HomeMy WebLinkAboutSAMPSON ESTATES BLK 3 LT 7Sampson Estates
Block 3
Lot 7
#051-811-33
$USMITTA1
AUG: 5 2014
Municipality of Anchorage
Community Development Department Page
On -Site Water and Wastewater Program
4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 • http://www.muni.org/onsite • (907) 343-7904
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP121089 PID Number: 051-811-33 ❑ New
El
1 of 3
Upgrade
Name:
Mollie Hall
ABSORPTION FIELD
Address
P.O. Box 770246 Eagle River, AK 99577
❑✓ Deep Trench ❑ Shallow Trench ❑ Bed 9 Mound
❑ Other
Phone
688-3667
Number of Bedrooms
4
Soil Rating
•8 GPD/SF
Total depth from original grade
12R.
LEGAL DESCRIPTION
Depth to pipe invert from original grade
Gravel depth beneath pipe
Subdivision Block Lot
4 Ft.
8Ft.
Sampson Estates 3 7
Fill added above original grade
Gravel length
Township Range Section
1-2 Ft.
50 Ft.
Gravel width
Beds: Number of Lines
Distance between lines
SEPARATION DISTANCES
3Ft.
Ft.
To
From
Septic
Tank
Absorption
Field
Lift Station
Holding
Tank
Sewer
Line
Total absorption area
800 Ft2
Number of trenches
One
Dist. between trenches
Ft.
Well
>100'
>100'
N/A
N/A
>25'
TANK ❑p Septic 0 S.T.E.P. 0 Holding ■ Other
Manufacturer
Capacity
Surface Water
>100'
>100'
N/A
N/A
Anchorage Tank
1,250GaI.
Material
Number of compartments
Lot Line
>5'
1'**'
N/A
N/A
NA
Steel
Two
Foundation
>5'
>10'
N/A
N/A
LIFT STATION
Manufacturer
Capacity
Curtain Drain
None
Noted
Gal.
Remarks **See Lot Lilne Waiver.
Pump on level at
Pump off level at
High water alarm at
in.
in.
in.
Pump make and model
Electrical inspections performed by
Installer
PIPE MATERIAL House to tank D3034 TankD3034
drainfield
PCN Construction
Drainfeld HDPE CO/MT D3034
Inspector MEA
BENCH MARK (Assumed elevation) 100.0ft
InspectionLocation
dates: 91 5/29/12 z•. 5/29/12
and description
3rd 5/30/12 4'"
Bottom of Siding
COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL
Conditional Approval: Date
�`_� �lk,it .
SF't.• �••�t�
as �i,
�,/
so 1k 4918 d\ ' *vi
i.. J......• •... t:
1110441••••••• • • en • 11 w
tae •
(/1/ Date / a,--/ 7-l4
MICHAS, E. ANDLIRSON :Lk el
i f.� CE -4381 •' $``•
I, <0.•.8'1 ,1Y ••••ky r
i enApproved
,,��\\\�i100"."
Ar/ / ,
LOT 7, BLOCK 3, SAMPSON
ESTATES SUBDIVISION
DESIGN FACTORS:
Four Bedroom House
Perc. Rate: 6-15 Min./Inch
Application Rate: .8 GPD/SF
SYSTEM REQUIREMENTS:
Deep Trench System
1,250 Gallon Septic Tank
8' Drainfield Rock
4 Bedrooms X 150 GPD/.8 GPD/SF (Application Rate) = 750 SF Absorption Area
750 SF/16 SF/ LF = 46.9 LF Trench Length
THEREFORE: Construct a 50' Long x 3' Wide x 8' Effective Depth Absorption Trench at the Location
Shown. Distribution Line to be Placed at 4' Below the Existing Surface. Total Depth to be 12' Below the
Surface. Decommission Existing Septic System in Accordance with Municipal Code. Provide 4' of Cover
Over Septic Tank.
3'6"
6"
8'0"
Natural
Backfill
5'
Geotextile
Fabric
4" Perforated
PVC (Holes Down)
Drainfield Rock
TYPICAL DEEP TRENCH SECTION
(NO SCALE) -.�P'C�.. .. ;qCq..
NOTE:
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the Area.
Minimum 100' Separation From Surface Water or Streams.
/
49th
O t MICHAEL E ANDERSON •
E':
• J, No. CE.43e1 /
♦f %.Ph....s&'t,9
Municipality of Anchorage
DEVEOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK. 99519-6655 - 343-7904
On -Site Wastewater Disposal System or Well Inspection Report
Permit Number: OSP121089 PID No. 051-811-33
Page 3 of 3
U 2
27)
In
99.2
CH CO
00
Existin. /
sFinished
,250 Gallon
Septic Tank
95.2
Existing & Finished Grade
99.8
95.05
U
Geotextile Fabric
94.1
Drainfield Rock
86.1
�/— 80.1
50' (Trench Length)
PR❑PILE AS-3UILT
No Scale
94.1
i 4
1 49th
••
•
MICHAEL E. ANDERSON j 1
•I�`�f'. Na. CE -4381 j ~�
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
August 5, 2014
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Lot 7, Block 3, Sampson Estates Subdivision
Separation Distance Waiver
Absorption Trench to Lot Line
Dear On Site Services Engineer:
SUBMITTAL
AUG 5 2014
65-1-i li-53
A second absorption system was placed on Lot 7, Block 3, Sampson Estates
Subdivision in May of 2012. The lot line was not located prior to placement of the new
absorption trench and it was laid out relative to the existing failed trench on the
property. The trench is located within 1' of the south property line. The septic system
on the lot to the south is more than 50' from the common property line and is not
impacted by the location of this absorption trench. We therefore request a waiver be
issued allowing the trench to be 1' from the south property line.
