HomeMy WebLinkAboutTURNAGAIN PARK BLK 1 TR 9
Municipality of Anchorage Page / 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
Permit Number: ~so~. PID Number:.
Name:
,,~,r,, ,~. ~oo~ Wastewater System: ~ New ~ Upgrade
Address:
~. ~.~ 2z~o~ ~,~ ~=~ ABSORPTION FIELD
Phone:
~No. olB~r~ms: D Deep Trench DShallowTrench ~Bed DMound DOther
LEGAL DESCRIPTION so,,.=..0: Total Depth from original grade:
Township: ~ Range: ~ S~hon: Fill add~ above original grade: Gravel length:
I
I
WELL: D New ~ Upgrade Gravel widlh: Numar of lines: ~ 0,sta~ ~ li~:
SEPARATION DISTANCES ~ septic ~ Holding a S.T.E.P.
Well /d~ ~ /~ i ~ ~ ~ ~ Material: Numar of Compa~menls:
Water /d~'e /OD'* ~ ~ ~ LIFT STATION
Line /~ /~ ~ ~ ~
Cu.ainDrain W~ ~ ~ ~ ~ PumpMake&M~el ~El~tricallns~tions.dorm. by:~
Remarks: BENCH MARK
: ioo. ~ ft
Inspections performed by: ~~..E. ~ Dates: l~f ~ ~-~
Department of Health,and Human Se~,ces approval
Reviewed and approved by:~ -- I 1. Date: ~
Permit No?w950548 Page 2 of 2
Municipality of Anchorage
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
Description:TURNAGAIN PARK, BLOCK 1, TRACT 9 PIDNo.: 01824205
Legal
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
-f_%
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930348
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:COOMBS RITA A
OWNER ADDRESS:P.O. BOX 220053
ANCHORAGE, AK 99522
DATE ISSUED: 9/07/93
EXPIRATION DATE: 9/07/94
PARCEL ID:01824205
LEGAL DESCRIPTION: TURNAGAIN PARK BLK 1 TR 9
1
LOT SIZE: 47480 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY: /3 J- (~" DATE:.
/ DATE:
SEWER & WATER
MAIN EXTENSI(~NrS
SEWER & WATER
INSPECTION
ROAD DESIGN
ROBERT SHAFER. P.E.
ROGER SHAFER, P.E.
August 18, 1993
CIVIL ENGINEERS
(907) 694-2979
FAX 694-121 !
{unicipality of Anchorage
)EPARTMENT OF HEALTH AND HUMAN SERVICES
325 'L' Street
~.O. Box 196650
~chorage, Alaska 99519-6650
{EFERENCE: Turnagain Park Subdivision, Tract 9
~equest you ~ssue a Dermit to drill a well and ~nsta11 a
seDtic system to serve the DroDosed four bedroom house on the
referenced DroDerty.
Two test holes were excavated and percolation tests
Derformed. The approximate locations of the test holes are
located on the attached site plan. During excavation water
was encountered at 12' in test hole #1 and after seven day
groundwater monitoring water was found at 11.5'. There was
no water found in test hole #2.
This property has enough area for a septic upgrade which can
be seen on the attached site plan. We do not anticipate any
adverse effects on neighboring properties bythe installation
of the proDosed septic system.
If you have any questions, or require additional information
for your review, please contact us.
A. Shafer, P'R~S/LSU/lsu . E.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
NV'Icl .';[£ I g
,Of:' =
~..llil Ill~ [ LEOA~ITRNAGAIN
x,~?.f ,.../
PARKSUBDIVISION. TRACT 9
I CKD. DATE
~,A S ~ ~-,/"","-~ [s.~. nr ~
co UT O
MI
CO
0
DETAIL
t
/-'FINAL GRADE
FILTER FABRIC fl~' INSULATION
~.':.'. >.;:( ;:' :'.:.. :':'.,~ ~..':.4-..:.T-.
otis j
GRAiL/SAND 20'
~ DI~. PIPES ~D ~HIN
SEWER ROCK. ~ UNDER
& ~ OVER DI~. P~ES
PROFILE
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
MATERIAL SPECIFICATIONS
REFERENCE: Turnagain Park Subdivision, Tract 9
GENERAL:
1.
e
The scope of this project includes the installation of a
1250 gallon septic tank and an absorption bed to serve
the proposed four bedroom residence 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. On all leachfield mound
systems, the property owner shall be responsible for
ensuring a satisfactory vegetation growth over the
mounded area.
