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Home My WebLink AboutKNIK HEIGHTS BLK H LT 11Knik H ight Block H Lot 11 #017-372-11 Municipality of Anchorage Page __.l DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVlRO;'iMENTAL SERVICES DIVISION P.O. Box 196650 ·Anchcrage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Name: ~'~ ~.%b~ ~ L) ~ ~.-F~T ~ Wastewater System: ~New ~ Upgrade Address: /~ lo I ~ I b5 N ~*.¢l) ~-~ ABSORPTION FIELD Phone: Tolal Depth from original ~rade: LEGAL DESCRIPTION soi,.~,i~. /.~ ~,s...~ Io - Lot: Block: Subdivision Depth Io pipe bottom from onginal grade Gravel depth benealh pipe Township: Range: Seolion: Fill added above original grade Gravel length: WELL: ~ew O Upgrade Gravel widllx ¢~_ Ft Number of Ilines Dist*nce betweeq lines:.~ Ft. Classilioation~rivate. A.B.C): Total Depth: Cased To: Fetal ahsorphon area: ~ Pipe material: Driller: Pump Sot al: Casinq Height Above Ground Yield: ,¢ GPM ¢* W ~_~t. ' ~ ~, ..... TANK S E PA R AT I O N D I STA N C E S ~opt~o ::: ,-,o,,h,~ "~ S.T ~.~. TO Seplio Absomlion Litt H.l',in9 P,,bUc Priva,e ~ ~ Well )C~ '~ [ I ~ ~ ~ ¢ ~{ M.,erial: Number of O~)8rtments: Surface w,t,r ..~ ~ ~ ~ ~ LIFT STATION LineL°t ~,~ l ~ ~ ¢ ~Size in gallons: Manufacturer: Fo,ndalion ~, ? ~ 1; /~ ..~' / '"Pump on' level at: 'Pump off" level al: High water alarm Remarks: BENCH MARl'( ENGiNE[R'S SE~L Inspections performed by: ~% Dates: I st /~-~/¢ (~ Department of Heall ~ and ~ ~n ~rvices approval Reviewed and approved by: ,/ ~(b~,/ ~b~ Date: ~.~_ ". 72-013 (Rev. 9/gl) MOA 25 ~' 20 I 20 BLOCI FND. I _ J -~> f~'ell I ? ~ ££PLAC£~ENI' T~ENCH /~ 150 TOBBEN SPURKLAND P.E. 203 W 15TH. AVENUE ANCH. AK. 99501 LOT 11, BLOCK H I(NIK ffI~TGHTS PETE ODENTHAL 15101 RIDGEWOOD SEPTIC SYSTEM AS BUILT DATE: NOK 26, 1995 SHEER 2/5 GRID: 2856 I~SG' go[ ,.Repfic ~.onf-' CO ~'t'ondor'o/ TF~nch¢5: CO 4/t7 SCALE C[eonoo'fs -- 6' Coven / 9~ /V/Op/ INK EL 90,3 ~40 85,8 4 ?~ of' ~e~'ic ~'ocl~ h'~ £CALE INKEL. 90.3 85.8 NO G£OUND~A?ER BOH 80 NO BEDROCK I~PERVIOUS YA?ERIALB EZ. 95.61 rOB]}EN SPUBI<LAND P.E-, 203 WIS-Lb Ave I [ gEPT]C SYSTEM AS BU~UL] ba~E: /'VD'/,,C 26, I995 PERFORMED FOR: DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGJi~ EER'S SEAL) LEGAL DESCRIPTION: koT'~(. '~- ~,'~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? Township, Range, Section: SLOPE COMMENTS S _~ ¢~_.~,~. (: iF YES, AT WHAT O -' DEPTH? p E Oeplh to Water Aller/ MonDoring7 ,~)J.'¥ %} Date: / SITE PLAN Reading Dato Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE Iminutes/inch] PERC HOLE DIAMETER ~ .~ / T,~T RUN BETWEEN ~_ FT AND / C) ~--FT P~RFORMED BY: I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES ,. DIVISION OF MINING & WATER MGMT WATER WELL RECORD LOCATION OF WELL BOROUOH SUBDIVI~IO~I ,,. LOT BLOCK SECTION OTB8 BEC'I'ION TOWNSHIP RANOE MERIDIAN LOCATION/SKETCH: WELL OWNER: [ ,~..~,~y /~.~..~-.,.