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Home My WebLink AboutELMORE BLK 2 LT 15 Municipality of Anchorage Page I of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Name: .~'p~..I l I ~ IE Wastewater System: D New ~[/Upgrade Address: Phone: ~.'~,,--"T&~"~ DDeepTmnch I-IShallowTrench r'lBed ~Mound mOther Total Depth from original fade: LEGAL DESCRIPTION ~/~"~', Lot: Block: Subdivision: :)epth to pip~ boftom Irom od ir~l grade' Gravel Oepth beneath pipe I Rang Sectio~ ~ Fill added above original grade: Gravel length: WELL: D New D Upgrade Ctassihcation (Private, A.B,C): Total Depth; Cased TO: Total absOrption area: Pipe material: SEPARATION DISTANCES [] Septic ~ Ho~ain~ ~ S.T.E.P. wo,, 115 Ic~ l'5.~ ~/~ t~/A Material: NumberofComp,rtmenls: Sudace w.,~ Io5' tl~ IOc~ ~/A ~/A LIFT STATION Lot Curtain ~ump Ma~e & Model [ Electrical Inspections pedom~ed by: Remarks: BENCH MARK Inspections performed by: Dates: 1st g'-~~~:.~_..~ Department of Health and-Hunlan.Servjces'~proval ~ ~2~',., . '~, ..",~.: PLM V~£V ~4L£, ]'. 15 Ft. M~ $~4LE TOBB£N 5PURKLAND P.E, 6751 V. DIMOND BLVD. ANCH. AK. 99502-3904 ~'RIL tEE SEPTIC SYST£H AS~UILT SHEET,.3~ GRID, 3036 AC~£A6E LIFT STATION £EL~CATE~ ~EPTIC TAX~' 50 SCALE, 1' = 50 BLllCK £ LO~ ~ ~LOCKI 2 ~U~B CO~H£N~ LI~I S~ATION INSP£C~ I'£RHII ~: 92-7714 £,~TE: 6/26/199 l'ypr. OL~ INSI:'£OTiON-' £1. ECT~TCA~, S}'.I~°JIt:£ 0 0 ! NO NONCO~?LIANCf: OBSERL~E£,i [ 3 COAR£CTlO[q5 E$S£NTIAI. AS · · . ~ gXI'LAXNEO [{gL£1t,I C J I,III. L I~££XhHINE AT NEXI IU~PECIION [ :1 [:0 NOT COtJC£AL UUIIL I~EXi'ISP£CTI:I~ COHHENIS: RECEIVED AUG 1 3 1992 x u S~'F,,CT 0 A'. ,~, Z ~.//,_..., ' [ n'~'r'. .......... ~/..,..~.~--: ...... ~ ........................ : ................................ ' I,I}IEN CORl~£CllOiq$ t~}:g Nn[ig, ['Lf.,',SE CALL · '... BO ~qo.'~ REMOVE. IHI$ NOIICI! MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 #L# STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 PAGE 1 OF 1 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW920138 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:LEE APRIL K & JEFFREY D OWNER ADDRESS:4601 SHOSHONI AVE ANCHORAGE, ALASKA 99516 DATE ISSUED: 6/18/92 EXPIRATION DATE: 6/18/93 PARCEL ID:01817120 LEGAL DESCRIPTION: ELMORE BLK 2 LT 15 LOT SIZE: 37299 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: THE BOTTOM OF THE WASHED SEWER ROCK IN THIS BED SYSTEM SHALL NOT BE AT A GREATER DEPTH AT ANY LOCATION WITHIN THE BASAL BED AREA THAN 1.8 FEET FROM THE GROUND SURFACE. DATE Municipality of Division of Environmental Department of Health and 820 I Street Anchorage, Alaska 99501 T. SF'URt(LAND &751 ¥. DIMON1) BLVD. ;tNCHORA~E, ALASKA 99502-]904 (?07) 2~8-5095 Anchorage Health Social Services Qune 16, 1992 Subject: Ground Water Monitoring Lot 15, Block 2 Elmore S/D Gentlemen; Per your request we have been monitoring the groundwater condi- tion since end of March, 1992. A 4-inch monitor tube was installed approximately 10 feet distant from the existing bed. The monitor is 8 feet deep. The following observations were made. 5/20 4/15 5/1 5/8 5/21 5/29 11.5" 8" 26" 20" 14" 11" 6/4 10" The highest water level observed was 6 feet below ground. The proposed septic system design will be revised to place the bottom of the septic rock at ma×imum 2 feet below surface. Please issue the permit for this system. Yours T. SF'UF;:K-.LAND P &751 #. BIMOND BLVD. ANCHOR~G£, ~LI~SKA 99502<5901 Municipality of Anchorage Division of Environmental Health Department o{ Health and Social Services 820 I Street Anchorage, Alaska 99501 Oanuary 22s 1992 Subject: Permit for Septic System Upgrade Lot 15, Block 2 Elmore S/D Gentlemen; I have been requested to design an upgrade system lot. for subject On October 25, 1991 me established that groundwater was present within four feet of the existing absorption field. Field meas- urements also shomed that the tank mas le~s than 100 feet distant ~rom rabbit Creek. We have been monitoring the groundmater situa- tion mince October and ~o ~ar the mater level ha~ remained con- stant with 7 inches being measureC in the monitor. We intend to monitor through break-up. Please approve the proposed design, with the groundwater monitoring through break-up shoms water level. condition that no increase in T. S PURr.