HomeMy WebLinkAboutHYLEN CREST #1 BLK 2 LT 3Hylen Crest
#1
Block 2
Lot 3
#0504m492_82
Municipality of Anchorage Page of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 • Telephone: 343-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number. s(.ti O Z O `E 1 PID Number. S2 d—�� Z— z
"'m°
riatt+� �r �e�t.� Mav� o (c{
stem: Wastewater S f�Vew O Upgrade
Y
AMrftso ,? Zl �{ °i tt L�
ABSORPTION FIELD
Phony /r �p z63
p (v
No- Of Bed a:
O Deep Trench naltow Trench ❑ Bed O Mound ❑Other
LEGAL DESCRIPTION
soil Rating: O 13
Total Depth tromoriginal gra0s:
5•
P Ft.
Lot Block: Subdivision:
ivision�:.^
Depth to pipe bottom from origknl grade
4
Gravel depth beneath pipe
ur el Vt
• ID Ft.
1.0 Ft.
Township: ' u N
Range.
Section: Q
Fill added boeoorigi� ��
Q
Gravel length: 19ck
J
kA Ft.
Ft.
WELL: NoL44 O New ❑ Upgrade
Gravel width:0
NumberotlirZ:
Z
WtsnwWMa %=
• Ft
rs Ft
C nvate. Total Depth: Cased
Total absorption aroa Ztc 4111
Pipe material: s $ D •O
k
wd lL. Q Ck FtFt.
Y"P�--Aw wtl
' r. rilNd: StaticwswLevat:
In Il�r: 1Wt - M"• , ,
i Iktd:
Z
Ft
1►•i
O
Yield:
Pump Set at
Caairg above Ground:
e N t M.RN' vowe S a .
9A** -1A0{At.y` 'YANK
GPM
Ft
SEPARATION DISTANCES
W<Ptic O Holding ❑ S.T.EP.
To Saotic Absorption uh "owing
Manufacturer.L
Capacity In gallons:
/4000
From Tank Field Staaon Twat aawerunss
KCk0 t&-V�k A-
Welt jJ0 09-J5
Material: S'icc.'
Number of comm
s°�BCe0 ►tom
Water
LIFT STATION t,J
Lot' '
Size in gallons:
Man ter:
Line
Foundation to O - 4 3
"Pump on* level at High water alarm at
Curtain �/iq
Pump
Electrical Impactions performW by
Drain
Remarks:
BENCHMARK
-
t ocab� Description: /s
CO VZ � �GtrY
frtt++M)
Kx
Zt44--
E0.5 -t- $-I a.
Assumed Elevation:
100,0 Ft
C1;L ••y d
THInspections
performed by: ��-�+ '�'r 15-- Dates:1 /o 1-1 •
• �''• _• •l _•
2nd1R�_
�+tc3;• GBEGONALAAE6EflLi
'•. CE 9254 •' i
�l,••••.....••��
Department of Healt and Human Services approval
Reviewed by: Date:
and approved
77-0?3 M". SM) %s0A t5 \-/ V
141,-Zv 1Z,
MUNICIPALITY OFANCHORAGE ! o�a-7 z
Development Services Department
On -Site Water & Wastewater Program
4700 South Bragaw Street
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-7904
ONSITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Permit Number: SW020411
Legal Description: HYLEN CREST #1 BLK 2 LT 3
Date Issued: Oct 15, 2002
Expiration Date: Oct 15, 2003
Parcel ID: 050-472-82
Design Engineer: 0821 Eberle Engineering Services Site Address: 021043 UPPER LOWLAND AVE
Owner Name: Brian & Carleen Mangold Lot Size: 20025 SQ. FT.
Owner Address: P O BOX 773214 Total Bedrooms: 3 Permit Bedrooms: 3
EAGLE RIVER. AK 99577-3214
This permit is for the construction of:
F✓ Disposal Field E✓ Septic Tank Holding Tank Privy E] 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 By:
Issued By:
Date: E.o 1 ZZ Oz,
Date: (% ��
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.cLanchorage.ak.us
(907) 343-7904
ON-SITE SEWERIWELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 056 L{ 1 Z $ Z Permit Number SW OZ 04 11
Property owners) BWow, , 4 Cwr[a..,e.v�- t"%K ae lal
Mailing address
pay phone 61q -4Z43
. Eo -g I.j.. -A%::- -
Mailing address (2) P-00 J?dl 7 7 3 L 1 y Zip Code
Legal description (Lot, Block & Sub'd.) 3 !—$ L Z, ., ` — C✓�`� D
Legal description (Section, Township & Range) Cxc.{ t a-►� 9 .$ ,Tl L1 ,v , 1-A W , 5't"
Lot Size 2-4;6� Acre Sq.FL Number of Bedrooms 3
�D oa S
THIS APPLICATION IS FOR:
Sewer Only Well Only ❑
Sewer and Well ❑ Water Storage ❑
Sewer Upgrade ❑
THIS PROPERTY CONTAINS:
Hot Tub ❑ Jami ❑
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.
(Signature of property owner or authorized agent)
Permit
Date of Payment: 1011,Loz.-
Receipt Number: OZto716
(Rev. 12M)
Waiver Fees:
Date of Payment:
Receipt Number:
Z•
Eberle Engineering services
WELL AND SEPTIC SYSTEM APPLICATION NARRATIVE
LEGAL: Lot 3 Blk 2 Hylen Crest–Section 8, T1 4N, R1 w, SM
Tueday, October 08, 2002
IMPACTS TO ADJACENT PROPERTIES
The location and design of this wastewater system is expected to have no impact on
adjacent properties. There are no wells or surface waters within 200 feet of this proposed
design; the subdivision is served by a community water system. The nearest existing septic
system on neighboring properties is to the west on Lot 2 and lies 25 feet from the proposed
bed system.
