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HomeMy WebLinkAboutLEACH LT 3OI511.t Municipality of Anchorage Page __ 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 Permit Number: __~.~J~__0.~07 PID Number: ¢2/~//Z Name: ~Upgrade .. ~¢.~ ~ ~ ~/~ ~ Z n~An.~/~ Wastewater System: ~ New Address: /o~/ ~o~ ~F ~. ABSORPTION FIELD _ Phone: ~C~¢~ ~ INc. of Bedrooms: ~ ~ Deep Trench ~ Shallow Trench Q Bed ~ Mound ~ Other I LEGAL DESCRIPTI ON so, Bating: Total Depth from origina~ade: ¢, ~ 6PD/Sq. FL /2. ' Lot: Block: Subdiv~ion: Depth lo ¢ipe bottom from original grade: Gravel depth beneath pipe Township: Range: ~ Section~ ~ Fill added above original grade: Gravel length: ~ Ft. WELL: ~ New ~ U pg fade Gr~vel width: Number of lines: Distance behveen lines: Classification (Private, A,B,C): ~/~, Total Depth: Cased To: Total absorption area: Pipe material: ~ ~/O Driller: Date Drilled: Slatic Water Level: installer: Date installed: Yield: Pomp Set at: Casing Height Above Ground: ~ ~ .u/~ ~,. z/ ~ ~. TANK SEPARATION DISTANCES ~Septic g Holding g S.T.E.P. To Septic Absorption Lift Holding Public/Private Manufacturer: Capacity in gallons: From Tank Field Station Tank Sewer Lines .~ ~¢ ~ ~ Material: Number of Compartments: su~ce ,, ,, LIFT STATION// Water /~ /~ ~ ~ _ Lot ~' I .... Size in gallons: jManufacturer: ~ Line I ~' ~ ~ "Pump on" level ~ off" level at: High water alarm at: Foundation Curtain Electrical Inspections performed by: Drain Remarks: B~NCH MARK Location and Description: Assumed Elevation: ,I;'~.'' ..,.I'....~..~:,'~ Inspections performed by: E,¢, Rlve~. Alaska 995~ Dates: 1st Z -P -~ (,.,~¢ (, (~ r- c ' ....... Department of Health ag~ HumCp,' es approval ' ''~,.''-''''. .... . . ...".-'?.... .< ?.. /_ :~ '~, ", "*-~.,.r'~..' .. by://%¢- ~a,e~- . '~,~,~.~...~- ' ~.,~,.~ ..... : ..... Reviewed and approved 72~013 (Rev. 9/91)MOA 25 Permit No,sw950007 Page _ 2 of 2 Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P,O. Box 196650 · Anchorage, Alaska 995t 9-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Legal Description.LOT .3, LEACH COt CO2 NEW 1000 GAL SEPTIC TANK ~ A B FCO 4.8 26.1 CO1 39.3 dO2 45.2 57.7 403 49.7 62,[ q04 49.3 67,~ dO6 69.6 8?.7 MTi 49.1 66.1 MT2 69.9 87.[ 100' WELL RADIUS SUBDIVISION GBADE--~ (CO3& C04) PIDNo.: o151 87'4~k (COS& C06) .~¢~') 5 4'- A 69.4~ NO WATER FOUND 237 SCAL~ NEW TRENCHES t" = 40' 1000 GAL.iSEPT[C TANK RO2[RT C, COWAN CE ~ ~JSO } · ,;,(,-/,? ........ ,'..-,.,;/ 72-013 A (1t93) ' MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMA~ SERVICES P.O. BOX 196650, 825 "L~' STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT PERMIT NUMBER:SW950007 DESIGN ENGINEER:S & S ENGINEERING OWNER NAME:ZOBOROSKIE DALE J & NORA J OWNER ADDRESS:10651 ABBOTT LOOP RD ANCHORAGE, AK 99516 DATE ISSUED: 1/25/95 EXPIRATION DATE: 1/25/96 PARCEL ID:01511237 LEGAL DESCRIPTION: LEACH LT 3 LOT SIZE: 29704 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION 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 (18AAC80) . 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 (24 HOURS) 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 PROVI S I 0~.:-~-:~ DEPT. OF ENVIRONMENTAL CONSERVA~ ANCHORAGE DISTRICT OFFICE 800 E. DIMOND BLVD., SUITE 3-470 Munic.~ .... ANCHORAGE, ALASKA 99515 Dept, Hea~tb (907) 349-7755 TONYKNOWLE~ GOVERNOR January 13, 1995 Mr. Robert Cowan, P.E. S&S Engineering 17034 North Eagle River Loop Suite 204 Eagle River, AK 99577 RE: Lot 2, Block 1, Leach Subdivision; Horizontal Separation Distance Waiver to Class "C" Public Water System Source Well. ADEC Project No. 9521-WV-362-023. Dear Mr. Cowan: This letter is in response to the materials received in this office December 28, 1994, regarding a request for a waiver of the required horizontal separation distance between a replacement on-site septic system located on lot 3, to the Class "C" well located on the above