HomeMy WebLinkAboutGREENBROOK BLK 2 LT 25Greenbrook
Block
Lot 2:5
#017-023-77
()
Municipality of Anchorage :'.':(
Development Services Department ""
Building Safety Division ·
On-Site Water and Wastewater Program, 4700 S. Bragaw SL
P.O. Box 196650 ),~chorage. AK 99519-6650 Page
www.ci.anc3orage.ak, us (907) 343-7g04
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number:. ..Cbt/OlOI(~' PID Number. ~)!'7 --C9 ?-7 - 7 7
..,,- Wastewater System: I-I New [] Upgrade
IgT.~O Lo man Crc'cfc, /I-~./) 99~'1~" ABSORPTION FIELD
LEGAL DESCRIPTION O. ~5'
Well: [] New I-I Upgrade
~, 3'*' Ho,,,e ~e~,,;¢~
SEPARATION DISTANCES [~septic r'lHolding I-IS.T.E.P. r'lOther.
Tank Field Station Tank Sen~' tine '7~ o/~ I ~..S'"(~ C-~
w~ ..... _q/-ee/
_ \¥/
~=w.,- > IoO' > ,'CO' - s~..
~,,o. I ~- ' 5"9 ' - - ~
..,.~ BENCH MARK
,/
· Engineers Stamp
Inspections performed by: ~'l~/-/c,/o 7'-eot; ..~'~,'¢ Dates: 1" ~'./t~fol
Developme~n~ervices~e/l~a.rtm~nt Approval -
Reviewed and approved by: ~2~'~/r ~/ 7~'~t'-Date: / Z/
-- / %,'~. * ~ · ...... ~,.~
PID NO: 017-023-77 LOT 25, BLOCK 2,
GREENBROOK S/D
PAGE 2 OF 2
NEW 56' LONG SOIL ABS. TRENCH
-- WITH 3.0' EFFECTIVE GRAVEL DEPTH
T.H. / ORIGINAL SOIL '!
.... ..... ....... , _ o
SEPTIC TANK
PLAN VIEW
SCALE: 1" = 30'
~_GROUND
ELEV. 97.0'
DRIVE
SWING TIES:
FROM: COR."A" COR."B"
TO:
S.T.C.O. "D" 19'
S.T.C.O. "E" 17'
DBL C.O. "F" 16.5'
OLD C.O. "G" 18'
OLD M.T. "H" 103' 77.5'
TR. C.O. "1" 96' 60'
TR. M.T. "J" 116.5' 85.5'
TR. C.O. "K" 142' 115'
COR. "C"
21.$'
28'
31'
38'
83.5'
2'+SOILCOVER
2" RIGID INS.
88.0' 3.0' GR~vEL ;: I~_iNV' LiNV.,I
,, BELOW PIPE I 88.0' I 88-
BOTTOM 56'-LONG TRENCH ELEV. 85.0'
i///--T.H. #1 Bo"FrOM ELEV. 79.0', M.T. DRY 5/25/01
PROFILE VIEW - NOT TO SCALE
CE-35C9
88.8'
LOT 25, BLOCK 2, GREENBROOK SlD
SEPTIC SYSTEM UPGRADE
AS-BUILT INSPECTION REPORT
~CI[NICAL SEI~VICES SCALE: AS NOTED
:4530 EClIO STREET DRAWN BY TFM
ANCI IOP. AGE. ALASY. J~ 99516 AUGUST, 2001
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 /~chorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWEPJ~NELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. C) / '7 - o ?....~ - '-z 7
Permit Number SWO_..~._~
Property owner(s)
Mailing address (1
Mailing address (2)
Day phone -':.':.':.':.':.':.~- ~ ¥~--7¢.z~.
Zip Code
· ' ~d
Legal descnpbon (Lot, Block & Sub .) ~/.- ~.c', ~/~.~/.< ~.
