HomeMy WebLinkAboutZODIAK MANOR ALASKA BLK 5 LT 8clia'k Mano
Bloc'k 5
Lot 8
#015-012-09
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage. AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-7904
Parcel I.D. 015-012-09
1. GENERAL INFORMATION
Complete legal description
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
HAA 0 2 004 2
Expiration Date: ~
[. ZODIAK MANOR SUBDIVISION; LOT 8, BLOCK 5, '
Location (site address or diractions) B651 PLUTO DRNE * ANCHORAGE, AK 99507
Current Property owner(s)
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing address
DON SHERWOOD Day phone ,346-3662
8631 PLUTO DRIVE * ANCHORGE~ AK 99507
Dayphone
JANET GELLERT w/ PRUDE,'riAL VISTA Day phone.
4241 'B" STREET * ANCHORAGE. AK 99503
440-4146
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 4
3. TYPE OFWATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
Community On-site
Public Sewer
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (I-IAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority
Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
Note: Alaska Water and Wastewater Consultants, Inc. shall be pairi $
to closing for the engineering services provided.
al orpdor
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, based on procedures outlined in the Health Authority Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is(are) 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 Municipality of Anchorage files and from my investigation and inspection, the
on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ALASKA WATER &: WASTE'WATER CONSULTANTS, INC. Phone
Address 6901 ~EBARR tOAD. SU~E 2B * ANCHORAGE. AK 99504
Engineer's Printed'Name JEFFREY A. CARNESS, P.E.
Date
337-6179
Engineer's Comments:
In conducting this evaluation, AWWC, Inc. affempted to provide a thorough,
conscientious engineering analysis of the system in accordance with ADEC end MOA
DSD Guidelines & Regulations. The reported results desctfbed the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local so~7s condition, groundwater levels that may
tTucfuate du#ng the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee futura performance of the system, nor do they guarantee that
there ara no hidden defects or encmachments. AWWC, Inc. can therefore not provfde
any warranty or future estimate of how long the system will continue.to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authortzed, nor will it confer any legal I~ght whatsoever.
5. DSD SIGNATURE
Approved for 4
Disapproved.
Conditional approval for __
bedrooms.
.... . ,.
bedrooms, with ~e ~owmg stipulations.
~.. ~.. '. O~-
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's P, eort
Other
Original Certificate Date: ~/(~'
(Rev. 12/01)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Slfe Water & Wasfewafer Program
4700 South Bmgaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
w~w.cLanchorage.ak.us
(9O7) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type PmVA'~
Date completed UNKNOWN
Toteldepth *157 fl. ~A
~f" FROM WELL LOG
ZODIAC MANOR SUBDMSION; LOT 8i BLOCK
*PER PREVIOUS HAA
If A, B, or C provide Pt/VSID~t N,/A
Sanitary seal (Y/N) YES
Cased to *40% ft.
Date of test
Static water level
Well production
UNKNOWN
UNKNOWN
UNKNOWN
WATER SAMPLE RESULTS:
Coliform 0 colonies/100 nd.
Amenlc: 0.002 mgJl..
D. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Parcel ID:
015-012-09
g.p.m. 6.2
well Log (Y/N)
Wires pmpedy protected ~/N)
Casing height (above ground)
AT INSPECTION
2,/1,/2002
102 ft.
g.p.m.
Nlltate 1,32 mg./L. Other bacteria
Date of ~ample: 2,/1,/2002 Collected by:
PUBLIC SEWER
Date installed
NO
YES
12+ in.
0 cctonies/100 mi.
AWWCf INC.
'Tank size, gal.. Number of Com~~~I~~~
Foundation clean~nk (Y/N) High water alarm (Y/N)
D ng Ptnnl:~r "
C. ABSORPTIONFIELOOATA PUBLIC SEWER
Date installed Soil rating (g.p.d./ft=or fl~xirm) System type
Length · ft. Wle~h ft. Grav~t/~'''''/ ft.
Total depth, ft. Eft. absorption ama fi~ Monito~g~.~r? Depre~ion over field
Date of adequacy test ~ For ' bedrooms
Fluid dep~ in absorptlon~ in. Water added gal. New depth in.