referenced lot. The Department has completed its review of the submitted materials which included a cover letter, site plan, statement of non-objection from the well owner and water sample analysis. Based upon this review, a variance from the required separation distance (18 AAC 80.030 and 18 AAC 72.015) of '150 feet to a proposed 116 feet between a Class "C" well and a neighboring on-site septic system is granted subject to the following comments: This Department regards the issuance of waivers very highly and must evaluate the potential adverse impact to the environment and public health. The absence of a well Icg for the Class "C" well in question for which the waiver is requested hinders the review process. However, based upon an engineering analysis of the materials submitted and information on file including a neighboring well 10g, it appears that the subsurface soils and topography in this area are amenable to allowing a lesser horizontal separation distances with minimal potential for contamination to the subject well. The water sample analysis collected from the well were satisfactory indicating that the existing separation distances which is less than the required distance has had minimal impact on the well. This approval does not grant additional authorizations, nor does it obligate any other state, federal, or local regulatory body to grant required authorizations. Mr. Robert Cowan, P.E 2 January 6,1995 Thank you for your cooperation with this Department, if there are any questions regarding the above please do not hesitate to call. Sincerely, Michael Lu, E.I.T. Environmental Engineer ML/cf ROBERT C. COWAN, RE. ROBERT A. SHAFER, RE. HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION ENGINEERfNG STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOILTEST PERCOLATION TEST STRUCfURAL & MECHANICAL INSPECTIONS ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN December 27, 1994 CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 MUNICIPALITY OF ANCHORAGE Department of Health and Human S~rvices P.O. Box 196650 Anchorage, AK 99519 REFERENCE: Lot 3; Block I; Leach Subdivision Requ~t you issue a p~rmit to upgrade the septic system s~rvin~ the th,~ee bedroom hou,6e o~ the. ~te~e,tene.,ed p~ope,'v~. An adequacy test performed on the existing system for H~h Authority Approval purposed found the absorption capacity of the system to be inadequate. A t~st hole was excavated and a percolation test performed. The approximate location of the t~st hole is located on the attached site plan. The mo~oring tube within the test hole has been check and found to be dry. Attached is the proposed upgrade design. We do not anticipate any adverse effects on neighboring properties by the installation of the proposed septic system. A waiver request has been sent to the State of Alaska, Dept. of Environmental Conservation for the Class "C" well located on the adjacent property (Lot 2). This will be forwarded upon receipt. If you require additional information please do not hesitate to contact us. Sincerely, ROBERT C. COWAN, RCC/gk ENCLOSURE 17034 NORTH EAGLE RIVER LOOP , SUITE 204 · EAGLE RIVER, ALASKA 99577 © / / 30WJOdFI ,og =: ,,I, -llVI3C]/NOIIO3~-X ~3¥0S 'S'±'N Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: 1 3 4 7 8 10 12 13 17 8 19- 20- DATE Township, Range, Section: WAS GROUND WATER ~.~ ENCOUNTERED? O S IF YES, AT WHAT ~ ~ DEPTH? p E Deplh ,o Water After ~t~¢¢ Monitoring? Dale: SLOPE SITE PLAN Reading Date ~'e~"- ~¢-'~.. '~[~" Depth to Net Time (~/¢,t= Time Water Drop ACCORDANCE ~U~~g~PAL GUIDELIN~IN EFFECT ON THIS PERCOLATION RATE ~-'f~ (m~nutes/~nch) PERC HOLE DIAMETER TEST RUN BETWEEN ,~__ FT AND 6 FT CERTIFY THAT T~S TEST./~AS PERFORMED IN /'~/~ ) /~' DATE. DATE: 72-008 (Rev. 4/85) ROBERT C. COWAN, P.E. ROBERT A. 