HomeMy WebLinkAboutPAULSON LT 65A$
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP171170
Work Type: Septic Upgrade
Tax Code Number: 01826123000
Site Legal Address: PAULSON LT 65A G:3035
Site Mailing Address: 14400 ELMORE RD, Anchorage
Owner: DUGGER GREGG G & GAYLA
Design Engineer: PANNONE ENGINEERING SERVICES
This permit is for the construction of:
Effective Date
Expiration Date:
Lot Size in Sq Ft:
Total Bedrooms
��rcnt
v
llepartment
7/10/2017
7/10/2018
48990
Q Disposal Field Q Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage
All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development
Services Department per AMC 15.65. Provide notification by calling (907) 343-7904 (24/7).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
shall be either:
a. Opened and Closed on the same day, or
b. Covered, sealed, and heated to prevent freezing
U ` n� 1 s d� 4ej-) f l,,-. le ( b'I o -v�A
LA) a_jl� Ulh a cyrl R t3r��
►re t� c� d'UA ; vu 0' 0 erL �0 04 O'er �b � � �J � '�'e c C�
Received By: Date:
Issued By: C0, cl' Date: D 20 1
MUNICIPALITY OF ANCHORAGE
Community Development Department /1 Phone: 907- = •04
Development Services Division . -� Fax: •+ . '• $ /7
On-Site Water& Wastewater Program
ti 41111111r
ON-SITE SEWER/WELL PERMIT APPLICATION a JUN z 9 2017
2
1
018-26 - 3 �6 1
Parcel I.D. �' �
Property owner(s) GREGG & GAYLA DUGGER Day phone "�6 0 Is q")
Mailing address 14400 ELMORE ROAD, ANCHORAGE AK
Site address 14400 ELMORE ROAD
Legal description (Sub'd., Block & Lot) PAULSON L65A
Legal description (Township, Range & Section)
Lot Size 48,990 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING:
(®all that apply)
❑X
Absorption Field ❑x Initial ElSingle Family (SF)
(w/wo ADU)
Septic Tank ❑X Upgrade Duplex (D) ❑
Holding Tank ❑ Renewal ❑ Multiple Dwellings ❑
Privy ❑ (SF and/or D)
Private Well ❑
Water Storage ❑
THIS APPLICATION INCLUDES A VARIANCE I WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
(Signature of property o er or authorized agent)
Permit/Rush Fees: 61 Waiver Fees:
Date of Payment: (Q`? c4 r I Date of Payment:
Receipt Number: 600-0 561 Receipt Number:
Permit No. C3 P1--1 +OD Waiver No.
Permit App_ - .:..c
Pannone Engineering Services ac
Steven R. Pannone, Principal
Registered Professional Engineer
E-mail:steve@panengak.com
June 29, 2017
Subject: PAULSON L65A
Septic System Permit Request
Design Narrative
This is a design narrative for a permit to install an upgrade septic system to be issued for this property.
The proposed system will serve an, existing three (3) bedroom single family. Currently the lot is
developed, and the existing septic system is connected to the primary residence. The proposed system
will utilize a new 1000g septic tank and conventional drain field. This lot and the surrounding developed
lots are served by private wells. There are no surrounding wells within 100' of the proposed septic
system.
1. Soils. One test hole was performed in the vicinity of this system by PES in June 2017, and groundwater
was monitored for at least seven days. No ground water was observed during excavation of the test
hole nor after the seven day monitoring period in June of 2017. Bedrock was not encountered in the
test hole to 15.0'. Based on the results of the percolation tests and overall soils appearance; an
application rate of 1.2 gallons/day/square foot was used for a conventional wastewater system, in the
area of the test hole.
2. Soil Absorption System Design.
a. See Sheet 1 of the design package.
3. Surface Water: There is no surface water within 100 feet of the proposed septic tank and drain field.
The proposed drain field upgrade will maintain at least 100 feet from all surface water and drainage
ditches, including the mapped creek on the next lot to the south.
