HomeMy WebLinkAboutTONJESS ESTATES BLK 1 LT 3
"' Municipality of Anchorage Page
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:
~c,~. fl~ WastewaterSystem: DNew ~Upgrade
~o~q~-~lll /~$. ~ ~ Deep Trench ~ShallowT~nch ~Bed ~Mound' ~Other
WELL: D New D Upgra ~m.~wl~tn:~ '
SEPARATION DISTANCES m s~p~i~ a Holding ~S.T.E.P.
Sudace
w~te~ P~'~ ~ V ~', LIFT STATION
Remarks: BENCH MARK
ENGINEER'S SEAL
2nd f~/~ ~~.~,
Depa ment of Health / Huma ces approval
Rev,ewed and approved by , _ Date:/d~
AS-BUILT
WASTEWATER DISPOSAL SYSTEM
Lot 3. Block 1, Ton jess Estates Subdivision
P,I.D. # 051 8`31 15
VACANT
-- ABANDONED SYSTEM
0
T.H. //2
B1-D1 = 16.01'
B2ID1 = 15.95'
B1-D2 = 70.44'
B2-D2 = 62.49'
BI-C -- 17.39'
B2-C = 25.40
B
A
/
/
/
/
/
/
/
/
/
/
PREPARED FOR:
Brook Stiltner
c/o Century 21 Realty
CHU~IAK, AK 99567
A-B"= .39' +
B-C,= 12'+
B-D =' 10'-~.
C-D:'= ~'5±~'
C-E '=
. D-'E.'= 10'+
KND ENGINEERING'-~
20441 - PTARMIGAN-.BLVD
EAGLE RIVER, A.K~ '99577
(907)696-6111/Fa× (907)696-811t
AS-BUILT DESIGN DETAILS
WASTEWATER ABSORPTION SYSTEM
Lot 3. Block 1, Ton jess Estotes Subdivision
P.I.D. # 051 8,31 15
PERH[T #SW950;:'69
'~SHED GRADE (ADD UNCLASSIFIED FILL)
SEWER ROCK
56.5' BED ~
2.5'(typ) ---~
~ 1/4" PVC FROM TANK TO FIELD
1/4" PVC FOR MANIFOLO
MONITORINO TUBE: CANTED DURINO BACKFILL
OPERATIONS. ACTUAL DIST. FROM TANK 5'.
g
:= ~ 1250 GAL
I
o I,~44'LI S.T.E.P~..I
~ p~o o~[--~
° ' c.o. [~o. c.o. 1 / ..
u, ~,*~ ~ 67 ~ 4"
2.5'(typ)---~ENDS OF PIPE CAPPED T{_T..~P) M.T.
.~51.25 LF 1 1/4" F /C W/3/16" HOLES
@ 6.8' SPACING FYP)
~ COVERS INSTALLE OVER HOLES
I
,~/~,' !6.5'
~ 45 DEG.
~ D3034
J_
,.. · · · . . .~,, ~ ·
4"~5'~' _A_'-?.. ~.
~ '~¢z¢~.~~c~;;~'7"~ ~ PREPARED FOR:
~~ c/o Century 21 Reolty
CHU~AK, AK 99567
KND ENGINEERING .~.~- ,
20441 PTARMIGAN BLVD '~
EAGLE RIVER, AK, 99577'
(907)696-61t I/F'o× (907)696-8111
TEL:6947292
It'Jl%lll..,lltl% l'-Lt;I, II~l~, ~U.
. i:'.,i ' '.;' '~
Sap 26,95
I'~X I{0. t~u76!N~uu~
16:22 No.O15 P.O1
';"' .",{' i~Dear Kqn, · ,; . '
';: ."1: ..Ii' , ' · ~ I,' '
,I ~S:, [~oJr_t,het. er.P-lect, rl.c,,.,C, qrpppl~y~[~s..done the electrical wiring to a
;':,':i~..:ii'no.~l¥ ineti~llgo e~aite .l}~t~i~)ibtlon and alarm at Lot3, I~1o6k
;';,'ri,::~,Lt'. 'ran_Qemm estete~,li-:~:a[ ,~b[f. tUg lhae been done In a¢cordqnce
· ' ,~:w. lth' tl~i) ~993 NatlbYgll":~.le0t~loaZ Code.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM
PERMIT NUMBER:SW950269
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:HARBOUR FRANCINE D &
OWNER ADDRESS:19239 ADLAIN AVE
CHUGIAK, AK 99567
(UPGRADE)
PAGE i OF I
DATE ISSUED: 9/11/95
EXPIRATION DATE: 9/11/96
PARCEL ID:05183115
LEGAL DESCRIPTION:
TONJESS ESTATES BLK I LT
LOT SIZE: 46936 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK 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 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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: ~~
~D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)694-2359/FAX (907)696-8111
August 31,1995
Munidpality of Anchorage
Dept. of Health & Human Services
On-Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: Lot 3, Block 1, TonJess Estates S/D, Sewer system upgrade
Gentlemen:
The on-site sewer system at the above location failed an adequacy test performed recently by S
& S Engineering. As a result an upgrade of the system has been requested by the owner.