--.L~-~NI:) P. E. 201 ¥ ]Stho &venue, Suitt ANCXORABE,'ALASKA 99501 (907) 279'I916 LOT SEPTIC SYSTEH DESIGN 15 BLOCK 2 ELMORE BRIAN WILSON Ground Water at 7 ft. Monitor Ground Water Levels Through Breakup. Use Pressurized Bed Soil Rating. From test January 21, 1992 <lmin/in = Sand Filter .7 gal/day/ftsq Required Area per Bedroom: 150/.7 = 214.5 sq.ft.. Number of Bedrooms 4 Bed Area 4x 214.5 = 857 sq. ft. SYSTEM CONFIGURATION BED TOTAL LENSTH 47.5 FT. TOTAL WIDTH 18 FT. TOTAL AREA 855 FT. SQ. TOTAL DEPTH 1,8 .~"P6 FT. ROCK DEPTH .5 FT. COVER ~ FT. ADDED FILL I FT SEPTIC TANK 1250 GAL. EXISTINE LIFT STATION 500 GAL The installation of this s&ptic system will not prevent wells from be installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. Septic System Design Lot 15 Block 2 Elmore S/D pg.1 I__ I T~BBEN SPURKLAND P.E. 6751 ~, 91MON9 DLV9. ANCH. AK. 9950E-3904 LOt 15 AOC~ g ~LF47RE ~RI4# VE..21~ SEPTIC SYSTEH DESIGN DATE* ~ ~ 1~'~~ SHEET" ~ GRID, 3136 ,'* ',?:' Municipality of Anchorage · ' ...... DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST · LEGAL DESCRIPTION: L_~.~ ! C ~ ~Z'/'~ l-~_Lt~_Ot0..l~TOwnship, Range, Section: SLOPE SITE PLAN ,A 3- 4 5 6 7 ~.O 8 9 I0 WAS GROUND WATER ENCOUNTERED? / IF YES, AT WHAT 12 DEPTH? 7 pO E / Oat~ Reading Date Gross Net Depth to Net Time Time Water Drop 14 15- 16- 17- 18- 19- 20- PERCOLATION RATE .~ 1 Im~nutes/mch) PERC HOLE DIAMETER ~,~ Il TEST.RUN BETWEEN ~*~/~'- FT AND ¢ FT It COMMENTS PERFORMED BY; -~ 2_.~ , CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~'~t,.,¢.~ ~--~ I ~/¢~ ~1 ~ / 72-008 (Rev. 4/851 DEA£MDUN R£AD N SCALD 1' = 100 Fl', TOgBEN SPURKLAND P.E. 203 V ISTH. AVENUE ANC~ AK. 99501 LOT 15 3LOCK 2 ELM£RE ~YAN WILSON 4gOl £H~£H[NI A V£. ~^T£, JAN. p£ 1998 $~:£T, 1/3 c-~II~, 20.96 J Well 0 EXISTING RELBCATE EAS SERVICE RE£~CATE EXIgTING TAN o °l I SCALE, 1' = 50 FT. .INE ]Tll]H~EN SPURKLAN]) P.E. :~03 ~,/ 15TH. AVENUE I SEPTIC SYSTEH J)ESIGN I ~nT£, JAJV, 22, 1992 I s~£?, 2/3 ~Rn~ 3036 T . S F"URi~.I__~"~'~NI~, 20~.~ISTH. AVE. SUITE ANCHORAGE, ALASKA SPECIFICATIONS FOR SEPTIC SYSTEM INSTALLATION LOT 15 BLOCK 2 ELMORE S/D SEC 54 T12N RSW 1.0 GENERAL 1.J Owner is Brian Wilson, 2879 South Fry, Boise, Ida. 85709. Telephone 208-562-2950. 1.2 Engineer is the person or entity hired by the Owner to inspect this project. The Engineer must be recognized by the Municipality of Anchorage, Department of Hoalth and Human Services. 1.~ Contractor is the person or entity hired by the Owner to install this pro~ect. The Contractor must be recognized by the Municipality of Anchorage, Department of Health and Human Services. 1.4 The Drawings, sheets 1 through 5, shall be part of this specification. 1.5 All, materials and workmanship shall meet the require- ments o~ the Municipality of Anchorage, Department of Health and Human Services, the conditions of the permit, and all applicable rules and regulations currently in effect. J.6 All excavation depths are advisory, and are to be verified and may be modified in the field by the Engineer. 1.7 It is the responsibility of the Owner or the Contractor to adhere to the approved design, to verify that the speci- fied separation distances are met, and that the required inspections are performed. 1.8 The Contractor or the Owner shall report to the Engi- neer any observed condition which would put the septic system in violation of State or Municipal regulations. 