HomeMy WebLinkAboutKINCAID HEIGHTS LT 11Kinceid H
ights
Lot 11
#011-
Municipality of Anchorage Page ! of 3
Depadment of Health and Human Services
Division of Environmental Services
On-Site Services Section 825'L' Street Room 502
P,O. aox 196650 ~chorage, AK 99519-6650
w~w~.ct,ancfloroge.ak.us (907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SWO00060 PID Number: 011-122-11
Bethard Construction, Inc. Wastewater System: New Upgrade
12801 Reata Dr. Anchorage~ AK 99502 ABSORPTION FIELD
345-1615 Five (5)
LEGAL DESCRIPTION .725 c.~ 3.2
11 Kincaid Heights 4 n. 8
I F,. 65
Well: Municipal Water System 3 n. I N/A
F~. Ft.1,040 r~ ASTM D3034 PVC
n. Glacier Excavatin~ 5/16/00
¥'""':o~ I~'''"s~':n. ic~,~, ..,~o,,.c,.,~:n TANK
SEPARATION DISTANCES E3 septic n Holding n $.T.E,P. r-I Other.
Tank Field Station Tank S~,.fU,. Anchorage Tank 1,500
w,, >200' >200' N/A N/A >25' Steel Two (2)
~'~ w..>100'>5, >3.00'>10, N/AN/A N/AN/A ~ ~: LIFT~.STATION~,a~,.,: - NONE ON LOT
F.,~ >5' >10' N/A N/A .,~,,.,-.,~,,.-~o o~,.~.,:
c,.,.~,~,. None Noted ~p,.,.,,.,&,.....
"'~°~': BENCH MARK
Garage Slab
100.0 FL
Inspections performed by: Mike Anderson Dates: 1*~ 5/16/00 ,. .....................
2'~ 5/16/00 ~. ~,. ~:CHAl~t E. ANDt~SON
Department of Health and Human Services approval "~.'~"~:.,-. CE- 4381 .* ~" .,-'
Reviewed and approved by: ..~_~ ~'~'/- ~:~/7~ Date: ~ ° ~' ~ I ',~ <"4',~'.. .."~,?~,~
Municipality of Anchorage Page 2 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION '
P.O. Box 196650 -Anchorage, AK 99519-6650 - 343-4744
On-Site Wastewater Disposal System or Well Inspnction Repo~
Permit Number SW000060
PID No. 011-122-11
A B
Sl 23.0 26.7
S2 30.4 34.2
C4 38.6 50.9
M1 70.7 72.5
C5 72.3 74.5
LOT 10 s' ~ s~
I
I
I
~ I
Site
C5'
PLAN ,AS-BUILT
SCALE
Page 3 of 3
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DMSION
P.O. Box 196650 - Anchorage, AK 995196650.343-4744 *
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number SW000060
PID No. 011-122-11
26'
.I
~0
)tic
Geotexttle Fabric
.' " "Drainfie'ld.' R0c~
· CE - 4381.
;' 65' (Trench Limits)
.. PROFILE AS-BUILT
1"=10'
Municipality ,of Anchorage
Building Safely D~vlston
6/7/2 O01
P.O. Ih>x 1,c~i~50 · 4700 S. Bragaw Street
Anchorage, Alaska !~,)519-C~0 * (!X)7) ~3-8801
h 11 l~://www.cl.tmchor~lgc.ak.u.~
Public Works
Bethard Construction Inc.
12801 Reata Dr.
Anchorage AK
Subject:
Expired On-Site Water and/or Wastewater Permit.
Permit Number: SW000060,
Parcel ID: #011-122-11
Dear Bethard Construction Inc.:
An On-Site Water/Wastcwater Permit, number SW000060, issued by this office for a
single-family system, expired on April 13, 2001. This permit was valid for 365 calendar
days.
If this was a well permit and the well has been drilled, a well log must be sent to this
office for documentation of the installation and to close the permit.
If this permit was for a wastewater disposal system, an original as-built inspection report
must be sent to this office for review, approval and documentation. This as-built
inspection report must be signed by the licensed Professional Engineer who inspected the
installation of the system. As-built inspection reports are required to be submitted within
30 days of the completion of the system.
If no system was installed under this permit, and you arc still planning to install a well or
wastewater disposal system, a new permit must be obtained from this office. When
applying for a new permit, the fees are: $320.00 for a wastewater permit and $120.00 for
a well permit.
If you have any questions, please call this office at 343-7904.
Sincerely,
{Letters Sent 6/7/01 without copies being made, second printing for file copies}
James Cross, PE
Manager
On-Site Water and Wastewater Program
enc: Copy of permit
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Initial
Date Issued: Apr 13, 2000
Expiration Date: Apr 13, 2001
Permit Number: SW000060
Legal Description: KINCAID HEIGHTS LT 11
Design Engineer: 0014 Anderson Engineering
Owner Name: Bethard Construction, Inc.