Several testholes were excavated on this property in an attempt to locate a suitable site for the
upgrade. Testhole #3 was excavated just west of the existing dwelling; percolation and water
monitoring results indicate this site is an appropriate location for the upgrade. In addition, this
site appears to be beyond the limits of the previously deposited fill at the house site.
The lot was originally much lower than the road it faces, and fill was placed for the driveway,
dwelling, and well locations. The balance of the lot is generally flat, with a slight rise to the
northwest side. I observed no surface water sources within 100 feet of the proposed upgrade.
I propose to abandon the old system, including septic tank, and replace with a new 1,250
S.T.E.P. tank and an absorption bed. Although there is sufflcent drop between the fill area and
the testhole to install the bed with gravity flow and distribution, I have choosen a pressurized
system in order to extend the life of system and to prevent premature failure.
If you have any questions about the design, please contact me at 696-6111 or FAX 696-8111,
Sincerely,
Kenneth M. Duff ,~P.E.
KND Engineering
attachments:
On-Site Well and Sewer Application
Wastewater Absorption System Details
Site Plan
Soils Log/Percolation Test
SI TE PLAN
WASTEWATER DISPOSAL SYSTEM
Lot ,3. Block 1, Ton jess Estotes Subdivision
P.I.D. # 051 831 15
VACANT
Well - 100'+
SYSTEM
PROPOSED
LOT SIZE: 46,936
LESS HOUSE FOOTPRINT: 1,900
LESS EXISTING SYSTEM: 825
TOTAL AREA AVAIL.: 4,4j211
PREPARED FOR:
Brook Stiltner
c/o Century 21 Reolty
CHUGIAK, AK 99567
KND ENGINEERING
20441 PTARMIGAN BLVD
EAGLE RIVER, AK, 99577
(907)696-61 Il/Fox (907)696-8111
bJ
DESIGN DETAILS
WASTEWATER ABSORPTION SYSTEM
Lot 3, Block 1, Ton jess Estotes Subdivision
PRESSURIZED
P.I.D. ~ 051 831 15
PERMIT #
FINISHED GRADE (ADD UNCLASSIFIED FILL)
DISTRIBUTION SYSTEM HOLE SPACING DESIGN kl
1. RESIDUAL HEAD - 5'
2. HOLE SIZE - 3/16" - 1.00 GAL. PER HOLE 0 30 PSI ~ mo. m.~'IA
3. 30 GALS (PUMP DELIVERY)/1.00 CALS./HOLE - ,30 HOLES
4, 205 LF LATERAL/30 HOLES = 6.8' SPACING PER HOLE
5. ALL HOLES SHALL HAVE CAPS INSTALLED PER MANUFACTURES SPECS.
2.5'(typ) ,~:AP ENDS OF PIPE(TYP)
2.5'(typ)
+51.25 LF 1 1/4" F ¢C W/3/16" HOLES
~ 6.8' SPACING TYP)
I
0
36,25'
1/.4' PVC FROM TANK TO FIELD
1/4' PVC FOR MANIFOLD
_L
4. 1.125 SF /20' W - 56.25' L
5. MINIMUM DESIGN SIZE - 20' W x 56.25' L BED
6. 2' HD INSULATION REQUIRED OVER FIELD <5' OF COVER
7. 2" HD INSULATION REQUIRED OVER TANK <4' OF COVER
8. ANY ASPHALT. CONCRETE OR APPERTANENCES DAMAGED OR
DESTROYED BY THE CONTRACTOR DURING CONSTRUCTION SHALL BE
REPLACED BY THE CONTRACTOR AT NO ADDITIONAL COST TO THE OWNER.