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 constructedby 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.
Ail standpipes on the septic tank shall extend a minimum
of 12 inches above final grade.
Page Two
Turnagain Park Subdivision,
August 18, 1993
Tract 9
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. from 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.
e
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
LEACHFIELD BED INSTALLATION:
Excavate the proposed Bed Area to the depth shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the bottom of the excavation becomes
smeared, it must be raked or scratched (ruffed-up) before
gravel or sand placement.
If a sand layer is required, place sand over entire
excavation to the required depth shown on the design.
The top of the sand layer must be within 2 inches of
level.
Sewer rock shall be placed uniformly throughout the
entire bed. Perforated distribution pipe must be
installed level with perforations down. Gravel depth
below the perforated pipe shall be a minimum of six (6)
inches. Gravel depth above the perforated pipe shall be
a minimum of two (2) inches. The total gravel depth
throughout the entire bed shall be a minimum of twelve
(12) inches.
The perforated distribution pipes must be no more than
six feet apart. The distance between the outermost
perforated distribution pipes and the sidewall of the
absorption bed must be no more than three feet.
Page Three
Turnagain Park Subdivision, Tract
August 18, 1993
Se
Silt barrier material 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 and
installed at the locations shown on the design. The
portion of the monitor tube extending through the gravel
depth shall be perforated six (6) inches below the bottom
of the horizontal distribution lines.
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 finished grade over the bed must be
mounded to prevent the formation of a depression after
settling.
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
The following pipe materlals are approved for use in
septic system installations in the Municipality of
Anchorage:
.T~De of Pipe
~erforated ~olld
Cast Iron Yes Yes
ASTM D3034 (PVC) Yes Yes
ASTM F810 (HDPE) Yes No
ASTM D2662 (ABS) 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, Fernco, or equal).
Page Four
Turnagain Park Subdivision, Tract
August 18, 1993
5. 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.
6. All leachfield gravel (sewer rock) shall be 0.5'-2.5"
screened gravel with less than 3% passing the #200 sieve.
7. When sand is being used as a filter material, it's
gradation specifications must conform to current M.O.A.
or D.E.C. requirements.
INSPECTIONS=
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
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.
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.
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 995020650
SOILS LOG --- PERCOLATION TEST
LEGAL DE$CmPTION: '~'-6~J~l. ll~ '~I~.K : /'~/_t' I/~,~Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
I
2--
3
4,
5-
6-
7
8--
9
10
11-
12-
SITE PLAN
IF YES, AT WHAT ' I
13 - Depth to Waler AIler
14 ~:>,0, ~ Reading Date Gross
Time
15
Net Depth lo Net
Time Water Drop
16
17,
18-
19-
20-
PERCOLATION RATE /._~_~ (mmutes/,nch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~,~--'~ ~T~AND
Municipality, of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: '~L.(..
LEGAL D E S C R I PTI 0 N :'"'~E/,.~ f/,J
1
2
3
4
5
6'
7-
8-
9.
11
12
13
14-
15-
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
Net Depth to Net
18
20-
PERCOLATION ~ATE , ~--, } (m,nutes~,nchj P£RG HOLE DIAMETER
TEST RUN BETWEEN ~TND ~'~ FT
COMMEN~S .
PERFORMED By; ;7~;-; =~'.~ ~:*,'z; Lc:~ ~c~J;~,Z~~ CERTIFYT~TTHISTESTWASPERFORMEDIN
72-~ (Rev, 4/~)
PER~'I I T t~O.