Sincerely,
Michael E. Anderson, P.E.
051914003
g 15-114
26-
67/3S62
Municipality of Anchorage
P.O. Box 196650 • 4700 Elmore Road
Anchorage Alaska 99519-6650 • (907) 343-7904 • Fax (907) 343-7997
http://www.munLorgiOnsite
Development Services Division
On -Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Waiver#: 141303 COSA#:
PID#: 051-811-33
Legal Description: Sampson Est. B-3 L-7
Engineer: Anderson Engineering
.Applicant: Mallie Hall
Permit#: 121089
Your request for a waiver of the required 10 feet horizontal separation from the absorption field
to the property line has been approved. The approved separation distance is 1.0 feet.
This waiver approval applies to the existing absorption field only. Any future upgrade to the on-
site wastewater disposal system will require all separation distances be met or another approval
from this department.
® The affected adjacent property owner(s) have been given a 7 day notice regarding this
waiver.
n Notarized letter(s) of non -objection have been received from the owner(s) of the affected
adjacent property.
❑ Adjacent properties are not affected by this waiver.
Waiver is Granted: X Waiver is not Granted:
Date: / Approved by: f 7
viewer
/1L
On -Site Wastewater Disposal System Permit
MUNICIPALITY OF ANCHORAGE
Development Services Department
On -Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Permit Number: OSP121089
Tax Code Number: 05181133000
Work Type: Septic Upgrade
Permit Effective Dates: May 24, 2012 to May 24, 2013
Design Engineer: ANDERSON ENGINEERING
Subdivision: SAMPSON ESTATES
Site Legal Address: SAMPSON ESTATES BLK 3 LT 7 G:1560
Owner/Address:
" �aq4a a . 31 )30t4
HALL MALLIE CLINTON &
JOELLE SLOAN REVOCABLE TRUSTS HALL M C & PO BOX 770246 EAGLE RIVER AK 995770246
Site Mailing Address: 22615 SAMPSON DR, Chugiak
Lot Size in Sq Ft: 40152
Total Bedrooms: 4
This permit is for the construction of:
Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
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 wastewater code requires inspections during the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either:
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions: PRIOR TO CONSTRUCTION: A testhole shall be completed to verify the
design prior to construction. The results shall be sealed by the engineer and submitted to the
On-site inspector for approval during the bottom -of -hole inspection. The contractor may proceed
with construction prior to the completion of seven day groundwater monitoring results at his own
risk.
Received By: 7I�`� Date: s �9rl v
Issued By:itiowv,Y/' jIi: Date:
MUNICIPALITY OF ANCHORAGE
Community Development Department
Development Services Division
On -Site Water & Wastewater Program
Mayor Dan Sullivan
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Phone: 907-343-7904
Fax: 907-343-7997
Parcel I.D. 051-811-33
Property owner(s): MaIlie Hall Day phone: 688-3667
Mailing address : P.O. Box 770246 Eagle River, AK 99577
Site address: 22615 Sampson Drive Chugiak, AK 99567
Legal description (Sub'd., Block & Lot): Sampson Estates, Lot 7, Block 3
Legal description (Township, Range & Section)
Lot Size' 40,152 Sq. Ft. Number of Bedrooms: Four (4)
THIS APPLICATION IS FOR:
(® all that apply)
Absorption Field X
Septic Tank X
Holding Tank ❑
Privy ❑
Private Well ❑Water
Storage ❑
THIS APPLICATION IS AN:
Initial ❑
Upgrade X
Renewal ❑
THIS APPLICATION INCLUDES A VARIANCE / WAIVER REQUEST FOR:
I certify that the above information is correct. I further certify that this application is being made
for a Single Family Dwelling and is in accordance with applicable Municipal Codes.
7014-(„LE
(Signature of property owner or authorized agent)
Permit/Rush Fees: 1530— Waiver Fees:
Date of Payment: £Z2a/i2 Date of Payment:
Receipt Number: Oa 12L t Receipt Number:
Permit No. OSPI a. I O?7 Waiver No.
C:\Users AndEng\Desktop\Mike1Sampson Estates\Permft Application Lot 7.docC:\UserslAndEng\Desktop\Mike \Sampson
Estates'Permit Application Lot 7.doc
ANDERSON ENGINEERING
P.O BOX 240773
ANCHORAGE, AK 99524
522-7773 677-7766 (FAX)
May 21, 2012
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 7, Block 3, Sampson Estates Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The existing septic tank and absorption trench on Lot 7, Block 3, Sampson Estates
Subdivision are in a state of failure and must be replaced immediately to prevent
damage to the house and possible environmental problems. We are therefore
requesting a permit be issued for the upgrade of the septic system to accommodate the
four-bedroom home on the lot. The attached Site Plan and backup documentation
identify the location and configuration of the upgrade to the proposed septic system.
The existing septic tank and absorption trench will be decommissioned in accordance
with Municipal Code. A new 1,250 gallon septic tank will be placed near the same
location as the existing tank. Also identified on the plans are the locations of the
existing well. No conflicts exist between the existing septic system and the systems on
adjacent lots. The wells on this and adjacent lots are more than 100' from the proposed
improvements. Drainage arrows are shown indicating the current drainage patterns.
The drainage patterns will be maintained after construction.
The test hole placed on the lot indicated silty gravel with some sand (GP). The
application rate was determined to be 180 square feet per bedroom. We are proposing
to construct a 50' long by 3' wide absorption trenches with 8' of gravel beneath the
distribution pipe. The distribution pipe in the trench will be placed at 4' below the
surface with the total depth at 12'. A test hole will be placed prior to construction to
verify the percolation rate, water table and bedrock locations. If conditions are found to
be different than anticipated work will stop and a new design completed and submitted
for approval. It is imperative the septic system be reconstructed soon as the existing
system is currently backflowing into the house.
