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HomeMy WebLinkAboutT12N R3W SEC 33 LT 32Bion 33
Lot 32B
#018-181-19
Municipality of Anchorage
Development Services Depadment
Building Safety Division
On-Site Water end Wast~afer Pr~ram, 4700 S. Bragaw SL
P.O. Box S~650 Anchorage, ~ 99519-6650 Page
~.d.an~orage.ak.us (907) ~3.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INsPEcTION REPORT
Permit Uumbec 5~OIO~11 PID Number: O1~-I~--I ~
"-Helv;~ ~.~v;~k WastewaterSystem: ~.ew ~Upgrade
W~'~t E~ Iq~ ~v~.¢ J,~a~e,~& ~5~U~/ABSORPT~ON FIELD
Well: ~New ~ Upgrade e~
~" -~+ /i IO
SEPARATION DISTANCES D sepllc ~ HoMing ~S.T,E,P. ~ Othe~
Septic Absorplion LI~Holding
,-- ~' ~7' ~' /~ '-"-'~ .'-'*'".
"~" BENCH MARK
Inspections pedormed DY'~~7 . Dates. 2~ JO-- I~-01 ~..~.-, ..........
Develbpme~t Se~lces Department Approval ~,'~
,,. ,,., //// '~,-~.'., . ,.,..-,.'"
P£R~T NO S~O ~ 05~ 1 PA~E 2 OF
Municipo~H~c_y_oF .A.n_c h.o F c~.e'
DEPARTMENT OF HEALTHAND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 mAnchop~ge, AIosko 99519-6650 m Telephone= 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
L£CAL LOT $2B, SECTION 55, T12N, RSW Pig. No. 018-181-19
/
3aA
_----_ \
~ ~ NEW 2000 GALLON ~r~\,-~
~ i E~f~fL__ J i~ ~,~.r~I
,mm' ~m ~A~IUS I ~l ,ABANDONED FOR m
~ ~ /UU w~ '"'~ m ~ ~UT2 N~W TRENCH I FUTURE USE
r'''~ ~ ~ -r J i J
~~ ~';~ ~'"'~;~'
~ , 4,. ... ............ .,~
P£R~rr NO SW010311 PAGE 5 OF 5
Municip. oAi~c oF .A.n c h.o.r'g g?.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 ,Anchor'age, Atasko. 99519-6650,Tetephone~ 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL iNSPECTION REPORT
L£C^L LOT 32B, SECTION 33, T12N, RSW
P.I.D. NO. 018--181--19
FINAL GRADE:
94.1 ,,/"
ST1 ST2 100.0'
_,
NEW 2000 '"'"'93.9'
GALLON S.T.E.P.
SYSTEM
MT3
MT3 MT2
~-101.5'
_ / ~,,/-FINAL GRADE
I S--~ .q'-- DISTRIBUTION
Iii 99.2' 98.6'
95,7''-/ 'X'"-MT2 = 95.7'
· MT1
WATER FOUND ® ~O.2'
8 ?.:;[ B.O.H.
= 95.1
PRESSURE DISTRIBUTION SYSTEM:
PUMP = 20 OSI 05HH - 5 STAGE (~30 GPM)
2 LATERALS ~ 62' & 16' LONG
30 HOLES (2.5' O.C.)
3/16"o HOLES FACED DOWNWARD
1 1/4% LATERALS
A 8
FCO 11.0' 21.0'
ST1 14.0' $2.5'
ST2 25.0' $8.0'
MH 29.0' 40.0'
MT1 72.0' 53.0'
MT2 97.,5' 72.5'
MT3 132.0' 113.0'
MT1
10/25/2001 07:34 FA][ 9078686770
NAME: E~'S FJ~EC
ADDRESS: 4101 E 142ND AVE
era~ar~z~e 01-9154
i:,Ar'£: 10/23/01
272~$91 I'IIOA~E #2:
LOT:. 3213 BLOCK: SUBDII.7,.VIOiV.. SEC 33
COMMEN'Rq C?Ji. 1ST TO
'IYPE OF ~ #2; ~,,~: ~.
IAWPEC?IO~: E!:.c~. 1::2 FLnz! ~:.f_, ....
._ ...~- ~.~ --?-~ _ -_....~.~.~...
' No aOa~o~ipli~ m~d. ~ ~ not ~ncg~ mLfil r~-~c~d, - ,
RcjJoAglvml~; .
MIEN CORRECTIONS ZtRE .~L'~DF., PI, FA.gE CALL FOR INSPEC-I~OIV
DO JVOTRE!,IOI~ Tills NOTIC~
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
I b lot
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Aug 10, 2001
Expiration Date: Aug 10, 2002
Permit Number: SW010311
Legal Description: T12N R3W SEC 33 LT 32B
Design Engineer: 0003 S & S Engineering
Owner Name: Helvie Sanvick
Owner Address: 4101 E 142ND AVENUE
ANCHORAGE, AK 99516-4021
Total Bedrooms: 5
Parcel ID: 018-181-19
Site Address: 004101 142ND AVE E
Lot Size: 39250 SQ. FT.
Permit Bedrooms: 5
This permit is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All 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 inspect[on. 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.
Received By:
Issued By:
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.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJ~VELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Permit Number SW 0 10 3! I
Property owner(s)
Mailing address (1) ~o~ F..~$'t- Iq.~N_~°.:?.v~ ·
Mailing address (2) ~,.~c'~o-~.~(~- · ~,~ ~-~.-~,~
Legal description (Lot, Block & Sub'd.)
Legal description (Section, Township & Range)
Lot Size 0 ,c~
THIS APPLICATION IS FO/~-
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Day phone
Zip Code
Number of Bedrooms ~1 ~.
[~ Well Only []
· [] Water Storage []
Jacuzzi
Water Softening Unit
[]
I certify that the above information is correct. I further cer[ify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
~Z *///~,~---'"'-"~' S & S ENGINEERING
17034 Eagle River Loop Road, No. 204
(Signature of property owner or authorized agent) Eagle River, Alaska 99577
Permit Fees:
Date of Payment:
Receipt Number:
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
ROAD DESIGH
TEST
ROBERT C. COWAN, P.E.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 69442t 1
July 25, 2001
MUNICIPALITY OF ANCHORAGE
Development Services Department
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 32b, Sec. 33, TI2N, R3W, S.M.
