HomeMy WebLinkAboutNORTH WOODS UNIT 3 BLK 12 LT 5North Wood
Block 12
Lot 5
#051-732-14
Municipality of Anchorage .'¢' ~%'
Development Services Department :~.'"- "~"
Building Safety Division ~
On-Site Water and Wastewater Program. 4700 S. Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650 Page of
wv,~v,ci.anchorage.ak.us (907) ~4~7904
Permit Number. SW~10154
Name:
Jerry Minter
~45 Green Garden. Chugiak, AK 99~7
696-3539 4
LEGAL DESCRIPTION
12 $ North Woods #3
Well: r"l New [] Upg~
ON-SITE WASTEWATER DISPOSAL SYSTEM ANO/OR WELL INSPECTION REPORT
PID Number: 051-732-14
Wastewater System: [] New [] Upgrade
ABSORPTION FIELD
0.8 ~ 8.51
2.99 ~,. 5.52
1.2' - 2.2 ~,. 70 ~,.
2 ~,. I I NA
~3 ~ D30~ & F810
Jor~ Minter S~A~ 71612001
TANK
SEPARATION DISTANCES El septic I-I Holding D S.T.E.P. r-I Other.
"F~ Septic Absorption Lift Holding Public/Private Me~ulaO, u~;
Tank Field Station Tank s~,u.e Anchorage Tank 1250~.
w., 200'+ 200'+ NA NA 25'+ Steer
s~.w,.. 100'+ 100'+ NA NA ~ LIFT STATIO_~.~
~ u. 5'+ 10'+ NA NA s...
Cal.
F,,~b~. 5'+ t0'+ NA NA ~..
*none known BENCH MARK
Existing tank & field abandoned per code. Deck floor
100 FL
Engineer's Stamp
-~.~.'~.%...'.:. ,.,~
Inspec~ons peffo~ed by: KND Enmneenn~ Dates: 1 7/6/2001 _
2
Development Seduces Depa~ment Approval~
'// /~ //
AS-BUILT SYSTEM DETAILS/SITE PLAN Pernit Swlo154
NORTH WOODS fl3, BLOCK 12, LOT 5 PIDttO51-732-14
/' '\
i SEPTIC ]
B-D:I7.8'
C-D:111.7'
B-E:24,9'
C-E:8.2'
A-F:33.1'
B-F=35.6'
A-G:85.4'
B-G:I05.2'
;EPTIC )
C,~AGC
PREPARED FOR:
JERRY MINTER
22945 GREEN GARDEN
CHUGIAK, AK. 99567
(907) 696-3539
SCALE' NTS ~ mo.
~ r,~: 01043.DW0 .~e ,,.: 01045
ENGINEE.,NG
20441 PTARMIGAN BLVD.
EAGLE RIVER. AK 99577-8736
(907)696-611 I/FAX (907)696-8111
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: May 31, 2001
Expiration Date: May 31,2002
Permit Number: SW010154
~[Legal Description: NORTH WOODS UNIT III BLK 12 LT 5 '
Design Engineer: 0070 KND Engineering
Owner Name: GERALD E. & DIANA A. MINTER
Owner Address: 22945 GREEN GARDEN Total Bedrooms: 4
CHUGIAK, AK 99567-
Parcel ID: 051-732-14
Site Address: 022945 GREEN GARDEN DR
Lot Size: 27000 SQ. FT.
Permit Bedrooms: 4
This permit Is for the construction of:
[] Disposal Field [] Septic Tank [] Holding Tank [] Privy
[] Private Well [] Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. Ail requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received By: ~
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
ON-SITE SEWER/WELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
_O
Parcel I.D. ~I-732-14
Permit Number ~W OIO 15"~.
Property owner(s) Jerry Minter
Mailing address (1) 22945 Green Garden Chugiak, Ak.