Lot 16, Block 3, Sampson Estates Subdivision
August 22, 2007
Page Two
The ground surface on the lot slopes slightly to the southwest at very shallow grades
approaching 1%. The trench will be constructed parallel to the contours of the ground
as much as possible and in conformance with design criteria. A minimum of 100' will
be maintained between all components of the septic system and the existing wells and
surface water in the area
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located in the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
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LOT 7, BLOCK 3, SAMPSON
ESTATES SUBDIVISION
DESIGN FACTORS:
Four Bedroom House
Perc. Rate: 6-15 Min./Inch
Application Rate: .8 GPD/SF
SYSTEM REQUIREMENTS:
Deep Trench System
1,250 Gallon Septic Tank
8' Drainfield Rock
4 Bedrooms X 150 GPD/.8 GPD/SF (Application Rate) = 750 SF Absorption Area
750 SF/16 SF/ LF = 46.9 LF Trench Length
THEREFORE: Construct a 50' Long x 3' Wide x 8' Effective Depth Absorption Trench at the Location
Shown. Distribution Line to be Placed at 4' Below the Existing Surface. Total Depth to be 12' Below the
Surface. Decommission Existing Septic System in Accordance with Municipal Code. Provide 4' of Cover
Over Septic Tank.
3'6"
6" -
8'0"
Natural
Backfill
5'
Geotextile
Fabric
4" Perforated
PVC (Holes Down)
Drainfield Rock
TYPICAL DEEP TRENCH SECTION -
NOTE:
(NO SCALE)
Grade Area Over Trench to Drain Away.
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' Separation From Wells in the
Minimum 100' Separation From Surface Wa
u: *♦♦
%
49th � l�`�:
•
vtdS
Area. ♦m} MICHAELEANOERSCN
ter or Streams. ♦♦% No. CE -4381 I
MUNICIPALITY OF ANCHORAGE
DEVELOPMENT SERVICES DEPARTMENT
4700 BRAGAW STREET ANCHORAGE, AK 99519-6650
DEPTH
(feet)
1
2
3
4
5
6
7
8
SOILS LOG - PERCOLATION TEST
LEGAL DESCRIPTION:
PERFORMED FOR: MALLIE HALL
DATE: 5/24/2012 PROJECT No •
PARCEL ID#: TECHNICIAN: M. ANDERSON
Lor 7, BLOCK 3, SAMPSON ESTATES SUBDIVISION
9
10
11
12
13
14
15
16-
17
18
19
20
a
OB/OG
TEST HOLE # 1
SILTY GRAVEL
a. GM
GREEN/GRAY
4
WAS GROUND WATER ENCOUNTERED'
IF YES @ W
DEPTH OF WATER AFTER MO
BOTTOM OF HOLE
DATE OF MO
SLOPE
NV1d 3115 33S
4i
��P�E,OF q(q,� -♦i
0
49jth •
?,3A ;MICHAEL E. ANDERSON
1. C.:
Professional Engineers Stamp:
SITE PLAN
SEE SITE PLAN
T DEPTH?
IITORING:
4ITORING' P SEE
SITE PLAN
E
DATE
READINGNET
GROSS TIME
(MINUTES)
NET TIME
(MINUTES)
WATERDEPTE To
(INCHES)
DROP
(INCHES)
5/29/12
TEST HOLE PRESOAKED PRIOR TO TESTING:
1
2
3
4
3
4
PERCOLATION RATE: 14 (MIN/INCH) PERC. HOLE DIA. 6 (INCHES)
TEST RUN BETWEEN: 4.0 FT. and 5.0 FT.
COMMENTS' TEST HOLE PRE SOAKED PRIOR TO TEST.
TEST PERFORMED BY ANDERSON ENGINEERING TECHNICIANS. I, MICHAEL E. ANDERSON CERTIFY THAT
THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPLE GUIDELINES IN EFFECT ON
THIS DATE: 5/29/2007
MUNICIPALITY OF ANCHORAGE
•
\
P t 1
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME r
5'4 S 4M a- �'''+ c'f.v�../.,z65vs-ivs-
PHONE
T NEW
❑ UPGRADE
MAILING ADDRESS
.ou w Wiz/ 4'.,5--.5-a fle.-:cI,.. .4kIs-o3
LEGAL DESCRIPTION
Lf 7 6 /h 3 S, .,..,..,,sem, E,r7'-4 C.r -T is.v ,*Z. / Gil fiec ��
LOCATION
/re ie.,71 C r e e i
NO. OF BEDROOMS
SEPTIC
TANK
DISTANCE TO:
Well,�
/ftej
Absorption area
a 9
Dwelling /
PERMIT NO. p 1� ,.7 3
J 7
Manufacturer �C
7�A
% t
Material S, � ,
/
No. of compartment
i
Liq. capacity in gallons
/001./001.:,
IF HOMEMADE:
Inside length
Width
Liquid depth
G �'
J02
O z <
1 F -
DISTANCE TO:
Well
Dwelling
PERMIT NO.
Manufacturer
Material
Liquid capacity in gallons
TILE
DRAINFIELD
TRENCH
DISTANCE TO:
Well leo .T
Foun� ti q
Nearest lot line 58, j
PERMIT NO. 8.y CG, 73
No. of lines
Length of each line i
pisS
Total llee'ngth of lines �
Trench width .
j® inches
Distance between linesl�
Top of tile to finish grade 11 /
(
Material beneath tile
-7 A inches
Total effective absorptiotn/area
C 4/6 `W
SEEPAGE
PIT
Length
Width
Depth
PERMIT NO.
