HomeMy WebLinkAboutT12N R3W SEC 33 LT 141BSection 33
Lot 141B
#018-292-70
Municipality of Anchorage Page ! of 3
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER' DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Permit Number: SW020447 PID Number: 018-292-70
Name:
Rick and Deborah Williams WaetewaterSystem: Upgrade
14840 Wildien Drive Anch., AK 99516 ABSORPTION FIELD
345-7~.~5 Three (3) 5' Wide Shallow Trench
LEGAL DESCRIPTION 1.2
141B 1.5
12N 3W 33 .5 - 1.5
Well: Existing Well 5 Ft. 3. ' Ft
Private Ft. Ft.375 F~ ASTM D3034 PVC
F,. Thomas Dev. 11/17.19/02
SEPARATION DISTANCES STEP
Septic Absorption Lift Holding )ublic/PrivatE ManufKtu~. CapK~y ~n C-aliens:
Tank Field StaUon Tank S~rU,e Anchorage Tank 1,500
w., >100' >100' N/A N/A >25' Steel Three {3)
s~,.~w.~. >100' >100' N/A N/A ~ LIFT STATION
250 o.,I Anchorage Tank/Orenco
Fo~ >5' >10' N/A N/A 43 nl 43 ,.I 45
C~.,,o=~ None Noted Orenco City of Anchorage
2" Insulation Placed Over Tank and BENCH MARK
Absorption Trench. L~,,~,~
Concrete Walkway Between House and
Garage.
98.3
Engineer's Stamp
Department of Health and Human Services approval
Reviewed and approved by; (/- ~
New
1,500 Gallon'
Municipality of Anchorage
DEVELOPMENT SERVICES DEPARTMENT
4700 South Bragaw Street Anchorage, AK 99519-6650.343-7904
On-Site Wastewater Disposal System or Well Inspection Report
Permit Number SW020447 PID No. 018-292.70
S.T.E.P. "" ' I
J'
~ SPI
~ 1%" ....%
>
· -& . Ball %
> Valves \ ..
1%"PVC ."'
25' x 5'
bs~.rption ".:
TH 2
MT ~
ttree
/
MT 2
I.
~ .
D
TH6
.-SOUTH TRENCH
I' Existing
, I Ab'sorpti..on bed
',.electric conduct~ors Swinq Ties
A B C D
; '3 BR Hse-
SP I 25.2 16.2
SP2 32.7 22.7
MH 35.0
VB 43.8 33.1
MT1 33.4 20.7
MT2 21.3
· driveway
/ , Legend
/ CO cleanout
/.
/
-. ' '~- El'. = 98.3 SP tank riser pipe
I'. t MT monitor pipe
135.0'
52' x 5'W x .5' E.D.
41' to Prop line
PLAN
I
Page 2 of 3
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VIEW
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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
Parcel I.D. 018-292-70
Permit Number SWO2~44~'
Property owner(s) Richard and Debbie Williams
Mailing address (1) 14840 Witdien Drive Anchorage, AK 99516
Mailing address (2).
Legal description (Lot, Block & Sub'd.) BLM Lot 141B
Legal description (Section, Township & Range)
Lot Size C~/O ~C:~' / Acres/~
THIS APPLICATION IS FOR:
Sewer Only
Sewer and Well
Sewer Upgrade
THIS PROPERTY CONTAINS:
Hot Tub
Swimming Pool
Therapy Pool
Day phone 345.7445
.Zip Code
Section 33, TI2N, R3W
Number of Bedrooms Three (3)
[] Well Only []
[] Water Storage []
[] Jacuzzi []
[] Water Softening Unit []
I certify that the above information is correct. I further cedify 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: z.//~, ~ ~ Waiver Fees:
Date of Payment: /'~ ' ~-Q ~' O 7.- Date of Payment:
Receipt Number: ~_7Q~ ~ ~e'-~.~ Receipt Number:
(Rev. 12/00)
ANDERSON ENGINEERING
P.O. BOX 240773
ANCHORAGE, AK 99524
· 522-7773 ~ 522-6779 (FAX)
October 29, 2002
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
4700 South Bragaw Street
Anchorage, AK 99519-6650
Subject:
BLM Lot 141B, Section 33, T12N, R3W
Septic System Design and Permit Application
Impacts to Adjacent Properties
Dear Onsite Services Engineer:
The septic system on the subject lot has failed and must be replaced. We are therefore
requesting a permit be issued for the construction of a new septic system to serve the
three-bedroom home on the property. 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 existing system,
existing well, test hole locations and wells and septic systems on the surrounding lots.