4. Topography: The existing topography on the lot generally slopes from east to west, with a slope
of approximately 1%-5%% in the area of the drain field. There are no steep slopes within 50' of the
proposed drain field. The proposed drain field will maintain 50' separation all steep slopes.
5. Drawing Markings: The Drawings are marked "For MoA Review Only". When written notification that
the review is complete and that there are no further comments is received from MoA On-Site
Department, the note will be removed and "Issued for Construction" drawings will be issued.
The proposed installation will not affect the future development of this or the surrounding lots.
Mailing: P.O. Box 100217, Anchorage, AK 99510-0217
Physical: 332 East Manor, Anchorage, AK 99501
Telephone: (907) 272-8218 FAX: (907) 272-8211
I -....._1..s.3.-1,1=4\\>
I
DESIGN PARAMETERS
/ 4,
PRIMARY SEPTIC SYSTEM _
NO. BEDROOM: 3(450 gpd) 7 -%'
\TANK SIZE: 1000g I * •
PERC RATE: 1 MPI • SEPTIC IFlim1 ***** 1
SOIL RATING: 1.2 GPD/SF
.-11w-AREA--/ **, 1
AREA RQD: 375 SF /
SYS. TYPE: DEEP TRENCH 5.0'ED
MIN LENGTH: 37.5 LF ��\ w. r r •
V\ TRUE NORTH ,_,,,. SCALE 1-= 50
USE: ----------' F
38LFx2.5'Wx5.0' ED., 9.0' TD `N
TOTAL AREA: 380 SF
- w w — WATER LINE /
WELL RADIUS _
—ss ss — NEW SEPTIC 1
4(1
ABBREVIATIONS
TH TEST HOLE
(P) PROPOSED ABANDON TANK & 11/
(E) EXISTING CRIB IAW MOA CODE
CO CLEAN OUT NO. 65A
- :
MT MONITOR TUBE NO. �i 5% �Ilip
•1: C*
TYP I TYPICAL7
TH-P1 1
ik„
_,..4 f . _ 3BR
M
116.4 SFD -
- I
``�; 142.9
i ■ W 11
` 63.1 ( I
\
I INSTALL ABSORPTION FIELD P
38.OLFx2.5 Wx5.0 E.D.9.0 T.D. 46.7
W/ MTs & COs AT BOTH ENDS1 7 DRIVEWAY
N
INSTALL 1000G SEPTIC TANK P 1L ,
W/DCOs BEFORE & AFTER TANK
\ w WELL (E)-
• --____ W
6 5B ��
/
111111111'W -------
� W
NOTES: PANNONE ENG SVC, LLC Date
06/29/17
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510
PHONE (907) 272-8218 FAX (907) 272-8211 '••.�4,. ••'• Scale
* • ,� ;� 1" = 50'
`�n1`�,z P.I.D. NO
PAULSON L65A -018-261-23
DRAWN JRL GREGG & GAYLA DUGGER ��O ^ i• -an^cfm PERMIT NO.
14400 ELMORE ROAD -'•.Rfv�:o776 z.49 OSP171170
SITE PLAN ANCHORAGE, AK 99516 °�� Sheet
1 OF 3
I
SOILS LOG - PERCOLATION TEST
TEST HOLE 1
SLOPE • •, SITE PLAN
OR TOPSOIL
1
2
3 65A
4
5n ,,,,,.....\
BROWN SILTY
SANDY
6 GM GRAVEL W/ X TEST
COBBLES HOLE 1 16.4
7142,9
8 _
Illrg
10
11
12
13 GRAY SILTY
GM SANDY SLOPE
14 GRAVEL W/ WAS GROUND WATER
COBBLES ENCOUNTERED? N
15 TH 1
BOH IF YES. AT WHAT
DATE PERFORMED: 16JUN17 DEPTH? -NA-' X
NO GROUNDWATER
QEPTH TO WATER AFTER
MONITORING? - DRY -
DATE: 29JUN 2017
CLOCK WATER RATE SOIL TEST RESULTS/ANALYSIS
READING DATE TIME NET TIME LEVEL NET DROP (MPI} • PERCOLATION RATE 1 (min/inch)
READING
(Hydrologic Soils Group: HSG A)
1 16JUN17 1105 5.900" • PERC HOLE DIAMETER 6"
2 1112 6.5 MIN 11.900" 6.0" 1,1" • TEST RUN BETWEEN 5 FT AND 6 FT
3 1113 5.900" • TEST RUN FOR OVER AN HOUR, LAST
THREE READINGS PROVIDED.