Type of crib
Crib diameter
Crib depth
Total effective absorption area
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
J
w
Class
Depth
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption areals)
OTHER
PIPE MATERIALS
,GI -,---areUt y4' U .C'
\`
We
II
SOIL TEST RATING
IS��
f
INSTALLER
i® J /,7
4 / JV[ 4 A.oin f $ �<rc ei IFC 7`i 015'
11 o.
.'"Se
%p
REMARKS
t
n •iAN
k-
4®d®i\®�
1
���OF.w'�g�l
�`/.� �. -• •ir i
"�
,•
A ,k: . , r
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k 1,-,T-
• t,.' 2225-E �' P
y.
;Q•
65
a
ra• JURE 25. 1_7L , 'k
%�I��ONAL �c _
APPROVED DATE LEGAL
Lt 7 /gilt' 3 S4 kez/elSot ,s-
72-013 (Rev. 3/78)
LOCATION OF WELL
(Please complete e cher la, Ib or Ic.)
la. Borough
An ch
Subdivision
Sampson
Lot
Block
3
Ic.
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological a Geophysical Surveys
Drilling Permit No.
A. D. L. No.
I D.I 1/4gtre.
_. of.- of__ -of —
Suction No
Township ND
sD
Range EDI Meridian
w❑
DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
Street Address and Area of Well Location
3. OWNER OF WELL:Mr. Ray Pelletier
BeOoistruction
Anchorage, Ak. 9950
Address:
2. WELL LOG
Feet Below
Surface
Motorial Type Top
Bottom
4. WELLr DEPTH: (final)
cF IJ ft.
5..9ATE OF CO1 LETI0N84
Soil, gravel
0
Pavel, SilL, Sand 3
Gravel, salt, warmer 58
3
38
45
Gravel, silt, sand 45
55
Gravel, gray sand 55
110
Gravel, sand, silt, water 110
Gravel, sand, water 132
132
144
6. 0 Cable tool )(Dietary 0 Drlvon O Dug
0 Auger D Jetted ❑ Bored ❑ Other:
7. USKTA Domestic D Public Supply D', ndustryi
D Irrigation D Recharge D Gommerleal
0 Test Wotl D ()fluor:
6f C(y,SING:: Thr!Q()de fih Welds p I!
Alpm. " .in tq1 4Pi� i� Depth I j!elght 1 7
I
diem. In 6,1 I t Depth I Stickup I
9. FINISH OF WELL:
Typo: ! , �ci !
Slot/Meth ISlze:
Set between`
Backfilling
Dlamoteri
Longo :
'ft. and �,[ 1. if 1.
Gravel pack
Mur\flcrPAury
Di'
DEPT. ANCHORAGE
=NVIRniJ,Rj�' HE, r �RAcir
�TAL PRC F
C)7pnt
NOV
I
1O. STATIC WATER LEVEL 'rv'" CI ! '4t.
0 Above or KBe ow land surface
Equipment used:.
I, I i
ip if -51
Date
1984
RECEIVED
II. PUMPING LEVEL below iapd surface ond,YIELQ'
f1. attar hrs. pumping �
ft. ':after : hrs. pumping
g.p.m.
g.p.m.
12.GROUTING Well Grouted Yes! D No
Material: 0 Neat CementO Other:
13. PUMP: (if available) HP
Longth of Drop Pipe
ft. capacity g.p.m.
D Subm. E) Jet Centrificat O', Other
16. WATER WELL CONTRACTORS CERTIFICATION:
14.REMARKS:production of 15 GPM
15. Water Temperature _°
This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief;
Magnuson Drilling AA 5385
Address
Signed
Registered Business Nome
P.O. Box 770504 Eagle River
Contract License Number
Ak. 99577
[Form 02-WWR (11/81)
Authorized Represent° ve
Aug. 21, 1984
Copy Distribution: WHITE- Stole DGGS, PINK -Driller, CANARY- Customer
'oN 10001 S9Sf1
0k
PERMIT NO:
DATE ISSUED:
���I C: I F" gr-; a_ -r 1011--111E3�PkI9 IF=
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
�FE: I 'TIE P40 EE: FR: IEE tF:"EZ.�IMI I "IF
840673 ,
08/07/84
APPLICANT: SHASTA CONST.
ADDRESS: 280 W. 34TH. SUITE 500
ANCHORAGE, AK 99503
CONTACT PHONE: 694-5195
LEGAL DESCRIP: SUBDIV18I81ft SAMPSON ESTATES
SECTION: 3 TOWNSHIP: 15N
LOT SIZE: 40152 (SQ.FT. OR ACRES)
MAX BEDROOMS: 3
LOT: 7
RANGE: 1W
BLOCK: 3
•Listedbelow are the options available� to you in designing your septic
system. Choose the option that best fits your site,
~
1-FREIP4CALA
DEPTH TO PIPE BOTTOM (FT.) 4.0
GRAVEL DEPTH (FT.) 6.0
TOTAL DEPTH (FT.) 10^0
GRAVEL WIDTH (FT.) 2.5
GRAVEL LENGTH (FT.) 38.0
GRAVE~ VOLUME (CU.YDS.) 22.8
TANK SIZE (GALS) 1,000.0 **
SOIL RATING (SQ.FT./BR) ^ 150
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
E3EEI3
4.0
0.5
4.5
9"O
36.0
25.3
1,000.0 **
150
WAP ��F17. Nil
4.0
3.5
7.5
5.0
49.0
36.2
1,000.0 **
150
I certify that:
1° I am familiar with the requirements for on-site sewers and wells as set
forth by the Municipality of Anchorage (MOA) and the State of Alaska.