It is requested that you issue a permit to install a septic system with a drainfield . _
and lift station to serve the existing five bedroom (four bedroom, adding one more)
dwelling on the referenced property.
A test hole was excavated and a percolation test was performed on 7/20/01. The
approximate location of the test hole is located on the attached site plan. Ground water
was monitored as shown on the attached soils logs & water was found at 10.5 feet. After
seven days of monitoring water was still found at 10.5 feet.
We do not anticipate any adverse effects on neighboring wells, septic systems, reserve
areas or drainage patterns by the installation of the proposed septic system. The
construction of this system will not prevent any future development on any of the adjacent
properties.
If you require additional information, please contact us.
Sincerely,
RCC nm
Enclosure
17034 NORTH EAGLE RNER LOOP ',' SUITE 204 · EAGLE RIVER, A.L,'~ KA 99577
J.H.M. R,C.C. ~: '7-30-01 1 OF 2
DESIGN CRITERIA: ~U~UR~. E~SE,~,'rS. OR £~CRO^C,.~)CrS .._[//'/,~,/.:.~:;.--:.,.,.~!
~F[~ 5 BDRM = 750 GPD SHOWN ON THIS SITB P~N AR~ ~ SHOWN ON
5' DEEP DI~ANC~. AND PROPER~ UN~ PRIOR TO
3.5' EFFE~IVE CO~RU~ION.
r~X~ (e0776~4-1311 (R = 0.~)
I I CONT~OR
DISTRIBUTION SYSTEM: I
3o Ho~ (e 3.~' o.c.)
il ~ I ~EX~STING SEPTC T~K ~ --
~ I/ a U~ STATION (TO SE X
31 ' _..,~.,,~/~ ..s.~.~w ~ ,
~-' - / ~ 1500 ~LON
e I ,~ t / / N WITH LI~ STATION
~, ~:~.- tN'~' X ::z:~ '
[ g ~ ' X-EXISTING L~CHFIELE 0
' ~ ~ X°~ ~,.- .~
~ ~ 33 t
I
ALL PORTIONS OF SYSTEM ~
, WITH LESS THAN ~.5' OF
COVER REOUIRF INSULATION
~'~" LOT 32B, SEC. 33, T12N, R3W, S.M.
sol~ - ~.~ GPD/SQ.~. THOMAS H. DREYER ~ ~,~ ......
,, ~, ~, TO VE~ ~EUEN~. REQUIRED SEPA~TION
TRENCh OaIT~IA: o:~,acm. AND PROP~ UN~ PmOR TO
,,o~ ~ ,~,, ~, ~ ~.s~s~xvs ' ~ -~, ...-. :-"/~>'-- ......... · ::.%%;
~.o,~ ~,o,~.,-,,,, !_.wl~_ ~ EXISTING SEPTIC TANK ~
,,,,~,o,),,,-,,,, (~-%~4) /& LIFT STATION (TO BE ~
~ -EXISTING INSTALL NEW o
,,~ ~co / ~ ~oo OA~LOa
: ~ / / 5 SEPTIC TANK
~~ F~T~ / / ~INSTALL PUMP BASIN
~~" / / / ~ WITH Ll~ STATION
0usE
' '.i.~'~ ~ ~ALTERNATE~ SITE '
:" [ ~,~' ~ '~,k ~x,s~,~e,l aa YELL / 'SEPT]
_ __ 100' WELL RADIUS ~ J' -- 'J~'Q ~EACHFIE~ ~ITHIN 100'+
~ ~ ' I FLATi MIN. 10' 'MT
~ X /
:' ~ ~ DISCONNECT
~ z
~ O
/
- ~-- EXISTING LEACHFIELD
ALL PORTIONS OF SYSTEM ~
WIT" LESS T~ ~.S' OF 5 o ~FORFUTURE USE
COVER RFOUIR[ INSULATION ~ ~
Municipality of Anchorage ~'4~tII~WG'INEER'~
Development Services Depa~ent
On~ite Water and W~ter P~=m
4700 S~ B=gaw SL
P.O. Box 1~ ~ge. ~ ~519~6~
Sods Log - Percolation Test '
Pe,o~ed Fo~ ~' ~ G A ce ~ Date.Pe~:
Legal Des~p~on: ~ ~ ~ ~ T~ship, ~nge, ~e~:
SIo~ Site Plan
2-
3-
4-
0.o.#.
6-
7-
8-
9-
10-
11-
12-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT DEPTH?
Depth to Water A~er
Monitoring?
Reading Date Gross Time Net Time Depth to Water Net Drop
,, ,' ~ Y;" ~o ~¥" 3"
,, " /o5' vo z :3
PERCOLATION RATE ;3. ~' (mmute*Yw~o~) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ Fi' AND .~ ~/~. Fl'
$ & S ENGINEERING
PERFORMED N A(~r.r..~ V~i~'~;,~L"L"~'~A-I~"'I~N~I..3:~IPAL GUI'~ELINES IN EFFECT ON THIS DATE DATE'
, ,'UasKa Y95~7 ' '
SO~.TEST
ROBERT C. COWAN. P.E.
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CML ENGINEERS
(907) 694-2979
FAX [907) 694-121
REFERENCE: Lot 32B, Sec. 33, T12N, R3W, S.M.
August 9, 2001
GENERAL:
The scope of this project includes the installation of a 1500 gallon septic, tank
and leachfield trench for the existing five bedroom house located on the
referenced property.
Construction shall be in accordance with the approved site plan and 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 any necessary underground
utility locates.
Unless specifically agreed otherwise, the property owner shall be responsible
for final grading areas subsequently depressed from soil settling.
Contractors installing wastewater disposal systems must be certified by the
Municipal Health Department for system installations. Owners installing their
own systems must also receive prior approval from the Municipal Health
Department.
SEPTIC TANK INSTALLATION:
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.
17034 NORTH EAGLE RIVER LOOP * SUITE 204 · EAGLE RNER, ALASKA 99577
Page 2
Lot 32B, aec 33, T12N, R3W, $.M.
Augu.t 9, 2001
4. Septic tanks installed with less than 4 ft. of cover shall be insulated.
A foundation cleanout shall be installed one to four feet from the building foundation. In
the line between the tank and the leachfield there shall be two adjacent cleanouts (unless
an effluent pumping system exists within the septic tank). These cleanouts shall be
located on undisturbed soil not more than 10 ft. fxom the tank. The first cleanout, in line,
shall be to clean toward the leachfield. The second cleanout shall be to clean toward the
septic tank.
