HomeMy WebLinkAboutHYLEN CREST #1 BLK 2 LT 11Hylen Cees
Block 2
Lot 11
#050-472-74
0
~ Municipality of Anchorage
Development Services Department ..
Building Safety DMslon -*: ' ~'~"
On-Site Water & Wastewater Program, 4700 South Bragaw SL ;'J~
P.O. Box 196650 Anchorage, AK 99519-6650
www.d.anchorage.ak.us (907) 343-7904 Page 1 of
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number. SW000489 PID Number. 050-472-74
N°me:MARK SHOPF' c/o DYNAMIC PROPERTIES Wastewater System: ra New · Upgrode
~ldress: ATTENTION: CAROL BENNETT
;3~1 c STREet. SU~ 100 * ANCHOP~GE. ~ 9950;3 ABSORPTION FIELD
Ph°ne:(907) 261--7648 3 O0..p ?.,nch laSha,o* ?r.~h OB~ OUo.nd
LEGAL DESCRIPTION = ~"~ 2.0 ~/~,, 4.2' AT DEEPEST POIm
11 2 HYLEN CREST #1 1.84' AT DEEPEST POINTF~ 0.56
-- -- - 1.0 - 3.0 r~ 45
!
WELLI [] New [] Upgrede 6 n 2
~. ~ ~ 270 s~. ~. /SCH 40 PVC/HDPE
r~ EAGLE MTN. EXC. 1/22-24/2001
SEPARATION DISTANCES = s.p~ = ,o,,;., ·
;o s. puc ~,o~pUo, u~ Ho~=.g ~,~/P~'~ ANCHORAGE TANK 1250
we, 200'+ 9,00'+ 200'+ - 25'+ STEEL 2
s~.o=, lOO'. lOO'. lOO'. - - LIFT STATION
Woter
Une 5'+ *5% 5'+ - - 1250~ ANCHORAGE TANK/ORENCO SYSTEMS
Foundation 5'+ 10'+ 5% -- - TIMER TIMER 45"
Curto~n
Droin 50'4- 20% 50% - - 20 OS 05 HHF CARCEL ELECTRIC
,~.o~k~: .W~R GRANTED W,H ~SSUANCE Or PER~m BENCH MARK
· *THIS IS A BOTTOMLESS INTERMITTENT SAND FILTER. (ISF~. TOP OF GARAGE SLAB
2.0 FEET OF M.O~. APPROVED SAND FILTER ADDED.
THE EX]STING SEFTlC TANK WAS REMOVED OFF SITE. 91.09
PRESSURE FOR AJR BLOWER WAS ;3.0 ON 1/;31/2001.
2nd 1/25/2001 t ........ '"'
3rd 1/=~/2oo~ .'
~"~e'.'~ ~ .... ~ ..... .'"~;''
Department of Healt~_~_d. Hyma~s approval ~/0~ /....
R~vlewed and approved by' ' '~ Da~e:2 ~/2z'-~! ~' ........
PE~ NODDY: AS BUILT DRAWING P~
swooo489 - oso-472-74
1. ~E K~ BOX ~D ~A~ UNE WERE LO~ ~ ~ . [ [
E~ ~ BE MH -- --
MT2 57.78 17.18-- -
~S~ ~TER & ~STE~I~R ,~ ~ ~~,
MARK SHOPE AGENT: 261-7648 2 OF ~
HYLEN CREST SUBDIVISION ~1; LOT 11, BLOCK 2,
AS-BUILT OF SEPTIC SYSTEM UPGRADE (BO~OMLESS ISF)
p[RMffNUUB[R: AS B'~'"~4T D~I~~G PARCEL ID NUMI3~'R:
SW000489 - 050-472-74
- 90.57 ~~P OF ~HO~
6.76 ~~bON
BUNG - 8~,12
101.8-~03.7
~~INSU~ON ~ORIGI~.I ~.8~G~
or
~D
~L~
/BOOM OF P~
NRUNE - 97.16 0~.)~ ~B0~U OF m~CH
- 95.65 (A~.)
. ~.~... ~.-'~ ~. ~"'~
A~SI~ ~TER & 5~STE~I'ER
,o~,~,~.,~,. . ....... :~[...~ ~: ..........
MARK SHOPE AGENT: 261-7648
~ *~.,.~.: ~0~.~ '....
HYLEN CREST SUBDIVISION ~1; LOT 11. BLOCK 2.
~E OF WORK:
PROFILE AS-BUILT OF SEPTIC SYSTEM UPGRADE (BO~OMLESS
02/04/200!
17:16 6948479
EAGLE HCI..HTAIN EXCAV
-CAR C__EL ELECTRIC
lOIlO FilllcYCir. A~c, bOra ,
PAC.~ 01
Eagle Mom~ta[n Excavation
/-I.C. 83 Box2426
Eagle River, AK 995TI
1-26.01
To whom it may concern:
Subd/v/sion in Eagle River AI~e]°catei:l a't Eot ] i','Blo~ 2, Hy-15n-Cr'~g-~l .................
Tiffs Bio-Cycle was wired per the
que~ons please give me a call 1999 National E/coY&al Code. I£you lmve any
Thank you,
Steve Cloud
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Sendces Pmgrarn
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Nov 22, 2000
Expiration Date: Nov 22, 2001
Permit Number: SW000489
Legal Description: HYLEN CREST#1 BLK 2 LT 11
Design Engineer: 0041 AK Water & Wastewater Consultant
Owner Name: Mark Shope
Owner Address: 17639 SE 293rd PI. Total Bedrooms: 3
Kent, WA 98042-
Parcel ID: 050-472-74
Site Address: 010225 SILVERTIP CIR
Lot Size: 23427 SQ. FT.