Drainage arrows are also shown and current drainage patterns will be maintained after
construction.
The test holes placed near the location of the proposed absorption trench indicated
gravel with sand and some silt. The percolation rate on the material was measured at 1
minute per inch. Ground water was found at 5.8' below the surface during the wettest
period of the year. We are therefore proposing to place a new 1,250-gallon STEP tank
with a new 75' long by 5' wide absorption trench with .5' of gravel beneath the
distribution pipe. The total depth of the trench will be 1.5' below the surface with the
distribution pipe at 1' below the surface. The trench will be placed in two segments to
avoid a large tree in the area. Insulation will be placed atop the trench to prevent frost
penetration.
The ground surface on the lot slopes at shallow grades from east to west. The
absorption trench will be constructed parallel with the slope as much as possible in
conformance with Municipal requirements. All components of the new septic system
will be constructed a minimum of 100' from'the wells in the area. The system will also
be constructed a minimum of 100' from any surface water in the area.
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
E LM Lot 141B, Section 33, T12N, R3W
October 28, 2002
Page Two
in the area or those to be constructed in the future'.
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.
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.
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
148B
(79-140)
Jpine Trail Road
41B
14lA ""~'"'
sBg]sI'38'V
80879 St6t~
Dr'ive
115.00
140A
Road
165.00
140B
8~o43
AREA SYSTEM PLAN
SCALE 1" = 100'
1,250 Gal. STE
'20' Long x 3' Wide
X .5 Eft. Depth
Abs. Trench
Existing Tree
55' Long x 3' Wide
X .5 Eft. Depth
Abs. Trench
Porcupine Trail R d
- -~o~--- -
~l ~14~1B ~
Tank
Existing Bed to Remain
For Future Use
I I
Three
Bedroom
Home
~ 2%-5%
Crush and Backfill
g Tank
Existing Well
SI
N
SCALE 1":
BLM LOT 141B, SECTION 33, T12N, R3W
DESIGN FACTORS:
3 Bedroom House
Perc. Rate: I Min./inch
Application Rate: 1.2 GPD/SF
SYSTEM REQUIREMENTS:
5' Wide Trench System ~
1,250 Gallon STEP Tank
.5' Drain Field Rock
3 Bedrooms X 150 GPD/I.2 GPDISF (Application Rate) = 375 SF of Absorption Area
375 SFI5 LF (Width)* 1(Red. Factor) = 75 LF Trench Length
Therefore: Construct a 75' Long X 5' Wide Absorption Trench With a .5' Effective Depth.
Flow Line Elevation in Trench to be 1' Below Original Ground Surface. Total Depth to be
1.5' Below Existing Ground. Maintain 4' of Separation From Ground Water. Maintain 100'
Separation From Well. Place 2" of Insulation and 2' of Backfill Atop Trench.
...... ~ ..... Natural ~ill ."~
6t!
'/I1/1/II/Iit
2" Direct Bury
Insulation
DrainfieId Rock
5!
NOTE:
TYPICAL WIDE TRENCH SECTION
(NO SCALE)
Grade Area Over Trench to Drain Away..
Minimum 6' Separation From Bedrock.
Minimum 4' Separation From Groundwater.
Minimum 100' From Wells in the Area.
Minimum 10' Separation From Water Service Line.