Final grading over the septic tank shall be such that a positive slope exists away from the
septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION:
Excavate the proposed trench to the dimensions shown on the design. The bottom of the
excavation shall be within 2 inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (rafted-up) before gravel (sewer rock)
placement.
Once the gravel is installed, the distribution pipe is to be installed level with the
perforations faced downward. Grovel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel layer and the native soil backfill.
Ensure the silt barrier covers the entire gravel surface before placing backfill.
Monitor tubes shall be of four (4) inch diameter, installed approximately in the locations
shown on the design, and extend a minimum of 12 inches above final grade. The portion
of the monitoring tube extending through the grovel shall be perforated from the bottom of
the trench to the invert ofthe distribution pipe. This is equivalent to the effective depth of
the gravel as noted on the design.
Backfill over the final gravel layer must not be less than twenty-four (24) inches.
Insulation must be installed when the backfill depth is less than thirty-six (36) inches. The
finish grade over the trench must be mounded to prevent the formation of a depression
after settling.
Page 3
Lot 32B~ Sec 33, Tt2N, R3W, 8.M.
Augult g, 2001
MINIMUM MATERIAL SPECIFICATIONS:
1. Any septic tank proposed for installation must be constructed by a Municipal approved
septic tank manufacturer.
2. The following pipe materials are approved for use in septic system installations in the
Municipality of Anchorage:
Type of Pipe Perforated Solid
Cast Iron
ASTM D3034 (PVC)
ASTM FSI0 (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct burial polystyrene (Dow Chemical
Company Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings (Caulder, Femco, or
equal).
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N, or equal) must be installed
between the final leachfield gravel layer and the native soil backfill.
All leachfield gravel (sewer rock) shall be 0.5"-2.5" screened gravel with less than 3%
passing the #200 sieve.
When sand is being used as a filter material, its gradation specifications must conform to
current M.O.A. or D.E.C. requirements, which ever requirement applies.
INSPECTIONS:
Typically them will be a minimum of three (3) inspections required during the installation of the
wastewater disposal system. These inspections will occur as follows:
Page 4
Lot 32B, Sec 33, T12N, R3W, $.M.
August 9, 2001
The first inspection must be conducted after the excavation of ditches, pits,
trenches, or beds and before the installation of any gravel. A septic tank may be
set in place, but may not be backfilled before this inspection.
The second inspection must be conducted after the placement of the silt barrier,
gravel, distribution lines, standpipes, cleanouts, and insulation, but before the
placement of any other backfill.
3. The final inspection is to occur upon final grading of the property.
Often there will be more than these 3 inspections required. Especially with the installation of
multiple trenches, sand filters, pressurized distribution systems, etc. Thus, the inspecting engineer
is to be contacted at least 24 hours prior to the start of construction. If necessary, a pre-
construction meeting will take place on-site. The inspecting engineer will not coordinate, direct or
control in any way the contractors activities.
The owner shall contract with the contractor to perform the work outlined in these specifications
and plans and in accordance with the attached M.O.A. permit. Them will be no contractual
arrangement existing between the contractor and S & S Engineering. S & S Engineering shall be
the owners representative and will inspect the work as stated above to document the contractors
activities. Final acceptance of the contractors work rests with the owner and the M.O.A.
S & S Engineering shall have no liability to the owner or to others for acts or omissions of the
contractor or any other persons performing work on this project or the failure of the contractor to
carry out the work in accordance with these construction documents. S & S Engineering's
inspecting engineer will not be responsible for the construction means, methods, techniques,
sequence, procedures or the safety precautions incident to this project.
CONTRACTOR/INSTALLER
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
PHONE '~Z ~'-~ [] NEW
LEGAL DESCRIPTION
I- ~ Material
No, of lines Length of eacl~ tine Total length of lines Trench width Distance between lines
iLiq. capacity in gallons
DISTANCE TO:
Type of crib
DISTANCE TO:
Crib diameter
Depth
Crib d e4~ IL
Sewer line
NO. OF SEDROOMS ,~
PERMIT NO.
No, Df compartments
Liquid depth
PER IT NO.
Total effective absorption area
Well Building foundation Nearest lot line
Building foundation
OTHER
PIPE MATERIALS
SOIL TEST RATING
/oo ~'/~
INSTALLER
REMARKS
i ,'~, ,,,~-/~,/ ' 1.¢'~ ,J~4,~ ~'~'~.
t PERMIT~NO.
Absorption area(si
Septictank // ~-- ! / '~-
72'013 (ROY. 3/78)
DATE LEGAL
DEPAWf'MI[i~NT OF' IIEAt/'FII AND ENVII:?C)NHI[IflTf~t.
B2.[..=; I... !S]'RIi!]!!W ~, ANCIff)RAI3E
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CONTACT' t:::'1K)fqli~:: 563'3560
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:t.,, ]: L:ull '[~:.uftJ.]:i. al' w:i. tll 'U-If.:! i'equ:i, p6mlelq'k.:; I'(::m cnl'"'i~i:i.t.(~ :SL!t,~¢,H"!:i
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2. :[ ,/,]i]:] :i. nsta:l, 1 t:.he syst:.em .i.l'~ ac:c:(::md,':u'~cc~ w:i,'{h ail
, 3,, I ~.:1.]. acJl'n:2r'e 't..(::) ail I'I[)A arn::I SLa't:.~.) ct.[' A],a:,l::a r~:,qu:ir~,>m(:.::~'t'.s ¢(::n' the s()'t, back
se)~JeH'age ~';,'/~'t:,~.:)g] cn~ th:i.s ~::~1' any adjacen"v[ c)r lltF)i'~['l:~y
]: und(/)rs[a~d i:.l]ai:. [his i::)0:H'm:i.t :is va].J.d ~'(:)r' a m.'~x:i, mum cof' 3 I::}~,.~c:h"[3oms and
cdp/ ('~n],ar'q(.:~merv(: w:i,].], r'(:;H]tJ:i. PE) al'l ~'?d:h::l:i, ticlna].
]: F:' A
'I"FIIEN
W:[I,.L NO'f' BE APF:'ROVI:!~D W I'l'l IOtJ'f' AIq E:L..li:CTR]:CAI..
