HomeMy WebLinkAboutDRAKE BLK 1 LT 3BI>roke
Block
Lot 3B
#017-461-21
0,com.try
MUNICIPALITY OF ANCHORAGE
On-Site Water&Wastewater Program5r;.
-ewe, PO Box 196650 4700 Elmore Road
Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997
http://www.muni.org/onsite
I)t'l,artntynt
4hCHOROt
On-Site Wastewater Disposal System Permit
Permit Number: OSP181381 Effective Date: 10/19/2018
Work Type: SepticTank Upgrade Expiration Date: 10/19/2019
Tax Code Number: 01746121000
Site Legal Address: DRAKE BLK 1 LT 3B G:2834
Site Mailing Address: 2850 HUFFMAN RD, Anchorage
Owner: CAMPBELL WILLIAM T IV Lot Size in Sq Ft: 42000
Design Engineer: ANDERSON CONSTRUCTION & ENGINEERING Total Bedrooms: 4
This permit is for the construction of:
❑ Disposal Field C✓I Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage
All construction shall 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 shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907)343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
Received By: nn Date: •
Issued By: �,IJ Q.0 Date: 10M 0 iS
Il Yd O I f! e k,L tY t7 tl OF : i C H o f O WG E Ru3
t " i
Development Services Department \� /+ Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
•
Parcel I.D. 6 11- 1.21
Property owner(s) jJi waxy.,O.VY1 ecom'beIt Day phone
Mailing address 5D r►u-C m !Coat
Site address S+09
Legal description (Sub'd., Block & Lot) r14.1iQ "31, L3.6
Legal description (Township, Range & Section)
Lot Size Sq. Ft. Number of Bedrooms 9
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(® all that apply)
Absorption Field ❑ Initial ❑ Single Family (SF) Ar(wlwo ADU)
Septic Tank Upgrade gr-
Duplex (D) ❑
Holding Tank ❑ Renewal ❑
Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property owner or authorized agent)
Permit/Rush Fees: 3(44.41 Waiver Fees:
Date of Payment: IO(IQ I Date of Payment:
Receipt Number: Receipt Number:
Permit No. (3 SP 213$1 Waiver No.
G:1Development Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
Oct. 19,2018
Municipalities of Anchorage
Departments of Health and Human Services
P.O. Box 196650
Anchorage,Alaska 99519-6650
Fax 249-7847
Re: Emergency Septic tank replacement permit
Legal: DRAKE BLK 1 LT 3B
To Whom it may concern:
This is a request for a permit to replace the existing septic tank due to failure. A new 4 bedroom tank will be
installed per the MOA guide lines,depending on the depth of the old tank. The old tank is a 1250 but will
be replaced with the a 1250 gallon unit.
The surrounding proerties will not be impacted by this new septic tank permit.
Please call me if you have any questions.
Sincerely j4
Michael N.Anderson, P.E.
4661 Natrona
Anch,Ak 99516
Ph 727-8864
01/27/00 11:16_ FAX 907 273 8110 _ PRUDENTIAL VISTA REAL ES 2 002
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I HEPE8Y CERTIFY THAT I HAVE SUAVI-YED THE SC - �•awt
IrOLLOWING DESCRIBED PROPERTY) • ♦T OF fl4��r,
AN. THAT NO M TJ DCISTDZ t AS l / Y,- • .,••1 •.;�,�4t
INDiCATEO, IT Is TIS RESPONSIBILITY OT 'tl E �/r�,r r Id).1 • • ^ ;c �' $
TWNF3t TO OL'7£RMiP1l='TH>+ SXIS7ENCti OF ANY aRtD<
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tiASDAENTS, COVENANTS, OR RESTRICTIONS .Ant,"y�.r 'i • ..
MOH DO NOT APPEAR ON THE REDORDED sum- ' 0 • .. • hiAk **word '
fiSION PLAT. UNDER NO CIRCOASTAKCLS MORI) F$' ff.'. P-45918 • x
tNY DATA HERm it USED FOR CONSTRUCTION • , ' .
