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Home My WebLink AboutOLSON HEIGHTS BLK 2 LT 2Olson Heights Block 2 Lot 2 #018-231-16 Municipality of Anchorage Page 3. of 3 Department of Health and Human Services Division of Environmental Services Or,Site SenAces Section 825 'L' Sb'eet Room 502 P.O. Box 196650 A~c:ho~age. AK 99519~650 www.ci.anchorage.ak.us (907) :343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Number: SW~010160 PID Number. 018-231-16 Permit "'~: Wastewater System: New [~ Upgrade Clinton C. Pearson 4250 E. 135th Ave. Anch. AK 99516 ABSORPTION FIELD 522-7773 Three (3) o o,~,~ LEGAL DESCRIPTION 1.2 c,o~e 6 n. 2 2 Olson Heights 4 I n. 75 Ft. Well: " 5 FL Existing n. ,. 535 ~e ASTM D3034 PVC ~, Acreage~_ ems 6/7,8/01 SEPARATION DISTANCES ~ Septic ri Holding n $.T.E.P. D Other. , _~,,,,~To Septic Abs<xptior Lift Holding ~blic/Priva~e Tank Field Station Tank Se~,U,e Rnchorage Tank 1,000 wa >100' >100' N/A N/A >25' Steel Two (2) s~.~w,,, >100' >100' N/A N/A ~ / LIFT STATION- NONE ON LOT u~ >5' >lO' N/A N/A ~ BENCH MARK E~istlng Septic Tank and Absorption Trench Abandoned. Septic Tank Pumped, Crushed and Concrete Slab at Base of Front Porch Steps. Backfilled On Site. 200.0 · EngirLee~'& ~tamp 49T. Inspections performed by: MEA Dates: 1 Department of Health and Human Services approval P.~'. cE-43s1 ..~.~.- Permit Number $W010160 EAST 135u' AVENUE " C3 · Page 2 of 3 PID No. 018-231-16 ~ell S2 A B S1 18.7 41.1 S2 27.0 42.2 C2 32.2 44.1 C3 106.1 104.0 M1 ~ 74.5 76.5 'PLAN AS-BUILT SCALE 1" = 30' 10' Utility Easement - CE 4381 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DMSION P.O. Box 196650 -Anchorage, AK 99519-6650 -343-4744 On-Site Wastewater Disposal System or Well Inspection Report Page 3 of 3 Pem~it Number SW010160 PID No. 018-231-16 100.4 Geotext/le 95.2 Drainfield * : · '.*'" Fabric Rock 92.9 95..2 43.3 86.0 31.7 ..... ,' Municipality of ~chorage Pedo~ For: Oyn2mic Prooeflies Date Legal Description: Lot 2. Block 2. Olsen Subdivision SLOPE North OGIOL GW Well Graded Gravel with Sand 2 3 4 11 Tighter South Was Groundwater Encountered? Yes If Yes, What Depth? 12' Depth to Water After Monitoring Date: 12 14 Bottom of Hole 15 16 17 18 SITE PLAN See Site Plan S L O P E Reading )ate Gross Net Depth To Net 'ime Time Water Drop 1 6/7101 12:15 1' 2 12:25 10 Dry 7.5" 3 12:26 1' 4 12:36 10 Dry 7.5" 5 12:37 1' 6 12:47 10 Dry 7.5" 21 Pero. Rate: 1.3 Min./Inch Pero. Hole Diameter: 8" Test Run Between 4 Ft. and 5 Ft. Comments: Testhole Presoaked Prior to Percolation Test. Same Material as Test Hole No. 1 Performed By: Mike Anderson. I, M~b,~E-~3~[P,J:~ Certify That This Test Was Performed In Accordance With All State and Municipal Guidelines In Effect On This Date: 6/12101 MUNICIPALITY OF ANCHORAGE Development Sen/ices Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Jun 04, 2001 Expiration Date: Jun 04, 2002 Permit Number: SW010160 :Legal Description: OLSON HEIGHTS BLK 2 LT 2 Design Engineer: 0014 Anderson Engineering Owner Name: CLINTON C. PEARSON Owner Address: 4250 EAST 135TH AVENUE ANCHORAGE, AK 99516- Parcel ID: 018-231-16 Site Address: 004250 135TH AVE E Lot Size: 49500 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: [] Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage Ail construction must be in accordance with: 1. The attached approved design. 2. Ail 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 DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 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. Date: 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.a nchorage.ak.us (907) 343-7904 ON-SITE SEWEPJVVELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 018-231-16 Permit Number SWO I0 1 g 0 Property owner(s) Clinton C. Pearson Mailing address (1) P.O. Box 225 Huntingtownt MD 20639 ~ address (2) 4 2,5-0 E/~$T /,~,5''r-'~ Jqu~,~'u£ Zip Code Legal description (Lot, Block & Sub'd.) Lot 2, Block 2, OlsOn Heights Subdivision Legal description (Section, Township & Range) Lot Size?~..~..~~Acre~l~) Number of Bedrooms Four {4) Day phone 522.7773 THIS APPLICATION IS FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub Swimming Pool Therapy Pool [] Well Only [-I [] Water Storage [] Jacuzzi Water Softening Unit I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00) Waiver Fees: Date of Payment: Receipt Number: ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 (FAX) ~ May 24, 2001 Municipality of Anchorage Development Services Department On-Site Water and Wastewater Program 4700 South Bragaw Street Anchorage, AK 99519-6650 Subject: Lot 2, Block 2, Olson Heights Subdivision Septic System Design and Permit Application Impacts to Adjacent Properties Dear Onsite Services Engineer:. The existing