Mailing address (2)
Legal description (Lot, Block & Sub'd.) North Woods #3, Block 12, Lot 5
Legal description (Section, Township & Range)
Lot Size 27000 sq.fL
Acres/Sq. Ft.
Day phone 696.3539
Zip Code
Number of Bedrooms 4
THIS APPLICATION IS FOR:
Sewer Only [] Well Only []
Sewer and Well [] Water Storage []
Sewer Upgrade []
THIS PROPER'fY CONTAINS:
Hot Tub [] Jacuzzi []
Swimming Pool [] Water Softening Unit []
Therapy Pool []
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.
(Signature of property owner or authorized agent)
Permit Fees:
Date of Payment: ~"/~-.,~/0/'
Receipt Number:
Waiver Fees:
Date of Payment:
Receipt Number:
~D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111 !FAX (907)696'8111
May 21, 2001
Municipality of Anchorage
Development Services Department
On-Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Sewer Upgrade - North Woods #3, Block 12, Lot 5
Gentlemen:
The owner has requested we proceed forward to obtain a septic permit to upgrade and
replace the existing septic system for the subject lot. The existing septic tank will be
abandoned in place and in accordance with municipal standards. On May 14, 2001 we
dug one testhole for the proposed system. The results of this test are attached. The
general slope of this lot is from north to south at a grade of approximately 1-3%.
We have designed our system utilizing the testhole we excavated for the .4-bedroom
house. The lot is served by a public water system. We propose to install a 2 wide deep
trench. Water was not encountered during the excavation or monitoring.
There are no public or private wells within 200' of our proposed system location except
as noted. There is no surface water within 100' of the proposed system and there are no
known curtain drains within 50'. We do not expect there to be any adverse effect on
adjacent lots by the development of this system.
If you have any questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
~I~]2) Engineering
attachments:
On-Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WELL
& /ASTE /ATER DISPF1SAL
NORTH WOODS #3, BLOCK
SYSTEM DETAILS/SITE PLAN
12, LIlT 5
7
/
DESIGN DETAILS
4 BDRM X ]50 GPD = 600 GPO
£00 GPD/O.B GPO PER SD. F'T. (15 MIN/IN.): 750 SD. FT
(750/(2'(V) X 5.5(D))) (5.5' GRAVEL) = 68,2 FT. TRENCH
USE ! TRENCH - 69 (L) X 8' tV) X 5.5'(D)
Totol depth or system is 8.5' From origimol grode.
Totot depth oF grGvel below distribution pipe Is 5.5' ·
NOTES:
I. USE 1850 GAL. SEPTIC TANK. INSULATE IF <4' OF' COVER.
2. INSULATE TRENCH VITH 2° HD BURIAL FOAM.
3. CONTRACTOR VZLL ENSURE MINIMUM 27. SLOPE INTO SEPTIC TANK.
4. ADDITIONAL FILL VILL BE ADDED OVER SYSTEM TO ACHIEVE
MIN. 3' COVER IF REQUIRED.
5. CONTRACTOR VILL ENSURE ALL SEPARATIONS TO ADJACENT
VELLS & SEPTICS.
PREPARED FOR:
JERRY MINTER
P2945 GREEN GARDEN
CHUGIAK, AK. 99567
(907) 696-3539
SEWARD m*,~ V~G
SEWARD c~cx~ KMD
SEWARD ~*~: 5/21/01
~o: NW1459
*c*o ~z: 01043.DWC ~e .~: 01043
Stole: 1'= 100'
PAGE I DF 2
]]~) ENGINEERING
~0441 PTARMIGAN BLVD,
(_907)696-611 I/FAX (907)696-81l !
WASTEWATER
NORTH WOODS
C[
DISPDSAL SYSTEM
fl3, BLOCK 1~, LOT 5
DETAILS
EPTIC
SEPTIC
...-
......
"P CD
PRDPDSED
BDRM
EXISTIN
BDRM HI
1850
GAL SEPTIC TANK
.~:.-. .... _~......~ ~.
