HomeMy WebLinkAboutCHANDELLE ACRES LT 7
Name
Address
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES O/~-- ~3
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
I DISTANCES
F,,,.,,,~-~ 41'~2~/~¢,,/' o~ .... . ~ SEPTIC ABSORPTION
::"Y ;;~_ TANK FIELD
LEGAL DESCRIPTION
Lot I Block
Township, Range, Section
7-1,~- /7/
Subdivision
TANKS
SEPTIC [] HOLDING
WELL
135./
LOT LINE
FOUNDATION
/-I0 /
WELL
7/
AS-BUILT DIAGRAM tShow location of well, septic system, property lines, foundation,
driveway, water bodies, etc.)
Manufacturer
Material
Capacity in gallons
NO. of Compartments
TYPE OF SYSTEM
[] TRENCH [] BED [] W. DRAIN [] OTHER
Depth to p~pe bottom from ~ ~ Total depth from original grade
original grade ~ FT
Gravel depth beneath p~pe
Fill added above original grade
Gravel length
,~/'o FT
Total absorption area
· ~gO SQ FT
Number of lines I Soil rating
Z-V ,,5 "~¢"~ I /~-'? SQ FT
Installer
Gravel width
Distance between lines
Pipe material
Date Installed
WELLS
FT
FT
~ PRIVATE ~'~"'~"%~ [] OTHER (Identify1
Classification (A,B,C) I Total Depth I Cased to
J
Installer Date Installed:
REMARKS:
FT
Municipal and State guidelines in elfecl oH e: . '
Health Deparlment Approval: ~~~/~ ~
//
72-013 (3/85)
Scale:
InSPections Performed by:
Eagle River Engineerino~ Services
P 0 Box 773294
Date ' '
Eagle River, AK 99577
certily that this inspection was pedormed according to all
M U N I C I F A L I T Y 0 F A N C H 0 R A G E
Depar~tment c)f Health & Human Se~-vices
O N '- S I 'T' F:' S E W E R P E R M I 1"
Pepmit Number: 8c~)133
Dat. e Issued,'.. 07 /,':75 /88
Upg r- ade
Engineer Designed
Owne~' blame: PERMANENT F'LII',ID CORPORATION
Owner' Addr'ess: POUCH 4--1000
JUNEAU, AK 99802
Day Phone:
248-2804
Pa~*cel Id: 051-065-75
L.o*L Legal: Subctivision:i'}~H~NI)ELLE ~RE8 Lo~:' 7
Section: 3 Township: 15N Range: 1W
Lot Size lA (sq. f'L. o~- acres)
Max Bedr*ooms: This F'er'mit: 4. 'Total Capacity: 4
Block: -
SEF:"T'tC TANK: M:i. nimum total septic tank capacity.' 1,.-.~~ gal].ans Eac:h septic
tank must have a'L leas'L 2 compar, tments. Depth lc, top o£ septic tank(s) <; 4,,0
.feet r'ec!uines insulation c;ven tank(s).
INFORM D.H.H,,S. F"RIOR "r'r.) :I. ST &. 2ND INSPECTIONS BY ENGINEER.~ IF'
AF'TER OF'FICE HOURS~ CALl_ 343-'4681 AND LEAVE A MESSAGE,
CONS"rI::~UCT F:'ER ENGINEERS AI"TACHED APPROVED DESIGN.
'tHIS F:'ERMIT EXPIRES 121:51/88.
THIS PERMI't' VALID F'OF;'. A SINGL. E FAIdILY RESIDENCE ONLY.
I ,,I:.K I:::'Y 'I'HAT':
1,, I am familiaP with the nequinements ~'or'. on-site sewens and wells as set..
~or'th by the Municipality ot- Anchonage ~MOA) and the State ot' Alaska.
.?.,, I will ins'Loll the system in accondance with all MOA codes and Pegulations,
and in compliance with the des'i, gn cpitePia ot' this per. mit.
5. I will adhePe ta all. MOA and State o¢ Alaska nequiPement, s fop the set back
distances ¢:'~om any existing well, wastewateP disposal system or' public
sewer'age system or"~ this o~ any adjacent or- neaPby lot.
4. I under, stand 't. hat this pePmi'f, is valid fo~~ a maximum o~' 4 bednooms.
also undePstand that the capacity of t. he 'Lotal system is 4 bednooms and
an.v enla~-gement will r. equir, e an addi'L~.onal penmit.
