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HomeMy WebLinkAboutMEADOW RIDGE ESTATES NORTH ADD TR BM ado.; I idg Estates No th #051-531-01 Department of Hearth a~d ~uma~ Services 825 Street P,O. Box ~96650 Anchorage AI~ska 995!9~6650 Novembez 13~ 11995 Johne S susar~ M Rurtz 23025 !p-~mdra Rose Avenue Ch~agiak~ Alaska 99567 5664 S~lbil}ect~ Tract B Headew Ridge ~istlees North Addition Permit {~S~9~0%30~ PID {}051~53! 01 issued November 10~ 199a by hals siRgie faml. iy we~ 10 1995~ expired as of November A new p(rmih mus{z he obtained frem this effice Eot a weal and/ex on~ite wa tewa~er system NOT installed by the expirati o~ da~e~ If Ye~l have drilled the wetl] ~ a w !~I leg mus'h be servh to thks of ice fer doc~amen%atien ef the ~sshat. tatcien and ~o clese hhe permib~ til a licensed Profe sional ~%;sgineer }~as inspeceed ehe iRs%ailatien o~ the on-site was{ewater sy hem~ the original as~bui3t inspection report mus't be senh to this office for review~ appreval and decumestatien Ail inspectie~ reports muse be s~bmithed wihRin 30 aays of constrecfsion completier~, ~.~;h the fees ar~} $320,00 ~{er an ~eer~ ar~plw~ng fox; a n ~ a~90 00 fox a wel~- permie we} ~ permit on~ ~he waseewa{e- ~{l ,-n s' te wastewaher an llf you Nave any que hhoRs~ ptea~e cell this office ah Cross~ P-~ gram Manager On-site Services enc~ Cepy ef permit cc~ S & S ~ngi~eering PAGE t OF 1 HUNIC._PALIP¥ 0F AN(iORAGE P~O~ BOX 196650~ 825 ~t }~pRIi, RT. NO()M 502 ~NCHO~A~E~ ALASKA ~9 19 66~0 ON SITE WASTEWATER i) IS Ot{A~ oYolEM ([t]iGRI~N) PERMIT DATE I~SJEI):11/10/94 EX]?tI~ATION DATE /1 PAR(Eib ID:051 i3]01 ZEGAh DESCRIPTION; H~P{Ii)OW RIDGE ES!APEo NO ADDN T R B S[ZIi,: 61015 (.~Q ) ~ ' '~ tHIS PP, RHIP~ 3 }~U~I!3RR OP BEDROOMS: ~, PHIS PERMIT IlS FOR THE CONtRi}(TION (}P: DISPOSAN FIELD /SEPTIC TANK SYS~LM , ~C(,ORIIAN( ~ ~LL CONSTRUC%ION P(UST BE tN '~ ~,~ WITH THE ATTACHED APPROVED DESIGN ALL REQUtREHENTS SPECIFII{~D IN ANCHORAGE HUNICIPAL CODE CHAPTERS 15~55 i.U~D t5~65 I~-{D 'I'HE STATE OF /LLASKA WASTEWATER DISPOSAL RSGULATIONS (18~L072) AN} DRINKING ~A'FNR NNG'ItLATIONS {18AACS0) ~ T!t~?, ENGtNEEN MUST NOTIFY DHHS AT LEAST 2 HO~IRS PRIOR TO EACH i[NSPEO'iPi ON PROVtDR NOFIPICATION B~ CALiI~ING 3%3 4744 (24 HO~JRS) PROM OCTOBER I5 TO APRIL 15 A SIIli~SURPACE SOIL ABSORPTION SYSTEM UNDItR CONSTRUCTION DURING FREEZING WEATHER MVST NE EITH IR: A~ OPENED AND CLOSED ON THE SAME D~Y B~ COVNRBI). SEAl,ED ~LNID HEATSD TO PREVENT FREEZING THE PO~,LOWtNG SPEOIAY.