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 ONSITE WASTEWATER DISPOSAL SYSTEM DESIGN ON-SITE ~I~TEOIATER PISPOSAL S~$TEM CONSTRUCTION PRACTICES ~ATERIAL SPECIFICATIONS CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 REFERENCE: Lot 3; Block I; Leach Subdivision GENERAL: The scope of this project includes the installation of two leach field trenches to s~rve the three bedroom residence located on the referenced property and excavation of the existing septic tank to verify it~ 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 gallon septic tank installed outside the I00' protective w~ll radius. Construction shall be in accordance with the approved site plan and d~sign drawings, Municipal p~rmit with any special provisions or conditions, and all applicable State and Municipal Wastewat~r Disposal Regulations. 3. 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 area~ subsequently depressed from soil settling. Contractors i~tal~ng wastewater 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 TA~K INSTALLATION: A septic tank is to be constructed by a certified septic tank manufacturer. Construction shall include two 4" cleanout~ for pumping access. 2. The septic tank shall be sufficiently bedded to prevent s~ng or shifting of the tank. 3. All 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 /.ot 3; Block I; Leach Subdivision December 8, 1994 Septic tanks installed with l~ss than 4' of cover shall be insulated. A foundation cleanout shall be installed one to four fe~t from the building foundation. In the line between the tank and the leachfield there shall be two adjacent cleanouts (u~less an effluent pumping system cxist~ within the septic tank). These cleanouts shall be located on undisturbed soil not more than 10' 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 exist~ away from the septic tank· ABSORPTION TRENCH/~.AINFIEL~) INSTALLATION: Excavate the proposed trench to the dimensions shown on the design· The bottom of the excavation sha,~ be within 2 inches of level. If the sidewalls of the excavation become smeared, they must be raked or scratched (roughed-up) before ~rav~l (s~r rock) placement. Once the ~ravel 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 backfire. Ensure the silt barrier covers the entire gravel surface before placing backfill. Monitor tub~s shall be of four (4) inch diameter and installed approximately in the locations shown on the d~sign. 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 ~ravel as noted on the design. Backfill over the final gravel layer must not be less than twenty-four (24) inches. Insulation must be installed when the backfill depth is l~ss 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 I. Any septic tank proposed for installation must be constructed by a Municipally approved septic tank manufacturer. Page Three Lot 3; Block I; Leach Subdivision December 8, 1994 2. The following pipe materials are approved for use in septic system installations in the Municipa~y of Anchorage: Type of Pipe Perforated Solid Cast Iron Yes Y~s ASTM D3034 (PVC) Yes Yes ASTM F810 (HDPE) Yes No ASTM D2662 (ABS) 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 out~ets shall be fitted with watertight couplings (Ca~der, Fernco, or equal). A permeable nontoxic silt barrier (Typar 3401, Mirafi 140/N, or equal) must be installed between the final leachfield gravel layer and the native soil backfill. All leachfield gravel (sewer rock) sha~l be 0.5"-2.5" screened grav~ 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.0.A. or D.E.C. requirements. INSPECTIONS: Typically there will be a minimum of three (3) inspections required during the installation of the wast~water disposal system. These inspections will occw~ 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, ~ravel, distribution lines, standpipes, eleanouts, and insulation, but before the placement of any other backfill. Page Four Lot 3; Block I; Leach Subdivision December 8, 1994 3. 