Other neighboring systems are shown on the plot plan drawings. We are requesting a lot
line waiver down to 0 ft. The design location causes no impact on reserve areas on
neighboring lots.
TOPOGRAPHY
Hylen Crest Subdivision #1 consists of single family homes lying near the toe of steep
mountains of the Chugach Range. Lot 3 Block 2 is flat; the land immediately to the north is
generally sloping 5%, plus or minus, to the south and toward the center of Eagle River
Valley. The subdivision is developed with water utilities, electricity, phone, and natural gas.
LOCAL WATER LEVEL
A 16 -foot deep soils -investigation pit was dug on site and a standpipe inserted to that depth
for monitoring groundwater. No groundwater was sounded to the 16 -ft depth for one
week—from Tuesday October 1, 2002 through October 8.
f;1:11:10101 •tils]a11*31I`3_L`LDI&I91061
The soil immediately underlying the 12 -inches surface organic layer consists entirely of sand
with gravel, sift and occasional cobbles to 8 inches, SP -SM by USCS. Three Falling Head
percolation tests were performed in accordance with Alaska DEC specifications in the holes
indicated on the attached sheets. The soils above 7 feet BGS percolated in the 6 to 15
minutes/inch range, resulting in a design rate of 0.8 GPD/SF or 188 SF/BR by Table 1 per
AMC 15.65 for the wide trench requirements and specifications.
Soil logged below 7 feet BGS consists of silty sand with gravel, SM by USCS. System
design depths were limited by the elevation of the top of the low permeability soil formation
from 7 to 16 ft BGS, having a percolation rate above 60 minutes per inch. See percolation
sheets.
Included: I -On-site Sewer/Well Permit Application for a Single Family Dwelling
1 Narrative (this sheet)
1 -System Specifications
1 -Design Site Plan
1 -Cross -Section and Profile
I -Design Dimensions
I -Buildings And Systems wrin 200 ft
1 -5 -WIDE Trench Drainfield Design Sheet
4 -Soils and Percolation Sheets
Eberle Engineering services
3875 Mariah Drive
Eagle River, AK 99577-975
Phone/FAX 907-696-0402
SPECIFICATIONS FOR ONSITE SEPTIC SYSTEM
LEGAL: Lot 3 Block 2 Hylen Crest SD—Section 33, T1 4N, R1 E, SM
October 8, 2002
2-30-- I2-2.(=�
2-7Z-5851
A. GENERAL
1. The septic plans are for a single-family, 3 -bedroom residence.
2. The site plan and profile drawings shall be a part of this specification.
3. All materials and workmanship shall meet the Anchorage Department of Health and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the
engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to
meet Municipality of Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate
any adjacent multi -family wells.
7. The excavation is to be exactly in the area shown on the site plan; any deviation requires
engineer approval.
8. It is always recommended that a surveyor locate the nearest lot line position and the location
of any easements.
9. Any remaining open test hole excavations shall be filled.
B. SEPTIC TANK
1. Septic tank shall be 1000 gallon.
C. 5 -WIDE DRAINFIELD
1. The trenching is to maintain uniform total depth.
2. The bottom of the trenches shall be level throughout their entire lengths and their perforated
pipes and sewer rock top and bottom of equal elevation.
3. The total depths of the trench excavations are not to exceed 4.5' at any point.
4. The effluent lines within the trenches shall be laid level within 0.03'.
5. The sewer rock gravel is to be covered with typar fabric material if not insulated.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be
placed over the trenches.
7. The area over the trenches is to be finish graded to prevent ponding of surface water runoff.
8. The septic tank and leachfields must not be closer than 100' to any existing private well, 150'
to any Class "C" well or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 4.5' GRAVEL DEPTH = 12" under pipe, 2" over pipe
TRENCH LENGTHS (CENTER) = 49' TRENCH WIDTH= 5'
SOIL RATING= 0.8 GPD/SQ.FT BEDROOM CAPACITY = 3
SEPTIC TANK SIZE = 1000 GAL. SEWER AND PERFORATED PIPE DIAMETER = 4"
Twenty-four (24) hours notice required for all inspections.
/
HOUSE
LT 4 BLK 2
2 BLK 2
H❑USE LT 3 BLK 2 HYLEN CREST #1
HOUSE
BM=100.0
Pr posedor¢'Q
Qr`C
q
tree Opt is ing
p3
3 tree 0 0 PI O 0
✓tree
/_
standpipe
deep pit
(�
0 40
80 it
UPPER LOWLAND SCALE
T—
SITE PLAN -- DESIGN
= �F•A�q �1
LEGAL: LOT 3 BLK 2 HYLEN CREST SDaw
��:
ca. •'`��,9��r
�r; 49n �j
....... . .... ..:..x
: GREGORY ALAN EBERLE .
SECTI❑N 8 T14N R1W SM
OWNER: BRIAN & CARLEEN MANG❑LD
CONTRACT❑R/BUILDER;
JOB N❑,; 02-002
DATE; 10/8/02
EBERLE ENGINEERING SERVICES
t •. CE 9254
,!j'i'�,°ROFFSSiON?�=r
3875 MARIAH DRIVE
EAGLE RIVER, AK 99577
�� tea•--�
907-696-0402 (phone and FAX)
(o 0Z
Existing and Perc. #2
Finish Grade 99.0 Perc. 43
Deep Pit w/
Standpipe
16' GS to Bottom
Top of Sewer Rock 96.0 _'z
Perf. Pipe Invert 95.5 Perc. #1
Bottom of Trench Elevs. 94.5
10' min.