absorption trench on Lot 2, Block 2, Olson Heights Subdivision has failed and must be replaced. We are t.he.refore applying for a permit to construct a new septic system on the lot to serve the exIsting fo?r-bedroom home. The attached Site. Plan and backup documentation identify the location and configuration of the new septic system and the parameters used in the design. It also shows the location of the existing septic system, which was constructed in 1980. We anticipate the existing septic tank is unsuitable for continued use and it will be removed from the site. Also identified on the plans are the location of the test hole and the neighboring wells. Existing drainage patterns are shown and will not be altered by the development of the lot. We have surveyed the area and the new system will not conflict with wells already in existence in the area. A test hole was recently placed on the lot to determine subsurface conditions. Soils were found to be fairly well graded gravels with varying amounts of sand. Percolation tests in the material indicated rates approximating 1.2 minutes per inch. Groundwater was found during the excavation at the 12' level and maintained that level during the monitoring period. We are therefore proposing to place an absorption trench 50' long by 5' wide with a 4' effective depth to treat the septic effluent. The distribution pipe will be placed at 4' to meet the service line exiting the house. The ground surface on the lot slopes as shown on the attached Site Plan with grades from east to west, which flattens in the area of the new absorption trench. The new absorption trench will be constructed parallel to the contours of the surface as much as possible In conformance with Municipal requirements. Grading will be accomplished to assure surface drainage is away from the new trench. The existing drainage pattern on the lot will not be affected during development. If the system is constructed in accordance with our design the following statements apply: t. The system, if constructed as designed, will have no adverse impact on the wells Lot 2, Block 2, Olson Subdivision May 24, 2001 Page Two in the area or those to be constructed in the future. 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. The system, if constructed as designed, will have no adverse impact on reserve 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. The current drainage pattern will be maintained. Sincerely, Michael E. Anderson, P.E. Attachments /1\ -,,. ',1 [ " ' I N ~i~L- ~ ,, THIS PROJECT ~c :..~'L :%. · T ' ' I t4 / X -.. CE ... ,7 '*,+2'.. ' ' ....L4%- AREA MAP' SCALE 1" = 100' EAST 135~ AVENUE SCOPE OF WORK: Existing Well 1. Verify Foundation CleanouL 2. Remove and Dispose Existing Septic Tank. 3. Abandon Existing Trench in Accordance With · ADEC Requirements. 4. Place New 1,250 Gallon Septic Tank. 5. Place 2 Post Tank Cleanouts.. 6. Construct New 50' Long X 5' Wide X 4' Effective Depth Absorption Trench. 6. Regrade All Disturbed Areas. 7, Reve etate Ama As Required. Four Bedroom House 50' Lonq x 5' Wide x 4' Effective Depth Eon Trench Existing Absol Trench SITE PLAN ./~ SCALE 1" = 30' 10' Utility Easement ~move Exis~ ·ace New 1 Septic Ti ,tion Ta LOT 2, BLOCK 2, OLSEN HEIGHTS SUBDIVISION DESIGN FACTORS: SYSTEM REQUIREMENTS: Four Bedroom Home Perc. Rate: 1.2 MinJInch Application Rate: 1.2 GPDISF 5' Wide Trench System 1,250 Gallon Septic Tank 4' Drainfield Rock 4 Bedrooms X 150 GPD 1 1.2 GPDISF = 500 SF of Absorption Area 500 SFI5 LF (Width)*.5 (Red. Factor) = 50 LF Trench Length Therefore: Construct a 50' Long X 5' Wide X 4' Effective Depth Absorption Trench. F ow ne Elevation in Trench to be 4' Below Original Ground Surface. Total ,,Depth to be 8' Below Existing Ground. Mound Over Trenches to Provide Minimum of 3 of Cover or Provide 2" of Direct Bury Insulation· · Natural : ''. Backfill '" .Geotextil~ .. . ',. ' J ' .Fabric. ralnfield ~'" Perforate~ · PVC (Slots Down) .', Rock '. .... $ ".~. . : . :.' ...... 5'0" ' "" NOTE: TYPICAL WIDE TRENCH SECTION (NO SCALE) Grade Area Over Trench to Drain Away. Minimum e' Separation From Bedrock. _~,~ ,~. .......~..~ Minimum 10' Separation From Lot Line. .~,~... ~ .;-'..[ .., Minimum 4' Separation From Groundwater. ,,., C,). --....." . ? ~,,, Minlmum 100' Separation From Well. ........ Munlclpah~ of ~cho~ge n~n~ n~ ~,h ~ Human Sewices 825 L S~t, ~cho~ge, AK 99502~650 SO,LS LO - E CO ,ON EST Pe~o~ Fort Dynamic Pro~die~ Date Legal Description: Lot 2. Block 2. Oisen Subdivision ~LOPE North 4 OGIOL GW Well Graded Gravel with Sand 5 South Was Groundwater Encountered? Yes S If Yes. What Depth? 