HomeMy WebLinkAboutNORTH WOODS UNIT 4 BLK 15 LT 3Northwoods
Block 15
Lot 3
#051-064-10
Municipality of Anchorage Page J of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~Su~';iHOO'/-/ PID Number:
Name:
~Av~C) ~ LO~TT~ ~US4H~D~ Wastewater System: ~ New ~ Upgrade
Address:
~.o.~o~ ~o~ c~, A~. ~ ABSORPTION FIELD
Phone:
~'H~ ~No, of Bedrooms:~ D Deep Trench D Shallow Trench ~Bed DMound ~Other
LEGAL DESCRIPTION soi~ Rating: Total Depth from original grade:
O. ~ GPD/Sq. Ft.
Lot: ~ Block: t ~ Subdiv~ion: Depth to pipe bottom from originai grade: Gravel depth beneath pipe
Township: ~ Range: ~ Section: Fill added above original grade: Gravel length:
~~ - -~ ~ '~ ~t. ~ ~ ~t.
WELL:~ New ~ Upgrad~ Gravel width: Number of lines: Distance between lines:
{ ~ Ft. ~ ~ Ft.
Classification (Private, A,B,C): ~ Cased To: Total absorption area: Pipe material:
~O~ CT~ ~ Ft. Ft. ~OO SO. Ft. ~/~
Driller: ~ Date Drilled: StaticWater Level: Installer: ~ Co~%T, Date installed:
~'Y~GPM J Pump Set at: Ft. Casing Height Above Ground:Ft. TANK
SEPARATION DISTANCES ~s~ ~ Ho~ding ~ S.T.~.~.
To Septic Absorption Lift Holding Public/Private Manufacturer: Capacityin gallons:
From Tank Field Station Tank Sewer Lines ~CHO~A ~
Surface
w~t~ ~oo~ ~oo ~ LIFT STATION
LineL°t ~o~ ~/ ~ ~ ~ Size in gallons: Manufacturer:
Foundation ~' I0' ~ ~ -- "~ump°n"l°velat: ~°lat: I~'~nwat°ralarmat:
GurtainDrain ~ ~ ~ ~ ~ ~ ~ ,, ~loetr~cal Inspoefions porformod
Remarks: ~ ~ ~-~ ~o~ BENCH MARK
Location and Description:
~0~ ~o~-no~ ~ ~- A~ ~A~A~
~ ~O~, ~ Assumed Elevation:
ENGINEER'S SEAL
17034 Eagle Ri~er Loop Road No. 2~
Inspections performe~ River, Alaska ~95~ Dates: 1st. ~- ~ - E~
2nd
Department of Health~Huma~ces approval ~ c~,sso]
72-013 (Rev. 9/91) MOA 25
Permit No,
SW940077 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
NORTH WOODS UNIT 4 BLOCK 15, LOT 5 05106410
Legal Description: PID No.:
i col ~o~
......................................... i ............. iii ...............
/ SEPTIC
/TANK il 91,3'~--~
il 8713'
· 82. i' WATER FOU~D 4-6-94-
A B
FCO 16' 42'
C01 15' 45'
-'602 ........... 19 ........... "zl:8' .....
CO3 21 ' 49'
C04 22' 50'
C05 13' 57'
MT1 14' 65'
C06 47' 58'
· .M-:I:-2 ........ 52~.... "'"4'6-'-'-
C07 5.5' 75'
CO3 i:
C02
1' = 40'
72-013 A (1/93) *
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW940077
DESIGN ENGINEER:DAVID R. DAYTON, P.E.
OWNER NAME:NEUSCHWANDER DAVID & LORETTA
OWNER ADDRESS: PO BOX 671305 CHUGIAK, AK 99567
DATE ISSUED: 4/18/94
EXPIRATION DATE: 4/18/95
PARCEL ID:05106410
LEGAL DESCRIPTION: NORTH WOODS UNIT IV BLK 15 LT
3
LOT SIZE: 23983 (SQ. FT.)
~ER OF BEDROOMS: 3 THIS PERMIT: 3
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 ALASRA 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 OR 343-4681 AFTER BUSINESS 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:
THE ORGANICS AND ~LT ~ST BE EXCAVATED WITH THE BED
INSTALLED ON THE TOp OF THE GM STRATUM. T_HE WIDTH oF THE
B,~ NOT ~CEF. D i5 F~.~_~ THE Di~ENSiON OF THE~BED iS
DAYTON, P.E., R.L.S.