Bottom Et. 83
5' wide-each trench
TWO WIDE TRENCHES
NOTES:
- Geofabric fines barrier over top of sewer
rock and
3 feet minimum soil cover unless wide trenches are Insulated.
- Blueboard Insulation to cover perforated sewer lines and
tank where soil cover is less than 3 feet
thick.
- Maximum digging depth 4.5 ft BGS
0
20 40 ft
.
SCALE
House Foundation Wall
SP\\tkef
House d F\o`N MTs
CO CO CO COs C❑s
1
Cos
o4 Existing and
Finish Grade 99.0
Tank Invert 96, 4 96,2
Top of Rock 96.0
Bottom El. 94.5
Pipe Invert 95.5
92.1
Tank Bottom 10 Two 5-Wide Trenches
1000 gal ~49'
Tank
0
20 40 ft
SCALE
CROSS—SECTION AND PR❑FILE
'-f OF
OF q ��
,.= .�.••••..lq ��
,� �P' •`S'�.�1�
.•'� �/
LEGAL; LOT 3 BLK 2 HYLEN CREST SD
SECTION 8, T14N, R1W, SM
OWNER; BRIAN & CARLEEN MANGOLD
`al
"" '�••�
•'.
CONTRACTOR/BUILDER:"""
JOB NO.: 02-002
DATE; 10/8/02
GREGOAYIIIANEBERIE•.' •i
'�J'•.• CEM
EBERLE ENGINEERING SERVICES
3875 MARIAN DRIVE
EAGLE RIVER, AK 99577
907-696-0402 (phone and FAX)
o 13 OZ
L /
3 B �
NYL c
N
5.0� L
3 gees
P--24.41
.9/
tree
UPPER LOWLAND
CROS
T #1
:istlKlm
'.EPLFGCE TANK
1000 GAL.
ISTING SEKIC T
0 20 40 it
SCALE
I SITE PLAN -- DESIGN DIMENSI❑NS
I FFAI : I nT :I RI K ? HYI FN (RFST ST)
SECTI❑N 8 T14N R1W SM
❑WNER: BRIAN & CARLEEN MANG❑LD
J IVU.: Ucf—uue I UH 1 t: lU/ bl Uc
EBERLE ENGINEERING SERVICES
3875 MARIAH DRIVE
EAGLE RIVER, AK 99577
907-696-0402 (phone and FAX)
LT 5 ELK 2 sf`
LT 6 ELK 2
E.
�rfA
HOUSE
LT 1 ELK 2 � Septic
HOUSE
LT 4 ELK 2
LT 2 ELK 2
Septic
HOUSE
LT 3 ELK 2 HYLEN
FH
CREST 41
HOUSE
Proposed,,-"'
\••� "
Sept[ -
Is Ing
UPPER LOWLAND
0 60 120 ft
SCALE
LT 3 ELK 1 LT 2 ELK 1 LT 1 ELK 1
Septic
Septic
HOUSE
HOUSE
BLDGS & SYSTEMS W/IN 200 FT
LEGAL: LOT 3 BLK 2 HYLEN CREST SD
r
.... .... ...
..... .:
• �l
SECTION 8, T14N, R1W, SM
OWNER; BRIAN & CARLEEN MANG❑LD
CONTRACT❑R/BUILDER.
JOB N❑. 02-002
DATE 10/8/02
.
',•ERE ORYWNEBERLE :'ge
ING SERVICES
l�t�cFs2saNP��r��
3875EBERLMAR AHNDRIVE
99577
EAGLE RIVER, AK
907-696-0402 (phone and FAX)
Let 31 z 41 LGA- CTA -It sk bd; v; s ; o
T i q i v -I t S�-i-�o �$, SM
fro Kt.. T�l� � CP,�••,L tis, b5] � 5�5� ..c�o �.
J`V" taf I 0-lok, �art� o l Nc�•��1,
L�tS
Soi �5 A� W
aoccAS ioKcL cobbGs -t 8"
`� ►88 Zl B2� 3 BR* = 563 kt
5
so. C.. f -,A VMq't t 3,vc. (0.87T
A!hgE.•• .•q`s'lll �T;v w/ l2
Ir
Raw
GREGORYAUW BE U i
,111 CE 92sa . •� D� S `I tJ
101
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage. Alaska 99502-0850
SOILS LOG — PERCOLATION TEST
.._,� vrA4 'Xl
// • •• GRE GORY AL ANEBERIE•.•
rr�;.• CE 9254 .
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PERFORMED FOR:r'�' • 'A� Q �� DATE PERFl1ORMED: • I
LEGAL DESCRIPTION: L i�s1(am . ( WSfTownship. Range, Swlion: T qI''v``) It.i W
�m
8
9
10
11
12
13
14
15
-M
Cst
�C-
C-0
wLoiSf� S i l� SAND
�•j t �� J Q (� WAS GROUND WATER
Go A le -s
S M,
c
SLOPE
PERCOLATION RATE (mmulwinch) PERC HOLE DIAMETER
' TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: I CERTIFY THAT TH TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNIOPAL GUIDELINES IN EFFECT ON THIS DATE DATE
72-106 (R4v. 4/85)
!!!!!!!!!!
PERCOLATION RATE (mmulwinch) PERC HOLE DIAMETER
' TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: I CERTIFY THAT TH TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNIOPAL GUIDELINES IN EFFECT ON THIS DATE DATE
72-106 (R4v. 4/85)
UuWdpo thr a Aedwrsp .