ELECTF,:]:C, AI.. WOF;:K MI.IST BIE DONE BY A I.]:[',IEI',ISE'O
I.. :1: F:T ST(-TI" Z (:)iq ]; S I I'.I,S:;]'AI..I .E:D I Ix! fin AF;%A [;OVIEF;:E:D [.",Y I'1OA ~':' ~ 'r , ¢' ..... :'
( J ) AN IEI..I:.L, I F,,.I...AI I::'I~:I:~M ]: 'T (]lqD ]:f',lSf:'li:[:'l"]]]l',l I"IIJST E',I: (]BTA]]',IE:(}', (;:;i'.) ,.. ,~ ,. ill I,i
A F:'PI. ]: C AIq'l':
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl. PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4-
7-
8
9
lO
11
12
13
14
15
16
17
18
19
2O
F~' t~ ('Th,'cY,~ on ~.) SLOPE
DATE PERFORMED:_ (~)~' ~- ~"~'~ /
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
, Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN __ FT AND __~ FT
~72-oo~ (6179)
ANCHORAGE, ALA. -~ 99503
Phone 561.5040
DHEDKED BY .... - DATE
LIFT STAT/ON DETAIL
NEMA 4
ENCLOSURE
GALVANIZED OR PAINTED METAL COVER
2" URETHANE FOAM
GLUED TO COVER
POWER AND PUMP
CONTROL LINES
I~Xd" DIA PULL- PIPE CONNECT~'D TO
PITI_ E'SS ADAPTER FOR
PUMP REMOVAL
GROUND LEVEL
I ~ DIA STEEL PIPE
PUMP
PUMP
POWER
FILLET WELD
AROUND RIPE ~"i
o "DIA SOLID PVC PIPEi
M SEPTIC TANK
.CALDER COUPLING
DIFFERENTIAL MERCURY
FLOAT SWITCH
ALARM
CORD
ADAPTER
I ~"~" COUPL lNG
2"SOLIDPE ORAB
4' MIN / . TO ABSORPTION
A REA
~HEAT TAPE
GALVANIZED STEEL
A-~444-76)
OR ALUMINUM CULVERT
ALARM LEVEL
· PUMt
/NS/DE OF PIT SHALL |
BE COATED WITH
BITUMINOUS PAINT ORTAR
~'"~,',,',,~'~.~, d~,~tl., ,-,f' ~.../ ~ ~?" ~,,'~,
PUMP "OFF" LEVEL
GALVANIZED OR
PAINTED STEEL PLATZ
MUNICIPALITY OF ANCHORAGE
DEPARTMENTOFHEALTH&ENVIRONMENTALPROTECTION (-/-0 (T C/ [
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, A~aska 99501 'relephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAI LI N~G ADDRESS
LOCATIO~c/,3~ .¢J ~
DISTANCE TO:
Liq, capacity in 9aliens
DISTANCE TO:
IF HOMEMADE: Inside length Liquid depth
Well DweNing PERMIT NO.
DISTANCE TO: / Well
No. of lines
Top of tile to finish grade
Width
Foundation /
Total len~ :,~es
Material beneath tile
Depth
]Wd~ ~
Near~st~'~ot Jine /
Trench. ic~t h//
[Tren ~)v/;~= inches
Liquid capacity in gallons
PE I NO.
/
Distance between lines
Total eff0cdve absorption area
PERMIT NO.
Type of crib Crib diameter Crib depth Total effoelive absorption area
Well Buitding foundation Nearest lot line
DISTANCE TO:
Class Depth Driller Distance to lot tine L~._~_/_~¢,~ /
Building foundation Sewer line Septic tank I Absorptio~ a~aea(s~
DISTANCE
TO:
OTHER
PIPE MATERIALS
SOIL
TEST
RATING
INSTALLER
REMARKS
APPROVED
DATE LEGAL
72-013 (Rev. 3/78)
1:;, E F" I:::11:;;i t" H E 1".! i
[ i:)(:::l::l I :1' I' t",l
t-.IE (131::1L
I"IFIV,:!:HIII"I H I"l[i[i:'l:;' OF' I:',E[:,f;i:CICd'I:!:: ...... 1.
liE: L [~:[lql:!i'l"H l):!: lll[i:~',l~ii: ]: (:)l"lt ]i i-i; TI I1_: I [::I",IG t-I I ( '[ tl,l I:'[:F:'!' .:' OF: "1'[ Iii: 'II'I:'i:IZI",!E:I I Ii]Il';: [::'t;~:1:1:1: t".tl::' :[ [::1 I.;'
III1.: Dt::t:::II[ll (I)F t:::1 'II:;:E:I",IE:II EII;;i [::I:I:T ];S I'tlE[ l::']:}~;l"l:::lt'lll:~:fi; E:Iii'I'H[:::{::I",I t'I'][-:: i~i;I. II:;:l::'l:::l~::[: OF: ]111:
I:il:;i:CILtt:,ll:)' I:::INI) '11'11}_ l;'i:Ci"l']Ollll Cfi: 'Illl[i: Ei:i:.:iE;I'::I',,,'I:::I'I ]:Otl':l (:i:I'.,I I:Ef:!:I).
'ItlE[;;'I:::: I '5 t'40 SEI' t,I ;1: Ii)TI II:::E6:'. 'll;i[[~l.,ll::;tlt~:!ii;.
IIIE GI,;:I:::I',,,'[::I I)[~:l:!'Iq ;I.::; I'/11: H(I",I[I'IlJ['I I:)IEP"II"I l::lt:::' (:il:;~:l:::l"ll:E:l_ IiiIE:TH[i:IEI",I I'IIIE EIt.I'tFI:I!.I. [:':!:t::'E
FIl"d::, ['H[i: B()I I'EIH O1:: 'f'11[!: I:V,I::t:I'v'I::IT;!:CII",t (]:i",1 I::E:I~i'::I.