Legal description (Section, Township & Range)
Lot Size ,~' Z: '7 I0
Acre~ Number of Bedrooms
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Well Only
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: ~' ~4:~ ~
Date of Payment: .~'/.~' / 0/
Receipt Number: ~'0 "~
(Rev. 12/00)
Waiver Fees:
Date of Payment:
Receipt Number:
CIVIL & ENVIRONMENTAL ENGLNEERLNG * ENERGY CONSERVATION & ANALYSIS
TllEODORE F. MOORE, P.E. 14530 ECHO ST.
PH: (90'/) 345-1355 ANCHORAGE, ALASKA 99516
May 30, 2001
M.O.A. Development Services Department
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
The purpose of this letter is to provide the required design narrative in support of our application for
a permit to upgrade the wastewater disposal facilities on Lot 25, Block 2, Greenbrook S/D, located at
12730 Langman Circle. The original soil absorption trench was sized only large enough for a 3-
bedroom residence, whereas the residence actually has 4 bedrooms. Soils logs, per¢ test results, a site
plan, design drawings and specifications are enclosed for your review.
The proposed system will be constructed in the vicinity oftest hole # 1. As can be seen from the soil
log, the native material between 2 feet and 18.5 feet below ground level is a very silty gravel with a
measured perc rate of 48 minutes per inch. Using the soil application rate of 0.45 gpd/sq, ft. specified in
the wastewater ordinance, this 1-bedroom addition to the system requires a total absorption area of
150/0.45 = 334 square feet. The proposed 56' long trench design with 3' of effective gravel depth has a
total absorption area of 336 square feet.
The topography of the lot in the area of proposed construction slopes down towards the south, with
the original trench constructed along a bench that rises towards the west. The result is that the
distribution pipe is a little over 9 feet below ground level at the west end of the existing trench. The
proposed trench addition will be on the same bench, south and west ofthe existing trench. Although the
ground surface slopes steeply down from the edge of the bench for a drop of approximately 15 feet, the
fact that the distribution pipe will be 9.5 feet below ground level means that a line sloping down at 25%
from the distribution pipe would not daylight within 50 feet.
The new trench will be connected to the distribution pipe in the original trench near its western end,
at a point 50 feet from the end of the new trench. Because fluid is able to flow freely throughout the
length ofthe original trench we do not anticipate any problem with septic tank effluent reaching the new
trench. We also plan to install a new 1250-gallon septic tank in conjunction with this upgrade.
The proposed project will have no significant impact on present or future water supply and
wastewater disposal systems serving adjacent properties, nor will it have any significant impact on
reserved space-surface and subsurface, or on drainage. Please give me a call at 345-1355 ifyou have
any questions on this submittal.
Sincerely,
Ted Moore, P.E.
\
SEPTIC \
SYSTEM \
i i LOT 26, BLOCK 2
i ~ ,, GREENBROOK S/O
-J I \
133 ,
~ : ~ ,~,~t LOT 25, BLOCK 2,
~ ~[ II ~ ~P ~ 1250-G~LON ~
: :: ~/_ ~ISTING ~SEPT C T~K
' e' I / ' ~ ~ISTING
NOTE:
HOMES IN GREENBROOK S/D
ARE SERVED BY A CLASS
COMMUNITY WATER SYSTEM
SO THERE ARE NO WELLS ON
EITHER LOT 25 OR LOT 26
LOT 25, BLOCK 2, GREENBROOK SlD
SEPTIC SYSTEM UPGRADE
SITE PLAN
FLATTOP TECI~CA~ SERVICES 1 INCH = 50 FEET
14530 ECIIO STREET DRAWN BY TFM
ANCIIOP, AGE, ALASY. A 99516 MAY, 2001
NOTE: THIS IS NOTASURVEYED PLAT.
ALL LOCATIONS SHOWN ARE APPROXIMATE.
EXISTING SOIL ABSORPTION TRENCH --
EXISTING
C.O.