Permit Bedrooms: 3
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. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18MC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling
(907) 343-4744 ( 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:
Oate:
Date: ]/-Z 2 - O0
Municipality of Ancho.rag¢
George P. Wuerch, P.O. Box 196650 Anchorage, Alaska 99519-6650
Mayor htr p://www.ci.anchorage.ak.us
November 27, 2000
Jeffrey Garness
Alaska Water & Wastewater Consultants, Inc.
6901 Debarr Road, Suite 2-B
Anchorage, AK 99504
Subject:
Waiver Request for Hylen Crest #1, Lot 11, Block 2
Waiver Request #WR000101
Parcel ID #050-472-74
SW000489
Dear Mr. Garness:
Your request for a waiver of the required 10 feet horizontal separation fi.om the
on-site wastewater disposal system to property line has been approved. The approved
separation distance is 1.0 foot.
This waiver approval applies to the existing on-sitewastewaterdisposal system to
property line separation only. Any future upgrade to the on-site wastewater disposal
system will require all separation distances be met or another approval fi.om this
department.
If there are any further concems or questions regarding this waiver, please call our office
at 3434744.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Water Quality Program
MUNICIPAUTY OF ANCHORAGE
Department of Health & Human Services
On-Site Services
Waiver Review Worksheet
WR#: WR000109'1 PID~. 050-472-74 HA#:
Date Received: November 16~ 2000
Legal Description: Hylen Crest #1~ Lot 11~ Block 2
Engineer:, .~-!-"-~' Water & Waetewater Conaultants~ Inc.
6901 DaBarr Rcedr Suite 2-B~ Anchorage, AK 9950~
Applicant: Mark Shope
Waiver Requested: I foot lot-line waiver
Criteria: 1.
Geology
A. Water Table
B. Soil Sorpfion
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Points:
Total:
2. Special Conditions:
3. Other:.
Waiver is Granted: Waiver is not Granted:
UstConditionsorReasonsforabove: ~gg- E,,t,/(~II~EE~ ' J' R)y'~ffl~z~ (.~lr~
Date: //'- 2. 2"
Rec#: .06454 Amount: $115.00
By: ~'~ ~
Name of Reviewer
Date Paid: 11116J00
ALASKA WATER WASTEWATER
CONSULTANTS, INC.
November 14, 2000
Municipality of Anchorage
Department ofHealth & Human Services
Division of Environmental Services
On-Site Services Section
P.O. Box 196650
Anchorage, Alaska 99519-6650
Reft Septic System Upgrade for Lot 11, Block 2, Hylen Crest Subdivision #1
(Bottomless Intermittent Sand Filter - ISF)
To whom it may concern:
The existing 3 bedroom house is served by public water and a private septic system. The existing
septic system consists of a 1000 gallon septic tank and a deep trench type drainfield. The
existing drainfield is surcharged and must be upgraded for the sale of the house. We are
proposing that a 1250 gallon S.T.E.P. tank and a innovative Bottomless Intermittent Sand Filter
(ISF) system be installed. Comments regarding the proposed upgrade are summarized as follows:
1. GENERAL: Two test holes were excavated northeast of the house in order to determine an
area suitable for a septic system upgrade. Due to a undocumented curtain/french drain, only one
test hole was found to be suitable for an on-site septic system. Given the location of the house,
the location of the documented and undocumented curtain drains, the setback from surface water,
and the presence of groundwater; it is our opinion that a Bottomless ISF system is the most
viable option.
2. SOILS: Attached is a log which shows the soil classifications, groundwater monitoring, and
the percolation test results. It is our opinion that due to the overall appearance of the soils, a
application rate of 2.0 gallons/day/ft2 should be used..
3. DRAINFIELD DESIGN: Bottomless Intermittent Sand Filter (ISF)
a. Percolation Rate: 3.3 minutes/inch
b. Allowable Application Rate for ISF: 2.0 gallons/day/ft2
c. Number of Bedrooms: 3
d. Des!gn Flow: 450 gallons per day
e. Mimmum Absorption Area: 225 ft2
f. Effective Depth below pressure pipes: 3.0+ inches
g. Width: 6 feet
h. Length: 60 feet.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwwc.com
i. Effective absorption area = 360 tt2
j. Air Supply: Thomas Industries, Model 5070, "Anchorage Tank".
k. Air Supply Line: "Wasteflow' emitterline, 1/2 inch I.D, "Anchorage Tank".
1. Sand Material: In accordance with M.O.A. latest standards
m. Pea Gravel: 100% passing 3/8" sieve, less than 20% passing the 1/4' sieve, and
less than 1% passing the #8 sieve.
We are proposing to excavate down to a depth of 4.5 feet (maximum - on uphill side), place a
minimum of 6 inches of sand, install the air supply line, and cover it with 1.5 feet of sand. On
top of the sand, we will place 6 inches (minimum) of 3/8 inch pea gravel, with the pressure
laterals midway in the layer. We will use a conventional lift station (Anchorage Tank), equipped
with a programmable timer so that flow can be intermittently dosed to the ISF.
4. SURFACE WATERS: The outfall for the documented curtain drain if 100+ feet from the
proposed upgrade. A small trickle of water was found on 11/7/2000 flowing from the outfall. The
100 foot setback from the outfall and surface water is to be flagged by a registered land surveyor.
5. TOPOGRAPIIY: As can be seen on the design draxving, the drainfield is to be installed near
the base of a 20 to 25 pement slope that runs from northeast to southwest approximately. In
short, we do not anticipate any slope concerns.