:1: I: :: l: i l ;: l ' ]: I::: h' I t'IFI [
:1.: :!: I:::11't F: f:ll"l :[ L. :[ I::1t:~: I.q ]: I'H i-HI!!: [;:'.[!~1~:!1. Ii: 1'4'.[:H[(I',I"i'S I:Of~: Of',l-":i:, ;i: I'f:: :!;[J;I,.tI:!:[;::S I::[N[) 141:1.1. S
I::CII:;;:IH [3? Ill[: I'tl..Iht]:I:::[I::'F:II.]:T'¢ Cfi:: f:IIqC:tlCIi:;:FI(~iE:
::: ]: I'1:1: [.l :1: N:::t't:::IL.t ['tie ?'¢~:'1%1'I I: H FI(::COI:~:I)f:II",IC:[:: I'1 :[ TI'I TI-II:
:~:;:: [ t..INf)EI:;i:?II:::II".f[) THI:::IT I IIE l:lhl'"'~:;:[]'l:( :~:;E. I4[::I;~: ?¢::;'1'1:1'1 t'"IF:I"Q [,~:1~:~1:;!1.):1:1:;~'.f~: l::hll..l:::l[;:Fi[il'l[X,l'l [[: file
F;'.I/~::Ei):I;'IEIq(;:E :1:~.; I;;:E:I'ICd)EI ED TO :[1",1(::1 LI[:'[~ fflCIf~'.[~: IIIFIH ":1.
:1: :::::::::J::::::) [:" , ~ ,.~,-.~..--':'~-'- "-[:: :::'' ::: ............. '"":::'
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-222'~
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5-
6-
7-
8
9
DATE PERFORMED: ~ ~''/'5 -7o~
C o lo b /,e 5 ~
SLOPE
SITE PLAN
10
11
12
13
14
15
16-
17-
18-
19-
2O
COMMENTS
WASGROUN"WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEE
'/Om 5', 5; ~
-- FT AND
(minutes/inch)
FT
72-008 (7/76)
b /~
That we~l i$ producing v,~all''
,MOON DRILLING ..
IJOX 3370
PA[MI R, ALASKA 9%45
1 [LI:PttONE 74:S-4071
BIk.~ Sub,~
I/
WELL LOG
ItLEA$1~ PAY FROM THIS INVOICE /.__~/ I
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
fi/o/
(b) Property owner ~::¢~'e
Mailing Address
(c) Lending Institution ~f~/ ~ o~ ~[~/=~ Telephone
Mailing Address
(d) Real Estate Company and Agent /"Ce /~¢.¢.
Address S ~'O O Go r ~:~'o v~x ~-~,,'
Telephone
Z76'-
Telephone: (home)'~¥-5-'~''z'~'? Business 5"d'/~ 303'3'-
(e) Mail the HAA to the following address: (or check here [], if hold for pick up.)
List contact person and day phone number below:
'7-ec.~ ~o~ re ~ ~'5'- / ~.¢'..¢
2. TYPE OF RESIDENCE
Single-Family [] Number of bedrooms
3. WATER SUPPLY
Individual Well [] Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site [] Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev 7/8§) Page 1 of 2
')pOM s,Jaeu!eua ISUO!SSajoJd aql u!
suo!ss!uJo Jo s JO J J@ JoI elq!suodsaJ lou s! e6sJoqouv jo,q!lsdfo!unR eq/'panss! s! also!t!lJeo s aJoteq elsp eZXlSUS Jo
suop, oadsu! lonpuoo lou op SHHC] jo saa,~OldUJa 'siueuJa]!nbaJ ale,s pue IsJepaj u!s),Jeo ,~JsRss oh ~ap~o u! suo!~n~!~su!
8u!pual ~!aLtl pus SeLUOq JO sJessMoJnd oi Xsa~Jnoo s ss s!q~ saop SHHC] aqj_ 'e)tSSlV to a~m,$ eq~ u! pa~a~s!6a~
~eeu!eue Isuo!ssajoJd luapuadapu! us/~q a^oqe ~ qdeJesJed u! ua^!6 suo!~e!uasaJde~ aLl~ uodn ,quo peseq pe~eo!jpao
le^oJdd¥ Alpoq),n¥ qtleaH senss! (SHHC]) sao!^~eS ueLunH pus M~leeH jo ~UaLU~]sdac] aeeJOMOu¥ to X),!led!3!un[q aM.i.
leUO!~!puoo
/
ISAoJddv ISUO!j!puoO jo SLUJa/
paAoJddss!O ~ paAoJdd¥
Xq sLuooJpaq ~ JO,[ paAoJddv
q'¢AO~dd'¢ SHHO '9
lees
MUNICIPALITY ~F ANCHORAGE (MOA)
Approval
(HAA)
343-4744
RECEIVED
A. WELL DATA
Well Classification t
Well Log Present (Y/N) )" Date Completed
TotalDepth ~o3' Casedto (~'~'
Static Water Level _ 6'7'
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot II E'
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line N,.4.
Legal Description:
£ ec~o~ 3.7
If A, B, C, D.E.C. Approved (Y/N) N, 4-.
8/~ /' 7¢' Yield
Depth of Grouting
Pump Set At ~> 8 '7 '
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Y
N
; On Adjoining Lots ;:> fcc '
/ '7 3' ; On Adjoining Lots _ ;> ~.,o '
To Nearest Public Sewer Cleanout/Manhole N, 4.
To Nearest Sewer Service Line on Lot __
Water Sample Collec!ed by
Water Sample Test Results
Comments D,X,'"~n..~ ~1/ ~(o~ ~
SEPTIC/HOLDING TANK DATA
Date Installed~¢~7~ _Size /~/ No. of Compartments
Standpipes (Y/N) .... ~ .... Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N) N,
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well I I ~"
To Property Line ~¢ '
To Water Main/Service Line ~ ~ '
To Stream, Pond, Lake or Major Drainage Course ~ (~o '
Comments
;Date 1/31 /90
,,/
Foundation Cleanout (Y/N) 'r'
Date Last Pumped I~'1~'[
; for N, ,4,
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
72-026 (Rev 7/88) From Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Datelnstalled H //~" /,~
Width of Field ..-¢.-8-r- I ~
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot ~ fo '
To Water Main/Service Line
'/L~'~ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /5- '
To Existing or Abandoned System on
; On Adjoining Lots ..~ 3'o '
To Cutback (if present) /~,/t.
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments i'1¢¢~t¢,~c¢' ¢,cc~/'~;e~ /¢~'~o~'
D. LIFT STATION
Date Installed (I lid- ,"<~'
Size in Gallons 5-g~' ~/ ;~: ~c~H /~ ~'/~
"Pump On" Level at '~ Y ~'
High Water Alarm Level at /¢~ ~'
Tested for /~y
Meets MOA Electrical Codes (Y/N) Y'
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level
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 ~.u~jQg~jn effect on the date of this
inspection.