12' L O 1 Depth to Water After Monitoring 12' P 11 Tighter Date: 5/24/01 E 13 14 Bottom of Hole 16 17 18 SITE PLAN 21 See Site Plan Reading )ate Gross Net Depth To Net Time Time Vater Drop I 5117/01 4:15 1" 2 4:25 10 Dry 8.125' 3 4:26 1' 4 4:36 10 Dry 8.125" 5 4:37 1' 6 4:47 10 Dry 8.125" Perc. Rate: 1.2 Min./Inch Perc. Hole Diameter: 8" Test Run Between 5 Ft. and 6 Ft. Comments: Testhole Presoaked Prior to Percolation Test. Performed By: Mike Anderson. I, Michael E_ Anderson Certify That This Test Was Performed In Accordance With Ail State and Municipal Guidelines In Effect On This Date: 5/24/01 ON-SITE WASTEWATER DISPOSAL SYSTEM CONSTRUCTION AND MATERIAL SPECIFICATIONS SUBJECT: LOT 2, BLOCK 2, OLSEN HEIGHTS SUBDIVISION GENERAL: The scope of this project includes the pumping, crushing and abandoning off site of the existing 1,250 gallon septic tank and the abandonment in accordance with City and State requirements of the existing absorption trench. In addition it includes the procurement and placement of a new 1,250 gallon septic tank at the location shown on the site plan. Work also includes the construction of a new 50' long X 5' wide X 4' effective depth absorption trench at the location shown. The distribution line in the trench will be placed at 4' below the existing ground surface. Total depth of the trench will be 8' below the existing ground surface. All components of the septic system must be placed a minimum of 100' from all wells in the area. 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 prior approval from D.H.H.S. before beginning system installation. SEPTIC TANK INSTALLATION 1. A new 1,250 gallon septic tank must be be procured from an approved source and installed at the location shown. A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanouts for pumping access. The septic tank shall be sufficiently bedded to prevent settling or shifting of the tank. All standpipes on the septic tank shall extend a minimum of 12 inches above final grade. Tanks installed without 4' of cover shall have a minimum of 2" of direct burial insulation. ·., Lot 2, Block 2. Olsen Heights Subdivision May 24, 2001 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 drainfleld. 7. Final grading over the tank shall be such that a positive slope exists away from the septic tank. DRAINFIELD CONSTRUCTION: The drainfield shall be constructed to the dimensions shown on the design. The bottom of the trench shall be within 2" of level. Distribution pipi.ng must be placed level with perforations down atop a level bed of dramfield rock. Rock should then be placed over the pipe to provide a minimum of 2" of cover. A silt barrier or geotextile fabric must be placed between the drainfield rock and the natural soil backfill. 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 drainfield are a minimum 100' away from any private water wells m 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). Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical Co. Styrofoam HI or equal). Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or equal). · · .... Lot 2, Block 2, Olsen Heights Subdivision May 24, 2001 Page 3 of 3 5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed between the final drain reck 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 prefessional 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 fabric, gravel, distribution piping, standpipes, cleanouts and insulation. No backfill should be in place at the time of inspection. Contractor shall previde a copy of all field survey layout and construction notes for use in p'repanng the certified as-bu'It of the completed system. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF FIEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl_ INSPECTION REPORT ' LEGAL DESCRIPTION LOCATION , - -~ I ~ _ / DISTANCE TO: ~.~, ~,~O ,,,, ~ ....... Fro-pt ~-~' /Manufacturer ~,~ ~ ~~ ~ oo./~ _ I=~q' IF HOMEMADE: Well DISTANCE TO: Manufacturer we" rO? D,STANCE TO: t <20 No, of lines/ Leng(~ceE~h line Top of tile finish grade l Absorpt~n ~rea Dwelling Inside length Owe n~ Foundation ~.~ I ~ Total~,~ o~ lines Material beneath tile Width Material Nearest inches NO, OF BEDROOMS ~o. of eon:~'~ments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO.~o<OO ~22. Distance belwe.an lines To ,cf ta egtiv, e ~ bsorption area Length Type of crib DISTANCE TO: Class DISTANCE TO: Width Crib diameter Well Depth Building foundation Depth Crib depth Building foundation Driller Sewer line Total effective absorption area Nearest tot line Distance to lot line Septic tank PERMIT NO. Absorption area(s) OTHER sh~PE MATER]ALS ~, SOl L TEST RATING ~. ~.~ '~,! I NS~.~ L L EJ~ V~ DATE LEGAL .... RETUHN ID: Division of Geolr,glcal and ~ yslcal Surveys [DGGS) 30OI Porcupine Orlve ('reit ,le: 277-6615) Anchorage, Alaska 95501 WATER WELL RECORD Drl~linq Company Nan.. V'ci['.rJ.t ~ ~.