(Owner') F'I.E'.RMANENT I.'.:'UND~ COF'
/
/
C~GIS~'
Hb'~
~4' X 3~'
LESS THRN 6' TDTAL D£PTH
/
/
/
/
/
/
~R[VE
NE]GH~rlR VELL
+100' l
IA_ELL _A_~_~ _SF-P!~_C SITE
LEGAL~ LE]T 7 CHANDELLE ACRES
E]WNER~PERNANENT FUND CE]RP,
PLAN
CDNTRACTDR:N/A
EAGLE RIVER
PB BX 773294
EAGLE RIVER,
694-5195
ENGINEERING
AK, 99577
SERVICES
EASEMENT
EXISTING LEACH FIELD ::::::::
NE~/ LEACH FIELD ::::::::
CLEANDUT - o
SCALE,
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
LEGAL: LOT 7, Chandelle Acres
GENERAL
1. The weii and septic plan are for a single family residence only.
2. The drawing and or site plan shall be a part of this specification.
5. All materials and workmanship shall meet the Anchorage Department of
Health and State Department Of Environmental Conservation require-
ments.
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 or
modified in the field by the contractor to meet Hunioipality of
Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permit~
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.
BED
1.
2.
3.
4.
5.
6.
7.
8.
The bed is to follow the natural land contour to maintain uniform
total depth of the bed bottom.
The bottom of the bed shall be level, plus or minus i.5"
The total depth of the bed excavation is not to exceed 6' at any
point in relation to test hole surface elevation.
The sewer line is to replace the existing sewer line that leads to the
existing trench
The bed 9ravel is to be covered with typar fabric material.
Soil or combination of soil and extruded board insulation to a depth
of 4' or equivalent is to be placed over the leachfield.
The area over the bed is to be finish graded to prevent ponding of
surface water runoff.
The septic tank and ieachfield 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
GRAVEL DEPTH = ~"
Soil Rating = 225
Bedroom Capacity = 4
Septic Tank Size = 1250 existing
BED LENGTH = 58'
BED WIDTH = 24'
***NOTE: EXCAVATION THROUGH ASPHALT APRON TO BE COMPACTED A~D ASPHALT SURFACED.
***NOTE: ELEVATION OF EXISTING TANK MAY BE REQUIRED TO MEET GRADE.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 g Street, Anchorage, Alaska 99501 264~,720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
SLOPE
k
SITE PLAN
COMMENTS_
WAS GROUND WATER S
ENCOUNTERED? j//~ ~' L
O
P
IF YES, AT WHAT /z~" A""~- E
DEPTH? ~,~ o ~, ¥.,. ,.~, f
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE P (minutes/inch)
TEST RUN BETWEEN '~ FT AND--~ FT
PERFORMED BY:
Eagle Rive: En~;ine~,rin[~ ?-,ervie~
CERTIFIED BY:~
72-008 (6/79)
P. 0. Bax 773294
£a~le River, AK 99577
69~-51~5
DATE:
. 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
~.~/¢.~K~ '
. ~ UPGRADE
MAILING ADDRE~
~ *T'~~ C A~ ~//e ~c, ~
LOCATION NO. OK ~S
Liq.~c~allons in*id* length Liquid depth
J~O ~ IF HOMEMADE:
~ ~ DISTANCE TO: Well ~ / /~ Dwelling PERMITNO.
O ~ ~ Manufacturer ~ ~ -
~ -- ~ [ ~ Material Liquid capacity in gallons
lenp~nes Trenc~th~,. inches Distanc~t~ines
~ T°~tilet~is~gra~ ~ __.~ ~ inches
M eri~beneat il~ ~ / Total effective absorption area
Length Width ~epth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorPtion area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class~ X [5 ('~, ~e~t~ Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
PIPE MATERIALS
INSTALLERS_
REMARKS
/
72
. _.._MUNICIPALITY OF ANCHORAGE.-.
Department :. Health and Environmenta ?rotection
825 ,. Street, Anchorage, AK. ~9501
264-4720
,~//~ * * * HANDWRITTEN PERMIT * * *
Permit
W/E~_L AND/OR ON-SITE SEWER PERMIT c"/ ,~ .-~
Applic~t: ~/r/+ m~--/ Mailing
Location: Phone Nu~er: ~-- ~
Legal Description: ~ C~~ ~~ Lot Size:
Type of Soil ~sorption System Is:
Trench: ~ Drainfield: Seepage Bed: Holding Tank
DEPTH
The Required Size of the Soil Absorption System Is:
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 : ~SO 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 departmen-
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee-
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 8 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 wil~stall the~ystem in accordance with codes.
(3) I u~der~nd t~//~he on-site sewer system may r~quire enlargement if
t~ res~ce/~remodeled to include more that ~bedrooms.