PREPARED FDR~
JERRY MINTER
P~945 GREEN GARDEN
CHUGIAK, AK. 99567
¢907) 696-3539
SEWARD ~^"": VBG
SEWARD c~:cx£o:. KMD
SEWARD o*,~:: 5/21/01
~ NW1459
~ ~tr: 01043.DWG .me,~: 01043
Scc~le: 1'= 80'
PAGE 8 OF 8
~1~) ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-611 I/FAX (907)696-8111
]~D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
!
SOILS PERCOLATION TEST
lerry Minter
_~,-~' ..°
Date PerformS: 5/14/01
Project:
North Woods #3, Block 12, Lot 5
TEST HOLE # 2001-1
Depth
(Feet)
2- ;,~
' .~,
15-
SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
Was Ground water encountered? NO
Depth to water after monitoring? NA
GM - reed dense brown/gray Reading
w/cobbles to 8"
What depth? NA
B.O.H.
Date? 5/21/01
Date Gross Net Depth to Net
Time Time Water Drop
1 5/14/01 1:00 7"
2 1:30 30 rain 5" 2"
3 * 1:31 7'
4 2:01 30 rain 5" 2"
5 * 2:02 -
6 2:32 30 min 5" 2"
16-
17-
15- * Water Added
IIOLE PRESOAKED
20- PRIOR TO TEST
Percolation Rate 15.0 (min/in)PerctloleDiameter
Test Run Between ~ feet and. 4 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
MUNICIPALITY OF ANCHORAGE
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
PHONE J [~*NEW
[] UPGRADE
LEGAL DESCRIPTIO_N~ l, ~ :~
OCA ,O ¢r L
in gallons I
DISTANCE TO: Well
Manufacturer
DISTANCE TO:
No. of lines
Absorption area /~,1 Dwelling
Materlal~.~ ~.
Inside length v/ IWidth
IDwelling /~
Wel~~ Foundation'/I1'// INearestl°tline
.....h ~,i~O' ~o.~, ,en..~. I T.e.?g;W
Material beneath tile
Top of tile to finish grade~ ~ q I
Length Width
Type of crib Crib diameter
Well
DISTANCE TO:
Class Depth
Building foundation
Depth
No. of compartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
Crib depth
Building foundation Nearest lot line
Driller Distance to lot line PERMIT NO.
DISTANCE TO: Sewer line Septic tank Absorption area(s)
Total effec/~ ~_~p~n area /
Total effective absorption area
OTHER
PIPE MATERIALS
DATE
72-013 (Rev. 3/78)
LEGAL
r ' MUNICIPALITY OF ANCHORAGE ... ,.~
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
EGAL DESCRIPTIO~
,,A_v [ DISTANCE TO' ~Well
(~ ~ Type of crib Crib diameter
' DISTANCE TO: Well
~ JCI~ D~th
Absorption area Dwelling
PHONE
NO. OFBEDROOMS
[i~N EW
[] UPGRADE
PEF~IT N~),
No, of compartments
IInside length Width Liquid depth
Dwelling PERMIT NO,
capacity in gallons
Nearest lot line
Material beneath tile
Distance between lines
Depth
effective rp~'n area
Crib depth
Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line PERMIT NO,
Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS j ·
SOl L TEST RAT,~:~ /
INSTAL LER
Ri EMA~K_S ·
DATE
72-013 IRev. 3/78)
LEGAL
DEPFIRTMENT b, ~HESLTH RND ENVIRONMENTt=IL , ~-,:OTECTION
8;.?.5 "L" STREET., RNCHORRGE., RI.::: L=.~D5E~:l.
