HomeMy WebLinkAboutSANDI HEIGHTS LT 4ASandi Heights
Lot 4A
#011-222-40
Municipality of AnchoragePage I of_3
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
~:~ ~ ~ ~ ~ ~ [~ ~ Wastewater System: ~ New ~grade
Ad~e'~/~O4' ~¢[/~ ABSORPTION FIELD
Phone:~ /~-,~--~--~d~ . ~ Deep Trench ~owTrench DEed ~Mound ~Other
Soil Rating: Total Depth from riginal grade:
LEGAL DESCRIPTION J. 2. ~/sq.~.
Depth to pipe ogom from original grsde: Gravel depth beneath pipe
Lot~. ~ Block: Subdiv~iOn:
Township: ~ R~nge: I Section: Fill added above original grade: Gravel length:
WELL: ~ New D Upgrade Gravelwi~:[ Number of lines: JDis,~ncebetweenlines:
Ft. ~ j ~ / Pt~
Classification (Private. A.B.C); Total Depth: Cased To: Total absorption area: Pipe material:
Dri~e~: ' / Date Drilled: StaticWster Level: Installer: Date installed:
Yie[d: GPM PumpSetat: Ft, ICasingHeightAbeveGr°und:Ft. TANK
SEPARATION DISTANCES ~)tic ~ Holding Q S.T.E.P,
From Tank Field Station Tank Sewer Lines ~ ~ ~ ~
Materia~ ~ ~ Number of Compartments:
Fou~dation ~/ ,~,~/ -- -- .-- "Pump on" level at: I ",.mp off" ,~v~] ~t: J H'gh water alarm at:
Curtain / . Pump Make & M0de~ Electrical Inspections performed by:
Remarks: BENCH MARK
Reviewed and al)proved b~~~ Date: ¢/~
72-013 (Rev 9191) MOA 25
Perrnit No..~ ~-~ x/4'P 4 ~'~' Page ~ of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Bo:< 196650 · Anchorage, Alaska 99519-6650, Telephone: 543-4744
On-Site Waatewater Disposal System and/or Well Inspection Report
Legal DescripUon: ~2'7'- '~L..,Ct ,~/W/2! !~/-E!E'/-/?S PID No.
(Jo
OE 8841
Oz
Municipality of Anchorage
DEPARTMI=NI' OF HEALTH AND HUMAN 8ER¥1OE8
EN¥1FiONMENTAL 81ER¥1QE8 DI¥iSION
PO. Box 196650 * Anchorage, Alaska 99S19-6650 * Telephone: 545 4744
On-Site W~tstewater Disposal System and/or Well Inspection Report
Legal Description: {...C~T ~-~.~-.f~zAJ~'2_L_~L_f4.-_t. fT~__ PID No.
POINT CNFR. A CNFR. B ELEV. GFRND. FR[MARKS
ELEV.
G'I 12.1 5'1.6 91.1 94.4 INV. OF PIPIT
C2 43.0 72.4 91.~ 94.3 INV. OF PIPE
M1 24.1 59.6 88.2 9fl.5 MONITORING I-UBE
C3 10.5 39.2 91.2 94.4 INV. OF PIPE
C4 42 65..5 91.2 94.4 INV. OF PIPE
C5 18 28.1 91.3 94.4 INV. OF PIPE
C6 19.5 26.5 91.2 94.5 INV. OF PIP[
M2 23.3 50.0 88.2 94.5 MONITORING TUBE
~rmi~ No. Pag~ ~ __of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICl--S DIVISION
P.O. Box ..... '~ ~
,dOODU ~ Anchorage, Alaska q9519-6650 · Telephone; 3~3-4744
On-Site Wastew~ter Disposal System and/or Well Inspection Report
Legol Descri~:ion: ,/..,-g."7" 4-/~' ..c ,~A//.')/ I-/F--/4..,~.z'~,__ PlD No,
'~-4" CLEAN OL
52'
· x~ 4" CLEAN
PLAN 'IEW
4"CLEAN OUT
FROM SEPTIC
TANK
4'CLEAN OUT
TORINO TUBES
32 LIN FT.
S-- 0.0%,
PERFORATE
MIN.
--FILTER FABRIC
L FROM SEPTIC
PIPE TANK
ELEVATION
SECTION
--FILTER FABRIC
z~" PERFORATED PiPE
DRAIN ROCK
LOT Z-A, SANDI HEICHTS SUB'D
PAGE
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES~ IA/~II~I~ ~
P.O. BOX 196650, 825 "L'1 STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW940449
DESIGN ENGINEER:DUMMY COMPANY
OWNER NAME:MALELU ROBERT D &
OWNER ADDRESS:9304 KAVIK ST
ANCHORAGE, ALASKA 99515
DATE ISSUED:12/15/94
EXPIRATION DATE:12/15/95
PARCEL ID:01122240
LEGAL DESCRIPTION: SANDI HEIGHTS LT 4A
LOT SIZE: 10624 (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 (18AAC?2) 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 PROVISIONS:
December 5, 1994
Department of Health and Human Services
Anchorage, Alaska
Re: Onsite sewer system design for Lot 4A, Sandi Heights
Subdivision.