i'IUN I C ~/~,~L I TY OF
DEPBRTf'IE~IT OF HEALTH AND ENVIROf'I~'IENTAL PROTECTIOf~
25i6 E. TUDOR RD., 8~'ICHORAG~, AK. 99587
276-222i
14ELL ~f4B. Of4--S I TE SEI4ER PERIl I T
APPLICANT ROBERT BLACK BX 3696 ~950i
LOCATION i"I~R D HL.f,'
LEGAL TRACT 9 Bi TURNAGAIN PARK SUB
TYPE OF SOIL ABSORBTION SYSTB.1 IS: TREt~CH
I'IRXIt,IU[,I HUf,IBER OF BEDRO01'IS = 4 SOIL RAT 110
THE REQUIRED SIZE OF THE SOIL ABSORPTION
DEF'TH= '12 LENGTH= 47
THE LEf'IGTH DI~IENSION IS THE LENGT¢
THE DEPTH OF R TRENCH OR PIT IS TF
GROUND AND THE BOTT011 OF THE EXCF
THERE IS NO SET FOR
THE GRAVEL DEPTH IS THE I'IIN
AND THE BOTTOf'I OF I EXCAVATIOfl
F~EBUIREB SE ~TiO TR
BBC)4FILLIHG OF ANY SYST WITHOUT FINF
DEPARTf'IENT I.IILL BE SUB T TO PROSECI
['IINI['IUt. I DISTANCE BETWEEN I, IELL AND
100 FEET FOR A PRIVATE WEL OR 208
WELL LOGS ARE REQUIRED AND BE
OF THE WELL CO~'IPLETIO~.
SF'ECIFICRTIONS RND CONSTRUCT
I NSTRLLRTI ON.
LOT SIZE
~44-5852
72808 SQURRE FEET
FT?BR)= 140
I)EF'TH= 6
OF THE TRENCH OR DRAIHFIELD.
BETWEEN THE SURFACE OF THE
BETWEEN THE OUTFALL PIPE
$ I ZE= ::L25c4 6F-I LLO I'-.i$
I[ISPECTION AND APPRO'v'AL BY THIS
ON-SITE SEI,IRGE DISPOSAL SYSTEI'I IS
FOR A PUBLIC WELL
TO THE DEPARTI'IENT I, IITHIN ;0 DAYS
'~RAI~I$ ARE AVAILABLE TO INSURE PROPER
F'ERI'-'I I T '-.-'Fro L I D FOR OI'4E "¢EFmR FROI"I I $SLIE
I CERTIFY THFIT
st: I Rf'l FAr'IILIAR I4ITH THE REQUIREI'IEIITS FOR ON-SITE SEI,I'ERS AND I,IELLS AS SET
FORTH BY THE ~'IUNICIPALITY OF ANCHORAGE.
2: I I,IILL I[.ISTRLL THE SYSTEI.1 IN ACCORDANCE I,IITH THE CODES.
~: I UNDERSTAND THAT THE ON-SITE SEWER SYSTE~,I IIAY REQUIRE ENLBRGEIIENT IF THE
RE$IDEf.~CE IS REI';ODELED TO INCLUDE I~IORE THAN 4 BEDROOf'I$.
s I GNED: _
APPLI(ANT ROBERT
ISSUED .... ......
1977
#?6509
Robert Black
~ox 3696
Anchorage, Alaska 99501
SubJ eot ~ Permit F~piration
Dear }L=. ~lack~
A~ernit issued by this department for well and/or on-site
sewer ~nstallation on Tract 9 Block i Turnagain Park
Subdivision has expired since the issue date ~xceeds one
(1) year.
In the event you still plan to install tho well and/or on-
site sewer syste~ a new permit is required. The original
soil test may be used to obtain a current permit.
If the well has been drilled, a we11 log should be sent
to this department to document the installation date.
If you have any questions regarding the above matterw please
do not hesitate to contact this office ~e~iately at 279-
2511w extension 224 or 225.
Sincerely,
Les ~I. ~uchholzw
Sanitarian
C ' /~JNIL"IPALITY OF ANOtOR~GE
~ ~ DEm'. OF HEALTH
~ I ( ,IVIRONMENTAL PRO~CTIOi~
2204 Clevefl. alT. d A,¢hoz'a.g'e, A].a,,::ka
Performed For ~--------~Of'" WOe
Lena1 ~lescrt ~ ~'~ Date Performed
ntion: Lot Blocl:. / Subdivision ~'~"q
This rorm Renorts'Sotls Loq ,4/,-~ Percolatioh Test_
Soil Characteristics
Penth
Feet
4 -
6 ·
8~
10~
. J
20~
Was Ground Water Encountere~?