1 fluid depth in. Absorption rate >=~ g.p.d.
uvenadon trealment (past 12 mo.) (Y/N & t~oe) If yes, give date
Cycles tested Meets alarm & circuit requirements?
E, SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot N/A
Absorption field on lot N/A
Public sewer main 46'+/-
Sewer/septic service line. UNKNOWN
*WAIVER REQUESTED
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout *70'+/-
Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
line Building foundation Water ~.__.....~ ~--'-"'~
Property
Water smviceline ~ ~rlveway, parking/vehicle storage
~ Walls on adjacent lots
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
rev/ew of Municipal reconts that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Nqme
Date
JEFFREY A. OARNESS
HAA Fee S ,-.-.-.~ ~7 ,/::~
Date of Payment
Receipt Number
(eev. ~2/o~)
953 .." "
Waiver Fee $ /~
Date of Payment
Receipt Number
/
· LOT 27
.~-'- . ~'~
~ '~¥~Z'.' ~/ "
~ "- -' "~ ~1~' ~t~,.~"'~
Municipality of Anchorage
George P. Wuerch, Mayor
Buildhug Safc~- Dirision
P.O. Box 1907~0 · 4700 S. Bragaw Street
Anchoragc, Alaska O0$19.CoE~0 ° (907) I~I$.8301
h t t p://www.cl.anchon~gc.ak.us
2~25/2002
Jeffrey A. Garness, PE
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road, Suite 2B
Anchorage, Alaska 99504
Subject:
Waiver Request for Zodiac Manor Subdivision Block 5 Lot 8
Waiver Request #WR020007
Parcel ID #015-012-09
Health Authority Approval Certificate Number HA020042
~epartment o~
Public Works
Dear Mr. Gamess:
Your request for a waiver of the required 100 feet horizontal separation from the
public sewer manhole to private well has been approved. The approved separation
distance is 65.0 feet. This waiver approval also includes the water well to public sewer
main of 46 feet.
This waiver approval applies to the existing public sewer manhole to private well
separation only. Any future upgrade to the on-site wastewater disposal system will
require all separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Water & Wastewater Program
WR#: WR02000?
Date Received: 2]22/02
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Was~ewater ProgT'am
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(9O7) 343-79O4
Waiver Review Worksheet
PID~: 01,~.012-09 HA#: HA020042 Pen'niB/:
Legal Description: zqdta~; Manor Subdivision Block 5 Lot 8
Engineer: ~
Alaska Water & Waatewater Consultants. Inc.
Applicant: Don Shen~tood
Waiver Requested: Wpf~er Well to sewer main of 46 feet and man hole of 65 feet
Criteria: Geology Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
Waiver is Granted: ~ Waiver is not Granted:
List Conditions or Reasons for above: ~'~'~ /°rTr"/c~ ('/c/'t? ~)
Date: ~ By:
Name of Reviewer
Rec#: 't~/407 Amount: $1000 Date Paid: 2/2512002
I
I
~
I~ ' · )~ = ~
' ' I~1~ 4/ .v&22-/- 7. 0
¢~ ' ' ._t- .=
¢.~.0.
.
7.2_
~.7
ALASIG WATER & WASTEWATER
CONSULTANTS, INC.
Febmary22,2002
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
Anchorage, Alaska 99519-6650
Subject: Waiver, Well to Public Sewer Main/Manhole. Zodiac Manor, Lot 8, Bk 5
To whom it may concern:
· During the evaluation ofthe subject well for the purpose of obtaining an MOA health authority
approval, it was determined that the well is approximately 70 feet from a punic sewer manhole
and 50 feet from a public sewer main. There was an HAA issued in October of 1985 at which
time it was determined that a waiver was in place for the subject encroachments. During the
current HAA review process it was determined by your department that there is no valid waiver
in place.
We are requesting a waiver at this time for the following separation distances:
* Private well on Zodiac Manor, LB, B5 to the public sewer main in Pluto Dr.: 46+ feet.
· Private well on Zodiac Manor, LB, B5 to the punic sewer manhole in Pluto Dr.: 65+ feet.
