HomeMy WebLinkAboutDENALI LT 124B
Municipality of Anchorage Page I of
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
.~ 'I ~ offo~, PID Number:
Permit Number:
Name: Wastewater System: [] New [] Upgrade
Address: ABSORPTION FIELD
8. o. .f~o;~ (,70~Tz ~u~,~:A~ ·
[=1~ ~D~ No. of Bedrooms:
Phone: ~--~1~ ~K~T~de ~ ~ ~ Deep Trench ~ Shallow Trench ~Bed ~Mound ~Other
Soil Rating: Total Depth from original grade:
LEGAL DESCRIPTION o. s ~.o~s~.~t ~
Lot: J ~ ~ ~ Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: ~I~ Range:I~ Section: _ Fill added above originalograde:. 0 .~ Ft Gravel length: ~ Ft.
WELL: ~x~s~,~ New ~ Upgrad~ Gravelwidth: Number of lines: I ~Oistancebe~eenlines:
~' ~ Ft. I - ' Ft.
Classification (Private, A,B,C): ~ Cased To: Total absorption ar~: Pipe material: A%~ -
~I~T~ ~ Et Ft. ~ ~ · ~ SQ. Ft.
Driller: ~ Date Drilled: Static Water Level:Ft. Installer: ~A ~o. Date installS: ~
'~GPM ~ Pump Set at: Ft. ~ Casing Height Above Ground:Ft. TANK
SEPARATION DISTANCES ~ Septic D Holding ~ S.T.E.P,
To Septic Abso~tion Lift Holding ~ublic/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~ ~ ~ ~A~ ~d~
/ Material: Number of Compa~ments:
Sudace ,+ ~ LIFT STATION
Water lob I~ ~
Lot Size in gall°ns: I Manufacturer:
Line ~0~ + ~o ~ ~ ~
Foundation ~' ~0' -- -- ~~ "Pump on" level at: ~el at: ] High water alarm at:
~' ~g ~o~ ' -- ~ ~Electricallnspectionspedormedby:
Cu~ain
Drain
Remarks: O~ ~/~3/~C ~ ~;~,,~,~,~ BENCH MARK
Lo~tion and Description:
Assumed
Elevation:
EN~~4L
,, ~ ..
Inspections performed by~ a s ENelNEERING~ ,.~,,{.~_,,.~
170~Eag~RiverC~R~a. No. Dates: 1st ~/z~/.~ ,; -" ,
EadeRiver, alask.~5~ 2nd. N/~/qC '&.~ rOBErt C. COWAN
Department of Heal~ and Human Se~ices approval i, ~.-., : ......
Reviewed and approved by: Date: ~-~- ~ "~'---":'::-
72-013 (Rev. 9/91) MOA 25
2 2
Permit No. SW950408 · Page of
Municipality of Anchorage
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
Legal Description: LOT 124B, DENALI SUBDIVISION PID No.: 05114462
ST 1 ~ TM
/.~1.00 ,2 /Z./.--- FINAL GRADE-~ MT1 C01
NEW
95.2 ~
1000 GAL ~, . ~94.8'
WA~ gR FOUND
~w ~ u - D~kl 24.2' 22.5'
C 1 56' 37.8'
C 2 32' 47'
SHED ~ /
I~ EXISTING ~ ~ ~ M 2 32.5' ' 47.3'
~0 3 BDRMHouSE-~ ~'~
~ XISTING ]
GRAVEL
I ~ DRIVE
SCA~
72-013 A (Rev. 9/91) MOA 25 /
/ /
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW950408
DESIGN ENGINEER:S & S ENGINEERING
OWNER NAME:LEE BEN
OWNER ADDRESS:20135 WHITE BIRCH RD
CHUGIAK, ALASKA 99567
PARCEL ID:05114462
DATE ISSUED: 1/02/96
EXPIRATION DATE: 1/02/97
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LEGAL DESCRIPTION:
DENALI LT 124B
LOT SIZE: 57960 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD SYSTEM
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 (ISAACS0) .
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:i~
ENGINEER SHALL PER~F~~IONAL GROUND WATER MONITORING~
~[~RIOR TO ~NSTRUCTION IN SPRING OF 1996.
DATE:
:meee nq
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
December 15, 1995
CIVIL ENGINEERS
HEALTH AUTHORITY
APPROVALS
SEWER&WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATtON
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK 99519
REFERENCE: Lot 124B; Denali Subdivision
(907) 694-2979
FAX (907) 694-1211
RECEIVED
DEC 1 9 1995
tViU~i;~.;~pai:~¥ O~ Anchorage
Dept. Health & Human Services
Reqaest you issue a Co~diticem31 Bealth Authority Appco~al o~ the
referenced property due to high excavation costs associated with cold
~eather cce3ditio~s a~d depth of fro~t.
System to be upgraded no later than 15 June, 1996. A request for
permit was submitted to your office on December 1, 1995.
If you require additional information please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
;zn znc
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
CIVIL ENGINEERS
December 1, 1995
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK. 99519
REFERENCE: Lot 124B, Denali Subdivision
Request you issue a permit to install a septic system to
serve the existing three bedroom house on the referenced
property.