1250 GAL
11S'T'E'P' '
C.O. IC.O.C.O. '
4' SOLID FROM HOUSE ~ a~/~ ~L ~o,~/ ~
DESIGN CRITERIA ~ ~
1. ~ BEDROOMS X 150 GAL/DAY/BEDROOM = 450 ~PD
2. SOILS RA~NC: 17 MIN./INCH~ 0.4 ~D/SF(BED)
3. 450 GPD/0.4 GPD PER SF = 1,125 SF
f.%'. =-,,,
9. CONTRACTOR TO VERIFY AND INSURE 2~. CRADE FROM HOUSE.
10. CONTRACTOR TO PUMP TANK AND DISPOSE OF ON-SITE.
PREPARED FOR: KND ENGINEERING
Drook Stiltner 20441 PTARMIGAN BLVD
c/o Century 21 Reolty EAGLE RIVER, AK, 99577
CHUDIAK. AK 99567 (907)696-6111/Fox (907)696-8111
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED tO.'.'.,
LEGAL DESCRIPTION:
4
5
6
· 7
8
9
10-
11-
12-
13-
14-
15-
16-
18-
19
20
j,~,.;....- ....... ~ a, I
I
~. ' r .*~***~-*~',***~ * ,o~.. ., * ~. I
Township. Range, Section:
SLOPE SITE PLAN
WASGROUNOWATER
ENCOUNTERED?
I; YES. ATWHAT
DEPTH?
~ k W~l~r ilar
G;oss Net De~th to Net
Read;ng
let/,'
O~te
Time T~me Water Drop.,~
PERCOLATION RATE
TEST RUN 8ETWE(N
{mmuleu~:h} PERC HOLE DIAMETER __
FT AND FI'
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0G50
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:.
LEGAL DESCRIPTION:
1
4
6.
7
8
g
10
11
12
13
14,
15-
16-
17-
18.
19.
2O
~ ~ DATE PERFORM~
Township. Range. Section:
SLOPE SITE PLAN
/
/
/
/
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT ~
DEPTH? pO
G~oss Nel D~oth to Net
Reading Date Time Time Water
PERCOLATION RATE tmmute~./mchJ PERC HOLE DIAMETER __
TEST RUN BETWEEN FT AND.~
COMME.~S O "~ ~'~ ~-~- ~ ~ -- '~'~
Munlclpalily of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 'L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
8-
9-
12-
14-
16-
17-
18-
19-
20-
COMMENTS
· ~ ---~ ~
DATE ~ERFORI
TOwnship. Range. Section:
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
IF YES, AT WHAT
DEPTH? p
E
,., HORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street o Anchorage, Alaska 99501 Telephone 2644720
~ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
DISTANCE TO: I 0 ~
Manufacturer ~ p~t~ ~.
/00 O IF HOMEMADE:
DISTANCE TO: Well
Dwelling
Material
'~ TE L:
NO. OF BEDROOMS
PERMIT NOo~ ~. il
No, of compartments
PERMIT NO.
DISTANCE TO:
No. of lines
I
grade
7-.3
Total length of lines
tile
Trench width
y in gallons
Distance between lines
DISTANCE TO:
Class
DISTANCE TO:
Well
Depth
Building foundation
Crib depth
Building foundation
Driller
Sewerline
OTHER
SOl L TEST RATING
INSTALLER
REMARKS
Nearest lot line
Distance to lot line ~[ PERMIT NO'~'~-~.
Septic tank Absorption area(si
APPROVE/
72-013 (Rev. 3/78)
DATE
LEGAL
~y.
DO~ Co,
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
STATIC LEVEL OF WATER FT. ~ 5--
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTION '/ '~ ,/?x ~-' /
DATE - Started ! ,/,//':' ? ~f-'~ Ended
PERMIT NUMBER
KIND OF FORMATION:
From ~--' Ft. to
· From >'~ Ft. to %': '~ '
From ~ ~ ' Ft. to
From Ft. lo
From Ft. to Ft.
From Ft. to , Ft.
From__.Ft. to Ft.
From Ft. to Ft.
From__.Ft. to Ft,
From__.Ft. to Ft.
From__Ft. to Ft.
From__Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From.__Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From__Ft. to FI.