Signer Issued by: ~'~ ~
~L~.~A 1 is an~ uSx v :,
Date: ~'~ ? -~
SWP/024 (1/81)
~' "~ [] SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
1
2
3
4
5
6
7
8
9
PERCOLATION
TEST
SLOPE
10
11 WAS GROUND WATER. V,~,,~ f ~.
O
ENCOUNTERED' / / PF
~2 /~41~,'/~- ,~ ,,,Es, ^T W.AT /~
Gross Net Depth to Net
ReadingDate Time Time Water Drop
s ,, ~:~ ~o,, 7% /~.
by
DOC Co.
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAKo ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS / L}
LEGAL DESCRIPTION
DATE- Started ¢4/,~
7
PERMIT NUMBER
Ended
DEPTH OF WELL 3 ~ O
STATIC LEVEL OF WATER FT. ]' ~ 0.9
DRAW DOWN FT.
GALS. PER HR 60
KIND OF CASING 6 ~'~O~
KIND OF FORMATION:
From O Ft. to tO- Ft.
From~ Ft. to .4~ Ft.
From ,,~ Ft. to ~',3 Ft.
From Ft. to Ft.
From_/~-~L_Ft. to '7~ Ft.
From
F rom
From~
From
Ft. to Ft
From~Ft. to .
From Ft. to
From.../.Og Ft. to I~l Ft.
From i ~/ Ft. to--Ft.
Fmm~Ft. to Ft.
From /~'7 Ft. to 1 7s' Ft.
From Ft. to~Ft
From /,7~'" Ft. to ~ Ft.
?rom _/~_ '7 Ft. to
/"rom "3~'~"'Ft. to _~.3 Ft.
From Ft. to Ft.
From ~C~,~ Ft. to ~D Ft.
I O~" .Ft.
Ft. ,5',O.,~0 ?' ~;~'m,-/~/_ From__
-3",~'~O~} ~ ~4~<' From__
Ft. t~~4
Ft. to Ft
Ft. to Ft.
Ft. to Ft.
From__Ft. to ..... Ft.
From__Ft. to Ft.
From Ft. to . Ft.
~g~/~From Ft. to Ft.
From Ft. to__
From Ft. to__
~"/~ d~e~"l~rom __ Ft. to_
i ,_~" C~,~ From~Ft. to__
~'0,~ ,'~ From Ft. to Ft.
Ft..~-~
Ft. ~ ' ~d'~
,IISCL. INFORMATION:
/
To I 75
DRILLER'S NAME ,~e~ ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-472O
Application Date June 20:1988
GENERAL INFORMATION
(a)
(b)
Legal Description (include lot, block, subdivision, section, township, range)
Lot 7 Chandelle Acres Sec. 3, T15N, R1W
Location (address or directions)
I~ne~ Circle Peters Creek. AK
Applicant Name Ha~,-.~-c~n R~a'l~v _'i'elep~.one: Hom. e. n~/a_ _ --
Applicant Address 2RFI4 W. Nn~fl-h~.rn T,i~h'l-.~ An~hc~ra~; AK 99503
Business 24B-2804
(c) Applicant is (check one): Lending Institution [] · Owner/builder [] · Buyer [] · Other [] (explain);
(d) Lending Institution n/n Telephone
Address
(e) Real Estate Company and Agent Appl 'ir-ant- Agone ? ,1~8n Hnhnnt-~-in
Address
Telephone
(f) Mail the HAA to the following address:
Pick up by Engineer
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms 4
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: tf community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [] 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.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION '~
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm Eaqle River Enqineerinq Services
Address P.O. Box 773294 Eaqle River, AK
Date ~A~/~'
Telephone 907/694-5195
99577
Approved for Z~. bedrooms by
Approved ~ Disapproved
Conditional
Terms of Conditional ApProval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
RECEiVE I 2
^. w,,, ,,,.,-,,, R E C E I V E D
" ~UNICIPALtTY OF ANCHORAGE -
ENVIRONMENTAL SERVICES DIVISION ~ MUNICIPALITY OF ANCHORAGE (Mg.-,)
MUNICIPALITY OFA~ HEALTH AUTHOFIITY APPHOVAL (HAA)
.,,I~P,.T. OF HEALTH &
:\J 2 I~I~JJ~MENTAL PROTECTIOI~ CHECKLIST - FEBRUARY 1984
264-4?20
Legal Description: ~'~ ~"
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
If A, B, C, D.E.C. Approved (Y/N)
Date Completed ~ 3'/" ~' 3 Yield
Cased to /~' ~ ~ Depth of Grouting ~_~
Pump Set At
Well Classification
Well Log Present (Y/N)
Total Depth ..~'~ ·
Static Water Level /?6 '
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot _ /'-?'""'- /
To Nearest Edge of Absorption Field on Lot
~'~ ~ ~'.