2. I will`install the system in accordance_ with all MOA- codes and regulations,
and in compliance with the design criteria of this permit.
3"_ I will -adhere to all MOA and State of Alaska requirements for the set. back
distances from any existing well, wastewater disposal system or public
sewerage system- on this or any adjacent or nearbylqt.
4. I understand that this permit is valid for a maximum of 3 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2Y AG-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICANT: ^S CONST.
ISSUED BY
DATE:
DATE:
,7/7/2
/
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
s/7erL5 61,stn.i-C f /vr�
111 SOILS LOG
PERCOLATION
TEST
DATE PERFORMED: Sej 3,1/4
Z- t- 7 43 /1r - ,Set pnsE �. E 211C -S-1 /.5' /
DEPTH // / / t",
SLOPE SITE PLAN
(FEET) 0R 6-A ' 1G
/
10-
11 -
12-
13-
14
e J D
A
s;/ t), s J7
6-ra vt /
g -o st kr !ul
F
15 -
.®.. . .4./. (.i
. Sir n
17 ;r ° 49TH
18.1,'r•P . 2225-E
p' < .4• JJNE 25, 1971
20- 11‘@h® 1
®
COMMENTS t; (7‘,6 i12rGL
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
L
O
P
E
Le—
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
/
/y
Fr Jr /t-,
s;ss
2
t/
,//
I/
L/
//
3
1,
(.:2.
s /s;b
`/
/6
'
645_
'
/ 6
PERCOLATION RATE �0 �3ec��u� Eminates/inch)
TEST RUN BETWEEN FT AND FT
A lc f O •Ro
/0 `u///7
rs
PERFORMED BY: 6Lt '/Y
72-008 (6/79)
CERTIFIED BY: DATE:/�/�L�
1Vlumcipal>Ity of Anchorage
Department of Health and Hutnan'Setvlces,t
` Division of Environmental Services
On-SiteServices •Sechon `825 i Street , Room502 .
•P.O Box.196650 Anchorag•e AK:_99519-6650'
www ci.ancho�age.ak us
r • (907) 34324744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL•
FOR A''SINGLE FAMILY: DWELLING,
•
Parcel I.D 051-811-33
:1:
51.811 33
r': GENERAL INFORMATION'-;
r
HAA #
Expiration Dale
Complete legal:description • •Lot 7, Block 3,•SampsonEstates Subdivision `
- •,
Location'(site address or directions) 22615 Sampson Drive , , ; `:i
Current Property uwner(s)',Dennis and Gwenn Colon- 'Dayphone •240.6577
Mailing address • 22615 Sampson Drive :t Chugiak, A}( 99567.9 404 <r. ylir
Lending agency Day phone
..
Mailingaddress •
RS Estate 'Agent:' Jennifer Renard Day phone _ :240.6577 `
• Mailing'Addrese;' s r
t
Unless otherwise requested HAA will be held by DHHS for pickup. HAA picked up bya
NUMBER OF BEDROOMS: ;Three (3). '
• 3.' :TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class • Well
PubTic Water System
TYPE OF WASTEWATER DISPOSAL 'v•
Individual On site = ❑: '
Individual Holding tank ' ❑ '
Community On-site c' ❑ .}
Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) Issues Certificates of Health
Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional
civil engineer registered in the State of Alaska. Certificates Health Authority Approval are required for the transfer
of title (except betweenspouses) on properties served by single family on-site wastewater disposal and/or water
supply system. DHHS also issues HAAs upon request to home owners: 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 arid may be reissued
with new water sample results Tess than 30 days old. 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 engineers work:
(Rev. iris)
5. STATEMENT OF. INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation
based on procedures outlined in the Health Authority Approval Guidelines for this Health 'Authority Approval t'
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. 1 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 incompliance with' all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation. ,
Name of Firm Anderson Engineering -'.
Address • P.O. Box 240773 Anchorage, AK 99524'
Engineer's Printed Name Michael E. Anderson, P.E. '
•
1
6 DHHS SIGNATURE
Approved for _
Disapproved.
•
Phone 522.7773 r.
:Date 1103101.'
.EN,,0*R41�r.z
.{r
bedrooms : , „e i,
r ly rF7 irt•eily0:,4:1W
. ' Conditional approval for bedrooms with the following stipulations •
• Additional Comments
By:
Attachments:
HAA Checklist Maintenance Agreements'
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory '.Other
Original Certificate Date: / — 14
Expiration Date: Lit- `7 ' Q f Reissue Date: `
. (Rev. 10/99)
tinicipality. ofAnchorage
Development Services Department
Building Safety Division
Onsite Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorageak.us
(907)3437904
HEALTH AUTHORITY APPROVAL CMEOKLIST
Legal Oesraiptlgn. 1.0t 7. Block 3. Sampson Estates
4 WELL DATA
Wel type Private = If A. 8, or C provide PWSID #
Datecornpreted 101211984 Sanitary seat (YIN)
Parcel ID: 051811.33
Weft Log (Y/N)Y
Wires properly protected (YIN) Y
Total depth 140.1t Cased to 140 ft. Casing height(above•ground) >24 in:
FROM WELL LOG AT INSPECTION
Date of test 101211984 12/17/2000
Statioavaiaftevet 109 • ft. 115 ft:
Well production 15' g.p.m. 6.9 g.p.m. -.
WATER BMPI-SfiliBULTS
Conformu` Jc O estlOB mi. Nitrate 2.79 mg,
Detect samolt (211711000 ' COAected by: MEA
8: SEPiIQFIbtblt1t tANR DATA
Tank Typedllt >5eptidSteet
Other bacteria 1. cdoniat100 ml.