From Ft. to FI,
From Ft. to Ft.
From Ft. lo__Ft.
From Ft. to Ft.
From Ft. to Ft.
From Fi. to Ft.
From.___Ft. to Ft.
From__Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From Ft. to__Fc
From Ft. to Ft.
From__Ft. to Ft.
From__Ft. to
Ft~
MISCL. INFORMATION:
DRILLER'S NAME / .~ -~--'/~/~- ~
, . r-lur~i I c I r--'~:lL. I TY OF AhlCH""'RAGE
' '- _ DEPARTMENT [, HEALTH AND ENVIRONMENTAL . .OTECTION
'~ '' 825 'k' STREET, ANCHOR~GE, ~. 995~1
"' ' 264-4720
~4E~L ~t~ ON--~ITE ~E~ER
PERMIT N0. ( 82110~ )
APPLICANT
LOCATION
LEGAL
SHORT CONST & EXCRVATIO
PO BOX 8 R-E 99508
L~ Bi TONJESS ESTATES
PERMIT
LOT SIZE 999999 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
Mfi×IMUM NUMBER OF BEDROOMS
SOIL RATING (SQ FT?BR)= 202
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
DEPTH= 8 LEhiGTH= 7 ~:.:.5 GRi::~VEL- DEP. TH= 4
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND R~ID THE BOTTOM OF THE E}{CRVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
REQU I RED SEPT I C TFINK --i:; I ZE= 1000 GFI[.-LONS
PERMIT APPLICANT HAS THE RESPOHSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF R~Y WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TklO (2 > INSPECT I O~lS lire REQU I RED
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION fiND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION,
MINIMUM DISTANCE BETWEEN R WELL RND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR i50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM R PRIVATE WELL TO R PRIVATE SEWER LINE IS 25 FEET AND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED fiND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS
OF THE WELL COMPLETION,
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY THAT
l: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES,
~: I UNDERSTRF~D THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THA~I ~ BEDROOMS.
si ..... ......................
RPPLI~NT SHORT CONST & EXCAVATION
I~UED B~_ -DATE .... ~ ~ V4. 0
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchm'lge, Alaska 99S01 264.4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR: ~"~h
LEGAL DESCRIPTION:
2-
3-
4-
5-
6
7
DATE PERFORMED:
SLOPE
SITE PLAN
10
11
12
13
14
15
16
17
18
19.
20.
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER IC~O I~
ENCOUNTERED? pO
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net ~ Depth to Net
Time Time (e~,~ Water Oroo
PERCOLATION RATE · :' ~ ~. ~'. (minutes/inch)
TEST RUN BETWEEN '~ :~' ' ;leT AND ' '~ ~ ~T
CERTIFIED~' , ~:~ -'' ,~ : ~ DATE:/
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUUAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~-~\ - q, -~ ~ ' ~ ~
1. GENERAL INFORMATION
Complete legal description
Lot $; Block I~ Tonic.66
3.
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
24980 Schaf f
C/uz~Za.k, AK
L~rr~ [~i~ ~ F,uznc~ Ha/cbou~c Day phone
C/O C~ntur. el Co~onia~ 11901 Supine.66 BJ~ud. Su~e 103
E~q~. Rluer
Day phone
AK 9957;
~ook Stll~ner/ Ce. retry ~I Colo~
Agent
Address 11901 Bu.6Znez, 6 Blue Su~t~ 103 Ect,a,~.e. Riuee.~
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ~
TYPE OF WATER SUPPLY:
NOTE:
Day phone 696-8600
AK 99577
Individual well XXJ(
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
NOTE:
Individual on-site X'VJ(
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
STATEMENT OF INSr'~CTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my inves.ti_.qation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
NameofFirm S&$£NGINE£RING Phone (~ciw- ;~¢) -~c)
17034 EaGle River Loop Read Ne. 204
Address Eaqle Riverr AI~Ea 99577 ,
Engineer's signature .~-~'(~ ~, l/"~ '~"~ Date ¢¢/~? /~I ~
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By:
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. 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.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Envimnmentsi Services Division
825'L" Street. Room 502 · Ancfiorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
A. WELL DATA
Well type
Date of les1
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~)
Date of sample:
If A, B, or C, attach ADEC leRer. ADEC water system number
Dat~ completed
Ca.wa ~o '/~"
FROM WELL LOG
g. pm.
