HomeMy WebLinkAboutBREITZMAN LT 3Brel*tzman
Lot 3
#015-231-79
Municipality of Anchorage Page i of 3
Development Services Department
OnSite Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW020126 PID Number: 015-231-79
Name:
Jeanne Bierlien Wastewater System: New ®Upgrade
Address:
11900 Hillside Drive Anch., AK 99516 ABSORPTION FIELD
Phare: NumberofBedrooms: Advantex Treatment System AX20 Mode 1A with Pod
244-1921 Four (4)
Sal Ratmg: Total Depth from original grade:
LEGAL DESCRIPTION 6 GPa'Ftr 4 Ff.
Block: Lot: subdivision: A; rG i tLznA ^ Depth to pope bottom hom original grade: Gravel depth beneath pope:
3 Bft4i-z ►a n 3 Ft. .5 Ft.
Township: Flange: section: Fp added above original grade: Gravel Length:
.5 Ft. 20 Ft.
Gravel width: Number of lines: Distance between Ines:
Well: Existing 10 Ft. 3 3 Ft.
Classofication (Private. A, B. C): Total Depth: cased! lo: Total absorption area: Pte Matowl:
Private Fl. Ft. 200 Fir ASTM D3034 PVC
Dnkx: Date Drilled: static Water Level: Installer. Date Installed:
Ft. Acreage Systems 6/18/02
Yield: (Pump set at: I Casmg P eight Above Ground: TANK
GPM Ft. Ft
SEPARATION DISTANCES STEP Tank (Advantex)
To Septic Absorption Lift Holding 'ubiic/Private Manuladurer; Capaoty in Gallons:
From Tank Field Station Tank Sewer line Anchorage Tank 19500
Material: Number of compartments:
Wel >100' >100' >100' N/A >25'
Steel Three (3)
Surface Water >100' >100' >100' N/A LIFT STATION
Site. Manutadurw:
Lake >5' >10' >10' N/A250 GaI. Anchorage Tank
'Pump ori level at; 'Pump off level at:Wgh water aarm at:
Foundation >5' >10' >10' N/A ,^ 1111152m.
None Noted Pump Make d Madel Elecmcal Inspedrau performed by
Curtain Dram Orenco Municipality of Anchorage
Remarks: BENCH MARK
Existing Septic Tank Abandoned. Septic Tank
Location and De pl.on:
Pumped, Crushed and Backfilled On Site. Existing West Edge of Sidewalk at Back Door (North Side of
Absorption Bed Abandoned in Place. Gravity Flow House)
Assumed Elevation:
From Pod to Absorption Bed. 100.0 Ft.
EngiOeers Stamp
OF
F�Cl) •. i I,a
Inspections performed by: MEA Dates: 1s' 6/18/02
MICHAEL E. ANDER=4 w t�
2nd 6/18/02 0 s :. CE-4381 •: \ ty
Department of Health and Human Services approval ��`cr��E'•..aa...••'•
Reviewed and approved by: �//,�'`1 Date: Zlglv3 md XOFESSV'� —
(Rw. 10,99)
M
Municipality of Anchorage
3PMENT SERVICES DEPARTMENT
r Street Anchorage. SystemAK 99519-6650
951 Well 343
.water Disposal
PID 1
26
330.00'
10' X 29' ABSORPTION S 89'56'49"E
BED �� t w t ML- ESMT- ] _ _ , - -- - - -
o
0
0
1
• I
M i
S r
• 1
I "OTE: NO CONFLICTS V'" WEBS OR
Yf
1 SEPTIC SYSTEMS 18 THE AREA
S1 20.1
MH 29.7 19.5
C2 26.5 25.9
M7 27.1 39.3
M2 20.2 21.8
C3 25.9 26.5
C4 19.2 34.8
S 89'58'49'E 330-00'
PLAN AS -B U 11
SCALE V = 30'
it LU
t�I mom'
o
DRNE
� f w Z GRAVEL
o
LOT
;. CMK
C)
I
A B
a+
111 itHt31{Iftllt
__
_ I '113
o
0
0
1
• I
M i
S r
• 1
I "OTE: NO CONFLICTS V'" WEBS OR
Yf
1 SEPTIC SYSTEMS 18 THE AREA
S1 20.1
MH 29.7 19.5
C2 26.5 25.9
M7 27.1 39.3
M2 20.2 21.8
C3 25.9 26.5
C4 19.2 34.8
S 89'58'49'E 330-00'
PLAN AS -B U 11
SCALE V = 30'
r l
C _/!'nom
MUNICGE CE
Development Services DepPALITY OF artment 6117 ` D
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: SW020126
Legal Description: BREITZMAN LT 3
Design Engineer: 0014 Anderson Engineering
Owner Name: Jeanne Bierlein
Owner Address: 11900 Hillside Dr.
ANCHORAGE, AK 99516-0000
jo:o'.�
Z. Zo�r�v
Date Issued: May 22, 2002
Expiration Date: May 22, 2003
Parcel ID: 015-231-79
Site Address: 011900 HILLSIDE DR
Lot Size: 49500 SQ. FT.
Total Bedrooms: 4 Permit Bedrooms: 4
This permit is for the construction of.
❑✓ Disposal Field ❑ Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction must be in accordance with:
1. The attached approved design.
2. 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
Issued
Date: (51402 -
Date: 5 /2Z/G2
Municipality of Anchorage
. --r 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
Parcel I. D. 015-231-79
Property owner(s) Jeanne Bierlein
Mailing address (1)11900 Hillside Drive Anchorage, AK 99516
Mailing address (2)
Legal description (Lot, Block & Sub'd.) Lot 3, Breitzman Subdivision
Permit Number SWOZ/Z6
Day phone 244-1921
Zip Code
Legal description (Section, Township & Range)
Lot Size 49,500 SF Acres/Sq.Ft. Number of Bedrooms Four (4)
THIS APPLICATION IS FOR:
Sewer Only
❑
Well Only
❑
Sewer and Well
❑
Water Storage
❑
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
❑
Jacuzzi
❑
Swimming Pool
❑
Water Softening Unit
❑
Therapy Pool
❑
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
/ • K4�d . c—'fau-,�
(Signature of property owner or authorized agent)
Permit Fees: 410 -0 Waiver Fees:
Date of Payment:
S'/5.02
Date of Payment:
Receipt Number: /17 %-S O Receipt Number.