6. LOT LINE WAIVER REQUEST: We request a I foot lot line waiver from the proposed
ISF drainfield to the northwest properly line. We are unaware of any adverse effects on the
neighboring property with the granting of this waiver.
7. MATERIALS AND CONSTRUCTION PRACTICES: The materials used, and the
construction practices will comply with DHHS' "Intermittent Sand Filter Design, Installation &
Maintenance Manual". The contractor should read this document prior to construction. Copies
are available at the Municipal Onsite Services office (5th floor, 9th & L St.).
8. CLOSING: I am open to any suggestions from your department, which would be an
improvement to the proposed design. I am unaware of any adverse impacts this installation
would have on adjacent wells or septic systems. If' you have any questions, please contact us at
337-6179.
Jcl '$yl,~l
PresidOnt ~
'ou for your assistance.
3amess, P.E., M.S.
6901 Debarr Road, Suite 2B * Anchorage, AK 99504
Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: akwxvc.com
MARK SHOPE ~: 261-7648
HYLEN CREST SUBDIVISION ~; LOT 11, BLOCK 2. ~h~-'~'.-
SITE P~N FOR SEPTIC SYSTEM UPGRADE (BO~OMLESS ISF)
~ NOTE: THE CONTRACTOR SHALI~ I..I~VE THE
Am COwKSSm S~LL ~ L~ ~ ~ ~ NOR~E~ PROPE~ UNE AND THE 100
~C~$$I~ F~ ~THIN ?~ ~[ ~D A ~ ~ ~ %~ ~ O~F~ ~D/OR ~ SURFACE WATER
v~ mT ~ ~ ~ ~GGED ~ A REGI~ERD ~D SU~OR
~]~s~c ~ ~-,PRIOR TO ~ CON~U~ON. ~0 THE
~7o, ~ ~[~ ~ ~ t~ t~ ~m ~ S~ ~ ~ CO~OR S~L ~ ~E WATER
z~ z~ ~z~ ~ ~ fi[cD, ~T~ v~ ~ z~ ~ ~- / SE~CE ~NE PRO~SIO~LLY LO~TED
~[T. ~ ~ ~L ~ ~1[~ ~ A NI~ ~ ~ ~ ~ ~y PRI~ TO ~ EX~VATION IN THE ~0~
rEIT. ~ xx OF T~ HOUSE.
~ ~ ~ ~O COMPL~Y lei 10+ ~ ~0~ ~E J I I
SE~CE UNE. / ~ ~ m
(,%~ N~O~- ~ I~ c~om I
11/14/2000
J.L.M.
WATER
GONSULTANTS, lNG.,
PHONE NUMBS: P~E NUMBS:
MARK SHOPE ~: 261-7648 2 OF 5
HYLEN CREST SUBDIVISION; LOT 1 1. BLOCK 2,
DESIGN OF SEPTIC SYSTEM UPGRADE (BO~OMLESS ISF) '~%~
/.-MONIft:~4t2 'IriS.5 (1YP.)
~SI~ WATER & ~STE~5~'ER o.L...
HYLEN CREST SUBDIVISION; LOT 11, BLOCK 2,
DETAIL AND PROFILE OF BO~OMLESS INTERMI~ENT SAND FILTER (ISF)
ALASKA WATER & WAS~,,T~W~A..~TF~..~' CONSULTANTS. INC.
PHONE (907) 337-6179 · FAX (907) 3.18-3246
ISOIL LOG PERCOLATION TESTI ,'~?'z!~!CJ~/~J 1 §~ '"?*~
LEOAL DESCRIPTION: HYLEN CREST S/D ~1; LOT 11, BLOCK 2. ......
PERFORMED FOR: MARK SHOPE
DATE PERFORMED: ll/7/2000
I~fEJ~. [J-J~ ORGANICS HAVE ITEST HOLE #11
iljlllI]IJ SEEN REHOVED q~P~rofe$~'~oO
SOIL CLASSIFICATIONS "--~-"'~---~_--.. ~,,
l[tJJJI[J GM/SM .,,.::- /,
.,.- ..... SP ////~, CH ./'a~:~'
GROUNDWATER .... ~, ~ ~'~J~'/ ~xl~ JJ
7.o '~ 1/z/gu x"-e4,~'~ j'~ Hog, s[
..o. ....
-I141oo
nAT~ R~ADIN¢. CLOCK NET TIME WATER LEVEL NET DROP
11 ........ TIME (HINUTES) READING (INCHES)
12 11/8/00 I 2?[4 ~ 6 .
2 2:44 10 2 5/4' 5 1/4
15 ~ 2:44 ~ 6'
4 2:54 10 3' 3"
14 5 2:54 6'
6 5:04 10 3'
15 7 ~:04 ~ 6'
16 8 ,,3:14 10
9 ~:14 6'
17 10 ~:24 10
11 3:24 ~ 6'
18 12 5:54 10 i
2 TEST RUN BETWEEN'--~----7~ /' J,~'5'
4.0
FT.
COHHENTS: P£RC-HOLE WAS PRE-SOAKED FOR 4+ ~OUFSJlIIIIJ..