~ ....... ~ , ~- ~-.. _ ~ ,~ LOCPTION OF WElL Please complete either la, Ib~ or la ~rough ~ Subdivision Lot Block lb. Fract'on Section No. ~c~ ~01~o~ H / / / Street Address and Area of Nell Location 2. WELL LOG I~a terial Type Feet Below Surface STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES U.S.G.S. Local Iio, Drilling Permit No. I Township N/stRange 3. OWNER OF WELL: Meridian E/W 4. WELL DEPTH: (completed) Surface Elevation Date of []Auger [1 Jetted [1 Bored 6. USE: [~Oo~stJc [~]Public Supply ~ Industry []Irrigation [~] Recharge ~] Corr~rc ia t [~Test Well []Other; 7. CASING: ~] Threaded [~_'We I dad ~in. to ft. Depth Weight _~_~__lbs/F~. in. tO ft, Oepth 8. FINISH OF WELL: Type:O p ell eilc} O ;ameter: Slot/Mesh Size: Length: Set between ft. and Fittings: Et, STATIC WATER LEVEL: ~ ft, []]Above [~8elow Jand surface Type of Heasurement: iO ~ IO. PUMPING LEVEL below land surface fL, after brs. pumping lh WELL HEAD COMPLETION: [~]Pitless Adapter Approved Pit inches obove grade Materlal: [~ Neat Cement []Other: 13. PUMP: (if available) HP __ 1_~.~ Length of Drop Pipe ~'~.9 Et. capacity ._~_____ Type: ~Submersible j~]Re¢iproca ting []Jet []]Other: 14. REMARKS: WATER WELL CONTRACTOR'S CERTIFICATION: This well ..vas drilled under my jurisdiction and this report is true to the best of my knowledge and belief; ~ Contract L'cense Number PF:RMIT NO. RPPLICFINT MERLE K. BEETER LOCFITION %.-.f. STH ,!it. BF.'.FIGRW L. EGFIL 1,2 B2 OL',SON HEIGHTS ~,~- DEF'FtRTMENT CIF' HERLTH laND ENVIRONMENTFIL F'RCTECT 8'25 '"L'" STREET., FINC:HORRGE, fig:. 264-47;20 / ~ '- ' I.l ']:44"-' SAR .L... L. OT SIZE ,::1,~,3E~0 Sf::!UFIF.:E FEET 'FYF'E OF _,UIL IIE,..,Ulq. FfiI_i"4 ... r_TEi'l I'-',. [F..EN_.H . -/ ,~ ...... :,GIL RFITIN~ :S.... FT..BF. ...... HFI,:':,IMI. fl NI MEEF." qF EE:DRnEblS = 4 c. , P " ' ..... , ....... THE RE.qUIRED SIZE OF' THE SOIL FIBSORF'TION SYSTEM IS: ]''FIE LENGTH DIMENSION IS THE LENGTH (IN FEET::, OF THE TRENCH OR DRRINFIEI....D. ]''HE DEPTH OF R TRENCH OR PI"[' IS ]''HE DISTFINE:E BET!.,.IEEi'-,I THE SURFFiCE OF THE GROUND AN[:, THE BOTTOi',I OF THE EXE:FIVRTION ,::II'.,I FEET). THERE IS NO SET WI[:,TH FOR TRENCHES. THE GRFI',,,'EL DEPTFI IS THE MINIMLIM DEPTI4 OF' GI;.:FI',,,'EL BETHEEN THE OUTFFiLL. F'IF'E AND THE BOYTOM OF 'rilE E,'..::CRVRTION (IN F'EET). PERMIT FIPPLICFINT HAS THE RESPONSIBILITY 'TO INFGRM THIS DEPRR"['MEr.,IT DURING THE INSTRLLFITION INSI::'ECTIOI'IS OF ANY WELLS FID.:rFICENI' TO THIS PROPERTY RI'.,ID THE NUi'dBER OF RESII}ENCES THFIT THE HELL WILL SER'¢E. TI,IlO ,~ 2 ]:, I r-,II'.:-];F"EC:T I C~l'-,l:,:~, A~,.-.'.E RE~]~IL..JI I F=: I~E [[:::, ................ E:RCKFILLII'.~IG OF FINY SYSTEM WITHOUT FINFIL INSPECT:[OI'4 FIND FIPPROVFIL BY THIS DEPRRTi'dENT WILL 8E SIJBJECT TO PROSECUTION. MINIMUM DISTFINC:E BETWEEN R NELL FII,ID FII'.,IY ON-SITE SENRGE B, ISPOSRL SYSTEM IS; 100 FEET FOR FI PRIVATE NELL OR 150 TO 200 FEET FROM FI PUBLIC WELL [:,EPENDING LIPGN THE TYPE OF PUBLIC NELL MII'.,IIMUM DISTFINCE FROM FI PRIVFITE WELL TO FI PR I ',,,'RTE SEI. IER L. INE IS 25 FEE']- FIND 'ro FI COMMUNITY SEI.,.IER LIhlE IS 75 FEET. WELL. LOGS RRE REQUIRE[:, AND MUST BE RETURNED, 7'0 THE DEF'RRTMENT 1.4ITlaIN ~:E~ [:'FI~r'S GF ]'HE WELL. COI"IPLETION. OTHER REQUIREMENTS MFIY FIF'PL"r'. SPECIFICATIONS AN[:' COHSTRLICTIOI"'I DIRGRf':IMS FIRE FI',,,'RILRBLE TO INSURE PROPER IN:STFILI...FI]'ION. F"E f;-.'.r-11 ]- E~-::P I RE.'_:; C, E: E: E ~-I E: E F: 3: J_., I CE:RTIFY THR].' 1: I FIM FRMILIFIR WITH THE REQUIREMENTS FOR ON-SITE SEWERS FIND HELLS FI2; SET FORTH BY THE MUI"~IICIPRLIT"r' OF RNCHORFIGE. 2: I I,.IILL INSTALL THE SYSTEM IN FICCORDRNCE WI"rH THE CODES. ]:: I UNDERSTFIND "[.HR]' THE ON-SITE SEWER SYSTEM MAY REL';:!UIRE ENLI=IRGEHENT IF THE RESIDENCE IS I;:EMODELED TO INCL. U[:,E r. IORE THAN 4 BE[:,RGOM'.5. ............ -. ............................ l FIPPLIC:FII'.,IT/ NERLE K. BEETER B','_ ........ , ,TE ........ 5 .... [. .57 '...',:,-. '.1~ SOILS LOG PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 lO 11 12 ~3 ~4 17 18 19 2O COMMENTS MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION Pouch 6-650, Anchorage, Alaska 99502 '276-2221' SOILS LOG - PERCOLATION TEST SLOPE [] PERCOLATION TEST WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? E Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE ~ I t~c~ CERTIFIED BY:__ . 72 008 (7/76) ¢~,:. . .. .... /'/.;,~.y.~\\'.: .,, ,, . :., . , .... ,,,. ,;: .... .---~-. : - ~.,,:.,:,. ,. ~ '..,.,..:, :, --.~,.,.., ..: .. ,..:~ . .-. , . ,.$~.~.%~ , .,. , , , -...... ((. e-~d[(~.~,~~, . : ...., Department oLHealth and.Human.Serv,ces..., , ~ .... ~',~]] '.' ... , *' .,.,, Division of Environmental ~ ..,, ,,..' :.