2.0 SEPTIC TANK % 2.1 If there is an existing septic tank, it may be used if it meets the capacity requirement for the residence. The tank shall be inspected by the Engineer, and its water tightness and structural integrity shall be verified. The existing tank shall be moved to obtain the required 100 feet separation from the Rabbit Creek. Specifications for septic system installation Lot 15, Block 2 Elmore S/D pg.1 2.2 A new septic tank shall be one fabricated by either Anchorage Tank and Welding or by Greet Tank The septic tank shall be a UPC-approved two-compartment tank, constructed of 12 gauge, or better, steel with bitu mastic coating. The tank shall be set level on undisturbed soil.The tank shall be covered with the equivalent of four feet of soil. 2.5 The septic tank shall be installed a minimum of five feet from the house foundation and a minimum of five feet from the absorption area. 2.4 The septic tank shall be a minimum of 100 feet from any well serving a single residence; 100 feet from any body of water, creeks or drainage ditches with flowing water; 150 feet from Class "C" wells, and 200 feet from Class A or Class B wells. 2.5 All pipe connections to the tank shall be mechanical watertight calder couplings. Cleanouts shall be installed as designated and capped with air-tight rain caps. Clean- outs shall extend a minimum of 12 inches above final ground elevation. Provisions shall be made for landscaping and importation if topsoil. 2.6 Lift station shall be as manufactured by Anchorage Tank and Welding or as provided by Acreage Systems, Inc. 5.0 ABSORPTION FIELD 5.1 Gravel used in the absorption field shall be 0.5 to 2.5 inch screened rock, with less than 5% passing the No. 200 sieve. 5.2 Sand, used for leveling or for filtering, shall have an effective grain size between No. 40 sieve and No. 18 sieve. Uniformity coefficient shall be less than 4. Not more than 5% by weight shall pass the No. 200 sieve. 5.5 4-inch perforated pipe shall be ASTM F810. For pres- sure distribution, pipe shall be Schedule 40 PVC or ABS. 5.4 Solid 4-inch pipe s~all be Cast Iron or ASTM D5054. 5.5 Monitor standpipes shall be installed as shown. That section of the pipe penetrating the gravel shall be perfo- rated, either by drilling 0.5" holes on &-inch centers or by joining a section of F810 perforated pile to a solid section of pipe. 5.6 Geotextile shall be Mirafi 14.0. 5.7 Insulation shall be extruded direct burial polystyrene. Dow Chemical Styrofoam HI 40. Specifications for septic system installation Lot 15, Block 2 Elmore S/D pg.2 5.8 Topsoil shall be a mixture of 40-60% 20-50% sand and more that 20% silt. All measured by volume. Grass seed shall be Kentucky bluegrass. organic matter, quantities are 4.0 INSTALLATION 4.1 Locate all underground utilities, property lines, future driveways, existing or proposed water wells, water ways, surface and sub surface drainage facilities, lakes, ponds, and all other facilities requiring separation dis- tances from the proposed septic system. Notify Owner or Engineer of any observed possible conflict. 4.2 Stake alignment of system with markers showing the protective distances from wells and water bodies. 4.5 Establish an elevation benchmark. This BM shall be easily identifiable, stable and permanent. An arbitrary elevation of 100 can be assigned. Use garage concrete slab. 4.4 Install the tank as shown on the drawings. Record the inlet and outlet elevations of the tank. Tank shall be placed on undisturbed native soil. 4.5 Excavate the existing absorption field. Remove the distribution pipes and the septic rock. Place a sand filter in the excavation. Top of sand filter shall be 4 feet above highest ground water level. Compact filter by rolling and by adding sufficient water to obtain minimum 85% compaction. 4.6 Place the rock to the depth specified. Do not contami- nate rock with native materials or spoils from the e>:cava- tion. Level the rock surface (+- 1") before installing the perforated pipe. 4.7 Install the distribution pipe. Record the elevation of each joint. For pressure system solvent weld the joints. 