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#015-312-39
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
].>.PHON E
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska ~99501 Telephone 264-4720
I[] NEW
E~'UPGRADE
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
Well Absorption area Dwelling
DISTANCE TO: ~ ":~' rX';~'~'~'/'° Material
Manufacturer ~:_-~" t~ ~. ...... ~1~~- /~
Liq, capacity._, in IF HOMEMADE: Inside length W dth
NO. OF BEDROOMS
PERMIT NO, I /
No. of compartments
2
Liquid depth
Well Dwelling PERMIT NO.
DISTANCE TO:
Manufacturer Liquid capacity in gallons
Foundation
Total length of li.nes
Material beneath tile
Depth
IWell ~
DISTANCE TO: ~(~l']l.t/v~/:,[,:.,'~/",::.l~'C i~,~t>':~:'L?.
I L~gth or.ach line
No. of lines / / t5'--:
Top of tile to finish grade ,.- ~
Width
Length
Type of crib Crib diameter Crib depth
Well Building foundation
DISTANCE TO:
Class
Materla[
Nearest lot line
ITrench wid:t~> inches
~,~.2 inches
Depth
Driller
DISTANCE TO: Building foundation Sewer line
OTHER
PERMIT NO,
Distance between lines
Total effective absorption area
PERMIT NO.
PIPE MATERIALS
~ ,:,~ c,3, ~-J
SOIL TEST RATING
INSTACLER
REMARKS ~£,::~':'(?h
, .
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Sept c tank Absorpt on area(s)
APPROVED DATE
LEGAL
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CONTFICT I::'HOt'.,tE:
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LOT
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.[:,EEF:'F:tlTThiENT OF:' HE;FE...'T'H t:::!ND Et",IVII::bEd",tI'fiEi:I",i'TF:tL F:'F.:.'Crl"E;CTION
8;;.::15 L. E;'TFi:Ei;E']"., F:iNE:HCIF.':FI(]iE:., Ftt.::] SE~dSE':kl.
2 E; 4 ..... 4 7 ;;.E: iZ~
::I.. T :.':tH ..hit l[ [....r,: !.,.I:[TH ..... I:;i:E!iC!U]ii:;UEHIEt'.,iT:i!~; !::'Ot:;;I ON.....:.~; ]: "FIE SE[,.IIERL::!; I:::INt;) t.,.IELLS El:E, SE:T
::' :liE:TH c:,,,.,., 'T'HE !','!i...!I'..! ]: C: ]: F'FtL. :[ T"r' f:'F .::IH "' HF' i:a::tGE ( t'"tOl::l ;:, i:::¢ND THE: '.E;'T'FfTE O1:: FtL. I:::tE;I<:R.
2:. ]: L,.! :[ I....L. I bl:i];'T'l::lt_.i. 'T'HEi: .............. -,. ' .'[ ....... iq :::I '": ......
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.'.~:.;[ I,t'.;L.L FI[)HEFLE TO I';:tL..L iiO!:::t ;::iN.r.~' :i!!;Ti:::i't"E Cd:::' l:!Ll::tl~!l-:'l;:;l I;:IE(i:E..i]:F;.':E;HENT?.:; I::'ID~;i'. THE: :E';EY!" Bl:::If_":t<;
[)Z::~;"q:::iNC:E;E; F:'.,r';;:Ot'"l FiN"r' E';:':; ]; :.:!;T ]; I",iCii HELl .... i.,.II::!E!;'T'EI.41:::!TEI:;:
:E;EkIEF.:l:::tt".:iE ~;'T'LE;TE;bl "'N "l"HI~!i; "'"~:::' F::!"!:v: F:t[),YF~CE]',I'T' Oi:;i: i".!EFIF'~:li.:.':"r' L(3'T'.
2:''
Permit
MUNICIPALITY OF ANCHORAGE
Department O~Health and Environmental~oteetion
825 L~ Street, Anchorage, AK. 9J301
264-4720
* * * HANDWRITTEN PERMIT * * *
~ ~2~m~-.s~'~--~-w~I T
Applicant:
Mailing Address:
Location:
Phone Number:
Legal Description:
Type of Soil Absorption System Is:
Trench: Drainfield:
Maximum Number of Bedrooms: /
Lot Size:
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br) ~-
The Required Size of the Soil Absorption. System Is:
DEPTH LENGTH t
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 :/~Q~ 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 31, 1 9 * *
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 tha~ bedrooms.