2(;4-472¢ : FINCHORFIGE (;94-2%]::1. : ERGLE RIVER
~.]~ ~'-~,~ -- :~.=.; Z *"If" 'IFZ '~_:'% E I1..--I1E F-: F' E F..: ~'*'11 ~. T
PERIdIT NO. 8Z.::1.:1.:~:±
I:;IPPL. ICRNT: S'TEVEN SKFIGGS PHONE: 688-28Z.':2L
RDDRESS: F'O BOX D
CHUGIRI<., RK
LEGRL. DESCRIPTION - SUBDIVISION: NOR]"HWOODS ~ BLOCK: t2 LOT':. 5
L. OT SIZE E1 SL.':h F'T. TO!.4NSHIP: .... RRNGE: - SECTION: -
MRXtMUM NUMBER OF BEDROOMS = 0 SOIL RRTING = 0 0 0 (SQ. FI'*. ,,."BR)
LISTED BELO[4 FIRE THE OPTiON-S RVFtILr":iBLE TO VOU IN DESIGNING 'FOUR SEPTIC
S"r%TEM. CHOOSE THE OPTION THFIT BEST FITS "fOUR SITE.
Z CERTiF"r: THRT:
:i.. I RM FFIMIL. IRR 14ITH THE REQUIREMENTS FOR ON-SITE SEWERS Bf',ID 1.4ELLS RS 'SET
FORTH B'¢ THE M, Ui",IICII'-"'I::tLZT'¢ OF FINCHORRGE FIND THE STFITE OF
2. I 14ILL. INSTFILL THE S'¢STEM IN RCCORDRNCE 14ITH ]'HE CODES FIND HRVE RECEIVED
FI COP'¢ OF THE CODE SUMMFtR'¢ FIND DIRGRFIM FITTFICHMENTS kli."IICH IS PRRT OF THIS
PERM i T.
]:. i UNDERE;TFIN[:' Tt'"IFI]" THE ON-SITE SEWER S"r'STEM I'"lW'r' R. EG!UtF.":E ENLRRGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THFIN 0 BEDROOMS.
PERMIT FIPF'LICFINT HFIS ]'*HE RESt::'ONSIBILIT"r' TO INFORM PERSONNEL DURING
THE INS]"RL. LRTION INSPECTIONS OF FIN'¢ WELLS FID..TFICENT 'TO THIS PROPERT'¢ RND
THE NUMBE'F.': OF RESIDENCES THRT ]'*HE klELL 14ILL SERVE.
IF I::1 LIFT STI::ITZON :[2; INSTRL. LE[-"., Ri",! ELEC]"RICFIL PERMIT RND INSPECTION MUST
BE OBTFIINED. RS-BLtILTS Ci::tNNOT BE RF'F'RO',,,'ED 1.4ITHOUT RN EL. ECTRICRL INSPECTION
REPORT. THE ELECTRIE:FIL I.,.IORI< MUST E:E DONE B"r' R LICENSE[:' ELECTRICIFIN.
S I GNED:
RF'F'L I CFII'.4T: '.:];7'EVEN SKFIGGS
IS'.E .El".', B"r':
[:,FITE: ±,.=~ :24-
I I
MUNICIPALITY Of ANCHORAG~-.~
Departmen%~-Af Health and Environment~~ protection
825 ~ Street,264-4720 Anchorage, AK. 99501
Permit # ~//~ * * * HANDWRITTEN PERMIT * * *
WELL AND/OR ON-SITE SEWER PERMIT
Applicant:~~.~/~ ~,~ ~'~_~ Mailing Address:~
Location: Phone Nu~er:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed~ __ Holding Tank:
Maximum Number of Bedrooms: ~ Soil Rating(sq.ft/br) /
The Required Size of the Soil Absorption System Is:
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
· * REQUIRED SEPTIC(HOLDING) TANK SIZE : 100~ GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feet
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a coremaunity sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more tha~ bedrooms.