4.8 Cover the distribution pipe with rock, and 'cover the excavation with geote~t~le be{ore backfilling and placing insulation, if required. · 4.9 Record the finished gro~nd elevation at the beginning, middle and end of trench. Record the finish ground eleva- tion ~t each corner ~nd at the midpoint of the bed. 4.10 Furnish a copy of all survey notes to the Engineer. 5.0 INSPECTIONS Specifications for septic symtem installation Lot 15, Block 2 Elmore S/D pg.5 5.) A minimum of three inspections are required. The first inspection will be of the open excavation after the removal of the existing bed. At this time the soil condi- tions will be observed and compared to the design a~sump- tio~s. Ground water conditions or presence of bedrock will be verified. The second inspection will be after placement of filter sand, gravel, standpipes, distribution piping, tank(s) and other components as specified. The third inspection will be after completion of the work. Any deficiencies will be noted and tho Contractor notified. Such deficiencies shall be corrected within ten days. 5.2 All electrical work requires either an MOA electrical inspection or certification by an licensed electrician. Submit proof of inspection or certification to the Engineer. 5.5 Submit catalog data of all mechanical equipment. 5.4 Notify Engineer at least 24 hours in advance of begin- ning any worE. Specifications for septic system installation Lot 15, Block 2 Elmore S/D pg.4 ~ MUNICIPALITY OF ANCHORAGE DEF. rMENT OF HEALTH AND HUMAN SERV. S ' ~' '- Environmental Health Division 825 %" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name ,~)~//~ /J/L$/~ DISTANCES **~,e~ TANK FIELD WELL ~a~ g~ ~ ~ AS-BUILT DIAGRAM IS.ow ,~a ,on o we 1..phc ,.tern. p,o.ny hnes. ,ounoa,,on. TANKS - FT ~,f FT 5 FT /¢ FT ~ PRIVATE ~ OTHER {Identify} Fl Fl ~vhO~ REMARKS: (3~85) WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geologica! a Geophysical Surveys Anch Elmore 15 2 ~rian Wilson J~"": 655 W. 22nd. St. ~0,..., T,,. To, ~0,,o~ 107 r,. 10 - ~mown e]~v & rooks 82 g9 O***.. 8. CASING: ~oThreo~ed ~ Wildl~ diom. b In. 1 17 lbs./ff. ~ MateHel: ~ NIQt Cement 0 Other: I$. Water Timber,lure o 0 F ~ C Somme~tlle Wel~ Drilling, A13788 MUNICIF'ALIT~Y~ OF? ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L STREET, ANCHORAGE, AK 99501 264-4720 PERMIT NO: DATE ISSUED: APPLICAN¥: ADDRESS: CONTACT PHONE: Ol~l-- S I 850697' 10/25/85 BRIAN WILSON 655 W 22ND ANCHORAGE, 277-7866 AK 99505 ' LEGAL DESCRIP: LOT SIZE: LOT LOCATION: MAX BEDROOMS: SUBDIVISION: ELMORE LOT: 15 BLOCK: 2 SECTION: 54 TOWNSHIP: 12N RANGE: 5~ lA .(SO.FT. OR ACRES) OFF DEARMOUN 4 Listed below are the options available to you in designing ~our septic system. Choose the option that best fits your site. TRENCH BED W. DF~AIN DEPTH TO PIPE BOTTO.M (FT.) 4.0 5.0 4.0 GRAVEL DEPTH (FT.) 4.0 0.5 5.0 TOTAL DEPTH (FT.) 8.0 5.5 7.0 GRAVEL WIDTH (FT.) 2.5 18.0 5.0 GRAVEL LENGTH (FT.) 50.0' 54.0 47.0 GRAVEL VOLUME (CU.YDS.) 20~9 ' 22.7 50.5 TANK SIZE (GALS) 1,250.0 ** 1,250.0 ** 1,250.0 ** SOIE RATING (SQ. FT./BR) 100 100 100 ** TANK MUST HAVE A[ LEAST TWO COMPARTMENTS I certify that: I.· I am ~amiliar with the requirements ~or on-site sewers and wells as set forth by the Municipality of Anchorage (MOA) and the State o~ Alaska. 2. I will ~install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria of this permit. 5. I will adhere to all MOA and State o~ Alaska requirements for. the set back distances ~rom any existing well, wastewater disposal s'ystem or public sewerage system on this or any adjacent or nearby lot. 4. I understand that this permit is valid for a maximum of 4 bedroom~ and any enlargement will require an additional permit. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY, MOA BUILDING CODES, THEN' (1> AN ELECTRICAL PERMIT~D ~NSPECTION MUST BE OBTAINED; (2) WILL f~OT ~E AF~ROVED""~' WITHOU~¢/¢ECTRICAL INSPECTION REPORT;" AND (~> 'THE ELECTRICAL WOR~BE D?