwelling
Material
Width
PHONE
NO. OF BEDROOMS
PERMIT NO.
Liquid depth
PERMIT NO.
Material Liquid capacity in gallons
Nearest lot line
PERMIT
I/~NEW
[~UPGRADE
MAI LING ADDRESS
LEGAL DESCRIPTION
LOCATION
I I Well ~o~ ~ ~- ~"~' I Absorption area
~ DISTANC T . I
~ ~ Manufacturer
/ s' '
~ .. ~ I DISTANCE TO Well Dwelhng
~ I Manufacturer '
~ ~ ~ ~ No. of lines ~ ~ Length of each li4e Total length of Hnes
Top of tile to finish grade ~ / Materia] beneath tile
~ ~__ Widt~ ,. h.. Dept~
~~ Crib diameter Crib depth
~ ,ICl~s~ Depth Driller
~ I DISTANCE TO Building foundation Sewer line
Trench width
'~ ~ inches
I
Distance betw~l~ /~
Total effective absorption ar, ca
PERMIT ~Z~l~/_
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST I~,~ATI N G.
0
INSTALLER
REMARKS
APPROVED
DATE LEGAL
72-0~3 (Rev. 3/78}
PERMIT NO:
DATE tSSUED~
L)
%][]:
][
DEPAR:'HqEItlT OF HEAL..TH AhlD ENViRONMENTAl_ F:'ROTE~C]~ION
825 L S'T'RE. IET,
8,q.()848
:L 0 / 04 / ~!~ 4.
A, I(..,,iORh,;~,:.., AK ...... J.
264-4720
APF'L t CANT
,-,D~,RE.~o.
CONTACT PHONE:
GA]:L &. L. EE RAYMOND
I:];O 2ND
EAGI..IE RIVER, AK 99577
694-967 :[
LEGAL DE:SCF~II::': ciL.BD [ , I.:~I .)iq. HF-:RITAGE F'ARK LOT: 4 ~.
LOT SIZE: .',SA (SQ.F'T. OR ACRES)
L&sted J::)(gIaw aP(~)tl]6~ ~)p'(t, ion~i ava~TM La , J. lq des~gl'lJ, rig yOLU" sE, pt:i.c:
system. Choose 4. I,,r~ cJpt ~ ~)t'l tha'L best ~ 'J,t~i~ yC)U.I .... ' '~"
DEPTH 'T'O PIF'E BO'I"TOM (FT,,)
GRAVEL_ DEPTI"4 (FT.
TOTAL. DEPTH (FT.)
GRAVEL WIDTH (FT.
GRAVEL LENGTH (FT.)
GRAVEL VOI..LJME (CLJ. YDS. )
TANI< SIZE (GALS)
SOIL RATING (SQ~F'T. /BR,)
EE: th,JI CE: B...-{
4; 0
8, 0
.1. 2 ,, 0
32.
250.0
125
TANK MUS]" HAVE AT L. EAST TWO ( QMF ..,-~l ,'-1El4, .::,
C:, ,, 5
20.0
38.0
28.2
5 C; ,, 0
.125
cer"t :i. f y that
for'th by 'Line MunicipaIity oF Arichor'age (MOA) and 'Lhe c:~ .~ .
3,, I ~il]. ~tdheP(~ tc) ali. MOA and S'[.at~ (]{' Aiasl.::;a r'(~qui~m~nts fcH'~ {h(.z, ~,t back
.d~stances [Pom al']y ex:i. st:Lrig we].L~ ~A, aS(.eW~:L~ d:LSDOSa], sys'L~rn, cH" publ:Lc
sewePage syst~.~m c,n finis or any adjacent (:r near'by Ic:)t.
4. I urlders'Lar~d ' ' ,.,,is permi'L :i.~ vaI:Ld COl" a maximum c:)f ~ bec~r'o(:,m~ and
any en:Lar'gemerrL ,ai].:l. r'equire afl addi'L:Lanal per'mit,
IF A LIFT STA'T'ION IS INSTAL. LED IN AN AREA COVEI~ED BY MOA BLJ:[L..DING CODIES,
THEN (1) AFt ELE(]TRICAI... I:'.'EF?MIT AND INSPL-]iC]TION MUS]' BE OBTAINED.~ (2'~) AS-BUILTS
WILL I',10]" BE APF'ROVED WITHOUT AN ELECTRICAL. INSPECTION RIEPORT; AND (3) THE
EI_ECTIRIC],AL WORK MLIS"t' BE DONE BY A LICENSEI) ELECT!~ICIAN,
. .