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 trench~s, sand filths, 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 wd~l not coordinate, direct or control in any way the contractor's activities. The owner shall contract with the contractor to perform the work outlined in th~se specifications and plans and in accordance with the attached M.0.A. permit. There will be no contractual arrangement existing between the contractor and S & S Engineering. S & S Engineering sha~l be the owner's representative and will inspect the work ~ stated above to document the contractor's activities. Final acceptance of the contractor's work rests with the owner and the M.0.A. S & S Engineering shall have no liability to the owner or to others for acts or omissions of the contractor or any othe~ 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 th~ project. CONTRACTOR/INSTALLER NAME~ MUNICIPALITY O1': ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAl,. PROTEC'¥1ON ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WEI.I. INSPECTION REPORT _l~ro N E ~'EW MAILING ADDRESS LOCATION/] -- I DISTANCE TO: /~ ~ ~ ] Manufacturer ~ ~, ,~.~ ~ L~)~t~n gallons IF HOMEMADE: Inside length ' ~ ,. ~ D STANCE TO' Well Dwelling ~ I Manufacturer ' I ~= I D~STANOETO: I '~f~ ~ ~ ~ No. of lines / Le~]g[l~ ~eacb lin,e / Total length o] lines ~ ~ Top of tile to finish grade ~ ~ Length Widt~ Depth ~ ~ I Type of crib Crib diameter Crib depth - ~ ~ DISTANCE TO: Well I-Building foundation i c,.,, Depth ~ DISTANCB TO: Buildin9 foundation ~ Sewer line Dwelling Width Material Nea~est~o~,~Se/ Tre,~; inches NO, OFBEDROOMS P E R M I,¢T~N.O. No, O~-~_~r~.~ pa r t m e n t s Liquid depth PERMIT NO. Liquid capacity in gallons Total eff~ct~e absofl)tion area PERMIT NO. Total effective absorption area Nearest lot line Distance to lot line PERMIT NO, Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING ¢~' I N ST..~.L E R . )i REMARI~S ' - LEGAL 72-013 (Rev. 3/78) "Fl.'fiE: i:::,iEF'"I"!-.! OF:' F! "i'F:!~:!'.,K::H OF: F':i:I' :!::S THE: !::,:(S'FF!I'.,K:::!:L:: !i{}~E:"['i,.IE~:E~:!'..! 'J'!.'!E: :i}i;L!Fi:F:'t:::K:::tS L'.'fF' 'I'HF:!: i. Jil:;i:Ot..!I'q.(::, F:'IH[:', 'fF.If_'ii: E:O'f"I"C!hl OF' '!'m~i: ~ii:;:':;CF:I'v'FIT ]: ON ':: :iN 'T'l..!.r.~:Bi~i!: .!:S; i'~!O :i~;!~:"F F!:I:D'i'H F'Oi::i: T!..IIi:;: !::il~?l:::!',/!!!i:L. [::flii:F:'"f'H :l:i!!i; THE: !','I :~ i'.,] :!:1',11...11',1 !::,!~:F'TH OF:' L:iFi:Fi',/!.:::L. ~i};!i~:"t"!,~iiii:~:!.!,.~! THIS C!LrTF:'FiL. L. FIND "!'HE: i!!',CKi"T!:)H C!F' 'FHEi: f.}i:::.::C:F!',/I:'.!T :!: C-IN ,:: :[ i'..! F'~i;:Z.{'T' ). SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchoraga, Alaska 99501 264-4720 SOILS LOG- PERCOLATION TEST PERCOLATION TEST ~ Lm/..) 5il-t' 2 3 5 6 7 8 9 10 ~2 SLOPE 5ihI l,ei~.~, of' 5,.,# 13I 14 16 17 18 cor¥,~EN','S Rat~,,-/ ,~'/" SITE PLAN ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? r ..]~ idPJ~Z'~'~I~7~ ] ,~ tl:t ~' !O' ~n Reading Date Gross Net Depth to Net Time Time Water Drop .t. ~; ~3' Id ~m _1, ~ ! ~, 31 PERCOLATION RATE __ 5 (minutes/inch), TEST RUN BETW,~EN __~ FT AND '~---- FT , _ CERTIFIED BY ~ DATE: ~ .~' r~. 72-008 (6/79} Date Drilled: Static Water Level Draw Down WELL LOG fee t feet Gallons Per Minute Total Feet of Uasing_./¢~ ?ype Material Drilled: to Hefty Drilling S.R.A. Box 1553 H Anchorage,Alaska 9950? ~UNICIPAI_ITY OF ANCHORAGE ~'i':;~ .