Signed ~~ ~
Company F{~ ~g~)¢~/ ~ ~'~
~ ...................... ~...~ Engineer's Seal
MOA No. ~ - /~
Receipt No. ~/~¢ ~¢ D Receipt No.
ate of . ment P*/ Waiver
Amount: $ / ~J' ~ Date of Payment
72 026[Rev 7/88) Back Page 2 of 2
OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)5'63-2343 ~'$~J~.L~//
ANALYSIS REPORT BY SAMPLE for Work Order I i9610 '~/-
Date Report P~lntod: FZ~ 6 90 ~ 12:47
Client Sample ID:L32E, SEC 33, TL2N. R30 S~ HOSE
PWSID :UA
Collected JAN 31 90 ~ 14:45 hrs.
Received JAN 31 90 @ 16:45 hrs.
Preserved with :AS REQUIRED
Client Name : FLATTOP TECHNICAL SRV
Client Rcct: FLATTOT
P,O.~ NONE RECEIVED
Req ~
O~dered By : TED ~OORE
Analysis Completed :FEB 2 90 Send Reports to:
Laboratory Supsr/~i~_j~TEPHEN C. ZDE lJFLATTOP TECHNICAL SRV
Special
Instruct:
Chemlab Re£ ~: 9398 Lab Smpl ID: I ~at~lx; WATER
Allowabl.
Parameter Tested ReCult Units ~ethod Limit,
NITRATE-N 0.85 mg/l EPA 353.2 lO
Sample ROUTINE SA~PI, R
Hemarke: SAMPLE COLLECTED BY T.F.~.
I Test, Performed See Special Instructions Above UA-Unavailable
ND- None Detected "See Sample Remarks Ahow
Nh= Hot Analyzed LT=tesm Than. GT-G[eatez Than
I/~UN',Ci%"BTY', OF ANL.HOt~A~[
MUNICIPALITY OF ANCHORAGE I:EP[, Of
DEPARTMENT OF HEALTH AND ENVIRONMENTAl. PROTECTIONE~%~;~''~'' '
mwS ON OF ENWRO.UENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
RISC
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, renge)
Location (address or dire~ions)
(b) Applicant Name ~~'~¢"/~f~., Telephone: Home ~¢~" '/¢.~'?' Bus,ness
(c) Applicant is;[c~eck one},j B~¢¢¢]h~.l9~t~ ~; Owner/builder~; Buyer B; Other ~ (explain);
(d) Lending ns~tuid~., kl,tl .?"Lr'"~ Telephone
Address _ ~
(e) Real Estate Com~ny,,~pd
Address
Telephone
(f) Mail the HAA to tire following address:
2. TYPE OF RESIDENCE
Single-Family'~ Multi-Fa2y [] Other
Number ol Bedrooms L_
WATER SUPPLY
Individual Well~ CommunityD Public[]
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 corrr munity well system, must have written confirmation from tire State Department of Environmental Conservation
attesting to the legality and status,
Page 1 of 2 72 025 (11~84)
ENGINEERING FIRM PROVIDIF. ~NSPECTIONS, TESTS, FILE SEARCIf, D,' , AND INFORMATION
As certified by my seal alfixed hereto arrd as of the validation date shown below, I verify that my investigation of this Health
Authority Approval 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 indicaLed herein. I further verily 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 //¢'~'~ Telephone
DHEP APPROVAL
Approved for
Approved
Disapproved Conditional ..
Terms of Conditional Approval
Date
CAUTION
The Muneipality of Anchorage Department of Health end EnvJronmentaJ Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaske. The DHEP does this as a coudesy to purchasers of homes and their lending
Jnstifutione in order to setiafy certain federal and stere requirements. Employees of DHEP do not conduct inspections or
analyze dete before a eertificate is issued. The MunicipaJity of Anchorage is nor responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
WELL DATA
...... DEPT. OF HEALlH &"
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOAI
HEAl. TH AUTHORITY APPROVAL (HAA) J U N 0 (~ 1986
CHECKLIST ~ FEBRUARY 1984
264-4720
Legal Description: /._ , RECEIVED
Well Classification
Well Log Present'N)
Total Depth / ~""~
Static Water Level
~'~,)~'/t'//~7'~¢''' If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~r-/~'~-?~' Yield ~'"~,./'-') ~'~
Cased t9_ /0/ / Depth of Grouting _ ~
73-~ - Pump Set At
~_ /, ~ / Sanitary Seal on Casing~N)
Depression Around Wellhead (Y~
Casing Height Above Ground
Electrical Wiring in Co~nduit~.)N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
! /
; On Adjoining Lots
/~
To Nearest Edge of Absorption Field on Lot _ ? ~-~ / ; On Adjoining Lots
To Nearest Public Sewer Lir;e ~ To Nearest Public Sewer
Cleanout/Manhole ,~/,,4 To Nearest Sewer Service Line on Lot
Water Sample Collected by /'¢'~¢~'~' /¢, /V/Z"/ ; Date ~-~-3 '?~
Water Sample Test Results
Comments ¢
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes~N) Air-tight Caps (~N)
Depression over Tank
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) -
Separation Distances from Septic/Holdin/g Tank:
Size /Z'-'-'-5~'¢ . No. of Compartmeets ~""
ItO
/eo
Foundation Cleanout(~N)
Date Last Pumped __7
/[/fl ;for ,'~J/~ ,
Temporary Helding Tank Permit (Y/N)
/
To Building Foundation
To Disposal Field ¢'~ /
To Stream, Pond, Lake, or Major Drainage
To Water-Supply Well
To Property Line
To Water Main/Service Line
Oe ~qf2
Pa
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ,/~'0
Date Installed //-/0 -~¢
Width of Field ,~"~" ~'~)~ .f~ . /
Square Feet of Absorption Area ~/~ Cf"
Depression over Field (Y~
Results of Last Adequacy Test /~"'~b'//r'¢'''~'''' --
Separation Distance from Absorption Field:
/
To Water-Supply Well
To Building Foundation
Lot ~--~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field .~---~¢~/
·
Depth of Field (-¢
/.
Gravel Bed Thickness ~' ~
Standpipes Presen~N)
Date of Last Adequacy Test ~ ~-~ ~¢'~
To Property Line ,/~"" /
To Existing or Abandoned System on
; On Adjoining Lots ~"~
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at 4
High Water Alarm Level at 4
)~-ested for
Electrical Codes ~N)
Dimensions
Manhole/Access~N}
"Pump Off" Level at
Vent(Y/N)
t/
Pumping Cycles during Adequacy Test. Meets MOA
Comments .~,&"~ /~/~/~/~' /,~d/?