~ Chugiak, Alaska 99567
20210 Donalar
(907) ~
696-2417
Lot 3, Block 15, Northwoods Subdivision, Unit #4
The proposed septic system Will se:
by a Public Water System.
The lot slopes from South to North
side.
As the subdivision is on a Public
of the well are extremely remote.
There will be no significant impa¢ on waste water systems on adjoining
properties or on drainage or reserved s~ces.
we a 3 bedroom home on a lot served
with the system located on the West
Iater system the chances of any contamination
David R. Dayton P~..
20210 Donalar St.
PERFORMED FOR:
LEGAL DESCRIPTION:
7
8
9
10
12
14
15
t6
17
18
19
20
COMMENTS
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG m PERCOLATION TEST
t~'r--I~', JlJo~L-1,~4:~o~ Township, Range, Section:
WAS GROUND WATER
ENCOUNTERED?
SLOPE SITE PLAN
IF YES, AT WHAT
~ ~,~ ~-tt, DEPTH?
~,/~
Monitoring? Dale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE ~ ~ {minutes/inchi PERC HOLE DIAMETER
TEST RUN BETWEEN .. ~ FT AND ~-~ FT
ACCORDANCE
WITH
ALL
STATE
AND
MUNICIPAL
~U,DEL,NES,. E~ECT O. ~.,'S ~*~. ~*~: .... ~/X~..':.~
72-008 (Rev. 4/~) . ~ / . v. · · . -
PERFORMED FOR:
LEGAL DESCRIPTION: L~T:~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
6
7
8
9
10
11
12
13
14
15
16
17
18-
2O
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
liepth to Waler Aller
MonitorinD? /O' Date:
SLOPE SITE PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
/ ,~,~ //~-~ ~ ~'"' -- / ~ i ~"
5 //~ /Z~ ~ ~'- /~ ~,,
I
PERCOLATION RATE _ ~' (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ' / FT AND ~'' FT
PERFOR~I'E~) BY:
· , , , A CERTIFY THAT?t~'S Td~T WA~'I~I~RFORMEO IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN Ei~FECT ON THIS
72-008 (Rev. 4/85)
Municipality of Anchorage •
On-Site Water and Wastewater Program '
t - (907) 343-7904
Sar [ r r
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel LD. 051-064-10 Expiration Date: 52-2 0 -i -g--)
1. GENERAL INFORMATION
Complete legal description North Woods Unit 4 Block 15 Lot 3
Location (site address) 21950 Sheltering Spruce Loop, Chugiak, AK
Current Property owner(s) Boomgaard Day phone 688-7826
Mailing address same
Real Estate Agent Day phone
61891077
2. TYPE OF DWELLING: �`'� A
® Single Family (w/wo ADU)
❑ Duplex E AUG i ZG17 'i'd
❑ Multiple Dwellings (Single Family and/or Duplex) jti
3. NUMBER'OF BEDROOMS: 3 �b or 6 s L g
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual
Individual Water Storage ❑ Holding Tank ❑
Community Class C Well ❑ Community ❑
Public Water System ® Public Sewer ❑
Received by: c Date: 7/43/4 7
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 524p Date:
Date of Payment 'j3 t 1 I Date of Payment
Receipt Number 0553/D Receipt Number
COSA# aYt 1103 Waiver#
S. 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.
Name of Firm NorthRim Engineering Phone 694-7028
Address PO Box 770724, Eagle River
Engineer's Printed Name Steve Eng Date 8/30/2017...
. 1"Ialki
6. DSD SIGNATURE,
t '.'.
System #1 Approved for bedrooms. ;
/ cf^YCn 4'S�. t-t1C • filer
•
System #2 Approved for bedrooms. `v r ='-/ te7 T-,,
i•.
Disapproved. `�i��' �• -/•'' 4.�
Conditional approval for bedrooms, with the following stipulations:'
ok016‘40,&!ii
•
ON-SITE
WATER AND
sem' WASTEWATER o
.cam PROGRAM
--(o
By: Original Certificate Date: % -/ 3 -17
The Municipality of Anchorage Devlopment 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 ActisdrC
Well Flow Advisory Other • _ .
COSA blue sheet 9.1.12.doc .
D. LIFT STATION 4,
Date installed Size in gallons Manhole/Access (YIN)
"Pump on" level at in. "Pump off" level at in. High water alarm level at in.
Datum Cycles tested Meets alarm&circuit requirements?