~. . .......... ~ ....... DEPTHS M~URED ~ROM~casing top ~ground surfec~ WELL bEPTH: ~: ~ ,,.. DATE OF COMP[ETlON - - Depth of hole:_~:J._~,~ fl BOREHOLE DATA= Depth Deptl~ ol caslng:~.~..~ft ~2' /~'~ Materi~l Type and Color From To ~ ,~ DEPTH TO STATIC WATER L~EL~ "' ¥' ~2 ~..~¢ _/¢~/ ft below ~top of casing ~ ground surf~ce ,,j.~,~ / /// /'~ ~ Date: /'~5:1~/~4~~' '"' ': .... '" i;~, .. ~.~J ........................................... . METHOD OF DRILLING: ~ eir rotary ~ oable tool .,, ~, r ~ , ~.¢ /..5' ' ,' ",' ~ other x ,,.'.~/ / .?/,/,. . USE OF WELL: ~ domestic ~ irrigation ~ monitor /¢.,%/,.,,~~.~,/, ~,~ .,.,,.,.,~.".~ public supply ~ Other, /' ' "~ ...... ' " CASING STICK-UF: ~?~;, ft. Diam: (;, In, t~tt ," ."' '/'[~ ¢ ."r :' i, · ...... .~~ ,, ,...¢. ~"'~,~.,:./ f;.~:...~,¢ 4" ~ ~ / Casing typ~;~,~Z'~ ~, · u /'~' . /.." ~/__ WELL INTAKE OPENINO TYPE: ~ opon end ~ screened ,"~'..~ ' ' '~'{,~;'" U perforated ~ open hole <,' /',~ , /':~..¢;~;',',,/~. , ,-' Depths 0f openings: tO _ ft ,¢, %5' " ' SCREEN TYP[: Diem: , , ,'./*" '/' ".',/ /',t' r · ¢~ *;' Slot/Mesh $1zet Length: It G~VEL PACK TYPE', Volume used: . Depth to top: .": GROUT TYPE: Volume: / "~'~ ') ~?S' c~ ''~ ' ' ~~ ...... ...., Depth: from ft tO ft .._~ Durat on ., ,, .. PUMPIN~.L~EL AND YIELD: ~0 '~- '[ ~(~5~.,,. ' _~t after % hfs pumping.. ~'.~ ..... Mttni(;~P[~ ~ V~Uma"~ PUMP INTAKE D~PTH: ft Horsepower; ~ .{emu,~. WELL DISINFECTED UPON COMPL~ION? ~ YES ~ NO .=.. ~?. ~-- , ,, , , _ ................................... OONT.AOTO.,NFO. ¢T,O., , .EMARKS, ..,,,...,//,'. : .:,,. · z~;;J: , ' ,"" .,/"",..~;'. (¢') , ,: ....... ., ,~,-.,, PLEASE MAIL WHITE COPY OF ~";:¢'""'.' . ...' ,~'. ~.'~.,'.w~ ....... - ,/¢ ....~' ~ ...... ;-,,> n~n/mma~ OF MINING & WATER MOMT Si~nat{J~e' of Au~horiz'~'R~s~r'~sept~'t~ve '-'' ' '~ / 360~ ~ ~t, Suite BOO -..Ancho~age~ Ag 99503~5935 203 W. 15th. AVE. SUITE 203 ANCHORAGE, ALASKA 99501 (907) 27%3916 Fax (907)-276-6013 Municipality of Anchorage Division of Environmental Health Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 Subject: Lot 11, Block H, Knik Heights "Pink" Sheet Gentlemen; Responses to your "pink" sheet: I/ :(12 January 16, 1996 1. One possible replacement site is shown. 2. Swingties locations have been COlrected. 3. Approximate location of block foundation is sho~vn. 4. Soil log is attached. 5. Ground elevation over tank has been corrected. The tank is 2 to 4 inches inches out of level, depending on manufacturing tolerm~ces. This has no effect on the operation of the tank. The baffles are not submerged and the holding capacity of the tank bas been reduced by less than 20 gallons.. Yours T. Sp~'kland P.E. 6~,5 Moni to C{eon C{eon ut Stondord ?renches: £' W/de $£.5' Long lO' Deep 4' Sey/er rock ~' Co vet PR£MARY ?RENCH 14 REPLACEMEN? TRENCH NU SCALE C{eonouts /- iNV. EL 90.$ ~vi/to £/ ].40 Pt oF Septic ~ock flu SCALE NO C£OUNDWA?ER BOH 80 NO SEDNOCK MIP£RVIOUS WATE£1ALS EL. ~5.11 Y. EL. 9J, 51 1o°50 got, sept,'c tonk BDVCH MARK, GARAGE FL OZVR ASSUMED E/.EIZ 100,00 TOBBEN SPURKLAND P.E. ~03 WtSth Ave Anchorage Ak 99501 L~]T11 ~LZ]CK H E/VIE HEIOH?S PE?E UI)EM1-HALL 13101 RIDGE!