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Home My WebLink AboutTHUNDERBIRD HEIGHTS BLK 3 LT 14Thund rbird H ights Block 3 Lot 14 #051-721-25 MUNICIPALITY OF ANCHORAGE On -Site Water & Wastewater Program PO Box 196650 4700 Elmore Road Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997 http://www.muni.org/onsite On -Site Wastewater Disposal System Permit Permit Number: OSP261149 Work Type: Septic Upgrade Tax Code Number: 05172125000 Site Legal Address: THUNDERBIRD HEIGHTS BLK 3 LT 14 G:1865 Site Mailing Address: 24939 THUNDERBIRD DR, Chugiak Owner: FRANCIONE KYLE Design Engineer: C&M ENGINEERING SERVICES This permit is for the construction of: Effective Date: Expiration Date Lot Size in Sq Ft: Total Bedrooms: cnt II If Departilicnt 6/11/2026 6/11/2027 25083 Non -Public D Disposal Field D Septic Tank ❑ Holding Tank ❑ Privy ❑ Water Well ❑ 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. Coodinate with On -Site staff regarding preferred method. 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 Special Provisions: 1. A test hole is required prior to construction of the absorption field, in the location shown on the site plan, to confirm minimum separation to impermeable soil and seasonal high groundwater, as well as percolation rate. Construction may proceed at your own risk prior to 7 -day groundwater monitoring. If results require a design change, construction shall stop pending approval of a change order. Please submit results with the inspection report (or change order, if required). 2. Show water line on as -built drawings 6 ( 14 17, l Issued To: C&M ENGINEERING SERVICES Issued By: Isatou B Njie Co z.'! 4 t� Ih CM�v f\_ 0a�j ��( fe add6c� Date: 6/11/2026 Date: 6/11/2026 MUNICIPALITY OF ANCHORAGE i Development Services Department _ Phone: 907-343-7904 On -Site Water & Wastewater Section Parcel I.D. 05172125000 Property owner(s) Mailing address ON-SITE SEPTIC/WELL PERMIT APPLICATION FRANCIONE KYLE Site address 24939 THUNDERBIRD DR Legal description Day phone THUNDERBIRD HEIGHTS BLK 3 LT 14 Number of Bedrooms 4 Engineering Firm C&M Engineering Building Permit Number Not Applicable ❑ APPLICATION IS FOR: APPLICATION IS AN: (® all that apply) Disposal Field 0 Initial ❑ Septic Tank 0 Upgrade P Holding Tank ❑ Renewal ❑ Privy ❑ Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A WAIVER REQUEST FOR: Permit/Rush Fees: Date of Payment: Permit No. i `f May 2025 Waiver Fees: Date of Payment: Waiver No. Distance: C&M ENGINEERING SERVICES Ph: 907-8545558 Municipality of Anchorage Onsite Water & Wastewater Program 4700 Elmore Rd Anchorage, Ak 99507 RE: Proposed Septic System for Thunderbird Heights Block 3 lot 14 — Change Order #1 Dear Reviewer, The above referenced property is currently served by an older 4 bedroom system. We are requesting a permit to install a new 4 -bedroom septic system. Our review of available documentation and field investigation show that this project will not adversely impact any nearby Wells, Wastewater disposal systems, replacement disposal sites, or drainage flowing onto and off of the subject property. As shown on the plan, the tank and field will be greater than 10' from the house foundation. The tank will be of MOR approved construction. The tank and field shall be covered with a minimum of 2" moa approved insulation and 3' of cover or a minimum of 4' of cover without insulation. A testhole was excavated on 6/15/2026 and revealed relatively free draining soils and groundwater at a depth of approximately 13' below ground surface. The water level will be monitored and we are proposing to maintain at least 5 -feet of vertical separation from the bottom of the sewer rock to the water level and at least 6 -feet