Dateinstalled 8115/1984r
Tank slus. J000", gal. Number of Compartments E Cleanouts (YIN) y
Foundation a tearidtt'(YJP4t Depression over tank (YIN) B High water alarm (YIN) 14
Dale of pumping. 3I212001 Pumper Sanitary Pumper
C. ABSORPTION 'VIIELD.DATA
Date atstalteg-1,OItS11984 _ Soft rating (g.p.dJR' or fk>lbdrm)150 SF System type Deep trench
Length 45, ft Width 7.5- tt Gravel below pipe 6 ft.
Total depth•Qft Eff. absorption area 54011' Monftoringtube Y Depression over field N
Qat* of esequatg3est 1211712000 Results (Pass/Fan, Pass For 3 bedrooms
Fluid depth bsibSOMtion field before test 15 in. Water added460 gal. New depth31 in.
Elapsed Tune: 3,440 min. Final fluid depth 15 in. Absorption rate >= 450 g.p.d.
3ly:rejuvenatIOntreatment (past 12 ma.) ()IN & type) N If yes, give date NIA
D. LIFT STATION
Date installed Size in gallons Manhole/Access (YM)
Pump on' level at in. 'Pump off' level at _ in. High water alarm level at
Datum Cycles tested Meets wenn a drools requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES-F;iQM WEIS QNt.OT TO:
Septic tankllif station oitlQt>100' On. adjacent:Ott A100'
Absorption field on lot >100' • Onadjacenflots >100'
Public sewer main WA
in.
PubRcsetntmanhole/cleanout NIA
Sewer /septic service line >29; Hdfdinglatti WA
SEPARATION OISTANCES.FRQM SEFROYHOLDING TANK ON"L`OT TO
Building foundation >5' Pfopertyaine >5' AbsofptIon field'' »s'.
Water main NIA Wat?Cservtcellne WA- Surfacawater >1004
Weals on adjacent lots, >100'
SEPARATIQN_DISTANCE FROM,ABSOi3PTION FIELD OR LOTTO
Property line >10'aw r Sanding foundation >1'- .Wafirsight
Water Service Ode P104; -. Surface -we 0;100' _ OrMtWal;'�atxtn9h!ehr t >2P
Gatlin drain _None Noted Wellson•�91agenttots>� 700^
F. COMMENTS
G. ENGINEER'S CERTIFICATION;
I certify that I have .date►mbedtluougllle/d.8►specUans end.
review of Municipal that theabeve systems mein
confomiance w1115'MOA.HAAguldefjtletinctfreCLQttfta ala:•
Engineer's Printed Name Michael E. Anderson P.E.
Data1/5/01
HAA Fee $
Date of Payment 'An ..tyr
Receipt Number eCr/
(Rev. 13/00)
too "
•
Waiver Feet$
Qae.ofPayolent
Receipt Hunter
12-21-00 17:21
L.
CT&E Refit
'Client Name
Project Namel#
Client Sample ID
Matrix
Ordered By
PWSID
t.
FROM -CTE ENVIRONIENTAL
5615301
CT&E Environmental Services Inc.
1007765001
Anderson Engineering
Lot 7 Blk 3 Sampson Est.
Lot 7 Blk 3 Sampson Est.
Drinking Water
0
T-642 P.02/03 F-449
Client POO
Printed Date/time
Collected Date/time
Received Date/time
12/21/2000 8:38
12/17/2000 12:10
12/18/2000 14:00
Technical Director /StephenCEC Ede
ynJ
Released Dy .2 "o"�"^7
Sample Remarks:
Panmcter
Results
PQL Units Method
Allowable Prep Analysis
Limits ..Date Date Init
Waters Department
Nitratc-N
Microbiology Laboratory
Total Coliform
2.79 0.500 mg/L EPA 300.0
0
Received Time Dec.21. 5:24PM
10 max 12/18/00 SCL
coi/lOOmL SM189222B 12/18/00 KAP
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
Parcel I D # SSI /l 3 3 &EDD HAA # l' c)11-,n1c1a1
1. GENERAL INFORMATION
Complete legal description
—32-
g
32
Location (site address or directions)
Z16/.� 54-ime0S441
Property owner dee ide& rcu o teri}- Day phone
Mailing address ZZ6/5 5 ri,1 -) Dei CW -4‘,41-,4`.
Lending agency Day phone
Mailing address
Agent a 2-1 f- /e. Alt,„ Day phone 696— ir-645149
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. 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.
72-025 (Rev. 1/91) Front MOA #21
tLcex— e- P./5
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
David R. Dayton P.E.
Name of Firm 20210 Donalar St.
Chugiak, Alaska 99567
Address
Engineer's signature
Phone Cife;V7
Date
mvaao aeoo�o eoa as
(}aviJ R, Ca/Iona 1,
'41:s"),..1),, NO. 2205.E es �t?. Ny
ts o �"
.(4,e s9n.aase0000°� <4e11
6. DHHS SIGNATURE � ?R0 EaatQ''tP,
Approved for (?)bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
By.
Date 14° ""i
CAUTION
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.
72-025 (Rev. 1/91) Back MOA 921
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Lmr 7 B4- 3
Legal Description:
A. Well Data
c Sr
Parcel I.D. 65 // 3 3 0o U
Well type )?R/0aTz= If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) Y Date completed Vie, Driller YY/A-'Jµssd
Total depth /T Cased to /,40 Casing height 3
Sanitary seal (Y/N) i1 Wires properly protected (Y/N) Y
FROM WELL LOG AT INSPECTION
Date of test 8 Vff V
Static water level X09
Well flow /D g.p.m. g.p.m.