I~ Yes, At ~hat Denth?
J" Readinq Date Grnss Time Net Time Depth to H20 Net Dron
colatinn Rate .~-L-~_ - /
Prnnosed Installation: Seenaae Pit Drain Field
Oeeth of Inlet Deoth To Bottom Of~tt Or Trench
Test Performed By ,'~,,~ ~l~C ~ Data
Certified BY:
Date: /~/~
Mmficipality of Anchorage
Department of Health and Human Services
Rick Mystrom, 825 "L" Street
Mayor P,O, Box 196650 Anchorage, Alaska 99519-6650
343-4744
May 9, 1997
Steven R. Pannone, P.E.
P.O. Box 142025
Anchorage, Alaska 99514
Subject: Waiver Request for Tract 9 Block 1Turnagain Park Subdivision
Waiver Request #WR970015, . PID ~018-242-05
Dear Mr. Pannone:
Your request for a waiver of the required 10 foot separation
between an on-site wastewater disposal system and a lot line has
been approved. The waived distance is 3.5 feet from the property
line to the monitor tube.
This approval applies to the existing on-site wastewater disposal
system lot line separation only. Any future upgrade to the on-site
wastewater disposal system will require all separations be met or
another approval from this department.
If there any further questions or concerns regarding this waiver,
please call our office at 343-4744.
Sincerely,
Daniel J. Roth
Civil Engineer
On-site Services
lJw ~7
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-site Services Section
WR# WR970015
Date Received:
Waiver Review Worksheet
PID# 018-242-05 HA# HA970153
04-23-97
Permit #
Legal Description: . Tract 9.Block I Turna~ain Park
Engineer: Steven R. Pennone, P.E.
Applicant: Rita Coombs & David Ginnett
Waiver Requested: Lot line waiver to 3.5'
Criteria: 1. Geology: Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
TOTAL:
2. Special Conditions:
3. O~her:
Waiver is Granted: X Waiver is NOT Granted:
List Conditions or Reasons for above:
Date: .~-- ?-~7 By: p//~/
Rec #: 02849
Amount: $ 11~,00
Name of Reviewer
Date Paid: 04-2~-~7
Steven R. Pannone, P.E.
Consulting Engineer
(907} 272-8218
Apd120, 1997
P.O. Box 142025
Aachorage, Alaska, 99514
{907~}272-8218 F:tx
Municipality of Anchorage
Dept. ofHealth & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519
Subject:
Tract 9, Block I Tumagain Park Subdivision
Request for a Lot Line Waiver
Gentlemen:
My firm was contacted to conduct a Health Authority Investigate ofthe well and septic system serving this
lot for a pending sale. During the investigation, it was discovered that the south west coruer ofthe soil
absorption system is closer than the required I0 feet to the property line. A surveyor had staked the
approximate south property line. I measured approximately 5.5 feet from the property line to the monitor
tube. The monitor tube is located approximately two feet from the edge ofthe bed. Therefore, based on the
information gathered this date, I request the MOA issue a lot line waiver to 3.5 feet for this system. The lot
located to the south ofTract 9 in currently undeveloped, though excavation has started for a new home
construction.
Thank you for considering this request, lfyou have any questions about the proposed installation, please
contact me at 272-8218
Sincerely,
~t~e~n ~one, P.E.
C:\WORIO~ I TLr~NI.001
.MUNICIPALITY OF. ANCHORAGE
DEPARTMENT OF HEALTH &,'HUMAN SERvIC~ES
Division of Environmental Services
On,Site Services Section.
P.O. Box 196650: Anchorage Alaska 99519-6650
343-4744
.. CERTIFICATE OF F!~-~LTH AUTHORITY :
APPROVAL FOR A SINGLE FAMILY DWELLING.:
-.
GENERAL INFORMATION "'"' ....... "
Complete legal deccription
Location (site address or directions) . /~'/-~"'~c~ '-z-~,z.~.,~¢,,4,.,~, ~'-~
Mailing~ddress
Lending agency Day phone
Mailing address :
Agent. Day phone
Address
e
Unless otherwise requested, HAA wi!l be held for pickup.