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IP FENCE LtN OR FOR ESTAZLISHIN1 ECCNO• ''•• ��
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t/l e9ed :Cb: ll 20.9L-Jdy !WC 900 L08 :uo0 uelsAalsem Aug JalE1;, Eise7v :/9 lues
GREAT ANCHORAGE AREA BOROn, H
Department of Environmental Quality
3330 C Street
Anchorage, Alaska ggs03
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME I ~
LOCATION
LEGAL DESCR,PT,ON
PHONE
SEPTIC TANK:
DISTANCE
FROM WELL ~
INSIDE LENGTH
MANUFACTURER ~#"x".~'~,,~' MATERIAL ~."¢-~-' ~ /
INSIDE WIDTH LIQUID DEPTH
NUMBER OF
COMPARTMENTS
LIQUID CAPACITYI.~I::~) GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL'Z4_OI FOUNDATION
NUMBER OF LINES ~ DISTANCE BETWEEN LINES
ABSORPTION AREA --7 0 ~).... SQ. FT.
&
DEPTH: TOP OF TILE TO FINISH GRADE l~L.
NEAREST LOT LINE '"~O
TRENCH WIDTH ,
LENGTH OF EACH LINE
TOTAL LENGTH
OF LINES ~
._ I~I. TOTAL EFFECTIVE
DEPTH OF FILTER
MATERIAL BENEATH TILg__~(~ IN. ABOVE TILE
IN.
WELL:
TYPE_ ',~v"L~,~-- ~ -Col~w~, CONSTRUCTION
BUILDING NEAR EST NEAREST
FOUNDATION__, LOT LINE__, SEWER LINE__
CESSPOOL
OTHER SOURCES
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE
TANK ~(':~ ~
, SYSTEM ~ 10 I
APPROVED DISAPPROVED REMARKS
DISTANCES: ~) t(''''
DIAGRAM OF SYSTEM
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL:
LOT SLOPE:
GREaTEr ANChoragE AREa BOROUgh
DEPARTMENT OF ENVIRONMENTAL OUALITY
3330 "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 274-4561
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
'"'/- ".-'5 -""1..5
PERMIT NO.
INSTALLATION LOCATION .,//~/~/~'~"2"-'~ ~'"~.~
LEGAL DESCR,PTION
INSTALLATION OF: SEPTIC TANK
TYPE AND SIZE OF FACILITY TO BE SERVED
MAILING ADDRESS
SEEPAGE PIT DRAIN FIELD OTHER
FINANCED THROUGH TO BE INSTALLED BY
SOIL'TEST RESULTS :~-~'~:~'~ "~----~"'~'/ ~ NOT£~ TmB ~'E~n' I= NOT VALID ~VIT~OUT BOIL T£=~
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICE REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
SEPTIC taNK SIZE
MINIMUM DISTANCES, REQUIREMENTS
FOUNDATION TO SEPTIC TANK ~
FOUNDATION TO SEEPAGE PIT
SEPTIC TANK TO SEEPAGE PIT WALL
,.----
SEPTIC TANK ~'~ ., SEEPAGE PIT
TO NEAREST LOT LINE.
WELL TO SEPTIC TANK
DRAIN FIELD
WATER MAIN TO SEPTIC TANK
DRAIN FIELD
/
SEPTIC TANK, . , SEEPAGE PIT
TO RIVER, LAKE, STREAM.
SEEPAGE AREA SIZE
DIAGRAM OF SYSTEM
DRAIN FIELD /'"/'~:) /
, DRAIN FIELD Jc~ /
, SEEPAGE PiT
ALSO CONSIDER AREA WELLS.
SEEPAGE PIT
., DRAIN FIELI3
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP OF
EXCAVATION 15 FEET INTO UNDISTURBED SOIL.