~ PROVISIONS DATH: ROGER S 4At: ER CiVil, ENGINEER) FAX 694-~2 I SEWER M^IN E× IENSIONS WELL INSPEG f & FLOW 1ES $OiLfESi Sox 196650 Anchorage~ AK 99519 REFERE~CE~ Tra~t B; Meadow Ridge Estates A test hole was ~cava~ed and a ~e. rcola4~on test pep~fo~med approx, imate local,.on o~ the t. e2,t hole ~ lo~zated on the a~;ta~,he.d site plan~ he. mo~itorin9 &~be wiJhi~, the test hole. ~as be~en chg~ked and We rgque.st that the: gun~ei~oality of Ancho~lage ~rant a w~ver ~or ~oot ho~izont~ sep~ation ob~.sta~ce ~rom the ehan~e in s~ope~ grea)se~ than ~5% to the proposed p,~e~sorizeZ distrLbu~on dr~n~ieZds~ A~ached is the proposesd de~i~n Ibis prope;~t¢ 5s served by a (omrmo,ii~:y Water System Ibis F~rope~ty has enow~h are~ ~or a ~;ure se;otic ~p~}rade. w~eh can seen on th~ attached site ;olan~ A test hole. is to be e~x(~v~X:ed gshe ~5mg of cm~:O~u~l~o~ t~ vg~d~g the soi~ and ground water a~5 th~5 ~Zte4 natg site~ We~ do g~ot ar~l?L(~pate any adverse e~ec~ on neighbori:tB p~oper~5 by the insta~la~%on of~ the proposed se. p4~c syst~m~ ~lhere. a*~ no protee4~ve, well ~adii which en~.oach upon the I~he i;x~oposed I~50 gallon S~,E~P~ is to be ~:~laced ot~4~lde. s~gface wate;~ protex~.ue s~rtback~ Al~ached is a site p~an wZ~.ch depicts the l~ eax~.on of 4he proposed I~ you ~.~v~ any que. s~ion,~, or r~quire ad(~g;~ona~ r~forma~on ~or your rev~ex~', p~ec;~se (o~,4ae~; us~ ROtERT C~ (0WM% P E~ 17034 NORiH EAGLE RIVER i~OOr' ~ SUllE 204 ~ EAGLE t;tlVER, ALASKA 99577 ( · :':, ?, / , I 'l~ NVId 3LIS ~ ~09 :~ ~ FOR: t~A 1 E 1 ownship~ Range, Section; 3 SFtE PLAN 7 Ef'~CQUNTEf El)? F YES, AT WHAT DEPTH I3 t4 20 D¢op PERCOLATION R^'t f .. (nlinutes/lachi ItERC ~iOLE DIAMEI ER .._~ 'I ESl RUN Bi::1 WEEN f'l AND 'I ~' ~ El .~8~.,.~ i THAi ?HIS TEST WAS PERFORMED iN PERFOBMED ACCOR©ANCE Wt'I H AL.[. S'~ATE Al'cD MUNICiPAl, GUtDELIN~S N EFt EC'~ ON ~H~S DATE. DAT: ~2-008 (Rev 4/85) ON SITE ~?d~TEWA'~E~ DIS~SA£ SYSTEM CO~STRUCTIO~ P~CTICES MAI ERIAL S?ECIFICATION£ REFERENCE: Fra~ $; M~adow Ridge Estates lhe s~opc of t~ projc<~; ino~des the installati~n o~ a 1250 g~lon septic tank e~tue~t pumicing ~S ~.E~P.~ syst~ axed X~o F~ress~'ize~ d~ib~on dr~.n~ields to set, ye th~. proposed thre~ bedroom residence io~;~ated on th~ re~ere, nc~.d property ~he exx~sting wate;r ?x. ne ~;nxw. ng a~ross the referenced prop~rty ,'.s to be ex~uvated and ~ts vertigO, and hori~ont~ posi2X, on vv~if i~d so that the proposed pressure distrd bu~;~' o~ dr~x'~n~iel~;~ may be ~nst~l~d wdth a ruling, mum o~ ~ separation ds~s~nc~ in accordance w~th the; M~O~A~ csdr~ Constrsction shall be in accordance with t~e approved s~**te ptan and des~gn dr~ngs~ Munirzip~ perm~ w~th any spe~ p~ovision~ or conditions ~ and a£X ap~li~able S2ate and Manici.~ Waste~ater D~?~posal Re~u.6a~ons~ ?he contractor sha2.~ be rrrsponsibI~e fo~ obtaining a~y n~.cessary underground uti~,ty loc~te~ Unless specifically agreed otherwise~ the property owner shall be responsible ~or fdn~'i grading are~ subsequengZy depressed ~rom soil set~%n~ On al~8 l~ach~i~g.d mound ~ystems~ the proper~y OWne~L sha~6~ be responsible for ens~in~ vege~tion growth o~er the mounded area~ Contra~:ors i~'~talling wastewater disF~osal syste, ms m~t be ce~.fied by the~ Mux~.