NEW 56' LONG SOIL ABS. TRENCH
W. 3.0' GRAVEL BELOW DIST. PIPE X
BETW. 9.5' & 12.5' BELOW GROUND
4" DI~ F-810 PERF-~
·
4" DIA~
D-3034
PLAN VIEW
SCALE: 1" = 10'
MONITOR TUBE
CLEANOUT
MOUND BACKFILL 6"
~- ORIGINAL GROUND
EXISTING
TRENCH
SECTION "A" - "A"
SCALE: 1" = 50'
-- 4" DI/L F-810 PERF. DIST. PIPE
-- 1Fff' - 2 1/2" SEWER GRAVEL
-- BOTTOM OF EXCAVATION
LOT 25, BLOCK 2, GREENBROOK S/D
SEPTIC SYSTEM UPGRADE
PLAN AND CROSS-SECTION
FLATTOP TEClI~CAL SERVICES
14530 ECtlO STREET
ANCl IORAGE, AK. 99516
SCALE: AS SI IOWN
DRAWN BY: TFM
MAY, 2001
Flattop Technical Services
14530 Echo Street, Anchorage, AK 99516
Phone (907) 345-1355
Lot 25, Block 2, Greenbrook S/D
12730 Langham Circle
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scopeofthe project consists ofabandoning an existing 1250-gallon septictank and
replacing it with a new 1250-gallon septic tank and constructing a new 56-foot long soil absorption
trench containing 3.5 feet of sewer gravel. The new trench is to be connected to the existing absorption
trench.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations from these drawings may be allowed or required by the engineer conducting the inspections.
Ail construction procedures and material specifications shall conform to Municipal and State
requirements. All separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around
any buried utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there are no residual
depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading
after the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the
construction.
2.0 Septic Tank:
2.1 The existing septic tank must be properly abandoned by thoroughly pumping, removing the top
and backfilling with soil.
2.2 The new 1250-gallon, 2 compartment septic tank shall be Municipally approved and shall be set
level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a
4" cleanout. Ifthe tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial
type, rigid insulation.
2.3 Ail pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a minimum slope of I/4'" per foot, and the
waste line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot.
A clcanout shall be installed within 5 feet ofthe building foundation, and a double cleanout shall be
installed within 5 feet downstream ofthe septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by excavating a 56-foot long trench to a depth of
12.5 feet below ground level at the monitor tube at the end ofthe existing trench. Insofar as possible the
long axis of the trench shall parallel a natural contour of the land.
3.2 The bottom of the excavation shall be level. Any compacted or smeared surfaces shall be raked
to allow proper infiltration. Sand for leveling or serving as filter material shall comply with Municipal
specifications.
3.3 A total of 3.5 feet of approved sewer gravel shall be placed in the bottom of the excavation with
the perforated distribution pipes laid level such that the pipe inverts are no less than 3.0 feet above the
bottom ofthe sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing
the #200 sieve.
3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design drawings. The portion ofthe monitor tube extending through the sewer gravel shall be
perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A
minimum of 2 feet of soil cover is to be placed over the filter fabric. Ifthe soil cover thickness is less
than 3 feet, two inches of rigid, burial type insulation is to be placed over the entire top surface of the
gravel, in addition to the filter fabric.
3.6 The top surface ofthe cover material shall be raised a minimum of 6 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3:1.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have
the site finish graded after the backfill material has stabilized, and for placement ofadequate topsoil and
seed to promote rapid revegetation of all areas disturbed by the construction.
4.0 Inspections:
4.1 A minimum of4 engineering inspections will be required during the course ofthe project: (1)
initial stakeout with the contractor to establish the location ofthe system and to discuss the plans,
specifications and construction procedures, {2) after the native material has been excavated to expose the
infiltrative surface to ensure that it is level and at the right elevation, and conforms with the soil test
information, (3) after the sewer gravel is in place and the distribution pipes have been laid and connected
up to the septic tank, but prior to placement of insulation or filter fabric, and (4) after rough backfill and
grading is complete. The septic tank requires one inspection after it is set level and the piping
connected, but prior to backfill. This inspection may be incorporated with any of the above inspections.