Owner Address: 12801 Reata Dr.
Anchorage, AK 99502-
Parcel ID: 011-122-11
Site Address:
Lot Size: 67203 SQ. FT.
Total Bedrooms: 5 Permit Bedrooms: 5
This permit is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well
[] Water Storage
construction must be in accordance with:
1. The attached approved design.
2. ,NI requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to Apdl 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.
Issued By: ~
Date:'[-°
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524.
522-7773 522-6779 (FAX) ·
April6,2000 ' - · : '
Municipality of Anchorage -
Department of Health and Human Services
825 "L" Street
Anchorage, AK 99502-0650.
Subject:
'Lot 11, Kincaid Heights Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Expired Permit No. SW940225
Dear Onsite Services Engineer:
The owner of Lot 11, Kincaid Heights Subdivision intends to construct a five bedroom
home on the lot. A permit was issued in July of 1994 (SW940225) to construct a septic
system for a four bedroom home. We are'hereby requesting this permit be reissued for
a five bedroom home. The attached Site Plan and backup documentation shows the
location and configuration of the new septic system, The lot is currently served by the
Municipal Water System and no conflicts exist between the location of the pdmary and
alternate sites and the water service line
Th(~ backup documentation originally submitted is attached for your review. The
intention is to center the new absorption trench around Testhole No.' 1. This testhole
indicated sandy material which was silty to a depth of 7' below the surface and then
became very clean. The new absorption trench will be constructed in 3' of the silty
sand and 5' of the clean sand; The average application rate for the two layers is .725
resulting in a 65' long trench with and 8' effective depth..The total depth of the trench
will be 12' with the distribution lateral placed at 4' below the surface.
The lot surface slopes from SOuth to north at varying grades. The trench will be placed
perpendicular to .the slope as required by the Municipal:Ordinance. The existing
drainage pattern on the lot will be maintained through final development.
If the system-is COnstructed in accordance with .our design the following statements
apply:
The system, if constructed as designed, will have no adverse impact on the we'Iis
In the area or those to be ~:onstructed in the future. The lot Is currently served by
the Municipal Water System. -'
The s~;stem,' if constructed as designed, will have no adverse impact on existing'
septic systems in the area or those to be constructed in the future.
Lot 11, Kincaid Heights
'April 6, 2000
Page Two
Sincerely,
The system, if constructed as designed, will have no adverse impact on reserved
space, either surface or subsurface, on any lots located .in the area.
The system, if constructed as designed, will have no adverse impact on draina{]e'
patterns in the area. The current drainage pattern will be maintained.
Michael E. Anderson,'P.E.
Attachments
SITE PLAN
SCALE 1" = 50'
.'
LOT 11, KINCAID HEIGHTS SUBDIVISION
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Five Bedroom Home
Perc. Rate: 9 MinJInch
Application Rate: .725 GPDISF
Deep Trench System
1,500 Gallon Septic Tank
8' Dralnfield Rock
5 Bedrooms X 150 GPD / .725 GPD/SF = 1,035 SF of Absorption Area
1,035 SF/16 SF/ LF of Trench = 64.7 LF Trench Length
Therefore: Construct a Deep Absorption Trench System With One Lateral
65' in Length with 8' of Drainfield Rock Beneath the Distribution Pipe.
Distribution Pipe in Trench Placed at 4' Below the Original Ground
Surface. Total Depth to be 12' From Original Ground Surface. Mound Over
Trench to Provide a Minimum of 3' of Cover.
3.5I
.5'
,~ ... 4',0, ?:; ,'~ .,,~.
~...~~.~
NOTE:
Natural
Backfill
;extile~
Fabric
4" PVC Boles DQwn
Drainfield Rock
3:0'
TYPICAL DEEP TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away.
Provide 3' Cover Over Trench and 4' Over Tank or Insulate.
Maintain 10' Separation From Lot Line.
Maintain 10' Separation From Water Service Line.
Maintain 100' Separation From All Wells
.Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L' Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: [~;l'rl ~. ownship. Range, Section:
i i - ' ' ' ' SLOPE SITE
13- ".
14-
COMMENTS
WA~ GROUND WATER
ENCOUNTERED?
IF YES, ATWHAT -
DEPT.? f ' ,?
· E
Reading Dele Gross Net Depth to Net
Time Time Water
~1~,~ ~'''- ~"~f'/~:"1~ ~/~0
PERCOLATION RATE . ~ (m,nutes/incn) PERC HOLE DIAMETER
FTANO '~ FT
TEST RUN BETWEEN
UEI'AR1MENT OF HEALTII & HUMAN
so,cs COG -- .~.COC~O~ TEST
1EST tt~. ,lb
L~u^LUESCf,r. tmr~: KincaJ.d Rd. & In.gram SL. lownshlp, Ra,go. Soctlon:E 1/2 t{N 1/4 fl~ 1/4 SEC 9 T12N
.~eA ~,v)c~ tcno.rage, AK
I
4
6
9
I!