4 INCH DIAMETER CAST IRON SIPHON PIPES ON SEPTIC TANK AND SEEPAGE PiT
FITTED WITH AIRTIGHT REMOVABLE CAPS.
GRAVEL BACKFILL
CONFORM TO BOROUGH REGULATIONS REGARDING INSTALLATION.
G.A .A .B.
OR
LICENSED DESIGNER
CE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE WITH SAIl:) CODE.
FORI~ NO, EQ-OI 6
ANCHORAGE
FAIRBANKS
JUNEAU
249 EAST 51ST AVENUE · P, O. BOX 6087 · ANCHORAGE. ALASKA 99503 · TELEPHONE 907-279-0483 · TELEX 090-35419
July 3, 1975
R & M NO. 562053
Mr. Buz Erickson
P. O. Box 1749
· Anchorage, Alaska
RE: Test Hole and Soil Log Report for Sanitary System
Lot 3B, Block 1, Drake Subdivision
Dear Mr. Erickson:
We are submitting herewith the test boring results and our comments
regarding soil conditions encountered at the subject site. This investiga-
tion was performed in accordance with your request of July 1, 1975, and
those procedures outlined in a letter dated December 19, 1974 by
Mr. Rolf Strickland of the Greater Anchorage Area Borough Department of
Environmental Quality.
A single test hole was put down within the Lot 3B area for the purpose
of defining general subsurface soil conditions for the porposed sanitary
system. Excavation was accomplished with a tractor-mounted backhoe and
the test hole was extended to a total depth of 16.0 feet below ground
surface. The final log prepared for the test hole has been included in
Drawing A-01.
Ground water was not encountered in the test hole.
We appreciate being given this opportunity to be of service to you.
Should you have any questions with regard to the above, please do not
hesitate to contact us.
Very truly yours,
R & M CONSULTANTS, INC.
ooney~/'~
Vice President
JWR/WED/sc
Enclosure
~-~c: GAAB
T.H.-1
7-2-75
0.0~
SILT, TRACE SAND Brown
2.0'
SAND, Grey WITH INTERBEDDED LAYERS
OF SILT AND GRAVEL (SM) ~
6.0w
S2LT WITH TRACE TO SOME CLAY, Grey
INTERBEDDED LAYERS OF SAND AND GRAVEL UP_
TO 3"-4" Ill THICK~FESS (~U~) .f
.-.?
12.0'
SANDY GRAVEL, Grey
TRACE SILT (GW)
NO WATER TABLE
16.0' TD
Log Represents
Lot 3B Block 1
Drake
Subdivision
Erickson Property
Log of Test Hole
Anchorage, Alaska
R Consultants inc.
L ANCNORAGE FAIRBANKS
ALASKA
JUNEAU
o o o o 0 o o o o 0 0 o
_.
:
0 0 0 0 0 0 0 0 0 0 0 0
~, 0 0 0 0 0
.<
Z
n~
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.ct.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
?arcel I.D. 017-461-21 HAA~ H/~
1. GENERAL INFORMATION Expiration Date:
Complete legal description DRAKE SUBDIVISION; LOT 3B, BLOCK 1,
Location (site address or directions)
2850 HUFFMAN ROAD * ANCHORAGEt AK 99516
Current Property owner(s) WALT STIEHM
Day phone 345-2850
Mailing address
2850 HUFFMAN ROAD * ANCHORAGE, AK 99516
Lending agency
Day phone
Mailing address
Real Estate Agent
Mailing address
BETH SIMPSON w/ DYNAMIC PROPERTIES Day phone
3111 'C" STREET * ANCHORAGE, AK 99503.
261-7600
Unlessotherwiserequeste~ HAAw~beheldbyDSD~rp~k~.
2. NUMBER OFBEDROOMS: 4
3. TYPE OF WATER 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 (HAA) based only upon the representations given in paragraph 5 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 sample results less than 30 days eld. (Certificates may be reissued for a pedod of
up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B
wetls 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 paid $ at, or pdor
to closing for the engineering sendces provided. · .'