~cipal ~ealth D~part:me. nt ~o~ syste~ insg~lla4~ons Own~*~s installing their own sys4em~ m~t also ~u~c~xve. p~ior approvo~8 ~rom the Mu~r~X~pa~f~ ~ealth Department~ septic tank is to be co,~structed by a c~?,~%.~ied se;~¢~c tank manafa,~urer *?o~.,st,u~tion shatX include ~**~o 4*~ cleano,~s ~. the. septi~ tank she,.ll be. suffi,~ently bedded to preven>; se4X~Xng or s~'~.ft.~.ng o~ t~e l:~nk~ Fra~t ~; M~x~dow Ridg~ Estate~ S~¥~temb~ 30, ~994 A~t~ s~andpipes on th~ septic ~:ank sha.$~ ~×tend a minXm~m of I~~ ineh~ ab~v~ final ~rade S~¥~X~c tan~s i~talled w~h les~ than 4~ o~ COV~L shall be dnsulated~ A ~oundat~on e~eanout sha~l ~ i~ta~ed one to ~our ~eg~ ~rom the b~ldin~ ~ound~on In th~ ine between the tank and the leach~i~d there sha~ be two adjacent ~X'~eanoa~ ~u~te~s an efflue~ /~m?ing syst~m exis~ within th~ ~e~tic ~ank~ Fhese ~leanou~ shale be located on undisturbed soi~~ not more than I~~ ~rom the tan~ in ~ine~ shat~ ~ to ~ean tow~d the leachfi~Id~ ~he s~a/~ be to olean toward the sep~X~c tank~ Final g~ading over the se~ tank shall be s~ tha~ a ~osil~v~ slo?e exis;t~ away ~rom th~ s~pt~x tank~ ~ESS~IZED ~RAINFIELD SYS~E~ INSTAL£ATIO~: I~ ~IW~ drainfi~!~ trench~z~ are to be e~cavated in accordan~te wi~h the s~:,e~fieaZ~ons on th~ des~gn~ 2~ l~he bottom o~ the basa~~ ~e~ area as we~l as the to? o~ the s~e~ ~ock ds to be within ~(~ inch~ o~ 3~ Fhe dist~c~batZon ?i?ing ~s to be of PVC [AS'~M D3034 or equo~)~ All jo .n~s ar~ to be solvent 4 Fhe ,~id~ slopes o~ the top Laye~ of th~ mound system must not b~ than 33% ~3 I)~ 5 '~he to? o~ the mound sha~l ~e covered w~Zh a minZmum of 6 inches topsoZ~ and ve~etat~d su~io~ently to preve~ 6~ ~lhe distribution piffles a~e to be ~bedded in s~er roche Car~ sho~d be take~ to bauk~Z~t in su~:~h a way ~ to ~re~vent damage to the system~ 7~ Silt bar~ mat~ae mu~t be dnstall~ be~een the fi,~l grave~ lay~r and the naZ~ve so~ back~ie~ E~ure th~ si~Z barrier covers the ~nti~e 8~ Backfill over the ~in~Z gravel t~ayer mu~t not be t~s than twenty~four ~24) ~nc~es In~ueatlon mus~: b~. inst~l~.d when th~ back~ill de?~:h is l~e~ss than thirty~six ~36) inches Tract ~'3~ Me~dow Ridge Septemb~J~ 30 ~994 ~l~41gU~ ~E~IA~ SP£CIFICAIiO~S: Any septic tan~ ?ropose~d ~or inst~l(~Xo~'t m~t be co~tract~d by a Municipally approved sep4~_c tan~ Fh~ ~oi~.owirig pip~ mat~s are approved ~o~ use dn septic sys;~m ~sta~ia;~Xo~ in the MunXcipality o~ Anchorage~ Solid ASTM D3034 IPVC) Yes ASTM D~662 {ABS) Yes IIse of a type of pipe othex~ than ~.sted above mus~ b~z. approved by the inspecting en~J neer~ Insu~'.ation shal~ b~. at t~ast ~ th,~ck ~.xd~ud~d direct b~ial {Dow Ch,~x~ic~'. Cam?any Styro~o~,i ~'I s*~ aquae}, ~(aalde~, F~.rnco~ or A 9e~x~eabla no~oxic ~ilt ba~rl~r (Typar 340~, Miaa~l ~40/~ o~ eqa~) must be 6.