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HomeMy WebLinkAboutEAGLEBROOK #2 BLK 2 LT 3BEaglebrook #2
Block 2
Lot 3B
#017-121-63
MUNICIPALITY OF ANCHORAGE � � _s � � -
DEPARTMENT OF HEALTH AND HUMAN SERVICES C5
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
DISTANCES
__ �L /S
TO
FROM
SEPTIC
TANK
ABSORPTION
FIELD
WELL
Address
(,X-3® 0 e/R. 99�L
®
/
Phone(s) Permit No. No. of Bedrooms
WELL
®®® .3
LOT LINE,�-
LEGAL DESCRIPTION
Lot
3
Block
Subdivision
FOUNDATION
®
°
-
Township, Range, Section
®
} 5firdriveway,
AS -BUILT DIAGRAM
(Show location of well,
septic system, property
lines, foundation,
A
water bodies,
etc.)
TANKS
SEPTIC /,k ❑ HOLDING
Manufacturer ®,/
f�
Capacity in gallons
Material
No of Compartments
TYPE OF SYSTEM[]TRENCH
❑ RED W. DRAIN ❑ OTHER
Depth to pipe bottom from
Total depth from original grade
original grade
FT
FT
-`
__
_-_
..—
Fill added above original grade d
Gravel depth beneath pipe
® FT
FT
G�
—
Gravel length ..
Gravel width
® �® ®
FT
FT
Total absorption area�y
Distance between lines
d r SO FT
FTsea
®
_
_
Number of lines Soil rating
Pipe material
� 3
/.50 ® SO FT
/®
&
�
Installer � G �2fY._ I
C i�d5
Date installed
WELLS
PRIVATE ❑ OTHER tldenli}d)
Classification (A,B,C)
Total Depth
Cased to
FT
FT
0
� /
W/
Installer
Date Installed:
REMARKS: AIVACe IA'Ath oB&M rendbil"ll"fird .
djT
v ® _
� /1®gg lg!�Z%lbgiWA�4
Scale:
S ENGINEER'S SEAL
Inspections Performed /
Date:
7-7-W
® ®
inspection was perlormed according to all
P
I cerllly that this
®7
Municipal and Slate guidelines in ellect on this dale:
e
^
Health Department Approval:
Date:
FA
MUNICIpALITY OF ANCHORAGE
Depar sent o[ Health & Human Ser .7es
825 L Street, Anchorage, Alaska 99501 3 4720
ON - SITE SEWER PERMIT
Permit Number: 880111 Upgrade
Date Issued: 07/06/88 Engineer Designed
Owner Name: PAUL M" & CORLISS SCOTT
Owner Addpess: 6230 ANDOVER CIRCLE
ANCHORAGE, AK 99516~4349
Day Phonw:
345�22�3
Parce1 Id:
017-121�63
Lot 1.ega1:
Subdivisian:
E2&'�/��� �
Section: 25
Township:
12N Range: 3W
Lot Size
67000 (sq"ft"
or a(:::reg)
Max Bedroomsp
Thisra Permit:
3 Total
Capacity: 3
GEPTIC TANK: Minimum tOtal septi� tank capacityx 1,00C) nsc
gall�" ��h septc
i
Lank must have at least 2 cDnpaPt0eDtim" Depth to top of iseeptic tank(s) < 4.0
feet requires in5ulati0n ova", tank(s).
INFORM D"H"H"S. PRIM TO 1ST & 2ND INSPEC"TIONG BY ENGINEER, IF
AFTER OFFICE HOURS, CALL 343-4681 t -ft) LEAVE A M�SSAGE"
CONSTRUCT PER EWGINEERS ATTACHED APPROVED DESIGN
THIS PERMIT EXPIRES 12/31/88
THIG PERMIT VALID FOR A SINGLE FAMILY RESIDENCE ONLY
I CERTIFY THAT:
1" I am familiar, with then rel?quipemc-�nts for ori -site svopowis aDd wells as get
forth by the Municipality (of ADChinPage (MOA) tand the gtate of Al�ska"
2. I will inirtall the system in accordance with all MDA (:,".codes and r�gulationsv
and in compliancem with thee deesign Criteria of th15 p(pP0it."
3" I will adhere to all MOA and State (of Alaska paqairements [or the set hack
dist�nces
from any existing wastewater, disposal ssymtem or public
sewerage system on this or ahy adjacent or nearby lot"
4" I unds�rstand that this permit is v@lid for a N@:imum of 3 beclroomis" I
also understand that capacity of the total systern is 3 b�drooms and
any enlargement wiI1 roequirew aO additiorsal parrmit"
Signsod: ~- DATE:
.... .... .... .... . 7,��1_~~~~
(Owner) PAU /� ORLI�� SCDTT
Issued By: DATE: 7-1
-~���
PERFORMED FOR:
���o�•° ®•®•®•® I 'VER'S SEAL)
a
Municipality of Anchorage • 4 • ®® • ° • ®• e•
DEPARTMENT OF HEALTH & HUMAN SERVI
825 "L" Street, Anchorage, Alaska 99502-0650 °•• ®® 0
® OY C. REID, JR.
SOILS LOG — PERCOLATION TEST '® C -2251 ®® Ar
DATE PEFTF
LEGAL DESCRIPTION: �� " " !�%��`/ ✓`' Township, Range, Section: 7-i7-11,) /F3 1-j JFC-
DEPTH F` SLOPE �'j SITE PLAN
(FEET) MMMMOMMME
10 i � I
11 j
12 I
�II
13 �I
14 j
16-
17
18
19
WAS GROUND WATER
ENCOUNTERED? _.. O
S
IF YES, AT WHAT L
O
DEPTH?
P
E
Depth to Water Alter
Monitoring? �� Date:
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
2
(minutes/inch) PERC HOLE
DIAMETER
3
,
?-' /
FT AND FT
�.