Municipality of Anchorage
Development Services Department/Building Safety Division
Onsite Water and Wastewater Program
4700 South Bragaw Street Anch., AK 99519
SOILS LOG - PERCOLATION TEST
Performed For, Rick Williams
Legal Description: Lot 141B. Section 33
7
8
9
10
11
12
OG/OL
GP
TESTHOLE No,2
Cobbles to
12"
Some
Silt
SLOPE
North
South
Was Groundwater
Encountered?
If Yes, What Depth?
Depth to Water
After Monitoring
Bottom of Date:
Test Hole
Date Performed: 10/14/02
SITE PLAN
· TH7
· TH2
13
14
15
16
17
18
21
· TH6
Yes S
6' L 2%- 5% ~
O
10/15/02 P
5.8' E
Reading Date IGmss Net Depth To Net
Time Time Water Drop
1 14-Oct 10:05 1"
2 10:35 10 Dry 8"
3 10:36 1 ·
4 11:06 10 Dry 8"
6 11:07 10 Dry 8"
Peru. Rate: 1.25 Min./Inch Porc. Hole Diameter:. 6"
Test Run Between 3 Ft. and 4 Ft.
Comments: Perc. Cavity Presoaked Prior to Test. Test Hole Placed During Construction
Performed By: A. Harala. I, Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10/27102
Municipality of Anchorage
Development Services Department/Building Safety Division
Onsite Water and Wastewater Program
4700 South Bragaw Street Anch., AK 99519
SOILS LOG - PERCOLATION TEST
Performed For:. Rick Williams
Legal Description: Lot 141B. Section 33
7
8
9
10
11
12
13
14
15
16
17
18
21
OG/OL
GP
.TESTHOLE NO,6
Cobbles lo
12"
Some
Silt
Was Groundwater
Encountered?
If Yes, What Depth?
Depth to Water
After Monitoring
Bottom of Date:
Test Hole
SLOPE
North
South
Date Performed:
SITE PLAN
· TH7
o TH2
· TH6
No S
L 2%-5%
0
10115/02 P
None E
Reading Date Gross Net Depth To Net
ITime Time Water Drop
1 14-Oct 12:15 .75'
2 12:25 10 Dry 9.25"
3 12:26 ,75"
4 12:36 10 Dry 9.25'
5 12:37 ,75"
6 12:47 10 Dry 9,25'
Parc. Rate: 1 Min./Inch Parc. Hole Diameter:. 6"
Test Run Between 3 Ft. and 4 Ft.
Comments: Perc. Cavity Presoaked Pdor to Test. Test Hole Placed Dudng Construction
Performed By: A. Harala. I, Michael E. Anderson Certify That This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10/27102
Municipality of Anchorage
Development Services Department~Building Safety Division
Onsite Water and Wastewater Program
4700 South Bragaw Street Anch., AK 99519
SOILS LOG - PERCOLATION TEST
Performed For:. Rick Williams
Legal Description: Lot 141B. Section 33
6
7
8
9
10
11
OGIOL
GP
TESTHOLE NO,7
Cobbles to
12"
Some
Silt
Bottom of
Test Hole
Was Groundwater
Encountered?
· If Yes, What Depth?
Depth to Water
After Monitoring
Date:
13
14
15
16
17
18
21
SLOPE
North
Sou~
Date Performed:
SiTE PLAN
~· TH7
o TH2
· TH6
10/14/02
No S
L 2% -5% ~
O
10115102 P
None E
Reading Date Gross Net DepthTo [Net .
Time Time Water Drop
I 14-Oct 1:08 .5"
2 1:18 10 Dry 9,5'
3 1:19 .5'
4 1:29 10 Dry 9.5"
5 1:30 ,5"
6 1:40 10 Dry 9.5"
Perc. Rate: 1 Min./Inch Perc. Hole Diameter. 6'
Test Run Between 2 Ft. and 3 Ft.