DEPARTMENT OF HEALTH 6 HUMAN SERVICES
825 -V Street Archwe9e. Alaska 99502•0860
SOILS LOG — PERCOu71ON'I ES I
FIDFORMED
LEGAL DESC
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TETT RUN aTwm ....L... FT AMD FT
comkouTS
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ACCORDANM WITHLL ASTATE AMD MUNXWft GUWCUIM w I"ZCr CN TMS DAIM CATS: r 0 $ OZ.
DEPARTMENT OF HEALTH i HUMAN SERVICES
W W S"K AnchonigM Almska 09502.0W
SOILS LOG — PERCOu►noN TEST
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LEGAL
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2
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9V%Lv30 w;'t k
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11
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14
15
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17
1s
19
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AMMAN=" M AU STA M Aim b"MCO u. GUMUN s IN EFFECT ON TMS OATS. OAT& 10TT'03e- . _-
724a mm..�a,
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
PHONE
EAEW
Jl?(,' — C-`0 4K. - -J
-'! _ JJ
❑UPGRADE
MAILING ADDRESS
" L 1. bit �4p� 1s/a'
LEGAL DESCRIPTION
LOCATION
NO. OF BEDROOMS
3
DISTANCE TO:
Well
Absorption are /
Dwelling A1
PERMIT NO.
Oy
n{'�1r17coi 7Y
jet
1- z
a
N
Manufacturer
fJ
Material
-LE -C-
No, of compartments -7—
IL
Z .-
57
(n
Liq. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
�C�z
DISTANCE TO:
Well ry !
Dwelling
PERMIT NO.
/y
= z F
Manufacturer
Material
Liquid capacity in gallons
L)
DISTANCE TO:
el
- j /w Uxj..ry
Foundation
(p
Nearest
PERMIT NO. r
ZNo.
F w
of line
Length of a h_ lirle
Total length of lues
31
Trench wid
inches
Distance between lines
h
Top of tile to finish grade /
Material beneath tile
8 `Finches
Total effective abso�rptioj) area
'
4
Length
Width
Depth
PERMIT
w
O
C i- -
CL
W
Type of crib
Crib dia a
Crib depth
Total effective absorption area
LU
DISTANCE TO:
Well
Building foundation
Nearest lot line
ClassDe
1 t
Dril er _
Distance to lot line
PERMIT NO.
10?
wh
�
DISTANCE T0:
Buildingfoundation
Sewer line
Septic tank
p
Absorption area(s)
p
OTHER
PIPE MATERIALS
P V"L
SOIL TEST RATING
3`'��2
INSTALLER
z 7'
REMARKS
41 r
s
Fr
,,i E;
'Ro
IL
or F',1+
1457 -k
o�
APPR ED _ DATE LEGAL
rz.0 i sAhev. '31 /6)
MUNICIPALITY OF ANCHORAGE
Department f Health and Environmenta" ?rotection
825 Street, Anchorage, AK. _9501
264-4720
Permit # HANDWRITTEN PERMIT
W L AND/OR ON-SITE SEWER PERMIT 6P
Applicant: x(9,1 0 k-2�`7' Mailing Address: 4--r
!J J
Location: Phone Number:
Legal Description: )4WZ-C->/l C4jF�j�Lot Size: _
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: Soil Rating (sq.ft/br) 1 'v—/
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH �� S GRAVEL DEPTH .17_ WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between.the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel.between the outfall pipe and
the bottom of the excavation(in feet). / /�
* * REQUIRED SEPTIC(HOLDING) TANK SIZE _.. G 000 GALLONS #
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.
#, TWO(2) INSPECTIONS ARE REQUIRED
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feel
for a private well or 150 to 200 feet from a_public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 31, 1 9 3 3
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2)I wi,l 'nstall the system in accordance -with codes.
(3) I nde nd t t the on-site sewer system may require enlarge"ent if
4phe
arsenc'remodeled to include more that rooms
Signe Issued by: L' P-
licant
Date
SWP/024 (1/81)
a
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
PERFORMED FOR: L7V"r'T_l 1j--� /y�� Ci�� �G DATE PERFORMED: L
LEGAL DESCRIPTION:_ Z-�7 K�L-K, f�LC',sA/
SLOPE SITE PLAN
RETTGV(�VONIC
8-
9-
'4
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
2
AvtL
3
'
E.
rKrnc_� cc I -)Y 4-,EA1S .s
0:
0 xik-
4
6
5120Y�1 /c.)
�,
7
/ /
/5 lee-
ee-
f
Sl�wDY G�i'1vtL.-
LCNSiiS _� WAS GROUND WATER S
L ENCOUNTERED? O
`f <� D
P
IF YES, AT WHAT E
DEPTH?
14
51617 15-
16-
17
18-
19-
21
8 1920 -L
COMMENTS
PERFORMED BY:
72-006 (6/79)
L
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
0'
PERCOLATION RATEPh(minutes/inch)
TEST RUN BETWEEN eve FT AND FT
CERTIFIED B
DATE:
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
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D. osn-472-s2 HAA#
1. GENERAL INFORMATION Expiration Date: . n - a - O
Complete legal description Lot 3: Block Hyten Creat #1
Location (site address or directions) 2`1043 1rg12Pr tovtnnd Avr FflgiP Ricrr_ AK 99577
Current Propertyowner(s) Michael Frieser
Mailing address same
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Dayphone 694-5715
Day phone
Day phone
Unless otherwise requested, HAA will be held by DSD for pickup. gl }/o s-
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual Water Storage
❑
Community Class Well
❑
Public Water System
E9
Individual On-site U
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 4 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. (Certificates may be reissued for a period of up to one-year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures 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 ts(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm
S & S Engineering
Address 17034 N Earle River Loon ate 204 Earle
Engineer's Printed Name Robert A. Shafer
5. DSD SIGNATURE
✓ Approved for 3 bedrooms.