NUMBER OF BEDROOMS: z/,~'
TYPE OF WATER SUPPLY:
Individual well "lc.
Community well
Public water
RECEIVED
APR 2 1997
Municipality of Anchorage
Dept. Health & Human Services
NOTE: If community well system, ' ~ "' ' ' · ·
prowde written confirmabon from State ADEC attest-
.lng to the legality and status of system.
TYPE OF ' ' ' " '" " '
4. WASTEWATER DISPOSAL:
Individ'. -! on-site
Holding tank
ity '
Commun on-site .. ' . ~.' ;:' -~'--,
Public sewer. , ,,/,,. ~,
NOTE: If commumtywastewater s stem ~ovide
.. Y , P written confirmation from State ADEC
at!esting to the lega/ity and status of syst~m.'
STATEMENT OF, INSPECTION BY. ENGINEER.' -
As certified by my'seal affixed hereto and as of th~ validation date shown below, I verify that my
investigation of this Health Autholri~App~"o~'~,l. appli~ation shows, that tl~e on-site water supply
and/or wast~water disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I fu rth~r ~;erifY tha~ based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or w..aste~ater.dispo~al system !~ in ~_omp!ia~nce'witl~.ell Udnicipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Engineer's signature-..~~---~
Phone ~;z~ --~5~zt
Date
' DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms. ~:;.....
bedrooms, with the following'stipulations:
Additional Comments
- '~ -. ~-~ '~ · ' "~ ........ ~ ' ' ....... n' ~,icee DHHS issues Health Authority
: ~'he Municipality of Anchorage Department of Health and Hume Se . . ( _ ! ....
'A~proval Ce-rtificat~based only upon the representations.given In pa~rapl~. ~,,e?ve oy an naepenaem
~rof~,.~ o'nA ~n~ ~'~. r~ s-{e-re~l in th~ stat~ (~f ~.i~s'k~;rhe DH HS does this as a courtesy to pu rchasera of homes
and'{helr'lend ng institutions n orderto satisfy certain federal and sate requlrar~en, ts.,Employees of DHHS do not
Co{~duCt inspect o~s' o'~: a~a ~z~ data~ I~fore a ¢ertifica{e~' Is' I~sued.:The- MU?!ci ,Pality~ of Anchorage is not
responsible f(~;r'errors Or o-missl0n~ I~ {he ~['ofe~i0~l~'~i~'s~(~r~ ·
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Oivision
825~" Street, Room 502 · Anchorage. Alaska g9501· (907) 343-4~'~'
Health Authority Approval Checklist
A. WRIJ- DATA
Welloq:]e~.~uA'l'~- lfA, B, orC, auachADF, CicD, gr. AD£CwatcT~stemnumher
L°glm:s~tt(Y/N) ~'~ Dalecomplclcd /e/~,; ?.~,
To~d dq~b ~t ( Cs. scd to ~/( Casing hcisht (above ~md)
Da~ oftcst
Static war~ leq~J
Well production
WATI~ ~ RESULTS:
ColEonn ~* G)
Da~ of sample ~/~c,/,~
B. 8EFFICEIOLDING TAN~DATA
FROM
'/?/,173
AT [NS1)E~-i~JON
g.p.m
EEeclh~al~o~p~ionama' /~'~c,~ MonitortngTubcprcsent{Y/N). '~ Dc~cssionoverfleld(Y/N). ~
l:)aM °f ~ -~'t?~ U"~ 'q'~ l q '~ P.,~dts (Pan/Fail) (P ~.~.~ For q I~Jroon~
Fluid dclXb in absorption fieM before ~s~ (in): ..'~ u.~'
Fluiddcp~'~ey (in~)Minutes t~,~_~
l'~,%~b u'eannent (past t2 months) (Y/N). .,~,~
D. L~'l' STATION
Date bmalkd Size in ~aons ~
High wa~ alarm level ~* / *Datum
E. SEPARATION DISTANCES
SHPARATION DISTANCES FROM ~ J- ON LOT TO:
Sc~ic/holding tank on lot ~ / oc~"r ; On ac!jafra lots
Butld~g foundation
Sm-'mcc wa~r
; Oa a~aceat 10ts /
PubUc ~cwet m~nhnlc/clcanout / ~ o ~
Lilt stati0n I ~o~'
SEPARATION DISTANCF. S FROM sI~rlc/HOLDINO TANK ON LOT TO:
BuUdi~g foumia~ion ~-t Prop~y U~ / o'~ Absorption field
Wa~' m~in/~cfeicc I~n~ / ~, '~' Surface w'~ef/d~"~Sc lO, c, ''~ Wells on aclj~ce~ lots
S~PARATION DISTANC~ ~,OM ABSOLUTION I~U~L.D ON LOT~.