4 1120 6.6 MIN 11.900" 6.0" 1.1"
5 1121 5.900"
6 1129 7.2 MIN 11.900" 6.0" 1.2"
COMMENTS:Test hole excavated by A+ HOME SERVICES.
PERFORMED BY:Joseph Lawendowski. I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE
AND MUNICIPAL GUIDLINES IN EFFECT ON THE DATE OF THIS TEST.
NOTES: PANNONE ENG SVC, LLCte
••�_ Da06/29/17
FOR CONSTRUCTION P.O. BOX 102954 ANCHORAGE, AK 99510 '•
PHONE (907) 272-8218 FAX (907) 272-8211 �:'- • ••*_••. Scale
*` I, NTS
• .��..� �'. P.I.O. NO
PAULSON L65A -� 018-261-23
DRAWN JRL GREGG & GAYLA DUGGER CE 8149 FERMI NO.
14400 ELMORE ROAD '^'•.IZI V [7/0:/1;••• 05P171170
SOILS LOGS ANCHORAGE, AK 99516 °." Sheet
2 OF 3
I
SPECIAL PROVISIONS TO SPECIFICATIONS
1. ALL CONSTRUCTION SHALL BE INSTALLED AS SPECIFIED IN THE MOST CURRENT EDITION OF THE MUNICIPALITY OF
ANCHORAGE STANDARD SPECIFICATIONS (MASS) FOR COMPONENT PARTS AND MATERIALS USED IN CONSTRUCTION OF
ON-SITE WASTEWATER DISPOSAL SYSTEMS AND AND IN ACCORDANCE WITH AMC 15.65 AND 15.55.
2. SCOPE OF WORK: INSTALL NEW 1000g SEPTIC TANK, AND SOIL ABSORPTION SYSTEM.
3. GROUNDWATER WAS NOT ENCOUNTERED TO A DEPTH OF 15 FEET BELOW EXISTING GRADE AS EVIDENCED BY THE SOIL
TEST HOLE, IF AN APPARENT WATER TABLE IS OBSERVED IN ANY OF THE EXCAVATIONS LESS THAN 15 FEET BELOW
EXISTING GRADE NOTIFY THE ENGINEER IMMEDIATELY.
4. THE CONTRACTOR (BOTH WELL AND SEPTIC SYSTEM CONTRACTORS) SHALL HAVE ANY WELL LOCATION AND SEPTIC
LOCATION STAKED AND ANY LOT LINE AND WELL RADIUS SHOWN ON THE PLAN WITHIN 30 FEET OF THE PROPOSED
SYSTEM STAKED BY A REGISTERED LAND SURVEYOR BEFORE STARTING THE WORK.
5. THE CONTRACTOR IS RESPONSIBLE FOR ALL R.Q.W. AND OTHER REQUIRED PERMITS, OTHER THAN THE ATTACHED.
6. THE CONTRACTOR SHALL CALL FOR LOCATING OF ALL BURIED UTILITIES.
7. THE CONTRACTOR SHALL PROVIDE 24 HOUR NOTICE TO THE ENGINEER PRIOR TO START OF WORK. ALL SURVEYING
AND LOCATES SHALL BE IN PLACE PRIOR TO NOTIFYING THE ENGINEER.
8. THE CONTRACTOR SHALL NOTIFY THE ENGINEER OF ANY DISCREPANCY BETWEEN THE APPROVED DRAWINGS AND SITE
CONDITIONS/LIMITATIONS POTENTIALLY CAUSING THE NEED TO MODIFY THE DESIGN.