Disapproved.
Phone 694-2979
Conditional approval for bedrooms, with the following stipulations:
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By; , J Original Certificate Date:
(Rw DIM)
Municipality of Anchorage
Development Services Department b;
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:sDT �J r �t�,cY :fit ttV xr 6ZOTAf ParcelID:_
A. WELL DATA 705LIc-
Well type _ If A. B, or C provide PWSID # _ Well Log (YIN)
Date completed _ Sanitary seal (YIN) _ Wires properly protected (Y
Total depth ft. Cased to ft. Casing height (abo ground) in.
FROM WELL LOG AT INSP ION
Date of test
Static water level ft. ft.
Well production g.p.m. g.p.m.
WATER SAMPLE RESULTS
Coliform
0ml. Nitrate mg.A. Other bacteria colonies/100 ml.
Arseni • _ mg.A. Date of sample: _ Collected by:
SEPTIC/HOLDING TANK DATA
Tank Type/Material 5tTn C-/ STr-e L Date installed 1 6 zx� - 16./TA
Tank size 1000 gal. Number of Compartments 3 Cleanouts MN) 't&5
Foundation cleanout(VN)t5-ILDepression over tank (Yt� L� High water alarm (Y/ip &�er
Date of pumping -T 1;% I ce Pumper 7:72 .3
C. ABSORPTION FIELD DATA
27-Lo�"
Date installed �. _/ Boil rating (g.p.d./ftp or ftZ/bdrm) 0 System type
ctCz � r r
Length I (7 ft. Width 5 ft. Gravel below pipe 1 ft.
Total depth S_% ft. Eff. absorption area q 90ft' Monitoring tube I
_kj Depression over field 0o
Date of adequacy test �1 OS Resul (Pas Faii) �+i3S For bedrooms
Fluid depth in absorption field before test -L in. Water added_Y_Tbal. New depthJb in.
n
Elapsed Time: bd min. Final fluid depth rin. Absorption rate >= 4 + g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y Pg type)
If yes, give date —
D. LIFT STATION
Date installed
'Pump on' level at _in.
Datum
Size in gallons
"Pump off" level at _ in.
Cycles tested
E. SEPARATION DISTANCES T`
SEPARATION DISTANCES FRO
Septic tank lift station o
Absorption feel lot
Publi er main
war /septic service line
�t-�JwT�2
ON LOT TO:
(Y/N)
water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Z� t
Building foundation � Property line 4Absorption field
Water main lb t f Water service line l D }" Surface water (�
Wells on adjacent lots N W
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
1�
Property line l r Building foundation 10 / Water main (b
t
I
Water Service line I b + Surface water e:10'� Driveway, parking/vehicle storage t0
Curtain drain Wells on adjacent lots Ib0
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined thr fie
review of Municipal records that he a vs
conformance with MOA HAA g eli sin
Engineers Printed Name
Date 7 /Z t'1D S
inspections and
vstems,are in
HAA Fee $
Date of Payment
Receipt Number%114.1T 7 __
(Rev. 12101)
Waiver Fee $
Date of Payment
Receipt Number
bit
W A. Obir
06 UP4
in.
07-07-05 12:41 FROM-Pudentlal Jack White Ea31e River
Lot 5
it
ta•. F,�r.. ar
Lot 4
t\y Story
. TCO
H'•CO •TCO
CO .'CO
9076996499 T-913 P-002/002 F-005
C"w F«n
t�
t /
Lot 3, Block 2 i
Hylen Crest X11
le Cb
/ L\,. ---N(. 2't on Lot LI a eB'S9'R0' W U7,71..
UPPER LOWLAND
NNtec
Ca - Or Ow
WT - r«np T.•.
To . T«. D.•• 0,1
e ar a n
SCALE
1 HEREBY CERTIFY .NAT 1 HAVE S "nTEO THE FOLLOWING
DESCRIBED PROPERTY;
LOT 3 BLOCK 2 OF HYLEN CREST SUBDIVISION, UNIT f1
LOCATED WITHIN THE SE 1/4,
SEWARD MERIDIAN, SECTION d, T fa N. R 1 W.
ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
IMPROVEMENTS SITUATED THEREON ARE WITHIN THE PROPERTY
LINES AND 00 NOT OVERLAP OR ENCROACH ON THE PROPERTIES
LYING ADJACENT THCRE70, THAT NO IMPROVEMENTS ON PROPERTY
LYING ADJACENT THERETO ENCROACH ON THE PREMISES IN
UCSON AND THAT THERE ARE NO ROADWAYS. TRANSMISSION
LLIINNESnOR OTHER VISIBLE EASEMENTS ON SAID PROPERTY EXCEPT
AS INDICATED HEREON.
DATED THIS 13 th DAY OF MAY
2003
ALAN J. ROOKUS
REGISTERED LAND SURVEYOR No. LS -8035
205 E. DIMOND #548, ANCHORAGE. AK, 99515
,RIJG-02-2005 1607 S&S ENGINEERING 907 694 1211 P.02iO4
P.2
THIS AOREMNXII, made srd emered W this !— day a(�, 28 D�
by and between MATANU6KA ELECTRIC ASSOCIATION, INC, an Ale w non -pro
member owned ekdrkc cooperative, whose pest office address k am 2929, Palmar,
Alaska, 99646. hereinafter colled'F4st Pay, angMMAL J. FR
addreN kMIR wfoe
FOLF
RIVER ALAsKAmn
h8minaRereaaed'Secord Party, WRNESSETH THAT:
Iee0M1eld system widiftr am 16 foot , - .tris a 1slsaema4rrdonda"
rt 410119 the 80th boundary 0f Lot 3, Black 2, NYLEN CREST 1
BION LJMT Allaceording.ip vW /rr348....
r .. • ; • .