E. SEPARATION DISTANCES
WELL ON LOT TO: pL)RL/C- 4J/VT Ef2-
Septic tank/lift station on lot On adjacent lots
Absorption field on lot On adjacent lots
Public sewer main Public sewer manhole/cleanout
Sewer/septic service line Holding tank
Animal containment areas Manure/animal excrete storage areas
SEPTIC/HOLDING TANK ON LOT TO:
Building foundation r'tProperty line /Q r7 Absorption field /C>
E
Water main /Qr� Water service line /Q �' Surface water /Qa
Wells on adjacent lots f
ABSORPTION FIELD ON LOT TO:
Property line ! '� /G/Building foundation � f Water main /0 r'
Water Service line /Q (74. Surface water 46 ('f' Driveway, parking/vehicle storage
-7-
Curtain
Curtain drain Urt//L Wells on adjacent lots /04 (4-
F.
tF. COMMENTS
G. ENGINEER'S CERTIFICATION 'r 4, i
k 41 1 certify that 1 have determined through field inspections and ,t- 4�
review of Municipal records that the above systems are in Y,.
conformance with MOA COSA guidelines in effect on this date. ;„,•
Engineer's Printed NameS ��=vri(/� :'c
x/31117
Date / ?�
f •
COSA yellow sheet_2-6-15.doc
If more than 1 septic system is on the lot:
COSA Checklist# of
Structure served by this system
Certificate of On Site Systems Approval! CheckU6st
Legal Description: /VOr 8/S 43 Parcel I D:C d Cgl/O
A. WELL DATA P(119-1C-- wi4Te
Well type If A, B, or C provide PWSID# • Well Log (Y/N)
Date completed Sanitary seal (Y/N) Wires properly protected (Y/N)
Total depth ft. Cased to ft. Casing height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 mL Nitrate mg/L
Arsenic ug/L Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SEPrr 2 IS 7—E" Date installed x/7,9¢
Tank size/cVC gal. Number of Compartments a Cleanouts (Y/N) '"7/,, /
Foundation cleanout(Y/N) A Depression over tank (Y/N) 4/ High water alarm (Y/N) �V
Date of pumping 30 ...17 Pumper
C. ABSORPTION FIELD DATA
Date installed cP/7/451 Soil rating (g.p.d./ft2 or ft2/bdrm) S System type ach
Length 'C.S ft. Width /5 ft. Gravel below pipe 0.S. ft.
Total depth .5 ft. Eff. absorption area?OO ft2 Monitoring tube y Depression over field A/
Date of adequacy test.6,4O// 7 Results (Pass/Fail) P For bedrooms
Fluid depth in absorption field before test 3 in. Water added L(.6'G gal. New depth .5 in.
Elapsed Time: Ei 6 min. Final fluid depth 3 in. / Absorption rate >_ 17/..5-0 g.p.d.
Any rejuvenation treatment(past 12 mo.) (Y/N &type) /V If yes, give date
Municipality of Anchorage
Development Services Department
Building Safety Division .~~~;
On-Site Water and Wastewater Program '~"
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. OcJ/'- O~,?' -/O
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
HAA# Oq
Expiration Date:
· Current Property owner(s)
Mailing address' ,'
Lending agency~
Mailing address
Day phone
Day phone
Real Estate Agent
Day phone
Mailing Address ..
Un/ess otherwise requested, HAA wi//be held by DSD for pickup.
NUMBER OF BEDROOMS:
e
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
COmmunity Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding tank []
[] Community On-site []
[~ Public Sewer [] -
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the,representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer of ..............
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon reguest to homeowners. Certificates of Health Authority Approval are
valid for 90-day~'fr0h~"{he 'dat~; of J~'~;U-~-f0F-p-F0-~'~i~"S'~-~-e-d"~y a P~:i~;~t~ 6~ Cl~S'~-C ~velJ 'a'n~f'may; be ~-~iss-u(~d ~vi~h .....
new water sample results. (certificates may be reissued for a period of up to one year-with validwater.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 F_~C-L.~ ~VE~ ~'~/~-~JE=~ ~J6-
Address I /')~1~3..I t/~C=lA) I~..~. : .~c~ /-/- E ~ I
Engineer's Printed Name 'C~f-~5/-'z~f>/~ P--. ~
DSD SIGNATURE
' ~ Approved for
Disapproved.