PERFORMED BY ALASKA WATER & WASTEWATER I, . ,~ ' ~'/ k , CERTIFY THAT
THIS WAS PERFORM~D I¥ ACCORDANCE WITH ALL S'~AI'E~.~ D ,4UNIC'IP~ ,L GUIDEIJNES IN EFFECT ON THIS
DATE. DATE: t~ll~/~
DEPTH TO DATE
GROUNDWATER
7.o' ll/7/oo
8.0' ll/8/00
7.5' 11/14/00
Sent. 6y: Alaska Wate~ and Wastewater Con; 907 338 3246; Nov-16-O0 lJ:22; Page 2
'" "' PROP
O]
· ~RTY OWNER MAINTENANCE AGREEMENT
-SITE WASTEWATER DISPOSAL SYSTEM
This agreement, dati~i /~:/F~ ~//, ,200~). is ~e ~twc~ ~c Munic~ali~ of
Anchorage ~p~cnt~ ~ tl~l~ aM Hu~ Scribes (DHttS) ~d ~c pr~ owner(s) of
~is =gr~e= b ~d= I ~ ~u~sc o~ ~=~ng an on-s~ wast~ater ~Js~sal system
on ~c sub~ pro~rty.
Th= pro~ owner(s) s; =c to ~c following:
~ pro~r~ o~r(s) ~vc ~ annul i=~tion of thc syst~ p~r fo~ by a registered
profession! =ng~ccr, ~ inspection shall v~=i~ ~at ali effluent a~ air pumps, t~s. ~d
aJa~s are ~=tioning d~ign~. Any dcficic~ies shall be corrected ~d ~c engineer's
s=tement ~at ~e systen is ~nctioning as ~sig~ sMll be filed ~ually wi~ ~cDHHS.
~o~ ~r N~= -- . . .. ~r0~y 0~ne,r ~ .
Judicial District SS. ~, P~.~,3 C'o~,/~ ~
On ~is f ~, d~y of ~)~~ in ~e
year ~ ~fo~ ~. ~e ~tgn~ ~
public, pcrson~ap~a~d:
~e per~n(s) wh~c n~e(s) Isl~ subScfl~ ~ ~c
wi~in ~nt ~ ~k~l~g~ ~nt ~lshe/~ey
ex~ut~ ~e s~c for ~e ~ ~
~n~d.
~ ~mess w~f, I ~to s~ my h~d ~d
NonpUblic (signature) /
(Ho~*~ pr~t~ ~e)
MY ~ss~n expi~s:
NAME
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
~¢'",~0 ~'~) [] UPGRADE
MAIL~ ADDRF~SS
LEGAL DESCRIP-rlON
LOCATION
NO. OF BEDROOMS ~
PERM,T NO , O 4'/¢"
No. of compartments ~..
ILicl. capacity in gallons IF HOMEMADE: Inside length W dt ~ Liquid depth
DISTANCE TO: Dwelling PERMIT NO.
DISTANCE TO:
No. of lines ~
!
L!.W~ Foundation /~ /
ngth o~a~., I~ne Total l engt.~ I~nes
Top of tile to finish grade
Material beneath tile
Width Depth
Type of crib Crib diameter
Well Building foundation
DISTANCE TO:
Driller
DISTANCE TO: Building foundation Sewer line
~city in gallons
Trench
Total e f f e c t i ve~ a bs o~pA~,p-a rea
PERMIT NO,
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO,
)tion area(s)
OTHER
so,, TEST RAT,NG..<~/ 'Z~
REMARKS
APPROVED
DATE
9-IO-
LEGAL
Zv7
72-013 (Rev. 3/78)
F:'E:F~M I T NIl ~
DA'TE I S,SUED."
85(),¢1.96
(:)Iii / :1, 2185
APPL .1: CAN'f':
ADDREE;S ~
CONTACT F:'HOI',IIE~
LEGAl... DESCR:I:F': .SUBDIVISION~[ HYLEN CREST LOT: 11
SECTION: 8 'T'OWNSI~II:::': :L4N RANGE: 1W.
I.OT SIZE: 23427 (SQ.F'T,. OR ACRES)
MAX BEDROI]M,r.~: 3
B L. O I::.)K ~
Listed beiow are the opt:i, or'is ava:i, lable to you in des:i, gning you,u' se]p't.:i.c
sys'Lem. Choose .'t..h~ option 'Lhat best Fits your' site,,
DEF:"T'H TO PIPE BO'TTOM (F:'T.)
GF;AVIEL DEF:'TH (FT.)
T(]TAL DE:F:']'H (F'T,,)
GI::~AVEI..,. 1,9 ]: D'f'l"] (F:"I".)
GF~AVEL. I.,.ENGTH (FT.)
GRAVI~:I,.., VOLUME ([]L,J. YDS.