~3,~~ W~ ~i~ ~
Wc~ on ~t Io~ /~
;, APR-29-199? 11:51
CT&E Ref.#
Cltent Name
Pro~ec~ Name/#
Cli~t Sample ID
Matrix
Ordered By
Client PO~'
Primed l)ate/Tlme 04/28197 ! 9:07
Coll~..ted Dat~ime ~0/97 ~:~
R~Gv~ D~t~me ~1/97 10:~
T~ Di~or: Stephen C. Ede
*N. Ho~ Bib
Sample coll~c~d by: $.R.P.
CT&E Microbiolog~ Drlnldn~ Water Pro~,,ram c~niflcadon s~n~s is provision,,,l as of 4!8/97.
0.766
Attowabte ~rep Anst~in
O.lO0 mg/L S~18 4SO0-NO3F 10 /~x OA/ZZ/97 JIL
cot/lOOnt $~t& 9ZZ2~ 0~/21/97 mm~
~.:-:..,;~ '. '. . ~ . ,. MUNICIPALITYOFANCHORAGE: ': :;.' :?:.!,. -..,,~, ,~ ...... :-,~
i":.;:, } :; ;'.'.'~, ~;, ',.' '.,, ,:'(~1~,""~) ' ' D,E?,A, RTMENT OF HEALTH & HUMAN SERV C
! :: - * ' On-S te Services Section
~'~" !~!:": ': ~' '-': ............ ;." 343-474;~ · c .: ·
· .~- ,.~ ... · !... CERTIFICATE OF HEALTH AUTHORITY
~-. , ,. APPROVAL FOR A SI~/GLE FAMILY DWELLING :'-
'" ; :' Completelegal ' ' .... "' ' "' '
· ' :~.' Location (site a.d_dress or directions)
! ;: '~ '~ .{:Lending ag Cy '
: ';, , en ' ' . -
· 'n-g
'~":, -.. f: Maih address
'~ ": "-" Agent_
~'.Property owner ..' -~e~/~ HOmP~ Day phone,
'" ' 'M? i ng address I g6~ .Gu.Z.~emo/c C~e.~. Ancho.~g~., AK 99516
~'~k~ "Address ..
· . ,Unless otherwise requested, HAA will be held for pl~k,u'p,.;:
Day phone _ ,?, .:
Day phone - '~" '
-'.,:'"' 2. NUMBER OF BEDROOMS:
·..',*:: ',}.:*' ..... .,.. .. . .........
· '.'::" ..'" 3. "TYPE OF WATER 'SUPPLY:
:' ' .... " Individual well
, , ".., ' ' · Community well
, . Public water, .
· · ' ' L"?_.TE ' ? ...............................
:.~.'--.'~','~:'~, : Ifco mun r e..w?_!tt~,e, nc ion, fro~Stat
i':":~" ::';';' .':",[,' ':.:: in~ t~ ~'~g ~t~ ~'n-~l j ~/ ~~'s-~'~'e-t~'. n rm~t e ADEC attest-
:.,: '. a sa s ..... :':', '~'.:*T:'~'' ............. ~ ........ -'
~ ~. 4 TYPE OF WASTEWATER ........................ ': ..... ' ':'-' - ---:- -'.-
· - ; ~- -*<.,-,., .... Ind~,vldua. I o?~lte .......... ;'.,~. . · : ' ,' '
': ' :.Ho. ding tahk ........ --, ,.,.- -
- *' Community on Site '" :
""' ; ~ "' Pub lc sewer ~- ......... , , , -:.- - :~:.., ·
· ,", .",''.' OTE. ' ............ '"' ''* ........ '~/,~e,'.w.,r.!'