~ 7 "'~' R£CEIVED '9 December 2. ~ 1978 I~780223 Donald Leach Box 988 Anchorager Alaska 99510 Subject: Lot 3 Leach Subdivision A permit issued by this department for well and/or sewer system has expired. Perntits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a ~¢ell log should be sent to this department to document the installation date o If there are any further questions, please contact this office at 264-4720~ Sincerely, Les No Buchholz, Senior Environmental Specialist LNB/ljw enc~ copy of permit 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 Parcel I.D. # 1. GENERAL INFORMATION Complete' legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING O) 3- )/2- 57 HAA# Lot $? Leach Sub.vision IGAq 50o,-/I Location (site address or directions) Property owner Mailing address 10651Ab§o,C~ Loop Ane. hn~g~: AK DaZe Zaboroskie 10651 Abbott Loop Rd. Anchorage, Day phone 346-2856 AK 99516 Lending agency Mailing address Day phone Agent David Zaboroski/ POLAR REALTY Address 1101 E. 76th Ave. Suite Bi Anchoraqe~ Unless otherwise requested, HAA will be held/or pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Day phone 349-7681 e TY' NOTEi Individual on-site Holding tank : Community on-site Public sewer provide written confirmation from State ADEC attest-. ' · ;tatus of system. )SAL: XXX 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 ~hat 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 S & S ENGINEERING 'i/u~4 i-~ie Kiver Loop Koa~i Ne. ~ Phone Address Eagle River, Alaska 99577 ~,' Engineer's signature ~, .... . -v . Date DHHS SIGNATURE ' ~L. Approved for 5 DiSapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date I[ The Mun~cipality 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. 72-025(Rev. 1/91) Back MOA#'21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~OT- ,~ /' CE,4cH ~'o)~/v/$/o.'J Parcel I.D. O/G-//Z-~ 7 A. Well Data Well type ~/~/v¢'l'E Log present (~N) yES Total depth / ~ O ' Sanitary seal(~N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Cased to IqO' Casing height $~$ Wires properly protected ~N) ~,/~-~ FROM WELL LOG Date of test Static water level /~cl ' Well flow ..S- Pump level1 SEPARATION DISTANGES FROM WELL TO; Septic/hoMif~j tank on lot /0o' Absorption field on lot I O0 ' Public sewer main 7~' ' + Sewer service line ?_E ~ ~- AT INSPECTION g.p.m, ~ ,(~ g.p.m. ; On adjacent lots ; On adjacent lots I00' Public sewer manhole/cleanout /o0 ' -+- Z ~C Petroleum tank WATER SAMPLE RESULTS: Coliform ¢ Date of sample: 2 - Nitrate /.¢~- ,~¢/~ Other bacteria Collected by: .% ,~ .~ -~-,'.O~IAJE~P-.//d B. SEPTIC/HOEBtNGrTANK DATA Date installed Cleanouts (~N) ~/~,~ High water alarm (Y/~ Date of pumping ~/4 Tank size /000 Compartments 2- Foundation cleanout t~N) 'y'E£ Depression (Y~ /k) //Or Alarm tested (V~.~_ /,.)O /t.J//dr- /t.) Et/V ?'~A) K-- Pumper /'J [ ¢r SEPARATION DISTANCES FROM SEPTIC/HOLDhNG TANK TO: Well(s) on lot /00 / On adjacent lots /fijL) ¢.ff Foundation ~' To property line ~o' Absorption field ~" Water main/service line /0 Surface water/drainage /~0 '4- 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Manhole/A~ces~/N). Vent (Y/N) "Pump on" level at / "Pump off" Level at High water alarm level / Cycles tested Meets MOA electrical codes (Y/~.....~/ SEPARATION DISTANC~-R~OM LIFT STATION TO: Well on lot ~ On adjacent lots D. ABSORPTION FIELD DATA Sudace water Date installed Length /-I ~' ~ Width Total absorption area .7.7c/ )z( Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) ~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Soil rating (GPD/FF) ..5' ' Gravel thickness Cleanout present (~) yes Depression over field (Y(~ Results (pass/fail) ~After test System type Total depth /,~' ' Bedrooms If yes, give date Well on lot /,¢¢ To building foundation On adjacent lots /0 Sudace water /O(') C~rtain drain /dONE On adjacent lots /Od ' ~- Property line /¢ ' To existing or abandoned system on lot /O /4- Cutbank E'O' + Water main/service line /O '+ Driveway, parking/vehicle storage area / t E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effe of this inspection. Signature Engineer's Name Date HA,& Fee $ Y Cd'~ ' ¢-'¢) Date of Payment Receipt Number 72-026 (3/93)* Back ~ :'~ .