/da'_
zd
4
'
,'>l
NNE
COMMENTS
5
EME
■■■116■■�■■■
6
/4
.77
781��
7
�FC. s
A' r✓l��/�----�
�■■■■�WN■
/t/<5
:%,d
PERFORMED BY:
/,?n /.7y
8
�j
THIS TEST WAS PERFORMED IN
10 i � I
11 j
12 I
�II
13 �I
14 j
16-
17
18
19
WAS GROUND WATER
ENCOUNTERED? _.. O
S
IF YES, AT WHAT L
O
DEPTH?
P
E
Depth to Water Alter
Monitoring? �� Date:
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
(minutes/inch) PERC HOLE
DIAMETER
TEST RUN BETWEEN
a !
?-' /
FT AND FT
�.
/da'_
zd
�.�h��' �AT ��7 �fla/9 /
/,98'/,47
,'>l
NNE
COMMENTS
EME
■■■116■■�■■■
/135
I,9/ - 1.U9
.77
781��
�FC. s
A' r✓l��/�----�
�■■■■�WN■
/t/<5
:%,d
PERFORMED BY:
/,?n /.7y
■■■
CERTIFY THAT
THIS TEST WAS PERFORMED IN
INEENNEINEE
ACCORDANCE WITH ALLSTATE
70_nno fog,, n,•a%
■■■■■N■■
ON THIS
DATE. DATE:
�■■■■■■■■■■
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
(minutes/inch) PERC HOLE
DIAMETER
TEST RUN BETWEEN
a !
?-' /
FT AND FT
�.
/da'_
zd
�.�h��' �AT ��7 �fla/9 /
/,98'/,47
,'>l
COMMENTS
/135
I,9/ - 1.U9
.77
781��
�FC. s
A' r✓l��/�----�
/t/<5
:%,d
PERFORMED BY:
/,?n /.7y
. 7 /
CERTIFY THAT
THIS TEST WAS PERFORMED IN
/" _ / '1
ACCORDANCE WITH ALLSTATE
70_nno fog,, n,•a%
AND MUNICIPAL GUIDELINES IN EFFECT
ON THIS
DATE. DATE:
20
G'
PERCOLATION RATE
(minutes/inch) PERC HOLE
DIAMETER
TEST RUN BETWEEN
a !
?-' /
FT AND FT
�.
�'(SF I50
�.�h��' �AT ��7 �fla/9 /
To
_
S 1���7Rk
COMMENTS
781��
�FC. s
A' r✓l��/�----�
`'-�''-
PERFORMED BY:
CERTIFY THAT
THIS TEST WAS PERFORMED IN
/" _ / '1
ACCORDANCE WITH ALLSTATE
70_nno fog,, n,•a%
AND MUNICIPAL GUIDELINES IN EFFECT
ON THIS
DATE. DATE:
� v
�OF AC �®
0000.,
F.0 • i®R'S SEAL)
y 04)®° ®� e
.6 ®. ®® ®® 0069®®®. 0
® Municipality of Anchorage ® 0
DEPARTMENT OF HEALTH R HUMAN SERVICE ®® .®® ®®•�
825 "L" Street, Anchorage, Alaska 99502-0650 I e ROY C. REID, JR.
SOILS LOG ® PERCOLATION TEST®® ®®•®C -2251®®���,�
0000®• 'v
PERFORMED FOR: �� ��^� DATE PERFORMED:
LEGAL DESCRIPTION: L0�3g 1-�IZrh6l,-�k' Township, Range, Section: yal /Z3ul S6C. 1�>ef�
DEPTH SLOPE SITE PLAN
10— WAS GROUND WATER /U
� N
(FEET)1'r/UL
ENCOUNTERED.
Net
Time
Depth to
Water
S
u
2
/o n l
'66-
66-6-7
IF YES, AT WHAT O
DEPTH? P
12
3
,.
4
13
6 -7
Monitoring? Date:
5
6
—
7
EnfU
8
7, rtv
9-
10— WAS GROUND WATER /U
� N
14-
15-
16-
17
4151617
18-
19-
Reading
819
Reading
Date
ENCOUNTERED.
Net
Time
Depth to
Water
S
11
L
/o n l
'66-
66-6-7
IF YES, AT WHAT O
DEPTH? P
12
'0-
E
Depth to Water After
13
6 -7
Monitoring? Date:
14-
15-
16-
17
4151617
18-
19-
Reading
819
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
/o n l
'66-
66-6-7
'0-
6 -7
20 '?/
PERCOLATION RATE (minutes/inch) PERC HOLE DIAMETER
a �
TEST RUN BETWEEN FT AND FT
cOMMENTs Soir__ cs47 3 A7 /��o ��yi,11� Fla/ l io 6 .Jo l�orJ/rR TRE 1,<157-,
/'F57 i�o� %�J �✓eR/F C�>J/7)i�lu �/�"� /,�
PERFORMED BY: /,L�/ 14` ""✓E�/ / �" ^ ` " ' �� CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 I R ev. 4/851
A
EC s ALASKA CIIUIROWnTAL COW OL HUNS, InC.
a
a Engineerinq & Enuironmental Studies
SPECIFTCATIONS FOR t FIVE -WIDE WASTEWATER TREATMENT SYSTEM
LOT 3B, BLOCK 2, 13AGLk°BROOK #2 SUBDIVISION
1,0 GENERAL
1.1 The drawings,sheets 1 through 3, shall be a part of this
specification.
L.2 All materials and workmanship shall meet the requirements of the
Municipality of Anchorage, Department, of Health & Human Services,
(DiSiiSl, the conditions of the permit, and all applicable rules and
regulations currently in effect..
1.3 All elevations and depths are advisory and are to be verified or
modified in the field by a DENS approved inspector.
l.4 it is the responsibility of the installer to adhere to approvers
designs for installation, maintain the Specified solluration
distances, and have the appropriate inspections.
1.5 If the installation is not inspected by an AECS engineer, AECS will
not be responsible for the installed system. An en;iDeer at AECS
should be consulted prior to construction, to determine the number of
inspections that will be required and to explain what these
inspections will involve.
2.0 SEPTIC SYSTEM
2.1 The existing septic tank may be used, if it meets the capacity
requirements for the residence and the approval. of DHHS. Older
systems may need tame integrity verified. Q not, then specifications
2.2 through 2.6 apply.