1:3.
14.
15.
4381 .E
II.
lB.
20.
I'OTAL UEPIII Ft.
--Slotted PVC )lonttor
lnstld. PenCOLAI~ONRAtE - '~'~'~ {mlnule~/tnch)PERCIIOLEDIAME1En . , 6"
COMMENTS Appltcat~.on R~.Le ~G~O/SF.. 35
PEn~Or~[DBY: A.~L.~U~[.~any, I.All~W. MurFtff C~n/frY~HATllnsI~STW~SP~nFOn~D~
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT11, KINCAID HEIGHTS SUBDIVISION
GENERAL:
The scope of this project includes the procurement and placement of a
new 1,500 gallon septic tank. It also includes the construction of one
new 65' long x 3' wide x 8' effective depth absorption trench at the
location shown on the attached Site Plan. The total depth from original
ground of the trenches will be 12' below ground, Mounding over the
trench may be required to provide a minimum of 3' of protective cover.
A minimum of 10' separation must be maintained from the water
service line on the lot to all components of the new septic system and
the reserve system.
Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations,
The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
Unless specifically agreed otherwise,' the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
pdor approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. The new 1,500 gallon septic tank must be procured from an approved
source and installed at the location shown on the plans.
A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. Ail standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
budal insulation.
· Lot 11, Kincaid Heights Subdivision
· April 6, 2000
. ~ Page 2 of 3
6. A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the trench shall be within 2" of level.
Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barder or geotextile fabric must be placed between the drainfleld
reck and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
Contractor shall vedfy the septic tank and drainfleld are a minimum
100' away from any pdvate water wells in the area, 150' from a Class
"C" Well or 200'.from any community well.
Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trenches to drain away.
A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall vedfy this condition pdor to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Femco, or equal).
Lot 11, Kincaid Heights Subdivision
· April 6, 2000
Page 3 of 3
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabdc, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as-built of the completed system.
Rick Mystrom,
Mayor
Mtmicipality of Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
July 6, 1995
Ross L. & Rebecca Clement
PO Box 221255
Anchorage, Alaska 99522 1255
Subject: Lot 11 Kincaid Heights Subdivision
Permit ~SW940225, PID ~011-122-11
The subject permit, issued July 6, 1994 by this office for a
single family well and/or on-site wastewater system, has
expired as of July 6, 1995.
A new permit must be obtained from this office for a well
and/or on-site wastewater system NOT installed by the
expiration date.
If you have drilled the well, a well log must be sent to
this office for documentation of the installation and to
close the permit.
If a licensed Professional Engineer has inspected the
installation of the on-site wastewater system, the original
as-built inspection report must be sent to this office for
review, approval and documentation. All inspection reports
must be submitted within 30 days of construction completion.
When applying for a new permit, the fees are: $320.00 for an
on-site wastewater permit; $120.00 for a well permit and
$440.00 for a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
Si~erely,
~;;aCmr~;geP~~7'~
On-site Services
enc:
Copy of Permit
cc: Anderson Engineering
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.0. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW940225
DESIGN ENGINEER:ANDERSON ENGINEERING
OWNER NAME:THORNLOW DON R & PAMELA G &
OWNER ADDRESS:6000 A STREET
ANCHORAGE, ALASKA 99518-1815
DATE ISSUED: 7/06/94
EXPIKATION DATE: 7/06/95
PARCEL ID:01112211
LEGAL DESCRIPTION: KINCAID HEIGHTS LT 11
LOT SIZE: 67203 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 (24 HOURS)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: ~ ~ ~
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
December 21, 1993
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Subject:
Lot 11, Kincaid Heights Subdivision
Septic System Design
Impacts to Adjacent Properties
Dear On Site Services Engineer:
The terrain of the subject lot slopes from south to north as shown on the
attached site plan with no drainage problems or surface water. The
drainage pattern will not be affected by the development of the lot. The
subdivision is served by the Municipal water system with no conflicts with
setback distances. If the system is constructed as designed the following
statements can be made:
The system, if constructed as designed, will have no adverse impact
on the wells currently in use or those to be constructed in the future
since the subdivision is served by the Municipal water system.
The system, if constructed as designed, will have no adverse impact
on existing septic systems in the area or those to be constructed in
the future.
o
The system, if constructed as designed, will have no adverse impact
on reserved space, either surface or subsurface, on any lots located in
the area.
The system, if constructed as designed, will have no adverse impact
on drainage patterns in the area.
Sincerely,
Michael E. Anderson, P.E.
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, ALASKA 99524
July 1, 1994
Municipality of Anchorage
Department of Heath & Human Services
825 "L" Street
Anchorage, AK 99502-0650
Attention: Dan Roth
Subject:
Lot 11, Kincaid Heights Subdivision
Septic System Design
Dear Dan:
Attached is the revised site plan and system design for the subject
lot. Following our conversation I modified the system to a single
lateral 75' in length. We are anticipating placing the effluent carrier
line from the septic tank in the same trench as the distribution line.