STATEMENT OFINSPECTI~N BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedty that my
investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application,
· showsthattheo~-sltewatersupplyand/orwastewaterdisposalsystemis(are)safe, functionalandadequate
· 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 t'#es and frern 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 regula!ions in effect at the time of Installation.
NameofFirm ALASKA WATER &: WASTEWATER CONSULTANTS, INC. Phone 337-6179
Address . 6901 DEBARR ROAD. SUITE 2B * ANCHORAGE, AK 99504
Engineer's Printed Name JEh-~<EY A. CARNESS, P.E.
Date
Engineer's Comments:
In conducting this evaluation, AWWC, Inc. attempted to provide a thorough,
conscientious engineetfng analysis of the system in accordance with ADEC and 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 soils condition, groundwater levels that may
fluctuate durfng 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 future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AWWC, Inc. can therefore not provide
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 authotfzed, nor will it confer any legal right whatsoever.
DSD SIGNATURE
~ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the fllowing stipulations:
~ : WASTEWATER :
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
{Rev.
~. '. PROORA;~{ .' .
~"~.~,"~',/~" ..... '
Manitenance Agreements :/.x.~,~ u/~,, ~ ,.. ,.~ ~'~,.,
Supplemental Engineer's Reort /~' ~jj ~ J ~ ~ ~ ....
Other
Original Certificate Date: Z.~ _ / ,~- 0 -~
Legal Description:
A. WELL DATA
Well type ~'A'~
Date completed
Total deplh 80
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bmgaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
wwv.ci.anchomge.ak.us
(907) 343.7904
HEALTH AUTHORITY . PPROVAL CHECKLIST
DRAKE SUBDMSION; LOT 5B! BLOCK 1~ Parcel ID:
Date of test
Static water level
Well production 15
WATER ~E ~SULTE:
Coliform ~ colonies/100 nd.
A~enio: ,eo¢~ mg./L.
SEPTIC/NOLDIN(3 TANK DATA
Tank Type/Material STEEL
If A, B, or C provide PWSID~ N/A
Sanitmy seal (Y/N) YES
Cased to 76 ft.
FROM WELL LOG
9/14/6,3
Foundation deanout (Y/N) eNO
Date of pumping 7/16/01
C.- ABSORPTION FIELD DATA
Date Installed 7/24/75
Leng~l 129 ft.
017-461-21
we, Log (Y/N)
Wires properly pmtectod (Y/N)
Casing height (above ground)
AT iNSPECTION
7/16/01
22 ft.
5.5 g.p.m.
Nitrate ~- ~"~"mg./L.
Date of sample: 2/13/2002
YES
12+ in.
Other bacteria .
Collected by:
*OK PER JEFF POET. ACCESS THROUGH DOWNSTAIRS BATHROOM.
Tanksize 1250 gal. Number of Compartments 2
Depression over tank (Y/N) NO
Pumper DENAL] SEWER &: DRAIN
Soil rating (g.p.d~ft~o~-"~ 85
(~ colonies/100 mi.
AWWCt INC.
Date installed 8/83
Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
System type TRENCH
Wldlh 3 ft. Gravel below pipe 3 ft.
Total depth 12.6 ft. Eft. absorption ama 702 ft~ Monitoring tube YES Depression over field NO
Date of edeqnacy test 7/16/01 Results(Pass/Fail) PASS For 4 bedrooms
Fluid depth in absorption field before test 0 in. Water added 1362gal. Now depth 0 in.
Elapsed Time: 0 min. Final fluid depth 0 in. Absorption rate >= 600+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & tTpe) NONE KNOWN If yes, give date -
D. UFT STATION
Date installed. Size in gallons ~
"Pump on' level at In. "Pu~ High water alarm level at in.