~ ROBERT C, COWAN ' ~' ', CE-8801 ", ~L'~ ,', ,':, ,Z :',L ,- ~-5;" Waiver Fee $ Date of payment Receipt Number 02/0S×95 15:00 COMMERCIAL TESTING * 90?6941211 client Name ordered By P~oJ,~t Name Projects PWSID CT&E Environmental Services Inc. I.aborato~y Division ~ ~- -~-J~______~J~_~_~_~_~-'-" ~_~ ...... ~_~_-__~_~._~_ _ Laboratory Analysis Report D3 LEACH 8/D WATER S & 8 ENGINEERING WORK Order RAY Pr£titsd Date Collected Date Eeosived Date UA 12433 02/06/95 02/03/95 ~ 03:4~ hfs. 0~/g3/~5 ~ ~5:~3 hrs. Technical Director STEPHEN C, ~DE Sa[nple Remarks: 8~MpLE COLLECTED By~ STACIE. QO Allowable Ext. A~al Parameter Results Dual U~ito Method Litalt~ Date Date Nitrate-N 1.05 mu/L ~PA 353.2 10. 0~/~3/95 8es Special Instructions Above UA - Ut%available See Sample Rel~arke Above NA = Not Analyzed Undetected, Repo~ted value 10 the practical ~antifioat%on ll~it. LT = Less Secondary d~on. GT = Greater Thall ~ W. Potter Drive, Aneh0rage, AK 99518.1605 -- Tei~ (907) 5G~-2343 Fax: (907) 561.5301 ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILUNO~S, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA MUNICIPkLITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HFS. TH DEP~RIT~iENT OF H~TH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE General Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicants Name ~_~? ' ;:~{~,d.~.~: l:~,; ::.~ Tei/e hdne ~ Itome .... ~_. ~ l'eie none - (c)Applicant is (check one) Lending Institution ~; ~mer/builder ~; Buyer ~ ; Other ~ (explain); /~:/ (d) Lending Institution Telephone A~ss (e) Rsal Estate Coo & Agent Address (f) Telephone Mail the HAA to the following address: '~' ~: ~ c: ,: ~ ,'.~..~c ~ c~ .... ~:~o ~ -' ~':~ ~'~'/' 2. T~e of Residence Single-Family~ Number of Bedrooms 3. Water Su~ 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.. Note: If community well system, must have written confirmagion from the Staee Department of Envirormaental Conservation attesting to the legality and status. : ', {!~age 1 of 21 E~ineerin~ Firm Providin~_~spection_a~. Tests File Sear~ 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 show~ 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 M~nicipality of Anchorage files and from my investigation and inspection~ the on-site water supply and/or ~rastewater disposal system is in compliance ~.[th all Municipal and State codes, ordinances, and regula- tions in effect on the date of this inspection° D ate ~ , 'x;,-~ ' % '4- (~N~ZNEE~ SEAL) .i". ,o _ //¥ .... ,-Y,.%; ................ :,.. ,(-,'~ D~E?~ //fl /q /// -- /_ .M'I / /~///.,/ bedrooms By ~~~ Approved/ Disapproved ~ ~onditional Te~s of Condigion~ Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES m~,ALTH 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° %%IE MUNICIPALITY OF ANCHORAGE 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 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: Well Classification /~r/~ ~./ Well Log P~esent .(Y/N) y~3 Total Depth / ~/d? ~7¢ Cased to Static Water Level /$1'ff ~'~ Casing Height Above Ground ~.o '~ Electrical Wiring in Conduit (Y/N) MUNICIPALITY OF ANCHOrAGe- DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION' APR Iveco If A, B, c~ C, D.E.C. Approved(Y/N) Date Cc~,gleted ~'/(?/y~Z. ~I¢. Yield ,/~ ~pth of G~outin~ ~ ~t At Sanit~y ~a1 on Casing ~ ~ession ~ound ~l~ead (Y~) Separation Distances f~om Well: To Septic/Holding Tank on Lot .. ; On Adjoining Lots To Nea~st Edge of Absorption Field on Lot/& To Nearest Public Sewer Line /y/~ To Nearest Public Sewer Cleancut/Manhole //7 To Nearest Sewer Se~vice Line on LOt water Sample Test Results" B. SEPTIC/HOLDING TANK DATA Date Installed ~/~//~ > Standpipes (Y/N) /~: Depression over Tank (.Y/N) Size /p ~ o No. of CQ%~a~tments ~'~ Air-tight Caps (Y/N) ~ ~ Foundation Cleanout (Y/N) ~z~; Date ast Pumping/Maintenance Contract on File (Y/N) f//~ ; for Holding Tank High-Wate~ Alarm (Y/N) ~//~_ Temporary Holdi~x~ Tank t%~rmit (Y/N) SeDaration Distances frc~ Septic/Holding Tank: To Water-Supply We 11 ~L ~ '/~ £~ o. :~' To Propemty Line .~ 3 o TO Watez. Main/Service Line coU~ .'..