-:.: ,.' : ~ : .. ~ ~: - · . :'. ,. . _ .~.:.,:. ~. . . . s~.~ .....,...., ~.:,.. :..,,~:.~..-. , .. .... , . :. . ,- ¢ .-. ,PO Box,196650 Anchorage AK 99519-6650 · .-' '..,' .'. ": . . : ,, .~ ...... ,~, , WWW cl.ancn~'age aKUS~ .. , ....... , ; , ,*~-, *., .,, ......... - . ,::L,:,';;. ",: ~ ,.',.,:,:,.. (907)3434744'.' ,,..~ ,.,,',c~,- -! "CERTIFICATEOF "' '"' APPROVAL: ~.. · : HEAL-TH ~U/lfORITY ,." . · .' -*"': ' ~ *.: . ,AlS ,.,~_,,=.l=A.u.v.r~=,:...,~_,,:..- ...- . .- - . "? : . ,. . , .. .... 'ParcelI.D. 018-23t-16 ' : "* ' : ....... ' ' HAA# ~" .': "*:' ¢ '""""' ....... " ::" ':. .:;.'*:v . - '~ ,', .' · . .. . .....7 r nDate:., .... ; ..... "" C~mple*le l~gra, I desCipl~n "Lot 2; BloCk 2, Olson Helghts~Julii]Ivtsion: . ' ....... ;'.: !' :,.. ..' '.:'.t- ' ..... · · ' "~at'0 '( ~:dEe '.ns) tt35~A e Lie :-.. .:~ .:- , ..Lo i n site add o clio !.; '. '_ , ,. tess 4250 Eas v n ..... : .... - · Current Propedy~ - owner(s) Clinton C: Pearson ...... .. ..... . ' ..; Day phone,522-7773 ",': ,. " Maili6gad'dl:e'ss;' -:' 4~50E' 'ti3~9~'A "* h'" AK995'1'6" ' ',) .... ' " '- ' - as venue' Anc orage~ ~ . ' --,' ' ;..'" ;.izeh'di~b aa~n~:v, .,'." ,~, . .," ;' ' :" , .... 7: :, . . .' '" "' ph'6n6 ,',. - , . ____,, o--, · ~ : .... ,' . .- .... : /Day, -:: ' ':"'/.,.:. :' Mailing addre{§ ~.-' ' . '-' '.' ....... ·- - - ... -'.. .... - · ,'- - ,:, :- ': ' ' ' RealE~tateA~6qt C o Benn "' _':'""" ....... ""' ' ' Day .,phone 273-7388~-:,_~ . - ., ar eft. :, . '* , ·'' Ma'iling Address' :J'lil C St~'e6i ',~ n ~:h0ra'~l~, AK 9958:~':., ,:': * ' ' : r ,-;..: .., Un/ess othen~,i~e requested, HAA c/~/I b~ h~Id b'y DHHS for ~i¢~f~:.HAA pick'bd ¢¢ t~):..· .:, ... ,,..:. -~ . . 2. I~UMBER'OF BEDROOMs: : · ,' Thi. ee(3)t. : '" ' ' ':' " t: -" ' ' · 3..TYPE.OF WATER SUPPLY: · - ,. TYPE OF WASTEWATER DISPOSAL: - IndividuaIWell ' [] .... Individual On-site , .:. r~- IndividualWaler Storage [] Individual Holding'tank; - [] Cor~munity Class :Well ' [] 'Commun!ty on:site ~: .'El " ' ' Public Water System" ' [] Public Sewer · [] The Municipality of Anchorage Department of Health 'and Human Services (DHHS) Issues Cedificates Of Health Authority Approval (HA,&) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Cedificetes of Health Authority Approval are required for the transfer of title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water supply system.' DHHS also issues HAAs upon request to home owners. 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. Cedificates 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. 5 STATEMENT OF INSPECTION BY ENGINEER"/' i: .... . · · . ¢. ~. ,. ': ., ..... . As cerbfied by my seal affixed hereto and as of Ihe vahdabon date sh.o~.n below I verify that my mvestigabon .... +' ' .... ' "~'" ~/ .... ti ..... " ' ' ' : '"' based on procedures'outlined In the Health Authority Appro al Grade nes.for lhls Health Authority Approval , ' :' application shows that =the &n-site water supply 'and/or ,W~t&wate:r 'disposal ;~;stem :is safe: functional and ,~ - · adequat~ f~r th&,fib .mi~(~'r 6[ fic'~dr'(~0ms' and type,of, struct[J?e,'!~,dic~!~ ~er, eip: I furth'~r]~df~.that ba~&d 6n the .... infl~rmation obtainea fr6r~ th'e M~nicip'ality ~f An~ch6?h~'gle§ ahd f~r0m ~y ing~stigati$h'a'nd inipecti(~h,'the 6n- ' site water s't/pp¥]~n~/6r'~aste~at&r disposal 'sy.~te~n is' in'c~'mpliaii~'~ith"all'apl~licable Mu'nic¥~l and Stat~, ' codes ord na~ncea ?n,,d reflu at OhS n effect ~t the time of n~tal ation ........ . ' ...../:':'.,:i.':i :.i:.~,.. :' .;:"..' , !.'::, ' .ii..; :.:". .. '2: '~ · Name of Firm · '...AndersonEn.qmeenn.q .... : ; ~:' -.: ' ' :' '... Phone 522-//15 : .'... ; .' ,,.,.,.,..,.;x;,,,,.,.,.,.,,nc,.ora. e,.^v~=.,,,,ru o'~ ~w~'l'~ ~'" ,W~n==~'~' ' ,...t . . . , . . Address _ ...l'Ja,~e' ' .... ' ' "' ~ MichaelE. Anderson, P.E.'~ :'. ..... '- Date Engineer's Printed .' . '..'-~,. , .,., ,., .,:,~ ,... ,. .,.', :,..-'..:...,. __ ,,,"'-,~; 4~]N~GFEF, RS ~..;,], . .',-'. .,, ' ........ .'-. ..... ' ..... '. '.'.',.~ .'.r:,,,,,~.~,,,,.,.~>"''~''""'"'"W.~--'/'/"'"'~' " ' , , , , . ,., , · ' . ..,.. .' .. ,.'~ · '~~ o~C;~rl E. fND~.RSON o,.~,j - 6. ' ;': ¢ ~'" ~;E 4381 ...,...~ . DHHSSGNATURE' '' ' : ' , ' --' '' , ~',,~.. ...~,.~.,, , · . ,~. . ' ' ". , ..-' ." , '. ' ': . : .' , . ~'~ ,~x..'Oo., o. ~; -~.. ,". . - J,,~' Approved for' ' ;.5,, - bedrooms.:. '. ". ' "~-, :, , :'., -~l:;'/'~.Or[$S~<'' ,., - ' .Disal~proved.,: ".- ' ',~.", .... , ' :: ;',':"'.. , . ';'" ' ::'. , ' .'.C~r~diiionaJ approval for,' ,: --: bedrooms; with'the following stipulations:' Additional comments ~ :. WA~i'EWAYER :' -., . pROGRAM ....