"I"AIxlI,::: SIZE (GAL. S)
S[:)IL. RAT']:NG (SD.F:T'./BR)
TANK MUST HAVE AT Llii.:.AST ]WO C[]MP~R'I"MEIxI'T'S
:i: (::er'Lily tha'!'..:
:1.,, I am Fam:i.l:[ar' with 'LI:~Q? P~I::ILIJ, PE]Iilen'~..[~ I'OP on.-sJ.]'..[.:~ seNePs ~d']d w(?].].~i
FOr'ti") by 'l:,h6~ Mur'iic:ipa:l. ity oF Anchor'age (MOA) and 'l:.he StaCe oF A].asl.::a,,
2, 3: Wi].]. J.r'M~'LE&].]. '[..h(~,2 s4iys~'l:.(...~)m il"i ¢~xcc:ol-(J~:u']c~:e wi. th ¢~t:l.]. MOA codes and
and in cc)mi:)], :i. ance with the (:le~ign ct' J.i:,er':i,~. [:)F 'Ll'l:i.~
:3~, :1: will adher'e to all IdI:]A and State o¢ hlasl.::a r'equir'ements For the set back
dismLances ('l".om E,i]y ex:i. st. ing well, wastewa'l'.er' disposal system om" pul:)].ic
4, I under'stand that this pe)m"m~t J.s valid For a max:Lmum oF 3 bedr'ooms am-id
any enlargement ~J.~l m"equ:i.r'e an acld:i.t:i, or'~a~
]:F:' A I_.IF::]" STATION "( .... ' ................... ' ..... '
1o .t. NolAI...L.I::.D IN hN AREA I..,(..)VE. RE:.D By MOA BLIII...DII,I6~ CODIES,
'f'HIEN (1) ~lxl EI..IECTRICAI.... F'ERMIT AND ZIxlSF'ECTZOIq MIJST BE OBT'AIIqED~ (2) AS-BUII....TS
W]:L.L NOT BE AF:'PRDVED NZTHC)UT AN ELEC"I'R:[CAL INSF'EC')"ZDN REF;'ORT~ AND (3) 'f:HE
E]JEC'T'I::~ZCAL WORK MUST' BE DONE BY A LICEIxISEI) EI....IEC'I"RICIAN,
ALASKA ENVIRONMENTAL
CONTROL SERVIC , INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-§040
SHEET NO. OF
CALCULATEDBY ~ 'T~K DATE
CHECKED DY DATE
SCALE
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20-
COMMENTS
PERFORMED BY:
72-008 (6/79)
,~- SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
SLdPE
DATE PERFORMED:.~--¢¢i, - ~';'~
SITE PLAN
No. 1/k§7-E
WAS GROUND WATER IS.
ENCOUNTERED? ~'~ -(~ 0
P
IF YES, AT WHAT E
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
(minutes/inch)
PERCOLATION RATE
TEST RUN BETWEEN FT AND , FT
-
.~ - DATE:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-472-74 HAA #
Expiration Date:
1. GENERAL INFORMATION
Complete legal description Lot 11 Block 2 HvleffS/D
Location (site address or directions) 10225 Silvertip Circle, EaClle River, AK 99577
Current Property owner(s) Therese and Mark Shue¥
Day phone 694-8503
Mailing address
ency
· 10225 Silvertip Circle, EaClle River, AK 99577
U.S. Inspect/Attn:Richard Sheehan Day phone 703-293-1525
Mailing address
3650 Concorde Parkway, Ste 100, Chantill¥, VA 20151-1129
Real Estate Agent
Day phone
Mailing Address
Unless othen~/fse requested, HAA wfll be held by DHHS for pickup. HAA picked up by: , '/
2. NUMBER OF BEDROOMS:
3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
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 ^uthodty Approval are required for the t~ansfer of
title (except between spouses) on properties served by a single family on-site wastewater disposal and/or water
supply system. DSD 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 and may be reissued with
new water sample results less 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 engineer's work.
%
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy that my Investigation
based on procedures outlined in the Health Authority Approval Guidelines for 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 vedfy lhat 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 applicable Municipal and
State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Enq. Svc. Phone 272-8218
Address P.O. Box 102954, Anch, AK 99510
Engineer's Pdnted Name Steven R. Pannone, P.E. Date
Engineers Comments: I~ conducting na ndcqum.T tc~ I attempt to provide a thorough, conscientious
en~ncering am~lysis of the system in accerdancc with MOA DSD G"idelines & Regulations. The
reported re~ul~ de.'.'.'.'.'.'.'.'.~fi be the pcrformanco of the systcm un&'r the conditions encountered at tho time of
the te~, and separation distances measured to readily i&'ntifiable f~tmes. The operational life of all
'wells and septic systems d~Tx.'nd on the local soil conditio~ gronad v, ator levels that may fl~tuat¢
during the year, and the v,~ater usage o£the family berg served by thc system. These conditions are
outside the control ofth¢ evaluator of this s~'tem. All systems eventually fail and satisfactory test
results do not gunnmten future pefformnaen of the system, nor do they g~amnten t/mt them are no
hidden defects or encroachments. P-E~ can therefore not provide any ,~arran~y for future performance
nor give any e~imatc of how long I~e s?,. ~'m v,~ll continue to meet me operational requirements of the
ADEC or MOA DSD. The content of this report is for thc sole Ixmefit of thc ownor listed above. Any
reliance upon or use of this report by any other porson or party is not authorized nor will it coffer any
legal right ~'hatso.wer.
6. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
X Conditional approval for 3 bedrooms, with the following stipulations:
At: the time of title transfer the new property ou'ner sha'll sign the attached
maintenance agreement which shall be returned to this office before an
unconditional approvalLis tssued.
Additional Comments
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
Expiration Date:
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Odginal Certificate Date:
Reissue Date:
X
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
' (907) 343-79O4
RECERTIFICATION OF INSTALLATION
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot t I Block 2 Hvlen Crest No. t
Parcel I.D.: 050-472-74
A. WELL DATA
Well type ppbli¢
Dale completed
Total depth
ft
Date of test
Static water level
Well production J
WATER SAMPLE RESU~LTS:
Coliform Jcolonies/100 mi
Deta, of'~of sample:
If A, B, or C provide PWSID
Sanitary seal
Cased to
FROM WELL LOG
g.p.m
Nitrate ' mg/I
Collected by:
Well Leg
Wires propedy protected
Casing height (above ground)
INSPECTION
in.
Other bacteria
g.p.m
colonies/100 mi
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Anchoraqe Tank Steel
Date inetalled 1122/2001 Tank size 1250
Cleanouts Y Foundation cleanout Y_
gal
Dep~'ession over tank N
Date of pumping 81112002 Pumper J.R,'$ Pumvina
ABSORPTION FIELD DATA to[IO/O;/.
Date installed 1122/2001 Boil rating (g.p.dJ/t
Number of Compartments ~.