~/~ To Building Foundation To Disposal Field_ ~/ ' .~'~ To Stream, Pond, Lake, c~ Major Drainage [Page 1 of 2] Receipt ~ Date Paid Amount: 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date .Installed ~//~//~z Width of Field ~ 6~" ~ Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test /~ ~ Type of System Design Length of Field ~/~ / ~<~ Depth of Field : / ~ Gravel Bed Thickness _%- / 7~ ~/~/0 ~ Standpipes P~esent (Y/N) /v~3 Date of Last Adequacy Test 9z/~/~$ Separation Distance from Absorption Field: To Water-Supply Well ~ / /~ ~-~, ~/ To P~operty Line ~> ~ ~>~ TO Building Foundation To Water Main/~rvi~ Line To St~e~ond~ke/~ Majo~ ~aina~ C~se To ~iveway, P~ki~ ~ea, ~ Vehicle St~a~ ~ea / D. LIFT STATION Date Installed Size in Gallons "Pump O~" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dirrensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles ~ing Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA ~quest ** ~Z_ /F~T- I certify that I have checked, verified, or conforn~d to all MOA HAA Guidelines in effect on t.he date of this inspection. Signed Date MOA No. KB1/d5/s [Page 2 of 2] ENGINE.E_RS 2-15-84 50i.'TnCENfRAL REGIONAL OFFkCE 43/ "Z" ST~4IiEi', SUi!'E 200 ANCHOt~;GE, ALASKA 99501 BILL SHEFFIELD, GOVERNOR Address' 274-2533 May 30, 1984 AlasKa Environmental Control Services 1200 West 33rd Avenue, Suite B Anchorage, Alaska 99503 Dear Sir: Subject: Well to Septic System Waiver, Lot 3, Block 1, Leach S/D The Department has reviewed the subject waiver request and hereby waives the horizontal separation between the private 'well and the septic tank to 91 ft and the private well and absorption field to 92 ft. Sincerely, ~r~u~ee E~ Er±ekson Env±ronmental Engineer BEE/msm MUNICIPALITY OF ANCHORAGE DIVISION OF kl~VIRONMENTAL HF~L'il'I DEPARTMENT OF ~AL~I ~D EN~IR~NT~ PR~'ECTION APPLICATION ['~R HEAL~ ~HORITY ~PROVAL CERTIFICATE 1. ~al Infor~tion ~plication Date (a) Legal ~s~-iption (inclu~ lot, block, su~]ivision~ ~ction, tcl~ship, (b) (c) Location (aC.d~ess o~ direct, ions) Applicants Na~ Applicant is (check one) Lending institut'ion Buyer C]][' Other [7---~ (explain)? (d) /ending Institution Adok'ess ..................................................................................................... (e) Ill. al Estate Co. & Agent Adck. ess Te le phone Water Su~lff_ Individual Well 'E;!:::t Cor~a]nity FjZI ~blic Note: If c~tmity w~ll system, must have ~it:t~n confir~]tion frt~l the State ~p~nt of ~viropa~ntal Conservation attosting to t[~ legality and status. Is the ~ell adequate fo~ the n~r of ~dr~s s~cified in this ~AA~ Se__wg~e.. Disposal Onsite ~i l%,bl:i.c Fj-~.; Community E]:~-1' Ho].ding Tank Is the wastewater disposal system adequate for tine nt.unbe?z of [Page 1 of 2] 2-15--84 5. _En_qgi~_~e.~i~ Firm Providinq~_n_spections, lbsts, Data and Information I certify ti]at I have checked, verified, or ¢.~nforme~d to all MOA BAA Guide].irms in effect on the date of this inspection. Signed ~.~-~t ~ Sig~d W Date 2' .7 ... ~ r (ENGINEER Disapproved E~ 6. DHEP A~proval Appr ova. d foL* Terms of Conditional Approval %he Municipality of Anchorage Depa~tn~)nt of ['faalth and Envirom-~ntal Puotection dops not guarantee the continued satisfactory [~rfo]:mance of ti'~ wate~ supply and/or the wastew~.te~ d:[sposal system. This appl, oval indicates that, as of t]~ validation clnte shown gd0ove, ba~d on the ct~ta and information furnished by an engil~er registered in the State of fklaska, the v~te~ supply and wastewater disposal system is safe and func~ tional fozt the F.t~ube~.' of bedroc~s m;d type of structu'~e indicated. (D~EP SI?AL) 7. Mail the HAA to the fol].cming address: KB2/d5/s [Page 2 of 2] 2--15-84 A® Be MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification Well Log P~esent~N) Total Depth lq D Static Water Level Casing Height Above Ground MUNICIPALITY OF ANCHOP, AOI: DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION~ Legal Description: ~2/?