Signed: Issued by :~,~ ~~ ~J
Applicant Date: //~2 fy
SWP/024(1/81)
DEI:::'I::II:;.:TME:t",i'T' ,:.., I"-IEI:::II....'TH i:::!ND Et",IV I I';.':ONI"IEt",tTRL k ,,::O'TECT 101",I
825 "' L." S'T'REET., F:INC:HORI::IGE., ~.K 995Et:1_
26,::,u.-47'2E~, : Ftt'-,ICHORFIGE E;94-.2:I.Z.'::I. : ERGLE R I VER
C~ il"..,~l ........ :Z~.';; :E '"'il'"' EE :El; KC II..4I EE E4;J.-. F" E=Z IF~'.' ~"-1 ][ ~'
F'ERM t T t'.,I0, 8]::1. i;;~:7
RF'P[.. Z CANT: I...IEI:.~:E: ECI<MFtI'.,tt',I PHONE: 276-S456
laDDRIi]!:SS: !'.,IOt'.,iE G I VEN
FIi'-,I fC H 0 RI:::I G E., FII<
L. EGI:::iL. DESCt';.':It:::'TZOI',! ..... :i;';UtBE:,IVZSION; HILLSIDE F'FtF.:K BLOE;K; "0" LOT: 2'8
L. OT SI;.:.-!'.E E'~ SQ. FT'. TONi'.,!SHII::': ..... -RFII'.,tGE: .... SECTION: -
l'"lfl;W, IMl...ll'"! t'-,II...tMBEI;i: 01::' I!.'}E[:,ROOMS = El '.:.;OIL. F..:I:.¥f'ING = (~i El F._'l (St...]. FY. ,.-"Bli'.)
t_ I S]"F:.I} E:I!!:'LOI.,.I I:::It:;::E THE OF'T IONS F:IVI:::I I I_I::tBL. E TO "r'OU I N DES I GN l NE'i '¢OUR SEPT I C
S"r'STEM. CI...IOOSr. E 'TI...IlE OPTION T'HWT BES]' FITS '¢OUR SITE
.'[ CER]' I F'""r' 'THFIT:
:1.. i RM FFIMt[.tFiR i.,.II]"H THE; REQUIREMEIqTS FOR ON-SITE :~;E!.4ERS FIND 1.4ELLS F:IS SET
FORTH ,E:'¢ THE MUNIC:i:F:'tS'II_IT'¢ OF t::INCI'..IORFtGI!!i; F:llq[:, THE '"_:";TRTE OF FIL.FISKFI.
2. I !4I[..I_ ].'i",ISTFtLL. f}'tE S'¢STEi]"I IN F!CCOR[:,Rt",IE:E 1.4I"I"H THE COPES I'::IND HFIVE RECEIVE[:'
1:::1 COP"r' OF THE CODE; :~:.:;L!Mt"ti:::IF::"r' FIND [>IFtGRRM I;::tTTI:::tCHME.NTS klHICH IS PFIRT OF' TI'IlS
PERM l ]"
3. I UNDEF.':i']';TFII",I['.', TI'"IF~T THE OI",!'""SITE SE:~I.,.IER S'¢STEM I"'tR'¢ RE;QUIRE ENLF'IRGEMEI'4T IF THE
RES I DEi",ICIE I :E; REMEd}Ii.:.:[..E[:' TO t I",!CL.UDE MORE THRi",! E~ Ei:EDROOMS.
F'E:".RH I T t::tF:'I:::'[., t CF!NT l'"lF!i'i; THE RESF'ONS I B I L. I T'¢ TO I i",IFORM F'ERSONi",IEL [:,I JR I NG
I-HIE i I",ISTFIL. LI":IT t ON t I",ISFdECT t ON!'!; OF 1";:11",I'¢ NELL. S i:::IDJI::tCENT TO 'Tt"I l S PROPERT'T' RND
THE NUMBER OF RESI[:,E!",tCE::]; ',"t'"11:::I~[' THE !.4ELL 14ILL. SERVIE.