4.2 The installer shall coordinate the timing ofthe inspections with the engineer sufficiently far in
advance to ensure the availability of the engineer.
TEST HOLE
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: Lot 25, Block 2, {3reenbrook
DATE PERFORMED: May 17, 2001
PERFORMED FOR: Frank Oregersen
DEPTH ~
(feet) PL
2
3-
4-
5-
6-
13-
14-
15-
16-
17-
18-
19-
20-
COMMENTS:
SLOPE
SM Reddish sandyloam
GM/ML Gray sitty gravel
Damp, many cobbles and boulders
Some sand
Depth to Groundwater Date
._No_groun dwater 511__ 7/01
_.Nlo.~RoLtube drv 5/25/01
SITE PLAN
SEPTIC
SYSTEM
Date Reading Clock Net Time Percometer Net Drop
Time (minutes) Reading (inches)
5/17 12" Presoak 27 11116
5/18 12" Resoa_k 27 3/4
AddJ~at er.~_~tal~ 2:28 PM 23-~__~
#1 2:58 30 22._7_/8 5/8
Add water 2.'_-58:_30 23_,5/8
#2 3:_28:30 30 22 1_5/16 11/16
Add w~ter 3.:29 23_3/4
#~ ~:~9 30 23 1116 11116
PERCOLATION RATE 48 (minutes/inch) PERC HOLE DIAMETER 6"
TESTRUN BEI'WEEN 9.5 FTAND 10.0 IrT
PERFORMED BY FLATTOP TECHNICAL SERVICES. I '"/-.~,~ '~% CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCEWITHALLSTATEANDMUNICIPALGUIDELINESINEFFECTONTHISDATE. DATE: ~'-/~'¢~' /0/
EL: '~_,t" MUNICIPALITY OF ANCHORAGE
/ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME PHONE [~'~ EW
[] UPGRADE
MAILING ADDRESS ¢0 ~0~ ~ 0'-7~ ~'D
LEGAL DESCRIPTION
Well Absorption area Dwelling
~ ~ Manufacturer Material No, of comparLments
Inside length Width Liquid depth
Liq, capacity in gallons
. /~ O IF HOMEMADE;
" Well Dwelling PERMIT NO.
~ g DISTANCE TO:
0 2 ~ Manufacturer ~ :~ Material Liquid capacity in 9allons
~ Well Foundation Nearest lot line PERMIT NO.
~ DISTANCE TO: ~0 mm-~ ZO~ wid~
~ No. of lines Length of each line, ~ Total length ofli~s~ Trench Distonce between lines
~ / ~ inches
~ ~ ~ Top of tile to finish grade ~ ~ Material beneath tile~ Total effective~absorption area
~ .~ inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
¢ DISTANCE TO:
~ Class Depth Driller Distance to lot Hne PERMIT NO.
Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOl L TEST RATING
INSTALLER
REMARKS
APPROVED DATE LEGAL
72-013 IRev. 3/78)
PERMIT NO~
[:,EF'RRTMENT OF HERLTH RND EH',,,'IR]NMENTRL PR]TE]TIEN
825 '"L" STREET., RNCHORRGE., BK. 9~50Z
254-4720
C~-~--S % TE EiE~-~E~: F'EFi:~4 Z "T
82:0449 )
RPPLICRNT HERZOG C:ONSTRUCTtON CO PO BOX t0-22:7 995±i
LOCRTION
'%'=; E:2
LEI3RL [.,~._ 3REEI'.IEF.'] 3K LOT SIZE
T"r'PE OF SOIl.. RBSORP'FION S'¢STEM IS: TRENCH
MRXIMUM NUMBER OF' BEDROOMS = 4 SOIL RRTING (SQ FT,.'"BR)= 165
THE REg!UIRED SIZE OF THE SOIL RBSORPTION S"r'STEM IS:
THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DR~INFIEL[:,..