Comments: Perc. Cavity Presoaked Pdor Io Test. Test Hole Placed Dudng Construction
Performed By: A. Harala. I, Micha(~l E. Anderson Cedify Tl~at This Test Was Performed
In Accordance With All State and Municipal Guidelines In Effect On This Date: 10127102
PRESSURE DISTRIBUTION
CALCULATION
Elevation at Highest Discharge Point
'Pressure at Highest Discharge Point
Liquid Level in Tank (Elevation)
Diameter of Holes in Distribution Line
Diameter of Distribution Line
Hole Spacing in Distribution Line
Length of Transport Line
Diameter of Transport Line
108'
5' Head"'.
100'
.1875" (3116")
3'
40'
1.25"
Q = 12.4~'1/~--= 12.4(.1875)(.1875) 5
= .9748 GPM/Orifice
= .9748 * 24
= 23.4 GPM
TDH = (113-100) + .0192(23.4)(23.4)
= 13 + 10.5
+ .000995(23.4) (40)
(1.25)~'~
+ 4.6
= 28.1'
Therefore 24 Orifices @ 3' Spacing With 28.1' Total Dynamic Head.
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION AND MATERIAL SPECIFICATIONS
SUBJECT: BLM LOT 141B, SECTION 33, T12N, R3W
GENERAL:
The scope of this project includes the procurement and placement of a
new 1,250-gallon STEP tank at the location shown on the site plan
and the construction of a new 75' long by 5' wide by .5' effective depth
absorption trench in two segments also shown on the Site Plan. The
total depth of the trench will be 1.5' below existing ground and the
distribution pipe will be placed at 1' below the surface. All
components of the new absorption trench and septic tank must be
constructed a minimum of 100' from wells in the area and 100' from
any surface water. Insulation will be required atop the trench to
prevent freezing. The existing septic tank must be pumped, crushed
and backfilled.
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.
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.
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.
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
pdor approval from D.H.H.S. before beginning system installation.
SEPTIC TANK/LIFT STATION INSTALLATION
The 1,250-gallon STEP tank must be constructed by a certified tank
manufacturer. Construction shall include an 18" manhole to provide
access to the lift station.
2. The septic tank shall be sufficiently bedded to prevent settling or
shifting of the tank.
3. All standpipes on the septic tank shall extend a minimum of 12 inches
above final grade.
4. Tanks installed without 4' of cover shall have a minimum of 2" of direct
budal insulation.
BLM Lot 141B, Section 33, T12N, R3W
October 28, 2002
Page 2 of 2
A foundation cleanout shall be installed one to four feet from the
building foundation. Two cleanouts are required between the tank and
the drain field.
6. Final grading over the tank shall be such that a positive slope exists
away from the septic tank.
DRAIN FIELD CONSTRUCTION:
The drain field shall be constructed to the dimensions shown on the
design. The bottom of the trenches shall be within 2" of level.
2. Distribution piping must be placed level with perforations down atop a
level bed of drain field rock. Rock should then be placed over the pipe
to provide a minimum of 2" of cover.
3, A silt barrier or geotextile fabdc must be placed betWeen the drain field
rock and the natural soil backfill.
Monitor tubes must be 4" in diameter and installed at the locations
shown on the design. The portion below ground must be perforated.
Contractor shall verify the septic tank and drain field 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.
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.
Grade area surrounding the absorption trenches to drain away.
A minimum 2' of accepting soil is required below the drain field 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:
The lift station must be constructed by a municipally approved septic
tank manufacturer. An Orenco 20 OSI 05 HHF-5 pump is
recommended.
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).
Insulation shall be at least 2" thick extruded direct burial polystyrene
(Dow Chemical Co. Styrofoam HI or equal).
Septic tank inlets and outlets shall be fitted with watertight couplings
(Caulder, Fernco, or equal).
BLM Lot 141B, Section 33, T12N, R3W
October 28, 2002
Page 3 of 3
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 fabdc, 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 cedified as-built of the completed system.
ANDERS'ONi ENGIN EE'RING i' '::!