/~/JlCENSED'ELECTRIBIA,. · , . APPLICANT: BRIAN WILSON ISSUED DY __~__~ .............. DATE: [o~~___. _ PERFORMED FOR: · Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 'L" Street. Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGALOE$CRIPTION: L,c,'~iS' ~.,J,.xJ, 2 -~'Jl~c:C_. Township, Range. Section: -~"' 5~1 TJ2~JP-~..,-- 6- 7- 8- 9- 12 13 14 15 16 17 18 20. SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S IF YES. AT WHAT ~) DEPTH? p E Water Alter 144mit~'ing? . D~te: N Gross Net Depth to Net Reeding Date /. Time Time Water Drop PERCOLATION RATE immures/tach) PERC HOLE DIAMETER .i TEST RUN BETWEEN FT AND ~ FT PERFORME~BY; /~'("~ /"~. '''eT ~pyc~'t ~t/ I ] ~ CERTIFY THAT THIS TEST WAS Pj~..RFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; 72-006 (Rev. 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:) f ~ CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) e e Property owner Mailing address Lending agency Mailing address Agent ,~'?,'; f /q?,-; ] J-~e Day phone ,~'~! 5'A~,..r/~v,; ~,,.~, ,4~4c,~-~p,¢., ~'n ~--,,~,~,.,~ Day phone Day phone Address Ed'o~ ~,~'~"o~, J'/., ~',~4~,~'~?~. A~ ~-~.~ - ~/ 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. TYPE 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. 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. NameofFirm I:l~/-J~ 7'~'c1~,,'c~1 ..C~.,--~,,c~,, Address Engineer's signature Phone, '3 ~'$-- ~ -7 ..~.~- Date )l~-~..l)g DHHS SIGNATURE [,'/ Approved for bedrooms. T/:'-, i?i P Disapproved. __ Conditional approval for bedrooms, with the following stipulations: Additional Comments The Municipali:. ot Anchorage Department of Health and Human Services (DHHS) Issues Health Authority Approval Cer'~ '.~tes based only upon the representations given in paragraph 5 above by an independent professional e; ,;~eer registered in the State of Alaska. The DHHS does this as a courtesy to pumhasers 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. REL. IVED Municipality of Anchorage ~ DEPARTMENT OF HEALTH .& HUMAN SERVICE~c,.~iY u~ ^N;..~ Environmental Sennces Division ENV~Ot~J~At S~V~CES~ 825 L Street, Room 502 · Anchorage, Alaska 99501 * (907) 343-4744 Health Authority Approval Checklist LegalDescdptlon: /..p f /.~'~ Z~/~,c~ ~., E//-,,o~"~ ..C/p Pamell.O.:. A. WELL DATA If A, B. or C, attach ADEC letter. ADEC water system numloer wellW~e F Log presem (Y/N) Total depm (o'~' /O/~¥ /~-~' Cased to ( o ? * Casing height (above ground) /~-" -/- ~' · ~ms pmpeW protected (Y/N). Y FROM WELL LOG AT INSPECTION Dateof test fo/9¥ /,~- ~/zK/~, Static water level ~ 5-' 7~"' Well production / o g.p.m. ~ 'V, ¥ g.p.m. WATER SAMPLE RESULTS: · Nitrate ~.o~ ,~ /~ Ot~rbacterta /Vo,,,~ ,~/,,,,-/',~ Collectedby: Fie~'/,,,~, 7'e ¢ ~,, ; ¢,, / $~.¢~., Date of sample: ~) IzK SEPTIC/HOLDING TANK DATA Date installed o/~£ rel~. Tankalze /~.rO~,,,/ Number of Compartments _ Foundation cteanout (YiN) /v Depression (Y/N) Pumper /f 't ~ C~eanoute (Y/N) r' High water almm (Y/N) A/./~, Date of Pumplng ,~(~-~-/9~ ABSORPTION RE~ DATA D~ i~1~ ~ / f 2 R~d d~ ~ ~ ~eld ~m ~ On.); Pe~ ~m ~ 1~ ~) ~) Sollrating (g.p.dJft=orfff/bdrm) O. 7 Systemtype ~e,,~ I~' Gravel thickness below pipe t~ Total depth ~//" Monitoring Tube present (Y/N) ~' Depression over tield (Y/N) Results (Pass/Fall) P~'~V' For z~ bedrooms Immediately after~8;~gal, water added (In.): Absorp~on rote = "~ K OO g.p.d. D. UFT STATION Date installed Manhote~Access (Y/N) High water alam~ level at* Cycles tested I O E. SEPARATION DISTANCES t' Size in gallons 'Pump on" level et" ~ ','" *Datum I~ele c~ ~m SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot I Abserptlonfleldonlot lt:a~' (I~5'° /~ m.t~.) Public sewer main ~/. Sewer/septic service line ~ Z.~" 'Pump off' level at' 72-026 (Rev. Date of Paymeot 2/z~-/ Waiver Fees Date of P~ment Receipt Number, Engineer's Name '7"~L~o ~.-/o~ I=:. t'Y o o ,-~ Date ?1 l :h.?, in conformance wt~ MOA HAA guidelines in effect o~ Ibis date. .