Hopefully, the elimination of the header pipe will lead to a more
even distribution of the effluent and a longer life for the drainage
trench. Please let me know if you have additional questions or
comments.
Sincerely,
Michael E. Anderson, P.E.
SHEET NO. OF
CHECKED BY. CATE
Lot 11, Kincaid Heights Subdivision
DESIGN FACTORS:
SYSTEM REQUIREMENTS:
Four Bedroom Home
Perc. Rate: 9 Min./Inch
Application Rate: .8 GPD/SF
Deep Trench System
1,250 Gallon Septic Tank
5' Drainfield Rock Under Pipe
4 Bdrms. X 150 GPD /.8 GPD/SF = 750 SF
750 SF / 10' SF/LF = 75' LF 5' of Drain Rock
Therefore: Construct a Deep Trench System with One Lateral Each
75' in Length. Line from Septic Tank may be placed in the same
trench as the lateral.
Alternate Site: Perc. Rate: 22 Min./Inch App. Rate .6 GPD/SF.
Construct Deep Trench System with Two Laterals Each 36 LF. Pipe
Set 2.5' Below Ground with 7' Gravel Beneath Pipe.
. Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG m PERCOLATION TEST
LEGAL DESCRtPTION: L~TI I. KIW Ip ..4~. ownship, Range, Section:
SLOPE SITE
5
6
7
9
10
11
12
13
14
16
17
18
19
20-
2
WAS GROUND WATER
ENCOUNTERED?
$
L
IF YES, AT WHAT
DEPTH? ~ 0
E
Monitoring? /~' Date:
COMMENTS
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ,~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN 7 FT AND ~!~ FT
· , · _,-?.:......A;
~,~] UEI' A~ ~ENI' OF HE~LTIt & HUMAN SEflVlC~,~4'~~
~ SOILS LOG -- PERCOLATION TEST '~,oG~'.. ~>4~.~x?~ ../~
IF YES, ~T WHAT
Depth te Waier ~[tef
No
I'(.)TAL DEPI)I Ft.
otted PVC Monitor
tld.
?LY"SgUD 'fL(. 0t~('~,f~ ll"S! nUN UE1WEEN ~
!.j_c_a..L.j on Ra La 'O, G GPO/SF.
Reserve Ar'e~ I~',9~O SF.
(mlnule~tlnch) PERC IIOLE DIAMETER __
'
AND .,~: ~r~---- FT
ii
_.0 ,
BY: _.A ,.__W.,_.. ~grfi k~..gompony.., ~ .A~.~, . MulrF-J ("t.-- C(~KI~'IK-Y IHAT TIllS ~ST WAS PERFOnMED IN
AC¢OtIf~Af/(~F. V,'I Itl At (. R'IA Il'. Al~l) MI.tt'iIOif'AI. (IIJI[I~L.I~IF$ IN EFFr-g! ON Tilts DALE, DATE: i~to,~,s~' ''/~ ! .o) o2~3~ .... .~
8HEETNO. OF.,.
CHECKED BY DATE
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..................~::. ~i=' .......... ~"~ ............. !.:.....:4...'; ............. ~ ......... %-: ........... ! ................ ] ................ /../.....i .......... L~:.....~.. : ~ ~ ~ ! . !.l~!/i.::.
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.... j"~,'":'i ':~:""!"?"::: .....
, "'"'"i ......... :'-~":"'~'"! .......... 7"?
..... :~...~ ........... ?...'~ ::. ::: ":"i77!'"::':'" :: ...... : ....... ! ~':' "
~ :..... · ~ i : i i.] .:, ......... ':: ......... ! .... 'i ~! 'F ..... :'"':': .... i':~:"":: i : ...... ....
~'"'i ......... i .............. :"~ ......... ?"'"'"': ...................... :??'"?:'"'~'":: :"'::' ?'?""i ...................... !': ; ................ i ........... -"-...- .......... i.----..~ ............ ~....
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....... ~.~...._:..~, ~ ....... ~ ....................... ~,.:...:.........:,~.....~__~.........~../ .........
~' .... :-'""i'.--.~..:.....n-.: ............... :.--:.: ........ ~ -? : ............... :~. :-- -~:.:..~ ? '
................ ~....:.-........l........~ .............. ~ ~ '- ...... .... ..... ~ "~ : ~ ........ !....L._~..~.
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: ..... .......... :..../ ............ :........_:.....:.........~..:,: ./.::....::?~~..
/' ~,': .... ~':"' ~. ' : .: ........ :..~~.~. ~.~.~__~i : : ~
- ./ ~.:~=.:,t,.