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I h~ch~ed, v~rifi~d, or conformed to all M~ and HAA guidelines in effect on the date of this inspection.
Signed ~L'~~ Date
No.
Company
Receipt No.
Date of Payment
·
Amount: $
Page 2 of 2
72-026 (11/84)
ALASKA 8 dlF oIlmel]TAL COI TI OL $Sr uIC $, IFIC.
~nqineerin§ 8 ~nuironmntd Studies
MARY & JAMES REBENACE
4](I] EAST 142ND
ANCHORAGE ALASNA
99516
SELLER-SAME
.JUNE 5 t936
MARY & JAMES REBENACI<
4101 EAST 142NU
ANCItORAGE ALASKA
99516
60257
LEDAL:T12N R3W SECTION 33 LOT 3215
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST [)ATE .JUNE 3 1986
THE TYPE OF ADSORPTION SYSTEM IS A BED WITII AN AREA OF 612 SQFT
TItE SYSTEM iS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF TIlE SYSTEM IS 603 GALLONS,
BASEI) UPON TIIE TEST DATA TIlE SYSTEM IS'ACCEPTABLE FOR A
4 BEDROOM HOME.
SEPTIC TANI( ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR
TItlS 4 BEDROOM HOUSE.
TIlE SEPTIC TANK/PACIiAGE PI,ANT WAS PUblPED ON ,JULY 25 1985 .
THIS REPORT DOES NOT VERIFY 2'lie INTEGRITY OF TIlE PIPING I,'OR TIlE WATER
SUPPLY OR WASTEWATER SYSTEbl.
FLOW TEST ON WELL
WELL FLOW DATE JUNE 3 1986
A FLOW TEST WAS PERFORMED ON TIlE WELL. 603 GALLONS OF WATER WAS
PUMPED Al' A RATE OF 8.6 i GPM OVER A DURATION OF 2.7 HOURS.
TIlE DRAWDOWN WAS 8.4 ' WITH A RECOVERY TIME OF 80 MINUTES .5 ~ ·
AND THE STATIC WATER LEVEL WAS 98.6 FEET.
THE WELL IS ADEQUATE FOR THIS 4 BEDROOM HOME,
200 ~esl 33rd hucnu¢, Suite B · Anchorage Alaska 995030(907)
bCdNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEAl,TM
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a) Legal Description (include lot, block~ subdivision, section, township, range)
Location (address or directions) ,
(b) Applicants Nam
Applicants Address C~ ([/_~_~.L..6 /c4 ~.~c~
~(c) Appl~iea.h)_i~ (check one) Lending Institution
.... Bu~ar ~ ':;i'; Other F--~ (explain);
(d) Lending' Institution
TeIephone
Address
(e) ileal Estats CO, & Agent ~~7
Address 'c~ ~ O_~J__A)~ C%6-~4'[~t~tg~
Telephone .. ~-q J - ZIO ~
(f) Mail the I~ to the following
2¥ '~of Reszoenc.
Single-Family~
Number of Bedrooms
~ate___~.' SUPP!.H
Individual Well~-----[.
Multi-Family
Other (describe)
Community ~ Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
Sewag~.O__isposal.
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 21
5. En in~i_ng Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that ny investigation of this Health Authority Approval 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 ~th all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Fir~_ ~C5
Address IL ~ O ~
(ENGINEER SEAL)
DHEP .kppr_oval
Approved for /~,'x' /~)bedrooms
Approved _--~. Disapproved
Conditional
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE ILEPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAl, ENGINEER REGISTERED
IN T~ STATE OF ALAS~%. THE DHEP DOES THIS AS A COURTESY TO ~PURCHASERS OF HOMES AND
TMEIR I~NDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP 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.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HFJkLTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
I,,~UNICIPAI.ii'Y OF ANCHORAO,~
DEPF. Ok ilEALiH &
I .u ~E L PRCidCI'iON
R i:! (] E!V D
Well Classification ~%p If A, B, Or C, D.E.C. Approved(Y/N)
Well Log P~esent ..~N) 7e ~ Date Completed ~'~ - ~ f'Q~ Yield
Total Depth ~/O%' Cased to ~ /~ ! ' Depth of Grouting
Static Wa~r. Level q 7, ~ ~ Pump Set At ~/' ~_!9 I
~asing Height Above Ground /,
Electrical Wiring in Conduit ~/N)
Separation Distan~ss f~om Well:
To Septic/~t~Pi~x~ Tank On Lot ~-/0
Sanitary Seal on Casing
Depression Around Wellhead (_Y~
_; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot~L I /
To Nearest Public Sewer Line ~3 ~
Cleancut/Manhole ~/~
Water Sample Collected By
Water Sample Test P~sults ~
; On Adjoining Lots~T/O
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date fo-ii~
B. SEPTIC/HOLDING TANK DATA
Date Installed{/~//~ Size~_~L ?O '.'-~ __. NO. of Compartments
Standpims~) ~5 Air-tight Caps ~) 9~5__ Foundation Cleanout~~
~p~ession ove~ Tank (X~O Date Last Pt~d /~
Pu~ing~aintenan~ Contract on File (~) ~- ; fo~
Holding Ta~ High-Wate~ Ala~ (Y/N) ~ ~m~ra~y Holding Tank Permit
Separation Distan~s ~ ~ptie~ Tank:
To Water-Supply ~11~..{0~.9' To ~ilding Foundation ~
To ~o~rty Li~ ~O ~ To Dis~sal Field. ~
To ~ter Main/Se~vi~ Line ~ TO S~e~, Pond, ~ke, or Major ~ainage
Cour se ~'~ ,' O0 '
[Pa~e 1 of 2]
Receipt ~
Date Paid.
Anlount: . 1f.-~:i~'.-
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~- ~-11-9%
Width of Field ~%'¢
Square Feet of Absorption Area
Depression over Field (.Y~ ~uO Date of Last Adsquacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ~-) t{; To PEoDerty Line
Length of Field
Depth of Field
Gravel Bed Thick~ess
Standpipes
To Building Foundation
Lot ~3 ~- ; On Adjoining Lots fr?/6~!