~ ~-----'-'----'--'-~Cycies tested. Meets alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot100'+ On adjacent lots 100'+
Absorption field on lot 100'+ On adjacent lots 100'+
Public sewer matn N/A Public sewer rnanhole/cieenout N/A
Sewer/septic service line 25'+ Holding tank N/A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field 5'+
Water main N/A Water service line 10'+ Surface water. 100'+
Wells on adjacent lots 100'+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+
Water service line 10'+
Curtatn drain NONE KNOWN
F. COMMENTS
G. ENGINEER'S CERTIFICATION
Surface water 100'+
Wells on adjacent lots. 100'+
Water main N/A
Driveway, parklog/vehicts storage
I certify that I have determined through field inspections end
mt4ew of Municipal records that the above systems ere in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed N/ame
Date
a,':J.I. KEY A. GARNF_..~$
Date of Payment
Receipt Number
(Rev. 12mo)
Waiver Fee $.
Date of Payment
Receipt Number
FEB-20-O2 05:25PM FROtI-CT,&E EKVIRON~NTAL
,~Tr~ CT&E Environmental Services Inc.
90756t$~01 T-514 P.OZ/03 F-025
CT&£ Ref, S
Client Name
Project Namem
Client Sample ID
Matrix
Ordered By
PWSID
Sample Remarks:
1020831001
AX. Water & Wastcwntcr Consultants Inc.
Drake S/D; lot 3B, Block 1
Drake S/D; lot 3B, Block 1
Drinking Water
PQL
Client PO~
Pdnted Date/Time 02/20/2002 ls:i2
Collected Date/Time 02/13/2002 12:20
Received Date/Time 02/13/2002 12:35
Technical Director Stephen C. Ede
Released By
Allowable prep Analysis
Units Method Limits Date DaTe Init
Me~:als Department
A~cnic
0.00200 U 0.00200 mg/L EPA 200.9
02/19102
JMP
Waters Depart. men:
NitTntc-N
3.87
0.200 mg/L EPA 300.0 (<101 02/13/02 JDT
M~.cz'obiolog~' Labor&tory'
Total Coliform 0
col/I OOmL SMI8 9222B (<1)
02/13102 SBU
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
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Lv, l~ ~ ~, hetnt~ ?,,.r'z.~t-c Day phone
2813 ~, T.,,~o~- ~z /t,,d~o,-~/ //-~ ,)¢507
Day phone
Agent Cen~'~,',y ~-/' -r4~cu
Address '~ a I.~ ~. 'T',.~c..(o~-
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
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.
72-025 (Rev. 1/gl) Front MOA ~21
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
Day phone
4. TYPE OF WASTEWATER DISPOSAL:
STATEMENT OF INSPECTION BY ENGINEER
As certified bymy 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.
Name of Firm
Address
Engineer's signature ~'~
DHHS SIGNATURE
,~./~.~._ Approved for _,'~'/~,)
Disapproved.
Conditional approval for
Phone ~
Date
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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#21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription: L.o{' 3~ ~/o,c/'m '/,, Dro.~e-~//)Parcell.D.
A. WELL DATA
Well type ~'~'~ If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) ~' Date completed 9/1¥ /~3 Driller ~,v
Total depth ~0 ' Cased to 7b" Casing height 3~.
Sanitary seal (Y/N) 'f' Wires properly protected (Y/N) Y'
FROM WELL LOG
Date of test 9 / I¥ / ~.~ ~/~-~ 1 9 ~.
Static water level /fO' 8~ ~
Well flow ~"'
Pump level c4~/~
g.p.m.
AT INSPECTION
~UNtCIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
L~AY ] 9 ~99~
'~ ~'. ~ g.p.m.
RECEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
ob£er~e~
WATER SAMPLE RESULTS:
Coliform o ¢o! /'
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed
Nitrate
Collected by:
Other bacteria
Tank size I ~-5'1~ Ue'~,/ Compartments
Cleanouts (Y/N) r ~ r"
High water alarm (Y/N).