High water alarm Y_._
System type Bottomless ISF ·
Length 4~ fl ' W~dth J._. fl Gravel below pipe 0.~15 ft
Tolal depth 3,1 -~ ft Effective abeoeptio~ area 270ff= Monitoring tube Y Depression over fle~d N
Date of adequacy test {~euD'~tlelResuits (Pass/Fail) Pass - For3 bedrooms
Fluid depth In absorption field before test - in Water added
Elapsed Time: 0 min Final fluid depth -' in
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N
gal. New depth ~ in.
Absoq)flon rate >= ~ g.p.d.
If yes, give date
D. LIFT STATION
Date installed
'Pump on' level at .
Datum ~
E, SEPARATION DISTANCES
gattons Manhole/Access
evel at ~ in High water alarm level at ~
Cycles tested
in
Meals alarm & circuit requirements?
SEPARATION DISTANCES FROM WELL ON LOT TO:...~/~0~
Sepiic tank/lift station on lot Oj~ad[a~ot lots
Absorption field on lot
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Building foundation
Property line
Absorption field
Wster main 10+
Water service line 10+
Surface water 100+
Drainage 100+'
Wells on adjacent lots 200+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line $' **
Building foundation 10+
Water main 10+
Water Service line 10+
Surface water 100+
Driveway, perking/vehicls storage 10+
Curtain drain 20'+
Wells on adjacent lots
F. COMMENTS
* Below Final Grade. 2' of MOA aplxov ,e~J, sand filter added below fioal orade.
O. ENGINEER'S CERTIFICATION ' ~,'c,~..'.."
c~ ~ MOA H~ ~8~s ~ e~ ~ ~is ~.
~[Steven R. Ponnone~
H~ F. $ ~ ~ ~ ~ Wa~er Fee $
D~e of Payment I 0 / I 0 / ~ D~e of Payme~
Re~i~ Numar ~ ~ ~ ~ R~i~ Numar
(a~. 11~)
jl
K~u,~... ~-~u... L~ ~' · · · ~'m'
PLOT P~S · LOT ~R~ , NO~
CONS~UC~ON, ~
TO ~1~ ~[ ~O ~ ~S ~ ~ ~1~
~1~ DO NOT ~P~
4121-S
C~lC~-~
VK)O0 D[CX
Prepared
by
Robert E. Johns, Jr. & Assoc.
Professlonal Land Surveyors
1" = 40'
OC'~'OBER 7, 2002 REJ
OCTOBER 7,2002 N~ 57
LOT 1!, BLOCK 2,
ADDITION #1
MLJ
22-250
HYLEN CREST SUBD
Municipality of Anchorage
Development Services Department
Building Safety Dlvlslon
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage. AK 99519-6650
www.cl.anchorage.ak, us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 050-472-74
1. GENERAL INFORMATION
I-/Ao10043
Date: 5--- I( -- 0 /
Completelegaldescription HYLEN CREST SUBD~SION #1; LOT 11, BLOCK 2,
Location (slte address or dimctJons) 10225 SILVERTIP CIRCLE EACLE RIVER, AK
Current Property owner(s)
Mailing address
MARK SHOPPE c,/o DYNAMIC PROP. . Dayphone
ATI'ENTION: CAROL BENNETT
261 --7648
Lending agency
Day phone
Mailing address
Real Estate Agent
CAROL BENNETw/ DYNAMIC PROP. Dayphone 261-7648
~Maillngaddress 3111 C STREET~ SUITE 100 * ANCHOP, AGE~ AK 99503
Unless o#~eg',dse requested, I-IAA ~MII be held by DSO tor plokup.
2. NOMBER OF'B'EDROOMS: 3
3, TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL=
Individual On-site
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 at' Health Authority Approval are required for the transfer
of titJe (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 pdvate or Class C well and may
be reissued with new water sample results less than 30 days old. (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
wells ar a public water system. The Municipality of Anchorage Is not responsible for errors or omissions In the
professional engineer's work.
Note: Alaska Wa ter and Wastewater Consultants, Inc. shall be paid $1,300.00 a t, or prior
to dosing for the engineering services provided.
4. STATEMENT OF INSPECTION BY ENGINEER
A~ cerfl*fied by my seal affixed hereto and as cf the validation date shown below, I varify that my
investigation, based on procedures outlined In the Health Autho#zy Approval Guldelines for this application,
shows that the on-site water supp~ and/or wastewater disposal system Is(am) safe, functional and adequate
for the number of bedrooms and ~e of structure Indicated herein. I further varify that based on the
information obtained from the Munldpatily of Anchorage files and from my Investigation and Inspect'on, the
on-site water supply and/or wastewater disposal system is(am) In compliance with all applicable Municipal
and State codes, ordinances, and regulations In effect at the time of installation.
Name of Firm ALASKA WATER &: WASTE'WATER CONSULTANTS, INC.
Address 6901 DEBARR ROAD, SUITE 2B * ANCHORAGE, AK 99504
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments: : ....
In conduCtihg this evalua#on, AWWC, Inc.. attempted to provfde a thorough,
conscientious engineering ana/ysls of the system in accordance wfth ADEC and MOA
DSD Guidelines & R~gutstions. The repen'~d results descnT;ed the I~erformance of the
s),~tsm under the conditions encountered at the lime of the test, and seperation
d/stances measured to rcadi~y ldentifiable features. The operalionaf life of all wells and
septic systems depend on the local soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being serwd by the system.
These conditions are outside the control of the evaluator of the system. ,.~atisfacto/y test
results ~to not guarantee futore performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AWW~, Inc. can therefore not provide
any werran~y or future estimate of how long the system will continue to m~et the
operab'onal r~quirsrnents 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 perty Is not authorized, nor wfll It confer any legal right whatseever.