Conditional approval for
Phone Gq~- cJIc/S'
Date'
bedrooms.
bedrooms, with the following stipulations:
¥
........
CHRISTOPHER R. WOOD
..........
Additional Comments'
Attachments:
HAA Checklist
' Septic System Advisory
Well .Flow.Advisory.
X
Maintenance Agreements . -
Supplemental Engineer's.Report
Other
B .'----~~>~---' '~/:'"-~~ ................ Odginal'Certificate' DateF-"-:c~'---; '-S'=-~)-'Z7~'''-
(Rev. 01/02)
Legal!es!
'MuniciPality of Anchorage
Development Services Department
Building Safety Division
: On-Site Water & Wastewater prOgram
' '! ' · . 4700 South BragawSt. '
~" P.O. Box 196650 Anchorage, AK 99519-6650
,. , . www.ci.anchorage.ak.us :~
Ii ' ' ~ (907) 343-7904
HEALTH AUTHORITY ARPROVAL CHECKLIST
.Par(J(~i ID: o~/-.o(¢~/- tO
A. WELL~DA~ :, . . ~- · . ~
Well t~'l~e~', ,'~'."~Z.4 C_ ' .If A, B.or C provide PWSIDi'# ". '. Well Lo~ i(Y/N)
Date completed_ m ' : ; · Sanitary seal (Y/N) '.. ' : Wires properly pr6tected (Y/N) ·
Totaldepth,, ~: 'ft.. · :. Casedto.~, - ft. I ,' :., ;:Casing height (above ground)
; ]I ii . FROM~WELLLOG -:', . : .i i ; . ':AT INSPECTION · ~
uateoftest f~ .,: .. . ~ , . . ' i . * ;! .... . . [. ~
Stabc water level : .... ~,ft. · .. , ;, I,,, ft.
Well producbon
: WATER SAMPLE RESULTS:
C i: colonies/100 mi.
Arsenic:
-, ~:ig.p.m.
Nitra!?i_
'mg./I.
mg./I.
6fsampl :~'t
Other bacteri;
Collected,bY:
g.p.m.
in.
colonies/100 mi.
LIFT STATION
Date installed
"Pump on" level at
Datum~
in.
Size in gallons
"Pump~
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
'.Septic tahk/lift Station on lot
i Manhole/A~ ,
High water alarm level at ;'
Meets alarm & circuit requirements? .
~ . ' '- .On adjacent lots ~:: ' ,
Absorption field on lot ' ~0~
Public sewer main ' ~ _.-..---.--'"'"~~r manhole/cleanout /
Sewe,~ ~ Holding tank ' '~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foUndation ~ ! ' Property line 4-- Ior Absorption field
Water main +' .~ ~' Water service line +lC) t Surface water ~'l°O ,,
Wells on adjacent lots ~/c'Ot
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 'J-lO ~ Building foundation '/'/O /
Water Service line +-I0/' ' ~ Surface water '/' IC~ ~
Curtain drain /'d'ot,~.- ~-.z~, · Wells on adjacent lots "f'~c,o !
in.
Water main ..t-- i0,/:
Driveway, parking/vehicle
F. COMMENTS
G. ENGINEE, R'S CERTIFICA'i;ION -- ' '
I certif that/hav~ determined ,hrouh field in'spections and
Y g
review of Municipal records that the above systems are'in
conformance with MOA HAA guidelines in effect on this'date.
' Engineer's Printed Name
. .
Date ~/~(/~ · ':.'~ ' ' .'' '
Date of Payment
Receipt Number
(Rev. 12101)
-Waiver Fee $
Date of Payment, ·
Receipt Number
11:29
1234567
907~941211
:i
JD~CHRISTY MECHEM
$ ~ND $ ED~IDEERING
PAGE
PAGE
~.um' Z
BULL]'
l~llml' "]~l/~{~l I Ill J/~] ~ I I-o. ,~:,:. l .... I 0{{'~ ~O' ' I Ip~('L6 iwclio. -
Municipality of Anchorage
Development SerVices Department
· . . Building Safety Division...
On-Site ,Water and Wastewater Progran~ '
· · ,. 4700 South Bragaw St.
P~O. Box 196650 Anchorage, AK 995t9-6650 ' ' ':
www.cLanchorage.ak.u{.