9. AT THE COMPLETION OF THE WORK, THE CONTRACTOR SHALL SUBMIT RED-LINE AS-BUILT DRAWINGS TO THE
ENGINEER. THE RED-LINES SHALL INCLUDE PIPE LENGTHS, ORIGINAL GROUND ELEVATIONS, PIPE ELEVATIONS, AND
TANK ELEVATIONS,
10. THE CONTRACTOR SHALL PROVIDE PHOTOGRAPHS OF THE SYSTEM INSTALLATION TO INCLUDE BOTTOM OF EXCAVATION,
TOP OF PIPE WITH CLEAN-OUTS AND MONITOR TUBES INSTALLED, INSTALLED TANK AND FINAL GRADING.
11. THE CONTRACTOR PROVIDED DATA (UPON WHICH THIS RECORD DRAWING IS BASED) APPEARS TO REPRESENT THE
PROJECT AS CONSTRUCTED. THIS DATA IN CONJUNCTION WITH THE PERIODIC FIELD OBSERVATIONS BY THE ENGINEER
(OR HIS DESIGNEE) AS REQUIRED BY AMC 15.65 DOES NOT GUARANTEE THAT THERE ARE NO HIDDEN DEFECTS BY THE
CONTRACTOR.
12. THE CONTRACTOR SHALL SIGN THE FOLLOWING:
I CERTIFY THAT ALL WORK WAS PERFORMED IN ACCORDANCE WITH THE APPEND PERMIT, AND ANY AND ALL CHANGE
ORDERS, AND THAT THE AS-BUILT REDLINES ARE TRUE AND ACCURATE REPRESENTATION OF THE PROJECT AS
CONSTRUCTED.
CONTRACTOR:
BY: . TITLE:
DATE:
NOTES: Dote
FOR CONSTRUCTION PANNONE ENG SVC, LLC �/
P.O. BOX 102954 ANCHORAGE, AK 99510 �PSC•►• 06/29/17
PHONE (907) 272-8218 FAX (907) 272-8211 �_• 1- ty
Scale
_ .• 1, "k '�* NTS
•• �•VO
•••• P.I.D. NO
PAULSON L65A - , 018-261-23
GREGG & GAYLA DUGGER I S3even Pannone PERMIT NO.
DRAWN JRL 14400 ELMORE ROAD RE(V 07]04,7. OSP171170
ANCHORAGE, AK 99516 •
��p''
DESIGN NOTES Sheet
. kms•` 3 OF 3
\ \'
MUNICIPALITY OF ANCHORAGE ~) / ~'
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a)
Legal Description (include lot, block, subdivision, section, township, range)
Location'(address or direciions)
(b) Property Owner "'~TZ~)* ~ Telephone: Home
(c) Lending Institution /~J~¢'~.-
Mailing Address . .-~
(d) Real Estate company a~d Agent
Address ~./~
Telephone ~' /~/¢
(e) M~il the HAA to the followina address: or: Check here~ hold for pick up.
List cont~9~ and d~p~one nu~er below.
Business
TYPE OF RESIDENCE
Single-Family',
Number of Bedrooms
WATER SUPPLY
Individual Well~ Community [] Public [] 4
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 (Rev 8/86~ Front
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 /~~'
Address /,~-¢.70 ~k] ),~ ~ ~'~'! ~
Telephone
DHHS APPROVAL
Approved for ~ -
Approved' X
bedroomsby ~~:::~ ~ ~ Date Disapproved GonditJonal
Terms of Conditional Approval
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 IRev 8/86/ Back
Ao
WELL DATA
MUNICIPALITY OF ANCHORAGE (MeAl
NtUNtCIP^UIY OF ANCt'~I~,JI~.[I'H AUTHORITY APPROVAL (HAA)
ENVIRONIVIENTAL SERVICES OlVI~CKLiST . FEBRUARY 1984
264-4720
, tN l ? 1988
Lega~ Description:
Well Classification
Log Present (~'~
Well
Total Depth ~) /.~
Static Water Level ~) ./O/,
Casing Height Above Ground
Electrical Wiring in Conduit ~)N)
Separation Distances from Well:
RECEIVED
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 ¢~/~'~'zf~'~)'V/ Yield
Cased to (~) 4f~ ~'~
Depth of Grouting
Pump Set At
Sanitary Seal on Casing~l)
Depression Around Wellhead (Y~)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
~--. gO/e-~ ;Date
,0~
TO Septic/Holding Tank on Lot
To Nearest' Edge of Absorption Field on
Comments t~)~ ~
B. SEPTIC/HOLDING TANK DATA
Date Installed //q~'~
Standpipes~:~lN)
Depression over Tank (Y{~)
Size //~ NO. of Compartments
Air-tight Caps{~) Foundation Cleanout (Y~:),
Date Last Pumped ~
. ,,4)/~ ;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field 4/ /
To Stream, Pond, Lake, or Major Drainage
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~//' ;~' / ,IC',~M
!