: · · ~'~i?~:,~i)';::"~:F,,..>~:....! ........... :... i ...... ......... ':. .... ..... ..:. .. / .:: :. : ~ : '
. .~ ~.~,.~.:~-..;.~:::~.,~.:~. ! : ; , - ~ ~ .. . . , ..
Lot 11, Kincaid ..Heights
DESIGN FACTORS:
Four Bedroom Home
Percolation Rate: 9 Min./Inch
Application Rate:. .8 GPD/SF
Subdivision
'SYSTEM REQUIREMENTS:
Deep Trench System
1,250 Gal. Septic Tank
5' Gravel Below Pipe
4 Bdrms. X 150 GPD /,.8 GPD/SF .= 750 SF '
750 SF / 10 SF/LF = ~75 LF, 5' of Drain Rock
Therefore: Construct Deep Trench System .with TWO Laterals Each
38 LF. Pipe Set 7' Below GrOund with 5' Gravel Beneath .Pipe.
Alternate Site: Perc. Rate: 22 Min;/Inch - App. Rate .6. GPD/SF
Construct Deep Trench System with Two Laterals Each 36 LF. Pipe
Set 2.5' Below Ground with 7' Gravel Beneath Pipe.
Anc~orso~
438'1 - E '
MUNICIPALITY OF ANCHORAGE
I
Development Services Department _ Phone: 907-343-7904
On -Site Water & Wastewater Section Fax: 907-343-7997
Certificate of On -Site Systems Approval
Parcel I.D. 011-122-11
1. GENERAL INFORMATION
Complete legal description KINCAID HEIGHTS LOT 11
Expiration Date: 02-0
Location (site address) 7920 INGRAM STREET, ANCHORAGE, AK 99502
Current property owner(s) ERIC STEENBURGH & MEGHAN STAPLETON Day phone
Mailing address
Real estate agent
7920 INGRAM STREET, ANCHORAGE, AK 99502
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Private Well
❑
Water Storage
❑
Community Well A
❑
Public Water System
Public Sewer
Waiver request for:
Received by:
5
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ SSU
Date of Payment 9:115/19
Receipt Number ,
COSA # (SSC [ R 13GZ
Day phone
TYPE OF WASTEWATER DISPOSAL:
Private Septic
Holding Tank
❑
Community
❑
Public Sewer
❑
Waiver Fee $
Date of Payment
Receipt Number.
Waiver #
Date:
Distance:
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, based
on procedures outlined in the Certificate of On -Site Systems 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm ANDERSON CONSTRUCTION & ENGINEERING Phone 345-3377
Address 4661 NATRONA DRIVE ANCHORAGE AK 99516
Engineer's Printed Name MICHAEL N. ANDERSON PE Date 07/12/2019
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices / methods. The assessment of the condition of the well and septic
*
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
QF AZ
Y'
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
••'"
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The life
operational of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
well and septic system. Therefore, any estimate of how long a system will function satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
discrepancies exist can be given by and Anderson Construction & Engineering.
MR
MICHAEL N. ANDERSON:
No. CE 9489
7/12/19 .•" 4'
......
6. DSD SIGNATURE
~'
SS100'
System #1 Approved for bedrooms
System #2 Approved for bedrooms
Disapproved
Conditional approval for bedrooms, with the following stipulations:
.IIko(((War.,_
By: '� `^ '�-- Original Certificate Date:
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist blue sheet
Legal Description: KINCAID HEIGHTS LOT 11 Parcel 1D: 011-122-11
If more than 1 septic system on lot: COSA Checklist # of
A. WELL DATA — PUBLIC WATER
❑ Well log is filed with Onsite (or attached)
Date drilled
Total depth _ft
Cased to _ft
❑ Sanitary seal is functioning correctly
❑ Wires are properly protected
Casing height (above ground) —in.—-."
Date of flow test for COS A-,-----,--,
�---- ` ,--
Static water Level' at beginning of test _ft.