ZF' F:t I_II:::'T :E;'T'FITIEd",I IS INSTFiL..LE[:,., FtI",t EL..ECTR]:CFtI.. PERMZT I::IND INSPECTION MIJST
BE 08TF:I l t",IED. FIS-'BU I LTL::i; E:I:::I!",INOT BE FII:::'I:::'t:;;:OVED 141 ]]"tOUT FIN ELECTR I CFIL I NSF'EC'T I ON
REF'OF.':T. THE E'L. ECTRIC'F:tL I.,.t0i:;;:1< MUST BE: DONE I!.:¢'r' F:t LICENSE:[:' ELECTRICIRN,
E; I GNED:
!:::!PI:::'L.. ~ CF!I'.,FF: HE'i;RB ECKMFII'.,It'-,I
~ SSI...IE:D Eft':
[:,I:::rT'E: ± 2,."::L 4,."8 ]:
.~IUNICIPALITY OF ANCHORAGE,--~x
Department~! Health and Environments! ~rotection
825 ~ Street, Anchorage, AK. ~9~01
264-4720
,,~ HANDWRITTEN PERMIT ~ *
Permit ~ ~ ' ~D/OR ON-SITE SEWER PERMIT
Location: Phone Number: ~LT~
Legal Description: ~/~ ~ ~-~-~ ~ ~/~Lot Size:
Type of Soil Absorption System Is:
Trench: ~. Drainfield: Seepage Bed: __ Holding Tank:
~aximum Number of Bedrooms: _~__ Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH ~ LENGTH ~'~ GRAVEL DEPTH ~D'-T" 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 = /~"~'~L])~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 departmentl
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 coramunity 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
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
include more that/~3 bedrooms.
the residence is remodeled to
SWP/024(1/81)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMEN]'AL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Foundation
Total length of lines
Material beneath tile
Depth
Crib depth
Driller
Sewer line
Building foundation
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
Well ,~,~ ,~ Absorption area
O ~ DISTANCE TO: ] ~
~ ¢ I G ~'~ Inside length
~ Liq, capacity in gallons
I~%O F HOMEMADE
~ O Z ~ I DISTANCE TO'. IWell ~ Dwelling
~= I DISTANCE TO: I
~ · ~ No. of lines Length of each line
Top of tile t0 finish grade
~ Length Width
~ ~ I Type of crib Crib diameter
~ DISTANCE TO:
Well
~ ICla,s Depth
~ DISTANCE TO Building foundation
HONE
~] NEW
[] UPGRADE
Dwelling
Material
Material
Nearest lot line
Trench wdt~o inches
inches
NO. OF BEDROOMS
PERMIT NO.
No. of compartments
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO,
Distance between
Total effective absorption area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorpt on area(s)
OTHER
PIPE MATERIALS
SOl L TEST RATI N~G
INSTALLER
DATE
LEGAL
LEL3FtL.
HEF:E:EFR T E ':; KF!F:IP',tN
L2E: H ILLS I [:,E
4.:t. 6:LZ SQUF:IF::E FEET
TYF'E OF' SOIL F!BSOF4:F"T' :[ ON E;'¢fS'T'EH IS: TRENCH
"FHE F;;:EQUIRED SZ2E OF' THE SOIL. F4BSORF'TZON S?E;'I"EH
THE: LENGTH DIHENS!ON iS THE LENGTH CIN FEET) OF: THE TRENCH OR ORFIIt',IFZEI...BL
THE DEPTH OF f:~ TRENCH OR PIT :CE; THE DIST'RNCE BETWEEN THE SIJF¥:'RCE OF' IT'HE
GROUND RND THE BOTTOH OF' THE EXCtqVRTION (IN FEE:T>.
THERE ZS NO SET WIDTH FOR TRENCHEE:.
THE GRFWEL. DEPTH IS THE HI NII"IUH DEPTH OF GRFCv'EL BETHEEN THE OUTF'RLL. PIPE
FIND, THE E~CFFTOH OF THE EXCFIVRTION <IN FEET).
PERHI'T RPPLI (]fZtll'~"[* HFIS THE RE:SF:'ONSIBI LI TY' TO INFORPI THIS [:,EF'RRTHENT C,U!:~:I NG THE
INS'TRLL.¢¥1"ION INE;PE;CT!ONE; OF RN? WELL. S RDJRCENT TO THI.S PROPERTY FII',ID 'T'HE
HUHBER OF: RESZ[:,ENCE'.S THRT THE WELL 14]:LL.