THE DEF'TH OF ~ TRENCH OF-.': PIT IS THE [:,IST~NCE' E:ETWEEN THE SURFFICE OF THE
GROUND ~I'.,ID THE E:OTTOM OF THE EXCFIV~TION (IN FEET').
THERE IS NO SET I.,.IIDTH FOF.'. TF.'ENCHES.
THE GRWCEL DEF'TH IS THE MINIHUM DEPTH OF GRAVEL BETWEEN THE OUTFBLL PIPE
~ND THE BOTTOM OF THE E',:'::C~',,,'~TION (IN FEET).
PERMIT RPPLICRNT HFIS THE RESPONSIBILIT'¢ TO INFORM THIS DEPRRTMENT DURING THE
INSTRLLRTIOhb INSF'ECTIONS OF RN"r' WELLS RDJRCENT TO 'THIS PROPERT'¢ FiND THE
NUMBER OF RESIDENCES THRT THE WELL WILL SERVE.
BRCKFiLLING OF FtN"r' SYSTEM WITHOUT FINRL INSPECTION RND RPPR. OVRL B'¢ THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
349-9987
999999 SQURRE FEET
MINIMLIM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DtSPOSRL SVSTEM IS
t00 FEET FOR R PRIVRTE WELL OR ~50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON TFIE T~PE OF PUBLIC WELL
MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND
TO R COMMUNITS' SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MR9 RPPL~'. SPECIFICRTIONS RND CONSTRUE:TION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTBLLBTION.
I CERTIF"r' THFIT
t: I FiH FRMIL. IRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH B'¢ THE MUNICIF'RLIT'¢ OF RNCHORRGE.
2: I WtL. L INSTRLL THE S"r'STEM IN FtCCORDF~NCE WITH THE CODES.
2:: I UNDERSTRND THRT THE ON-SITE SEWER S"r'STEM MR'r' REL~UIRE ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BE[:,ROOMS.
'--; I ~]NE[:,: .............
iF'F'L, ICFINT HEF.'.Z,-uS C']NSTRUC:T InN C:O
ISSUE[:, B'r ................. DF~]'E .................. (..-/ V4. ~'-~
F'ERMIT NO.
DEF'RRTMENT O,~=/tERL. TH FIND EN',?IRONMENTRL ~.., ~TECTION
8'25 "'1_'" STREET., RNCHORRGE,, BK. 995~
264-4720
82:0206 )
RF'PLICRNT
LOCRTION
LEGRL
ECL!PES CONST.
LOT 25 BLK 2 GREEN BROOK
855t NORTRR CIRCLE
LOT SIZE
TYPE OF SOIL RBSORPTION SVSTEM IS: TRENCH
MR::<iMUH NUMBER OF BEDROOMS = 4
~44-±680
99999 SQURRE FEET
SOIL RRTING <SQ FT,'"BR)= 167'
THE REQUIRED SIZE OF THE SOIL RBSORPTION SYSTEM IS:
[:,E F'TU-~ = :5: L E ~-~ ~]~'TH = E:4 ~3 F: 8"..-" E L [:.EF"I-H= 4
THE LENGTH DIMENSION IS THE LENGTH (IN FEET:) OF THE TRENCH OR [:,RBINFIELD.
THE DEPTH OF' B TRENCH OR PIT IS THE DISTBNCE BETWEEN THE SURFBCE OF THE
GROUND BND THE BOTTOM OF THE EXCBVBTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRBVEL DEPTH IS THE NINIMUM DEPTH OF GRBVEL BETWEEN THE OUTFBLL PIPE
BND THE BOTTOM OF THE EXCBVBTION (IN FEET).