OX 24077~3:.:!::{~!~' :':::. ;::~i' ': ::' :, :.:
ANCHORAGEs'AK 99524 :::~ ..'..:: .~.i' ',~:., 'i.I
:!522-:6779 (FAX)::' :.'~: :~:i~ iiI
October 28, 2002
Municipality of Anchorage
Development Services Department
On-Site Water and Wastewater Program
P.O. Box 196650
Anchorage, AK 99519-6650
Subject:
BLM Lot 141B, Section 33, T12N, R3W
· Separation Distance Waiver
Absorption Bed to Lot Line
Dear On Site Services Engineer:.
The existing septic system on the subject lot has failed and must be replaced. Several
test holes were placed on the lot to determine the most suitable location for the
replacement site. Unfortunately, the only appropriate location was within 2' of the
western lot line. Soils in this location are clean gravel with some sand and silt. The
water table was located nearly 6' below the surface dudng the wettest period of the
year. The new absorption trench will be a shallow 5' wide trench with a .5' effective
depth.
The septic system on the lot to the west is more than 100' from the property line. No
conflict will exist therefore between the new trench and the system to the west. All
required separation distances can be met between the new trench and all wells in the
area. We therefore recommend a waiver be issued allowing the new trench to be
located 2' from the west property line.
Sincerely,
Michael E. Anderson, P.E.
Municipality of Anchorage
Development Services Department
Building Saftety Division
On-Site Water nnd Wastewatef Program
4700 Brngaw Street
P.O. Box 196650 Anchornge, AK 99519-6650
www.ci.anchornge.ak.us
(907) 343-7904
~ WR020083
Date Received: 10/29/02
Legal Description: ,T12N R3W Section 33 Lot t41B
Engineer:. Michael E~ Anderson
Andersqr~ ]~nalne~rl~g
Waiver Review Worksheet
PID~: 01829270 I-tA~: Permit~:
Applicant: Richard & Debble Williams
Waiver Requested: 2 feet from ;~bsomtl0p field to lPf~ line
Criteria: Geology
A. Water Table
B. Soil Sorption
C. Permeability
D, Water Table Gmdient
E. Horizontal Separation
Total:
Points:
Waiver is Granted: ~. Waiver is not Granted:
LlstConditionsorReasonsforabove: 5'J~6: ~,~.I/.,E£1~ LE/'7'~t~ PF
Data: /~/;::~/tg~.. By: ~)_~/Ip/
Name of Reviewer
Rec~: 27469 Amount: $150.00 Date Paid: 1012912002
Municipality Anchorage
Building S,'ffcty Dn ision
P.O. Box 19('>650 * 4700 S. Bragaw Street
Anchorage, Alaslm 99519-6650 · (907) 3/t3-8301
http://~rw.cl.anchomgc.ak.us
11/5/2002
Michael E. Anderson, PE
Anderson Engineering
P.O. Box 240773
Anchorage, Alaska 99524
Subject:
Waiver Request for T12N R3W Section 33 Lot 14lB
Waiver Request #WR020083
Parcel ID #018-292-70
Construction Permit Number SW020447
Department of
Public Works
Dear Mr. Anderson:
Your request for a waiver of the required 10 feet horizontal separation from the
absorption field to property line has been approved. The approved separation distance is
2.0 feet.
This waiver approval applies to the existing absorption field to property line separation
only. Any future upgrade to the on-site wastewater disposal system will require all
separation distances be met or another approval from this department.
If there are any further concerns or questions regarding this waiver, please call our office
at 343-7904.
Sincerely,
Daniel J. Roth
Civil Engineer
On-Site Water & Wastewater Program
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 9950'1 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
~;~~_.~?~¢ CC Buck Construction
MAILING ADDRESS
LEGAL DESCRIPTION ..~' ~
LOCATION
Manufacturer
Liq. capacity in gallons IF HOMEMADE: Inside length
OISTANCE TO: Well Dwelling
Foundation
DISTANCE TO:
No. of lines Length of each line :h of lines
Top of tile to finish g adc -~'
Length Width Depth
Type of crib Crib diamete]
Well
DISTANCE TO:
Oept,y 3/
foundation
DISTANCE TO:
Nearest lot line
Trench width
PHONE ~ NEW
NO. OF BEDROOMS
PER T NO.