A test hole was excavated and percolation test performed.
The approximate location of the test hole is located on the
attached site plan.
At the time of excavation water was encountered at 17.5
feet in the test hole and after seven day ground water
monitoring, water was found at 16.5 feet.
We do not anticipate any adverse effects on neighboring
wells, septic systems or drainage patterns by the
installation of the proposed septic system.
If you require additional information, please contact us.
Sincerely,
Robert C. Cowan, P.E.
RCC/gk
Enclosure
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
SITE PLAN UPGRADE
1" = 40'
WHITE BIRCH ROAD
Z
m
x
Municipality o! Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR: ~2~.%~ ~-~
LEGAL DESCRIPTION:
1
2
3
4
7
8
12
~4
15
15
17
18 --
19
20
WAS GROUND WATER
ENCOUNTERED? q¢.~
I
S
L
IF YES, AT WHAT ) O
DEPTH7 17'<~'' P
E
~.x ~.. .... ~.,...
"~ ~9 ~' 1[ ",.'..~ TS,
DATE PERFORME~,
Township, Range, Section:
SLOPE SITE PLAN
Depth to Water After
Monitoring? ~ (~,'5 Dale:
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN __
fl (m,nutes/inch) PERC HOLE DIAMETER
[-.~ '~' FTAND "7.5/' FT
COMMENTS
PERFORMED BY: $ & S ENGINEERING ~ Fp~-~ ~, ~ ~>
17034 Eagle River Loop Road No. 204
ACCORDANCE WITHL3~e~3'{~t.~A~[~I~IN~ GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE: 17~ ~ l- '[~'
zneeeznq
ROBERT C. COWAN, RE.
ROBERTA. SHAFER, RE.
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOIL TEST
PERCOLATION
TEST
STRUCTURAL &
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
ON-SITE WASTEWATER DISPOSAL SYSTEM
CONSTRUCTION PRACTICES
and
MATERIAL SPECIFICATIONS
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
REFERENCE: Lot 124B, Denali Subdivision
December 1, 1995
GENERAL:
1.
®
The scope of this project includes the installation of
a leachfield trench to serve the three bedroom
residence located on the referenced property and
excavation of the existing 1000 gal septic tank to
verify its integrity. If the integrity of the
existing septic tank is poor the existing septic tank
is to be excavated, pumped, crushed, and abandoned in
place and a new 1000 gal septic tank installed.
Construction shall be in accordance with the approved
site plan and 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 any
necessary underground utility locates.
Unless specifically agreed otherwise, the property
owner shall be responsible for final grading areas
subsequently depressed from soil settling.
Contractors installing wast·water disposal systems
must be certified by the Municipal Health Department
for system installations. Owners installing their own
systems must also receive prior approval from the
Municipal Health Department.
SEPTIC TANK INSTALLATION:
A septic tank is to be constructed by a certified
septic tank manufacturer. Construction shall include
two 4" cleanouts for pumping access.
The septic tank shall be sufficiently bedded to
prevent settling or shifting of the tank.
Ail standpipes on the septic tank shall extend a
minimum of 12 inches above final grade.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 · EAGLE RIVER, ALASKA 99577
Page Two
Lot 124B, Denali Subdivision
December 1, 1995
Septic tanks installed with less than 4 ft. of cover shall
be insulated.
A foundation cleanout shall be installed one to four feet
from the building foundation. In the line between the tank
and the leachfield there shall be two adjacent cleanouts
(unless an effluent pumping system exists within the septic
tank). These cleanouts shall be located on undisturbed
soil not more than 10 ft. from the tank. The first
cleanout, in line, shall be to clean toward the leachfield.
The second cleanout shall be to clean toward the septic
tank.
Final grading over the septic tank shall be such that a
positive slope exists away from the septic tank.
ABSORPTION TRENCH/DRAINFIELD INSTALLATION=
Excavate the proposed trench to the dimensions shown on the
design. The bottom of the excavation shall be within 2
inches of level. If the sidewalls of the excavation become
smeared, they must be raked or scratched (ruffed-up) before
gravel (sewer rock) placement.
Once the gravel is installed, the distribution pipe is to
be installed level with the perforations faced downward.
Gravel is then to be placed over the distribution pipe to
provide a minimum of 2 inches of cover over the pipe.
A silt barrier must be installed between the final gravel
layer and the native soil backfill. Ensure the silt
barrier covers the entire gravel surface before placing
backfill.
Monitor tubes shall be of four (4) inch diameter,
installed approximately in the locations shown on the
design, and extend a minimum of 12 inches above final
grade. The portion of the monitoring tube extending
through the gravel shall be perforated from the bottom of
the trench to the invert of the distribution pipe. This is
equivalent to the effective depth of the gravel as noted on
the design.
Page Three
Lot 124B, Denali Subdivision
December 1, 1995
Backfill over the final gravel layer must not be less than
twenty-four (24) inches. Insulation must be installed when
the backfill depth is less than thirty-six (36) inches.
The finish grade over the trench must be mounded to prevent
the formation of a depression after settling.