~,~tai~d b~tween the ~i~,~8 leachfield graveF, lay%'~, and the AIl le~cbfi~d ~rave~ [sewe~ rook) sb~.~' be 0~5' 2~5' scrgene, d ~rave~ w~th l~sss thor, 3% pass,{ng the #~'00 si~v~5~ When s~nd is beinB used us ~ filter m~rial~ its spee.~.~icat~o~'l~ must co~,i~orm to cu~re~,~t' !~,0,A, or D,E~C req~remer~?;s~ I~SPECi~ IONS: ~ypL~2~y ~:h~.,.r~ wtZ.~ be~ a m~nim~,~ o~ three~ { ) ~nap~+c~ions r~q~.~r~d du:~ing the ir~ta~la~on of the wast~/~ter disposal syste~m~ hose lnspecX~o~, J ;he ~[.rsZ lnspecJion must be conducted after the gz~2~vation pitS, 4~'~ench~s, or be~ and b~fo~e :lh~ instxllation o~ any ~rave~L A sep~c ;tanJ~ may be Set in ~la~te~ but may not be bac~i~ted before t~  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 PHONE ~W LEGAL B"SCRIPTION .......... ~ ~ ~%~ ~L~ '~.~ ~ NO. OF BEDROOMS PERMIT NO, Well ~/~ Absorption a~ea Dwelling /~ / DISTANCE TO: ~ M~(, ~ Materia~~ No, of co rtm~nts Liq, capacity in gallons Inside length Width Liquid depth ldO) IF HOMEMADE: ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO. O 2', ~ Manufacturer Material Liquid capacity in gallons ~-'~ - Distance lines ~ No, of linest Length offside Total le~ ~ines Trench~ ,/ ' inches ~ between ~ ~ ~ Top of tile to finish grade // Material 6eneath tile Total effective absorption area ~ ~~ '' ~Z 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 ~ot Hne PERMIT NO. ~ Building foundation Sewer line Septic tank ; Absorption area(s) ~ DISTANCE TO: OTHER PIPE~ERIALS ~ SOIL TEST RATING INSTALLER/rl/~ %~' ~-- REMARKS~ ~r~; Russell L. Oyster t ,~ ~%~ APPROVED DATE LEGAL PERMIT N0. I""ILIN I C I ~ qL I T',.r' OF i:ll'-,mc:H"-'F;::R(~iE DEF'ARTMENT t., HEALTH AND ENVIRONMENTAL . ,OTECTION 825 '"L" STREET, ANCHORAGE, AK. 2G4-47~0 Cm~--S ITE SEP4ER PERtl I 'T < 7804~-b: > APPLICANT KEN WERT SR BOX ii05 CHUGIRK 99567 688-2t1~ LOCATION HOMESTEAD ROAD LEGAL N ADD TRB Si/2 Si/2SWl/4 SEC2 LOT SIZE 326?0 SQUARE FEET TYPE OF SOIL 8BSORBTION SYSTEM IS: TRENCH MAXIMUM NUMBER OF BEDROOMS SOIL RATING THE REQUIRED SIZE OF THE SOIL 8BSORF'TION SYSTEM IS: &~EF'TH= 8 LENGTH= 4-:~ 8RA~/EL DEF'TH= 6 THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE GROUND 8ND THE BOTTOM OF THE E×CGVATION <IN FEET>. THERE IS NO SET WIDTH FOR TRENCHES. THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFRLL PIPE AND THE BOTTOM OF THE EXCAVATION <IN FEET>, REQId IRED SEPT I m2 TA~k;: SIZE= 1E4¢~0 FdRL.,_LIZmf4S PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SERVE. TWm3 42> I N_~.PEC:TI Cm~l.S ARE REm~IJIRE[: BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL. BM THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN A WELL AND AN~ ON-SITE SEWAGE DISPOSAL SYSTEM IS 100 FEET FOR A PRIVATE WELLJ OR 250 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL.. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS 8RE AVAILABLE TO INSURE PROPER INSTALLATION. F-ERtl IT E>IPIRES DEC:EMBER I CERTIFY THAT l: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELL~S AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE S~STEM IN ACCORDANCE WITH THE CODES. ~: I UNDERSTAND THAT THE ON-SITE SEWER S~STEM MG~ REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS. APPLICANT KEN WERT ~ O ~ E GED. ,:CHNICAL ~ DEVEL_PMENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694-2774 SOIL LOG r~8-228o Soils ~ Foundations Land Development Performed for: Name: Mai ltng Address Legal Description: Sol] ~haractertstlcs Depth (feet) /~z,4,,d 9 10 11 12 ~5 ~6 Ground Water Encountered: Yes__ No Proposed Installation: Seepage Pit '~"~,,~";~ Comments: ~)~<:~-'~z.~ ,o1: c~,,-~7,~/ .. Munic a of,.A..nc rage,, ip lity Development Servi~:e~'Departm'ent ',"' :""' .... ..... U ~)1[ w [ nu wa tewa~ r ug~amBUildlng Safety Division .' ~n..~.,e,, ,a,er a_-., ,, ,:s,~.;.:.,er ,-,r ...._~_ _. ...... . 4700 South Bragaw St.". ..... ..... - : ... 'P'.O. Box1966~0 AhChb~'J~g~,AK;99519-6650." "' '"" · ,,.,,,,. -,v o----'''~'.''l.an''h;'ranea~.i~'.-' . ... ,.. - "'""' "': .... r,'. CERT FICATE OF HEALTH AU O I.'r~':AP~P.,R6V~,L ....... FOR A SINGLE Par }~- - 31-01 . ,.,":~"""~.. -. , -.- Expiration D~tei ' --71. 1.-': GENERAL INFORMATION ' '~-Complete legal description .Iraet B,: 'l. lead~r R~.dge~ l~'states ,lq'or~h".^dd~.t].on ~ .L.~ti~o,n. (eit~ addres~ or directions) 24916 'Homestead 'R'o'ad Cu. rrent~ropedy~wner{s) 5ohn & Susan l(urt~ Dayphone 24916 Homes read "Road ;."Chu~.i ak. Day phone "~:. Mailing J~ddress' Lending agency Mailing address · 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER ~UPPLY: Individual Well Individual Water Storage Community Class Public Water System ..................... Day phone ......... Real Estate Agent tv1'aili~ Address Unlesso,hervd~erequested, HAAwi/lb~be~dl~yD$b'~;pickb~.'-~J~-~ ?/,/o1 TYPE OF WASTEWATER DISPOSAL: ] Individual On-site [] Individual Holding tank [] Well [] 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 propedles 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 aid. (Cedificates 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 outiined in the Health Auth0rib/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 he:~ein. I further'verify that b~sed on the information obtained from the Municipal[b/ of Anchorage files and from my tnv.estigatibn and inspection, the on-site water supply and/or wastewater disposal system Is(are) in compliar{ce With all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm Address , ~ 4 F..a~lle River Loo~ Road Ne, 204 · ...-,~:~ River, Alaska ~577 Engineer's Printed Name Robert C. Cowan~ 5. DSD SIGNATURE "' / Approve.allot. 9 bedr. og.m.i. Disapproved. .. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: "~' .