The sewer service line has been in place since 1974. At that time, there was not an established
separation distance requirement between a private well and a private sewer service line. The
actual separation distance is unknown.
Justification for the waivers is summarized as follows:
· The well is uphill from the sewer manhole, therefore, it is physically impossible for
overflowing sewage to run towards the well head. All contamination must be via subsurface
migration.
· Based upon correspondence in your department files (See DHHS records for Zodiac Manor
LID #850, it appears that the subject sewer main/manholes were constructed so as to be water
tight.
· The subject encroachments have existed since 1974 (almost 28 years). Recent water samples
(2/1/2002) indicated no bacteria were present, and nitrate levels of 1.32 mg/L. This is an
indication that the subject encroachments have not adversely impacted the water quality.
6901 Debar Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
Attached is well logs from six (6) nearby lots· Thc depths vary from 94 fcct to 165 feet, with
groundwater being at 94 feet or more below grade. Thc log for one of thc closest wells (Lot
6, Bk 5) shows a layer of hardpan soil between 87 fcct and 151 feet. Thc othcr'logs show
various layers of sand, gravel, and clay. Clearly, these geological soil layers have served tO
protect thc aquifer.
Based upon the aforementioned facts, it appears that there is minimal risk associated with
granting the requested waivers. If you have any questions, or require additional information,
please contact us ~337-6179.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
ALASIC& WATER & 5~STE~TER ~ , .
CONSULTANTS, INC.,
DON SHERWOOD (907) 244-4986
ZODIAC MANOR SUBDIVISION; LOT 8, BLOCK 5 ~¢e_~.....~ ....'
DRAWING FOR WAIVER REQUEST
:Box 1369, STArt l/ou'rE A ' ASCr~On~GEe .dkLASKA 99502
SlX INCH W~'~'ER WELL DRILLED ANI~ CASED OUT TO THE DEPTH OF '
DRILLED AT THE RATE OF ~ PER ~:~O~..~,~q S.
PROPERTY OWNER ~. Glea ~ 27h-J~30 1~ ~te~*t
Customers )iee~n/c~l C~ntracters lncorp, 1~1.~ Sp~' Ave°
LOCATION OF WELL SIT ~ '
DRILLER ~r~e ~a~ of ~ ~t11~ ~orkl.
WELL LOG:
87~1§1"
l~ater bearing sa-a. Very silty.
Good stable rater be~tng gravel producl~ 10 GI~ ~rlth a flay foot he~d.
Cased to 1.~ feet. l~mp lho-~a be /nst,~d t~n feet off bottma..
Cost of ]:~*~*~'~,,g~ $2~18o00
Sec 10~ T'IZ/V~ R=Jw, ,SM
W~'?- 1~.9 ~?~'~, 2
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF' SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF
THANK YOU VERY MUc~
DAT~
BERNIE CLAUS OF' RAMPA,,I~T DRILLING. WORKS
SERVICE CHARG£Op ~% PER MONTH WILt. B£ ASSE.$S£D ON PAST DUEACCOUNT~.
MILE~O~ PARKS HWY
8~2-7950
JOE GIELAROWSKI ·
DRILLING ~O.
·
0 NER OF LAND ................... ~.- .......
FROM ............. FI',TO, , , ri'
/ FROM ' FT. TO ,
INFORMATION: ~ ~ .5' o~ bolt. m
(choc~ o~e) Open ~ ( ~ . Scroen . ( ): ~er£orated (
Describe screen or per£orations:
Well .pu~p.ing t~t a~allons per (h~.) (~tn~for
'2 ~ 'fe~ra~clo~n from static .level.
Finish or.ell
).
hours with
. Date ~:o leted . . ~ . I~ELL LOG' ·
Depth in £eet From Give details oi' £ormations pene~ated, size o~ ~terial, -
~o~d s~face col~, ~d h~ess,
.
~.::-~ - . . - . .. _
to
to
to
~o
to
~33 E~t ~2nd Avenue
OWNEEOFL~D. Ken G. MerCtn
DAILY DRILLING LOG
PENN JERSEY DRILLING CO.