¥[70~ R~]AD IS£PTIC SYSTEM AS BUIULT I]~TE: /VUV. 25, 1995 SHEET: 3/3 6RID: 0O836 F ~11 ~,,.:: 49t¼ ',BEN SPURKLA hiD. 6E-~85 50 75 ~ SCALE; 1' : SO FF, 115 I 150 I I I I TOBBEN SPURKLAND P.E. J J 203 W 15TH. AVENUE II ANCH. AK. 99501 _(907~ 279-5916 LOT 11, BLOCK H KNII( H~7GHTS P£1'E ODENrHAL I510! £1DOEWOOD SEPTIC SYSTEM AS BUILT DATE: NOV. 26, 1995 SHEET: 2/5 GRID: 2856 FITUNDA T]£1N £L EANI]UT £~ean ]4 PPINAPY TRENCH ,2EPLACFklEN? ?,2FNCH iVl] £CALE / 6 ' Co VPF INK EL 90,5 ] 4 0 85.8 £~ o£ ~ept/c RooF( INKEL. 90.,~b EL. 95.61 85.8 flO GROUNDWATER BOH 80 NO BEDROCK YdPERVIOUS YATERIALS ~ENCh'/q~B~, d;A~AdE~D£ ASSUME~ ELE~ /O0. O0 rOI}BEN SPURI<LAND P.E. ~03 WlS~ch Ave Anchorage Al< 99501 .?~?-,~?16 L~]; 11 ?LITC/( H YY[/( PEIE {]~DV?HALL lgJol ,2/~6El/g~? SEPTIC SYSTEH AS BU]ULT DATE: ~4 Z~ ]995 SHEET, 3/3 GRID, 2836 PAGE 1 OF 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW950294 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:ODENTHAL PETER & CHERYL D OWNER ADDRESS:13101 RIDGEWOOD RD ANCHORAGE, ALASKA 99516 DATE ISSUED: 9/27/95 EXPIRATION DATE: 9/27/96 PARCEL ID:01737211 LEGAL DESCRIPTION: KNIK HEIGHTS BLK H LT 11 LOT SIZE: 43500 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION 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 (iSAACS0) . 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: PRIOR TO FIRST INSPECTION, EXTEND TEST HOLE TO A DEPTH OF 16 FEET TO VERIFY NO BEDROCK. CONFIRM PERCOLATION RATE AT THE 12'+ DEPTH PER SOILS LOG FOR T.H.#i AND SUBMIT DATA WITH INSPECTION REPORT. PAGE 2 OF 2 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ENTER TRENCH AT MIDPOINT AT A RIGHT ANG~LE. RECEIVED BY' ~ -f~ ~,,{.,~,..,,'~ .~ '{-"{"6/{/ DATE: DATE: 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 11 BLOCK H KNIK HEIGHTS PETE ODENTHAL No Ground Water or hnpervious Layer to 15 ft. Use Standard Trench Soil Rating. < 1 min/in = See Sieve Analysis Use 1.2 gal per sq.ft/day No. of Bedrooms 4 Required Area per Bedroom: 150/1.2 = 125 sq.ft.. Total area required: 4 x 125 = 500 sq. ft. Finish Floor Elevation 105 Ground Elevation at Absorption Field 100+- Testhole Total Depth Less 6 Unsuitable 6 ft Separation To Bedrock Rock Depth Length of Trench Extend Testhole to at least 16 feet to verify no bedrock 500 / 8 = 62.5 ft SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 62.5 FT TOTAL WIDTH 2 TOTAL DEPTH 10 ROCK DEPTH 4 COVER 6 SEPTIC TANK 1250 GAL The installation of this septic system will not prevent wells fi'om 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 fi'om this installation. pg.1 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEERI$ SEAL LEEAL DESCRIPTION: I-..-a -~ ¢1, D [/~" tcJ~ Township, Range, Section: SLOPE 81TE PLAN 11 s L IF YES, AT WHAT O 1 2 .~ .