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots "'/ee
· ~-1o,~ ~(9,~,'~) On Adjoining Lots ~-/*e ·
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
;Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) ,Y
Depression over Tank (Y/N) ,V
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~/~
Separation Distances from Septic/Holding Tank:
Size /.,.~ 5-~ No. of Compartments
Air-tight Caps (Y/N))/ Foundation Cleanout (Y/N)
Date Last Pumped ~y/,P,t
' or
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
To Building Foundation
To Disposal Field ,-~-
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /,~JE' 2'
Width of Field "~ "'
Type of System Design
Length of Field ~ /
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ,.~ o /
To Existing or Abandoned System on
; On Adjoining Lots '" ~"~ /
To Cutbank (if present) ~',/~'
/v/',r
Square Feet of Absorption Area
Depression over Field (Y/N) /1,/
Results of Last Adequacy Test ~"~,,"-,.r
Separation Distance from Absorption Field:
To Water-Supply Well /,r./~ /
To Building Foundation "~--~ /
Lot
To Water Main/Service Line ~'~ /
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~/~/4~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
Signed ~"'~'~--~'~:~---"~'"~'~ - Date ~/~_2~.~,¢,~
MOA No. -('-,~-'"',~ ~',,~ -
Company Eagle ~iv~r Engineering S~ices
Receipt No. [a~le ~iver, A[ 9~b17
Amount: $ ~ /70, ~
Page 2 of 2
72-026 (11/84)
MUNICIPALITY OF ANCHORAGE
DI~PARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
' Application Date
GENERAL INFO'RMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~-~t~ i'¢-.E::>I.~L.t~.¢. TeJephone: H. ome ~'~- ?i_~'~ Business
Applicant Address ~)O i~o~. (~'")O~l~' C{AIXc71~- ~
I
;' - ' Owner/builder ~-; ' I
(c) Applicant is (check dne):!Lending Institution []; Buyer []; Other [] (explain);
}
(d) Lending Institution ~ Telephone
Address
(e) Real Estate Company and Ag~'n, ~O/x,~_.'~ /~h~/<~x~
Address
Telephone
(f)
Mail the HAA to the foil_owing address:
S&SEn~~
Ea,jle '~.iyer; Alaska
TYPE OF RESIDENCE
Single-Family'r~ Multi-Family []
Number of Bedrooms ¢
Other
WATER SUPPLY
Individual Well ¢ Community [] Public []
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 (11/84)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA.AND I~NFORMATION
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 ~..& $ F.r~gJne~ing Telephone
Address SRB 196x
Eagl6 °,tver;.Alaska 99577
Date ~
DHEP APPROVAL
Approved for '~='~'"" bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 {tl/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description:
NJUNICIPAUTY OF ANCHORAGE
DEPT. OF HEALTH &
ENVi~T/I~L PROTECTION
MAR 0 ?
ECEIVED
WELL DATA
Well Classification --'~ ~, ~¢N~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (~/J~ Date Completed ~-~-.-_~,~'"~..]' Yield
Total Depth ~ Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit
Separation Distances from Well:
To Septic/Holding Tank on Lot
Depth of Grouting
Pump Set At
Sanitary Seal on Casing~'/.N')
Depression Around Wellhead-¢t'~
/'~o l ~- · On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /~/~- · On Adjoining Lots
'To Nearest Public Sewer Line ~J/~4- To Nearest Public Sewer
Cleanout/Manhole /d.~ To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (~'/..N)' Air-tight Caps
Depression over Tank ~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) -~J'/~"
Separation Distances from Septic/Holding Tank:
To Water-Supply Well j
To Property Line ~'~
To Water-Marl't/Service Line
Course
Size /~-~::~ No. of Compartments ~-
Foundation Cleanout ~/.N)
Date Last Pumped ,~-~'"'-~ (-~
/--V~.. ' for ~
Temporary Holding Tank Permit (Y/N) Y'J~A-
To Building Foundation /~ ¢
To Disposal Field .,,~ ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ,/O"/~.~
Width of Field
Square Feet of Absorption Area
Depression over Field ~
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present~/J~
Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot
To Water.MemCService Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line
To Existing or Abandoned System on
· On Adjoining Lots ~ '
To Cutbank (if present)
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
· Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed $ & $ F..nCnem'ing Date
$R8 196x
Company ~ , ,~ ,~__~__ ~,~r.~.r MOA No.