-~ - O/ Municipality of Anchorage Development Services Department Building Safety Dlvlsio~ On-Site Water & Westewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 (SO?) 343-79O4 HEALTH AUTHORITY ApPRovAL CHECKLIST A. WELL DATA Legal Description: ' ~ . Parcel ID: Date completed Total depth Well type _~/~ / ~ ~ ~ B, or C p~e ~SlD ~ ~ ~ seal ~) ~ ff. ~ed ~ ~ ~OM ~~ ' Data of test Static water level / ft. Well production /// g.p.m. WATER SAMPLE ~JLTS: Coliform ,//~onies/100 mi. Nitrate Date Of sampl~ Collected by: B.'*SEPT]C/H~31,4~RG'TANK DATA Tank size'_/Og~) ' gal.:" Number Of Compartments..~ Foundation clea~out (Y/N)~_~ Depression over tank (YIN)/"%/O Data.pUmping: ~,/~-~f/O / Pumper 'Tank Type/Material 05- ) -.¢'7 I-o I Well Log (Y/N) Wires pmpedy protected (Y/N) Casing height (above ground) AT INSPECTION Other bacteria g.p.m. colonies/100 mi. Date installed ~ ~'_~ Cleanouts (Y/N) ~ High water alarm (Y/N) /~///~- C. ABSORPTION'FIELD DATA r~ Length ~ ft. Width ~ ft. Gravel below pipe Total depth 10 ft. Eft. absorption area ~'/'& ft2 Mor~itering tube ~ Depression over field ./%/ Date of adequacy test'~ Results (Pass/Fail) ~ Fluid depth in absorption' I ~'field before test ~1' ~. Water added~)~' gal. Elapsed Time: ~ min. Final fluid depth ~'~ in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) For y bedrooms New depth Yb'- in. J./.t'"' O g.p.d. -"/~/~ - If yes, give date D. LIFT STATION ~ ~S Date installed , ize in gallons 'Pump on' level at~ in. 'Pump off" level et __ in. Datum /' Cycles tested E. SEPARATION DISTANCES ~,~,~,~U~,~, / ~=~ ~'~o,- ~ SEPARATION DISTANCES FROM WELL ON LOT TO: Manhole/A_,~e__ss (Y/N) High water alarm level et Meets alarm & circuit requirements? Septic tank/lift station on lot Absorption field on lot Public sewer main On adjacent lots On adjacent lots Public sewer manhole/cleanout Property line Water Bervice line Curtain drain Sewer/septic service line Holding tank SEPARATION DISTANCES FROM SEPTIC/HI31d~G TANK ON LOT TO: Building foundation ~- t.~. Property line ~"~' Water main / ~ ' 'f Water sen, ice line / O /~- Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation / ~) '/- su cewatsr / on adjacent lots WeUs / F. COMMENTS Absorption field ~' /~' Surface water / ~ ~' Water main aweway, par no/ve , e =rage / G. ENGINEER'S CERTIFICA'FION ..~,,<. ~., ................ · : ' .../ ~ I certffy thet l have determlned through field inspect/ons and ~ ~,~ : .... ~ ~ ~. ~ conformance with MOA HAA guidelines in effect on thls date. ~ ~ ~ Engineer's Printed Name Ri~ ~,,,(~'- ~'. ~d/~,/,~ ~'~f~fi~'~l"~2~ ....... . vain .... ' - ' ~I "~" ............ ,x¥'-'~ HAA Fee $ ~00. Date of Payment Receipt Number (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF A~NCHOPAGE DIVISION OF ~%%/iRONMENTAL HE,~YLTH. DEPA~.[ME~Ff OF [tEALTH ~ID F>)VIR@~MENTAL P~)TECTION APPLICATION FOR HEALTH AL~i].