of vertical separation to any impermeable layer. . Due to the free draining nature of the soils, the design has been amended to include a 2' moa filter sand liner below the bottom of the field. The effective depth of the field has been reduced and the length increased accordingly. We request the department approve a change order for this revised design. Upon completion of the installation, a record drawing will be submitted showing the location of the new tank, leach field, well, and other applicable features. Thank you for your time in reviewing this permit request. Please do not hesitate to contact me at 907-854- 5558 or by email cgbalzarini(o)amaii.com with any questions or concerns. Sincerely, Charles Balzarini, PE 4,��.'"�'�"�1j►"\ 6/16/26 CHARLES C BALZARIt°, CE13854 1� ��1Of-E5S14..'"' NOTE: INSTALL ALL COMPONENTS IN ACCORDANCE WITH MUNICIPAL CODE, or— APPROVALS, POLICIES, AND MANUFACTURER'S RECOMMENDATIONS. 0, ko AN ASBUILT SURVEY MUST BE COMPLETED AFTER THE INSTALLATION OF THE 0 ,owo: SEP11C SYSTEM COMPONENTS. TH INSPECT EXISTING LINES FOR DAMAGE, SLUDGE, AND / OR BLOCKAGE t ' ' OBTAIN APPROVAL FROM THE OWNER BEFORE COMMENCING WORK. ANY CHANGES N " ' " 'G . . TO THE APPROVED DESIGN MUST BE APPROVED BY THE OWNER, ENGINEER, AND MOA CHARLES G BALZARINI CE -13854 A THE DESIGN IS SUBJECT TO CHANGE UPON EXCAVATION OF THE PROPOSED TESTHOLE, o GEA AW LEND CLEANOUT PROFESSO�� * * MONITOR TUBE Z TEST HOLE THUNDERBIRD HTS B3 L12 THUNDERBIRD HTS B3 L14 THUNDERBIRD HTS DRIVEWAY B3 L13 5' WIDE DRAINFIED WITH 0.5' EFFECTIVE 2' SAND LINER MAX 9' EX DEPTH 100' TOTAL LENGTH 0 TESTH Z (OPTIONAL) — ABANDON OLD LEACHFIELD IN PLACE, OR CONNECT WITH DIVERTER VALVE FOR FUTURE USE. THE PROPOSED SEPTIC IS GREATER THAN: 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION THE SUBJECT LOT AND NEIGHBORING LOTS ARE SERVED BY PUBLIC WATER SCALE: 1" = 30' MNEW IAND 1250 OWNER:FRANICIONE I DATE: 4/29/261 REV. I DRAWN: -CB REF: MOA POLY TANK W/ INSULATED RISER DOUBLE COs AFTER TANK 1 '27'7-1 1 2' - 3 BEDROOM HOUSE OUSE DECOMISSION OLD SEPTIC TANK PER MOA REQUIREMENTS. ACTUAL CONFIGURATION 10' UNKNOWN nivrRTER VALVE (OPTIONAL) — ABANDON OLD LEACHFIELD IN PLACE, OR CONNECT WITH DIVERTER VALVE FOR FUTURE USE. THE PROPOSED SEPTIC IS GREATER THAN: 100' FROM ANY PRIVATE WELLS 200' FROM ANY PUBLIC WELLS 100' FROM ANY SURFACE WATER 10' TO ANY PROPERTY LINE OR FOUNDATION THE SUBJECT LOT AND NEIGHBORING LOTS ARE SERVED BY PUBLIC WATER SCALE: 1" = 30' C&M ENGINEERING SERVICES 907-854-5558 LEGAL DESCRIPTION: THUNDERBIRD HEIGHTS BLOCK 3 LOT 14 OWNER:FRANICIONE I DATE: 4/29/261 REV. I DRAWN: -CB REF: SITE PLAN NEW C&M ENGINEERING SERVICES 907-854-5558 Septic Design Calculations Residence: Thunderbird Hts B3 L14 number of bedrooms 4 br Water usage/bedroom 150 gpd/br Water Usage 600 gpd Calc By: CGB Date: 6/16/2026 AWiFtfRA lQ, '-CHARLES G BALZARINf -E13854 �. ''''ti system type: Conventional type: trench 1.2 Application Rate required absorption area 500 sqft width (W) 5.000 ft MIN gravel depth (D) 0.5 ft STF 1 Min Required Length: 100.000 ft Groundwater Depth: 13 ft 2026 Th Testhole Depth: 14 ft 2026 Th Max Excavation: SEE PLAN ft REFER TO PLANS FOR DETAILS OF CONSTRUCTION Calc By: CGB Date: 6/16/2026 AWiFtfRA lQ, '-CHARLES G BALZARINf -E13854 �. ''''ti ~ ~ MUNICIPAL,TrOt ANC.ORACE ~. ~,--- ~::)~.~ ~' DE,ARTME.TO~.EA.T.~ENV,RONMENTAL,ROTECTION L.-~-~ ~-' ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 2644720 ~,~,~_.,Z[~.J~¢,.- ~ ' ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ,- [] UPGRADE LEGAL DESCRIPTION LOCATION I NO. OF BEDROOMS DISTANCE TO: ~/~. Manufacturer ~a~...~r.~..' Materia,~l~...~ No. of compartment$~ DISTANCE TO: Well Material Total le~l~ ~.J i~e, Trench~wldth Material beneath tile '~.--~L PERMIT NO. Liquid capacity in gallons PERMIT NO. PERMIT NO. < I- Type of crib Crib diameter Crib depth Total ef fecti~e absorption area uJ Well Building foundation Nearest lot line u~ DISTANCE TO: ~ Class Depth ~ Driller Distance lo lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer hne Septic tank Absorption area(s) OTHER INSTALLER APPROVED DATE LEGAL PERMIT HO. MUNICIPALITY OF Ar`ICHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL.PROTECTION 825 'L' STREET~ ANCHORAGE, AK. ~501 2~4-4720 ON--SITE SEWER PERMIT ( 800102 > I APPLICAIIT O.S.K. CONST. SRA ~105 A-~ PALMER LOCATION THUNDERBIRD DR ~OT l .... LEGAL 4 BLH ~ THUND£RAIRD HITS: LOT SIZE TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH 745-255~ SQUARE FEET MRXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT?BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: DEPTH= ~ LENGTH= $5 GRAVEL DEPTH= 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>. REQU I RED SEPT I C TAr`IK S I :::'E= ::1.250 GALLONS PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTALLATION INSPECTIONS OF ANY WELLS RDJRCENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THRT THE WELL WILL SERVE. TI~IO ( 2 > I NSPE~:;T I Or-IS RRE REQU I RED BRCKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND RPPROVRL BY THIS DEPARTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSRL SYSTEM IS 100 FEET FOR A PRIVRTE WELL OR 150 TO 200 FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC ~IELL. MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS ?5 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. PERMIT - EXPIRES DECEt'IBER :~:l., :L980 I CERTIFY THAT l: I RM 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 THE CODES. 3: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. APP/~IC~IT /~. S. K, CONST. performed for: d'~ ~-~' la ol~c. -,L~-r- /,y' M.D.G.';- 'ENGINEERING /ground Velar ~'~-~ deplh I t')°--- .15- 17- 18' date Ig- ~- . . . · 20' ' · perc. rate '.,~/4.- .-...,-.-~,~,~. m./m. .' between ,_~ ;ornm~ · ~·'~'~,'..,.*"~.~,,.' 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. # C~5 I- '7'7-1- 1. GENERAL INFORMATION legal description Location (site address or directions) Z.4~j ~ "l-~,.~'c~,;,.J ~ "~r~O~. Property owner Mailing address Lending agency Mailing address Agent ~ Address ~ ~1~ Unless othe~ise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~PE OF WATER SUPPLY: NOTE: Day phone Day phone Day phone Individual well Community well 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 H~lding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 5. STATEMENT OF INSPECTION BY ENGINEER Name of Firm ~---~n~<~-~ ~,<.'~,-,~ Address ' ,~<~.~-~ ~ ~--~c. "~. ~>95"~"'+ As certified by my seal affixed hereto and asof the validation date shown below, I verify that my investigation of this Health Authori.ty 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. Phone Engineer's signature DHHS SIGNATURE Approved for Disapproved. bedrooms. Se Conditional approval for Date ...' ~_ ~r '~"v ~ 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. Parcel I.D. it 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 r ' ' Complete legal description ' "",',',',',',','~'~,'/~; ~P'i'~',d Location (si!e ~a.ddress or directions) '"' ','Property 0wne'r; "Matli~g address ,. Lendin'g ag,encz.- Ma~hng address - · Ageht "' ~'' :' Address Day phone Day phone Day phone 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. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site · Public sewer .. NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. . 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 Ea le River En in h,. Address P,O. B~ :7732(~. E,.~,. l?~,e,., AK Engineer's signature ~~"'"'~-" Date ~'~ · I,/ Approved for FO Id/~ bedrooms· Disapproved. __ Conditional approval for 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 courtesyto 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 ts issued. The Municipality of Anchorage is not responsible for errors or omissions In the professional engineer's Work. RECEIVED Municipality of Anchorage JUN 1 5 J99~J~ DEPARTMEN.T OF HEALTH & HUMAN. SERVICES - Environmental Services Divis,on ~aP,,v,.rn, 825 L Street, Room 502 · Anchorage, Alaska 99501 · Health Authority Approval Checklist LegaJDescripfion: -~u,J¢~.~,'~',~ ~/=.,,~T; /-/~ ~'~ ParcelI.D,: ~-J-~.,~ Well type If A, B, or C, attach ADEC letter. ADEC water system number Cased to CaD--bore Sanitary seal (Y/N) ~"~ _ Wirier'properly protected (Y/N) AT INSPECTION Date of test Static water level ~/~ Well production g.p.m, g.p.m. B. SEPTIC/HOLDINGTANK DATA Date installed ~-/~-~'C) Tanksize /ZS',O Number of Coml~,,ents ~. Cteanouts(Y/N) ~-~ Foundation clea~out.(y/N) . ~'~.; Depression (Y/N) /V~J High water alarm (Y/N) -- DateofPu~rll3~l~l":'~'-/~'f~' ': Pumper ~-'~ c. ADSO;t~O. REU~ 0ATA '. '"" ~l~~ Datein~t~ll'e~l'''7-/~: ' Soilrating (g.p.dJfForft=/bdrm) ~ ~"/~-Systemtype Length '.-~",C Width Gravel thickness below pipe ~-?'~ Toteldepth Effective ab$oq:~l~ Da area' ~¥~' ~"~ ~' Monitoring Tubff. present (y/N) ~'~-~ Depression over field (Y/N) -*,.. ~ Date of abequacy test e"-/~-f~' Rasulte(Pass/Fail) /~o.~5 For ~/l~-'z' (~) bedrooms Fluid depth in absorption field before test (in.); ~ Immediately after~'¥/ gel. water added (in.): Fluid depth 7 (ins) Minutes later: .~ Absorption rate = ~ ~ ~ .,c'- g'P'd' Peroxide treatment (past 12 months) (Y/N) If yes, give date . 72-o26 (Rev. Date installed Size In gallons Manhole/Access (Y/N) *Pu .nlp-on~leve ~'~~*Pump off* level at' High water alarm level at* ~- *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: C~'~,~'~,~,/'~'~' Septic~olding tank on lot On adian,~ Absorption field on lot On adjacent lots Public sewer main ~ Public sewer manhole/cleanout S~.e~.~e~ ~ line Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation ~" / Property line ~'/¢:~ ~' Absorption field Water main/sen/ice line P/~ · .Surface water/drainage Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line Surface water Curtain drain H~ Building foundation '/ C/'~ ~~,,--,~ Water main/sewice line 4'/~o · Driveway, parking~hicle storage area ~ /~',A ~ Wells on adjacent lots -/- '2.~,~ / R ENGINEER'S CERTIFICATION · HAA Fee $ ,~ Z~, ~ Receipt Number '~'0 3 (/'776) Waiver Fee $ Date of Payment Receipt Number 72-o26 (Rev. 3/96)* Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescdption: LI415~ T~,~C~.~j~.~, ~1-,~ Pamell. O. 051- '77..t-'Z.s A. Well Data Well type pu~-~(.. ~'q"E~', B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Sanitary seal (Y/N) Date of test Date completed / Driller Cased to J Caslng height ~e~properly protected (Y/N) FROM WELL LO~,x/ I AT INSPECTION Static water level Well flow g.p.m. Pump level1 Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line SEPARATION DISTANCES FROM WELL TO: ,~n adjacent lots ~) ~ ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Nitrate...) h Dateof sample: f -- Collected by: Other bacteria g.p.m. I'-rl B. SEPTIC/HOLDING TANK DATA Date nstalred ,3',.,'t-',, ~ ~)[:',o Tank size 1%$0 Cleanouts (Y/N) ~ Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping 7_. Compartments Depression (Y/N) I',J ~ Alarm tested (Y/N) 7-9~ ~ .~ ~'~ Pumper ~-~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot r4 To property line Sudace water/drainage On adjacent lots , ZcDo' Foundation Absorption field ~' ' Water main/service line * loc)' 72-026 (3,~3)°Fmet CONTINUED ON BACK PAGE C. LIFT STATION Date Installed Size In gallons Vent (Y/N) 'Pump on' level a/t.~ High water alarm level tJ Meets MOA electrical codes (Y/N)~ SEPARATION DISTANCE~FROM LIFT STATION TO: Well on lot On adjacent lots ~s 'Pump off'Levelat Cycles tested Surface water D. ABSORPTION FIELD DATA Date installed ~-uL~ Length. ~,<;/ Width Total absorptlo~ area 5 4o ~: Date of adequacy test '7- 90- 9-5 Water le,~el in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) Gravel thid~ess 7_ Cleanout present (Y/N) Results (pas~a~) 4 O- SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot /"J P~ To bullding foundation~- IO° On adjacent lots 4. Ioo/ Surface waler -t--t oo' Curtain drain +5o' System~pe Total depth 7 Depression over field (Y/N) ~,,~s s for Nter test 0 - If yes, give date Bedrooms On adjacent lots '+Z~ / Property line 4- Z~" To existing or abandoned system on lot Cutbank .~lt:~ ' Water main/service line Driveway, parking'vehicle storage area ~-/["' E. ENGINEER'S CERTIFICATION I cern'fy ~at I have checked, vedtied, or conformed to all MOA and HAA guidelines Signature Engineer's Name Date HAA Fee $ /~CO O0 Date of Payment ~- ~7/'~ ¢--~ - Receipt Number C>~/.~ ~/0~ 72-028 (3'1)3)° Waiver Fee $ Date of Payment Receipt Number TIME INSPECTION APPOINTMENTS TIME DATE RECEIVED TIME DATE DATE DATE INSPECTOR INSPECTOR INSPECTOR MUNICIPALITY OF ANCHOr~A~ ULFI. OF h~U. TH & MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION j. DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825LStr.t-Anchoraee, Ala~k, 99501 OCT 2 1 ~0. ENVIRONMENTAL SANITATION DlVlSlONTelephone 264-4720 RECEI.V. ED. REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts Der page 1. Incomplete reques~ will not be processed. Please allow ten (10) days for processing. PHONE MAILING ADDRESS PROPERTY RESIDENT (if different from above) PHONE MAILING ADDRESS /~.~7---~ ~ ~ ~ 4. REALTOR/AGENT MAILING ADDRESS PHONE PHONE 5. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE ~ SINGLE FAMILY I--I MULTIPLE FAMILY 7. WATER SUPPLY i'--I INDIVIDUAL' 15~ COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM ~ INDIVIDUAL/ON-SITE** I--I PUBLIC UTILITY N~M~ER GE~EDROOMS I'-I One i'-I Four [] Other [] Two [] Five [~ Three [] Six ATTACH WELL LOG. A well log is required for all wells drilled since ,June 1975. For wells drilled prior to that date, give well depth (attach log if available.) /~...1 YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010 (Rev. 6/79) 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY .THIS SIDE FOR OFFICIAL USE ONLY . , . NUMBER OF BEDROOMS [] ONE I-1 THREE [] FIVE [] TWO [] FOUR [] SIX [] OTHER WATER SUPPLY I-'1 INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM I-'IINDIVIDUAL/0N -SITE []PUBLIC UTILITY Connection Verified F'-ISeptic Tank or r-]Holding Tank Size: give dimensions: TYPE OF TANK PERMIT NUMBER DATEINSTALLED INSTALLER IfTankishomemade $OILS RATING MANUFACTURER TOTAL ABSORPTION AREA 4. DISTANCES WELLTO: Absorption Area to nearest Lot Line 5. _COMMENTS MATERIAL Sept,cJHotding Tank IAP$olption Area ISewer Line · I Nearest Lot Line DATE [~PPROVED FOR ,.'~ BEDROOMS I'"1 CONDITIONAL APPROVAL (letter must accompany certificate) t-"l DISAPPROVEDJBY /~ 72.010 (Rev. 6/79) Parcel I.D. O~/- ?-.'~-/- ~ 1. GENERAL INFORMATION Complete legal description Municipality of Anchorage o Development Services Department Building Safety Division On-Site Water and Wastewater Program · 4700 South Bragaw SL A P.O. Box 196650 Anchorage. AK 99519-6650 ~<1~-,,,,,,, www.ci.anchorage.ak.us I It i ~ ~ ,~ '"',,J CERTIFICATE OF HEALTH AUTHORITY APPR(~JJAL "~ FOR A SINGLE FAMILY DWELLING.= Expiration Date: / / ~ ~-'- Location (site address or directions) Current Property owner(s) Mailing address Lending agency Day phone Day phone Mailing address Real Estate Agent Day phone ~ ~ ~-¢~/',' Mailing Address .,4,.-~.,/-.,,,-.~.)-,._ . Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: /'-/ 3. TYPE OF WATER SUPPLY: Individual Well Individual Water Storage Community Class Public Water System Well TYPE OF WASTEWATER DISPOSAL: E]~ Individual On-site Individual Holding tank u [] 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 ere required for the transfer of title (except bet~,veen 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 old. (Certificates may be reissued for a period of up to one year with valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based on procedures out~ined in the Health Authority Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of bedrooms and type of structure indicated herein, I further verity that based on the information obtained from the Municipality of Anchorage flies and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name or Firm ~..a~]e ]:~.J.?c~' ~.~z,--~[ucex;,,,~ ~e- -_A_ Phone Address P.O. Bo~ 2732o~, E,~{~ R,,~. A E oe,=;7-/.~?~ $ Engineer's Pdnted Name /-.-~,,.,,~ ,.C.-A..,~ Date 5. DSD SIGNATURE Approved for L.~ Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Sox 196650 Anchorage, AK 995'19-6650 www.ci.anchorage.ak.us (907) 343-7904 HEALTH AUTHORITY APPROVAL CHECKLIST Parcel ID: ~5'-/- WELL DATA /~,//~ /~,~.~,~. ~,,~,.. Well type ~ If A. B, or C provide PWSID # Date compte~d Sanitary seal (Y/N) Total depth'.,~__fl. Cased to ~ft~ FROM WELL LOG Date of test ~ Static water level ~ ft. Well production ~ g.p.m. WATER SAMPLE RESULTS~ ~,t~or(~sa_~ple.' celonies/,00~L ;J~tec~edby: mg./I. Well Log (Y/N) Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION In. g.p.m. Other bacteria colonies/100 mi. B. SEPTIC/HOLDING TANK DATA Tank Type/Material .~ V-~ / Tank size ,/2 5'-~ gal. Number of Compartments Foundation cleanout (Y/N) ~' 'Depression over tank (Y/N) Date of pumping /4'- '~ - 4, ~_ Pumper :3"~ ~- Date installed '~- Cleanouts (Y/N) High water alarm (Y/N) ABSORPTION FIELD DATA Date installed '7-/%P,-, Soil rating Length ~c'5- Total depth 5~. & ft. Date of adequacy test Fluid depth in absorption field before test Elapsed Time: ~P min. ft. Width 2~" '~. Eft. absorption area ~. '/4t2 Monitoring tuba __ Io - I,~- ~-3.- Results(Pass/Fail) O in. Water added ~o~ gal. System type Tr~',~l Gravel below pipe c,~ ft. Depression over field ~ For z~' bedrooms New depth /"/ in. o'"~,~ g.p.d. Final fluid depth ,~ in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (YIN & type) ,,~,~ If yes. give date D. LIFT STATION Date installed 'Pump on~4~'~ in. D~dm Size in gallons "Pum~ in. Cycles tested Manhole/Acce.~.~_/ High ~t~rm level at Meets alarm & circuit requirements? in. E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic tank/lift station on lot /~'/~ Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots ,'~"/~' On adjacent lots ~'/~' Public sewer manhole/cteanout Holding tank .,~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation Water main Property line 2,~ ' Absorption field ~'~'~'. Water service line ,' ,,-," Surface water ;/,'~' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~ o ' Water Service line Building foundation -' ~ ' Water main ~' ~ ' Surface water ~' t= ~, · Driveway, parking/vehicle storage Curtain drain Wells on adjacent lots *,~,~ ' F. COMMENTS G. ENGINEER'S CERTIFICATION I certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Printed Name ,~',,..;' ~P~ ~'-- ,. Waiver Fee $ Date of Payment HAA Fee $ ~_~g .~o Date o¢ Payment t~I ~ ~ ,~"~. Receipt Number ~.:~ 67~ ~p~. (Rev. 12/00) Receipt Number