Anchorage, AL~sJ~
~UNICIPALITY O? ANK~ORAOE
DEPT. OF . :!.vi. t:
EN'¢I,~O,%LV[I:I . . ,.CTION
b~AR 1 ~: ,~0
R E C E
DEPI~/OF w,.:,.'r- _ 152 *
ADDm$..._8621 Jupiter Dr. Anchorage, Alaskz 99507 STATIC ~ OF WA'A'~K ~ .... ~[. ~
~¢~ ~e~¢P ........................
D~,~..., A~ust 13, 1979
..................................................... o~ ~ ~ .................. .~_~L
D~__~ Aught 14, i979 ~ 0~ CAS~G 6" steel ~lded c~s~ng
lVllSCl~ T~"ORMA'I"~ON:
some Sand & Water.
~ROSt' ...............IT. TO ............. ~T ........................
k'~,~O M .................... FT. TO ............... ~ .....................
~tOM_ ............... ~1'. TO ................ FT' ..................
FP4),WL ........... ._,~T. TO ................. .F/' ...................
l~.OM .................. .Fi'. TO ................ F'l' ......................
FROlVi ................. F'l% TO ................... ~ ........................
FROM ...................... FT. TO ..................l~t ..............................
FROM ................ FT. TO ................... &uT ..............................
IrR O.'VL ..............FT. TO .................... FT ........................
DRILLER'S N~-VIE Ted Schaehle & George Riley
· -I '.'~.
I. rs
i
/\
'il
~IX INCH WATER WELL DRILLED AND CASED OUT TO THE D~PTH OF
DRILLED AT THE RATE OF ~.v~ PER FOOT. .; ...... .,.<,.~'t,
~OPERTY OWNER ~ 8~. ~44-7750 277-~4~5 ' ' /;~;'~ ~:'...,
'LOCATION OF WELL SITF ~' ~ B~. 5 ~
DRILLER_ ~ C~ o~ ~ ~ ~o~. ' '
0 .... 25~ ~1. ~u~. ~O~g
· " ' ': .... ' · ' ""'~.' .' ::'-'r.,.":~.~"',':':;:'
· . .. ...:,~ ... ~.,~.,.~,:
· C~ST~INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF BAlD DRILLING. ".L'%;'.r,
' R eCK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF ~12617o00'
THANK YOU VERY MUCH.
DA'~F 0c,%. 12,~, .1978
SERVICE: CHARGEOF '1~% PER MONTH WILL BE: AGSESS£D ON PAST DUE:ACCOUNTS.
BERNIE CLAUS OF RAMPART DRILLING WORKS '
':;':.'?,...
I
tVlUNICIPALITV OF ANCHORAGE
DEPARTed'lENT OF HEAL'tH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRON~/IENTAL HEAl. TH
CERTIFICA rE OF INSPECTION [;OR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACII_ITY
264-4720
Application Date
GENERAL, INFOR[VIATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~ ~ +--~P7 ~--¢z~%:: '~ulelophone: Home ~ ....... ¢--.- Business
Applicant Address __~*/:FYY~ ~-~
(c) Applicant is (check one): Lending Inst~tut~o~Owner/budder ~ Buyer ~ · Other ~ (explain);
Address
(e) Real Estate Company and Agent
Address
Telephone ..........................
(f) Mail the I~AA to the following address:
TYPE. OF RESIDENCE
Single- Fa md y,~}'~ M ult,- Fa m~ty []
Number ol Bedrooms '---m-?_ .
Other
WATER SUPPLV
Individual Wel~tE~O Community [] Public []
Note: If community well system, must have written confirrna on from the State Department of Environmer:LE5 Donservation
attesting to the legality and status,
4. SEWAGE DISPOSAL
Onsite [] Pubhc/~J~ Community [] Holding Tank []
Note: If commueity well system, must have written confirmation h'om the State Department of Environrner :% ~,onservation
attestin9 to the legality and status.
Page 1 of 2
ENGINEERING FIRM PROVIDING IN.~;PECTIONS, TESTS, FILE SEARCH, DATA AN[) 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 tl~at 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 ~s in compliance with ali Municipal and State codes, ordinances, and regulations in effect on
the date of this ins. pection.