ISSUED BY ,.~__~'-~.. ........ ~~.7~~ ............. ~. DATE.-"./_
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST~
,~ SOILS LOG
[] PERCOLATION
TEST
SLOPE SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
1
2
3
4-
5
6
7
8
9
10
WAS GROUND WATER ~ ~,~) SL
11 ENCOUNTERED? O
12 E
IF YES, AT WHAT I
DEPTH?
13
14
15
16
17
18
19
20
r"E ~, C,C, LAT; O ~; RATE / '~""~ ~ (minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
'./
PERFORMED BY: '~g~"~'"~"~ CERT, FlED BY: DATE:
72-008 (6/79)
Municipality o.f 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 HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-211-76
1. GENERAL INFORMATION
Cornpiet'e' legal desCription
· Expiration Date:. ~z'-. /7' O~L.
~eritac3e Park SE) Slo~:k 2. Lot 4
Location (s. ite a.d.dress or direct, ions) 10644 Traditi°n Ave.. Eagle River, ~K
Current Property owner(s)' I-'ce Raymond Day phone 694-8565 -
Mailing address 11~17 Old Glenn Hwy.. Eaole River, ~K 99577
Lending agency .. Day phone
Mailing address
Real Estate Agent .. Kathl Olmstead {RE/Max of F_R.) Day p_.ho..n.e 696-2209
e
Mailing Address ' .. 16600 Centerfleld Drive. Ste 201, Eagle River. AK 99577
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~ Well
Public Water System
'i~PE OF WAS'~ ,-WATER 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. Certificates cf 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 ~ 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 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 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.
Name of Firm KND Enqlneerinq;
Address '20441 Ptarmigan Blvd.~ Eaale River. AK 99577 '
Engineer's Pdnted Name Kenneth M. Ouffus
DSD SIGNATURE
· ' ~ Approved for /'7
Disapproved.
Conditional approval for
bedrooms.
Phone 696-6111
Date 05/08/2001
bedrooms, with the following stipulationsi '
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~ - / 7 - 0 /
Municipality of Anchorage
Development Services Department
Building Safety DMslen
On-SIta Wafer & Wastewafer Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
vnvw.ci.anchorage, ak. us
(9O7) 343-7004
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Heritaae Pan Blo=k 2. Lot 4
Parcel ID: (1~0.21t.76
A. WELL DATA ·
Well type Community If A, B, or C provide PWSID # 21229t Well Log (Y~) ~,,'"""~
Data completed Sanlta~/seal (Y/N) Wires pm~/~etl~ct~ (Y/N)
Total depth __ft. Cased to __lt. ~st~lght (above ground)
FROM WELL LO0~ AT INSPECTION
Date
Static water level ~ ft. ft.
Well production f g.p.m g.p.m.
WATER--TS:
C.C.C.C.C.C.C.C.C.~. ' colonlas/lOO mi. Nitrate mg~t. Other bacteria
Date of sample:. Collected by:
B. BEPTICJHOLDING TANK DATA
Tank TYpe/Matarlal Greet - ~teel
Date installed 1t/t9984 Tank size t250 gal. Number of Compartments Z
colonies/100mi
Cleenoute yes Foundation cleanout yes Depression over tank no High water alarm no
Date of pumping ~/8/2001' Pumper JR'!
C. ABSORPTION FIELD DATA
Date installed t0/1984 Boll rating (g.p.d./ft; or ~/bdrm) 1~
System type T~nch
Length ~1 It. Width {; ft. Grovel below pipe J~ ft.
Total depth 12 fL Eft. absorption area 640 ~ Monitoring tube Vsa Dep[e~sion over field no
Date of adequacy test 5/~200t Results (Pass/Fall) PaSS For~beqrooms -- --
Fluid depth in absorption field bafom test DRY in. Water added ~00 gal. New depthO in.
.Elapsed TIme: 1min. Final fluid depth .9_ in. Absorption rata >= ~1~0 g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give data
D. UFT STATION
Date installed
'Pump on' level at _ in.
Datum
E. SEPARATION DISTANCES
Size in gallons Manhole/Access (Y/N) j..,,/
'Pump off' level at __ in. High water alarm level at-~- in.
Cycies tested ~~uit requirements?
SEPARATION DISTANCES FROM VVE~
Septic tank/lift station on lot ·~On adjacent lots
field on I~g,,/ On adjacent lots
Absorpfion
~main __ Public sewer manhole/cleanout
Sewer/septic sewice line Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~'+
Property line ~'+
N~sorpfion field ~'+
Water main
Water se~,.Ice line lQ'+ Surface water 100'+
Wells on adjacent lots 200'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Pmpe~/line lQ'+
Water Sewlce line lQ'+
Curtain drain 50'+ rhone known)
F. COMMENTS
Building foundation
Surface water t00'+
Wells on adjacent lots
200'+
Water main lQ'+
Ddveway, parking/vehicle 8Image 25'+
G. ENGINEER'S CERTIFICATION
' m~ew of Mun~pal mm~s mat me a~ s~ms am/n
~nfo~an~ ~ MOA ~ gu/defines ~ effe~ on mis date.