Signe~: ,/;~(L~] ~ ~?A~C~Zk.-'~ Issued by.'~ ~~'z-lD-:¢-~''~
Applica~
Date:u'~ -- ~' /~__/,~C~ ~ ,
SWP/024 (1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~SOI LS LOG
~PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
SLOPE SITE PLAN
1
4
5
6
7
8
9,
11
12
13
14
15-
16-
17-
18-
19-
20-
COMMENTS
PERFORMED BY:
72-008 (6/79)
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
(
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ ~dzA 2:3~ /~ · q~ ,/~
bbb ' - 2:3q . ~3
z z.q~ - - q¢ ,/K
Ab~ Z: q~ · bi
PERCOLATION RATE 1 ~ (minutes/inch)
TEST RUN BETWEEN 2,./2~- , FT AND ~ FT
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. #
1. GENERAL INFORMATION
Complete legal description
Lot 5i Block 12; Northwood Subdivision #3
Location (site address or directions)
22945 Green Garden Drive
Property owner
Mailing address
Lending agency
Mailing address
Chugiak AK
Glen & Catherine Justis
22945 Green GardEn Drive
Day phone
Chuqiak, Alaska
Day phone
688-5982
99567
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
XX×
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
XXX
Public sewer
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
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 ~hat 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 Firms __
*-'"ress 17034 Eagle River Loo o _
Engineer's signature ~
D~,~,SIGNATURE
.. Approved for ~'~
Disapproved.
... Conditional approval for
.... bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By:
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.
724)25(Rev. 1/91) Back MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ ~ ~--I~ ~o~--~c..~r>~l~~ Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number.
Date completed Driller
Cased to Casing height
FROM WELL LOG
A. Well Data
Well type ~k
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Wires properly protected (Y/N)
AT INSPECTION
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
g.p.m.
O
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~ ~.- -~--% '3
Cleanouts~/N) ~
High water alarm (YI~
Date of pumping
Tank size [ o ~ o Compartments
Foundation cleanout~/N) "-// Depression (Y~
Alarm tested (Y/N) ~ l~
· pumper . ~.7"~ -~_.$&
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~-~> ~, On adjacent lots
To property line t ~ ' Absorption field
Sudace water/drainage / ~ ~
Foundation
Water main/service line
JD
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at "Pump o~
High water alarm level C~
Meets MOA electrical codes (Y/N) ~
SEPARATION DISTAN~ON TO:
W~ On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date installed \ -~ ~'~
Length ~('~ '
Soil rating (GPD/FF)
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months)
. System type
Width I ~5 ~ Gravel thickness c),:5- ' Total depth
'7~ 2, nout present ~ ? Depression over field (~)
~C/t~a )' N
7 ~'~' -/~ '~2~.,'v ..~ Results~ail) f'~'~ -~ for ;~ Bedrooms
3 ~ After test
~,J~ ~:~/~o ~/,J If yes, give date ~//~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot Zoo
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots ~/~ Property line
//' To existing or abandoned system on lot
Cutbank "J//'~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or (
Signature
Engineer's Name
Date
HAAFee $ ~
Date of Payment
Receipt Number
and HAA guide/ines in effect on the date of this inspection.
Waiver Fee $
Date of Payment
Receipt Number
72-026 f3/93)* Back
% MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF I~_ALTH AND F~VIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AD~II~ORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a) Legal Desc~ipti9~ (include ,]~, b~qck, subdivis%Qn,~ection, tcwnship, range)
Loatiq~ (ad~es~ ~ directions)
(b) Applicants N~ ~,~A~f
(c) Applicant is (check o~) ~nding Institution ~; ~er~uil~r ~ ''
Burr ~; ~her ~ (e~lain); ~ , '
Telephone
2. Type of B~sidence
Single_Family~
Number of Bedrooms
Multi-Family
Other (describe)
Note: If c~i~,~nity ~11 system, must have written confirmation frc~ the State
Depa~T~nt of ~vironzental Conservation attesting to the legality and status.//
· Is the ~11 adequate for the number of bedrooms specified i~ this HAA (Y/N
4. _Sewage Disposal
Onsi Public [-~ Corarmnity ~ Holding Tank
Is the wastewater disposal system adequate for the 'rimaber of b~¢trocms .