................... T' ~..,..~ CZ) *::;; ;~: 3:, Z ~",,~ ZE; F" EE CZ: 'T
BRCKFI L.L. ING OF F:[N:'r' S"r:%'T'EH t.4!THOUT FINRL INSPECT l ON t::!NB' RPF':'ROVIqL B'T' THIS
DEPFd;YFHENT b.!IL.L BE S!...IExfECT TO PROSECUTION.
HINIHUH [:'ISTF!NCE BETWEEN R WEL. L FIND
198 FEET FOR R F'RIVFFFE WELL OR &58 TO 200 FEET FROM R PUBLIC 14EL. L DEF'END!NG
UF'ON THE T'T'F:'E OF' PUBLIC WEL.[ ....
MtNIHUH DIST'RNCE FROH R F'R!'v'RTE WELL. TO FI PRIVRTE SEWER LiNE IS 25 FEET FINE:'
TO FI COHi'!UNIT'¢ SEWER L..INE IS 75 FEET.
OTHER F'.EQU I REHEN]"S FIFPY RF:PL"¢. SF'EC l F I CRT IONS F~ND COHSTRLICT:[ ON [:'t F4GF:FIHS F~F:E
F:I',,,'FtlL. RBLE TO INSURE PR'.CIPEF:: IN:STRLLFFFZON.
I CERTiF'¥ 'T'HRT
i: i aM FRHIL. I'RF;: I.,IIYH THE F,'E:C~UZREHEN'FS FOR ON-SITE SEWEF=:S FINE." f.4E:'LL..S F~S SEI?
FORTH BV THE HUNIE:I PRL,.Cr T"¢ OF FtNCHORFK3E.
.E': ! WILL ZNS"t"FiLL THE E.?~'SYE:H IN F!C::COF;!DF'tNCE F.!tTH TFIE CODE~:.
:~:: I iJN Ei':.:STF:INf.:' THFFF THE ON-SITE SE:FiEF'. S"?STEH t"'IFiY I:;.':EI]:!UI[;'.E E'NLI::IF:'.GEHENT IF:' THE
RESIDE l:~: REMODELED 'TO !NCL. LE)E I'IORE 'THRN 4 BEDROOHS.
. I CFZ!N'F HEF.:E:EFYf' EC:K'HFIi',IN
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
LEGAL DESCRIPTION: P~//'l _~
DATE PERFORMED:
SITE PLAN
10
11
12
13
14
15
16
17
18-
19-
20-
WASGROUNDWATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
/rEST RUN BETWEEN FT AND ~ FT
,
DATE:
Parcel I.D. #
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DMsion of Environmental Services
On-Site Services Section
P.O, Box 196650 Anchorage, Alaska 99519-6650
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILLY DWELLING
015-312-39
1. GENERAL INFORMATION j2Ut~
Complete legal description HILLSIDE PARK SUBDIVISION: LOT 28
Location (site address or directions) 72oo CROOKED TREE 0RIVE
Property owner PATRICK DUFF'(
Mailing address ¢/o PRUDENTIAL JACK WHITE
Lending agency
Mailing address
Day phone
Day phone
(907) 762-3111
Agent BETH MEHNER Dayphone
Address 3201 "c" STREET. ANCHORAGE, AK 99503
Unless otherwise requested, HAA will be held for pickup,
2. NUMBER OF BEDROOMS: 4
3. TYPE OF WATER SUPPLY:
Individual well
Community well xxx
Public water
NOTE: If community well system, provide wdtfen confirmation from State ADEC attest-
lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding Tank
Community on-site
Public sewer
NOTE:
XXX
If community wastewater system, provide written confirmation from State ADEC
lng to fhe legafity and status of system.
72425 (Rev. 1/91 ) Front MOA #21 Computer Version
Note: Alaska Water and Wastewater Consultants, Inc. shall be paid $800.00 at,
or prior to, closing for the engineering services provided.
5. 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 suppty 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/a~d State codes, ordinances, and regulations in effect
on the date of this inspection. ~ ~// ,
Name of Firm ALASKA WA,'f'~ ~AS~A/TJRCONSULTANTS, INC. Phone f907)337-6179
Address 6901DEBARRF~AD,/~ F~ ,~2.1~,A/NO~ORAGE, ALASKA 99504 /
EngineeCs Signature ~,_/~ ~~ [)ate
In conducting this eva/uation, AVVWC, In~/ ~ /pted ,o~p~lde a thorough, conscientious engineering/analysis of the
system in accordance with ADEC and f~OA D~ -IS Guidelines & Regulations. The reported results described the
performance of the system under the conditio[ encountered at the time of the test, and separation distances
measured to readily identiflable features. The, ,erational life of all wells and septic systems depe d,~,,~,%~.,~,%%, .~
on the local soils condition, ground water levels that may fluctuate during the year, and the water
usage of the family being served by the system. These conditions are outside the control of
the evaluator of the system. Satisfactory test results do not guarantee future performance . ./..~..
of thesyatem, nordotheyguaranteethattherearenohiddendefectsorencroachments.