Foundation cleanout (Y/N) ~ · Depression (Y/N)
N,/I., Alarm tested (Y/N) ^~ ~,
Date of pumping ~:: 5-/ lB / ~ E.
Pumper ~-'.~'~ ~ cd
SEPARATION DISTANCES-FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I ~'3-''~' ~' ,, · -'": · On adjacent lots T> loc'
To property line ~ ~o ' Absorption field IO'
Surface water/drainage
Foundation I
Water main/service line ~--
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
Date installed
Manufacturer
Size in gallons
Manhole/Access (Y/N)
Vent (Y/N)
"Pump on" level at
"Pump off" level at
High water alarm level
Meets MOA electrical codes (Y/N)
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Width
Date installed
Length I ?-9 /
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months)
Soil rating
System type Dna,l) ~1~ / Tr'¢.c 4
Total depth 15' '
5'1 ~/p ~'
/
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
(.cnou.,n c,~c If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ;>
To building foundation ~$'
On adjacent lots ~. ;30'
Surface water ~ ¢oo '
Curtain drain
E. ENGINEER'S CERTIFICATION
Onadjacentlots ;> ¢~o' Propertyline
To existing or abandoned system on lot
Cutbank N,/~. Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines_i~Le~ffect on the date of this inspection.
_ . ..
Date ~y I~ 199~ ~,. r: ~;8~ ,-~e
HAA Fee $ / ~ Waiver Fee: $
Date of Payment ~'/~' ~ Date of Payment
~eceipt Number ~ ? O ~- ~ / ~ ~) fleceipt Number
72~026 (~ev. 3/91) Back MOA ~1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-472O
Application Date __
GENERAL INFORMATION
(a} Legal Description (include lot, block, subdivision, section, township, range)
Location {address or dire~ions)
-
~c~ A~;~cant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); __
Lend,nc Insbtution Telephone
Address
Rea; Estate Company and Agent
Address
Te~ephor~e
Mai~ the' I-iAA to the following address:
TYPE OF RESIDENCE
S~ng~e-Famiiy ~ Multi-Family []
~,~umber of Bedrooms ..... _/"/.
Other
WATER SUPPLY
~,.,qdividuat Weil ~ Community [] Public []
,fl'o~.e: tf community well system, must have written confirmation from the State Department of Environmental Conservation
a,*testing to the ~egality and status.
SEWAGE DISPOSAL
OnsCte [] Pubi.c [] Community [] Holding Tank []
~;ote: I~' community we!i system, must have written confirmation from the State Department of Environmental Conservation
atte~,tir'~§ ,to the iegai~ty and status.
P,~-~ 1 Of 2 72-025
ENGINEEI~NG FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by~ myseal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
~y~1 shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
~ 1~ num~ ~r~ms and type of structure indicated herein. I fudher verify that based on the information obtained
~om t~ Mu~ty of Anchorage files and from my investigation and inspection, the on-site water supply and/or
w~~ d~ system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
~ ~ ~ ~ i~ion.
~Firm ~~ '~C~~ ~ Telephone ~-
I
Engineer's Seal
DHEP APPROVAL b~_
Approved fo~ ~~ bedrooms ~ Date
Approved _~ D,sapprov~ ' - ' --~'"'C'/ondition;~
Terms of Co~d,'*_~,r:~ Approval
CAUTION
The Munc~pal';ty of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval cer:d;,catc~ based solely upon the representations given in paragraph 5 above by an independent professional
engineer reg.~ste.rc-~ in :he State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
inst.ltutior~s in o,r,'je.r to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or'
a~alyze da,'a be'fore a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
profe~siona.~ e~,~ c, ec-fs work.
Pa~e 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH*AUTHORITY APPROVAL (HAA)
.... CHECKLIST- FEBRUARY 1984
MUNIC/~AUI'Y OF .~NcHORA4)E 264-4720
DEPT, OF HEALTH &
INVIRONMENTAL PROTEC1101~
SEP 1
Well Classification
Well Log Present (Y/N)
Legal Description: /,-0'/" "~ r~
/~r'r~ "' If A, B, C, D.E.C. Approved (Y/N) ~,,~.