(Rev. 12100)
r
ANDERSON ENGINEERING
BOX 240773
ANCHORAGE, AK 99524,
522-7773 5226779'(FAX)
May 15, 2002
Municipality of Anchorage
Development Services Department
On -Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject: Lot 3, Breitzman Subdivision
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The septic system currently serving the four-bedroom home on Lot 3, Breitzman
Subdivision has failed and must be replaced immediately as the septic tank is currently
being pumped on a near daily basis. We are therefore requesting a permit be issued
for the construction of a new septic system to serve the home. The attached Site Plan
and backup documentation identify the location and configuration of the new septic
system and the parameters used in the design. Also identified on the plans are the
location of the well on the lot, test hole location and the location of the existing septic
tank and absorption bed. No conflicts will exist between the new septic system and the
well on this or adjacent lots. Existing drainage patterns are shown and will not be
altered by the development of the lot.
Unfortunately very little area exists for the septic upgrade. The well is located in the
middle of the lot restricting the amount of area available. In addition, the existing
absorption bed covers the majority of usable area. We are therefore proposing to place
the new Advantex Treatment System with the AX20 Mode 1a 40x94 Pod. This system
requires a much smaller absorption area and is ideal for this situation. The existing
septic tank will be pumped and removed from the property and replaced with the new
tank in nearly the same location.
The test hole placed near the location of the proposed absorption bed indicates silty
sand with some gravel to a depth approximating 6'. The percolation test completed in
the material resulted in rates of 13 minutes per inch. No groundwater was found
during the placement of the test hole and none was noted during the monitoring period.
We are therefore proposing to place a 10' wide by 20' long absorption bed with .5' of
gravel beneath the distribution pipe. The total depth of the bed will be 4.5'. The
distribution pipe will be placed at 4' below the ground surface to allow gravity flow from
the pod to the absorption bed.
The ground surface on the lot slopes as shown on the attached Site Plan with only a
.10
Lot 3, Breitzman Subdivision
May 15, 2002
Page Two
slight slope to the west in the area of the new absorption bed. The new absorption bed
will be constructed in conformance with Municipal requirements and parallel to ground
contours where possible. All components of the new septic system will be constructed
a minimum of 100' from the well on the lot and 10' from the service line from the well to
the house.
If the system is constructed in accordance with our design the following statements
apply:
1. The system, if constructed as designed, will have no adverse impact on the wells
in the area or those to be constructed in the future.
2. The system, if constructed as designed, will have no adverse impact on existing
septic systems in the area or those to be constructed in the future.
3. The system, if constructed as designed, will have no adverse impact on reserve
space, either surface or subsurface, on any lots located In the area.
4. The system, if constructed as designed, will have no adverse impact on drainage
patterns in the area. The current drainage pattern will be maintained.
Sincerely,
Michael E. Anderson, P.E.
Attachments
.••��� a ...... 444
C9 �.Q�
49th VX -
MICHAEL
MICHAEL E. ANDERSON
's, No. OE -4381 I
u
i
1BDIVIS
3
.F.
10'X 20' ABSORPTION
BED S 89°58'49"E 330.00'
Ti�1 0 0 10' UTIL. ESWF.
�D
_
2%
I I .-I
1 1 2%'
Inter
II
o
0 rx
(WM
Q
U) II
W
m m 0
c;
It,
X0:= GRAVEL DF
5.
i
u. .
Reve
S 89°58'49"E 330.00'
o
oil
m �
.—
DECK
N
O
1-
o
1
�
• KL
ca..c,
UKx
z
i
i
I
I
I
H-
S
i
NOTE: NO CONFLICTS WITH WELLS OR
1
SEPTIC SYSTEMS IN THE AREA
•
SCOPE OI
1.
Pum
2.
Inter
3.
Place
Modi
4.
Con:
Dept
5.
Regr
6.
Reve
S 89°58'49"E 330.00'
SITE PLAN
SCALE 1" = 30'
ULATION TO BE
AdvanTex' Treatment System = I P�EHAS THE INSTALLED OVER THE SEPTIC TANK k 4-
AX20 -Mode 1 a ADV N TEN MANLIA` BEYOND ON ALL SIDES EXCEPT UNDER
46. THE ADVANTEC FILTER. THIS WILL ALLOW
40x94Pod `"""rte, FOR HEAT ESCAPE FROM TANK &
RISE TO T THE FILTER ABOVE R.
6' dM CAP
F04AL GRADE—\ (TYP.2)
6' PVC PUMP-0VT
OWS)�
e' PVC COUPLING
CLUED TO TANK—\
(rw-2)
AX20 POD
�aaw.RoSEwutac
330 INCH
wsuuTED
R177 .
INLET_
�vl.
•{
SLIDE SECTIONS
.'. i�li
{ii,
OF 6' PIPE
0VER TI"' CONNECTION
4 BEDROOM
E
SHEER PROTECTION-
EXTEND TO
:
- ADVANT (�
I
BRIDCE EXCAVATION
i
I i . .: i , ' ,TANK ,
' {
l i i
, �
�II �
SYSTEM SECTION
NOT TO SCALE
P:^ T E: SYUElawl !.RUST BE PLACED IN STRICT CONFORMANCE WITH
MANUFACTURER'S RECOMMENDATIONS.