~^ . : Attachments: HM Checklist Septic System Advisory Well Flow Advisory By: ,/~,~.,~...., ~' Expiration Date: "7 (~. '1o~) X Maintenance Agreements Supplemental Engineer's Report Other Original CedifiCate Date: ~ - / ~'- {3 / Reissue Date: Municipality of Anchorage Development Services Department Budding Safety Division *', ' On-Site Water & Wastewator Program 4700 Soulh Bragew St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage,ak.us (S07) ~4~-7~04 HEALTH AUTHORITY APPROVAL CHECKLIST LegeJ DesoriptJon: Lot 2. Block 2, Ol$on Heights Subdivision A. WELL DATA We" type Private Date completed f413/'1980 Total depth 64.5 lt. IfA, B, orC provide PWSID # SaNtary sen (Yn~)[ Cased to )40 fl. Date of test Static water level wen pmduct~. ~ WATER 8AMPLE RF_~UL*T~: CelIfonn 0 oukx~es/lO0 nd. Data of sample: 6///2001 semc, moLD~o TA,~ DATA T..XTyp.n~, s,,pth:~tHt Parcel ID: 01~-23t.t6 FROM WELL LOG 6/13tl980 27 we, Lng (Y/N) Y Wirespropedyprotected~/N)Y CesinghelgM(abovegmund) ~4 ATINSPEC~ON 43 g.p.m. Nib'aW 4.02 mgJI. Other bacteria 3 coloni~Jl00 mi. Tanksize t,~00 gal. Number of C~mpaflments _2 Foundation deanout (Y/N) y Delx~inn over tank (Y/N) N_ "Date of pumping Pumpe~ C. ABSORPTION FIELD DATA Date installed 6~200t ~ rating (g.p.dJft~ or ~x:lrm) t.2 GPD/SF Length 7S ft. Width $ ft. Data of adequacy test Results (Pess/Fatl) Fluid dep~ in absorption field before test in. Wate~ added gal, Elapsed Time: min. Final fluid depth in. Any rejuvenation Ireatment (past 12 mo.) (Y/N & type) C~eanouts (Y/N) y High wator alarm (Y/N) N System type 5' Wide Trench Gravel below pipe 2 ff. Depre~___.,~3n over field ~ For bedrooms New depth in. Absorption raw >= g,p.d. If yes, give date D. UFT STATION Date instalied 'Pump on' level at __ in. Datum E. SEPARATION OISTANCES Size in gallons 'Pump off' level at in. Cycles t~ested SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot >100' Absorption field on lot >100' Public sewer main N/A Sewer/septic cewice line >25' Manhele/Access (Y/N) High water alarm level at Meals alarm & cim~it requirements? On adjacent lots >100' On adjacent lots >100' Public sewer mantmle/eleenout N/A Holding tank N/A SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Propmty line >5' Water service line >10' Abserptlon field >5' Surface water >100' Building f~undaflon >5' Water main NrA Wells on adjacent lots >200' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundaticn >t0' SurPace water >100' W~s on adjacent lots >100. Property line >10' Water Service line >10' Curtain drain None Noted F. COMMENTS G. ENGINEER'S CERTIRCATION I car t/fy that I have determ/ned through fie/d/nspect/ons end review of Municipal recorcls Utat the above systems am in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Michael E. Anderson, P.E. Date ~ 2J91 Water main >10' Waiver Fee $ Date of Payment Receipt Number HAA Fee $. Date of Payment Receipt Number p~v. 12mo) ANDERSON ENGINEERING P.O. BOX 240773 ANCHORAGE, AK 99524 522-7773 522-6779 (FAX) MEMORANDUM DATE: June 19,2001 TO: FROM: Jeff Poet Mike Anderson, P.E.-~/~~''-' SUBJECT: Lot 2, Block 2, Olsen Heights Subdivision Septic System Design Revision Permit No. SW010160 Certificate of Health Authority Approval Existing conditions found dudng the reconstruction of the septic system on Lot 2, Block 2, Olsen Heights Subdivision resulted in a field revision to insure the new system met the requirements of the Municipal ordinance. We found the sewer service line exiting the house at more than 4' below the surface. This caused the depth of the absorption trench as designed to encroach within the required 4' separation distance to groundwater. Monitoring of the test hole placed on the project during the design phase indicated groundwater at 12'. We therefore modified the absorption trench design to include only 2' of drain field rock beneath the lateral instead of the design depth of 4'. We also increased the length of the trench to 70' as opposed to the original design of 50'. The effective absorption area remained the same at 500 square feet. The new system is heady 5' above the monitored groundwater level and meets the criteda established by the ordinance. We therefore request the Certificate of Health Authority Approval be issued for the reconstructed system. Thank you for your assistance with this project. .1~4-12-01 1G:32 F~ T-e~8 P.OZ/01 F-~8~ Client Name Client Sample ID Ordered By PWSID 1013205001 Azxde~on Engineering Lt 2. B~k 9, Olson His Lt 2. B~k 2, Olean llt~ Drin.~ing Water 0 Sample P~Tks: ' Nitrate-N 4.02 0.500 Unit~ Client PO0 Printed DateJ'flme 06/12/2001 15:13 Collected Datefrln~ 06/07/2001 20:00 Received Date/Time 06/08/2001 8:40 Technical Director Stephen C. Ede Relear,~d By~ ~ A~ow~hlc ~ An~ysis Mct~d Llmiu Date Date Init mg~ EPA 300.0 (<10~ 06/08/01 SCL Micx'ob:~o].ogY y.,~v, o z'a C o z"y' Total Coliform 3 OB. No Coli coUl00mL SMI8 9222B (<1] 06/08/01 SKW Received Time Jun.12. 