2.2 The septic tank shall be a UPC approved two-compartment tank,
constructed of 12 -gauge steel with bitumastic coating, set level
on undisturbed soil and insulated with overlying layer of 2 inch
burial type polystyrene,
2.3 The septic tante shall be a minimum of 5 feet from the house
foundation, and a minimum of 5 fees: from the absorption area.
2.4 The septic tank and Grainfield shall be a minimum of 100 feet from
any private well or body of water, 150 feet from Class C wells, and
200 feet. from Class A or P wells, unless otherwise specified. Less
than the required separation distance must have prior approval or
waiver by Alaska Department of Environmental Conservation (ADEC).
2..5 piping shall be fitted with a mechanical- watertight calder coupling;
of the inlet and outlet of the septic tank. Piping; shall be 4 -inch
ASTM D3034 or cast iron, sloped a minimum of 1./4 inch per foot.
1200 West 33rd Auenue, Suite B e Anchorage. Alaska 99503 ® 19071 561-5040
?.G C;lea?hf", t1 �= shall beinstalled,. us C, e. �;imn a3 t,,a'i. capped with air light.
rain caps (Jim caps or equivac.lent), and extend: a minimum of 2 feet,
above ground level.
2.7 Tf a lift: station is shown on the drawings it shall be Anchorage
Tank or MOA approved equal.. (See attached
3.0 DRAI1'FTE D SYSTEM
3.1 The gravel for the tirainficld shall be V5 to 2.5 inch screened =ock
with less than 3% passing the 1200 sieve. All. substitutes must have
prior T7US approval.
3.2 The bottom and side of the excavation shall be raced with the backhoe
blade to ensure that it has not, beer compacted during excavation.
The Bottom elevation shall be level.
3.3 Monitor standpipe=(S) shall be placed as shown in the drawings, and
shall be rigid PVC ASTM D3034, or 4—inch cast. iron, The section
showan with holes may be drilled. 0.5 inch holes on the S --fraena centers
on opposite sides of the pipe;, or a regular section of pei'F=ted
sewer pipe, clamped to a sol -id section, with either a no hub coupling
or a solvent. joint. A rubber rain cap (Jim cap or equivalent) shall
be placed over the top of the ;,Ripe.
3.4 The distribution paps: shall be 4 -inch rigid PVC with a sni.niMUM crush
strength of 2500 lbs or equal. Ali distribution pipes shall be laid
level.
3.5 if the final grade of the c=rainfield is less than e feet above Phe
gravel, insulation is required wising clow extruded blue styrofoam
board or equal. There shall be 1 inch of insulation for every foot
of soil less than the required 4 feet of cover, but there must be at
least. 13 inches of soil cover even though insulation is used. The
solid pipe extending from the septic tame or lift station to the
drainfield shall also have 4 feet: of cover or an equivalenat layer of
insulation to prevent freezing of the line.
3.0 if insulation is not necessary, the gravel shall be covered with a
layer of nonwoven engineering fabric.
3.7 it, is recommended that the area excavated in the vicinity of Me
drainfield shall be planted with a white clover, red fescue mix and
Kentucky blue= grads.
VO In.`hP CTIO S
r
T.? .l minimum of three inspections are required for installation of the
trench. The first inspection will be of the excavation to verify
that the installation will be $ n the proper soil.
4.2 The second inspection will be after placement of the gravel, monitor
standpipe(s) and distribution pipe to verify propyr installation
before backfin .
4.3 The third inspection shall be after the druinfie,ld is backfilled aaK
the around graded.
ALASKA ENVIRON NTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB 4 1_"_
SHEET NO.
CALCULATED BY
CHECKED BY
SCALE.
DATE
k
WX
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'T
pN➢h�p1E S uJDE
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RUW
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RUQ WALKWAY
miry. �J12f 1;6 ®®vc 4v Fa
PFwIup--c,cAY, � ,g
P "'-:eO I11V83 -
RECERT[FICATIOU
iTHIS .A5L3UILT" WAS
F®9�-IMpRA EHDM4 61�GE'
0916INAL.'AS-BUIV
DATED APRIL Z8, 1988
® "11A A—
!—
o
r
-® ® OY C. REID, JR.&
®®eCE - 2251
� �°rotessiona\V� `.
A
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NOTES,
6. IT SMALL BE THE RESPONSIBILITY OF T"9DUILO[ROROWNER TOY[NI/T THAT
BUILDING LOCATION SHOM WEET0 ALL SUBDIVISION COVENANTS AND
01101NANCC®.
0. B4 Is Tuff ®ffflb a ft.®u Iva � Tuff ®alae w®Im
/
B q
,
,vom e. /.ori
2 I'
-MID WA.K W,1`(
g�cI1,P.�' p/Fly
K
C�'e4}gIN I.tl�� 004 RUN
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RUQ WALKWAY
miry. �J12f 1;6 ®®vc 4v Fa
PFwIup--c,cAY, � ,g
P "'-:eO I11V83 -
RECERT[FICATIOU
iTHIS .A5L3UILT" WAS
F®9�-IMpRA EHDM4 61�GE'
0916INAL.'AS-BUIV
DATED APRIL Z8, 1988
® "11A A—
!—
o
r
-® ® OY C. REID, JR.&
®®eCE - 2251
� �°rotessiona\V� `.
A
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I
9
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NOTES,
6. IT SMALL BE THE RESPONSIBILITY OF T"9DUILO[ROROWNER TOY[NI/T THAT
BUILDING LOCATION SHOM WEET0 ALL SUBDIVISION COVENANTS AND
01101NANCC®.
0. B4 Is Tuff ®ffflb a ft.®u Iva � Tuff ®alae w®Im
ALASKA ENVIRON -NTAL JOB /o7
CONTROL SERVICES, INC.
i Onn \Alae+ ' 4QeA 6vanita Ctii+a R SHEET OF
_ Municipality
o
Department of Health and Human Services
Tom Fink, 825 "L" Street
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
July 12, 1988
Alaska Environmental Control
Services, Inc.