B. TANK DATA — 5/16/2000
Age of tank(s) 19 years
Tank type/material SEPTIC / STEEL
Measured operating fluid level in septic tank 49"
® Standpipes/foundation cleanout per record drawing
Date of pumping 6/28/2019
Structure served by this system
Well production at time of test _gpm
Water storage tank volume_ gallons—
Well disinfected for coliform test? ❑ Yes ❑ No
❑ Coliform -bacteria is Negative
Nitrate _ mg/L EJNitrate less than MRL (ND)
Arsenic — ug/L ❑ Arsenic less than MRL (ND)
Collected by
Date of Sample
C. LIFT STATION - NA
❑ Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA — 65'L x 3'W x 8'ED — @.725 GPD/SF = 1040SF
Which system tested (date installed) 5/16/2000
® ALL standpipes present per record drawing
Total measured depth from grade 12 ft (max)
Measured depth to pipe invert from grade 3.4+ ft (min)
❑ N/A — pressurized field
® Monitor tubes go to bottom of effective. If not, state
depth into effective
® Code -required soil cover over field
❑ System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced _gallons
Comments/Deficiencies
COSA Checklist.docx
Adequacy test date 6/28/2019
Results E Pass For 5 bedrooms
Fluid depth prior to test 0 in
Water added 750 gal
New depth 21 in
Elapsed time 220 min
Final fluid depth 0 in
Absorption rate 750+ gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Is
E. SEPARATION DISTANCES
From PrivatfWell on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station of > 100'
® Yes
if No
Community Sewer Manhole/Cleanout > 10 '
Yes
if No
ft
s
if No
Neighboring Tank > 100' ® Yes
if
ft
Private Sewer/ ine > 25' ® Yes
if No
Absorption Field on Lot > 100' ® Yes
if No
ft
ing Tank > 100' ® Yes
if No
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal nment > 50' ® Yes
if No
if No
ft
Manure/Animal Excreta age > 100'
Community Sew in > 75' ® Yes
if No
ft
Yes
if No
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' ❑ Yes if No *5+ ft Wells on Adjacent Lots:
Property Line > 5' ® Yes if No ft Private Wells > 100' ® Yes if No
Absorption Field > 5' ® Yes if No ft Community
®
Water Main > 10' ® Yes if No ft > 200' Yes if No
Water Service Line > 10' Yes if No ft
If septic tank is under driveway comment below
®_
Surface Water > 100' ® Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
ft
ft
ft
ft
ft
Wells
ft
Building Foundation > 10'
® Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' ® Yes if No ft
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No ft
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
*Per MOA record docs.
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance
with MOA COSA guidelines in effect on this date.
COSA Checklist.docx
OF �L
49 TH
%MICHAEL N. ANDERSON.
No. CE 9469
.7/.1
F'ESSIO��
Municipality of AnChorage
Development Services Depsrtment
Building Safety Division
On-Site Water & Wastewater program
4700 Elmore Road
P.Oo Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE
FOR A
OF ON-SITE SYSTEMS APPROVAL
SINGLE FAMILY DWELLING
Parcel I.D. 011-122-11
1. GENERAL INFORMATION
COSA# 0~--II ~\~ ~
Expiration Date:
Complete legal description KINCAID HEIGHTS S/D; LOT 11
Location (site address) 7920 INGRAM STREET * ANCHORAGE, AK * 99502
Current Property owner(s) KENNETH ROOSA
Day phone 441-0507
Mailing address
7920 INGRAM STREET * ANCHORAGE, AK * 99502
Lending agency
Day phone
Mailing address
Real Estate Agent
~'.? "Mailing address
Unless otherwise: requested, COSA will be held by DSD for pickop.
2. NUMBER'O.F BEDROOMS: 5
KATHI JOHNSON W/ PRUDENTIAL Day phone 762-3123
3801 CENTERPOINT DRIVE, #200 * ANCHORAGE, AK * 99505
3. TYPE OF'WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well [] Individual On-site ·
Individual Water Storage [] Individual Holding tank []
Community Class Well [] Community On-site []
Public Water System · Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On-Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On-Site Systems 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 COSAs upon request to homeowners. Certificates of On-Site Systems
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are'valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECT!ON BY ENGINEER
As ce~ified by my seat affixed hereto and as of the vafidation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of Qn-Site Systems Approval Guidelines for this application,
shows that the on-.~ite 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 fu,fher verify that based on t,~e
information obtained from t,ffe Municipafity of Anchorage files and from my investigation and inspection,
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 GARNESS ENGINEERING GROUP, Ltd.
Phone 557-6179
Address 5701 E. TUDOR ROAD, SUITE I01 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, PoE.
Date
Engineer's Comments:
In conducting this evaluation, GEG, LtD. attempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC and MQA
DSD Guidelines & Regulations. The reported results described 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
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during 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 are no hidden defects or encroachments. GEG, LTD. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
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 party is not authorized, nor will it confer any legal right whatsoever.
DS~D S~I~ATURE ~
Approved for ,~) bedrooms.
Disapproved.
Conditional approval for
%.~/' CE~795'~' .."~
·
ON-SiTE_
·
bedrooms, with the following stipulations:
~.,uS~', ~.,h~cr, ho~
Septic System Advisory
Well Flow Advisory
x~r~',e ~dg~u~ y
(Rev. 11/05)
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www. muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
CHECKLIST
Legal Description:
WELL DATA
Well type
KINCAID HEIGHTS S/D; LOT 11
I PUBLIC WATER I
If A, B, or C provide PWSlD# ~
Parcel ID: 011-122-11
Well Log (Y/N)
Date completed
Total depth ~
.ft.
Date of test
Static water level
Well production
:::o::
Sanitary seal (Y/N) Wires properly protecte~.). J
Cased to ft. Casing he__round) in.
FROM WELL LOG AT I..bLSPECTION
.~~.p.m. g.p.m.