::," ,r com..munlty was. t,ewr.~e.r,,s, ys,,(e,m~:~r?. ' ti.e,n.'confirmation
attesting to the legahty and status of syst~ '::' '"" r:' :,cc',.; .:.-. ,
6: ' 'DHHS'SIGNATURE
STATEMENT..OF INSPECTION :BY,ENGINEER L ,,~. ': ' . ./*-~?'-'-'
; *'' .- , ,*./' 'i*',~/ ;[ :~ ~ i~ i*' : ~.';~'i~."~*~, :"*' ..... '
· · m Sea ~ffixed hereto and as of the vahdabon date show, n bel.ow, I verify that my.
As ce.rt,fl..ed .b.y,...y;. _. ;:L ;:.;,.'1;..',~?,;*..;~,,;;,~ ;;;,~,iica~ 0~'shows that t~e on-site water supply.:** i;i.* /.
and/or wastewater disposal system is safe,,.funct~onal ano aoequate lot m~ nu,,u=, ~,. ,~y. :,~. ...... ..-
and type of structure Indicated herein. I furth*er Ve¥ify that based 6n the information obtained from
the Man c pality of Anchor,a.ge fi[ .es· ,.a,.rl~ ?~m mYc ??s.?_ga.~ion,. ,an~d Ins ~pe?on, the °n'slt,e water
wate~· ~1 -~" ' ',~ system ~i~'h ~on~pl[an~W.'itfi all 'Mun cipal and State codes]
SU and/or waste _ ~ , , ~ .~ . , ........
PP Y ..... ' ...... n .
ordinances, and regulations In effect on the date of th~s inspec{~o i"' · ;' .
/'~ ': '~ ~ '* PhOne '
NameofFirm $ ..... ; ........... / :~ ,,: , ..... I .... ...
, . 17034 £igl, Rives;' ~L~p' Road 1~204 ~;~, :. ., .....
· - ' r'ss nature ! ~"~ - ,·.
, . . . ,, ,
. .....,' ..' ',, ~.;/:'/~"/'~ .... ' rT~.>'./.."'-/,;'~";.?,.f:.'~ ..
...... .....,,
- ,,. · , · , . - V7~?~.,
. .., ....... , ...
· ///.~//~?-..L- ,>,.,:.:..,;..:'/~,,~. '",-
..,, ; .... : ...... -- U//~:~'c~-~.~.~_.~"-'---'-' ' -
Disapproved.
Conditional approval 'fo~".
· bedrooms, w th the follbwing sti'lSUla~ions:
Additional Comments
The Municlpaht'/of Anchorage Depertm~nt~of Healtfi'an~l Human Services (DHHS) Issues Health Authority ..
Approval Certificates based only'.ul~on .t~e representations given in paragraph 5'ab~e by an IndePendent
professional engineer registered In the State of Alaska. The DHHS does this as a c°urtesyt° purchasers °f h°m--
a~d their lending institutions in ord~ t0satis;ly,~:-~!tain i~deral and stat~'r~qui~en~s~ Employees of. DHHS do n~ot ";~.
conduct inspections or analyze,data .b~..fore.a ce~ _,c~'{~ is issued The Munic pelity of Anchorage[Is not
.... m or'o~nissio~-Ir~'tl~6'~)~'~fe~i~n'al 6r~gin~'s ~*rk.'. ' .... .". ' .. ' ....
responsible for erro .,..
Department of Health and Human. Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: "~'-~/,~'T ~. ~,'C~'/4/_~/~,.J f~/~,/~ Parcel I.D. /~//'JI-
A. Well Data
Well type. ,P~ t
Log prese.t /N) _
Total depth .
Sanita~ seal ~) ~J .
FROM WELL LOG
Date of lest
Stat~ waer level
Well f~w
~ level1 ~/'
~EPA~T]ON DICTatES FRO~ WELL TO~
~eH~ tank on lot
~ion field on lot
Pu~ s~er
~ewer so.ice li~
WATER ~A~PLE RE~ULT~
B-SEP~~TANKDATA
Date installed /t~ / ( (-/-'/
Clea ls )N)
High water alarm (Y,~
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed. /0/! / ?'t Driller/~/./'"/,~' f~:~ICr. J/J~..~ ~J'T'.