Address
°ate_ I
Engineer's Seal
DHEP APPROVAL/
Approved for ~//~/~¢',~' b e d r o o m s j~L~ ~_ ~'~F~_~. ~.0
Approved .... ~i~s~ip p r~o ~ .'___i._.~i-~/~ C ~n cjitiTo n al ~.-
Terms of Conditional Approzal
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State ol Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Ernployees of DHEP 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
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
Well Classification ~, :~-'¢~-~ If A, B, C, D.E.C. Approved (Y/N)
Yield
Well Log Present (Y/N) ,~,~l;~ Date Completed ~,~,~,~¥~-,~..~'~;;:x...~'~,
Total Depth ~¢'.,~7 _ Cased to 4'L~O '4'"~' Depth of Grouting
Pump Set At
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot _ '~"~t~¢"~; On Adjoining Lots
To Nearest Public Sewer Line 4~¢''~ To Nearest Public Sewer
Cleanout/Manhole _~"' ~---- To Nearest Sewer Service Line on Lot '
Water Sample Collected by . ~ V~'~ ~" ~'T%c,~d-J~-'~--- .; Date _ '
Water Sample Test Results _
SEPTIC/HOt. DING TANK DATA ~:'-~ .---~
Date Installed Size __ ___ No. of Compartments
Standpipes (Y/N) Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
__ To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026{11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
Stream/Pond/Lake/or Mcsj~r Drainage Course
To
To Driveway, Parking A~, or Vehicle Storage Area
Comments
Type of System Design
Length of Field
Depth of Field _ /
Gravel Bed Thickno~
__ Stan~tCpes Present (Y/N)
,/,~t~ of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
M
Dime
(Y/N)
"Pump Off" Level at
Vent (Y/N)
· Pumping Cycles during Adequacy Test, Meets MOA
** Check Permitted
I certify that I hav
Signed
Company
Receipt No.
Date of Payment
Amount: $ _
Page 2 of 2
72-028 (11/84)
Rating Against HAA Request **
o all MOA and HAA guidelines in effect on the date of this inspection.
Date
MOA No,
Engineer's Seal
DAT~/~ ECEIV ~D
INSPECTION APPOINTMENTS
INSPECT?~ I1 INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE ~UNICIPALI~ OF ANCHO~GE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO~ DB~T. OF H~ALTH &
~25 L Street - Anclmmge, Alaska 99501 ENVIRONMENTAL pRO'[E~ION
) ENVIRONMENTAL. SANITATION DIVISION OCT 1 ? 1979
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL
DI RECTIO~8~ Complete all parts o, page 1. Incomplete requests will not be procossed, Please allow ten (101 days for processing.
1, PROPERTY OWNER
PHONE
MAILING ADDRESS *
PROPerTY R ESI ~N~ (If different from~e PHON E--
MAILING ADDREgS
3, LENDING INSTITUTION
MAILING ADDRES~ u --
d
5. LEGAL DESCRIPTION
6. TYPE Old'RESIDENCE NUMBER OF~BEDROOMS
~J, SINGLE FAMILY ~ Ong ~ Four ~ Other
~ Twc ~ Five
~ ~ULTIPLEFAMILY ~ Three ~ S~x
7. WATER SUPPLY
~ INDIVIDUAL' ~ ATTACH WELL LOG. A well log ~s required for all wells drilled
~ COMMUNITY since June 1975. For wells d '(lied prior to that date, give well
~ PUBLIC UTI LITY de~th (attach log if available.)
8. SEWAGE DISPOSAl. SYSTEM
~ IND~VIDUAL/ON-SITE~' YEAR ON-SITE SYSTEM WAS INSTALLED.
~ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESS] NG CAN BE INITIATED,
72-O10 [Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY E~] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY )ATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIViDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified iNSTALLER
[]Septic Tank or [] Holdin§ Tank
Size: if Tank is homemade SOILS RATING
give dimensions:
'YPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Hoiding Tank IAbsorption Area Sewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
, -~-APPROVED FOR -, BEDROOMS
[] /CONDITIONAL APPROVAL (letter must eccompa~.~certificete)
E[~/' DISAPPROVED ."2. ~Y~
72-010 (Rev. 6/79)
4.