II-/~'-~ ~.
Casing height (above grouedl
AT INSPECTION ~r~
Nitra~ 7~ 74-
~ -/5% 9~' Collected b:,.':
Other bacteria 0
B. SEPTIC/ilOLOING TANK DATA
Date installed
Tank siz~
Fo--dmion cleanout (~N) y Depression (Y~
Date of ~umping ~//~ '~J~-~J Pumper
C. ABSORPTION Iq~:Ln DATA
Da~ in~med 5'-
Number of Companments 2.- Cleanouts~N)
High water siann
~ength ,5"G.5-' Width
Soil rating (g.p.d./fl~ or ft"/bdrm)
2~ ' Gravel thicknms below pipe
Effective absorption ama //SD Monitoring Tube present(~O
Date ofad__%~acy test /~//~ -~/~/ Results (Pass/Fail)
Fluid depth in abeoq~tion field before te~ (in.);
Fluid depth ~ (ins.) Minutes later:
Peroxide treatment (pa~ 12 months) (Y/~
~ Immediatelyafler~- gal. water~OOed (in.):
~ Absorl~on rate = '""- g.p.d.
De
LIlT STATION
Date i~tslalled
High water alan'n level
Siz~ in gallons
"Pump on" level at* -~ ~z
*Datum
'*Pump otf' level al*~ q'Z"
Cycles tested /~
E. SEPARATION DISTANCES
SEPARATION DISTANCT=S FROM ~ ON LOT TO:
Sep~c/holdia~ tank on Io! /0 ~ I '~' : On adjacem lots
Ai~orption field on lot /OD ! ~' .; On adjacent lots /oD / '/'
Public sev,~r main ~J'//~ Public ~ nmnhole/cleanoat
Sewer/septic s~vice line ~' Lift station /'D~
SEPARATION DISTANCES FROM SEFFIC./HOLDING TANK ON LOT TO:
Building foupd~fion /~ t ~ Property line J~ / ?' Absorption field
Water main/service line. /D /~' Surfacewater/drainage ,/oo /4'Welisonadjncentlots
Building foundation
Surface watcr
SEPARATION DISTANCE FROM ABSORPTION FIt:! I'~ ON LOT TO:
Water mnin/service line
Dfix~ay, parking/vehicle stomg~
cuOa~n drain /~,*,'JP- (~,J,d~/ Wefts on adjacent lots /oo I ~' Propeay. line
F. ENGINEER'S CERTIFICATION ~ooA~'~o~ ~o A ,~.-,A~
I ceftin, that I haw determined thr~ field inspections ~nd re~i~ o
in co~formanc~ with M~)A J~4 Ruideline~4n effect on ~is date.
HAA Fee S
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Rrc~ipt Number
CT&E Environmental Services Inc.
L~boratory Divls;o~ =- r ------ ·
Laboratory Analysis Report
~ Xllowable F~. ~nal
" ~00 W, ~otte~ ~e, A.chc~age. AK 9951.8..1605 -- ?e~: (~07) 662-2~43 ~: (90?) $$~.$]01
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date I,{~z~.C~. ~It 19gg
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner ,~./~. F. (~. Telephone: Home
Mailing Address r;~ ~. S4tA
(c) Lending Institution Telephone
Mailing Address
(d) Real Estate Company~nd Agent
Address 1~00 C~Z~d O~u~ ~Oi EA~¢ ~Zv~, AR~6~ 99511
Telephone &94-4~00
(e) Mail the HAA to the followina address: o~ Check here~, if hold for pick up.
List conta~ person and day phone number below.
Business
TYPE OF RESIDENCE
Single-Family []
Number of Bedrooms
WATER SUPPLY
Individual Well ~ Community I-I Public
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite'1~ Public I-I Community I-I Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that 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 verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm $ & $ -",~:=;N"--"~!N~ Telephone
Address 17034 Ea~le Ri'~J' ~ Re, a~ I'~,.
Date Eagle RIv~', Alaska 9~$77 _~,....~. ~.~,~,. ~:/
Approved for ~ bedrooms by Date
Approved ~/ Disapproved Conditional
Terms of Conditional Approval
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues He~]th Authority Approval
certificates based only upon the representations given in paragraph $ 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.