1200 West 33 Avenue, Suite B
Anchorage, Alaska 99503
Attention: Mr. Alan C. Wien
Subject: Waiver Request for Lot 3B Block 2 Eaglebrook S/D #2
Waiver Request #WR88-032, Permit #880111
Dear Mr Wien:
Your request for waiver of the required 100 foot separation of
a septic system to a private well has been approved. The
approved separation distance is 98 feet. This waiver approval
also includes the 5 foot encroachment of the septic system to
the west lot line.
This waiver approval applies to the existing septic system to
well separation only. Any future upgrade to either will
require all separation distances be met or another approval
from this department.
Sincerely,
0�)� ;. -/&�
Daniel J. Roth
Civil Engineer
On-site Services
DJR/ljw#6
A
EC ALASKA HUIROWnTAL COnTnOL SUS, InC.
CS
Cn
Q Cngineerinq & Enuironmental Studies
Jgrnc 243. 1988
Municipality of Anchorage
Department OF Health V Human Services
25 J: Str,pet
Anchorage, Ali. 99501
AUP: Dan Ro&
Re: Lot. 3R, Block 2, 7aglehrook *2 Subdivision
This lot re,guires, an upgrade to its Rbsorption field. See attached design. "hdi
existing ihee wplj# The well was drilled after
this system was installed. The best place for the upgrade is as designed which
will utilize area above the existing trench as Well as the addltlooal. 5 root
wide drainfic3-6.
The well is 1€32 feet deal?, r.a:aer`: to the tar7ttc'ir, gtiiill a ;itse'c..ic levet. of 213.1 feeK
On 6/1/88. a well flow 'test showed ra yield of 6.2 GPM with a drawdown of 23
feet. The well is slight3y downhill from the trench. Water samples taken
5/9/68 are satisfactory. We feel this reduction of the required separation
distance will not pose a threa°t of contaminalton to the well. We request you
Vaunt €a waiver -fry Walk to upgrade absorption are4, of 96 foot, which should be
the closest edge of the hrencla.
Also, we.zaa°e,xoquenting «a a root lEat. Time waiver,from the > wide draainfield to
Weft lot -1004 Attached is a letter of non -objection from the owner of lot 4
if you have any question, please cull.
Sincerely,
Alan C. Wien
Engineering Technician
Approved by:
lit e 4;q n.
mmm, t
..a.wwd�aP a �P-q
A`0 m0 a ®0@00000 ®bV
M :A
one x c�nw®sL msa�
C.nREID, JR m
pp o n � anm �
�Q �OS `�kt�fiL"LT'a:'�•
1200 West 33rd Auenue, Suite Be Anchorage. Alaska 99503 a (901) 561-5040
5e4t5. 5 joJeR s 157Chv5 ejT Alete.4edI165A/7' e2d
�f� A57' /-®i L®a/E
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 I ONEW
�A I'y' �4d06 5[l ❑UPGRADE
MAILINGADDRESS
_
_..— _-
----- ---
LEGAL DESCRIPTION
-a
.- L L f E Fa C _c a k'_rn o K -
LOCATION
NO. OF BEDROOMS
rryy
Well Aro Par
Absorption area
Dwelling Ar1,7 9r,E
PERMIT NO.
U y
DISTANCE TO:
c s
•S 0003 ,- I
Z
LZ
L
Manufacturer � _---
__-- -__-
Mat
Material
4
No. of compartments
LU h
_6 r`- E E t:
"-T. E u t-
c».
N
Liq. capacity7n—gal lons
.v IF HOMEMADE:
Inside length
Al
Width
A/.4
Liquid depth
'4 /.A? .
®=
DISTANCE TO: Well
Dwelling
PERMIT NO.
J Z Z
--
2-F
Manufacturer
Material
Liquid capacity in gallons
®y
DISTANCE TO:
Well A ,"7' e 1,
Foundation & j. 7 y
Nearest lot line - P
PERMIT NO,
`fie=sCi
w
J LL 2
Z
No. of lines
Length of each line
Total length of lines
Trench width
Distance between lines
- w
M-
_.-
��
_--_- _____ __.
l I inches
� h
Top of file to finish grade t
L�
__ _.
Material beneath file �
Total effective absorption area
®
1 ' -inches
r
Length
Width
Depth
PERMIT NO.
LU
d� b
wa
Type of crib
Crib diameter
Crib depth
Total effective absorption area
N
DISTANCE TO:
Well
Building foundation
Nearest lot line
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
w
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS -_---- -
SOI L TEST RATING
_--
-----
----"
-_"`-
J. h,pP���
—...
__._
1
X19
%.
y
-
INSTALLER_...-.. 9 .__..._
T, (,"- , I� �.e t' C_" It (- R�. I � F"
,!
t
REMARKS _
�.
1--1 r.r f=�_ `@.i �,.�.�va_ A
--
-
J"
—cikFsr S jAE,N F" u� t�
_ . - F' .> '1` >� '- E? F a� fed l->
,
.. _
iv
II
I
APPROVED DATE LEGAL
72-013 (Rev_ 317 R )
A
ter.:
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DEPARTMENT HEALTH AND ENVIRON11ENTAL -_ITECT I ON
825 "L. STREET., ANCHORAGE. Ak '.. 99btil
264-4-720
I. -A EL L_ LP-.0 C -A CH P-4 I -T'E: _E. E-'-- 9-4 E -E. U`Q." F="E_:7 F-° Ir -1 1 7
PERIL IT NO. ( 8_300,91 )
APPLICANT HARR'-rt,F SHFDRE 6937 OLD SEWARD HIGHWAY 99502 349-6537
LOCATION
LEGAL L30 EAGLEBROOK #2 LOT SIZE 999999 SOLIARE FEET'
TYPE OF SOIL. ABSORPTION SYSTEM IS: TRENCH
IIAXIMUM NUMBER OF BEDROOMS = 3 SOIL RATING (SO FT/BR)= 140
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
E., EE F:::n 7' L_ I=- P4 02 -r H - 2Z f --j FC n %en I= IL_ E -o E®F"1- i -I = E.
'THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
'THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
'THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL CEPTH :15 'THE MINIMUM DEPTH OF' GRAVEL. BETWEEN THE OUTFALL. PIPE:
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
FZa0kJ1F;?aE-u !s-1z;_7EE_ :jL 01929 r=9 p:3 F1 L_ L_ ID r_j
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPEIRT11ENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND 'THE
NUMBER OF RESIDENCES THAT THE HELL WILL -SERVE.
_r LII < -.2 > I N _� F:10 EE ul:- -F 1 0 N!F. F-1 IFR -0 ER' F;;:o E=_"G,78_0 I FRO I=- r -a -- ------
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT I. -JILL BE SUBJECT TO PROSECUTION.
I',1INIllUf1 DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM I'S
100 FEET FOR A PRIVATE WELL OF: 150 TO 200 FEET FROM A PUBLIC I. -JELL DEPENDIF-IG
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL. LOGS ARE REQUIREG, AND 11UST BE RETURNED TO THE DEPARTMEhIT WITHIN 30 DAYS
OF THE 14ELL COMPLETION.
OTHER REG!UIREMENTS MAY APPLY. SPEC IFICAT IONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
1=E:F?11 I -F aX.'F-" IFRIEZO—H-3 E-® EE o::. FE 1'-1 En E: F;;' =< --t. _L 0=-s
I CERTIFY THAT
1: 1 Fill FAFIILIAR' WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE NUNICIPAL ITY OF ANCHORAGE.
2: 1 WILL INSTALL. THE SYSTEM IN ACCORDANCE WITH THE CODEE".
3: 1 UNDERSTAND THAT THE ON-SITE SE14ER SYSTE11 MA', -1 REf:iUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ---.: BEDROOIlS.
-a _:� y �)
,'
_-z-,uy %4. 0
...-DATE---
ISSUED BY- - - - - --
MUNICIPA
DEPARNT of REALT}{ANpOF ANCHDRAs
ENVIRD, NTAL 1
GF B25 Lr Sfr® ME
�. Anchor,ap®. Alms4s e 'ROJECT!(),�
19SD8 f'[RCOI_
SOILS �sa.4'a® ATION
LOG —. PERCO TEST
1,. L<1ilOn! 7F=S7
�ERFOR
4' MED (0R:
EDAL DE SCRIP _ TIO(V:� E�
-
0^T`� PEAT-, p
s,.
FRO L EAJ TC)
2 RACE oRC,r,gNIC'a 'To I U'
0
3
4
a
5
l IGairID �wM ait_T-y
6 �BBLP-:5 I lol� p N rv1
7
8
0
e
7
DATE PERF
DRMED:
Z
-SITE PLAN
WAS GROUND WATER
ENCOUNTERED) S
A901®➢ c' O�dF-c , C' m, 'F Tip AT WHAT O--
--
- --
A%l�j
!
1(j L �"p3E3LC AT ! `.®' t1 -- Date cross N®f ---- —__..
Time
!� -d'TN OF 6()pdtlG. a —"_ 'rime-
C
mII® .tysp � pr eP t p ✓,I A,EQ7��, ____ _. S� — _ '
e '
J.,Ln N'. L
d:
r
PFRCOLATION RATE---
�u..�,�zi�attia
cw
i -EST TiUN P
"'------ Er;Gn
-�`� =� �$--� =�✓tyr -- EEN
FT AND
FT
---
G�. ' 1 r A / rm 1 ^ a ry 1_® C` e- /e - r- C` a` I o �pp ri
is L) d L_ , i d e-® L_ w ! -o + L- .� .) a> L) L>
ACCEPTANCE OF DEDICATION
TAX CE'RTIFICAT
Tho of Onr ,cnc nnr/ All ran/ nrnnbrty to
N89°59'56'°W 488.83' REC. P77-34
N 89''5' "W 489.12' MEAS
I10.30 37.8225� 5®
`
20 Tele. 8 EI®o. Esmi00 . s
ca 50 Public Access EasemE
NCP15'19"W Automatically Vacated WI
I 71 .I6 — — Access Becomes Available
1 ®e s North Of Lot 8
m 0
1
66,886 S.F ® -\ /
ra
0 �. 1.536 AC. i , 1
VE
j 54,256 S.F ��°tA � / o �� �l
I I 1.246 AC. �' / 00
I I zz
Thi:
N6501$'22"E Fron
25.Lot
157.13' N
OD
cc PO
Mai N N Tr. -I
I _ 23.00 151,386 S. F. 1 .1> ® 0
N50,588 S.F. 3.48 AC. `1 � o
N 1.161 AC.
m 20 Drainage Esmt.
Co 1
p1 \
00 0
0 010 ® \ a
0 00 0
�ca
10' Tele. & Elec.Esmts, ® 10°Tole. 8 Elec. Esmts. 1 11
1
1 ®ee
OD
502240 S.F �.®off® W'48
Co T or1.153 AC. ®� `� �
I 1 ®� A\ rte 0\9 �-
I 3 % r0 0®
z �-
�� 6 ARC =76.12 I _ F
1'(CHD=73.63' I o j Recovered 5/8''Rob�
N 22050.00Q801L 10'2 ✓� I®.Eleo Esm4s1 I 25.00'
I III OCK
� s:
10° Tele. > Elec. Esmt. —�__� ® w
I > O
OD
20' Drainage I I 0
859736 S.F 3 Esmt. _, N 3°30;13" E N, 1
1 1.968 AC. in _� 1 ?.58.64 / Recovere
"' 13108 S.F
I°�0 3.012 AC. N6505G'07"W
04 ® I 154.52 (P78-158) ;��
Esmt.
— I 11.78' -' \ \
i
64Q�,`p7B'�5g1 O_ r
i N
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0
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5®S genies ° 1A 604
rt f . — ND
I e.