MINIMUM MATERIAL SPECIFICATIONS:
Any septic tank proposed for installation must be
constructed by a Municipally approved septic tank
manufacturer.
The following pipe materials are approved for use in septic
system installations in the Municipality of Anchorage:
Type of Pipe
Perforated Solid
Cast Iron
ASTM D3034 (PVC)
ASTM F810 (HDPE)
ASTM D2662 (ABS)
Yes Yes
Yes Yes
Yes No
Yes Yes
Use of a type of pipe other than listed above must be
approved by the inspecting engineer.
Insulation shall be at least 2" thick extruded direct
burial polystyrene (Dow Chemical Company Styrofoam HI or
equal).
Septic tank inlets and outlets shall be fitted with
watertight couplings (Caulder, Fernco, or equal).
De
A permeable nontoxic silt barrier (Typar 3401, Mirafi 140N,
or equal) must be installed between the final leachfield
gravel layer and the native soil backfill.
Ail leachfield gravel (sewer rock) shall be 0.5"-2.5"
screened gravel with less than 3% passing the %200 sieve.
When sand is being used as a filter material, its gradation
specifications must conform to current M.O.A. or D.E.C.
requirements.
Page Four
Lot 124B, Denali Subdivision
December 1, 1995
INSPECTIONS:
Typically there will be a minimum of three (3) inspections
required during the installation of the wastewater disposal
system. These inspections will occur as follows:
The first inspection must be conducted after the
excavation of ditches, pits, trenches, or beds and
before the installation of any gravel. A septic tank
may be set in place, but may not be backfilled before
this inspection.
The second inspection must be conducted after the
placement of the silt barrier, gravel, distribution
lines, standpipes, cleanouts, and insulation, but
before the placement of any other backfill.
e
The final inspection is to occur upon final grading of
the property.
Often there will be more than these 3 inspections required.
Especially with the installation of multiple trenches, sand
filters, pressurized distribution systems, etc. Thus, the
inspecting engineer is to be contacted at least 24 hours prior
to the start of construction. If necessary, a pre-construction
meeting will take place on-site. The inspecting engineer will
not coordinate, direct or control in any way the contractors
activities.
The owner shall contract with the contractor to perform the work
outlined in these specifications and plans and in accordance
with the attached M.O.A. permit. There will be no contractual
arrangement existing between the contractor and S & S
Engineering. S & S Engineering shall be the owner's
representative and will inspect the work as stated above to
document the contractors activities. Final acceptance of the
contractors work rests with the owner and the M.O.A.
Page Five
Lot 124B, Denali Subdivision
December 1, 1995
$ & S Engineering Shall have no liability to the owner or to
others for acts or omissions of the contractor or any other
persons performing work on this project or the failure of the
contractor to carry out the work in accordance with these
construction documents. S & S Engineering's inspecting engineer
will not be responsible for the construction means, methods,
techniques, sequence, procedures or the safety precautions
incident to this project.
CONTRACTOR/INSTALLER
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 I ~NEW
MAILING ADDRESS
-~EGAL DESCRIPTION
· - ~ NO. OF BEDROOMS
LOCATION
i WelI , I Absorption~re~ Dwelling~o, ,PERMIT NO.
DISTANCE TO: /
an.f o,ur.r
~' L iq. c,pacity in gallons Inside
/~ IF HOMEMADE: ' '
Well Dwelling PERMIT NO.
~ ~ DISTANCE
O Z ~ Manufacturer ~ Material Liquid capacity m gallons
Q Well Foundation
~ DISTANCE TO:
~ N°'°flines/ Length of each line Total lengt2~l~es TrenchwiOth .. Distance~w~e~linek/
~ ~ ¢1 inches
;~ Top of tile to finish grade , Material benea,~ e~ ,/,¢~ Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
m Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING
iNSTALLER ~ ~-/~
REMARKS
~w ~- ee'
Av ~' .-
2?._.. v ....
.I ~ ..emu ~,
....
/
72-013 4Rev. 3/78)
i_.. E (.":- F! L
Td. SNR;J-N ~-~ L±24E:
Z :~ G i'-,!!E E
ENGINEERS. INC.
7125 OLD SEWARD HW~
ANCHORAGE, ALASKA 99503
349-6561
[] SOILS LOG
PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:
10
11
12
13
14
15
16
17
18
19
20
SLOPE
WAS GROUND WATER j ! S
L
ENCOUNTERED? - ~ 0
P
E
IF YES, AT WHAT
DEPTH?
SITE PLAN
Gross Net Depth to Net
Reading Date
. l.~l~ ~.- ~ Time Time Water Drop
...A
PERFORMED BY: -
CERTIFIED BY: DATE:
72-008 (6/79)
January 4, 1982
Merle D. Gordon
SR Box 486
Forest Park
Chugiak, AK 99567
Permit ~ 810798
Subject: T15N R1W Section 9 Lot 124
A permit issued by this department for a well and/or sewer
system has expired as of December 31, 1981.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent to
this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for our
files.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Sewer and Water Program
Enclosure: Copy of Permit
P1 Ell INI ][ C: ][ F' F~ L I -"r '~.' ~-"'~ F' f:l ~-,! ~]:: H F-'~ F: F~ ~a E
DEF'FtF.'.TMENT C!E HERLTH FIND ENVIF.:ONMENT~L F'J~'F~TECTION
:_=:25 '"t STF. tEET., RNE:HOF.'.RGE, RK. 99.