Pump levell i/%e G/
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot 004`
Absorption field on lot
Public sewer main
/OD y -
x.)//4..
; On adjacent lots /e'c:) f
; On adjacent lots /O° 7
Public sewer manhole/cleanout
Sewer service line 7s f Petroleum tank
WATER SAMPLE RESULTS:
Coliform 0 Nitrate , 9,c) Other bacteria U
Date of sample:
Collected by: ix) --P
B. SEPTIC/HOLDING TANK DATA
Date installed /9H Tank size /€20 v Compartments 1-
Cleanouts (Y/N) ')' Foundation cleanout (Y/N) Y Depression (Y/N) A/
High water alarm (Y/N) AJ/4- Alarm tested (Y/N) �ig-
Date of pumping 7/z 743 Pumper A+�o-rttr,y 1`14.0t4-19Vn 5
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot Obi-- On adjacent lots /Ooh Foundation 5 -
To property line ZSR-- Absorption field ZO Water main/service line Z 3- Vz-
Surface water/drainage l 0 if;) -.1---
rrll
\C- \ g _6\_6\:3..(vojc N d 0ct _l M
72-026 (3/93)* Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed ^'/Y— Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at - - "Pump off Level at
High water alarm level Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed (/erfi Soil rating (GPD/Ft2) /-5-741System type avew
Length 5‘5Width Zw Gravel thickness 6Total depth /0
Total absorption area s40 Cleanout present (Y/N) y Depression over field (Y/N) Al
Date of adequacy test /0///93 93 Results (pass/fail)5 for 3 Bedrooms
Water level in absorption field before test 5 % " After test OVIrs � 3 "
Peroxide treatment (past 12 months) (Y/N) N If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot f On adjacent lots loo i
To building foundation
On adjacent lots f Cutbank
Property line
5—
To existing or abandoned system on lot A-4
A/4
Water main/service line
Surface water /o o f— Driveway, parking/vehicle storage area
Curtain drain /Ides
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
David R. Dayton P.E.
20210 Donalar St.
Signature Chugiak, Alaska 99567
Engineer's Name
Date /g',
Doyon ; �w
s : 2 5 - °
°.��c�;;
0 o„ee
HAA Fee $ r..26•5
Date of Payment
Receipt Number
72-026 (3193)' Back
/0
Waiver Fee $
Date of Payment
Receipt Number
D. R. DAYTON, P.E., R.L.S.
MUMMA= Chugiak, Alaska 99567
20210 Donalar
October 4, 1993
WELL FLOW TEST
Legal Description: Lot 7, Block 3, Sampson Estates
Date of Test: October 1, 1993
Well Depth: 140 ft.
Static Water Level: 114 ft.
Driller: Magnuson Drilling
Requirements: 3 BR - 450 gallons per day
(9a7AMINNER
696-2417
Test:
The well was tested with the existing pump through an outside
hose bib. Volume and drawdown were measured through the test.
Results:
The well produced 457 gallons in 80 minutes at an average
flow tate of 5.7 gallons per minute.
Maximum drawdown was 1 ft. The drawdown was fully recovered
within 10 min. after pumping was stoppped.
The well is currently producing adequately for a 3 BR home.
D. R. DAYTON, P.E., R.L.S.
MOMENlega Chugiak, Alaska 99567
20210 Donalar
October 4, 1993
(907) ENEiff2:.
696-2417
ADEQUACY TEST
Legal Description: Lot 7, Block 3, Sampson Estates
Date of test: October 1, 1993
Septic Tank: 1,000 gallon, 2 compartment, steel tank (DHHS Records)
Absorption System: 45' long x 6'.effective °°depth ..trench (DHHS Records)
Soils Rating: 150 sq ft per bedroom (DHHS Records)
Requirements: 3 BR - 450 gallons per day
Test:
Water was pumped into the trench while measuring volume and
water level rise at timed intervals.
After pumping was stopped, the water level was measured at
timed intervals. The results were plotted on a graph of time and
gallons absorbed and extrapolated to 24 hrs.
Results:
The absorption system is currently functioning adequately
for a 3 bedroom home.
NOTE:
There were 58" of water standing in the trench before the test.
24 hrs after the test the water level was back to the.original
level.
This amount of water standing in the trench may indicate the
absorption system is in its waning years.
�...7t7 .'�‘ l kith
—�C1r�
�7 ee(1c nAt
U c, 7.
I i ,-..o.. ,A, e -
:
a
_.-�AO seg as a.��'a///sani{yYo�f/xj�o�nJwe'i%.;y
6
f,,„ tA• David R. Dayton �' <v P
�� J'•"a t40. 2205-E `1;
R i • +• +� F
/4 .414;i FESSI�� '�.��®
COMMERCIAL TESTING & ENGINEERING CO.
AleL_ ENVIRONMENTAL LABORATORY SERVICES
SINCE 1909
Chemiab Ref .1s
Client Sample
Matrix
Client Name
Ordered By
Project Name
Projectile
PWSID
REPORT
:93.5268--5
1D :L1 B3 SAMPSON EST.
:WATER
:DAVID DAYTON, P.E.
:DVIt) DAYTON
:DA
of ANALYSIS
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
WORN Order :71751
Report Completed :10/08/93
Collected ' :10/04/93 @ 14:30 hrs.
Received :10/05/93 @ 11:00 hrs.
Technical Di.rector:STEPHEN,F. EDE
Released. By �j* f'2..-
Sample Remarks: ROUTINE SAMPLE COLLECTED BY: D.R. DAYTON./
r
QC Allowable Ext., Anal.