BIOTUBE
SCREENED
VAULT
ORENCO
�q EFFLUENT
F� PUMP
i 49th /'r•°
�E MICHAEL E. ANDERSON = _i.
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
.522-7773 522-6779 (FAX)
MEMORANDUM
DATE: May 22, 2002
TO: Dan Roth
FROM: Mike Anderson, P.E.
SUBJECT: Lot 3, Breitzman Subdivision
Septic System Permit
Attached is the revised detail for the shallow bed absorption system for Lot 3,
Breitzman. We have modified the application rate to 5 gallons per square foot per day
and recalculated the required size of the bed. We still intend to construct the bed for a
total of 200 square feet of absorption area. Please review the attached information and
advise if further data is required prior to issuing the septic system upgrade permit.
LOT 3, BREITZMAN SUBDIVISION
ABSORPTION BED
DESIGN FACTORS:
4 Bedroom Home
Perc. Rate: 13 MinAnch
Application Rate: 5.GPD/SF
SYSTEM REQUIREMENTS:
Shallow Bed Disposal System
4 Bedroom Advantex Treat.System
1' Total Drain Field Rock
4 Bedrooms X 150 GPD /5 GPD App. Factor = 120 Square Feet
120 SF/10 LF (Width of Bed) = 12 LF Length of Bed
Therefore: Construct an Absorption Bed Larger Than Design Requirements 20' in Length
by 10' Wide for a Total of 200 Square Feet of Absorption Area. Bottom of Distribution
Piping to be 4' Below Existing Grade. Total Depth of Bed to be 4.5' Below Existing Grade.
Mound Over Bed to Provide 3' Minimum Cover or Provide 2" Direct Bury Insulation and 2'
Minimum Cover to Prevent Frost Penetration. .
NATURAL BACKFILL
31 /---- GEOTEXTILE FABRIC
.51 C
.51 — 'DRAINFIELDROCK
4 DIAMETER PVC 2' 3' 3 2 'MONITOR TUBE
(SCHEDULE 40) I i i 1
SHALLOW BED DETAIL
(NO SCALE)
NOTE: Grade Area to Drain Away.
Maintain 6' Separation From Bedrock. 0,C
Provide 3' of Cover or 2" Insulation and 2' Cover.
Maintain 4' Separation From Groundwater.
Maintain 100' Separation From Well and Surface Water.
i 49
MICHAEL E. ANDERSON =
' NO. CE -/381
1�,,� ILIL ���
i r
��„x, i� 49th
Municipality of Anchorage I r f~t 1. l .
• _.....»» .....».
Development Services DepartmenUOn-Site Water &Wastewater Program i � M CNAEL E. ANDERSON
4700 South Bragaw Street Anchorage, AK 99519 �i c�J No. CE -4781
SOILS LOG - PERCOLATION TEST ���ff `•.,,� �,..••`
Performed For. Jeanne Bierlien Date Performed: 5/8/02 ♦♦� ��`S:;a:��
Legal Description: Lot 3. Breitzman Subdivision
SLOPE SITE PLAN
1 ■ OG1PT
2
3
TEST HOLE NO.1
4
SM
See Site Plan
5
Silty Sand
w/Gravel
6
7
8
Was Groundwater
9
Encountered?
No
S
ML If Yes, What Depth?
L
10
Depth to Water
O
After Monitoring
None
P
11
Date:
5/15/02
E
Medium
12
Dense
Reading
Date Gross Net Depth To Net
Time Time Water Drop
13
1
8 -May 5:18 1.75"
2
5:48 30 4.25" 2.5"
14
3
5:49 1.75"
4
6:29 30 4.13" 2.38'
15
5
6:30 1.75"
6
7:00 30 4.13' 2.38'
16
Bottom of
Hole
17
18
Perc. Rate: 13 MinAnch Pero. Hole Diameter. 8"
22
Test Run
Between 4 Ft. and 5 FL
Comments: Test Hole Pre Soaked Prior to
Testing.
Underlying ML Layer Peres. < 40 Min.Anch.
Performed By: Mike Anderson. I, Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 5/15/02
21
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: LOT 3, BREITZMAN SUBDIVISION
GENERAL:
The scope of this project includes the pumping, removal and
abandonment of the existing septic tank. Work also includes the
procurement and placement of a new Advantex Treatment System
with an AX -20 -Mode 1a 40x94 Pod at the location shown on the Site
Plan. The new septic system also includes the construction of a new
20' long X 10' wide absorption bed at the location also shown on the
Site Plan and at the configuration shown. The distribution line in the
bed will be placed at 4' below the existing ground surface. Total depth
of the bed will be 4.5' below the existing ground surface. The new
system must be placed a minimum of 100' from the well on the lot and
10' from the water service line between the well and the house.
2. Construction shall be in accordance with the approved site plan,
design drawings, Municipal Permit with any special provisions or
conditions, and all applicable State and Municipal Wastewater
Disposal Regulations.
3. The Contractor shall be responsible for obtaining all underground utility
locates and for the layout of the septic system and verification of the
location of all lot lines.
4. Unless specifically agreed otherwise, the contractor shall be
responsible for final grading areas subsequently depressed from soil
settling. Property owner shall be responsible for revegetation of
affected areas unless specifically agreed otherwise.
5. Contractors installing wastewater disposal systems must be certified
by the Municipal Department of Health and Human Services for
system installations. Owners installing their own systems must receive
prior approval from D.H.H.S. before beginning system installation.
SEPTIC TANK INSTALLATION
1. The Advantex Treatment System must be installed in conformance
with specifications and regulations furnished by the manufacturer,
Anchorage Tank and Orenco Systems Incorporated. No variances
from the manufacturer's specifications will be allowed without
permission from the manufacturer and Municipal representatives.
2. A septic tank is to be constructed by a certified septic tank
manufacturer. Construction shall include two 4" cleanouts for pumping
access.
3. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
4. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
. Lot 3, Breitzman
May 15, 2002
Page 2 of 3
5. Tanks installed without 4' of cover shall have a minimum of 2" of direct
burial insulation.
6. A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drainfield.
7. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAINFIELD CONSTRUCTION:
1. The drainfield shall be constructed to the dimensions shown on the
design. The bottom of the bed shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a
level bed of drainfield rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3. A silt barrier or geotextile fabric must be placed between the drainfield
rock and the natural soil backfill.
4. Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
5. Contractor shall verify the septic tank and drainfield are a minimum
100' away from any private water wells in the area, 150' from a Class
"C" Well or 200' from any community well.
6. Direct bury insulation must be placed over the distribution system if
less than 3' of backfill depth is available. Finish grade over the trench
must be mounded to prevent settlement or depressions.
7. Grade area surrounding the absorption trench to drain away.
8. A minimum 2' of accepting soil is required below the drainfield rock for
a 5' wide trench. Contractor shall verify this condition prior to
placement of the rock. All pockets of unacceptable materials must be
removed and replaced.
MATERIAL SPECIFICATIONS:
1. Septic tanks must be constructed by a municipally approved septic
tank manufacturer.
2. The following pipe materials are approved for use in septic system
installations in the Municipality of Anchorage:
Cast Iron (perforated and solid), ASTM D3034 or P.V.C. (perforated
and solid), ASTM F810 or H.D.P.E. (perforated, but not solid) and
ASTM D2662 or A.B.S. (perforated and solid).
3. Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Lot 3, Breitzman
May 15, 2002
Page 3 of 3
4. Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Femco, or equal).
5. A permeable geotextile fabric (Typar, Mirafi or equal) must be installed
between the final drain rock layer and the native soil layer.
6. All drain rock shall be .5" to 2.5" in diameter with less than 3% passing
the #200 sieve.
INSPECTIONS:
Municipal Ordinance requires a minimum of two inspections. These
inspections must be conducted under the supervision of a professional
engineer registered in the State of Alaska. The first inspection must be
conducted after the excavation of trenches, beds or pits and before the
installation of any gravel. A septic tank may be set in place, but may not
be backfilled.
The second inspection must be conducted after the placement of the
geotextile fabric, gravel, distribution piping, standpipes, cleanouts and
insulation. No backfill should be in place at the time of inspection.
Contractor shall provide a copy of all field survey layout and construction
notes for use in preparing the certified as -built of the completed system.
FROM JSANNF-„STEVE FAX NO. May. 15 2002 09:09AM P2
Municipality of Anchorage
Development Services Department
Sni4$ns Safay mbion
OaSite ware *paadd� W�awwi eProgrm
4700 R m Stmt
?-0- 34X 1%650 An¢ arW, AK 99519-6630
W WW.CLsec6oss4e.ek.Uu
On 343.7901
PROPERTY OWNER AGREEMENT FOR THE MAINTENANCE OF AN Obi -SUE
WASTEWATER DISPOSAL SYSTEM
Tbis agreement, dated �-^ �5-bot , is made between the Mimicipality of Anchorage
Development Services Department (DSD) and the pr aperly ouner(s) o£
k1q[x-) V inks"P �n2. ".1 ftf� ggS1�,
This agreement is made for the purpose of mamfaining an on-site wastewater disposal system on
the subject property. ., . .
The property owners agree to the following:
Submit to the Nfunieipality of Anchorage, on an annual basis, an inspection and operation
statement from a registemd professional engineer. This inspection aad operation statement shall
verify that the engineer has inspected RU efIIncat and air pumps, timers, and alarms, and that any
defici ' s \ve be hat is functioning as designed.
( ignature) (Signaature)
(Printed Name) (Printed Name)
dliltllll/jw, 'Ihe regomi; ins7ument was acknowledged before me by
�N6RRJ,�G'i��, 1�Ai'J/� L'j�c�7'�rL onthis�day of
C7;
0�1 In 3e-
Co,
r qqq
F c'
� (Nom y, PTMteda0me) es
My Commission Expires A��
Received Time May -15. 9:01AM
•' wu&A.. 7A"I .111. /01.1
0
/—� 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
NEW
?ONE
J"'�
❑ UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTIO�':5,
,
LOCATION
NO. OF BEDROOMS
U Y
DISTANCE TO:
Well
aO
Absorption areaDwelling
r
-^ I
/
PERMIT N
.�
n~ 2G
Manufacturer
Material
No. of com artments
LU I.L
C4
Liq, c p§city i�allons
�O
IF HOMEMADE:
Inside length
Width
Liquid depth
0 z
DISTANCE TO:
Well ^O
Dwelling
PERMIT NO.
G
2 Z F
Manufacturer
Material
Liquid capacity in gallons
J
DISTANCE TO:
Well ^
vo t,
Foundation
Nearest lot line
PERMIT NO�
W =
CQr
�� a
u. z
No. of lines
Length of each line
Total length of lines
Tre width
Distance between lines
�2W
cc
inches
'7.
R
Top of tile to finish grade
Material beneath tile
Total effective absorption area
inches
Length
Width
Depth
PERMIT NO.
w
C7
Q I-
wa
Type of crib
Crib diameter
Crib depth
Total effective absorption area
W
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
W
DISTANCE TO:
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
14 ST,06 -3 4 �E
SOIL TEST RATING .12
tom/,`/
�
INSTALLE
-''
REMARKS
7
i
APPRO D DATE LEGAL
/Z -U73 IKev. 3/78) U
M U f`4 10 1 F=* n L_ I _r V 121 F-- �N IZ�. " CA F--.-* n 0 E:
~ -
DEPARTMENT [ HEALTH AND ENVIRONMENTAL DTECTION
825 'L STREET, ANCHORAGE, HK. 99oa1264-4720
CA r"_I I- E: "=-. F= L4 E: FR. �E: T. -r_ �
PERMIT NO. ( 800320 )
APPLICANT JOHN BENEDICT SRA BOX 1371
LOCATION HILLSIDE DR.