No. of com?~.~ments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PE T,~N Q. .
inches Distance be~l~n ~.~es ~
Crib depth
Total effective abs tlon are
PERMIT NO.
Total effpctive absorption area
Building foundation Nearest 10t line
Distance to lot line
Septic tank
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
Absorpt~).. ,/,/~ ~,
APPROVED DATE LEGAL
72 013 (Rev. 3/78)
JAMES 8. ROIBER?~, PE~ ~LS
360 West Benson Blvd,, -~207
Anchorage, AK 99503
SOIL I_OG
PERCOLATION TEST
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ GeophysicolSurveys
........... /V/8 i-o,--o,--o,-I 3:5 /~- sm w~
Ic~.IDtSTANCE AND 0 RECTION FROM GOAD INTERSECTIO, NR.~
4. WE~.~.,EPTH; (final) ,5. DATE OF COMPLETIO~.~.-
.z~'.~ :., t,. ~ --? 1 - Z,~
Feet Below
Top Bottom
t ~"> ~/
_1/,'/
E. [] Coble tool ~rRot.ry [] Drive.
[] Irriqallon [] Recharge [] Commerlcal
[] Teet Well [] Other;
8. CASING: [] Threaded ~T Welded
Yype: ~>?'~"~{'~" Diameter:
I2.GROUTIND Well Greuled: [] Yes ~ No
Materl(~r: [] Neat Cement [] Olher:
° []F []c
~[UNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF I~ALTH AND ENVIROI~iENTAL~ PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Infomnation Appli~cation Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
(~)
(d)
Location (address or directions) ~- , /
__ -~ ........... ~ ~ ~<- h,~~
Applicants Name_~_/'~.:i~_~'/;'~j[~~ Telephone-' Home Business
Lending Institution
Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
Mail the HAA to the fol].o%;ing address:
T~y~__o~ Residence
Single-Family~
Number of Bedrooms
Other (describe)
Water Supply
Individual Well~-~x~ Community ~ Public I----~
Note: If community ~;ell system, must have written confirmation from the State
Department of Enviromnental Conservation attesting to the legality and status.
Sewage Disposal
Note: If community ~.~e].l system, faust have written confirmation from the State
Department of Environmentai Conservation attesting to the legality and status.
[Page I of 2]
5- M~%~.eri~g ~'irm Providin? Inaoections, Tests, File Se.ar__~. Data and Infonnation
cer$ifisd 5~ ~_y ~3eal affixed hereto .and as of the validatioa date shown below, I
that ~z7 i~vestigation of this Health Authority Approval shows that the on-site
,s'~pply ara,d/or wastewater disposal system is safe, functional and adequate for
~x~u*~ber of barrooms and type of structure indicated herein° I further verify that,
~,n th~ f~fo~]tion obtained from the Municipality of Anchorage files and from my
iaw~iga$ion ~.d inspection, the on-site water supply and/or wastewater disposaI
!~ im cc,3.ptiance with ~ll Municipal and State codes, ordinances, and regula~
i:% effact or~ the date of this inspection.
CAmOM
ANCHORAGE DEPAR~ENT OF ~ALTH ~D E~IRO~NTAL PROTECTION
~UTI.[ORIrY APPROV~ CERTIFICATES BASED ~OLELY UPON T~ REPRESENT-
P;2~AGr~PII 5 ABOVE BY ~ INDEPENDENT PROFESSIO~L ENGI~ER ~GISTERED
,~u,~, THE DHEP DOES THIS AS A CO~TESY TO PURC~SERS OF HOMES AND
~.~,~z~ollONS IN ORDER TO SATISFY CERTAIN FEDERAL [u~D STATE ~QUIRE-
[~IEP D0 NOT CONDUCT INSFECTIONS OR zVNAL YZE DATA BEFORE A
i$¢UED. THE MUNICIPAL2TY OF ~CHORAGE IS NOT RESPONSIBLE FOR ERRORS
PROFESSIONAL ENGINEER'S WORK.