Page 2 of 2 72.ms ~Rev 8,8~! BaCk
MUNICIPALITY OF ANCHORAGE (MOA)
264-4744
WELL DATA
RECEIVED
Legal Descriptio?~ ~ ~ '~. ~
Well Classification "~-..-t v/',~ If A, B, C, D.F_C. Approved (Y/N)
Total Depth ~ I Cased to ~ ~
Static Water Level ~ i
Casing Height Above Ground '~'?
Electrical Wiring in Conduit ~N) ~'
Separation Distances from Well:
To Septic/I-~ Tank on Lot ~ '.-~:~ ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on I-ot ~ ?--'"'~ ~ ; On Adjoining Lots \ ~f'~'
To Nearest Public Sewer Line .IT'5,J,Z~' To Nearest Public Sewer
CleanouUManhole ~"~//~ To Nearest Sewer service Line on Lot ,~..~_~ Idf.
Depth of Grouting
Pump Set At
Sanitary seal on Casing~[~N)
Depression Around Wellhead (Y~
B. SEPTI~ TANK DATA
Cate Installed ~'Z--"~-(3'7~,. Size
Standpipes(~)
Depression over Tank
Air-tight Caps(:~N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
separation Distances from Septic/He~i,',~ Tank:
To Water-Supply Well [ c:::~t
To Property Line
To Water Main/Service Line I ~ t"lr
Course
Comments
No. of Compartments "~
Foundation Cleanout (Y.~ ~
Date Last Pumped ~ \ ~-,Z~. ~ ~)"'~
r~-- ; for -
Temporary Holding Tank Permit (Y/N) I.~'
To Building Foundation
To Disposal Field ~" ' ~! ~ *:'~:~-~"~"<'~
To Stream, Pond, Lake, or Ma or Dra nage
Page 1 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~ ?~ Type of"sYs't~m' Design
Date InstaIled ~'~.-~"~ - 'E:>'?---- Length of Field """7''~' I
Width of Field ' '~' '~ ' Depth of Field ~'~
Square Feet of Absorption Area
Depression over Field (Y.~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well \
To Building Foundation ~,.~/
/A
Lot "'
To Water Main/Service Line ~ ~ I..~.
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Gravel Bed Thickness
Standpipes Present ~N)
Date of Last AdequacY '[est ~1-)_/.~-~,.~_ ~;z~'"/
.J
To Property Line
· ' To Existinp or Abandoned System on
; On Adjoining Lots · ~
To Cutbank (if present) //~'
Comments
LIFT STATION
'D'~''~ate Insta~3'-.-. ' -; ' ; '
Size in Gallons
'Pump On" Level at
Dimensions
Manhole/Access (Y/N)
"Pump Off'' Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
_ Vent (Y/N),
quacy Te'st. Meets MOA
Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signe~ & $ £HG!~;I:; lNG Date
1 ?o:~4 Eagle River Leer, Road No. 2~A
C o n', I~e ~.l-~.7-Ali~ No.
Receipt No. ~ ~ ~ ~
Date of Payment ~ ~. ~
Amount: $ / ~ ~
Page 2 of 2
! APPLI""",NT FILLS OUT UPPER HA'"~ ONLY
Buyer
Address '~. Zip Code
~ Other
Time Time Time Time
Date Dale Date Da ·
Inspector Inspector Inspector Inspector
Field Notes:
( j,.,,,.,v~pPROVED BEDROOMS 'CONDITIONS OF APPROVAL
( ) DISAPFROVED
( ) CONOITIONAL APPROVAL'
Soils Rating Date Eewe* Installed Well To Absorption Area / '~,.-.,~ Well Log Received
F~bruary 4, 1983
John S ho~r t
P.O. Bo~AE
Anchorage, AK, 99508
Subject: Lot 3 Block 1 Tonjess Est.
Approval for the individual se%let and %;ater facilities cannot
be granted until the follo~ling items have been completed:
A well log submitted to this office for our files and
review,
~0~he %later analysis report needs to be submitted to this
office from the Chem Lab, 5633 B Street, for our revie%~.
/"/The depression over the sewer system will need to be filled
~ t~ so that surface water drain~ away from the sewer system.
Conditional approval can be given if monies are escrowed
/~--for backfill over the tank area if you desire.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-4720.
Sincerely,
JR59/p/EH
Jim Roberts
Associate Environmental Specialist