~ DEPTH? p E Oeplh to Water Alte~// Gross Net Depth to Net Reading Date Time Time Water Drop 15 17 19 20 PERCOLATION RATE tmlnutes/inch) PERC HOLE DIAMETER A TEST RUN BETWEEN FT AND __ __ FT / \ ~ERFORMED BY; ~' ~ ~~I ~ CERTIFY THATITHICEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE D MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~ 72-008 (Rev. 4/~ Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502~0650 SOILS LOG m PERCOLATION TEST (ENGINEER'S SEAL) PERFORMED FOR: LEGAL DESCRIPTION: L(.,~'7 ~, [ 3 5 Township, Range, Section: SLOPE SITE PLAN 10- 11 12 13- 14- 15 16 17 18 19 2O WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E Depth tn Water Alter Monitoring? Dale: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ . (minutes/tach) PERO HOLE DIAMETER TEST RUN BETWEEN FT ~,ND FT COMMENTS ,,, ~ERFORMED BY: '(.. Em ,~../'~['A-"'"~ ~ '~l CERTIFY TH,AT T, JqI~S T~S~ W,~AS PERFO"M ED IN COORDANCE WITH ALL STAT~ AND MUNIC/PAL GUIDELIN~S IN EFFECT ON THIS Dk i'E. DATE: */J/e~ 72-008 (Rev. 4/85) N /4 5O 300 13 VACAN I // ® VACANT /0 LEYPE L VACANT I I VACANT II II TOBBEN SPURKLAND P.E. 203 W 15TH. AVENUE ANCH, AK. 99501 LOT 11, BLOCK H IfNIK ltEIGHT'S PETE ODEN?HAt i$i0! RIDO£WOOD SEPTIC SYSTEM DESIGN DATE: SEPT. I0, 1995 SHEET: I/3 GRID: 2856 ~5 0 ~5 5O SCALE: I I 75 ~IGO ] 5 50~f. ~ I I I I I / ~- fYell TOBBEN SPURI<LAND P.E. 205 W 15TH. AVENUE ANCH, AK. 99501 LOT 11, BLOCK Y ICNII( IIEIGHTS PETE ODEflTHAL 15101 PlDGEWOOD SEPTIC SYSTEM DESIGN DATE: SEPT. 10, 1995 SHEET: 2/5 GRID: 2836 ?EJUiVDA Th?N CL EANZTUT 1250 9oi Septic tank Moo/raj Cleon Standard Trenches; c~' ~J. 5' Long lO' Deep .I' Smlver rock 6' Cove? Cleon /4 PR/MARY TRENCh' REPLACEMENT ?REMCH SCALE / / C{eol?oUtS .-~ Topsoil lQ Non/to: Cover '~ /~ LxlsL', Orounc/ 4' M/n Cover To nk M/mo P/ 140 4 Pt o£ Smpt,'a Fiock SCALE ,Go/, septic tank 3ENCI-f MARK, ?{TP ElF F$~UNDA ASSUMFD E/ EV, ]O0, O0 TE]]~]}EN SPURKLAND P,E. ~03 WlSth ave Anchorage AP.' 99501 L:? 11 ?L/JCK H PETE DDEiVI'HALL 13101 £IJOEI,/ITDP SEPTIC SYSTEM DESIGN DATE, £EPT, /C Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage.ak.us (SO7) 343-7~4 HEALTH AUTHORITY APPROVAL CHECKLIST Parcel ID: O I 7- '~'7,L - t t A. WELL DATA Wel~ type ~ Date completed t%at~ Total depth ~o 5 ,ft. Date of test Static water level Well production ifA, B, or C pmvtde PWSID # ~'~ . San y (Y N)y Cased to lo .~ ..ff. FROM WELL LOG Io/ / ~o l ft. ~ g.p.m. Well Log (Y/N) Wira~ properly protected (Y/N) Casing halght (above ground) AT INSPECTION ' / ~-'~/o ~- g.p.m. in. WATER SAMPLE RESULTS: Coliform ./~ colonies/100 mi. Nitrate ~.. ~./1. /o Date of sample: q 2- C.,~ected by: I - Other bacteria ~ colonies/100 mi. B. SEPTIC/HOLDING TANK DATA Tank Type/Material ~__ Tank size ~ gal. Number of Comparlments ~ Foundation cleanout (y/N) / Depression over tank (Y/N) H c .no (Y/N) 'y' High water alarm (Y/N) ~ Date of pumping I/~0(/~ P'- Pumper A ~.c~. C. ABSOR~ION FIE~ DATA Date ins~tlod '~l~/f~ ~" rating (g.p.d.