F-:Ei;.~L.I Z F-:EE:, '_=.EPT 1' C: TR~-~::: ~ ][ ZE= ±25~2~
PERMIT RF'PLtCRNT HRS THE RESPONSIBILITY TO INFORM THIS [:,EPBRTMENT DLIRING THE
INSTRLLRTION INSPECTIONS OF RNY WELLS RDJBCENT TO THIS PROPERTY RND THE
NUMBER OF RESIDENCES THRT THE WELL HILL SERVE.
T~-,.lC, ,:; ~-~_' ::, ][ ~-~SF'E~Z:T :[ C,~-~S ARE F-: E ~_~ L~ ][ F-:E [:,
BRCKFILLING OF RNY S'?STEM WITHOUT FINRL INSPECTION RND FtPPRO',,,'FtL BY THIS
DEPRRTMENT WILL BE SUBJECT TO PROSECUTION.
IdlN!MUM DISTRNCE BETWEEN R WELL RND FINV ON-SITE SEWRGE DISPOSRL SYSTEM iS
±OF~ FEET FOR R PRIVRTE WELL OR ±50 TO 288 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINiNLIM DISTRNCE FF'ZM R PRIVRTE WELL TO R F'F.:IVRTE SEWER LINE IS 2R FEET FIND
TO R COMMUNIT'¢ SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS MR'¢ BPF'LY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRI'"IS PRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
PE~:M Z T E.':-:." F" :E FzES [:.EE:Ef. IEE:EE: '-~::1_.
I CERTIFY THRT
±:. I BM FRMILiRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
2: ! WILL iNSTRLL THE SYSTEM IN RCCORDRNCE HITH THE CODES.
~: i UNDERSTBND THaT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF' THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN 4 BEDROOMSi
'¢4. 0
SET ~'[OTH FOR TREHCHE'5.
-,,~H,~= ~.iELL '*~ &~g TO ",o¢~ FEET FROH
OF F J~LT,. WELL.
,~.~/ MUNICiPALIT, Y OF. ANCHORAGE,,.=.)
DEPARTMENT OF HEAL, THANDENVIRONMENTAL ?ROTECTION
~,~$ ~.. StreeT, AnPhors~eo Ale'fl~ 99~0T 2G44720
:. PER,eORMED FOR:
~'"~1~ ER CO LATION
LOG- PERCOLATION TEST
LEGAL OESCRIPTION:
-:3
4
'12
?o
SLOPE SITE PLAN
WAS o~ou.~ wA'rEr~
0
P
Oc~qelly /2,0' IF YES, AT WHAT E,
DEPTH?
I I
Reading DaTe Time Time{ {- Water Drop
.-? 'C"'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D. # c~ ! '7
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
- d 'Z ~' - "7'"7 HAA#
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent N ~ ~
Address
P~ c;/¢,r'c //-[,~,,"~ f'¢o,-'-~¢-,~.¢~ Day phone
¢ (/
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~ ~
TYPE OF WATER SUPPLY:
Individual well
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. ' '~'YPE OF WASTEWATER DISPOSAL:
Individual on-site
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
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation 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.
Nameof Firm i-~/~./-~, 7"/~4~;~,~/ ~,t.z Phone
Address 1~4-3 o ~4o %~.~. ~c4o~¢¢,. ~ ~e~/~
Engineer's signature ,~~ ~~ Date
DHHS SIGNATURE
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
By:
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) Back MOA
Municipality of Anchorage ,,JUN 0 o ]999
DEPARTMENT OF HEALTH & HUMAN SER¥~.G~E~Ln'¥ O~ANC.o~ t
Environmental Services Division F~NVIRONMENT^LSERVICE$ DIVI$11
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description: Lo
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Health Authority Approval Checklist
r-j / ~: ~ ~--r~ ~/~ r-~o/~ Parcel I.D.:
~17-~:~ ?-..7 -77
"A" If A. B. or C. attach ADEC letter. ADEC water system number
Date completed
Cased to
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
FROM WELL LOG
g.p.m.