To Property Line /0 ~
To Water Main/Service Line /O
Course /dO /
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /'~
Width of Field ~¢/J~'~J~/')
Square Feet of Absorption Area
Depression over Field (Y(~
Results of Last Adequacy Test ~__~v,¢. ~/¢E'
Separation Distance from Absorption Field:
To Water-Supply Well /~"/'~//~f
To Building Foundation ~/t~, ,' )~-/4 $/"d~)~/~/f~r',
Lot ,W/'/~' ; On Adjoining Lots /4)
To Water Main/Service Line /O/'"/'" To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area /'~
Comments
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
LIFT STATION
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Pump'mg ~during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have, ehec_,kcd, velified, or conformed to all MOA and HAA guidelines in effect on t h.e~,Of~ ~. ~pection.
~. - ~~
~lgnea ~ ~ - / - ~ -' · , ,. .,,
Company ~ MOA No
Receipt N
Date of Payment
Page 2 of 2
72-026 (11/84)
ALASKA I IIUIROIlmI rlTAL COIqTROL $1 RUICI $, II'lC.
~n§ineerin§ ~, ~nuironmenlal Studies
Municipality of Anchorage
Department of Hea].hh & Human Services
825 L Street
Anchorage, AK. 9950].
Attn: Susan 0swal. t
R~.;: !,or 65A, Pau]sen SubrlivisJon
July 5. 1.9oo
191UNIcIPALITY OF: ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
JUL ? 988
RECEIVED
Per your request, on 6/29/88, I probed the subject lots septic tank to try to
determim; its type. A st~;e] pipe was used for p~-o~Jng. The bo't'tom is hard and
smooth. Sliding the probe f.~'om side to side, a rounded bo'ttom can easily })e
detec'ted. Thumping the probe on the bottom c~mses an echo of an empty si. eel
tank. The tank is determined to be a steel tank. The pumper reported removing
1100 gal?tons which is adequate for 'the 3 bedroom house.
If you have any questions, please call.
Sincerely,
Alan C. Wien
Engineez'ing 'P¢,'cl'mici an
Approved by:
PE
1200 UJest 33rd Auenu¢. Suite B e, Anchoracl¢. Alaska 99503 e,(907) 561-5040
ALASKA ENVIRONMENTAL
CONTROL SERVICE~' INC.
:1200 West 33rd Avenue :uite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NO .... OF
CALCULATED BY,., DATE
CHECKED BY DATE
SCALE ? ; 7'~
Municipality of Anchorage
825 "L' Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
PERFORMED FOR: >/[!~
LEGAL DESCRIPTION:
,,-~-~. -o ...... o.'-,~ ~_. ~'
Section: ~ . /-~ ..... .;~ :4. ~
Township, Range, ~~~-'J ~;Z
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Wale, After
Monitoring? J')~7 Dale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
.--.....
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/tach) PERC HOLE DIAMETER ,, ,
FT AND FT
PERFORMED BY: /~["'('" / V.J//:/' I ,
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE.