264-4728
I~,-IELL PEF-:r'I Z T
~4o,¥' ROUTE ~ SR BOY, 4:-=:6 FOREST PK ~
PERtdIT NO. ( 8~0798 )
RPPLICRNT MERLE D. GORDON
LOCRTION JRYHR!4K DRIVE
LEGRL
Tt5N RiW SECTION 9 LOT 224
LOT .=,I--'E
¢900A SL.-~UFIF.:E FEET
MINIMUM [:,ISTRNCE E:ETNEEN R NELL RN[:, RNY ON-SITE SEI4AGE [:,ISF'O'E, RL S'¢STEM I'=
100 FEET FOR R PRI',/RTE NELL OR 150 TO 288 FEET FROM R PUE:LIC NELL [:,EPEN[:,ING
UPON THE TYF'E OF PUBLIC: NELL.
MINIMUM [:,ISTFtNCE FROM Ft F'RIVRTE NELL TO R PR ! ',,,'RTE SENER LINE IS 25 FEET RND
TO R COMMUNITY SENER LINE IS 75 FEET.
NELL LOGS ARE REC4UIRE[:, RN[:, ML--,T BE F.:ETURNED TO THE [:,EPRRTMENT N ITHIN '~:A
OF THE NELL COMPLETI
OTHER REQUIREMENTS MR¥ RF'PL'¢. SF'EF:IFIC:ATIONS RN[:, CONSTRLF:TION [:,IRGRRMS RRE
R'v'RILRBLE TO INSURE PRAPEF.: INSTRLL. FITION.
PEF:P11 T E.',=-CF' I F:ES [:.EC:EI'-IE:EE: ---=::.1_.. ::L.'.L-~- 8::L
I _.ER.IF~ THRT
t' I RM FFIMILIRR NITH THE RE6!UIREMENTS FOF.'. ON-SITE SENER$ RN[:, NELLS 85 SET
FARTH B'¢ THE MUNIL':IPRLIT'¢ OF RNCHORRGE.
;2' I N!LL !NSTRLL THE =,~=,TE[1 IN RCCOR[:,RNCE 14ITH THE
S I GNE[:, '
RPPLICRNT MERLE [:,. GORDON
! SSUE[:, BY
[:,RTE
Department
..--MUNICIPALITY Of ANCHORAGE--'
Health and Environmental rotection
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT * * *
WELL AND/OR FBISl.elT[:. _ ,.,,_,,_,,°~'"~ PERMIT
Mailing Address: 4,'
Phone Number:
Holding Tank:
Soil Rating (sq.ft/br)
Applicant:
Location:
Legal Description: -~cC/N,J ~i'''~r,~., ~ ~
Type of Soil Absorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms:
Seepage Bed:
The Required Size of the Soil Absorption System Is:
DEPTH LENGTH GRAVEL DEPTH 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 = 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 feet
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 1 9 8 1 * * *
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 will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more t~ha~t 3 ~edrooms.
Signer: Issued by: ~ /~ ..... ~,.L ~7 -~/~,:~ _ ~J~'
Applicant J", ~'~'
Date: ~//7:11~/~, -/
SWP/024 (1/81)
MUN I C ! PAL 1 'FY OF ANCHORAGE.
Depar~an~ o~ Bea%~h and ~n¥lronm~ntal
825 ~ ~t, ~bo~e, AK. 99501
2~1-47~0
WELL In"
~ of ~il ~cptLoa Syst~
DF_J~F'd LEN6Dt .___ GRA',/~ DEJa~ - WIDTH
The length d~nsLon t~ ~e Length(in eee~) or ~he ~e~ or ~akn~LeLd.
d~th O~ a tr~h or pit L~ the d~k~ce ~~a t~ ~c~ of
t~ ~tk~ of t~ excavation(ia f~t),
* ~ R~UIRED S~TIC(~I~) TANK 8[~ = .....
P~xe ~plxcant hA~ the ees~sibili%y to tn~o~ this de~r~n~ d~ing
[mstaLlakion ins~ti~ nE a~ wells ad~ent ~o thL6 pc~rt~ and
+ ~ ~ ~(2) INSP~CTI~S A~ REQUIR~ * ~ *
~k~LL~g oE any ~yst~ wLt~ut ~a~ Lns~~a a~ a~rova~
~in~ dL~a~e ~tw~en a well ad ant on-site ~age dt~eat
f~ a pciva%e wel~ oc LSO eo 200 feo~ fr~ a ~bl~ ~11 d~ndtnff
of p~Li~ ~li. Mtn~ dtst~ from a private well ~o a
i~ 25 ~t and tO a ~~%ty ~ Lt~ is 75 ~e~. Well l~$
and ~s~ ~ rekurn~ to thL~ de~rt~t qtthLa 30 day~ of the
avaiLabi~ ~o inset pro~c insta[Latgon,
I certify tha~:
(L) ~ ~ ~LLLac ~Ltb the r~e~ for oa-s[~e ~ers a~d
~t ~octh by t~ ~i=~aLit7 Of ~rage.