LEGAL �
TYPE OF SOIL ABSORPTION SYSTEM IS: DRHINFIELD
'--''� --- --
'
-^ 344-1992
LOT SIZE 49500 SQUARE FEET
/0 fo
�MXlML� NUMBER OF BEDROOMS = �5' SOIL RATING (SQ FT/BR)= 257 / ^
/- `�--~- \ -
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYQTElM S:
UN E77 F"* T 1-1= to. t5 L_ K rA w ir v" 0 1 Fl %I E" L_ ��F-"::-r t-1= :1-'!ffa
N�^
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRHINFIEL' 0 -`-`
�
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE ` ~ �)
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
Ft -AE:--- �F--_*r--r-A17_3A �l0A"rl--i I E 1 02-19-390 F=F=r--"T'
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
���UlF;-�E:U-- -rnNK ::lL!ffsc00
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
___ 714 1___v <;2 > 11 PA "a F" E" CT ir 3E C3 P4 "a Fl Ff E" FZ FE= 1--4 111 FZ E: E-1
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE IS 25 FEET AND
TO'H COMMUNITY SEWER LINE IS 75 FEET.
OTHER REQUIREMENTS Any APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
���M I -IF F=* I F;"." U"H. �U 0 C- N 0 FE F-" I E-:3 1-21
I CERTIFY THAT
1: I HM 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.
]: I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED THAN 5 BEDROOMS.
4
�Jjk� i
SIGNED: _ --------
APPLICANT JOHN BENEDICT
IS
Sucvo,���-�le�NOW Y4. 0
L^^
f0blc C-11
/1
��,' �� l���& L���� ��L/� 5�u�� '
+~~� /° �y"� ~~-^ Ade --~' ~_'-_. ^
k �J � � &� ' �L- ) ��8���� u �� ��/ v4.. X0
��^~�^^-- - / °l -r- - � ' °- ~-- - ~ -- ' ~ ' &;
J""^^�_�. -����^-�~�/�Lo 4r `
» ``'~~-^--� �-~^�~~-' l
CONSTRJCTION
TEST LAB
PERFORMED FOR: John Benedict
LEGAL DESCRIPTION: Lot 3 Block
THIS FORM REPORTS: O Visual Soils Examination
DEPTH SOIL
cc97T I)FSCRIPTION
NOTES
6"
Topsoil
0 HRS 5 1
— 2'
Brown -orange sandy -silt w
obbles
"
2 15/16'
7/23
10:27
Brown Silty Sand Relativel
7/8"
—
Dry w/some cobbles
4.0 HR 1,
7'
-SM-
-
PERCOLATION RATE : 32
PROPOSED INSTALLATION:
COMMENTS :
9.5'1
DRAINAGE REQUIREMENTS' 257 sq.f-E_/hedrnnm
PIT %Pc DRAIN FIELD O OTHER
�~
10,
w i i VIYI yr nvL_� 0t
WAS GROUND WATER ENCOUNTERED YES r 49TIi
IF YES, WHAT DEPTH
1806 uv 48TH AVE. STE. 'C'
ANCHORAGE, ALASKA 99503
248-1333
DATE PERFORMED: 7/21-7/23/80
Subdivision Brightsman
Percolation Test ACTL 80-1400
W
a_
0
J
N
W
H
U)
z
W
sot , Rin�st�d
LEGEND James R. t
AD - Perc zone+�'.��No. C.E. �IR13�
®S - Sample taken �'�f''•.�,�����,..••'�'i`„�! GENERAL SITE SLOPE
— Water table#l�r�OiiSS10���--
BEADING DATE GROSS TIME NET TIME DEPTH TO H2O NET DRAINAGE
7/22 SATURA ION PERIOD
7/23
6.57
0 HRS 5 1
0"
7/23
9.5
"
2 15/16'
7/23
10:27
3.5 HR
7/8"
7/23
10:57
4.0 HR 1,
15/16"
PERCOLATION RATE : 32
PROPOSED INSTALLATION:
COMMENTS :
min/in .
O SEEPAGE
DRAINAGE REQUIREMENTS' 257 sq.f-E_/hedrnnm
PIT %Pc DRAIN FIELD O OTHER
TEST PERFORMED BY: L. Sims
DATA CERTIFIED BY: James R. Ringstad, P.E.
DATE: 23/80
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6650, Anchorage, Alaska 99502 276-2221
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:) !�! C JLQ'a's. DATE PERFORMED:
�._. 1--)
- a
LEGAL DESCRIPTION: 4'lm IV CLY1-
EPTH
(FEET)D---
❑ SOILS LOG
❑ PERCOLATION
TEST
SLOPE SITE PLAN
1
2
3
4
5
6
7
8
9
11
12-
13-
14-
15-
16-
17
21314151617
18
19
20
COMMENTS
PERFORMED BY:
72-008 (7/76)
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE (minutes/inch)
T ST RUN BETWEEN FT AND FT
CERTIFIED BY:
iA
IZA
3
XPLORATION SUPPLY AND EQUIPMENT, INC.