N, RAW tiECE aJY, ANCHORAGE REtORWNG DISTRICT, Third
kL State of Alaska ...
NOW. T14EREFORE.Ycr&WJncmWdmftn:of.eheirmu WapremmMand,
oftr good and valuable e0nskdei360n,1hi reeelpt of which is hereby adorowledged;
Fket Party, for ftW, lea ors
suOm •and assigns, waives ft obJections to Sseond Pad
eneroad,merd on the said easement forthe purpose rw*wled, subject to the
on ;
following cdWorrs: i
1. Second Percy will Bold Visit Pa* hamllim from Aablilly for any IrM
or damage to any fwJm •or p im" whiNmay result from Bud+ or oadm>ent.
2- This rwr�QW*6orl i$ granied With the W
a9resmerit by al partlee having art.kri rear. eprHs property that ft
s and
enmadmrant v pl in no wsy ftcb ct wgink theitarrreiit or future ability of MEA to
enjoy Ste bwAflL4 Of the teaeenwd for sM and'ag oft Purposes that It preeerttiy
envoys order the easement. This non•obJectltr b full
oer conditioned by the stip
that MEA will be tteld:harrttleis from 1gtEkylaranyard ag dartrages t0 the r I
etmoedtmeM that may restrR 8om`the'ekistin9etd future use of said eesemem by ,
MEA. Rs contractors, suocemo.m, operda; 6oer%mw,, or'rrasigns,
as a fen* of wxh esidda FMPa� w� are damagd or
oaww" Wbe repaired
jr replaced. The cost of repair or
replacamant wal ba paid Oft" by tsstaw Party..
4. Second P r
arty ata oanpywtllt M aPDGmble aakty codes end
segumtiena. •, ,_ , �
5.'Anye>greraseas+I+ l'liatPartyc*In" intherabc"mor
rnmiscatilm of tis ladOtiaa to aeeommodate the laid rirraoadtment win be paid
by Second Party.
8. K tre6ord party add World •
rslnacWres, hAEA moat ba notified br Ydvanee. ••. • ,. ,; story or mad►(y ordering7khs BY Ib emmNon d ft Agroeme % Second Party agrees, fa itself
suoeessots end assigns. that hs ft*"m eAment t" the Warned easement as
her' ^spa merrifan®d wN be wtijed to tha'fuege;ip condtdon
IN W(TNEseWHEREOF the parties havvulhotegia caused000cutsd by their thk Agreement m
abve rrrsrf6odflad �P!�sntatlKs and agents as of the aye year
.AW -02-2005 16:07 S&S ENGINEERING
8 -81 -*BM 2e3APH FROM
EnaolPar
ehmert Na+•Ob!egion and AOmn; N '
907 694 1211 P.03/04
P.3
s�
r
S.
oL
a
El Egl IC ASSO
BY.
GewcA Manager or his Re r
STATE OFAL.ASKA L E
:
THIRD JUDICIAL. DISTRICT
mane .yreemerd was ackrro%Wgsd before rre fhls day a
g,y •us�tr; � ! ;
t, H Public r the scam g�aa�
�i Yconmasionexpirac:6/- ;
BEOND ...
9Y: ;
Mk*2M J. FrM"r !
•St
' •1
STATE OF ALASKA + t
THIRD JUMIAL DISTRICT ,
20e by sgreemeritwbs admow+edped before roe dnc �dsy�,(
r.
• ,r
NotaryPuVicfor the
stateotaaNra };
w commieslon aures: k
RCTURN To: ILEA, P 0 SM 27!20, PALMER. ALASKA SOWS I
.AUG -02-2005 10:07 S&S ENGINEERING
•. ��w .s vv•... w, ....V 1.YwV ..Hla IVHIL
NTA OSP ENG 907 761 2646
N roue COPRPAN V
:TION TO
907 694 1211 P.04iO4
Inn nU, OUIC14juve r. uelu:
07/26 105 14:44 N0.063 01/01
By this document Matanuska Telephone Association, Ise. (A¢
encroachment of aseptic system wilt the piatted• 15/ $} f4$a
Wen Cmst #1 Subdivision. Anchorage ir
Section 8, T14N. R1W. SIL
U& that it has no objection to the
one Easement upon Let 3, Block 2,
District, State of Alaska, situated in
fffff ff 4fMatsf aafff Ff fi1
Plea be advised that MTA through the 1M11 = of this document does not forfeit nay of its rights to the use
of the area cited. In the exercise of these rights MTA Wi11, if weded, upgrade, maintain, repair, and/or replace
buried or aaial telecommlmicaticns facilities within t'he'emenlent Any repairs that mW be required to the
eneroadvaaat as a to At of utility consWuian will be borne by the property owner of record. This docnment
docs not au thorsm the placeweat of arty additi6iW'incroac6ents within the casement area. Property owners
are roquired to obtain utility locates before doing'any kind. of.work is the utility easements and will be liable
for any damages caused by their =' struction %W* m the easeiocnM .
This document is in no wav_ 411 @°rernieet to vat2LG env twrNo n sE a lhaw ea--- ent w&9Lc&jd not be
h.
Issued forM&tsmtskz T fthane Association. Inc. this 26th day of July, 2005, by,
Rai Estate &•Properties 34avisor•
TWS tS TO CERTIPY, that on this 26th day of duly, 2005; befoi+e me the pndarsiocd, a Notary Public in and for
the 3bte of Alaska, duly eor»issiaaed cad swpttt as sucfi, peasorial)y ppjteated Bonnie Bailey known tome
and to the known to be the individual named in.acd ivbo ..c oc t d the foregoing hultrumatt and aelmowledged
to me that be signed and aealeb tiie serge as a volurttaiy lRo and deed for the uses and purposes therein
mentioned.
i. have baeuato set itiy'6ullii Ad dikcial seal the day and yew ffist
MaranUaka TolePHona Association, Inc.