/
Sboet l;v:.-,% e i'
0.417
/ /75 4/-
'"S tie
7:. ~ t
SLeet
C.(i3
.1
1
/ 77_(, ¢7
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
9,5-04-26
i1:08
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# 051-144-62
1. GENERAL INFORMATION
Complete legal description
RCVO
Location (site address or directions) 20135 White. Birch Road
Property owner
Mailing address
Lending agency
Mailing address
Agent Cindy
Address 11411
Ben Lee Day phone
P.O. Box 670372 Chugiak, AK 99567
Day phone
Lindblom/Greatland Realt~ Day phone 694-9125
01d Glenn Hwy. Eagle River, AK 99577
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
NOTE:
Individual well ×XX
Community well
Public water
community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev 1/91) Front MOA #21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I furtherverify 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 S & S ENGINEERING
.~._,,...~-,,, ,~a~ Phone ~'~¢¢'-'~'~7 ~J
1:7u~4 F. aglm ~,;,~r L r ............
Address Eagle River, Alaska 99577
Engineer's signature
DHHS SIGNATURE
Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date ~- ¢"' - ¢)~/
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their iending 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. 1,91) Bac~ MOA
96-04-26 11:07 RCVD
:neee nq
april 2b, 1996
ROBERT C. COWAN, RE.
ROBERT A. SHAFER, RE.
CIVIL ENGINEERS
(907) 694-2979
FAX (907) 694-1211
HEALTH AUTHORITY
APPROVALS
SEWER & WATER
MAIN EXTENSIONS
SEWER & WATER
INSPECTION
ENGINEERING STUDIES
AND REPORTS
WELL INSPECTION
& FLOW TEST
SITE PLANS
ROAD DESIGN
SOILTEST
PERCOLATION
TEST
STRUCTURAL&
MECHANICAL
INSPECTIONS
ON SITE
WASTEWATER
DISPOSAL SYSTEM
DESIGN
Municipality of Anchorage
Department of Health and Human Services
Attention: Daniel J. Roth
P.O.Box 196650
Anchorage, Alaska 99519-6650
REFERENCE: Lot 124B, Denali Subdivision
The work required on the Conditional Health Authority
Approval dated 1-2-96 has been completed. Attached is the
on-site inspection report of the upgraded system. Please
issue a final Health Authority Approval.
Sincerely,
Robert C. Cowan, P.E.
17034 NORTH EAGLE RIVER LOOP · SUITE 204 ° EAGLE RIVER, ALASKA 99577
DEPARTMENT OF HEALTH & HUMAN SERVICES
:' ~' Division of Environmental Services
.... :~" ~: -' :?' ~' ?-'- ' ': - .... On-Site Services Section
~ ,n-~.- ...... -, v: ~ -_ :;..~ ~ ' '~ P.O. BOX 1~0 AnChorage, Al~ka 9951~650
,~,- .~- ~m'~":~~ ...... i~ ~ CERTIFICATEOFH~LTHAUTHORI~
' - APPROVAL FOR A SINGLE FAMILY DW~
I. "GENERAL INFORMATION '~ .~
..~ ~omple~e legal o~crlp~ o
iress 0~ dii:i~Jtion~) "?~"'~ 20135 ~'hiC~ l~ireh l~cl~
:'..~Unl~ss'bt~'erwise requested, HAA will be held for pickup. ~ ~'~
~ .... ~ :', ' -: h.;~:,'- ,.c. "'~
-...~ : PE'OF WATER.SUPP~Y:'~:~:.' -.
. ., '. · .... ..... . .... .~,
NOTE: .If community well system, provide written confirmation flOor. State A. D. EC attest-
NOTE: If communi~ wastewater system, provide wri,en con~e.~p~,from State
a~esting to the tegali~ and status of system. .:
STATEMENT., OF INSPECTION BY ENGINEER
As certified byway seal affixed hereto and as of the val,dat,on date shown below, I verify that my
investigation '~llis Health AuthorityA~*i~r;0~a.I .applicatiOn shows that the on-site water supply
and/or wasteWater disposal system is safe, functional andadequ.a, te for the number of bedrooms
and type of st~cture indicated herein. I f~rther verify that based on the information obtained from
the Municipality of Anchorage flies and from my inves.t~ation and inspection, the on-site water
supply and/o~ Wastewater disp~3sa[ system*is in cOmplian.ce~W!th all Municipal and State codes,
f_ - .. , . ..... ~- ~:~,..,... .
ordinances, and regulations in effect on the date of this inspection.
'SIGNATURE '±~'" -
· - t:~.~- ~5:..~,:i...? '
.. ~.Approved -for '.-'
--"-'~ Dmapproved.