Municipality of Anchorage
Development Services Department
i Building Safety Division
On -Site Water and Wastewater Program , 1
4700 South Bragaw St. ° +
P.O. Box 196650 Anchorage, AK 99519-6650
www.cl.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. _O 17 l2 f— 6 3 HAA
1. GENERAL INFORMATION Expiration Date: _3
Complete legal description ' j -o t 3 0, 13 /o
fc S
Location (site address or directions)
K 2 30
Ari dov er Drrti�
Individual Well
Current Property owner(s)
Jofrn
E Oran& Raine_ Day phone
266 - 9 210
Mailing address
X230
ht)c6c er
Dr'i f}n�t
rg [c 99Sf�
Lending agency
R &J' Al; h / twr A9
Lvged Day phone
-j7?--&,6/,7
Mailing address
t yoo
W. 13emr o,7
)31LV /}..c/, 41c y9S0�
Real Estate Agent FS co) Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup. /ll eave erf /2,
2. NUMBER OF BEDROOMS:_
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
®
Individual On-site
59
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 Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates 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
valid ly system. forr 90 daysDSD from also the date of ssue for properties served by a private upon request to homeowners. ertificates or Class Cfwell and may be reissued lare
with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
own
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation ate sh 'nes fo� his appfy that l cit onmshows investthat the
based on procedures outlined in the Health Authority Approval
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
Investigation and inpection, the on-site water supply and/or
bedrooms and type of structure indicated herein. I further verify that sbased on the information obtained from e
Municipality of Anchorage files and from my 9
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
lai•/a Teen%tal S�cl Phone 3 d_S"! 35�—
Name of Firm 919S116,
Address "i53C/ P zv 2 200/
Engineers Printed Name �'L��"'� F iYaore Date Na
5. DSD SIGNATURE
_z Approved for bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following
ON-SITE
Additional Comments -. WASTEWATER
Attachments:
HAA Checklist
Septic System Advisory _ IG
Well Flow Advisory —
f0aintenance Agreements —
Supplemental Engineers Report
Other
Original Certificate
By: /
(Rev. IZW)
F Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519650
www.ci.anchomge.ak.us
(907) 34379(4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: .._f 30 [3//r2 9*?44,004 S/D P2 Parcel ID: 0 1 -12/-6?
A. WELL DATA
Well type • n± If A. B. or C provide PWSID #
Date completed 3 / 17 / 83 Sanitary seal (YIN) Y
Total depth 18Z R. Cased to /@Z ft.
FROM WELL LOG
Date of test 'J//7/8?
Static water level
Well Log (Y/N) Y
Wires properly protected (Y/N)
Casing height (above ground) 20 in.
AT INSPECTION
3 o ft.
Well production I S g.p.m. (lj / 8 r g.p.m.
WATER SAMPLE RESULTS:
Coliform _L—colonies/100 ml. NitrateO.
Si._,S, m9.A• Other bacteria _�Z colonies/100 ml.
Date of sample: 11 / 19 / O / Collected by:Flatrb,. -7: /i Svc
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material SCC HC / s/vir / Date installed s / 9/e3
ra�r•7/s g
Tank size 1000 gat. Number of Compartments Cleanouts (Y/N) Y
Foundation cieanout (YMlvderJe ipression over tank (Y/N) N High water alarm (YM) At ..{.
4
wr
Date of pumping LQ / rs / O r Pumper
C. ABSORPTION FIELD DATA
Date Ingtalled -71YL4-9-0 Soil rating (g.p.dJW or ft=/bdrm) If OQ��. System typeL.ia/ t-tne/i -
Length 89 R. Width S' C ZS ft. Gravel below pipe 2' 0 B' ft.
Total depth H' ft. ER. absorption area Vii@ ft= Monitoring tube Depression over field Al
10
Date of adequacy test R /W /O / Results (Pass/Fail) —�� For. bedrooms
Fluid depth in absorption field before test &Cm. Water added tiYo gal. New depth -21 -fin.
'V%S- ./..
Elapsed Time: 73 min. Final fluid depth � in. Absorption rate >= riS'G
s'o. y g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) Naas Jtrrou.n If yes, give date N. A.
D. LIFT STATION N• A.
Date installed Size in gallons Manhole/Accm (YIN)
'Pump on" level at _ in. "Pump oft level at _ in. High water alarm level at
In.
Datum Cydes tested Meets alarm b circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAtft station on lot I Cg On adjacent kits IVB'
On adjacent lots >
Absorption field on lot 96 r 1 D '
Public sewer manhole/cleanout
Public sewer main
Sewer /septic service line 7 Holding tank N A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
S'
Building foundation S Property line > 10Absorption field
Water main V 4•
Water service line > /O Surface water -> ! U 0 '
Wells on adjacent lots —
X(0 -0 -SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 5
r Building foundation > f U Water main N• 1%
Water Service line
IO' Surface water > 1 00' Driveway, PaftVN Ohlde storage b'
�_
Curtain drain N1o2G ,gem ' Wells on adjacent lots -2,100'
F. COMMENTS
Watvt/ rlJued 7/121
G. ENGINEER'S CERTIFICATION
1 certify that 1 have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name��r=
Date Nov 29� 2 0o f
HAA Fee $ 300 Waiver Fee $
Date of Payment I I / Z9 /ZLYZ/
Receipt Number 70 ?-9Q ZZ 4v—
(Rev: 12100)
Date of Payment
Receipt Number
E O�• � j a .t,`
.........................
THEODQ*E F. 490RE
MOV -29-01 08:38AM FROM-CHE ENVIROMENTAI SRV
CUE Environmental Services Inc.
s rrir�i�rrrr�rr��ri��
9075615301 T-553 P.02/05 F-393
CT&E Ref.# 1017971001 Client PO# Pte -Paid COlts/NO3
Client Name Flattop Technical Sty. Printed Date/Time 11/28/2001 8:20
Project Namc/# Ea¢lebrook Collected DalcMn a 11/19/2001 12:45
Client Sample ID UB, Blk 2, Eaglebrook p Received Date rime 11/19/2001 14:10
Alatris Drinking Water Technical Director Stephen C. Ede /%
Ordered By 4w"
PWSID p Release)
Sample Remarks:
Allocable Prep Analysis
Parameter Rewits PQL Units Method Limro Doe Date Init
Waterer Department
Ndrate-N 0.5000 0.500 mg/L EPA300.0 (<10) 11/19/01 SCL
Microbiology Laboratory
Total Coliform 0 coVl00mL SM1892228 (<1) 11/19/01 KAP
MUNICIPALITY OF ANCHORAGE
M E M O R A N D U M
SEPTIC SYSTEM ADVISORY
HEALTH AUTHORITY APPROVAL NO. Q 10 (D 0'7
Prior to a recent adequacy test on the septic system for
this lot, G•S inches of standing rater was observed in
the absorption field. This indicates that approximately
�_$ of the absorption area is inundated. Although ,
this system passed the adequacy test, the remaining life
expectancy may be limited.