P.O. 0ax 3550. Palmer, Meek, 9W4"se0
1A -7*0 510 a 907.741=10 1 Fax 807.761.28"
TOTAL P.04
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 SUBMITTAL COMMENT SHEET
To: Bob Cowan
Legal description: glen Crest #1 Block 2 Lot 3
The attached paperwork has been reviewed and is being returned for the following reasons:
❑ Original signature or stamp missing on
❑ Calculation error in design.
❑ Additional soils information needed. _
❑ Water monitoring results inadequate. _
❑ Discrepancy in information submitted.
❑ Topographic information missing or inadequate.
® Incomplete; missing Need Right of Way approval for septic in util. easement
❑ Incomplete; missing
❑ Additional adequacy test information needed.
❑ Water sample unacceptable. _
❑ Measured/proposed distances/dimensions missing.
❑ Locations of all soils, percolation and water monitoring tests not shown.
❑ Proposed system too deep for soils information submitted.
❑ Well log required.
❑ Omission in narrative.
❑ Insufficient fill over tank or field._
❑ Other.
Name of reviewer: Jeff
Date: 7/27/2005
Please supply the necessary information and re -submit your request.
LEAVE THIS FORM ATTACHED TO THE PAPERWORK
® JR I ++1
Mayor .Dark Bggich
Al unicipa ty Of
RO. 1Wx 1!MX6511 • Anchorage, Alaska !.1751946 ) • Tc! phonc (917);WS-SM t Fax (!X)7113:b8_(X)
371X1 nnlgaw Sired • Anchumgc, Alaska !M1797
""V.nuwLorg
Iluil(ling Safety Division
August 2, 2005
Robert Cowan, P.E.
SSS Engineering
17034 Eagle River Loop Road, Suite 204
Eagle River, AK 99577
Subject: Waiver Request for Ilylen Crest #1 Block 2 Lot 3
Waiver Request WR#: 050055
Parcel ID # 050472-82
PERMIT: SW020411
Dear Robert Cowan, P.E.:
Your request for a waiver of the required 10 feet horizontal separation from the
absorption field to the property line has been approved. The approved separation
distance is 1.0 foot. This waiver basically was in effect at the time of the issuance of
permit SW020411
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,
r0 oodall
vll Engineer
On -Site Water & Wastewater Program
Corti num ity, Security, Prosperity
Municipality of Anchorage
Development Services Department
Building Safety Division
J� On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650 Anchorage, AK 99519.6650
www.ci.anchorage.ak.us
(907)343-7904
Waiver Review Worksheet
WR#:050055 PID#:05O-472-82 HA/Permit# PERMIT: SW020411
Dale Received: August 2, 2005
Legal Description: llylen Crest #1 Block 2 Lot 3
Engineer.
Robert Cowan, P.E.
S&S Engineering
17034 Eagle River Loop Road, Suite 204
Eagle River, AK 99577
Applicant: Brian Mangold
Waiver Requested: 1 foot lot line waiver
Criteria: Geology Points:
A. Water Table
B. Soil Sorption
C. Permeability
D. Water Table Gradient
E. Horizontal Separation
Total:
seen .... @@@see ... 0886656 ...
Waiver is Granted: X
List Conditions or Reasons for above:
Waiver is not Granted:
Date: WV05 By: Joe Goodall
Name of Reviewer
lose .... masses@ ... *seems@ ... 06680886 ... 060660666 .... ODOM@@*@, esdowevess
Rec#: Amount: $0 Date Paid: 812/2005
Municipality of Arich;orage'
• q1�, ..4,., /,i L4 t' 7 >''et Hp♦
.� ' DeVdlooment'S6rvi&esvDeoailmetit -
-;..Building Safety. Division
On S
ite Water and Wastewater Program JSAT,
t , 4700 South Bragaw St "
P 0, Box 196650 Anchorage, QK 199519,6650
www.ci.anchorage.ak us
(907) 343-79N,
CERTIFICATE.OF HEALTH AUTHORITYAPPROVAL.
' •' ' 1'. i
FOR -A SINGLE FAMILY DWELLING t 1
ParcelllD:`'� Liz�SZ '' 1 'i r HAA#!
r. Expiration Date:*
1:' GENERAL INFORMATION
"Complete legal description; L3 Z `►
ZZ.pq� ��. Lowc,at tzc�le >z��.e.tr,
Locaiion (site addressor directions) j� Cas kc�
C0.0 .l Qct Day hone &i q -7&2,63.
Current Property owri r'r t a Y P
Mailing addressJ. , �O :56,v,, �� 3Zl µ �aA �2 eU lr I �c% �g s7.7
Lending agency Day phone'
Mailing address.
Real Estate 'Agent
'Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS.
3: TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual On-site
Individual Water Storage ❑ Individual.Holding tank " E]
Community Class Well ❑ Community On-site ❑ : .
Public Water System [tl 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 professional
engineer's work.
4. STATEMENT•OF INSP.ECTION,BY ENGINEER .
As'certified by. my seal affixed hereto and as of the validation date shown below,�I verify1hat my;inyestigation, • .