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform
Nitrate
g.p.m.
Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed o" / / / / g 3
Tank size
Foundation cteanout (Y/N)
Date of pu'n~ping
C. ABsoRPTION FIELD DATA
Date installed
Length~ ~'$-' Width
~-~'~.~/ Number of Compartments '~ Cleanouts(Y/N) ~
Depression (Y/N) /v High water alarm (Y/N) /v. ,~
PUmper
Soil rating (g.p.d./ft~ or ft~/bdrm)
~ ' Gravel thickness below pipe
Effective absorption area F'~.E a' Monitoring Tube present (Y/N) Y'
Date of adequacy test ~,-//~ / ?~ Results (Pass/Fail)
Fluid depth in absorption field before test (in.); O Immediately after
Fluid depth 1.5' .3/~ (ins) Minutes later: ~ ~ Absorption rate = "~ 6'~ c~ g.p.d.
System type '7'~,-~ ~, c ~'
Total depth ~ ~ ~
Depression over field (Y/N) ~
For ~! bedrooms
Peroxide treatment (past 12 months) (Y/N) I~(~,,~ /~,,~,,-.-~ If yes. give date
72-026 (Rev. 3/96)*
LIFT STATION kl. ,f-.
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot -
Absorption field on lot -
Public sewer main -
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation _ I ,~ ' Property line ~O '
Water main/service line ~ tO ' Surface water/drainage '~ / oo '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Absorption field It,
Wells on adjacent lots
Property line
Surface water
Curtain drain
Building foundation '~ ~' Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
F. ENGINEER'S.CERTIFICATION
I certify that I have determined thru field inspections
in conformance with MOA HAA guidelines in effect on this date.
Signature
Engineer's Name
Date t~y 9_~,, /~99
are
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment.
Receipt Number
: APPLI(- NT FILLS OUT UPPER HA[ ONLY
Phone
Property Owner, .~,.-'~
. .
Mailing Address ... ., , : ~,. _? Zip Code ' , /
Buyer
Address ~ . Zip Cede
Lending Inst tut on. Phone
Address Zip Code
Realty Co. & Agent Phone
Address Zip Code
Legal Description
Street Locatic¢~ (~ ,~./~-/~ .~ Z2b.~')/_~ ~ '--~--~.
Type of. Residence
[~'¢~ingle Family
[] Multiple Family No. of Bedrooms_
[] Other
Water Supply
[] Individual ATTACH WELL LOG. A w641 log is required for all wells drilled since June 1975.
~P'dommunity For wells drilled prior to that date, give well depth (attach log if available).
[] Public Utility
Sewer Disposal
.[]"Individual Year Individual Installed:
[] Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
~ield...['~tes' ~¢ ..'~ ~ ,./ · MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL pROTECTION
RECEiV£D
( ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
("~) CONDITIONAL APPROVAL'
Soils Rating Date Sewer installed Well To Absorption Area Well Log Received
Well to Tank Septic Ta~k Size
72-023 (3182)
~LJ~[~ r', 'UII'IUIIIIIL;III£1L, vv~l~vu v,., -,,~-,,--,
~nqm~rin~. [, ~nulronm~nlal ~tudi~s
Subdivision
Supplemental 5oils Information.
C~,¢~h~oo~ Block ~-
LOT Z6
TH %
1
2
3
4
5
6
~ 50
10
11
t2
13
14
15
16
17
18
19
14
16
17
18
19
~e~S% ~s'~c
20
5/q/JSb
LOT
1
0
8
11
1'/
20-
1200 J. LJesl 33r(1 ~ucnu¢. ~uuit~ J~ · Anthol'aq~. Alaska 995o3 · [9071 276.1361
LOT %~
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