[Page 1 of 2]
2-15-84
5. E__~gineering Firm Providing Inspections, Tests, D~ta and Information
I certify that'~i--h~ve checked,,verified, or confo~me.d to all MDA HAA Guidelines in
effect on .the dat~/ ~f ~th~s'.~ection.
i ,
Date
(ENGINEER SEAL)
6.DHEP Approval
Approved for ~ h~..droc~s
Approved ~ Disapproved ~
Conditional
Te~ws of ~nditional Approval
The Municipality of AnchOrage Department of Health and Enviro~x~ntal Protection dces
not guarantee the continued satisfactory pe~fomuance of the wate~ supply and/o~ the
wastewate~ disposal system. This approval indicates that, as of the. validation date
sh(x~n above., based on the data and info~mation furnished by an engineer registered in
the State of Alaska, the water supply and wastewate~ disposal system is safe and func-
tiQnal for the rnmbe~ of bedrocks and type of structure indicated.
( E~EP SEAL)
7. Mail t~he ~t.C.~ f~t~win9 address;
KB2/d5/s
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2-15-84 -
ao
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH A[FI~ORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification I B, c~ C, D.E.C.
Well Log P~esent (Y/N) Dath~ Cc~pleted
Total Depth Cased to
Electrical Wiring in Conduit (.Y/N) // ~
Separation Distances f~cm We 11.
To SeEtic/Holding Tank on Lot
To N~a~st Edge of Absc~ption Field on Lot
To Nearest Public Sewer Line
Cle ancut/Mmnhole
Water Sample Collected By
MUNICIPALITY OF ANC~ORAGIE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
Yield
Depth of G~outing
Sanitary Seal on Casing (Y/N)
Depression A~ound Wellhead (Y/N)
; On Adjoining
Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewe= Service Lir~ on LOt
~ Date
Water Sample Test Results
Cc~wents
Be
SEPTIC/HOLDING TANK DATA
Date instal~9~ /~//q/~ ~ Size /~p No. cf Compartments
Standpipes~ / .~ Air-tight CaP~(Y,~ Foun~dation~ Cleanou~.~
Depression over Tank (~/ Date Last P)~ped t~
Separation Distances f~cm Sep~tic/Holding Tank: (.~
TO lhtoperty Line //~ To DisPOsal Field
To Water Main/Service Line ~/~ To St~eam, ~P~], ~ake, c~ ~~ajor D~ainaGe
[Page 1 of 2] 2-15-84
C. ABSORPTION FIE.LD DATA
Soils Rating in Ab, s~o~tion Strata
Date instalted/l/~/~ 3
Width of Field /~
Depth of Field
Square Feet of Absorpti. o_n~ea
Depression ove= Field (~/
Results of Last Adequacy Test /~
Separation Distance f~om Absorption Field:
· / To Existing or
To Building Foundation ~/~ .. · · Abandoned System cn
Lot X/ '77 On
TO Wats= Main/Service Line ~P ~ ... To Cutbank(if . esent) /t///~
To St=eam/Pond/Lake/c~ Major D~ainage Course
To D~iveway,~Parking Area, o~ Vehicle Stc~age A~ea /.,~7
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
Dimensions
Manhole/Access (y/N)
"Pump Off" Level at
Vent (Y/N)
High Water Alarm Level at
Tested fo~ Pumping Cycles du~ing Adequacy Test. M~ets MOA
Code s ( Y/N?_Y_/N_~______~
Electrical
C~t~Y~nts - '
·
** Check Permitted Bed~oc~ Rating AGainst HAA 9equest
I
ce=tify
on the ~tg~of
Signed ~~~( Date P
~ ~,-/ ~fi ~0~x · ~OA No. .
KB1/dS/s
[Page 2 of 2]
2-15-84