5.
6.
Approval requested by:
Mailing Address:
Property Owner:
Mailing Address:
Legal Oescription:
Location:
/GREAI~q~.R ANCHORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street, Anchorage, Alaska 99503 274-4561
Date Received //
Time of Inspection
Date of Inspection
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WATER FACILITIES
FOR
Phone:
q:.
d~
Type of facility to be inspected .~,J_,
Well Data: ' ~ / '//
A. Type ~-,~-,~' ,-~ ....... (~. B. Depth
C. Construction ~.~' ~,~.~ ~.~..~
Sewage Disposal System:
No. of bedrooms
D. Bacterial Analysis
A. Installed ~-~-' B. Installer
C. Septic 'rank: 1. Size
D. Seepage Pit: 1. Absorption Area
2. Manufacturer
2. Material
E. Disposal Field: Total length of lines
8. Distances:
A. Wel'l to: Septic tank '
Nearest lot line '
B. Foundation to septic tank
, Absorption area
, Other contamination
, Absorption area
C. Absorption area to nearest lot line __
, Sewer Lines
EQ-034 (1/74) Page 1 of two pages
Pi ~ 2 of two pages - Re
Le~ I~ Description
St for Approval of Individual r "er & Water Facilities
Comments
Approved
~°~c~/L ~ ~-,~y~,m _ Disapproved
Approval~Valid for one year from date signed
Greater Anchorage Area Borough, Department of Environmental
DIAGRAM OF SYSTEM
Date
Quality
certify that the information contained in this request for approval to be a true and
accurate representation of the subject sewer and water facilities and these facilities
are operating satisfactorily.
SIGNED Date
EQ-034 (1/74)
3330
GREATER ANCtlORAGE AREA BOROUGH
Department of Environmental Quality
"C" St., Anchorage, Alaska 99503 - 274-4561
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER & WA-FER FACILITIES
Type of Inspection CMRO
Property Owner:
Mai.ling Address
Name of Buyer: .= ,
Mailing Address
Name of Lending Institution:
Mailing Address:
Name of Realtor or Agent:
Mailing Address:
VA
FltA CONV
Day_ Phoiqe
Phone
6. Legal Description: ~ (, / ~ .....
Location:
7. Type of Facility to be inspected:
8. Water Supply
Type of Supply: Public Utility
If Individual, number of dwellings
If Individual, depl:t~ of well
Sewage Disposal System
Type of System: Public Utility _,
If Individual, date
EQ-037 (1/7~)
No, Bdrms.
Individual
presently served
of installation
1' '/ · /
06. J 220
Rev 1973
48 Hours
OGICAL WATER ANAL~"SIS RECORD
--AGAR
Reported by __~ ~ (.. .
MUNICIPALITY OF ANCHORAGE
DEPT, OF HEALTH &
ENVIRONMENTAL PROTECTION
OO-f' 8 1985
RECEIVED
July 8, 1981
(2er tland Bruberg
8429 Jupit~ Drive
An=borage, Alaska 99507
Sub~ ee.t z
198l Sew~ ~tension, Pluto I~ive
Wast6water l~aviev #8121-DA03 6
Zodiak Manor S/D, Ane~raSe
Dear Mr. Brob~rg:
We have r~viawad your report and recommendations conae~ling
a reduction o£ the protective radix for the well locate~ on
Lot 26, BI. oak 4, ~odiakManor S/D.
We h~eby grant a waiver of 18AAC 80 020 which requires a
minimum separation of 75 feat between a private single family
wall end a community sewer line to 23 feet, and a mininmm
s~peration of 100 feet between a private single family well
and a sewer main cleanout to 40 fmat for the subject proJeat.
The pro]~c~ im hare by approved for cons~ruc=ion for the items
with which that dapartnent is concerned. This letter conatitutee
the permit ~e(~ired by AoS. 46.03.720 (a) for approval of
sewerage systems.
If you have an questions, feel free to contact me.
Sine.ely, , //
Thomas L. Murroll
Environmental ]~ng inear
e~ A.D.H.E.Po