3:33PiV MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITF SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING t~l\°/~- ~:::~%~ - \L~o HAA# ~otCh,-h 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 2; Block 2; Olson Heights Subdivision Location (address or directions) 4250 East 135th Avenue (b) Property owner Mailing Address Telephone: (home) (c) Lending Institution Telephone Business Mailing Address (d) Real Estate Company and Agent MARSTON REAL ESTATE AT'FN: Peqgy French Address 2_~04 We~t North. em /igh.~6 /~?_-~d: Anchorage, ~k, 9950~ Telephone 248-2804 (e) Mail the HAA to the following address: (or check here D;rJdf hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle Ri,ve~* Loop Road No. 2(~4 Ea~lle River, Alaska ~9577 TYPE OF RESIDENCE Number of bedrooms Single-Family 12¢( WATER SUPPLY Individual Well ~X Community [] Public [] Nole: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. SEWAGE DISPOSAL On-site [~X Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, Iverifythat my investigation of th is Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional end 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 flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firth& $ ~NGiNF-ERiNG Telephone 17034 Eagle River L. oop Road No. 204 Address i~agJa i-dYer, AJ~ka ~57] Date ~ ~ '4) ,~ ~ ~ .-.. :. ,~%~ ~ DHHS APPROVAL ¢~ /ff Approved for ~-~ bedrooms~~~' ' Cate ~~¢) Approved ~ Disapproved Conditiona~ Terms of Conditional Approval ~ ~ The Municipality of Anchorage Department of Health and Human Services(DHHS) issues Health Authority Approval cerificated based only upon the representations given in paragraph S above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHSdo not conduct inspections or analyze data before a certificate is issued. The MunicipalityofAnchorageis not responsible for errors or omissions in the professional engineer's work. A. W E L L~'~ATA Well Classification _~.~i ~4,/d~ ,~./v~'~ ]~ Well Log Present (Y/N) 4---Date Completed Total Depth ~z¢..~' Cased to ~r'6)'~Depth of Grouting Static Water Level ~ z~ J MUNICIPALITY OF ANCHORAGE (MOA) Health Aulhority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: ~----~'~ If A, B, C, D.E.C. Approved (Y/N) /~/~ Z. - ~0 Yield " Pump Set At Casing Height Above Ground / Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot / CC) -/- To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Sanitary Seal on Casing (Y/N) W ' Depression Around Wellhead (Y/N) To Nearest Public Sewer Cleanout/Manhole ; On Adjoining Lots / ; On Adjoining Lots Comments B. SEPTIC/HOLDING TANK DATA Date Installed ~ -2/- CDSize Standpipes (Y/N) b1 Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SI--PARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well [ 0_(:2 To Property Line [ 0 To Water Main/Service Line I 2 "~-~,/~] No. of Compartments Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Date Last Pumped . ;for /"J/~ Temporary Holding Tank Permit (Y/N) t~/~A To Building Foundation 'Fo Disposal Field To Stream, Pond, Lake or Major Drainage Course ~/~r Comments 72-026 {Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed z_~ - 2. / - Width of Field ~ ~ _¢::~ ~ ¢//~2b ~:~ Type of System Design ~;)C~ Length of Field 2- ~ Depth of Field ! ~-- Gravel Bed Thickness ~ '~ Square Feet of Absortion Area /-~ I ~, ~ Statndpipes Present (Y/N) Depression over Field (Y/N) t',) Date of Last Adequacy Test Results of Last Adequacy Test ,_~/ %f~d~'~o¢'~ _ z./ /'~Oo~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well / OO/'f To Property Line / O To Building Foundation ~ ~' ~ To Existing or Abandoned System on Lot ¢")//~ ; On Adjoining Lots %0 /'~ To Water Main/Service Line !O ¢ To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course / fPO/'~ To Driveway, Parking Area, or Vehicle Storage Area Z o - Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **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 Company Date MOA No. $ & ~ ENGINEERING 17034 Eagle River I. oop Roa~l No. 204 Receipt No. ~J J Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633BSTREET · ANCHORAGE, ALASKA99518 . TELEPHONE (907)562-2343 FEDERAL TAX I.D. #92-0040440 ANALYSIS REPORT BY SAMPLE for Work Order ~ 26073 Date Report Printed: AUG 6 98 @ 12:29 Client Sample ID:L2 B20LSON HEIGHTS PWSID :UA Collected AUG 1 90 @ 15:00 hrs. Received AUG 2 90 ~ 16:45 hrs. Preserved with :AS REQUIRED Client Name : $ & S ENGINEERING Client hcct: SNSENGP P.O.