'.based on procedures outlined in the Health Authority,App'r I tGuidelines for this application; shows that the
on-site water supply and/or,wastewaterdisposaisystem is(are) safe, functional and adequate
.for the number of • .
bedrooms and type of structure indicated herein -1 fuiiherverNy that based on the information:obtained from the
Municipality, of Anchorage files, and from my .]V. tig'ation and inspection,,the'on-site •water -supply and/or -
'wastewater, disposal system is(are)`in 1.compliance 11.
ithlali applicable ;Municipal -and State codes; ordinances,
and regulations in effect at the time of installation ` _
Name of Firm �»�' A �V _dkVI � (Le._y.1; . SVCS, . Phone
Address,_ 307S"Nf�,\rtc.�� V�V�,::�`t lCic:��r, �k. 577
'�
Engineer's'P.rinted Name'
?Date `-
CIL-
ER S
0 AM's
GRE60RYAlJWEBEBIE.:. 0 1
5. ( DSD SIGNATURE r ' ` 't ^ -� l i, s ' 1, �l •'.• CE 9254 n44
r
c0•'. . •'t��J�-
'�• Approved for i -,bedrooms J �� ` �i �? • cjpNP�
'
Disapproved."
Conditional approval for • bedrooms; with the following stipulations `
rrfr�r�r�����
Q` y'
Additional Comments
PROGRAM
Attachments: _.... .
HAA Checklist X Maintenance Agreements .
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date: 1los
(Rev. I2C0)
-.. .... ..r. .. -_ ...1..111..
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchomge.ak.us
(907) 343-7904
H EALTt i AUTHORITY APPROVAL CHECKLIST
Legal Description: L 3 13Z. 4AA (—V --0-5f 4' ( Parcel ID: O sm' 4?Z._8L
A. WELL DATA N p W"(
-rt y NI i w� 5 • 8 /
Well type _
Date -completed
Total depth fL
Date of test /
Static water level
Well production
WATER SAMPLE RE
Colito
Date
Date mole:
If A, B, or C provide PWSID # _
Sanitary seal (YM) --
Cased to R.
FROM WELL LOG
00 ml. Nitrate
B. SEPTICIHOLDING TANK DATA
Well Log (Y/N)
Wires property prrASA "d (YM)
Casing hSigllf"(above ground) in.
g.p.m.
mgA. Other bacteria
Collected by:
Tank •Type/Matedal
Tank size 1000 gal. . Number of Compartments Z�
Foundation cleanout (YM) Y Depression over tank (Yo
'D�2" I1D2
Date of pumping Pumper
ft.
g.p.m.
colonies/100 ml.
Date installed _L 2'I 0'L-
Cleanouis&) _ TW O Z
High water alarm (YAQ W_
C. ABSORPTION FIELD DATAIlj:t#�^T
1
Date installed /� JOZ oii rating g.p.dJft' r ft'/bdrm) �S System type Q
zx441
Length ft. Width _ ft, gravel below pipe I • ft.
Total depth .�•Cj.. ^ - "':: o6iaa '4iOft2 Monitoring tube Yes Depression over field
Date of adequacy test Oy !Pass/Fail) For bedrooms
Fluid depth' sorption field before test _ in. Wa dded^ gal. Nevepth_ in.
Elapso'f ime: — min. Final fl. epth _ in. Abso on rate >= g.p.d.
Any rejuvenation tree nt (past 12 mo.) (Y/N & type) If yes a date
D. UFT STATION No
Date Installed
'Pump on" level at _ in.
Size in gallons
Cycles tested
High water alarm level at
Meets alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO: t p We, l (s ' 1�1,,A 6 ki G WAAA+
Septic tank/rift station on lot On adjacent lots
Absorption field on lot acent lots
Public sewer main Public sewer manhole/cleanout
Sewer /septic se Holding tank
,;;;,/se ARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ? Property line 1 Absorption field 10
Water main Z Water service line _ Surface water NdtilQ�
Wells on adjacent lots No WJS
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
•��Property Zine Building foundation 110_ Water main
Water Service line Surface water NOV\Q Drivma y, parkinglvehicle storage
Curtain drain toAbwtti Wells on adjacent tots
v t*A7W D �
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAAguidelinesin effect on this date.
Engineer's Printed Name Pk lZbe r l e.
Date SIAM — 11 (-I 1 072 -
HAA Fee $
Date of Payment l3O2.
Receipt Number I()Q¢Z
(Rev. 12100)
I
AW
1 00-
....
it�� •�'•.
CEWU .•,.moi
Waiver Fee $
Date of Payment
Receipt Number
APPLIC NT
FILLS OUT UPPER HAI. ONLY
Time
Property Owner .Sf/%. S7r4 C.C)/1/S 7-'QjU C-7-10AI
Phone
Mailing Address ul
J Zip CodeBuyer
Date
Inspector
Inspector
Inspector
Address ..
Address
Zip Code
Lending Institution
'CONDITIONS OF APPROVAL
Phone
Address
Zip Code
Realty Co. & Agent CFWP N1�b/14LAJ 15-4 1,7/-/
/q-!� b; /-17 I/V C
Phone
Address �� r= G R, CL� . ///%t1/
/()! V C;- PQ Zip Code
,,% y ?.� t•_ y__
Legal Description
—
—
Street Location
Septic Tank Size
---
Type of Residence
XSingle Family
❑ Multiple Family No. of Bedrooms
❑ Other
Water Supply'
❑ Individual
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975.
Community
For wells drilled prior to that date, givo well depth (attach log
if available).
❑ Public Utility
Sewer Disposal
,Individual
Year Individual Installed:
❑ Public Utility
When Connected to Public Utility:
❑ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Inspector
Inspector
Inspector
Inspector
Field Notes:
( —1 APPROVED BEDROOMS
'CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITION L APPROVAL'
DATE d
BY:
Soils Rating
Date Sewer Installed
Well To Absorption Area Well Log Received
—
—
Well to Tank
Septic Tank Size
---