At44,VC, Inc. can therefore not provide any warranty for future estimate of how long the
system will continue to meet the operational requirements of the ADEC or MOA DHHS. . ........ : ....
vA
The content of this report is for the sole benefit of the owner listed above. ,4ny
reliance upon or use of this report by any other person or party is not authorized, /~.... . .~ .
nor will it confer any legal right whatsoever.
6, DHHS SIGNATURE
~ Approved for ,'Lc-
Disapproved
Conditional approval for
bedrooms
bedrooms, with the following stipulations:
Additional Comments
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 DH HS 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. 'i'he Municipality of
Anchorage is not responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91) Back MOA fY21 Computer Version
Municipality of Anchorage AU(; 0 ;~ ~.000
DEPARTMENT OF HEALTH & HUMAN SERV~I~r-.~ALI~' O~ ANCHOI~
EnvirOnmental Services Division ..... '~.~NTAL SERVICEg
825 "L" Street, Rm 502 Anchorage, Alaska 99501 (907) 343-4744
Health Authority Approval Checklist
Legal Description: HILLSIDE PARK S/D; LOT 28
Parcel I.D.:
015-312-39
A. WELL DATA
Well Type COMMUNITY If A, B, or C, attach ADEC letter. ADEC water system number ~212461
Log present (Y/N) Date completed ___..____
Total depth Cased to ~ing height (above ground)
~ Wires properly protected (Y/N)
Date of test
Static water level
Well production
FROM WELL LOG
/ g.p.m.
AT INSPECTION
g.p.m.
WATER SAMPLE RESULTS:
Coliform
Nitrate
Dat~
B. SEPTIC/HOLDING TANK DATA
Date installed 10/28/82 Tank size
Foundation cleanout (y/N) YES
Collected by:
1250 Number of Compartments
Depression (Y/N) NO
2 Cleanouts (Y/N) YES
High water alarm (Y/N) N/A
Date of Pumping 7/27/2000 Pumper McDONALD'S PUMPING
C. ABSORPTION FIELD DATA
Date installed 1o/28/82 &: 5/14/8~- Soil rating (g.p.d./ff2 o~ 85 & 100 System type
Length 26' & 15' Width 5' & 3' Gravel thickness below pipe 5' Total depth
Effective absorption area
Date of adequacy test
Fluid depth in absorption field before test (in.);
Fluid depth 0 (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)* Computer Version
TRENCH
11' - 12'
410 SQ FT MonitodngTubepresent(Y/N) YES Depression over field (Y/N). NO
7/27/2000 Results (Pass/Fail). PASS For ~- Bedrooms
0 Immediately after 1864 gal. water added (in.): 0
0 Absorption rate = 600+
NONE KNOWN If yes, give date
D. LIFT STATION ~
Date installed ~ ......
Manhole/Access (Y/N) ~t*. "Pump of~' level at*
High wat~ *Datum
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot On adjacent lots
on lot O~ent- ots~''--~
Public sewer main U~\~ ........
Absorption field ~ublic sewer manhole/cleanout
~ Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation 5'+ Property line 5'+
Water main/service line 10'+ Surface water/drainage 100%
Absorption field
Wells on adjacent lots
200'+
SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOT TO:
Property line
10'+
Building foundation 10'+ Water main/service line
Surface water
100%
Driveway, parking/vehicle storage area
Curtain drain NTE KNOWN
//
F. ENGINEER'S CERTIFI~/),TIO~
of Municipal ('eco~ Js t~ t~f~,~bove ~ystems a~e in conformance
Signature ~. ~'~f/"V'[TM%__/
Engineer, sN~e~F IJ JEFFREY A. GARNESS
Data ~/~ OD
Wells on adjacent lots
200' I-
10'+
5'+
HAA Fee $ ~ ~ '
Data of Payment
Receipt Number ~-C7 ~,J
72-026 (Rev. 3/96)* Computer Verslon
Waiver Fee $
Date of Payment _
Receipt Number
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. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~J ~,~ ~ HAA #
1. GENERAL INFORMATION
Complete legal description /.oT ~, I~t~CS'~ (~R~'~. ~:~
OCT 0 ] 1991
REEEIVED
Location (site address or directions)
Property owner
Mailing address
Day phone
Lending agency f Day phone
Mailing address /
Agent ~-~O,,~ ~ ~,~ //V~J~,/~ ~.~--~-~ -7(~.~3111 Day phone
Address ~
Unless otherwise requested,~h~AA will be held for pickup.