~<~:::~' CondEional approval for :" ~:;~ ":- ' bedr00ms,:"with' the following stipulations:
:~e Muln~pality"c~_~'~chora~e Department of Health and Human Services (DHHS) issues Health Authority
"'. '~,,~' oor°val[~rtifica'{~"l:~ ~)nly upon the representations given in paragraph 5 above by an independent
~D~fessional en~irmer~eoistered in the State of Alaska. The DHH$ does th~s as a courtesy to purchasers of homes
m3.d. the~r'lend,n~ 4nstitubons m order to satmfy certa,n federal and state requ,rements. Employees of DHHS .do not
c°i~duct inspecti~,ns Or analyze dam before a certi.ficate is issued. The MunicipalitY of A~ch0rage ,s not
responsible for errors or omissions in the professional engineer's work.
Note: The well for this property meets existing
State and Municipal Codes. There are~!?n~i~rates present. It is
suggested that a periodic testing be performed to insure the wells
continued suitability. Nitrate concentration is 6.3 mg/1. EPA
maximum concentration is 10.0. mg/1.
Legal Description:
A. WELL DATA
Well type
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
....Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744
Health Authority Approval Checklist
If A, B, or C, at,ch ADEC letter. ~EC water system number
Log preseut (2~rlq) x,/ Date completed ~Ub ~
Total depth ?~c~ ~, ' Cased to ~e'7 ~ Casing height (above ground) tx,ti 4-
Sanitary. seal ~?N) ~ Wires properly protected{~)~q) ~7t
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform 0 Nitrate
Date of sample: ~ [ - I fi' - ~1 ff'
B. SEPTIC/HOLDING TANK DATA
Date installed E,. t'5 ~15'/..- Tank size
L,,. '5 Other bacteria
Collected by: $ & $ ENGINEERING
17034 Eagle River Loop Road NO. 204
Eagle River, Alaska 99577
Number of Compartments 'z.- Cleanouts (I~/N) ,../
Co
Foundation cleanout (Y/I~ ,d,
Date of Pumping
ABSORPTION FIELD DATA
Date installed
Pumper
Soil rating
Depression
(g.p.d./fl2 or flZ/bdrm)
High water alarm (Y/N) ~
System .type
Length ~ '3 ~ Width
Effective absorption area O I,:"--
Date of adequacy test t [- I"/~ q'
Fluid depth in absorption field before test (in.):
Fluid depth '7/o (ins.) Minutes later:
Peroxide treatment (past 12 months) (Y/~
Gravel thickness below pipe O~-- Total depth
Monitoring Tube present~) ~ Depression over field (Y~5)_
Results (Pass/l~ ¢-/~-tt..' For '~ bedrooms
Immediately after~7a gal. water added (in.):
Absorption rate = ~ g.p.d.
If >,es. give date
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N'} ~ ...... Pump off' level at*
High wat~ *Datum
C.~ted
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot I o~ [ ~ · On adjacent lots
Absorption field on lot [ Do t ~ ; On adjacent lots
Public sewer main ~[~-' Public sewer manhole/cleanout
Sewer/septic service line '7~' ~'¢ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundatiou \-/~ Property line I c> ~ ,c Absorption field
Water main/service line ~ o Surface water/drainage lt~x3 Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation ~ ~ ~
Surface water ~,~,o ~ I'~
Curtain drain 3 t~ ~ o ~ t 4~
Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots
Property. liue I o
F. ENGINEER'S CERTIFICATION
I certi~, that 1 ~ave determined thrufield inspections and review of Municipal records thaMS~)~tf~ns are
m conJbrmance wit~ ~IOd ~4 guid~nes in effect on this daW.
Signature
Waiver Fee $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
C T&E Environmental Servioes Inc,
Laboratory Division :-- ~--:--~-~ -"
WA~R
~ lent Sample ~D L124B DENALX
:ent Nama S & ~
:-d~red By R. Cow~N
:oJec~ Name
?;SI D
Laboratory Analysis Report
WORK order 1971a
Printed DaCe 11/22/95 ~ 17:28 hr~-
collected Date 11/1~/9S ~ 13:00 hro,
Received Date 11/1~/95 ~ 17:00 hrs.
Technical Director
STepHEN C, EDE
Remarks: SAMPL= COL~CTED BY: RAY.
QC Allowabl~ Ex~. Anal
Pa~&~et~ Results Oual Un~t~ Method ~mits Da~e D~Ca Ini~
:.trat~-N 6.20 mg/5 EPA ~00.0 ION 10 11/21/95
See Special Instructions Above UA - %~available
See Sat~pl~ Remarks Above NA = Not Analyzed
Undetected, Repo~ted value is ~he practical c~u&n~ifica~ion l~mlt. LT = Les~ Than
Secondary dilution. GT = Greater Than
200 W. Potter Drive, Anchorage, AK 99518-1~O~ --Tel: (907) 562-2343 Fsx: (907) 56~-~301
~N¥1RONMENTAL FACILITIES iN ALASKA, CALIFORNIA. FLORIDA. iLLINOIS, MARYLAND, MICHIGAN. MISSOURI, NEW JERSEY, OHIO. WEST VI~G{NIA
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# C}~--~\ - 1~-~-\ -I¢--E~
GENERAL INFORMATION
Complete legal description
Lot 124Bi Denali Subdivision
Location (site address or directions)
20135 white Birch Road
Property owner
Mailing address
Lending agency
Mailing address
M6rql Gordon Day phone
"$310 144~th Av~.~u~_ East: Puya~up: Wa~h~',g~nn
NORTHLAND MORTGAGE Day phone
Ea~16 River, Alaska/ATTENTION: Trish
Agent Lffnda Banner - RE/MAX OF EAGLE RIVER
Address 14400 O.a;~.¢a.~fJa2d D~.iuo¢ .%J~o ¢fl1~ Eag2a
Unless otherwise requested, HAA will be held for pickup.