5. DSD SIGNATURE
Approved for 3 bedrooms.
Disapproved.
Conditional approval for __
Phone 337-6179
Date ' ·
. / /
.. ..
~ .' 0N-SITE .~=
~ . WATER AND .rn-,
b,' ......... ~ : WASTEWATER ~ ~
e~moms, w~m me a[ow~ng sfipu~afions:~ ~ PROG~M ~ ~
.... ..
Attachments: HAA Checklist
Septic System Advisory
Well Flow Advisory
Manitenance Agreements
Supplemental Engineer's Reort
Other
Original Ced/ficate Date: '~ ~" / ~ '~ O/
Municipolity of Anchorege
Development Services Department
On..Slte Water & Wastewater Pn)gmm
47Q0 South Bmgaw St.
HEALTH AUTHORITY APPROVAL CHECKLIST
LegelDescrlptloll: HYI._FN CREST SUBBNISlON ~1~ LOT 11 t BLOCK 2t PamellD:
A. WELL DATA
Od
050-¢72-74
Welltype PUBUC IfA, B, orCpmvldePWSID# --- --- --'W~II~.~...~...~..~)~
Date completed ~Wlms pmpedy protected (Y/N) _
T Cased to ff. Caelng height (above ground) in.
FROM WELL LOG AT INSPECTION
Date of test
Stell~ water level
Well producllon /J
WATER SAMPLE RESULTS:
Collfon~ - colonies/100 mi.
Date of sample: -
SEFTIC/HOLDING TANK DATA
Tank Type/Mateflel STEEL
g.p.m, g.p.m.
Nltrate - mg./L. O~er bacteda - colonies/100 mi.
Collected by: -
TanksIze 1250 gel. NumperofCompertments 2
Foundation deanout (Y/N) YES Depression over tank (Y/N) NO
Date of pumping NEW Pumper
ABSORPTION FIELD DATA
Dete illSte[led 1/22-24,/01
Toteldepth '~-~-sff. Eff.-bsoq~onerea 270 It' Monltodnotube YES
Date of adequacy test NEW Results (Pass/Fall) -
Fluid depth in absof~n ~lb be .f~e test - In. Water added - gal.
Elapsed Time: - min. Finalfluld depth - In. Abeoq~tlon rate
Any mJuvenauon ~a~ment (past t2 mo.) (Y/N & type) N/^
Oatelnelalled 1/22-24/2001
CleaRoute(Y/N) YES
H~hwateralarm(Y/N) YES
SollratlnO(l[p_-,i~Torft'/Ixh, m)2.0 Systemtype BOTI'0MLESS ISF
~ 6 ff. Gravel below pipe 0.36 ff.
Depression over field. NO
For 3 bedrooms
Now depth - In.
- g.p.d.
If yes, give date -
D. UFT STATION
Date Insteffed S~e in gallons ~
'Pump on" level at in. 'Pump . High water alarm level at in.
Da.~_~m Cyclas tested Meets alarm & olrcult requirements?
F- SEPARATION DISTANCES
Septic tank/IB station on lot
Abeoq~on field on lot.
Public eewer main
SEPARATION OISTANCES FROM WFI I ON LOT TO:
On adjacent lots -..-.-~'-
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5% Property line 5'+
Water main 10'+ Water ~endce line. 10'+
Welb on adjacent lots 200'+
N~sorption field,
Surface water.__
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line .5'+
Water sen'Ice llne 10'+
Curteln drain 2o'+
Building foundation 10'+
Surface water 100'+
Wells on adjacent lots, 200'+
Water main 10'+
Driveway, parldng/vehlolestemge 10'+
F, COMMENTS
G. ENGINEERS CERTIFICATION ,~.~.....U~F/~.?~
I certify that I heve deteflnlnnd through field Inspections end
review of Municipal mconfs thet the above systems em In
conformance with MOA HAA guidelines in effect on this date.
Engineer's P~.~ NAme JEFFREY A. GARNESS
Date
Waker Fee $,
Date of Payment,
Receipt Number
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1, GENERAL INFORMATION
Complete legal description
LOT 11; BLOCK 2; HYLEN CREST #1
10225 SILVERTIP CIRCLE
Location (site address or directions)
Property owner
Mailing address
MARK SHOPE
Day phone
SEATTLE~ WASHINGTON
Lending agency
Mailing address
Day phone
Agent CAROL BENNETT FORTUNE PROPERTIES, INC. Day phone 562-7653
3000 A STREET SUITE #101
Address ANCHORAGE.. ALASKA 99503
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ~
TYPE OF WATER SUPPLY:
NOTE:
Individual well ..... j
Community well ~ L~ ~(_--¢/'-<t~\A,~~
Public water Y~ ~~~
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
community on-site
Public sewer
XX
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
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.
Name of Firm
$ & S ENGINEERING
Address 17034 Eaqle River Loo- Re.~ ~,~ ,~n~
Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
/'~ Approved for ~ bedrooms.
Phone
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date
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
Parcel I.D.
Legal Description: ~ \\ ~U.¢-'~
A. WELL DATA
Well type ~(2/~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed Driller
Cased to Casing height
Wires properly protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot '~¢~o ~ ~
Absorption field on lot
Public sewer main
Sewer service line
g.p.m.
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
r'rl i .... Kc
g.pfr~l ._¢ ~ o~
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate Other bacteria
Collected by:
lB. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts ~/N)
High water alarm (y~,,9
Tank size \ OO~> Lc,~-t~ Compartments ~
Foundation cieanout ~¢N) ',~ Depression (Y(~ ~
r~ Alarm tested (Y/N) 6i*
Well(s) on lot
To property line
Surface water/drainage
Date of pumping ~ ..--/..\ ~ c~ I Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
"2~',~' ~ \'~ On adjacent lots
Absorption field
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electric~
S~STANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manufacturer
Manhole/Access (Y/N)
.----'-"~Cycl es tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~'1 -- ~, E> - ~ ~'
Length ~'~' Width
Total absorption area ,~L.
Depression over field (Y~¢'¢'~
Results~---~/fail) I¢,,N~/
Peroxide treatment (past 12 months)
Soil rating I~'~ 4/1~'.
Gravel thickness
Cleanouts present
Date of adequacy test
for -'r"~,.c--~_-~z.~
if yes, give date
System type
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~-'¢~ ~ On adjacent lots
To building foundation
On adjacent lots
Surface water
Property line
To existing or abandoned system on lot
Cutbank ~/,A~ Water main/service line
Driveway, parking/vehicle storage area ~L.
¢.cu rtain drain ~l/),.
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.
Signature
Engineer's Name
Date
S & SENGINEERING
E~cjJe River, Alaska 99577
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
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
264-4720
Application Date c~,~
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
tozz5 stcu6 fiP c/?,
Applicant Name .~1~ Ol14b~ Telephone: Home 6P~-~O~O Business ~-~O~O
ApplicantAddress 7Z? D~O~~ DA, ~P~ ~1~ ~c~?.~'7~
Applicant is (check one): Lending Institution D; Owner/builder ~; Buyer ~; Other ~ (explain);
Telephone
(d) t Lending Institution
Addr,.ess - ·
(e) Real Est~.t~ Com'*p'any andAgent
Address
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-FamilyJ~ Multi-Family []
Number of Bedrooms j3
Other
WATER SUPPLY
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 [] Com~nunity [] 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 72-025 (11/84)
ENGINEERING FIRM P~OVIDIN~ ,NSPEGTIONS, TESTS, FILE S~A~CH, D~... AND INFO~hTION
AS ~e~ifiod by my seal ~ffixed h~mto and os of th~ voli0ation d~te shown below, I wrify that my inwsti~afion of this
A~thority Approval ~hows that th~ on-site w~t~r supply and/or wast~woter disposal system i~ sof~, fun~tionol and adequate
for th~ number of b~drooms an0 type of structure ind~oted herein. I fu~her verify that based on th~ information obtains0
from the ~on[~ipality of An~horoge files ~nd from my inwstigation and inspection, tho on-si~o water ~opply ond/or
wast~water disposal system is in ~omplian~o with ~11 Municipal and 8tot~ ~odos, ordino'n~$, ond regulofion~ in eff~t
the dat~ of this inspection.
Name of Firm ~C~ [~C, Telephone
Date ~ ~
6. DHEP APPROVAL
Approved for ]'"~" ~'~=~: ('~) bedrooms by
~~::t "~ Disapproved
Terms of Conditional Approval
Conditional
Date
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State 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 requirements. 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.
Page 2 of 2
72-o25 {11/84)
MUNICIPALITY OF ANCHORAGE (MOAI
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST ~ FEBRUARY 1984
264-4720
Legal Description:
MUNICIPALITY OF ANCHORAG~
DEPT. OF HEALTH &
ENVIRONMENTAl.. PROTECTION
u 2 5 1986
WELL DATA
Well Log Present (Y/N) Date Completed Yield_
Total Depth __ Cased to ___ Depth of Grouting
Static Water Level ..... Pump Set At////
Casing Height Above Ground o / Sanitary Se, at'on Casing (Y/N) _
Electrical Wiring in Conduit (Y/N) __~/ /1~ D~Around Wellhead (Y/N)
Separation Distances from Well: I ' / , ~ ~
To Septic/Holding Tank on Lot // /" ; On Adjoirdng Lots
To Nearest Edge of Absorption Field on Lot~/ ; On Adjoining Lots
To Nearest Public Sewer Line / To Nearest Public Sewer
Cleanout/Manhole // To Nearest Sewer Service Line on Lot
Water Sample Collected by //' ; Date
Water Sample Test Resu/[~"
Comments //
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes CN)
Depression over Tank (Y,~
Size
Air-tight Caps (~N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well '~
To Property Line / / /
,To Water Main/Se~:vi,ce Line J 0 "' ''''~-
Course "(O 0
Comments
'2..
NO, of Compartments
Foundation Cleanout ~N)
Date Last Pumped
;for /['///~
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
11/
To Stream, Pond, Lake, or Major Drainage
Page.1 of 2 ' ~?
72-026(11184)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~///q/_~:~-
Width of Field L'/~7.-- //
Square Feet of Absorption Area
Depression over Field (Y~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
TO Water Main/Service Line
Type of System Design
Length of Field '-~'~' /
Depth of Field ~P /
Gravel Bed Thickness ~///
Standpipes Present ~N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) /V'/~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Oomments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions /
Man hole/Acces~s-C'/N) _
~/// /Level at ___
1~ / '/'/' Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
/
/
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have.~hecked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~'-') J/~/~~ Date
Company . _ .
Receipt No. ,'~*(~'O ~o
Date of Payment (.o - ~ ~"~ ~*~
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Page 2 of 2
72-026 (11/84)
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA 99501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
DATE:
To Whom it May Concern:
According to records on file in this office the ---~,-'-,, .~
/
~'/D Water System is in compliance with the State Drinking
Water Regulations
Sincerely,