{£)RITY APPROVAL CE~]7IFICATE t. Ger:eral Inforn~tion Application Date_ ~/~ ?/~>'~ .... (a) l~.~gal Description (inclu_d¢l~ lot,/block, subdivisicn~ ?~3ction~ tcwnship, range ) Lo~tion, (ad~ess~r directions) .... ~ . Buyer ~ , Other ~ (e~lain); (e) }%~ai Estate Co. a Agent Address 're lephone _T~_. _of. Res idence Single-Family ~ Nu~he~ of Bedr¢~ms Water Supply Individual Well Multi-Family Other (clescv:ibe) Note: If cc~nunity well system, must have written confirmation frown the State Depa~tm~F~t of EnvirorF~ental Conservation attesting tc the legalit'f and ~tatus. Is the well adequate for the n~nber of bedrocms specified in this HAA~_(~/N~ ~ ~wag~e Dis~x~sal Onsite ~ Public [.-_.--:'[ Community !::: Holding Tank ~ Is the wastewater disposal s~stem adequate rcm the n~m~ber of b,~drccms [Page 1 of 2] 2-15-84 5. E_~9~lineerinq Firm Providing Inspections, Tests, Data and Information I certify tha~.~..'i[-"Na~ c~cked, %erified~ or conforn~d to all MOA HAA Guidelines in S igne~>~~ ....... Da to .~~-~_ ~ Natre, ~f/Firm Telephone d'~?~/,- ~ ~>~ ~ Address Signed by Date ENGINEER SF~XL) 6. DHEP Approval Approved for, Appr ov~ed ~: Disapproved ~-~ Ccnditionai~-~j~ Temrs of Conditional Approval The Municipality of Anchorage Department of ~a].th and Environmental Protection does not guarantee the continued satisfactory .~erformance of the water supply and/or the ~astewater dislw~sal system. This approval indicates that, as of t~ validation d,%te shown above, ba~d on the data and information furnished ky an engiDeer registered in the State of Alaska, the water supply and wastewater disposal system is safe and ticnal for the nDmber of bedrocks and type of structure indicated. (DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [P~.~ 2 of 2] 2-15-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well~ Classification Well~LogP~esent (Y/N) Total Depth Static Water Level Cased to Casing Height Above Ground / / Sanitary Seal on Casing (Y/N) EleCtrical Wiring in Conduit (Y/N)I~ / / Depression A~ound Wellhead~ .(.Y/N) sepa~ati°nDistances f~c~lWell:/'V / //~ _ To Septic/Holding Tank on Lot / / (/?~joining Lots To Nearest Edge of Absorption ~eld on ~ / }m~; ~%=(~.~. Adjoining Lots.__ To Nearest Public Sewer Line / ~' To Nearest Public Sewer Cleanout/Manhole______ p Nearest Sewer Service Line on Lot Water Sample Collected By ~ ; Date Water Sample Test Results Cc~Tents SEPTIC/~ TANK [~TA StandPipes ~' ~Air-tight Cap~/(Y~/~) Founda~ioD Cleanout ~P~ession o~ Ta~ (~')) ~te ~~d ~l,~ P~ing/~intenan~ ~n~ct ~ ~i~e/(Y~/~' ; foz ~ ~ Holding Ta~ HiGh-Wate~ ~a~ (~)/~' "~a~y Holdi~ Tank Petit (~~ ~p~ation Distan~s ~ ~pti~olding Tank: To Water-Supply ~11 , ~/~ TO ~ilding Foundation To Water Main/Service Line "~C~ 2~-'~ Comments To Stream, Pond, Lake, c~ Major D~ainage [Page 1 of 2] '~c~7~ ~