HAA Fee $300 Waiver Fee $
Data of Payment 05/09/2001
Data of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH "AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE~OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
'OF ON-SITE SEWER AND WATER FACILITY
264-4720
GENERAL INFORMATION
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b)
Applicant Name/-
Applicant Address
Telephone: Home
Business
(c)
Applicant is (check one): Lending Institution []; Owner/builde, r~; Buyer []; Other [] (explain);
Lend,ng,nst,tution O ,ephone
(d)
(e)
Real Estate Company and Agent "~ //~tL~).xi ~
Address ,/'
Telephone /
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family'~ Multi-Family []
Number of Bedrooms Y
Other
Page 1 of 2
WATER SUPPLY
Individual Well [] 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 ' "i,,///
Onsite/~[' Public [] Community [] Ho'ldiqg T,a, nk [] '
Note: If community well system, must have written c~o~fi/-rcation from the State Department of Environmental Conservation
attesting to the legality and status.
/ '., 72-025 (I 1/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARC',--!, DATA AND INFOR~,~ATiON
As certified by my seat affixed hereto and as of the validation date shown below, I verify that my investigation of th~s
Authority Approval shows that the on-site water supply and/or wastewater disposal system ~s sate, funct~onai and adequate
for the number of bedrooms and type cf structure ~ndicated herein. I fu~her verify that based on the :nformat~on obtained
from the Municipality~of Anchorage files and from my investigation and inspection, the on-site water suppiy and, or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and mgulabons ~n effect on
the date of this inspection.
Name of Firm Eagle giv~ En~in?erina Ser,,1oes Telephone
P. O. Box 773294
Address
Date ~/~5~
Approved for '~g~-~.~L-~'- ~?m.~,=~by _ ~:' --' ~¢ '
D ' sT~/a~ ~ ~ Conditional
Approved .~ , FF %~
Terms of Conditional Approval ~
Date
The Muncipa!ity of Anchorage Department of Health aao Env[ror~P-~ental Protection (DHEP) issues Heaith Author ty
Approval certificates based solely upon the ~(.,p~ese ~tations gp,,en [n paragraph 5 above by an independent profess~ona,
engineer registered in the State of Alaska Ti~e DHE?doesthisas~ ~a courtesy to purchasers of homes and theu !ending
institu!ions in order to satisfy certain federa! and stale r~qu,~ement~. Employees of DHEP do not conduct inspections or
analyze data before a oertificate is issued. The Fv~,unicipaht/O~ Anchorage is not responsible for er[ors or omissions ~n the
professional engineer's work.
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: Z~ ~
ENVIRONMENTAL PROTECTION
Well Classification C¢"~'~ "'~ *~ ".~ I{ A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Date Completed Yield
Total Depth. Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Depth of Grouting
Pump Set At
Sanitary Seat on casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed J'¢/ ~' ~7~ ,~gv. ~Size /2 ~ ¢~,z¢, No. of Compartments
Standpipes (Y/N) ¢~/ Air-tight Caps (Y/N) /Y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /V' Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ~ ; for
Holding Tank High-Water Alarm (Y/N) ,,,~/.//.,4' Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~¢~ ¢'
To Property Line /~ /
To Water Main/Service Line /~ ¢
Course ,,4,/~ ,~
To Building Foundation ~ /
To Disposal Field /¢ /
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84]
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~)~. ¢"/
Width of Field ,~'
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ~'~
To Building Foundation
Lot /'"'~'/'¢~'~ ~
Type of System Design
Length of Field ¢'¢'¢ /
Depth of Field / '~ /
~'¢/-/~~Gravel Bed Thickness ~' /
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~
To Existing or Abandoned System on
; On Adjoining Lots ~ c-
To Cutbank (if present)
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION /[//~
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** 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 ~¢~ ~.,~-~- Date '~.~T//,¢ ~-
Company ,/~"4¢r/,~ /~,,,,.-~,. ,zF'~r,~, MOA No.
Receipt No. '~.~
Date of Payment
Amount: $
Page 2 of 2
72-026 (1 ~/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA g9501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
To Whom it May Concern:
According to records on file in this office the /~~¢~'~ ~/l~c//
~,,L~~~ Water System is in compliance with the St~e Drinking
Water Regulations
Sincerely,