206-840-6248
9837¢
Day phone 694-4¢00
P/ua,'r ; A~a.~ba 99577
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
NOTE:
Individual well ~)~
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
XXX
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. 1/91) Front MOA ~21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that m~
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage flies and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance':with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Phone ~
Name of Firm ~EERING
17034 Eaqle RiYer Loop
Address -- Eagle River, Alaska 9951,
Engineer's signature
6. DHHS SIGNATURE
bedrooms.
Approved for
__---- Disapproved.
bedrooms, with the following stipulations:
Conditional approval for 1 for this property meets existing
--- zt
. 'n be performed to insure the wells
a eriodic testl g ~ · 's~.9 mg/1. EPA
~~~zvu. u~ll~c~r~,e concentratzon z
maximum concentratlo ' '
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional enginee¢s work.
72-025 (Rev. 1/91) BacV, MOA ,~r21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~-.'~' \'Z.~ [)~_.~..~k.~.~ ~[rp Parcel I.D.
A. WELL DATA
Well type
Log present {~N)
Total depth
Sanitary seal (_.~N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to L~'~ ~ Casing height
Wires properly protected (~YN)
ADEC water system number
la ~ t Driller
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTIOI~NtCiPAUTY OF ANCHORAGE
~ o- '~ ~ ~NVIRONMENTAL SERVICES DIVISION
OCT 1 0 1991
i CEIVED
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
seWer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank '/--~
WATER SAMPLE RESULTS:
Coliform ~ c'°~/Iex:) ~-~-
Date of sample:
Nitrate
B. SEPTIC/HOLDINGTANKDATA
Date installed
Collected by:
Other ba~;teria I~o~
S & S ENGINEEEING
Eagle River, Alaska ~5~
Tank size I~'C>~:, 4,~A4_. Compartments
Cleanouts (~N) y Foundation cleanout (Y/~ ~ Depression (Y~;)
High water alarm (Y~N~ /'J Alarm tested (Y/N)
Date of pumping ~ ~ ~c~ Pumper ~--J~-_
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot \C~:> t'~'' On adjacent lots ~C)~ ~ Foundation I"~ ~
To property line ~ ~' Absorption field Lc' Water main/service line ~, 0 ~ '~
Surface water/drainage ~,C)~..~ ~ ~
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes~
Well on lot On adjacent lots
Man u factu rer
Manhole/Access (Y/N)
~"~f" level at
-~ Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Widt
Soil rating 9o ~/{~.. System type "["~
Gravel thickness '~ ~ Total depth
Cleanouts present ~N)
Date of adequacy test ~--1
for "~ {~-~'~) bedrooms
~,'J~- 1~'~''s If yes, give date
Date installed
Length ~,~
Total absorption area
Depressi°n oVer field (YZ~
Results~ail)
Peroxide treatment (past 12 months) (Y~/_/~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~oc:) ~ ~
To building foundation
On adjacent lots
Surface water
Curtain drain "
On adjacent lots
Property line
Cutbank
To existing or abandoned system on lot
~ 1 ~ Water main/service line
Driveway, parking/vehicle storage area
ENGINEER~S CERTIFICATION, ' , T .
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in,
S & S ENGINEERING
Signature ; 7034 I~am_le RLver L~.m
~le r{iver. Alaska ~)577
Engineer's Name
Date 1C~ - ~ ~
HAA Fee $ / ~'/--.~
Dat~of Payment /'~
Receipt Number ~ 3/--~ -
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev, 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALYSIS REPORT B! SAMPLE foz WORKordert 39016
Date Report Printed: OCT 8 91 ~ 07:42
FAX: (907) 561-5301
Client Sample ID:L124B DENALI S/D Client Name :S & S ENGIMEERINC
PWSID :UA Client Acct :SNS[NGP
Collected OCT 3 91 ~ 13:20 hms. BPO { PO ! NONE RECEIVED
Received OCT 4 91 ~ 13:45 hms. Req !
Preserved with :AS REOUIRKD Ordered By :
Analysis Completed :OCT 7 91 Se~] Reports to:
Laboratory Supervl~o~_~l.~.;~EP~N C. EDE lis & S ENGI~ERING
Rele.,d 2j
Chemlab Ref t: 915285 Lab Smpl ID: 7 Matrix: WATER
Allowable
Parameter Tested Result Units Method Limits
NITRATE-N 6.9 mg/1 EPA 353.2 10
Sample ROL~INE SAMPLE COLLECTED BY: RAY.