(DHEF SEAL)
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAL)
CHECKLIST - FEBRUARY 19,84
Well Classification
Well Log P~esent (Y/N)
Total Depth. /~i~' Cased to
Static Water Level _
MUNICIPALITY OF ANC:I'ICJI~AGE
D~PT, O1: IIEALTH &
ENVIRONMENTAL PROTECTIO~
:L 8 lg85t
RECEIVED
Legal De s~=.i..~io n:
If A, B, C~ C, D.E.C. Approved(Y/N)
Date Completed
/ {~ __ iDepth of G~outing /~//~
At
Casing Height Above G~ound
Electrical Wi~ing in Conduit (Y/N)
Sepal?etlon Distances f~cmWell:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot //~
~o Nearest Public Sewe~ Line
Cleanout/Manhole
Water Sample Collected By__
Wats= sample Test P~sults
Comments
Sanitary Seal on Casing (Y/N)y_
Dep~essionA~oundWellhead (Y/N)/V
; on Adjoining Lots
_; On Adjoining
iTo Newest Public
TO ~est ~ ~rvi~ Li~ on ~t
Be
SEPTIC/HOLDING TANK DATA
Date Installed ~.//~/~'~_ Size /,~:'~_? ~,,,," NO. of Ccmpa~tr~nts
Standpipes (Y/N) ~-~ Aid-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) ?" _
Depression ove~ Tank (Y/N) z%/ , Date Lest Pumped,/J,~3~/
Pumping/Maintenance Contract on File (Y/N)/¥/.~ ; fo~_
Holding Tank High-Wate~ Alarm (Y/N) /~./'~ Temporary Holdir~3 Tank Permit (Y/N)~../~
Separation Distances f~om Septic/Nolding Tank:
To Wate~-Supp!yW~ll
To I~ope~ty Line
TO Water Hain/Se~vice Line
Course
To Building Foundation ,~5;"
To Disposal Field /~/
To Stream, Pond, Lake, c~ Major D~ainage
Counts
[Page 1 of 2]
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata _ /~ ~Type of System Design
Date Installed__ ~/~'~ __ Length of Field ~/~
Width of Field ~ ~ ~pth of Field ~ ~
~ ~ravel ~d ~ick~ss .~
S~e Feet of ~so~tion ~ea . ~~ . Stan~i~s ~esent ~Y~)
~p~ession ove~ Field (Y~) ~ ~te of ~st A~a~ Test
Results of ~st ~a~ ~st ~/~
Separation Distan~ f~ ~sorption Field:
To ~te=-Supply ~11 //.~ To ~o~rty Li~ ~ ~
To Building Foundation .~ ~/z ~ ~' To Existing or ~ndo~d System
Lot ~/~ ' ; ~ ~joining ~ts . ~
To Ware= Main/~=vi~ Line ~ To Cut~( if pre~nt)
To St=e~ond~ke/~ Majo= ~aina~ C~se
To ~iveway, Pa~ki~ ~ea, ~ Vehicle St~a~ ~ea ~ ~'
De
Date Installed
Size in Gallons
"Pump On" Level at
High Ware= Alarm Level at
Tested for
Electrical Codos (YfiN)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
** Check Permitted Bedroom Rating Against HAA R~quest
certify that I have checked, verified, o~ confo~r~ed to all MOA HAA Guidelines in effect
o? the date of this inspgction.
Company ~/~L'~ ~ ,~.~ ~ ./3~.~/~.~/~MOA No.
KB1/d5/s
[Pa~e 2 of 2]
2-15-84