$ NONE RECEIVED Req $ Ordered By : R. SHAFER Analysis Completed :AUG 3 90 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE l)S & S ENGINEERING goloaeod By : ~--~ ~ 2) Special Irmtruct: Chemlab Ref ~: 902800 5ab Smpl ID: 3 Matrix: WATER '~ Allowable Parameter Teeted Reeult ~t~ Method Limit~ NITRATE-N /' 2.7 ~/1 EPA 353.2 lO Sample ROUTINE SAMPLE. Remarke: SAMPLE COLLECTED BY RDJ. 1 Tests Performed ' See Special Instructions Above UA-Unavailable ND- None Detected "See Sample Remarks Above NA~ Not Analyzed LT-Lees Than, GT-Greater Than CHEMICAL & GEOLOGICAL TELEPHONE (907) 562-234:3 Anchorage, Alaska g95'1'8~ ~\~j~///~ Drinking Water Analysis Report for Total Coliform B TO BE COMPLETED BY~VATER SUPPLIER [] PUBLIC WATERSYSTEMI.D.# ~ I [ [ I I I ~ PRIVATE WATER SYSTEM '~i Name .:'~ Phone No. S & S ENGINEERINt3 Mailing Address 17034 Eagle Rlve~ Lo~p~eed Ne, 204 Eagle River, Alalka ~li~· City ~ate Mo. Day Year Zip Code SAMPLE TYPE: Routine Check Sample (for routine sample with lab ref, no, [] Special Purpose ) [] [] Treated Water Untreated Water SAMPLE NO, LOCATION I 41 Time Collected Collected _~ tcteria TO BE CO! PLETED BY LABORATORY sh, vs this Water SAMPLE to be: / /~J Sat isf act.,.O rY [] Unsatisfactory [] Sample to~o long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sam@lo via special delivery mail. Date Received ~'"'~'- ~ Time ReceiVed Analytical Method: Membrane Filter * No. of col0nies/100 mi, Lab Ref. No. Result* Analyst READ INSTRUCTIONS BEFORE COLLECTING SAMPLE BACTERIOLOGICAL WATEFI ANALYsIs RECORD Membrane FIIten Direct Count Verification: LTB Coliform/lO0 mi BGa I~lnal Membrane Filter Results Reported B~Date ~ Time: TNTC = Too Numberous To Count OB - Other Bacteria Coliform/lO0 mi p.m. DATE 4 n~,~ DATE }ATE / / INSPECTOR INSPECT ~ MUNICIPALITY OF ANCHORAGE DEPT. OF DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION~Nvi,~ONMENFAL 825 L Street - Anchorage, Alaska 99501 ENVI RONMENTAL SANITATION DIVISION Telephone 264-4720 DIRECTIONS= Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing, MAI LING ADDRESS ' -- PROPERTY R ESI D ENT~~rom~~ "~ PHONE MAI LING ADDRESS .... 3, LENDING INSTITUTION MAI LING ADDRESS MAI LING ADDRESS ~ ~ 5. LEGAL DESCRIPTION STREET LOCAT,ON 6. TYPE OP RESIDENCE SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One ..~3" Four [] Two E] Five [] Three [] Six [] Other 7. WATER SUPPLY ,/~ INDIVIDUAL* COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach Icg if available.) 8. SEWAGE DISPOSAL SY,(~TEM y IN DIVI DUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED, NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 'Rev. 6/79) ~"~-~ THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [~ MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOGREOEIVED U¢¢ ~ 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] I NDIVl DUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY ~/~_ £r ~ Connection Verified INSTALLER []Septic Tank. or [] Holding Tank ~.~ Size: ( ~.3~0 If Tank is homemade SOILS RATING give dimensions: / ~.% ~::::~ TYPE OF TANK MANUFACTURER /(~ ~ 0.~--~ TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Roldin§ Tank ]Absorption Area Sewer Line I Neerest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS FOR z~ BEDROOMS [~"~APPROV ED [] CONDITIONAL APPROVAL {letter must accompany certificate) [~ DISAPPROVED DATE BY~ .~.~~ Municipality of Anchorage Health and Environmental Protection Department Sewer and Water Program 264-4720 Application Fee: $25.00 INFORMATION SHEET Health Authority Approval of Water and Sewage Facilities Lending institutuions request the Municipality to approve the water supply and sewage facilities on specific lots. The Municipality will inspect the well construction, sewer design(required components and bedroom rating) and protective distances between each. The water supply will be analyzed for bacteriological quality. An inspection will collect and deliver a water sample to a private laboratory. Forty-eight(48) hours after the inspection, the homeowner or agent must make payment(S15.00 lab fee) to the laboratory and deliver or mail the analysis report to this department. The lab's address is: Chem Lab,:5633 B Street, 274-3364,~ Items ~ha~ must bep~ov~de~ to the Municipal.ity~at the apPlicant]'s expense prior to If the on-site sewer system is over two(2) years old; the septic tank needs to be pumped with a receipt provided to this department. If the on-site sewer system is over four(4) years old; the septic tank needs to be pumped and an adequacy test performed on the existing leaching area. This is to insure the on-site system is working adequately. Private engineering firms conduct this test. A listing is available from this department. The report and pumping receipt need to be provided to this department for review. If there are any questions regarding the above procedures, please contact this office. SWP/O16 Rev. 4/80