NUMBER OF BEDROOMS: 5~J ~ ~ '~'~
TYPE OF WATER SUPPLY:
Individual welt
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: 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
5. 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 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
Engineer's signature
DHHS SIGNATURE
J~.'~ Approved for ~
Disapproved.
Conditional approval for
bedrooms.
Phone
Date
bedrooms, with the following stipulations:
Additional Comments
By: ~,,,//"~¢~ ,//~. . Date
*The Municipality of Anchorage Department of ilealth and Human Services (Dill-iS) issues ilealth 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 DMHS does this as a courtesy to purchasers of homes
and their lendin9 institutions in order to satisfy certain federal and state requirements. Employees of DHH$ do not
conduct inspections or analyze data before a certificate is issued. The IViunicipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-025 (Rev. 1/91 ) Bact( MOA ~21
Municipality of AnchorageSERVl~,L~lCiPAUTY oF ANCHO~
DEPARTMENT OF HEALTH & HUMAN ~i~ONMi~NTAL.~;ERVICES Dl~
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 3~lLT0z~ 1997
Health Authority Approval Checklist R ECE I VE D
LegalDescription: LOT ~t ~iLL-3//?~ ~,0~' ParcelI.D.: ~/~",~/'~-"~
A. WELL DATA
Well type ~u/~/'r~ It~, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N) /~J/~ Date completed
Total depth /'J//~ Cased to A///~ Casing height (above ground)
Sanitary seal (Y/N) ~//Y Wires properly protected (Y/N) /~//~
FROM WELL LOG AT INSPECTION
Date of test /~//~ /~//~
Static water level t
Well production g.p.m.
WATER SAMPLE RESULTS:~' C(::H~r~/
Coliform /~J//~ Nitrate
Date of sample:
Other bacteria
Collected by: /~//'~
g.p.m.
B. SEPTIC/HOLDING TANK DATA
Date installed /0/~/~2. Tanksize J~,~O d~c Number of Compartments ,~ Cleanouts {~).
Foundation cleanout (~N) Y~ Depression (Y/~ ~ High water alarm (Y,{~
Date of Pumping ~c~/~;Z l~ ~' Pumper ~C~ ~0,~4~pJ:
ABSORPTION~FIELD D~'r~A
Date installed(~ .~ ~ I~'/- ~/~'~Soil rating
Length o~''kl~- ~l~ ~ ~'' . Widt~
~-r~)
Effective absorption area ~/~
Date of adequacy test
Fluid dopth in a~sorption fiold boforo tost (in.); ~¢~ Immodiatoly a~or~3~al, wator addod (in.):
Fluid dopth D~ ~ (ins) Minutes lalor: ~g ~ ~sorpfion rate = qSO + g.p.d.
Peroxide treatment (past 12 months) (Y~ ~ ~ ~ If yes, give date ~/~
85 Systemtype ~ 7E~-u¢l~l
Gravel thickness below pipe ~ ~T/~w~Total ~ depth ~' ~ ~ ~A
Monitoring Tube present ~N) ~ Depression over field (Y/~ ~o
For ~ ~ bedrooms
Results (Pass/Fail) ~ ~ ~
72-026 (Rev. 3/96)*
D."'EIF..T STATION
Size in gallons
Date install~ ~
Manhole/Access (Y/N) ~"Pum " at* "Pump off" level at*
High water alarm level at* ,.~~ ~
SEPARAT~CES FROM WELL ON LOT TO:
Septic/holding tank on~~
~ On adjacent ~
Absorption field on lot ~~n adjacent Iots~
Public sewer main .~~ ~~~_
.S~tic sewice line Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~'~
Prope,y line ~ ~ Absorption field
Water main/sewice line J0 ~ Sudace wateCdrainage /00 ~ Wells on adjacent lots ~0~
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ~ 0 ~ Building foundation /0 ~ Water main/service line
Surface water ~0~ ~+ Driveway, parking/vehicle storage area ~
Curtain drain ~,~0,,~5. ~-t~,~ Wells on adjacent lots ~0(~ "f
Io t
ENGINEER'S CERTIFICATIONJ
I certify that I have det~r/~nine~.~dt~r~ field inspections and review
inconformanc~H~h~.~( g~eli~nesin effecton this date.