A~'s~nic: ~ ug./L. Date of sample:
Nitrate i mg./L. Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPTIC/STEEL
Tank size 1500 gal. Number of Compartments
Foundation cleanout (Y/N) YES
Date of pumping 8/6/10
C. ABSORPTION FIELD DATA
Date installed 5/16/2000
Length 65 ft.
2
Depression over tank (Y/N) NO
Pumper,
~*BEI,OW EXISTING GRADEI
Soil rating ~r ft2/bdrm).725
Width 5 .ft.
Date installed 5/'1 6//2000
Cleanouts (Y/N) YES
High water alarm (Y/N) -Y'EC"-"J~.~/~
NORTHLAND PUMPING
Total depth * 12.2 ft. Eft. absorption area 1040 ft2 Monitoring tube YES
Date of adequacy test 4/8/2011 Results (Pass/Fail) PASS
Fluid depth in absorption field before test 0 in. Water added 750 gal.
Elapsed Time: - min. Final fluid depth 0 in. Absorption rate >-'
Any rejuvenation treatment (past 12 mo.) (Y/N & type) NONE KNOWN
System type DEEP TRENCH
Gravel below pipe 8 .ft.
Depression over field NO
For 5 bedrooms
New depth 0 in.
750+ g.P.d.
If yes, give date -
D. LIFT STATION
Date installed
Size in gallons
Man hole/Access (Y.~.N_.) --
"Pump on" level at in. "Pump off" leve~igh water alarm level at
in.
Da~ J Cycles tested.
Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
I PUBLIC WATERI
Septic tank/lift station on lot
On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main ~ manhole/cleanout
Sewer_/se~ ------'"'-'~ Holding tank
Animal'C~ntainment areas. Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation '5'+ Property line 5'+
Absorption field
5'+
Water main i 0'+
Water service line *'10'+ Surface water
100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water service line ** 10'+ Surface water 100'+
Curtain drain NONE KNOWN Wells on adjacent lots 100'+
Water main 10'+
Driveway, parking/vehicle storage 10'+
F. COMMENTS
*PER 5/16/2000 INSPECTION REPORT. **PER MIKE ANDERSON
12/14/1993 SITE 'PLAN. SEE AI-rACHED.
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA COSA guidelines in effect on this
date.
Engineer's Printed Name JEFFREY A. GARNESS
Date
COSA Fee $
Date of Payment
Receipt Number
(Rev. 11/05)
Waiver Fee $
Date of Payment
Receipt Number
_ _ _ ~_,~0~.~ ~~~ ~,
., ~ ~ ~' ~ i I \
I
UNDER NO-CIR~MSTANC~$ SHOU~ AN AS-BUILT 8E USED F~R CONSTruCtOR OR FOR ~ABLI~HING $OUNOARY OR F~NCE UNE$.
~E SURfeR TAKES R[~PONSIBIE~ FOR ~E INI~AL TRANSACTOR O~Y AN~ A~$UMES FINANCIAL U~I~ ONLY FOR ~E cOST OF ~E ~UR~Y-
USeD OISTANCES FR~VAIL O~ SCA~NG. REFROOUC~ON MAY CAU~ E~OR$ IN ~CA~.
~ ~o~ ~ SURVEY TYPE SYMBOLS
RN~ 5~U~NE ~S-aU&T 0 FOUND REB~ ~ ~ ~ WOOD ~NC~ ~ CONC~
~TP~ . . . A~-~ILT.. , ~OT ~R~Y, , , ~HT ~ ASSUM~ E~V. ~ METAL ~NCE ~ WOOD DECK
~ A~OLJJLT... Ng 9nRNERs ~ ~ RE~'.RC~ ~-~uILT , , NO ~NE~ ~
'-PLOT PLANS ~ LOT SURVEYS NOT~:
IT IS THE RESPONSIBILITY OF THE BUlmER OR OWNS, PRIOR TO ONLY THO~E IMPROVEMENT~ ABOVE GROUND AND VISIaLE WILL
CONSTRUCTION, TO ~RIFY PROPOSED BUILDING GRADE RELA~ SHO~. FENCES. ~LL$, SEPAL C~ANOUTS, SIDEWAYS, DRIVEWAYS.
TO RNISHED GRADE ANO U~LITY cONNEC~QN5 AND TO DE.RHINE ETC., ARE SHOWH IN THEIR APPROXIMA~ LOCATION. ONLY. SNOW
~E EXIS~NCE OF ANY EASEMENTS. COVENAN~ OR E~TRIC~ON$ MAY PRE~NT SOME IMPROVEMEN~ FROM BEINC ~EEN AND
WHICH DO NOT APPEAR ON ~E RECOROED SUBDIVISION P~AT. A~L DISTANCES ARE RECORD UNLESS OTHERWISE NOTED.