Remerks:
1 Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected "See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-Greater TMn
Member of the SGS Group (Socibtb Gbnbrale de Surveillance)
DEP^.TME.T OF .E^LT. · .UM^" SE.V, CES
D,V,S,O. OF E.V,.O.ME.T^~ SERV,CES
CERT,~,C^TE OF ,.SPECT, O. ~O..~ALT, AUT.OR,TV APPROVAL
Or O.-S,T. S.VVE. A.D WAT.R .AC,L,TV
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include_lot, block, subdivision, section, township, range)
/_,,-r /z,/,~ (~5~ ~,,~ ;sa_g}
Location (address or directions)
(b) Property Owner /~Z:'~/-~' ' ~;~'~ Telephone: Home ~:~d-
Mailing Address ....
(c) Lending Institution r: Telephone
Mailing Address .,
Business
(d) Real Estate Company.and Agent
Address
Telephone
(e)
Mail the HAA to the followina address: or: Check here E], if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family'~
Number of Bedrooms
WATER SUPPLY
Well'~ Community [] Public []
Individual
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~,, Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72-025 fFlev 8/86} Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DA1A 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 /~'~
Address /
Date
Telephone .~"'~, / -_~0
Approved for ~ bedrooms by _. . / . .
Approved ~ Disapproved Conditional
Terms of Conditional Approval
Date 6 -2 /-~
CAUTION
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
certificates based only upon the representations given in paragraph 5 above by an independent professional engineer
registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in
order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data
before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
Page 2 of 2 72-025 (Rev 8/86) Back
WELL DATA
MUNICIPALITY OF ANCHORAGE (MO~)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
I¢'UNICJPALiTY OF ANCHORAGE 264-4720
Well Classification
Well Log Present~)~
Total Depth ~ff-.~O Cased to
Static Water Level ~ /~ ~'
Casing Height Above Ground /
Electrical Wiring in Conduit~"'~)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Man hole
ENVIRONMENTAL SERVICES DIVISION
J U 1 1988
Water Sample Collected by
Water Sample Test Results
Comments ~ ~
Legal Description:
If A, B, C, D.E.C. Approved (Y/N)
Date Completed
Yield
Depth of Grouting
Pump Set At .
Sanitary Seal on Casing(~)
Depression Around Wellhead (Y~])
~.~i ' /,'~,~' ! . On Adjoining Lots /~O t · On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
/.d/&~-;J ;Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~-/-'~ ~<~'-" Size /_~"c"~ No. of Compartments
Standpipes~N) Air-tight Caps ~IN) ~eanout (Yi~)
Depression over Tank (Y~) Date Last Pumped //-.~c,-~'
Pumping/Maintenance Contract on File (Y/N) '~J/"~ 'for
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
t
To Water-Supply Well /~'
To Property Line /'~ '"/-
To Water Main/Service Line
Course
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Comments
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area .~;~"/
Depression over Field (Y~)
Results of Last Adequacy Test /
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water Main/Service Line
/30
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments /¢¢8~'/z-~" ~ /,/¢¢' ~'//¢~ '7~F'/b~
Type of System Design/
Length of Field
Depth of Field
Gravel Bed Thickness ~'
Standpipes Present~)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
· On Adjoining Lots ~
To Cutbank (if present)
D. LIFT STATION
Da~t lied ,f-,J')~ Dimensions
Size in G~~ Manhole/Access (Y/N)
"Pump On" Level at ~ "Pump Off" Level at
High Water Alarm Level at -'~,~.. Vent (Y/N)
Tested for Pu ' Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
** Check Permitted Bedroom Rating Against HAA Request **
I certify that l ha~c-w~e~d,, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed /~'~-------L~ F~.~I.-----/'~//~/' I' Date
Company ~ MOA No.
Date of Payment A ~/~ --~
Amount: $
Page 2 of 2
{70
72-026 (11/84)
Municipality of Anchorage
Department of Health and Human Services
825 "L" Street
Torn Fink,
Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
August 4, 1988
Merele D. Gordon
Cynthia L. Gordon
PO Box 671228
Chugiak, Alaska 99567
Subject:
Lot 124B Denali Subdivision
HAA 9H88-227
Please be advised of the following that should have been
noted on the recent Health Authority Certificate.
Note:
The well for this property meets existing State and
Municipal Codes. There are nitrates present, however,
it is suggested that periodic testing be performed to
insure the wells continued suitability. Nitrate
concentration is 5.2.
If there are any questions, please call our office at
343-4744.
Since/~el~,
Daniel B~lles
On-site Services
DB/ljw
cc:
Alaska Environmental Control Services, Inc.
1412 West 33 Avenue
Anchorage, Alaska 99503
~/o
~ CHEMICAL '~ °~'~~
& GEOLOGICAL LABORATORIES OFALASKA, INC. ~ ~
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ~.
?~$ID · Cl~ent ~cct :
Speziai
Instruct:
Chemlab k~f 8: 1311. Lab Smpl lO, i Matrix: Watez
&tlowabto
~aramete~ Tested Result/U~ts Method Limiss
MTR~TE-N 5.2 mg/i EPA 353.2 10
Sample ROUTINE SAMPLE
~,~nmrk~ SAMPLE COLLECTED B'~ A. WIlN.
None Detec',.ed "See Sample 5~ks ~,bc. ve