Signature
Engineer's Name t' ,,..]~ ,Z~ ~:~__.~-..r
HAA Fee $
Date of Payment / 0/~/~?
Receipt Number _~
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
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
A p piicat ion Date ~',~'/,~,/~
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
'- ~; Business
(b) Applicant Name ,~'~z~J &~'~,~//e;~t' Telephone: Home
Applicant Address 7~t'¢~' L~-~'7-4L¢~) "~.,-E" )ff. f¢~/~'! //~'/~
(c) Applicant is (check one): Eending Institution []; Owner/builder~; Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single-Family'~ Multi-Family [] Other
Number of Bedrooms __ zt
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.
4. SEWAGE DISPOSAL
Onsite~l,l~ Public [] Community E] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
D~,'~=, t ~ o 72-025 (11/84)
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 ,/~"~ ~ . Telephone
DHEP APPROVAL
Approved for 'f~ ~
Approved ~
., '
bedrooms by ~' '~¢'*'~"~ Date
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.
Pnn~ 9 ¢',f 2
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MUNICIPALITY OF AI',iC:HORAGI~ CHECKLIST - FEBRUARY 1984
DF?T. CP HEALTH & 264-4720
EI4VIRONMENTAL PROTECTION Legal Description: ~.~.~:r" ,~.~'
[',!.~ :; 198{; -~4 ~J,W
Well ClassificationS__- ~/~ If A, B, C, ~.E.C. Approved~N)
Well Log Present (Y/N) ~/~ Date Completed ~ Yiel~
· C.se ,o e.,,o, rout,.g
Static Water Level' ~ ' Pump Set At ,~¢
Casing Height Above Ground ~ Sanitary Seat on Casing (Y/N)
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Depression Around Wellhead (Y/N)
.; On Adjoinin~g Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ,/g)'~/';~'~' Size
Standpipes(~) Air-tight Caps~N)
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N) ~/~
Separation Distances from Septic/Holdin{] Tank:
To Water-Sul~ply Well ;~¢'~
/
To Property Line ~
To Water Main/Service Line
Course
No. of Compartments
Foundation Cleanoul~N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
/
To Building Foundation
To Disposal Field
To Stream, Pond. Lake, or Major Drainage
Comments
Page 1 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata /.~' /'~'~)~'/~ Type of System Design
Date InstalledD~'/~/~/~'' /~-~--~2,-/~,/]($~ .,~ -'~'/~'~'¢Length of Field_
Width of Field ~ f,~';~ ~ ~'' / /~'"/-"~/~'/~--~' Depth of Field
Square Feet of Absorption Area ¢/~ ~ Gravel Bed Thickness
Standpipes Presen~lN)
Depression over Field (YO
Results of Last Adequacy Test /~'~ ~
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ~///~
To Water Main/Service Line
To Stream/Pond/Lake/or Majo~ Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~ / '~
To Cutbank (if present) ,~/'/,~1
Comments
LIFT STATION
Da~ Dimensions
Size in Gallons
Manhole/Access
(Y/N)
"Pump On" Level at ~ "Pump Off Level at
High Water Alarm Level at ~~ent (Y/N) _
Tested for ____ Pu~uring Adequacy Test. Meets MOA
~1:: :Cea~ t~ o d es (Y/N)
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I ~,~hec/~ed~.v¢ified, or conformed to all MO~ and HAA guidelines in effect on the date of this inspection.
Signed _ ~--"-'----C - //~/~'""- .Date
Co~pany ~'~ MOA No.
Reoeipt No, ,~ ~ ~ ~
Date of Payment ~ 'g- ~
Amount: $ (~-,
Page 2 of 2
72-026 (11/84)
ALASKA elIUIROFImeFITAL COFITROL $1 RLIICeS, IFIC.