(907) 343-7904
· ·CERTIFICATE OF HEALTH AUTHORITY APPROV/ ,L
OR A'SINGLE,FAMILY DWELLING
Parcel I.D:~.-~ I-
Expiration Date:
1. GENERAL IN'FORMATION
ocatlon (site address or d~rectlons) c~ J
Current Properly OWner(s) PP__~.Er' ~ ,,.J [(t~c,1 x.].O/1 rl.SOr') Day phone
Day
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone.
Unless otherwise toques!ed, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: , ~
3. TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage []
Community Class Well []
Public Water System []
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of AJaska. Cedif~cates o[ 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 lo 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 ere valid for one year for properties served by Class A or B wells or a public
water system. The I~,~unicipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
1%0. l~ox 113Z~, I::ag~e l, Uver~iag~. ~)57~-.~1Z~
Name of Firm
Address
Engi~'ee~'s Pdnted N~me (..D~5 '~, ~,)UJ(-~/3.. ! ~ Date
~ ' Approved for ,' ~ bedrooms. . Disapproved.
Conditional approval for bedrooms, with the foltowing stipul~tions:
o,
4. STATEMENT OF INSPECTION BY ENGINEER 'f , ,
As certified by my seal affixed hereto and 'as of the validation date shown betow, I verify that my investigation,
based on procedures outlined In the Health'Auth0rity 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 insta~lation.
5. DSD SIGNATURE
Additional Comments
By:
Attachments:
HAA Checklist
Septic System Advisory _
Well Flow Advisory _
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: g, -. / ~ ~9 /
Municipality of Anchorage
Development Services Department
Bui~diog Safety Division
On.-~lta Water & Westewator Program
4700 South Bragaw St.'
P.O. Box 196650 Anchorage, AK 99519-6650
www.cLancflorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalOesoriptfon:/Votfhwood~ ~,;+ Iv Z 3' ?3'/~.- : PorcellO: {~5'1- 0~- l0
WELL DATA /~0 we Il' -/~6,/,~* ,~,/~-~
IfA, B, or C provide PWSID #
Well Log (Y/N)
Sanltmy seal (Y/N)
Wires properly protected (Y/N)
__ft. Cased to.__
FROM WELL LOG
Casing height (above ground)
AT INSPECTION
In.
Date
Static water ft. ft.
Well production
g.p.m.
g.p.m.
WATER SAMPLE
Coliform
Nilmta mg.fl. Other bacteria __
colonies/lO0 mi.
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material ~*J'ee. I
Tank size ~ gal.
Foundation cieanout ~N) ~Y
Date of pumping ~'/'.2 ~, J 01
Number of Compartments .~
. Depression over tank (Y~) ..
Pumper j ~
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
C. ABSORPTION FIELD DATA
Datainstalleq 9'*'7-'~'e Soilrattng (g.p.d./t~or~/bdrm)
Length ~'3'/ It. Width I~' / ft. Gravel below pipe
Totaldepth ~,~ ft. Eff. absorption area '~O0 · Monitoring tube Ye..<
Date of adequacy test .,¢/.2 3/o ~ Results (Pass/Fall) /'e..~ ·
Fluid depth in absorption field before test I't in. Water addedardd gal.
Elapsed Time: t~'., min. Final fluid depth ~ in. Absorption rate >=
Any rejuvenation treat~nent (past 12 mo.) (Y/N & type)
__ Depression over field
For ~ bedrooms
New depth I~'
in.
If yes, give date
g.p.d.
STATION
installedI S~e in gallons
on" level at In. "Pump off' levet at in.
. Cydes tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Se~c tank/lift station on lot
Absd~tion field on lot
Public~6~ewer main ~
Sewer/s~pfl(= service line
Manhole/Access (Y/N)
High water alarm level al
Meets alum1 & circuit req~rements?
t(
On adja~nt Iota. $/~
On adjacent lots "--
Public sewer manhole/cJeanout
Holding tank ~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~' Property ine ..-3 $ ' Absorption field
Water main '~'/(~ / Water sewice line ¥-/o Surface water
Wells on adjacent ote. ~//~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Propen'y line ~ I~ / Building foundation / ¥1 Water main
Water Service line -~/~ ' Surface water f-,~,~ ' D~veway, parking/vehicle storage
Cudain drain a ~J k',v,~,,v Wells on adjacent lots -flf~ ·
F. COMMENTS
G. ENGINEER'S CERTIFICATION
con~an~ ~ MOA H~ guidelines ~ effed on ~ date.
HAA Fee $
Date of Payment
Receipt Number
(R~. 1~)
Waiver Fee $
Date of Payment
Receipt Number