X
S
C
0 Drill Shift Report
CONTRACTOR DATE
PARTY
NO
DEPARTED CAMP
ARRIVED FIELD _
DEPARTED FIELD
ARRIVED CAMP
LOCATION
AY r
DRILLER
HELPER
ROCK BITS Z
INSERT BITS
MUD USED
TRAVEL TIME
BREAKDOWN TIME
MOVE TIME
CHARGEABLE TIME
FORMATION
C� (/Q2 ! dam' �JG, I✓� .R% / ✓
A
Al ro
eill I/ Al
FOOTAGE
rm=
TIME
TIME
APPROVED BY
��J P-4 1 r--- I, ��I -r I -e I -D F= ��1-': F4 F;;?. F-1 0 EZ
DEPARTMENT 11-r HEALTH AND ENVIRONMENTAL �..{OTECTION
825 'L' STREET, ANCHORAGE, HK. 99501
264-4720
PERMIT NO. ( 810003 )
APPLICANT WILLS CONST, SRH BOX 2522 ]44-16]8
LOCATION HILLSIDE & HTLHNH
LEGAL. L3 BPEITZMQv.'!, )L LOT SIZE 54000 SQUARE FEET
MINIMUM DISTANCE BETWEEN H WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR H PRIVATE WELL OR 150 TO 200 FEET FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTANCE FROM H PRIVATE WELL TO H PRIVATE SEWER LINE 15 25 FEET AND
TO H COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
�l=F;;."M I -r �XF=*" I F;;?.E:'-c-- ��������F;.* ��� :jL����
I CERTIFY THAT
1: I HM 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.
SIGNED:________________________________________
HPPLICHNT WILLS CONST.
�
ISSUED BY_^� ------ ------- DHTE----/-'-/=z�-�> / Y4.0
-mga'
"unicipaiity of Anchorage GAO B4
Development Services Department
\ i Building Safety Division_
j'
1`
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 015-231-79 HAA # yf t✓ y�n �
1. GENERAL INFORMATION
Complete legal description Lot 3. Breitzman Subdivision
Lo_2:ian (site address or directions) 11900 Hillside Drive
Current Property owner(s) Jeanne Bierlien
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Expiration Date: 5114103
11900 Hillside Drive Anchoraoe. AK 99516
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: Four 4
3. TYPE OF 117ATER SUPPLY:
Individual Well
Individual Water Storage ❑
Community Class Well ❑
Public Water System ❑
Day phone 244.1921
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding tank
❑
Community On-site
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days 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 professiona!
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 outlined 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 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm Anderson Engineerinq
Address P.O. Box 240773 Anchoraqe. AK 99524
Engineer's Printed Name Michael E. Anderson, P.E.
5. DSD SIGNATURE
Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
By:
(Rev. 12100)
X
Phone 522-7773
Date 9/7/2002
�Ale • • . • �:
40 p
t�tttLZL :lYtc'44c>
bedrooms, with the following stipulations:
C,i�
J=:• ON-SITE ••���;
`'� • WATER AND � m=
PROGRAM
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: 2 Plo;
i
Municipality of Anchorage
• '� Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw SL
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Lot 3, Brettzman Subdivision
A. WELL DATA
Well type Private
Date completed 1990
Total depth 53 ft.
Date of test
Static water level
If A. B, or C provide PWSID # _
Sanitary seal (Y/N) Y
Cased to _9—ft.
FROM WELL LOG
ft.
Well production 3540 O.P.M.
WATER SAMPLE RESULTS:
Coliform 0 oolonies/100 ml. Nitrate 4.55 mgA.
Date of sample: 91212002 Collected by: MEA
B. SEPTICIHOLDING TANK DATA
Tank Type/Material STEP/Steel•Advantex
Tank size 1.500 gal. Number of Compartments 3
Foundation cleanout (Y/N) Y Depression over tank (Y/N) N
Parcel ID: 015.231.79
Well Log (YM) Y
Wines properly protected (YIN) Y
Casing height (above ground) >24 in.
AT INSPECTION
912!2002
8' R
5.6 0 -
p.m -
Other bacteria 0 colonies/100 mi.
Date installed 611 812002
Cleanouts (Y/N) y
High water alarm (YIN) Y
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date instailed 611812002 Sol rating (g.p.d.&2 or ft2/bdrm) 6 GPDISF System type Advantex
Length 20 R Width 10 ft. Gravel below pipe .5 ft.
Total depth 4 ft. Eff. absorption area 200 ft' Monitoring tube Y Depression over field N
Date of adequacy test Results (Pass/Fail) For _ bedrooms
i
I Fluid depth in absorption field before test _ in. Water added^ gal. New depth_ in.
Elapsed Time: _min. Final fluid depth ^ in. Absorption rate >= g.p.d.
Any rejuvenation treatment (past 12 mo.) (YM & type) N If yes, give date
D. UFT STATION
Date installed 6MB12002
Size in gallons 250
Manhole/Access (Y/N) Y
"Pump on" level at _ in.
"Pump off' level at _
in. High water alarm level at 52
Datum Bottom of Tank
Cycles tested New Const. Meets alarm & circuit requirements? Y
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tankAift station on lot >100'
On adjacent lots >100'
Absorption field on lot >100'
On adjacent lots >100'
Public sewer main NIA
Public sewer manhoWdeanout NIA
Sewer /septic service line >25'
Holding tank NIA
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation >5'
Property line >5'
Absorption field >5'
Water main NIA
Water service line
MW Surface water >10V
Wells on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD
ON LOT TO:
Property line >IV
Building foundation >10'
Water main >10'
Water Service line MW
Surface water >100'
Driveway, parkingtvehide storage >25'
Curtain drain None Noted
Wells on adjacent lots
>100'
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that t 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 Michael E. Anderson. P.E.
Date 9172002
w
HAA Fee $ Ik75Waiver Fee $
Date of Payment 7-9- oz. Date of Payment
Receipt Number ZSUPI � Receipt Number
(Rev. 12100)
.tAW
�tr•. n '•.`rj�e
s'•, CE - 438' 1 .' i+
• ��
i
ow�
Ik Ik O�~'�
in.
•�JUL-15-2002 04:54 PM EDS. ELECTRIC 272 4590 P.01
#.*=rob
•-j0;Lf!ghtFAX 6/21/2002 5:16 PAGE 1/1 RightFAX.