To Water Main/Service Line ~- To Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course C~ 7 ~ o ~ '
To Driveway, Pa~king Area, oE Vehicle Storage Area 71 I
~'~' P--g,q/ To Existing or Abandoned System on
D. LIFT STATION
Da~led
Size in Ga/l~
"Pump C~" Level
High Water Alarm Level at
Tested foe
Electrical Codes(Y/N)
C~ments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
~ Vent (Y/N)
** C~eck Permitted Bedrcx~m Rating Against HAA Request **
I certify that I have checked, verified, oE conformed to all MOA HAA Guicl~lines in effect
on the date of this i~.s~pection.
Company
KB1/d5/s
Date
MOA No.
[Page 2 of 2]
2-15-84
..lx~4~d~.~ON FIE[iD Ila
Soils ~:tir. g in Absorpti°n Strata
DaLe Installed
Width of Field, ....
Square Feet of ~pti~ ~ea
~press~on over ~i~l~ (Y~)
Results cf ~st
Type of System E~sign
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of L~st Adequacy Test
To Water-Supplyi..~WsllPi -h~, >: To Property Line
To Buildings. Foundation '. ~ TO Existi~ or ~ndo~d Sys~m
Lot - ; ~ ~joining
TO ','~at,.m Main/~vi~ Li~ To ~t~(if pre~nt)__
To otream~ond~ke/~.~]~ ~ai~ ~
To ~iveway, Parki~ :~ea, ~ Vehicle St~a~
· Date Installed
Dirge ns ions
Si~e in Gallons
b~w_~l at.
i'esLed for ' .... ~.::...'':'
Electrical Co~s (Y~)'
Manhole/Access (Y/N)
"Pump Off" level at /~
~/~ Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Con~n~ nts
' ' c'i~,~et i%z:'mJ I:ted Becl~oc~n RatinG AGainst ~ ~q~st **
i (~r'tifv ~at I ha~ ~ed, ~rified, ~ ~f~d to all b~3A ~ ~i~li~s in effect
2~15-84
ALASKA F1UII OFlm FITAL CO[1TROL SeRUICe5, IrIC,
~r, qiue~rin~ $ ~nuironmenlol $ludies
OCT 19 1984
ADAM JOBNSTON
4100 E 142ND AVENUE
ANCHORAGE AK 99507
SELLER - VICK VAILEY BUYER -
SUBDIVISION - T12N R3W SECTION 33 BLOCK -
LOT - J2B
ADE~dACY TEST FOR SE~4~R SYSTEM
FLOW TEST ON WELL
THE WELL FLOW RATE WAS 2,368 GPM FOR J HOURS.
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 550 S~JZT.
THE SYSTEM IS CAPABLE OF ACCEPTING ldo GALLONS OF WATER PER DAY,
THE 5URGE CAPACITY OF THE SYSTEM Z5 290 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS NOT ACCEPTABLE FOR A
HONE OF 4 BEDROOMS.
THE SEPTIC TANK WAS PUMPED ON OCT 19 1984 '1 ~
SEPTIC TANK ADE~JACY
THE EXISTING SEPTIC TAN{ VOLUME OF 1250 IS ADEQUATE FOR
THIS 4 BEDROOM HOUSE,
1200 L[lesl 33fa Auenue. Suile [~,, Auchoraqe. Al~sko 99503e(907) 561-.5040
--D ,~T~ RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
-~ATE DATE DATE
INSPECTOR INSPECTOR
INSPECTOR ,-.
MUNICIPALITY ©F ANCNO~AGE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~IVIROb~.,,[[,~,~L , . ~ LCTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
Teleph.n. 264-4720 , R~C~Iv~D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTION8: Complete all parts on page 1, Incomplete requests will not be processed. Please ~llow ten (10) days for processing.
MAILING ADDRESS--
PROPERT~ RESIDENT (l~differee~from abo~~ PHONE
2~ BUYER '
MAI LI~G A D D~R~ - '~ --
MAILING ADDRESS y ' '
4. RBALTOR/~GE~T -
PHONE
MAILING ADDRESS ' --
~--. ~E-~'~. DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER O F ,B E D~,~_~ M S
[] One '~ Four
[] Two E3 Five
[] Three [] Six
[] Other
7. WATER SUPPLY
~, INDIVIDUAL~
[] COMMUNITY
[] PUBLIC UTI LITY
8, SEWAGE DISPOSAL SYSTEM
"'~;~ INDIVIDUAL/ON-SiTE*'
[] PUBLIC UTILITY
ATTACH WELL LOG. A well Icg Is reaulrecl for all wells drilled
since June 1975. For wells dri led prior to that date, give well
depth (attach Icg if available.)
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BI.-' FORE PROCESSING CAN BE INITIATED,
;¢,' "x~qq MUN,O,PAL,,M OE ~.~.O.~ ~V,~O~.~.. ~ ~.. ~,O~
ENVIRONMENTAL ENGINEERING DIVISION
Telephone 264-4720 R E C E i ~ E D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on paae 1, Incomplete requests will not be proc0ssed, Please allow ten (10) davs for orocessing,
1. P PERTY OWNE~R
PR O¥~ERT~I~R E~' DENT (l~f dllOh~o~t from
2 BUYER
MAILING ADDRESS
MAILING ADDRESS
4, REALTOR/AGENT
PHONE
PHONE
P~'N E
PHONE
MAILING ADDRESS
E, LEGAL DESCRIPTION
STREET LOCATION
6--TYPE OF RESIDENCE
NUMBER OF BEDROOMS
,,,~ SING LE FAMILY
[] MULTIPLE FAMILY
7. WATER SUPPLY
[] One ..~J~'Four
[] Two El Five
[Z] Three [] Six
[] Other
~,~ I'qDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
S. SEWAGE DISPOSAL SYSTEM 4~' INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
+ ATTACH WELL LOG. A wall log is required for all walls drilled
since JuDe 1975. :or walls drilled prior to that date, give well
depth (attach log if available.)
'*If individual/on-site, give insta lation d to ,
If system is over Two (2) years old an adequacy test is required
NOTE: THE NSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
72-010(3/78)
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR I NSP ECTOR
DIRECTIONS:
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 LOG RECEIVED~ .~_~
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED(..~
E~PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: )o~~''~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACT~
TOTAL ABSORPTION AREA MATERIAL
4, DISTANCESwELL TO: Septic/Holding Tank Absorption Area Sewer Line Nea'rest Lot Line
Absorption Area to nearest Lot Line
'~. COMMENTS
~ APPROVED FOR ~.~-- BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev, 3/7B)
CON'rROL SERVIC' INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561.5040
JOB -- '
SHEET NO
OF
DATE~
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