* · : ...... ~, SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Property line I~' Surface water I/~" Cu~atn drain /~o/~ e Foundation I I ' PropeAy line Water main/sewice line ~> I~' Surface water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:. Building foundation 10' Water rnaJn/servtce line Driveway, parking/vehicle storage area Wells on adjacent lots ~> (oo ' F. ENGINEER'S CERTIFICATION Absoq~on field ~'' Wells on adjacent lots On adjacent lots ';> On adjacent lots Public sewer manhole/cJeanout Uff station 13'5' ' CT&E Environmental Se~vices Inc. CT&E ReLII Client Name Project Name/# Client Sample ID Matrix Ordered By PWSID 983952001 Flattop Technical n/a Lt 15 Blk 2 £1more S/D Drinking Water 0 Sample Remarks: Client PO# Printed Date/Time 09/01198 16:22 Collected Date/Time 08/26/98 16:00 Received Date/Time 08/26/98 18:15 Technical Director: Stephen C. Ede Released By ~ ~,~ Results Units Hethod Atio~abte Prep AnaLysis Limits Date Date Init Total CoLiform #itrate-N 0 cot/lO0~ SH18 9222B 08/26/98 KAP 2.00 0.100 mG/L EPA 300.0 10 max 08/27/98 08/27/98 RHV 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. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description LoT Location (site address or directions) Property owner Mailing address' Lending agency __ Mailing address Agent Address Day phone ,,~-/,, ~ 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. TYPE 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. 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. ~ NameofFirm '~ ~',~'~.~' ~]~'~/".-~-~c-'/'~--- Phone Address ¢~.Z) ~> ~ l ~" ~ ~ ~J,~ Engineer's signature DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date 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. Em ployees 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. T. S PURI~LAND P.E. ANCHDRAGE, ALASKA 99502-~904 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 I Street Anchorage, Alaska 99501 Sub,eot: SW920158 LOT 15 BLOCK 2 ELMORE July RECEIVED JUL g 199 · Munfcipality of Anchorage Dept. Health & Human Services Gentlemen; A conditional HAA was issued ~or this property, grade of the septic system. pending This upgrade was performed on July 5, 1992, as per the asbuilt. Please issue an unconditional HAA. an up- attached 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. it CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address. Agent Address 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 con. firmation f. rom State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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. Address ~O Enginee¢s signature DHHS SIGNATURE Approved for Disapproved. ~ . Conditional approval for bedrooms. bedrooms, with the following stipulations: Date 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 a. na!yze' data before a certificate is issued, The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work, Municipality of Anchorage . Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: L o-r'/~~; .'~ 14. ~.: ~ ~ ~ e ~ Parcel I.D. A. WELL DATA ..... Well type ~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. - ADEC water system number ? toT Y Date completed [O ,~.~o ~.~, . Driller Cased to I O '7 Casing height Wires properly protected (Y/N) Date of test Static Water level Well flow Pump level FROM WELL LOG AT INSPECTION r h-71 g.p.m. ; On adjacent lots ; On adjacent lots I SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~ ~ p'' Absorption field on lot I ~O '{' Public sewer main Sewer Service line Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate B. SEPTIC/HOLDING TANK DATA Date Installed [[' ] ' g-&~' Tank size Cleanouts (Y/N) _~ Foundation cleanout Other bacteria Collected by: Compartments ~ Depression (Y/N) ~ High water alarm (Y/N) Date of pu~nping Alarm tested (Y/N) ' ' t~/"{%. ' ' ' Pumpe~i' /~t~_ C~__~$~t"~e.,( SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ "~/')-~ On adjacent lots 1/-,~ + To property line ~O ' Abso'rpti0n field ~(~ Surface water/drainage ~Je 72-026 (Rev. 7/91) Front Foundation ~ Water main~ervice Ii'ne '~' ~"' ' CONTINUED ON BACK PAGE C. LIFT STATION r,,// Date installed ~ ' Manufacturer Size in gallons ':: ' ' ~ ' Manhole/Access (Y/N) Vent (Y/N) "Pump on" level at ' High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot ~ On adjacent lots ' D. ABSORPTION FIELD DATA Date installed Il I - ' ' ~Length S I.J WidtJ? ' ~'~ Total absorption area /~ I 4,_ - Depre?sion over field (Y/N) ' Resuits (pa's~}fail) ' ~' - , : . ,,p~mpoff,,levelat,: Cycles tested Surface water. - - Soil rating System type Gravel thickness , .z- ' Total depth Cleanouts present (Y/N) ' J'~ ,:Peroxide t~eatment (past 12 months) (Y/N) , SEPARATION DISTANCE FRoM ABSORPTION FIELD;I'O: Well on lot .On adiacent lots · Date of adequ'~cy test ~/~-?A( ' 'If yes. give date bedrooms Property line To building fc~uhdation To existing or abandoned system on lot Oh adjacent lots Cutbank Water main/service line Surface water Driveway. parking/vehicle storage area Curtain drain -' ' ' .... ' ' .... E.'ENG'INEER;S CERTIFICA~'ION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines In'effe~t'onthe'date of this inspection. Signature Engineers Name HA,~ Fee $-' 1 7~ Date of Payment Receipt Number Waiver Fee: $ Date of Paymer~t Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE. ALASKA 99518 TELEPHONE (907) 562-2343 Date Report Printed: OCT 9 91 8 11:38 FAX: (907) 561-5301 Client ~ample ID:MI!gATE L15 82 Collected $~P 27 91 4 18:00 Received SgP 28 91 8 08:00 KLNORE Client Mane Client Acct BP0 ! Ordered By Analysie Conpleted :OCI 9 91 Send Reports to: Chenlab Raf B: 915134 Lab Smpl ID: ! Matrix: #ATEB Allovahle Parameter Tested Betult Onitm Method Liners NITP, ATE-M 2.5 hq/1 EPA 353.2 10 ~ample RO~Tlb~ SAMPLE COLLECTED Testl PerforMd * See Special Inatructtorm Above UA-Unavailable Mono Detected "' See ~asple Renarks Above Not inaly~ed LT-Les, Than, CT-Greater Than ~,~ SGS Member of the SGS Group (Soci~,~ G~n~rale de Surveillance) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION . DIVISION OF ENVIRONMENTAL HEALTH ' ' ' CERT F CATE OF NSPECTION FOR HEALTH AUTHORITY APPROVAL '~,~ ~;~ .. ~) ~::.:~C~ ~. *OFON-S TE SEWER AND WATER FACILITY,:;,¢'~.:~ ;~'-:'.-'.~.,~,'*~ ~:~ ~-.?¥;~.'~--: i~"i · - ' . · .' Application Date 1.'.cGENERAL INFORMATION t * .*.;..-, :, . ,. *.',. .' ,.. * ..; ,_:;, * ; ~ ~.~;,:, ?.;*;.';'-t.~:','.,,: c,~ Legal Descnpaon 0nclude lot, bloc~ subdwls~on, section, township, range) . ,.,.; Locabon (addre~ or d rect OhS) ~.. , . ~ ,phone' Home ( , I Institution ~; Owner/budder ~; Buyer ~; Other ~.'(explmn); InStitution :, Real RESIDENCE ~, Multi-Family FI ! ~f Bedrooms~:-,--:. YATER SUPPLY - ~.-~- ..... ,*... *,,. , ~ * -': . . ,, , ~, .:- ~ ,.~... .... ~; , ~ Ind v dua We Commun t . ~ :, "' ~' '" ~ ,f community well syste~ must have written co :S i~: Communityr'l~ HoldingTankl"l ;:, ,_,. z:~::: '-.~'-':~:! .... -',-~:~.Tt'".~Note- lcommunit~well$¥$tem musthavewrittenconfirmation fromtheStateDepartmentof Environmenta[Conse~ation '2/ · ~*. ~".;' ?l,~.-attest~ng to the legahty and status., .5 y..-,'; ?: :i-':X ~:'; '~ ! ~ '.' '/:. ~ ~ ';' ~-*. '~ ~.~,.',".t;:~ ,.~'~: {*;'/,"/j.~'~' .,: ~.2'~;~,',-L' ~:- ... ENGINEERING FIRM PROVIDINb, ,NSPECTIONS, TESTS, FILE SEARCH, DA AND INFORMATION 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 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 vedfy that based on the information obtained from the Municipelity of Anchorage files and from my Investigation and inspection~ the on-site water.supply and/o~ State .cod.es ord~na, nc.es, an.d. reg~la!~ons in effect o ~'wastewater d sposa system is in coml~liance With ... · ,,..the date of this Inspection..,_ ..~,.. Name'of Firm '-' ....,.,.:.., .,.. .... · , ....... ,.., ,; .,' eng neet reg State.,o.f ,A..laska.~,T.h,e DHE~ s ~,. ,,x-'.-;.:..,'~ nsttutons nordertosat,'sfyce~'federalands~aterequl ,ployees ....... . ~.r ;.'