~ ~) L ~ system ~ Leng~ ~y~ ,. ~ ~ ff. Gr~al bal~ pipe ft+ Total depth I~ ft. Eft. absorption area 5m~ · Monitoring tube Date of adequacy test t/zq/~ ~.- Results (Pass/Fall) ~ Fluid depth in absorption field before test ~ in. Water added ~,OO gal. Elapsed Time: -~-? I'l'l~e- It~J, Final fiuid depth __~ in. Any rejuvenation treatment (past 12 mo.) (Y/N & type) Depression over field ~,"'-~ For /'/ bedrooms New depth/_.~_ in. ~ 0-~ g.p.d. If yes, give date I~ Absorption rate >= · D. LIFT STATION Date installed S,/~e in gallons ~s (Y/N) "~mp on" level at ,~in. "~ump off' I~vel at __ lo. ~' High ~.~tar alarm level at Datum J Cyctas tested J Meets alarm& circuit requirements? E. SEPARATION DISTANCES in. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lilt station on lot t o ~ Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cieanout Holding lank SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK .ON LOT TO: Building foundation ~,-~ Property line /~ ~' Water main I'W/~, Water service line C~ O Wells on adjacent lots I~L.~ 4- Absorption field Surface water ' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I {;)~ Building foundation ~o I Water Service line lO0 -I- Surface water 1-41 o Curtain drain ~',1 / o Wells on adjacent lots I o-0 -l, Water main Driveway, parldng/vehicte storage /-~ F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal reconfa that the above systems are/n conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name Date Date of Payment Receipt Number (Rev. 12/00) Waiver Fee $ Date of Payment Receipt Number .J~-31-02 11:45~ :ROII-CT&E EN'tlR~NTAL SRV ss CT&E Envlronmentnl Service-, Inc. 90T§EIS~01 T-011 P.0Z/~3 1020522001 Tobben Spmkl~nd P.E. Kink His, LI 1, Knik Hts, LI l, BH Drinking Wnter CT&£ RI~f.# Client PO~ P~e-P~id Colis/l~03 ~roleet Na~ Cotl~ed Dat~im~ 01~9~002 16:30 Client Sample ID R~lv~ ~t~ 01~9~002 19:lO TechnicaIDimtor a' Stephen C. ~ . j _ MatH. Ordered By PWSID 0 Sample R~a~k$: ~n~ ~ul~s PQL U~ M~I~ L~m D~m ~e lni~ N,ttatc-N 0.200 U 0.200 fuE/L EPA 300.0 (<10'~ 01/29:02 t&~.crobiolog¥ L~e~ral:ory Total Coli£orm 0 ¢o'./100mL SMI8 9222B 01/29/0} SBH R~OGEWOOD ROAD L~ N 00'05'17"V,' 14~,.98 / N 00'04'08"W 144.~7' (KIE.A~) iO:J9 RCVO 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 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 C;"[')E,-h!T ~.4-& L P'~-T~---- P~ Dayphone Day phone Day phone _ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: W 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. 72-O25fRev. 1t91} Front MOA~21 o 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 '10~b~,1 .~'pu~-~'-.-~-~/2' P-~:~ Phone ~7~-~/~ Address ~O~ ~ 1~ ~ ~0'~ Engineer's signature ~ %~~¢ Date ~/~, DHHS SIGNATURE Approved for '¢ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Municipality of An~:horage Department of Health and Human Services (DHHS) issues Health Authority Approval Cerlificates 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. 