Inspection Report
Municipality of Anchorage, !Building Safety Division
4700 South eragaw
INSPECTION: VOICE 343-8300 INSPECTION: FAX (907)249-7777 INFO: 343-5211
Name ED'S ELECTRIC Permit 02-8038
Addram 11900 HILLSIDE OR Phone 272-4591
Legal LT 3 Inspection Date 6/21/2002 AM
Subdivision BREITZMAN
Comments or Directions
AM -CALL 54 TO MEET ON SITE -SEPTIC SYSTEM
Inspection Retro Electrical Reinspection N
bNNO NONCOMPLIANCE OBSERVED
❑ CORRECTIONS ESSENTIAL AS EXPLAINED BELOW '
❑ WILL RE-EXAMINE AT NEXT ❑ DO NOT CONCEAL UNTIL REINSPECTION
INSPECTION
COMMENTS: (for inspector use only)
c�4 Sf 1G p,
u
f
Inspector '-1H
Received Time Jul.15•• 4:15PM
Date:
-Z/- 0'2 -
SEP -06-02 04:04Pi1 FROM -CUE ENVIRONIENTAL SRV
CUE Environmental Services Inc.
' � Yeo ri��ri�rsrrrr�rar�.�..
CT&E Rcf.#
1025678001
Client Name
Anderson Engineering
Project Name/#
Lot 3, T3rcirzrnan
Client Sample 1D
Lot 3, Breitzman
Matrix
Drinking Water
Ordered By
PWS1D
0
Sample Remarks:
9075615301 T-317 P.02/02 F-989
All DatcwTimes are Alaska Standard Time
Printed Date/Time 09/06/2002 16:17
Collected Date/Time 09/02/2002 13:30
Received Datefrime 09/03/2002 14:00
Technical Director phen C. Ede
Release
Allowable Prep Analysis
Parameter Resulu PQi_ Units Method limits Date Date /nit
Waters Department
Ninate-N 4.55 0200 mg/L EPA 300.0 («10) 09/03/02 JDT
Microbiology Laboratory
TotalColifonn 0 cot/100ml. SM189222B (<--1) 09/03/02 KAP
Received Time SeP. 6. 3:13PM
79-167
BREITZMAN SUBDIVISION
LOT 3
49,500 S.F.
S 89°58'49"E 330.00'
R"=W4LL �� N 10' UTIL. ESMT. — — A.C. DRIVE
—
—---——— — — — — —— ——————-----—————————————————————
GRAVEL DRIVE
22.0•
I +2.0' x 23.7'-+ N
I cMrr
WELL
• N
I seenc 371. PZrAQIW wai
0
35.4' VETt15 ,
6.7' °' 5.0
EXISTING �_ aoNC. CURS
O I a:°w. xcswra N' BUILDING Op
O W .O GRAVEL DRIVE p
to _ j I 8.T. o o to
w r
i93
O I 2.0'02.3' 4. CANT .0• LOT 3
oO
O I 2
38.2' DECK O
N� 4.3' I ------2s.-r--. N
O O
°p I REtWq� WUL O
p I COM. WALK O
Z I Z
I
7.4'
I of
1 "=30'
I
. I .
S 89058'49"E 330.00'
AS -BU I LT I hereby certify that I have surveyed the
property depicted above and that no
GASTALDI LAND SURVEYING encroachments exist except as Indicated. OF �.
,..... . .
Jeff A. Gostaldl, R.L.S. It is the responsibility of the owner to '±
�
P •Q�s�
4726 West 88th Ave. determine the existence of any easements, t Cl)� 9TH***.
�'V
Ar
Anchorage, Alaska 99602 covenants or restrictions which do not r *'•4••••••••
PHONE 248-5454 appear on the recorded subdivision plot. Under no circumstances should any data �Y�. a �J eastaldi I o
hereon be used for construction or for: AV
AirGRID DATE' .• LS -6091 ; • ���
establishing boundary or fence lines. ^P •,• ,.• :3;2739. 9/29/97 #ap 6
ANCHORAGE RECORDING DISTRICT, ALASKA �� pofessional t-ev, "
F.B. JOB NO. •a� titer•
97-18= BREITZ3 NOTE: NO CORNERS SET THIS DATE.
0
50' o
J
J
N114
"NWERSON1,10W. N .. I.NG
0? NOMA'
MEMORANDUM
DATE: February 2, 2003
TO: Joe Goodall
FROM: Mike Anderson, P.E.
SUBJECT: Lot 3, Breitzman Subdivision
Certificate of Health Authority Approval
Attached is the property owner agreement for the maintenance of the new Advantex
septic system recently placed on the lot. The agreement now has original signatures
and has been notarized. All information requested has now been submitted for the
Certificate of Health Authority Approval for this lot. Please issue the certificate at your
earliest convenience.
MUNICIPALITY OF ANCHORAGE }�
• Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES M
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ® 11,:0_ QIA- _V) HAA # I4Qot '-LDC -
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (add'ress-dr'dirrec.#j'c*
�� 9f�a - h' i'sr✓ y�'r L v 2.
r • w -'W
040 440
(b) Property'owner
h� Fc
Mailing Address
(c) Lending Institution,
Mailing Address
Telephone: (home) Business
Telephone
(d) Real Estate Company and Agent
Address zoob C s ceZ
Telephone SL,2
(e) Mail the HAA to the following address: (or check hereoif hold for pick up.)
List contact person and day phone number below:
A r c s --t,
2. TYPE OF RESIDENCE
Single-FamilyX Number of bedrooms
3. WATER SUPPLY
Individual Well Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site X Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
72-025 (Rev. 7/88) Page 1 of 2
5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND 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 4e -CS- _Z mac- Telephone 4g7 --22y-_-rf-3
Address PD jy:?�2[ 9 Y 1.-, 6 T- �.z.7reg e r ?,,,!L 4,4t 99l'a e-D6,Q'-
Date
6. DHHS APPROVAL
f�
Approved for _ bedrooms by
Approved —� Disapproved
Terms of Conditional Approval
0 A4 Aitk.44
i
��dJisl� „te�,�a
Conditional
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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. 7/88) Back Page 2 of 2
F PNGN�RP
AVN+G\Q PN Pp0-' 0
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Well Cl asllsiif``ic''ation �� u e
Legal Description: 4 3 Q-rer/zria., S"uZ.