~__ . Yield Depth of Grouting /~/~ Date Completed Cased to ;~0/ Pump Set At MAY 1984 jREC] IVED Electrical Wiring in Conduit~N) Separation Distances f~omWell: Sanitary Seal on Casing ~N) Depression A~ound Wellhead _(Y~_J To Septic/Holding Tank on Lot ~// ~ ~. ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot'.~ ~./~ ; On Adjoining To Nearest Public Sewer Line /L3/,Q~-- TO Nearest Public Sewer C leancut/Manhole To Nearest Sewe~ ServiceLi on Lot /~/i~.~Q/~-. ; Date ~-// /~'4ne water sample Collected By Water Sample Test ~Results~ ~/~i%'~L~¥~%~ ~ SEPTIC/HOLDING TANK DATA ~6~ ~ Standpipes ~N) Air-tight Caps _~N) ~u°~aN~i~oOnA~ Depression over Tank (Y~ Date Last Pumped_ Pumping/Maintenance Contract on File (Y/N) [13/fl~ ; fo~ Holding~Tank High-Water Alarm (Y/N) ldl~- Temporary Holding Tank Permit (Y/N) · Separation Distances f~tcm _~ep~tic/Holding Tank: To Water-Supply We. ll C~i' '~- ~ ~ To Building Foundation //,.~. '~ To Property Line ~ 5©' To Disposal Field /?! To Water Main/Service~Line IL)/~'~ To Stream, Pond, Iake, or Major D~ainage co. se [Page 1 olf 2] ......... ~"*LUr OF ANCHORAGE DEPT, OF HEALTH & ENVIRONMENTAL PROTECTION JlJtl I984 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 4/f~ Width of Field ,~ ~- Square Feet of Absorption A~ea Depression over Field (Y~ Results of Last Adequacy Test /~--~-J/' Type of System Design Length' of Field ~'~ Depth of Field 9'~'- Gravel Bed Thickness ~/~Y'C3 ~ Standpipes P~esent Date of Last Adequacy Test /~///~ Separation Distance f~om Absc~ption~Field: To Water-Supply Well C.~_' 0~' ~ TO ~o~ty Li~ To Building Foun~tion ~~3 To Existing or ~ndo~d System Lot ~;~ ; ~ ~joining ~ts To Wate~ Main/~vi~ Line ~/,~ To ~t~(if p~e~.~t) ~,/~ To St~e~ond~ke/~ Majo~ ~aina~ C~se To ~iveway, Pa~ki~ ~ea, o~ Vehicle Sto~a~ ~ea D. LI~ STATION ~ Date Installed Size in Gallons "Pump Oa" Level at High Wate~ Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. 'Meets MOA Co~nts ** Check Permitted Bedroom Rating Against HAA t%equest I certify that I have checked, verified, or conformed to all MOA HAA on the dat Signed Company KB1/d5/s [Page 2 of 2] in effect ~of thi. s inspection. .) Date No. 2-15-84 DEPT. OF ENVIRONMENTAL CONSERVATION SOUTHCENTtLAL REGIONAL OFFICe: 437 "E" STREET, SUITE 200 ANCHORAGE, ALASKA 99501 BILL SHEFFIELD, GOVERNOR Telephone: (907) Address: 274-2533 May 30, 1984 Alaska Environmental Control Services 1200 West 33rd Avenue, Suite B Anchorage, Alaska 99503 Dear Sir: Subject: Well to Septic System Waiver, Lot 3, Block 1, Leach S/D The Department has reviewed the subject waiver request and hereby waives the horizontal separation between the private 'well and the septic tank to 91 ft and the private well and absorption field to 92 ft. Sincerely, tfruce E. Erickson Environmental Engineer BEE/msm APPLIC NT FILLS.OUT UPPER HAl ONLY Mailing Addre~ ~ .... ,) . . ZiP Code _ . ~.,., .,.~ (/?C~-.-II '~- Buyer / Address Zip Code Address //7~/~/; ~' ~ 7 ~';~ Zip Code Realty Co. & A~nl Phone Address ( ~.~:/-~1 ~ /~, (2 ,,~/ Zip Code '/ Street LocatlmC?~" ......./"~] ''} / [ V /:~"~0 {~. r~' ~ Type of Resi~nce / " - ~' Single Family U Multiple Family No. of Bedroo~ ~ Other Water Supply ,~ ~ Individual ~¢Lp ~ ~ ATTACH WELL LOG. A w¢l Icg is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach Icg tf available). ~ Public Utility Sewer Disposal ~ ~ ~uBIio Htllit~ When Gonnocto0 ~o ~uBlio Htlllty: ~ Holdino Tank ROTE: TH~ I~SP~OTIO~ ~[ M~ST ~CGOM~Y fi~GH ~fi~[Sl ~FOB~ ~OGES8~ Time Time Time Time ~.~L~.i_~ I~--( ~-~_L~\O~_9 Date Date Date '~ ~ Insp~tor Insp~tor Insp~tor ~ Insp~tor ~ .~ ~ ~_, O, MUNJC~PALtTY OF ANCHORAGE - 2~ZT Cc iJ~':r'4 . ,, RECEIVED _ ('~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL' gATE ~--~ ( ~ Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received ~- ~ ~ Well to Tank Septic T~k Size 72-023