72q325 (Rev. 1/91) Bac~ MOA ¢21 96-04'-05 10:39 RcYD Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Log preseut (Y/N) TOtal depth Sanitary seal (Y/N) Health Authority Approval Checklist If A, B, or C, attach ADEC letter. ADEC svater system manber __ Date completed Cased to I 0 ~ t Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample:- FROM WELL LOG to, ?.'.z,,q~ B. SEPTIC/HOLDING TANK DATA . g.p.m. Nitrate Co AT INSPECTION g.p.m. ~') .~/ H4'6~/ Other bacteria ~ Collected by: ~'C -~ III / ¢ Date installed ! i,Y/r~2~ Tank size J ~-:~0 Number of Compartments ~ Cleanouts (Y/N). Foundation cleanout (Y/N) y Depression (Y/N) 1'"4 High water alarm (Y/N) ~ ~ Date ofPmnping _ ~,/~-X~ Pumper 'll'-///,~ .y ABSORPTION FIELD DATA Date installed I lll .'~- [~:~ ~ Length /a ~, .~ [ Width _ Soil rating (g.p.d./fl~orft2/bdrm) l,~ Systemtype '~f4, t, le.~/q Gravel thickness below pipe /.// I Total depth Effective absorption area Date of adequacy test N/t~:,~ Fluid del)th in absorption field before test (itl.); Fluid depth {"'d/~,2,,-- (illS.) Minotes later: Peroxide treatment (past 12 months) (Y/N) Monitoring Tube present(Y/N) y Depression over field (Y/N) ~'J Results (Pass/Fail) '~'-~ For Z-/ bedrooms Immediately after ~gal. Water added (in.): __ ~///.X. Absorption rate =_ ~>' ~ ~O g.p.d. ~ __ If yes, give date LIFT STATION Date insta[lcd Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons ~'Pump on" level at* *Datum E. SEPARATION DISTANCES Septic/holding tank on lot Absorption field on lot Pablic sewer main Sewer/septic service line SEPARATION DISTANCES FROM WELL ON LOT TO: iO~I On adjacent lots I t ~ t On adjacent lots /'~//~.~, Public sewer manhole/cleanout b o station SEPARATION DISTANCES FROM SEPTIC~ TANK ON LOT TO: Building foundation /~ ~/ Property line J/~ Absorption field Water main/service line ~OI Surface water/drainage Iq} O Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation /_o I ~ Water main/service line [ OO Surface water ~ I/.) Driveway, parking/vehicle storage area //,t~9 I ~. Curtain drain iq l ~ Wells on adjacent lots / ~ ~" ~ -- Property line ] O F. ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the above systems are in conJbrmance with MOA H~L4 guidelines in effecLon this date. Signatur~ ~ ~t_Jff<~, Engineer s Name' [~~ ~0'~ l~ ¢~ Rev. 8/95 OSS: haa.wk.doc Waiver Fee $ Date of Payment Receipt Number CT&E Environmental Services Inc. Laboratory Division ~/~/~~./y/?-/-?/~/~.~///~.~/~.~ Laboratory Analysis Report CT&E Ref.# Client Sample ID Matrix 961095.8943 Lll BH KNIK HTSI i095-01 Drip,king Water Collected Date 03/29/96 Technical Director Released By,,,:::- Sample Remarks: Nitrate-N Results 0.201 QC PQL Ouat Units Method Allowable Prep Analysis Init Limits Date Date 0,100 mg/L EPA 353.2 04/02/96 EMB ?0. ' -?9 200 W. Potter Drive, Anchorage. AK 99§18-1605 -- Tel: (907) 562-2343 Fax: (907) 561 5301 3180 Peger Road, Fairbanks. Al( 99709-5471 -- Tel: (907) 474-8656 Fax: (907) 474-9685 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA