HomeMy WebLinkAboutSAMPSON ESTATES BLK 3 LT 14Sampson
Block 3
Lot 14
#051-811-40
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
www.d.anchorage.ak.us (907)343.7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
U
Ira II:
Page of
Permit Number: SW010124
Name:
DUANE ROMBERG
Aden:
P.O. BOX 670036 CHUGIAK. AK. 99567
Phone: Number of Bedroans:
(907) 688-9797 3
LEGAL DESCRIPTION
Block L01: $ubdmeian:
3 14
iownehp: Range: Section:
SAMPSON SID
Well: 0 New
Classmutcn (Prrvwe. A. B. C):
0 Upgrad-
Twl Depth: Cased to:
Ft. Ft.
PID Number: 051.811-40
Wastewater System: 0 New ® Upgrade
ABSORPTION FIELD
0 Deep Trench IS Shallow Trench 0 Bed 0 Mound 0 Other.
Sol Rang:
0.8 GPOSI'
Depth to pipe bottom tan original grade:
1.34 Ft.
Fla added above aginl grade:
1.7. 1.4 Ft.
Total Depth kom original grade:
2
Gravel depth beneath ppe:
0.65
120
Gravel Length:
Gravel *CM: Number 01 blies
5
TOMO absaptan area:
Omer: ,r. Date Droned: Mahe Water Level: tistalier:
Ft. RPC
Yea:
GPM I Pump Set at:
F1. munI Cap heogh1 Above Grated:
Ft.
600
SEPARATION DISTANCES ® Septic 0 Holding
7o Septic Absorption Lin Holding PubIi JPrivate Mamrlaclw°`.
From Tank Field Station Tank SewerLlne Anchorage Tank
100'+ 100'+ NA NA 25+ ten:
W°' Steel
Surface Water 100'+ 100'+ NA NA
Lot Line 5+ 10'+ NA NA
Foundation 5'+ 104 NA NA
cutar orale NA *501+ NA NA
Remarks:
*EXISTING SEPTIC TANK AND FIELD WERE ABANDONED
Inspections performed by: KND Engineering, Inc.
Development Services
Reviewed and approved by:
(Rem. 11100)
Sae.
Pump on level M.
Pwnp Make & Model
Ft. 2
Pipe "tetanal:
Fr D3034 & F810
Date Installed:
FI.
Ft.
Ft.
Distance between Lows:
10+ FI.
6/12/2001
TANK
0 S.T.E.P.
LIFT STATION
Manulaauer.
Gel
Pump oil level at
Location and Descnptan:
BOTTOM OF SIDING
0 Other.
Capacity.
1000 Gal.
Number of Compartments:
2
Hrgh water Merm at:
In
ElecUaal Inapedan° p&caned by
BENCH MARK
Dates: 1°1 6/11/2001
ed 6/12/2001
Department A proval 7"�I%l/Ft
aZZ 'Coq /0-'6-02
in.
Assumed Llevalan.
100 FL
Engineers Stamp
vitro ° OF ...... it
II 5 es
%*+ 4 ea�9,1I
�e N° • •yeweweea emo e/
i rri• Kenneth M. Du
s% CE7116 ta�%
KND
AS -BUILT SYSTEM DETAILS/SITE PLAN PERMIT# SW010124
SAMPSON S/D, BLOCK 3, LOT 14 PID# 051-811-40
1J
1NG TMtC CIP
000 GAL
SEPTIC TANK
EXISTING 3
DDRII NOUSE
1 1
1
� K'
A -C= 26.7'
B -C= 51.4'
A -D= 32.8'
B -D= 58.1'
A-E= 57.6'
B-E= 78.2'
A -F= 58.8'
B -F= 68.4'
A -G= 73.0'
B -G= 99.7'
A -H= 85.6' SCALE. NTS
B -H=107.4'
A -I=79.0'
B -I=74.2'
ND 01
O
C90.00D
oar, IOC= nar
FINAL GRADE
MUAis
Mite Par
SCALE. 1' = 50'
SEWER ROCK
TRENCH 1 ll
89,4 89.3 1
li-iIL.IMIMIMIMI,,; Ir y�• .,r ... .,. ,I` �. 4,0 d
,onm TIDE
ap.2 FINAL GRADE
v4"-9310 `
d
rm'm' n •I, ., .SlNlta E -.IF -114+11
rammer /MLLATY
IL SEWER ROCK
T X87.6 TRENCH 2 C „7. 1
I ,ty)kyICiICIp.L� 011--.11--1n--11MIe�IC11
700d'
C77.6t'
PREPARED FOR!
DUANE ROMBERG
PO BOX 670036
CHUGIAK, AK 99567
(907) 688-9797
FIELD BOOKS
°01"x"" SHADRACH
"'an SHADRACH
Ate" SHADRACH
DIG. /ILL:
AO10 FU` 01015.DWG
COMPVIIIt
CRAM vBG
"Gat KMD
DATE 7/2/01
au NW1560
10B "I 01015
SCALE'ALNTS
IK D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)896-8111/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
Permit Number: SW010124
Legal Description: 'SAMPSON ESTATES BLK 3 LT 14
Design Engineer: 0070 KND Engineering
Owner Name: DUANE ROMBERG
Owner Address: 22533 SARAH CIRCLE
CHUGIAK , AK 99567-
pr`n 4:5orm
,..to 0/f Z 3 r'
Date Issued: May 22, 2001
Expiration Date: May 22, 2002
Parcel ID: 051-811-40
Site Address: 022533 SARAH CIR
Lot Size: 40220 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
❑� Disposal Field Q Septic Tank O Holding Tank ❑ Privy 0 Private Well 0 Water Storage
All construction must be In accordance with:
1. The attached approved design.
2. All requirements specified in Anchorage Municipal Code Chapters 15.55 and 15.65 and the State of Alaska
Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ).
3. The 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:
Issued By:
Date: S/oQI
Date: ,S` — 2 7 —0/
Parcel I.D. 051.811.40
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
0
Permit Number SW 010124
Property owner(s) Duane Romberg Day phone 688-9797
Mailing address (1) PO Box 670036. Chugiak, AK 99567
71
sahrtatttng address (2) 22 5-33 SARAH CIRCLE Zip Code
Legal description (Lot, Block & Sub'd.) Sampson Estates B3, L14
Legal description (Section, Township & Range)
Lot Size4 01 Z 20Acres/ . q.F Number of Bedrooms 3
THIS APPLICATION IS FOR:
Sewer Only 0 Well Only 0
Sewer and Well 0 Water Storage 0
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub 0 Jacuzzi ❑
Swimming Pool 0 Water Softening Unit 0
Therapy Pool 0
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:
Receipt Number:
Revival)
V32-0
es/034/
302,1
Waiver Fees:
Date of Payment:
Receipt Number:
•
IKN]D ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(i
(907)696-6111/FAX (907)696-8111
May 2, 2001
Municipality of Anchorage
Development Services Department
On -Site Water & Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject: Sewer Upgrade — Sampson SID, Block 3, Lot 14
Gentlemen:
The owner has requested we proceed forward to obtain a septic permit to upgrade and
replace the existing septic system and tank for the subject lot. The existing septic tank
will be abandoned in place and in accordance with municipal standards. On April 12,
2001 we dug one testhole for the proposed system. The result of this test is attached.
The general slope of this lot is from south to north at a grade of approximately 5 — 8%.
We have designed our system utilizing the testhole we excavated for the 3 -bedroom
house. The lot is served by an individual well. We propose to install two 5' wide
shallow trenches. Water was not encountered during the excavation, but after
monitoring water was observed at a depth of 6.0'.
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,
END Engineering
enneth M. Duffus, P.E.
Attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WELL & WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN
SAMPSON S/D, BLOCK 3, LOT 14
IC PUNIC WELLS WITHIN tW Or
PRIED SYSTEM.
NO PRIVATE YELLS VETCH tW Cr
PROPOSED SYSTEM EXCVT At AUTOS
IC SEPTIC SYSTEMS VTTOM pW' Ol
PROPOSED VW. EXCEPT AS OUTER
DESIGN DETAILS
3 BDRM X 150 GPD = 450 GPD
450 GPD/0.8 GPD PER SQ. FT. (5.33 MIN/IN.)= 563 SQ. FT
(563/5'(W)) (0.5' DEEP)= 112.6 FT. TRENCH
USE 2 TRENCHES - 1ST 57' (L) X 5' (W) X 0.5' 0)
- 2ND 57' (L) X 5' (W) X 0.5' 0)
Total depth of system Is 2.0' from original grade.
Total depth of gravel below distribution pipe Is 0.5'.
NOTES'
1. USE 1000 GAL. SEPTIC TANK. INSULATE IF <4' OF COVER.
2. INSULATE TRENCH VITH r HD BURIAL FOAM.
3. CONTRACTOR WILL ENSURE MINIMUM 2X SLOPE INTO SEPTIC TANK.
4. ADDITIONAL FILL WILL BE ADDED OVER SYSTEM TO ACHIEVE
MIN. 3' COVER IF REQUIRED.
5. CONTRACTOR WILL ENSURE ALL SEPARATIONS TO ADJACENT
WELLS IL SEPTICS.
PREPARED FOR:
DUANE ROMBERG
PO BOX 670036
CHUGIAK, AK 99567
(907) 688-9797
nal) BOOKS
man" SHADRACH
NO" SHADRACH
"at SHADRACH
OM 111:
carom
DRAMA VBG
CHECKED: KMD
pAIO 5/2/01
auk NW1560
ACJD ^2' 01015.DWG '108 M>: 01015
Scale' 1'= 100'
}�
PAGE 1 OF 2
PEND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
WASTEWATER DISP❑SAL SYSTEM DETAILS
SAMPSON S/D, BLOCK 3, LOT 14
L
KND
ISTING SYSTE
cn
D
ECU
EXISTING 3
CO
MT
P❑P❑SEL
CO 5
T
CO
PRIMARY SY TEM
MT
"cC❑
SPLITTER
cn
co
TH# ND 01
PROPOSED 1000 GAL.
SEPTIC TANK
PREPARED FORK
DUANE ROMBERG
PO BOX 670036
CHUGIAK, AK 99567
(907) 688-9797
FIELD BOOKS COYPU
"'cum SHADRACH °RAM'° VBG
°A1O1* SHADRACH *clam 10M0
A911D SHADRACH pAm 5/2/01
DWI It[: °e° NW1560
AOAD FILE 01015.DWG 'p° Ru 01015
Scale' 1'= 20'
PAGE 2 OF 2
IEND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
(907)696-6111/FAX (907)696-8111
KND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
1
Performed for.
Project:
Depth
(Feet)
SOILS PERCOLATION TEST
Duane Romberg
Sampson S/D, B3, L14
1- -ry Org— red/brown overburden
13-
14-
15-
16-
17-
18-
19-
20 -
GM/SM— gray, sandy gravel, w/
silt and cobbles to 1'
dry, mod. dense—silt &
density increasing
w/ depth
THOLE PRESOAKED
PRIOR TO TEST
1
'�f; �F AC•4�I1
•
�9. MM {ii �•
E.14•00 Ct e
I,r^N :Kom'CC 7116 J '•€.'%
Date Performed: 4/12/01
TEST HOLE # 2001-01
SEE ATTACHED SITE PLAN
FOR HOLE LOCATION
Was Ground water encountered? NO
Depth to water after monitoring? 6.0'
Reading Date Gross Net
Time Time
1 4/12/01 1:00
2 1:30 30 min
3 • 1:31
4 2:01 30 min
5 • 2:02
6 2:32 30 min
•
Water Added
What depth? NA}
Date? 4/19/01 /5/y
Depth to Net
Water Drop
8" -
26/16" 510/16"
26/16" 510/16"
8"
26/16" 510/16"
Percolation Rate 5.33 (min/in) Perc Hole Diameter 6"
Test Run Between 2.5 feet and 3.5 feet
I, Kenneth M. Duffus, certify that this test was performed in accordance with all State and Municipal guidelines in
effect on this date.
72-013 (Rev. 3/78)
•Tho
(1 /
//
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
1?-.\/ ANI
OP -F
PHONE
J2iNEL
' LJ UPGRADE
MAILING ADDRE-) S CI E
'J 6(67/A 'e,i/V.6 — '/2-434--7:42-i3 (C/(2) 4`-�
LEGAL DESCRIPTION C ��
Lam- i /3L < 3 .� .s-el;,; 4 C
LOCATION
_P61612 -c c--2 �� .
NO. OF BEDROOMS
3
SEPTIC
TANK
DISTANCE TO:
Well
/t"..�[�
Absorption areal
/tl
`,
Dwelling A/4
PERMIT_ALO �j
-d 1/ 3:3rf
Manufacturer
0 2.e--
I2_
Material
s -f >
No. of compartments
2
Liq. apaci y/ i gallons
(iJc6
IF HOMEMADE:
Inside length -- -
Width �.y...a---
Liquid depth
-10 z
O z G
2 -I-
DISTANCE TO:
Well �. /
�/
Dwelling
PERMIT NO.
Manufacturer
l
Material
Liquid capacity in gallons
TILE
DRAINFIELD
TRENCH
DISTANCE TO:
Well
F undation
Nearest lot line
PERMIT NO.
No. of lines
Length of each line
otal length of lines
Trench width
inches
Distance between lines
Top of tile to finish grade
aterial beneath tile
inches
Total effective absorption area
SEEPAGE
uin
Length .---'}/ .'.
Width 27 /
D!tt ,O 6, e, ..s,/z, c /o
PERMIT/ �(S 3, 7
'-`/4� /
Type of crib
Crib diameter
.—
Crib depth
�-
Total effective absorpti,9n
./'',.5
area
0
DISTANCE TO:
Well /tale %
J
Building foul ikin
j`
Nearest lot line 7,:s---...
J
/.--
W
Class E
De
Driller
Distance to lot line
PERMIT NO.
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area (s)
OTHER
PIPE MATERIALS
ABS' 1•-PY
SOIL TEST RATING
Z. eg -- `3q=-1'4/19 2 .4),T
iAm_11�
-'"
,Yea
'
.
INST F>�LER
III
11
REMS Y / /1 INSW-P -6 .-
11■■li■iiil■■f�■I
E
■■■
.111
111111111
111111
aNct" ft.., -4
numallim
IIIIIIISSICI
emiNrs
EN
EEO
. , 4
..i• -s ,......0÷-1,
..„.4.,.. , A
IIIIUht11IIIII
rt v'.,'� !Wort A. Sireforr rty
am•••.g'..:ISxg, et.• 00-
APPROVED 8, e tr tTO1'4_V+'rtlt DAT / LEGAL . (G/G/Ye� �
srii ,ll r1
Myr, SRNa, :scat t w.. ;, �� K 1
_
lr
„4 , /Tl
72-013 (Rev. 3/78)
PERMIT NO:
DATE ISSUED:
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
,
tai Ir -4 I C: 1 F° IL_ I lr Nr° F',= 1* -4 C: CI F: FRI C7ifE
DEPARTMENT -OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK 99501
264-4720
a Is awa w t_ F. a Fcm
840327
05/11/84
BRYANeR@FF ROFF
% S&S ENGINEERING
EAGLE RIVER, AK 99577
694-2q7q
SUBDIVISION: SAMPSON gatkleho
SECTION: 3 TOWNSHIP: 15N RANGE: 1W
40500 (SQ. FT. OR ACRES)
LOT: 14 BLOCK: 3
LISTED --BELOW ARE THE OPTIONS AVAILABLE TO YOU IN DESIGNING
SYSTEW CHOOSE THE OPTION THAT BEST FITS YOUR SITE
DEPTH TO PIPE BOTTOM (FT.
GRAVEL DEPTH (FT. )
TOTAL -DEPTH (FT. )
GRAVEL WIDTH (FT.
GRAVEL LENGTH (FT. )
GRAVEL VOLUME (CU. YDS. )
TANK 'SIZE (GALS)
SOIL RATING (SQ. FT. /BR)
17FR: EEI-4
4. A
7.0
7. 0
175. 0
• 56. 7
1, 000. 0
349
**
** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
VOUR
SEPTIC
EcE),
4. 0
0. 5
4. 5.
(
50.
4.
1. 00 0
284
**
I -J. CAF:F1 r-1
4.0
7;
7.0
5. A
123. 0
79.7
1.. 000. 0
349
**:
*
RUNS (NOT EXCEEDING 75 FT. EACH)
I 'CERTIFY THAT:
1. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MIA) AND THE STATE OF ALASKA.
2. I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS,
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
2. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT.
4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 3 BEDROOMS AND
ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN '.1) AN 'ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED
APPLICANT:
-ISSUED-BY-
1.1,4,td DATE: .6/1447/
DATE:
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
Z an Aq14
/0,5-414J ,
SLOPE
COMMENTS
PERFORMED BY:
72-008 (6/79)
SOILS LOG
PERCOLATION
TEST
DATE PERFORMED: `T
SITE PLAN
L
3
WAS GROUND WATER
ENCOUNTERED?
0
1F YES, AT WHAT
DEPTH?
P
E
s
T7
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
t5=-144.-/
/,�_5
2 of t (
—
2
81
2) 25
go1/J
t i
3 ,4 "
3
``
2531
to G(
414
/"3
a. /56
/0 ,.?
6 '/,
71,,
PERCOLATION RATE
TEST RUN BETWEEN
FT AND
(minutes/inch)
FT
DuRbiNflLiq Co.
Mile 1.2, Lucas Road
P.O. Box 871348
Wasilla, Alaska 99687
(907) 376-2305
Name: -..„, r ,' r : • :true f.:,'i sY!'
Address: , . ,r. '1, '':. : ; ,•-i- 'f:-.'
City: '. f:.1. _! :, :', ... ' -.,:y- , y
Phone: -f.?;7r
Jobif .t j , ;;•i ,-q:",7. 5-;Cri ',.::11-',;':,,
Location: - ' ' ry - " -
. ;.y. .... ..... t (.“
Crew,
Date* :''''::Q1 '
Notes.
-(' :., s: '..''''. '1:,±)..1:-.1,n "A, , .i.11(:•1 :.,. ''.:I.;.
i'._i cif -1.1
.',.., tr i-. 1 C I', • L i'' J. v 03. : 1.5'; f' i.... -
,:c..::):;! ,:-.!.1,.-.6 .,.. '..,,.?t•'(. LII::: 1 ', 4
Depth
Well Log
..._
l'..i.'4:"'•,,I0i
',,,-- i• 0
.
H.
) A
\
1
MUNICIPALITY OF ANCHORAGE 1
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
ApplicationDate t 2e -I
/9v
1, GENERAL INFORMATION
(a) Legal !ascription (include lot, block, subdivision, fiction, township, range)
Locatio (address or directions)
(b) Applicant Name Telephone: Home‘ ---FX-- 73-4 7 Business
Applicant Address SOOD a4Z 4 7
(c) Applicant is (check one): Lending Institution /builder K Buyer 0 ; Other 0 (explain);
(d) Lending Institution
Address
Telephone
(e) Real Estate Company and Agent
(f)
Address
0,- ,
T'lephr,ne
,/
v.011"."- th
AA to the following address:
/ 9Q%�
'.� ,99577
69'-977
2. TYPE OF RESIDENCE
Single -Family 57K Multi -Family ❑ Other
Number of Bedrooms -3
3. WATER SUPPLY
Individual Well I$ Community 0 Public 0
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 0 Community 0 Holding Tank
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11/64)
Page 1 of 2
5. ENGINEERING FIRM PROVIDING .SPECTIONS, TESTS, FILE SEARCH, DA -I. ;ND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm
Address
Date
61113 '6we.s
,,4Ef1,V11.-60PqLA�S�tt
RE2)SF:T,,,
Telephone
6. DHEP APPROVAL •ry
Approved for edrooms by 115.....,
Approved
,yaep�pepp P
i � 0p
apo 9 y�
IT
I 6
--°°""rd of
'wbart A. Shaw a 45'
No. 1457-
e.
457-. *0. eap9e(,N
Disapproved Conditional
Terms of Conditional Approval
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
72-025 (11/84)
A. WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE
DEPT. Of HEALTH &
ENVIRONMENTAL PROTECTION;
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) NOV 0 4 NO
CHECKLIST - FEBRUARY 1984
264-4720
R€C,f1VED
Legal Description �: )` -,
/tcv"l'� Sem.-CAT
If A, B, C, D.E.C. Approved (Y/N)
Well Log PresentON) Date Completed -' t - 8`T
Yield Zo APi'1
Total Depth I, O3 Cased to 1 'Q Depth of Grouting
Static Water Level t S2` Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit ?N) Depression Around Wellhead (YAP
Separation Distances from Well:
To Septic/toldirrg Tank on Lot (� ; On Adjoining Lots
I
Ze7.
Sanitary Seal on Casing (?N)
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line To Nearest Public Sewer
�Cleanout/Manhole A
; On Adjoining Lots
To Nearest Sewer Service Line on Lot
Water Sample Collected by �t^� `�` ; Date
Water Sample Test Results
Comments
B. SEPTIC1.I#9kBtNG TANK DATA
Date Installed S- 2-4e- 134SizeNo. of Compartments
Standpipes' N) Air -tight Caps (DJ)
Depression over Tank (Y/1
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High -Water Alarm (Y/N)
Ni
Foundation CleanoutN)
Date Last Pumped t•--
; for
;for
Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Mel-di-mg Tank:
t
To Water -Supply Well o (A - To Building Foundation j
To Property Line 1 k- To Disposal Field
To Water Main/Service Line i Lot To Stream, Pond, Lake, or Major Drainage
Course P
Comments A- •s:5----A---c- C ... --.1s1-&->.. V1/41t - —r 05� ,
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
2-7 '
Type of System Design ;.7
)
Length of Field
Depth of Field 6 �JL_A)
Gravel Bed Thickness toM
Square Feet of Absorption Area Standpipes Present (N)
Depression over Field (Y/. I) Date of Last Adequacy Test
r -S
Results of Last Adequacy Test
Separation Distance from Absorption Field:
i
To Water -Supply Well 1 60 fi' To Property Line 1 D
To Building Foundation 35 To Existing or Abandoned System on
1,3
Lot A ; On Adjoining Lots �`� '
To Water Main/Service Line 1 b -� To Cutpank (if present)
To Stream/Pond/Lake/or Major Drainage Course
4
To Driveway, Parking Area, or Vehicle Storage Area I
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Access (Y/N)
"Pump On" Level at I "Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that 1,0,4ye,-Ch.e-gMcloie,rffigd, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Si ned ° 110 194 r.,._., //-/'- s�
g ti'1e�s,IALfaWt. ��_le Date Pb �,it
is ty g4 gS-6 b � F�
Company ,�h3� a �` MOA No. ' !)
Receipt No. S 9 $ (D%
Date of Payment /1- 4
Amount: $
Page 2 of 2
72-026 (11/84)
r,s=Seal^"
:- boy i A. 5hahle
No, 14:574i
e°
PiT'ori.S.