~ngmecri~q 8 ~nuironmcntal $ludics
HERB ECRMAN
7200 CROORED TREE DRIVE
ANCHORAGE ALAS I~A
99507
SELLER-HERB EC~I~N
/28/86
HERB ECl<MAN
7200 CROOKED TREE DRIVE
ANCHORAGE ALAS RA
99507
60084
LEGAL:HILLSIDE PARK SUBDIVISION LOT 28
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST DATE-2/24/86
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 410 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 600 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 901 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
4 BEDROOM HOME.
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR
THIS 4 BEDROOM HOUSE.
THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 2/25/86 .
THIS REPORT DOES NOT VERIFY THE INTEGRITY OF THE PIPING FOR THE WATER
SUPPLY OR WASTEWATER SYSTEM.
ALASKA ENVIRONI~C~NTAL
CONTROL SERVIC/~ ~ INC.
1200 West 33rd Avenue. Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
SHEET NC, /~'~,. OF
CALCULATED BY ' - DATE
CHECKED BY DATE
SCALE / :~
/
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCHORAGE, ALASKA g9501
BILL SHEFFIELD, GOVERNOR
Telephone: (907)
Address:
274-2533
DATE:
PWS I.D.#
To Wh om it May Concern:
A~i~r~ing to records on file in this office the ....
,~__ ~/~ Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
APPLIf NT FILLS OUT UPPER HAI '! ONLY
~' '~ ,~ '. Phone
P?perty Own~er ~,~/\~ /-~-~ /~ ~'% 2 ,~ ~
Mailing Addre, ~/..~ ( ~f ~ / ~ /-/~ ~ ~ Zip Code
Address Zip Code
Lending Institution Phone
Address Zip Code
Realty Co. & Agent Phone
Address Zip Code
Legal Description ~ ~ ~ ~tt ~ ~ ~ ~ ~,~~'~
Street Locati~
~ Single Family ~ '
~Multiple Family No. of Bedroo
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A well log is required for all wells drilled since June 1975.
~ Community ~ ~~ ~,~ [~ Forwollsddlledpdortothatdato, oivowolldopth{a~tachlooHavailaBlo).
~ Public Utility ~-
Sewer Disposal
~ Individual Year Individual Installed:
~ Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED.
~ '~ I \t"--' ~, ) \_/ t i~----':-
Time TimeI Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
MUNICIPALITY OF ANCHORAC~E
Field Notes: C ~ ,~"~,C ,-- ~.~, ~
DEPT.
OF
HSALTH
&
5
RECEIVED
( ~ APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL*
I
Soils Rating Date 8ewor Installed Well To Absorption Area Well Log RecoJved
Well to Tank Septic Tank Size
September
SRA sox 2830
Anchorage, AK 99507
~,ub-~ect: Lot 28, ~lls~de t-ark
A[~proval for the individual sewer and water facilities cannot
be grant, ed until the following items [lave beeii completed:
i'i-'[~e application shows the number of bedrooms exceeds the
nu~'~iber the on-site se%,ler system was originally designed
for. An upgrar.~e will be required. Prior to any upgrade r a
ermit needs to be issued from this depart~%ent.
'he en<~ineer's as-builts, %;t]ich have Deen suDmitted to
his o'[-fice, are not '~ithii'l the parameters of the on-site
~.~.nstallation permit issued by this departT.~ent~. ~i~he
discrepancies will need to De corrected before this
department cn accept the suDmitted enr-3ineer as-builts.
Please notify this Department for a reinspection wl~en the
noted discrepancies have been corrected. If there are any
further questions, please ca].], this office at 264-4720.
Sincerely,
C~34/ejlB2
Cory ;$illis, R.S.
ALA.$KA
elldlROnmenTAL CONTROL SeRUICt $,
InC.
September 19, 1983
Department of Health & Environmental Protection
825 L. Street
Anchorage, Alaska 99501
Attn: Cory Willis
Dear Cory:
In regards to the depth of the sewer system on Lot 28 Hillside Drive.
The sewer system was installed at a depth of 11 feet. Our original test
hole only showed a depth of 12 feet. It was not noted on the inspection
report that Ned Newton had dug deeper at the end of the trench to verify
no groundwater within 4 feet of the system. Groundwater was not
encountered. Also the work was done it 1982 not 1972. My apologiesl
Sincerely
roy ¢,
Pres zde~
eid jr.,
PE