Parameter Results Qual Units MethodLimits Date
Date Tnit
Nitrate -N 0.90 mg/L EPA 353.2/300;0 10 10/06 W1
* See Special Instructions Above
** See Sample Remarks Above
U Undetected, Reported value is the practical
D Secondary dilution,
quantification limit.
‘SGS Member of the SGS Group (Societe Generale de Surveillance)
UA Unavailable
NA Not Analyzed
LT = Less Than
GT = Greater: Than
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
/
(a) Legal Description/�(include lot block, subdivision, section, township, range)
L c t- 7 ,&/a c /r 3 .n,P "5a+-. E.s {5 /rs 7-/f /?J /c / 44/ Sec 3
Location (address or directions)
P��c'.rr Ch�e-X
(b) Applicants Name SAe s Cvr, rty. ,me) Telephone - Home Business
Applicants Address 200 3.,51 .53-6 95 3
(c) Applicant
Buyer
is (check one) Lending Institution
; Other) ' (explain);
; Owner/builder
,
(d) Lending Institution , /15/ .7 /t e't,,QC RAI/le-Telephone
Address
G'Ge 2/ c/' -
(e) Real Estate Co. & Agent iVeef ,'/-LES'
Address£f,1 (,'L ,�/u,�/2 Oz7,
Telephone
0614/- X999'
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family 15; Multi -Family
Number of Bedrooms 3
3. Water Supply
1 1
Other (describe)
Individual Well Community Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4., Sewage Disposal
Onsite Public I Community
Holding Tank
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
•
5. 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 regula-
tions in effect on the date of this inspection.
Name of Firm 7 A o -e. --r, SOI( r
Address ,;Zi.) 3 -/ /6- ' -oj L}hc 4 p e/ Air
Telephone
_275 -39/6 -
Date No./ /, /gel/
(ENGINEER SEAL)
6. DHEP Approval
Approved for /i/,6beds
Approved Disapproved
Terms of Conditional Approval
..
� •
n••
N. 2225-E: �' ,
!4 JUNE 2.'4 1371
�4aao�n.�t
By
Conditional
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES 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.
RR4/ej/D18
[Page 2 of 2]
(DHEP SEAL)
7-19-84
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description: 2-0 7/0c� 3
MUNICIPALITY OF ANCHORAGp
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
NOV 1984
RECEIVED
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Well Classification fe-i u4 If A, B, or C, D.E.C. Approved(Y/N) 6v/4, -
Well Log Present (Y/N) l Date Completed 3/ice P Yield /.5--
Total
5Total Depth / z/e) Cased to /4/e ' Depth of Grouting /4
Static Water Level /c?% Pump Set At /.:R.‘
Casing Height Above Ground a % / Sanitary Seal on Casing (Y/N)/1/
Electrical Wiring in Conduit
Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot lot) / ; On Adjoining Lots /lo 7`
To Nearest Edge of Absorption Field on Lot /Dat ; On Adjoining Lots /r>o
To Nearest Public Sewer Line 4/o, To Nearest Public Sewer
y
Cleancut/Manhole 410'"e-- To Nearest Sewer Service Line on Lot 75-
Water
S
Water Sample Collected ByF., , e ; Date /a/6-/.4/
Water Sample Test Results s Gfoev^y
Convents
B. SEPTIC/HOLDING TANK DATA
Date Installed 2f15-' ( Size /mora G-5 L No. of Ccupartnents off.
Standpipes (Y/N) / Air -tight Caps (Y/N) Y Foundation Cleanout (Y/N)
Depression over Tank (Y/N) /V Date Last Pumped /Yew
Pumping/Maintenance Contract on File (Y/N) '1/4 ; for
Holding Tank High -Water Alarm (Y/N) //7/,4 Temporary Holding. Tank Permit (Y/N) /L"%1
Separation Distances from Septic/Holding Tank:
To Water -Supply Well /6D 7` To Building Foundation
To Property Line /d t To Disposal Field .6".
To Water Main/Service Line VS- To Stream, Pond, Lake, cr Major Drainage
Course /7/vn e
Comments
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11 '1 vcsy
[Page 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /5.v Type of System Design 74 -Ye nc h
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N) /IJ
Results of Last Adequacy Zest Ne w
Length of Field 4`s
Depth of Field /e2
Gravel Bed Thickness
5 4'o Standpipes Present (Y/N) )'
Date of Last Adequacy Test tie}
Separation Distance from Absorption Field:
To Water -Supply We11 /2 f
To Building Foundation 2e) r
COY.s1�.
To Property Line 678/
To Existing or Abandoned System
Lot /Va - C ; On Adjoining Lots 3e2
To Water Main/Service Line /D ' To Cutbank(if present)
/t/d-2-1
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area 74-,/e2
/
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles curing Adequacy Test. Lets NIDA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conforned to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed
Company
KB1/d5/s
Date No,/ 7 /9e/
7 i -, 5ik dr ( PG .MOA No. Sy —Stull
[Page 2 of 2]
2-15-84
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AS -BUILT
I hereby certify that I have surveyed the following described
property: J P f 7 151" k"
i E4f.e<'a•;_. 3 t A.1 ;`*•91
Anchorage Recording Precinct, Alaska, and that the improve-
ments situated thereon are within the property lines and do npt.
overlap or encroach on the property lying adjacent thereto, that
no improvements on property lying adjacent thereto encroach
on the premises in question and that there are no roadways,
transmission lines or other visible easements on said property
except as indicated hereon.
Dated at Eagle River, Alaska
this_j day of -5--a 0 19 'G%•
ROBERT C. JOHNSON7t" .` r e
SCALE: Registered. Land Surveyor No. $80 -LS
1" - Box 77-0456, Eagle River, Alaska 99577
Phone (907) 694-2543