Receipt No. -'~.~
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
I~NICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL ffFALTH
DEPARTMENT OF HEALTH AND ENVIROI~DgNTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date ~
(a) Lega~ De_~scriptig~include/lp~, block, subdivision, section, township, rare)
Location (address or directions)
(b) Applicants Name
Telephone - Home
Business
Applicants Address
(c) Applic~ant is (check one) Lending Institution ~-~ ; Owner/builder ~-~ ;
Buyer ~--~ ; Other ~--~ (explain);
(d) Lending Institution
Telephone
Address
(e) Real Estate Co. & Agent
Telephope
(f) -~he HAA to the following address:
Single-Family~
Number of Bedrooms
3. Water Supply
Individual Well~
Multi-Family ~--~
Other (describe)
Community ~--~ Public ~-~
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. Sewage Disposal
Onsite.~. Public ~-~ 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 1 of 2]
5. En~ineerin~ Firm Providing Inspections~ Tests;. File Search~ Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or wastewater disposal system is safe, functional and adequate for
the number of bedrooms and type of structure indicated herein. I further verify that,
based on the information obtained from the Municipality of Anchorage files and from my
investigation and inspection, the on-site water supply and/or wastewater disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the date of this inspection.
Name of Firm Telephone
8 & ~ ENGI~IEF-.RIH~
8RB 198X ,
Address · ~,~ ~,~,~p. ~ a~ ~
DHEP Approval
Approved ~ · Disapproved
Te~s of Cdnditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHOP~[GE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
Total Depth ~6~O ~ Cased to
Static Water Level //~ ~ !
Casing Height Above Ground
Electrical Wiring in Conduit ~/~
Separation Distances f~cm Well:
To Septic/Holding Tank c~ Lot
TO Nearest Edge of Absc~ption Field on Lot
To Nearest Public Se~ Line
~ NICIPAdTY OF ANC,qORAG~:
DEFi-. OF HEALTH &
MUNICIPALITY OF ANCHORAGE (MOA~NvIF, ONt, Z,,ENTA~_ P2OTEC-nON
HEALTH AL"THORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Descrip tion [~1~ ~~~//~,
Cleanout/Manhole /~' lQ To Nearest Se~r Service Line on
Lot
Water Sample Collected By ~-~' ~/~F~.//a; ; Date //////~ ~/'
.-C"",~
Water Sample Test l~esults
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed /0/~.~ Size /~ ~.~O No. cf C~,%~a~tments
Stan~i~sXY~ ~ Ai~-ti~t Zapata) Fcun~ticn C~a~o~tdY~
~ession~ Ta~ (~ ~te_.///~~st ~d _~_ __
~in~intenan~
~n~a~ ~ File (Y~/~' ; f~
Holding Ta~ High-Wate~ ~a~ (Y~/~ ~~ Holdi~ TaD~ ~t (Y~/
~D~ation Distan~s ~ ~ptic~olding Ta~:
To ~te~-SupDly ~11 /~ <~ To ~ildi~ F~ndation
To Disposal Field ~- /
To Stream, Pond, Lake, c~ Major D~_ainage
To Property Line
To Water ~3~4~./Service
Course
Comments
Receipt ~ '-'~C'~ (~
Date Paid:
Amount: "--I~
[Page 1 of 2] 2-i5-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date .Installed
3
Width of Field
Square Feet of Absorption A=ea
Depression over Field (~
Results of Last Adequacy Test
Type of System Design
Length of Field ~O '
Depth of Field ~ ~
Gravel Bed Thickness ~
Standpipes Present ~
Date of Last Adequacy Test
Separation Distance f-rcm A~scrption Field:
To Water-Supply Well //~'O ~
To Building Foundation
Lot /O ~ ~"~1~
To Wate~ 9~Se=vice Line
To Stream/Pond/Lake/c= Major Drainage Course ~
To Driveway, Parking Area, c~ Vehicle Storage Area
Cc~zents /C~ o ,~
To Property Line /D
c-~c~ ' To Existing or Abandoned System cn
; On Adjoining Lots ~o ~
__5-tm ~ To Cutbank( if present)
/
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Distensions
· Manho~.e/Access (Y/N) ~ "pump~ ~f" Level at
/~' -//,~t (Y/N)
Pumping Cycle~s ~ing Adequacy Test.
Conm~nts
**
** Check Permitted Bedrocm Rating Against HAA Request
I certify that I have checked, verified, or confcz~ed to all MOA HAA Guidelines in effect
on date of this inspection.
Date
Signed ~ & ~. ..............
8AB 196X MOA
PH. 69~2~79
KB1/d5/s
[Page 2 of 2]
2-15-84