~:";', 'analyze data before a certif cate s issued.'The Mumc~pahty of Anchorage is ~ot responsible !orerrors or.om~ss~c , . . WELL DATA ~"*~~ g~O~ HEA~--'*- LTH AUTHORITY APPROVAL (HAA) ~ ~ ,~"~ CHECKLIST-2~7~FEBRUARY We, Classification tO~l ~//~ ~ If A, B, C, D.E.C. Approved (Y/N) Well Log Present,N) . Date Completed ~ 0/~ ~/~< Yield Total Depth J O 7 ' C~ to ~ 0 7 I Depth of Grouting Static Water Lev~ ~,~ ~ Pump ~t At Casing Height A~ve Ground [, ~ / Sanita~ ~al on Casing ~N) Electrical Wiring in Conduit ~N) Depr~sion Around Wellhead (Y~ ~paration Distanc~ from Well: To ~ptic/H~ding Tank on Lot ~ 2 / ; On Adjoining Lots TO Nearest Edge of Absorption Field on Lot ~ ~ ~ ; On Ad}oining Lots To Nearest Public ~wer Line ~/~ To Nearest Public ~wer Cleanou~anhole ~/~ To Nearer ~wer ~ice Line on Lot Comments B. SEPTIC/HOLDING TANK DATA Standpipes ~/N) Depression over Tank (Y,~) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) /V/~ Separation Distances from ~pti~Holding Tank: TO Water-Supply Well ~ -~ I To Prope~y Line I 0 / To Water Main/~ic~ Line I00 + Comments No. of Compartments ~" Air-tight Caps {~N) Foundation Cleanout ~/N) Date Last Pumped /~/~ · **,or Temporary Holding Tank Permit (Y/N) /V/~. To Building Foundation '~ · TO Disposal Field / ~ ,-,,~ ~ To Stream, Pond, Lake, or Major Drainage Page 1'of 2 72-026{ 11~ 84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Date Installed I Width of Field Square Feet of Absorption Area Depression over Field (Y~ Results of Last Adequacy Test Separation Distance from Absorption Field: Type of System Design Length of Field Depth of Field Gravel ~ Thickne~ st~.~pi~ P~nt (Y/~ Dale of Last Ad~uacy Test To Water-Supply Well /(~ ~/' ! To Building Foundation Lot To Water Main/Se~ice Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line /~) / To Existing or Abandoned System on ; On Adjoining Lots ~ ~ ''''~' To Cutbank (if present) lDO * 4' D. LIFT STATION Date Installed 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 ( Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I hav~ c,~ ~M',7.k ed, yerjfied, ~r conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Dale /*1 ~_ . ./ co~.~.~ ~ /~d~ ~O~.o ~ece~m No.' /0~/ Date of Payment Amount: $ Page 2 of 2 72-026 ( I t~84) ALASKA ENVIRONI~NTAL ~ CONTROL SERVICe..~ INC. /,,.~c~. z.~ 12oo West 33rd Avenue, Suite B ~. ----~J ANCHORAGE, ALASKA 99503 ~ (907) 561-5040 SHEE? NO DATE~ DATE 5EPIC 03 HOtlSF~ II~IVIIAIAL SE'P-'J~ ~ HATER FAZ:ILITIES F~R Il, ll,l~l'~! I I:q , L N '~, ~.-~. PIT c. ~sK)s~Fz~ F, I:OOiEATIa~ TO SEPTIC T~,i ~, Fa/~ATIOK TO SEEPAGE PIT. II. SEEPAGE PIT TO ~ LInE 3, Cai I:.;TS: / ~ INDIVIDUAL SgWAGE ~D~TER FACILITIES (Fill ou~ in T~lplica~): ~. ,,a~ .Of per,on ~que,~,ng approval ~. tiu~ez,-o~e~0ms in house. ~ jl b. Depth /~ ~ ' d. Distance from well to closes~ existing 3. Seepafe Area__~L. Cesspool' i. S. Property Line houses, barn, drainaEe ditch, etc. Sewage disposal system. a. Age of system b. Septic tank capacity in gallons___ ¢. Name of septic tank manufacturer 1. If "home made" show diagram on reverse side of this form. Other sources of possible contamination, i.e., creeks, lakes, Disposal field or seepage pit size and type 1. Distance to property line to house foundation .. Percalatlom. Te~t '~esults f, ?ercolation Test performed by ,. Use t~,e reverse .side of this form to show dia£ram. Diasra~ should include '%he foJl.er,,ing infor~,ation: p.roperty llnes; .well location, house location, 4,:,,~c tank location, disposal area locatJcn, location of percolation test. a~,~ dJzection of Cround slope. TLe ~,,f',,=,-~,,n on tkis form is true and correct to the best of my knowledge. ' .~ ~natu~e o~ ^pplica~ ~ate $i~ne~ T_O_ BE FILLED OUT BY HEALTH DEPARTqENT P£RSONNEL ~wb~ve described sanitar~ facilities are hereby approved, s~ec~ ~o ~he -~ n~ conditions ~ Condit ~o~.~: The above described sanitary facilities are disapproved for the following reasons: Approval is valid for one year following the date of approval. CPJ:cw