�a/V 2.3w 5.23
If A, B, C, D.E.C. Approved (Y/N) �f9
Well Log Present&N) Date Completed •- 19110 Yield i
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ;2S7 Q/D� Type of System Design die ^�
Date Installed/ Length of Field �S• ��
Width of Field /g/. /9� Depth of Field '
Gravel Bed Thickness /
Square Feet of Absortion Area X717 Statndpipes Present (9/N) *-e
Depression over Field (Ye Date of Last Adequacy Test op_i -l90
Results of Last Adequacy Test AleA& /Awsf'
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water -Supply Well ,/oo' s To Property Line
To Building Foundation /% "'k To Existing or Abandoned System on
Lot 6�IA ; On Adjoining Lots > ZD
To Water Main/Service Line ZSR To Cutback (if present) All*
To Stream, Pond, Lake, or Major Drainage Course > boa /
To Driveway, Parking Area, or Vehicle Storage Area % 30
i
Comments „ A -04d Mo
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at A
High Water Alarm Level at
Tested for
Meets MOA Electrical Co (Y/N)
Comments
f � v
Dimensions
Manhol cess (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guideli f ft 414e date of this
inspection. •„•••••••.,•� h♦
Signed �r�Q.•+ '•"�*
Company
+'tom I+ 49t •••.•.s• • • C
�•• wn�er's Seal
5-23 1r'O 0.0.0• 0 %
Date 0 ,.•+•
#, or o SR• .
0 C, ROD, 6 /
MOA No. CAF CE. 2251 o s
Receipt No. _ Receipt No.
Date of Payment 5`3 % � iJ Waiver Fee: $ —
Amount: $ /70 0 - 00 Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET • ANCHORAGE, ALASKA 99518 • TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANAVISI.: REPOhl Si SAMPLE for Work Dtdei #f ;:19
bat;: Repu':t tr.iikti`d: 1o1Y 25 90 11:10
Chant Sawpl,a ID:L3, BPRFiTZkAN TAP 4IAIER Clie,.,t NaTA& E C. a
Nd'S 1: :Jii Ciigr;t A'ct
Co Iin, 1iedt MAY 21 i(1 0: oc iiC F.,..# NOR U'l"-' V'lz'
Rar.ev9u MAY 23 90 e 11:0; hr keq I
Pt seiypcl witJl :AS REQUIRED 0;:ae:red j : LLE UID
OF.ENDEDENOE
Hf`
V
_ � O
dy .ter y
wr ��
G
Anaiysiw Completed, -MAl 23 "°
G end Reports Lu:
L�.bar.atury "aper'rrsor S EPFIEN C. EDE �,i E C S
,: <,r.,3., tom,,...._..,.,.-.,..,,�..,...,.a..d,...._:..,....,,.:._.,..y.....,..�.,�._...,,,.my.....==„x..m...<...,._..,......o�v .F„.�_.,.,x,r...
.il,ecist
Instruct:
Choml,.ib Ref #: 901192 !'.ab umpl lb: t Mat Li.x: WA R
Allowable
Ear:arnetex Teste6 Result U:cies Met u,d L`uo-t6
141'Pii.UE-N 4.0 l,u,/1 EPA i53.' 10
aamP16 SAMPLE C'OLLECIED BY L. REID. AOUTINE SAMPLE.
° waz ks
1 ` nts 1'erf unwed
`. ee
: pecJ E,l
Ln;tiuctions Aboye Ult -Umavai1ao', p
fill= Nona D,-teccl.ed
”" See
: a nplp
Rem,-c's Above
sA= Not Analyzed
LT -Les::
Than,
0')'w:. -,eater Tian
5. LEGAL DESCRIPTION
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME
TIME
TrME
DATE
DATE
DATE
�-
INSPECTOR
INSPECTOR
INSPECTOR
MUNICIPALITY OF ANCHORAGE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH& ENVIRONMENTALPR��f'b%• OF H-ALT.I &
825 L Street - Anchorage, Alaska 99501
""'KONMCNTAL f "OTICTION
ENVIRONMENTAL SANITATION DIVISION JAN 12 € 81
0*
Telephone 264-4720
❑ PUBLIC UTILITY
RR��(('''' [[' tt ``// rr
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND'3LsYV'�IR•i VEDIES
8. SEWAGEDISPOSAL SYSTEM
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PRO BRTY OWNER
❑ PUBLIC UTILITY
PHONE
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
MAILINGADDRE S
PROPERTY RESIDENT (If different from above')
PHONE
/J(74fs/n�Q $ l�
,
S4PAI '1z-)
2. BUYER
PHONE
MA LING ADD ESS
3. LENDING INSTITUTION
PHONE
_
�t U
MAILING ADDRESS
4. REALTOR/AGENT
PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
,.
Ir
TYPE OF RESFIDENCE
NUMBER OF,BEDROOMS
g_—S1_N'GLE FAMILY
❑ One C7 .'Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
ree ❑ Six
7. WATER SUPPL
INDIVIDUAL*
* ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
8. SEWAGEDISPOSAL SYSTEM
Z� INDIVIDUAL/ON-SITE**
e5(!�:) YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) �f
72-010 ( Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE
❑ TWO
❑ THREE ❑ FIVE ❑ OTHER
❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
.❑INDIVIDUAL/ON -SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATE INSTALLED
—
INSTALLER
❑Septic Tank or ❑ Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL T0:
Septic/Holding Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
ED, --'APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE
BY
72-010 ( Rev. 6/79)