This advisory must be attached to all copies of the subject
Health Authority Approval.
MUNICIPALITY OF ANCHORAGE
® DEPARTMENT OF HEALTH & HUMAN SERVICES
Q 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
Parcel I.D. # 01 `1 A 1 a.1- Ln b
=11R.
Complete legal description Lot 313; Btock 2; Eagtebrook Subdivision #2
Location (site address or directions) 6230 Andover, Anchorage, Ata.6 a
Property owner Duane R. Wohrs Day phone '564-4704 wk
Mailing address 129.40 Mtiszion Grate, Anchorage, A2azka 99516
Lending agency
Mailing address.
Day phone
Agent Kathy Fernandez/VISTA REAL ESTATE Day phone 344-9603
Address 621 West Dimond, Anchorage Ataska 99515
Unless otherwise requested, HAA will be held for pickup.
t. •
Individual well XXX
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
® ,.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
NOTE: 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
91
a
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 is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S&SEN Phone
17034 Eagle River Loop !toad No, 204
Address Eagle Rlver-,-Maska 99577
Engineer's signature
DHHS SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
bedrooms, with the following stipulations:
By: (3 41�L Ert ITS-¢ Date �
111t r,
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 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 DHHS do not
conduct inspections 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) Beck MOA#21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST 44
Legal Description: SOT �4, �L� 7 Chu �ZaarcW A Parcel I.D.
Well type 1-KAO F— If A, B, C, ADEC letter. NIA
or attach ADEC water system number
Log present lam") yE5 Date completed 3 `« g3 Driller[Zt sy Ilrid's ��t2ru 7uc �n
Total depth ��� r Cased to h�Casing height
II/a0
Sanitary seal ON) YDS Wires properly protected (8/N) XIS
FROM WELL LOG AT INSPECTION
Date of test
�
Static water level SU r a� r
v
1
Well flow g.p.m. �F� g.
ua
Pump level UK
�
SEPARATION DISTANCES FROM WELL TO:
Septic/ tank on lot On adjacent lots CDU y
� r
Absorption field on lot 91 ; On adjacent lots
Public sewer main �v/ia Public sewer manhole/cleanout
//,�NLR
Sewer service line a5 Petroleum tank 0/UE- 411/OWe,
WATER SAMPLE RESULTS:
Coliform � Nitrate GWEaTFc7FF_g Other bacteria
Date of sample: —a I ®92 Collected by: S CNG c1 +rz�Lll
B. SEPTIC/BOLDING TANK DATA
Date installed 41 "`i-�33 Tank size 1600 GALL- Compartments TWO
Cleanouts&N) TNfo Foundation cleanout ®/N) YE --S- Depression (Y/8) _Ivo
High water alarm (Y/& t "/A Alarm tested (Y/
/n� eAl
Date of pumping _®�6 � _ Pumper_ fr.� f-tUNtE S�r2UlC�}
SEPARATION DISTANCES FROM SEPTIC/H LZA- G TANK TO:
Well(s) on lot Ite r On adjacent lots I; d Foundation 5 �
To property line IUI± Absorption field , S r Water main/service line {o l�
Surface water/drainage
,¢
72-026 (Rev. 7/91)Front ZNts�D AP9ROxinmwr5t�V a.` QN —,ime CONTINUED ON BACK PAGE
6F- uP*_ 8v A.E,C.S.
STATION N/A
Date installs
Size in gallons
Vent(Y/N)
High water alarm level
"Pump on'
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Date installed ?-_�-89 Soil rating
"Pump off' level at
Cycles tested
Surface water
System type -L✓ 4J AFw
Length _ 89 Width a,5 5 Gravel thickness a Total depth
/ $
Total absorption area Y6 SF Cleanouts present ON) Y/ -,S __2& ro7?t_
Depression over field (Y6 mc® Date of adequacy test
Results (6s/fail) RAS for 1 bedrooms
Peroxide treatment (past 12 months) (Y/®)---N01---k ruowN If yes, give date N /-)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot q6 On adjacent lots Property line
PAR --r OF 88 U1'VA�DF_
To building foundation ID To existing or abandoned system on lot bs ovER 0 Y'v/P
On adjacent lots a + Cutbank N A Water main/service line_
Surface water ._____ - Ioo f Driveway, parking/vehicle storage area
Curtain drain - 0-QNCz kj,�owrJ
/D ¢
S d
-# lWArvED by 1J,?, issu&,p4o -88
E. ENGINEER'S CERTIFICATION WR # 69-0 , i>oPA�kIr 4rl)i
I certify that 1 have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Em
HAA Fee $ ZZ -01
Date of Payment �—
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
F-15116ILT1
5633BSTREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
ANALYSIS RESULTS for INVOICE # 53975
Chomlab RefA 92.2268 Sample # 3 Matrix: WATER
Client Sample ID DRINKING WATER L3B B2 EAGLEBROOK SD #2 Client Name :3 & S ENGINEERING
PWSID UA Client Acct :SHSENGP
Collected MAY 21 92 0 19:30 hrs, BPO# POB :NONE RECEIVED
Received MAY 22 92 6 14:30 his. Req#
Preserved with AS REQUIRED Ordered By :R. SHAPER
Analysis Completed MAY 27 92 Send Reports to:
Laboratory Supe �via r TEPREN C. EDE I)S f4 S ENGINEERING
Released By : C'_ tz4,,-- 2)
................................................ M ................................. M ........ M ........................ ......