"' Dat~ Completed /o/t~//g~ Yield I~'~,.~n ~e,~ ~
Total Depth
Static Water Level
Cased to 7~'
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N) Y'
Depression Around Wellhead (Y/N)
N
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Y
J ~'~" ; On Adjoining Lots ;> too '
To Nearest Edge of Absorption Field on Lot .~' I[~~'' ; On Adjoining Lots ~, too,
To Nearest Public Sewer Line t~,~. To Nearest Public Sewer
CleanouVManhole
Water Sample Collected by
Water Sample Test Results
Comments
To Nearest Sewer Service Line on Lot
; Date ~/Y/~',~"
B. SEPTIC/HOLDING TANK DATA
Date Installed, .~/~$
Standpipes (Y/N) Y' Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) jqe/3.
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 N//Or
Course .-~
Size 1'~,.5'~ffa( No; of Compartments P--
Foundation Cleanout (Y/N) N
Date Last Pumped ~/',~/'c~'"'
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation 13 '
To Disposal Field (o~
To Stream, Pond, Lake, or Major Drainage
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ?/~J// 7~'"
Width of Field ,~ '-o"
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
~5"~/$I~R/~ Type of System Design Dr~m ~Z~ /7"~'~;
Length of Field 1 ~-P ~
Depth of Field I~- '-~ ~'
Gravel Bed Thickness 30" ~¢
7o2 Standpipes Present (Y/N) N
Date of Last Adequacy Test Ho#~ /~ ~.,,~,~e' /f~ ?/'Y/~,.4""
Separation Distance from Absorption Field:
To Water-Supply Well ~'
To Building Foundation '~, -~
Lot I~,,~.
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway. Parking Area, or Vehicle Storage Area
Comments ~ O~,~f ~ ~
S~ ~ccep~
To Property Line ~' o
To Existing or Abandoned System on
· On Adjoining Lots ~:> ~ '
To Cutbank (if present) N,/~.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~.~ Date
Company ~'~'{~ 7'~.Jt,,t;¢~( ~u,~j, MOA No. ~C~'-'~..~'Z
Receipt No. ~:)~)~O"~ ~t ~
Date of Payment C~.~ -- \(~ -~:~'"-
Amount: $ Z-~%-~ {,~, Engineer's Seal
Page 2 of 2
72-026 (11/84)
"' APPLI, NT FILLS OUT UPPER HAl ONLY
Property Owner / ~,--' ,' /- ? ~ ~' ? ?/" ~"~ Phone
Mailing Address ,/~'~.,'J- /" // ~)~ ,~ ,~. /~,~ :' ~ /~ ~ Zip Code
Buyer
Address Zip Code
Lending Institution /~ Z ,~ ~;" ~ ' ,~- ,~/ -/,"~".~' -i-'~ ~ ~" :" ~'~ ~:.~ Phone
Realty Co. & A~nt Phone
Address .... Zip Code
Legal Description Z ~ ~ ~ ~ Z ~ / /~-'~
Street Locati~ ~',',: ~ ~ .'.'? '~ t, /, ~;~ ,~. ~.~- - ,- ,? ~ ~ ? z..
Type of Resi~nce
~ Single Family
~ Multiple Family No. of Bedroo~.
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
Sewer Disposal
~' Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspectq~?, /
MUNIC, IPI,LITY OF ANCHORAGE
Field Notes: {j~,rb L ' ~ J C- ~ ENVIRONMFNTAL PROTECTION
RECEIVED
( ) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
( ~'~iSAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received
Well to Tahk Septic Tank Size
72-023 (3182)
ALASKA PUMPING & LINE CLEANING
Box 10232 South Station
ANCHORAGE, ALASKA 99511
Phone 344.7732
returned goods MUST be
640~