72-008 (Rev. 4165)
CERTIFY THAT THIS TEST WAS PERFORMED IN
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
264-4720
Application Date ~/'~ v/~ / ~}:;~'~'
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdiv, v,v, ision, section, township, range)
(b)
(c)
Location (address or directions)
Applicant Name -/'~eh -~,v~'/,~-r' -~/'~ Telephone: Home ~¢(~.) Business ~
Applicant Address / ~ ~ ~,/~~ ~ ~
Applicant is (check one): Lending Institution D; Owner/builder ~; Buyer D; Other ~ (explain);
(d) Lending Institution
Address Company and Agent
(e) Real Estate
Address
Telephone ~'"~
(f) Mail the HAA Lo the following address:
Telephone
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
WelI~L, 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.
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 01/84)
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.
Approved for "/¢)_,~'477 bedrooms by
Approved ~,~ , Disapprove~ - Condition('aF~
Terms of Conditidnal 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)
WELL DATA RECEIVED
Well Classification PC/V ~'7/~
MUNICIPALITY OF ANCHORAGE (MOA)
MUNI~PAu'rY OF ANCHOIbklIJ~LTH AUTHORITY APPROVAL (HAA)
DEPT. OF HEALTH & CHECKLIST- FEBRUARY 1984
ENVIRONMENTAL PROTECTIOI~ 264-4720
MAR g 1986 Legal D scrip.tion:,
If A, B, C, D.E.C. Approved (Y/N)
Well Log P~'esent (Y~_~ Date Completr~d ~ Yield
Total Depth ' .~ .~' Cased to,;-~ ~ ~ Depth of Grouting
Static Water Leve~ ~* ~' Pump Set At
- . / ~/
Casing Height Above Ground / ~ Sanitary Seal on Casin~)
Electrical Wiring in Conduit) Depression Around Wellhead (~.
Separation Distances from Well: i
~ ~ ;On Adjoining Lo~%
To Septic/Holding Tank on Lot . _ ~-~ r , On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ·
To Nearest Public Sewer Line ~/~ To Nearest Public Sewer
Cleanout/Manhole ~/~'' To Nearest Sewer Service Line on LOt
Water Sample Collected by '~/ '~~ ~ ~ ;Date
Water Sample Test Results ~ ~ ~ / ~ ~. ~ ~ ~
Commen,s
SEPTIC/HOLDING TANK DATA
Date Installed ~
Standpipes ~,~1) Air-tight Caps(~l)
Depression over Tank (Y~)
Pumping/Maintenance Contract on File (Y(~' "/~
Holding Tank High-Water Alarm (Y/N)
Separation Distances f~ Septic/~olding Tank:
TO Water-Supply Well ~ / /
To Property Line ~ ~ ~ / C.
To Water Main/Service Lin~
Course ~~ ¢~
Comments~ ~~ ~~;.¢~~ /~ ~/~
No. of Compartments
Foundation Cleanout (Y(~ ·
Date Last Pumped / ? /~. _~./'-'
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation ~---~/~
To Disposal Field ~'~4 ~,~
To Stream, Pond, Lake, or ~ajor Drainage
Page 1 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~bsorption Fie~d:
To Water-Supply Well "" /'~ ,4, .
To Building Foundation ~"~ ~ '
.'~.~.~J~?,~ 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
Lot /~/~ ? . ; On Adjoining Lots _
To Water Main/Service Line. /~/"/x~ T_o~Cutbank ~f present)
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area ~ _~_.,
Comments ¢ /l~_J?_~'~.. ,~ ~_.~,~.~_~ .~,/,~,~
To Existing or Aban,(;toned System on
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 che)~e¢
Sig ne~l ~/~_./~.,y~)~ I verit, ied, or conformed to all MOA and H~.A guidelines in effect on the date of this inspection.
~~, Date ~~< )~
Comp~y~~
Receipt No. ~
Date of Payment
Amount: $ ~
Page 2 of 2
72-026 (11/84)
A well flow test was performed simultanously with the adequacy
test of the on-site septic system. This test showed the well
to be adequate for this 3 bedroom home.
Sincerely yours, ~
,i~mes F. S±zemore PE
6410 Switzerland Drive
Anchorage, Alaska 99516
L.OT' GG A
v~c LL
..... ! i ,::":it?f £c:,