Cased to. r~ //' Casing height .
Wires properly protected ~',1) ~"'~' ~
ATINSPEC~ON
g.p.m.
; On adjacent lots / O b /-7/--
;Onadjacentiots_ /r...~3 r.~_. i
public sewer manholelcleanout /OO ~'~
Petroleum tar~ /C/r~,,<J~'
Tanksize_ /7_-...~'~ (~(.._ Compartments ~..
Foundation cleanout(~N) ~/'~"~l Depression (y~_~...~/,~
Date of pumping ~,..~,J
SEPARATION DISTANCES FROM SEPTIC~ TANK TO:
Well(s) on lot /C.~O r../_.. On adjacent lots /'~O ~
To property line /'O ~ Absorption field /~) f-'/"-'
Surface water/drainage, f"O/._~ ! ~
Alarm tested (.,Y~)
Water ~i~sewice line
~2-~e r'~e)'~:r~,~ CONTINUED ON BACK PAGE
C: UFT 5TA11ON /d ~,<.J ~"
Date installed
Size in ~allons
Manufacturer ~"~'"'~ '
/ 'Pump off" Level at
,'Pump on" level at
...~'~'~ Cycles tested
Vent (Y/N)
High water alarm level
. Meets MOA electrica~'c°d~
~~ . On adjacent lots
D. ABSORPTION FIELD DATA ,/~E/''''') ~ '*~"~"'7"~/~'~
Leah ' ~P ~h Gruel ~ess
Total ~tbn area
.Sudace water
.System type
~_. /,Total depth ~',~' /
Del:x'ession over field (Y/~ -~
' Water ~r~,el i~::~oq::~ion field before lest
· ; P~mxide treatment (past 12 months) (y(~
S~PARATIOI~ DISTANCE FROM ABSORPTION FIELD TO:
Ntertest
If yes, give date
Well on lot //(~C> r--~- On adjacent lots / O o/"~ Property line /(-~ (''~- -
To building foundation :; / ('~ / To existing or abandoned system on lot
On adjacent lots ~O (-/-' Cutbank ~ ~.j:~Water main/servloe line //O (-/"-
Suffacewater /(--)/-) / ~ ,Driveway pa~ngtvehidestorage area
E. ENGINEER'S CERTIFICATION
- H~A Fee $ ~.~J ~.. Waiver Fee $
Date of Payment '~f ~' 7 / c~ ~ Date of Payment
Receip~Number ~'~tT,"~('<, ( /~"~ ) Receip~Number
OJYlT/9~ 10:~8 CT~E EhFJIRO~UI'AL LAB SERUICES
zTF_
CT~E
Client ~ampl¢ ~
Sa."nplc R.c'm~k:s:
NO. 010
Commercial Testing & Engineering Co.
Environmental Laboratory Service8
LABORATORY ANALYSIS REPORT
94.108.%3
WA~R
S & $ £NG~J~P,L~O WOKK Order ?6579
~S Pdnt~ Da~ 0~/IW94 ~ 10.09 ~.
Coll~t~ ~te 0MI ~4 ~, 11:1 ~ hrs.
UA Receivtdl~te . 03q5194 (~ 12:10 hrs.
LEC~D ~y; ~ ......
~MI'I E COt .......
H[trate-H
QC AlI,:'a able Ex'. Aaa!
Result.~ Qaal L'r.i:,~ M-~',hod Limits Date I)*.t~ Ini~
0.62 mg,"L E P/,. 35 .'1.2 ,.'3~3:~.0 10 CCU16194 I.l,l.I
"' ~:~e Sar~le R~nmks ASovc UA' t;navailabl¢
~-.Not
TO - IJn~t~tc~ ~o~ val~ is ~te praaical ~mtifi~tlon limi L
· ~'- J:r= l~ss
~' D:S~on~ ~h~ion.
5633 B Sl?~t, Anchorage. AK 8~618.1600 ~ Tek {907) ~62-2343 Fax. (907) 561
E~IRONMENTaL FACIL~ES IN A~S~A, COLORADO, FLORIDA, ILLINOIS, MARY~ND, fdEW JERSEY, OHIO, ~AH, WE~T VIRGINIA