Parameter Results Units Method Allowable Limits
------------------------------------------------------------------- I ------------------------------------------------------------------
NITRATE-N ND(0.10) mg/l EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY: J.W.
Remarks:
............ ................................................................ M ............................. —M— ...................
I Tests Performed See Special Instructions Above UA -Unavailable
ND- None Detected See Sample Remarks Above
NA- Not Analyzed LT -Less Than, GT -Greater Than
420813BMember of the SOS Group (Soci6t6 G(5n6rale de Surveillance)
MUNICIPALITY OF ANCHORAGE
DEPAR`rMENT OF HEALTH & HUMAN SERVICES Q
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date 7_6'-T;y
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
a
(a) Legal Description (include lot, block, subdivision, section, township, range)
Z,)7-,3,6 13teeX 1-&-07eve -W.P- _71-2-A% ZAJ 519 -5;
Location (address or directions)
(b) Property Owner Telephone: Home Business
'Mailing Address 6z,�o "VIAge f9SiL
(c) Lending Institution t
Mailing Address C
(d) Real Estate Company and Agent
Address
Telephone ®�
(e) Mail the HAA to the following address:
List contact person and day phone nu
TYPE OF RESIDENCE
Single-FamilyYN
Number of Bedrooms
U
3. WATER SUPPLY
lndividualWellx Community ❑ Public ❑
Telephone
Check here E if hold for pick up.
!r below.
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite 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.
Page 1 of 2 72-025 (Rev 8i861 From
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CH
®RAGE
P� $1ON
M��tG14Jt V.V' SE�O ALITY OF ANCHORAGE (MOA)
��v,R®Nps HEALTH AUTHORITY APPROVAL (HAA)
la �S . ECKLIST - FEBRUARY 1984
264-4720
Legal Description: A Z K
b/y
Well Classification PZ/✓ If A, B, C, D.E.C. Approved (Y/N) _
w4
Well Log Present N) Date Completed Yield
Total Depth ®��P P
Cased to /�Depth of Grouting _ —
0
Static Water Level -/ _.___r__ Pump Set At __ _ J+
P
Casing Height Above Ground ® _. Sanitary Seal on Casing CNN)
Electrical Wiring in Conduit&N) N) Depression Around Wellhead (Y(9
Separation Distances from Well:
To Septic/Holding Tank on Lot On Adjoining Lots /
To Nearest Edge of Absorption Field on Lot © 0 ® ; On Adjoining Lots
To Nearest Public Sewer Line_. A To Nearest Public Sewer
Cleanout/Manhole _ To Nearest Sewer Service Line on Lot
Water Sample Collected by _ S �J; Date 7`7
Water Sample Test Results ®—_ Y _—
Comments 7�_!�'®` ® d,/A? . __. 4'r- ___
Date Installed 31604e�f Size _ No. of Compartments _.
Standpipes ON) Air -tight Caps((Y N) Foundation Cleanout(Y N)
Depression over Tank (Y N Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) A)/A' ; for __
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (Y/N) %t —
Separation Distances from Septic/Holding Tank: i
0
To Water -Supply Well /drTo Building Foundation
0
To Property Line To Disposal Field
r
To Water Main/Service Line /® e To Stream, Pond, Lake, or Major Drainage
Course /&0 �'t-
v . i. .i" k 3��.', _ °, o '" . r? "��T A6 a / t� w #,,c,
ye,• a
�,��. d' i r �'': rD
2-
compherEp wanmC l? 7,bf ?' to . cweyf t#Ea
LiFra
Page 1 of 2
72-026(11/84)
� ',. •'. it �'
Soils Rating in Absorption Strata ® Type of System Design b
Date Installed 7'% Length of Field ?
Width of Field Depth of Field _
Gravel Bed Thickness
Square Feet of Absorption Area Standpipes Present Y/ )
Depression over Field (Y Date of Last Adequacy Test w
Results of Last Adequacy Test
Separation Distance from Absorption Field: / R
To Water -Supply Well f To Property Line
To Building Foundation `�, f' To Existing or Abandoned System on
Lot &dor On Adjoining Lots e
r
To Water Main/Service Line To Cutbank (if present) w4i
r�
To Stream/Pond/Lake/or Major Drainage Course �
To Driveway, Parking Area, or Vehicle Storage Area
Comments iz Al*t1f W ,Clyr,
D. LIFT STATION
nstalled —
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) —
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
°° Check Permitted Bedroom Rating Against HAA Request °°
Vent(Y/N)
Cycles during Adequacy Test. Meets MOA
I certify that;l h ch ed, v rified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed Date 7
Company A��5 MOA No. _®( ®_ ®p
Receipt No. _
SCP /
Date of Payment 7. _.
Amount: $ d
®S 2.2 0
Page 2 of 2
72-026(11/84)
APPLK NT FILLS OUT UPPER HAI ONLY
PhoneProperty Owner
3e
Mailing Address < Zip Code
Buyer
Address Zip Code
Lending Institution Phone
Address Zip Code
Phone
Realty Co. & Agent
Address Zip Code
5,
Legal Description
Street Location
Type of Residence
�Z Single Family
El Mtjltiple_Family No. of Bedrooms
El Other
Water Supply
X Individual ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
11 Cmmunit For wells drilled prior to that date, give well depth (attach log If available).
0 y
EJ Public Utility
Sewer Disposal
Individual
Year Individual Installed:
Ll Public Utility
When Connected to Public Utility:
7 Holding Tank
EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY
3
Time
Date
Inspector
Field Notes:
t4.,- D
"11 IMORNP-w-M =�
APPROVED BEDROOMS
DISAPPROVED
CONDITIONAL VAPPR V,
DATE
BY:
0 ✓CTCV
C)
Time
Date
Inspector
Time
Time
I
Data -70
Inspector Inspector
MUNICIPALITY OF ANCHORAGE
DEPT. OF HFA' 'TFl C,
IENVIRONMENFAL PRO-IECTION
of 12,
RECEIVED
*CONDITIONS OF APPROVAL
FWell To Absorption Area Well Log Received -rj�Ld.a_
Solis Rating Date Sewer Installed Well to Tank
JSeptic Tank Size d P7