P~epored ~
SURVEY CERTIFICAT~0N
,~ ~[ ~'~. Robert E. Johns, r. ~ Assoc
, h~, ~lf, ~.,I ~. ~', ~ ...' ..........~ee Profession al Lan dSurveyors
h~ ~ ~ ~ ~ 01 ms I.~ ~. ANCHORA~, A~A ~9504
FOUNDA~ON AS-BUILT "" Ch*eked ~WL
-~-" .... ~"-' ~ /, o ' o.,~ ~,.-.: 4122/11 2222 11-74
FIN~ 5~UC~RE AS-~UILT Legal De=¢iptlon:
-e.: ~ .... :--:_..~%$' LOT 11 KINCAID HEIGHTS
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION'
Complete legal description ~-O~'- tO ~' ~NCA~
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency
Mailing address
Day phone
Agent Day phc ne
Address
=
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ...
- . ;\X -
TyPE OF WASTEWATER DISPOSAL: :.7 .
NOTE:
Individual on-site
H°lding- tank ''
Community on-site
.... - ~, .; - ~ .... ~:.,
· '¢4 ~,.,/
"?' 7" ' '
Public sewer ? ' ' 77: .,,' ,,",-
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
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 ~s in compliance with all Municipal and State codes,
ordinances, and regulations n effect on the date of this inspection.
Address
Engineer's signature
Phone
Date
,DHHS SIGNATURE
/~ Approved for d
Disapproved.
Conditional approval for
bedrooms.
bed rooms,
with the following stipulations:
Additional Comments
.-- r : . \.;.; -,
.3.;,,'
i.'i.The M~Jh'fCi~lity of ArC,borage Department of Health and Human Services (DHHS) issues Health Authority
Approval C~ificates~b~sed only upon the representations given ~n paragraph 5 above by an independent
professiopal engin'.e~r.registered in the State of Alaska. The DHHS does th is as a courtesy to purchasers of homes
and the r i~hding institutions in order to satisflj certain federal and state requirements. Employees of DHHS do not
conduct i'ri§~e'btions 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. 1/91) Back MOAii~l
Legal Description:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 * Anchorage, Alaska 99501-(907)343-4744 "^t
Health Authority Approval Checklist
It2/ Vl~4d-ai~ ~t~t&l-J:l-'~ ParcelI.D.:
IfA, B. or C, attach ADEC letter. ADEC water s
· ,j~.?lctpalay oi ~,~cr~orage
~2~)Health & Human
~Ek.rt ................. darvioe8
number
Date completed
Cased to
height (above ground)
properly protected (Y/N)
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed ~'~0/q/v
Foundation cleanout (Y/N)
Date of Pumping I'//l~-
Tank size /;9_o¢a-O Number of Compartments e¢~ Cleanouts (Y/N)
Depression (Y/N) ~ High water alarm (Y/N)
Pumper r-J/~_ ~ b40 '[" '[Z ~' Igor' l CZ ~--D ~
Co
ABSORPTION FIELD DATA
Date installed g/~O ]~'t fi, Soil rating (g.p.d./fi2 er-4CCodI'~)
Length ~0 I Width ~ I Gravel thickness below pipe
Effective absorption area 7,~t9H L Monitoring Tube present(Y/N) y
Date of adequacy test lq I F4- Results (Pass/Fail) ~
Fluid depth in absorption field before test (in.); ~'/ hnmediately after
Fhfid depth ~ (ins.) Minutes later: ~
Peroxide treatment (past 12 months) (Y/N)
I~ ,¢_ System type 'Tr e ~ c ~t
7, c~, i Total depth ~ O ~
Depression over field (Y/N) iQ
For ~-' bedrooms
~gal. water added (in.): o'~
g.p.d.
Absorption rate =
~ If yes, give dae~
LIFT STATION
Date installed
Manhole/Access (Y/N)
Size itl gallons
"Pump on" level at*
"Pmnp off" level al*
High water alarm level at*
*Datum
Cycles tested
mo
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: b'~ O ~
Septic/holding tank 011 lot : Ou adjacent lots
Absorption field ou lot
: On adjacent lots
Public sewer main
Public sewer inanhole/cleanout
Sewer/septic service line
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundatiou ~ Property lille ,~--)tD Absorption field
Water main/service line ~Ot Surface water/drainage b~Ov~ ~ Wells oil adjacent lots
Building foundatioo
Surface water
Curtain drain
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Ix.I o
['x,~ o vi ~_ Wells on adjacent lots
Water lnain/service lille "~ ~ ]
Driveway, parking/vehicle storage area ] ~
~'-]0 ~ ~-- Property line
I
ENGINEER'S CERTIFICATION '
! certify that I have determined thrufield inspections and review of Municipal record~~ that'the aboge ,~vgtems are
in conJbrmance with MOA H,,M guidelines in effect on this date.
HAA Fee $ ~(DID ~ (DO Waiver Fee $
Date of Pay.lent
Receipt Number
Date of Payment __
Receipt Number
Rev. 8/95 OSS: haa.wk.doc