Dear DHHS,
This is a request for an onsite sewer permit for an existing
residence located at the above address. The existing system has
been in place about 20 years and has failed. A test pit was
excavated located as shown in attached plan view. The soil profile
showed a sandy/gravel to a depth of 15 feet with a percolation rate
of than 1.2 min/inch.
The existing tank a few years old and will remain.
No impacts to the surrounding properties are foreseen. Ail
have onsite systems already and appear to be preforming adequately
and are served by a community water system. The required set-backs
are easily obtained within the confines of the lot.
The topography of the area is flat. The lot footprint is
about 78 feet fronting Brooks Street by 136 feet deep for an area
of 10,600 square feet.
Sincerely
~ames M. Wright P.E:
Permit No ................ Pege ! of ~
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Bo;< 196650 · Anchorage, Alaska 99519-6650 · Telephone: .34.3 4744
On-Site W~stewater Disposal System and/or Well Inspection Report
legal Description: /~-4*~7'~___'~_/~__5'._~M~OM I-/~/~rZ:/-~-xS PID No.
C
CLEAN OU1 ~-'-~-~~."--4 CLEAN OUt
PLAN VIEW ~MONI TORINO
,~ ~/~- FILTER FABRIC
~-~'~,.~-,~-,'T~X~X~T~.~"L~~X~_ ~ FROM ,SEP TIC
~-'-- o.o~, ~" ]~'] ~OVE.~1
EL EVATION
FILTER FABRIC
SECTION
PIPE
LOT zl-A, SANDI H[ilGHTS SUB'D
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
I+a~.~
PE.PORMED POR:_$
LEGAL DESCR,PTIO"= Lo
1
2
3-
4
5
6
7
8
9
10
11
14
17-
18-
20-
//£1¢rft~T~ownship, Range. Section:
SLOPE-'
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
Mon~mrino? l~ ~" Dam~ J-~/.~ / ?,
Reading Date Gross Nat Depth to Net
Time/~[i/~ Time/v/Q? Water Drop
7,'~ ~, ~"
PERCOLATION RATE ~L~--~ (minutes/mctel RERC HOLE DIAMETER
TEST RUN BETWEEN ~ FTAND
3OMMENTS
PERFORMEDC~y: .L.~./~'/27¢1'''' ~J~/~r~'~ I
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON TH~S DATE.
72-~8 (Rev, 4/85)
CERTIFY THAT THIS TEST WAS PERFORMED IN
DATE:
Depcmment of Environmental Quality~l;i,=A?l=R .il, NCHO~.~l: ARI:.~t, BORO!'"' ~
3500 Tudor Road -- Pouch 6-650 HEALTH DEPARTMENT
Anchorage, .Alaska 99502 327 EAGLE ST. ANCHORAGE, ALASKA: 99501: :=279-251i"
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
MAILING
ADDRESS ~//
PHONE
LOCATION ~ ~'[).0o 4( /
SEPTIC TANK:
LEGAL DESCRIPTION
DISTANCE FROM WELL
LIQUID CAPACITY ]
GALLONS.
MATERIAL ~"j i~C: J'' NUMBER OF ;~.
COMPARTMENTS
LIQUID
INSIDE LENGTH INSIDE WIDTH _DEPTH___~
SEEPAGE SYSTEM: SIEPAGE PIT:
NUMBER OF PlTS____OUTSIDE DIAMETER
LINING MATERIAl r'~
NEAREST LOT LINE
or WIDTH__ t c. , LENGTH_ ( ~'~, DEPTH
_, DISTANCE FROM WELl (?(Zi Yd\ BUILDING FOUNDATION.
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ;~t~t~ SQ, FT.
TILE DRAIN FIELD:
~NEAREST LOT LINE
TRENCH WIDTH
TOTAL LENGTH
_, OF LINES
IN. TOTAL EFFECTIVE
ABSORPTION AREA__
SQ. FL LENGTH OF EACH LINE
DEPTH: TOP OF TILE TO FINISH GRADE
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE__
WELL:
NEAREST
LOT LINE ., SEWER LINE
DISTANCES:
DEPTH_
SEPTIC
, TANK
DISTANCE FROM WATER
,BUILDING FOUNDATION. SAMPLE .,NEAREST
SEEPAGE OTHER
, SYSTEM , CESSPOOL , SOURCES
--DIAGRAM OF SYSTEM
APPROVED ~ ./~ ' :.,/_ZZX-
~ HEALTH AutHOrItY
MUNICIPALITY OF ANCHORAGE
DI:-PARTMENT 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
~ ? / ~' '~' ~ ~ HAA #
1. GENERAL INFORMATION
Complete legal description ~_.,~7"' ~./Z/~
Location (site address or directions) ~¢d ,/~/~v',~.. ¢..~7~'~. ~¢/~.~o-',r,~¢¢(.
-
Property owner k C'/,*,/ P'~ ,4-M ~ 5 Day phone
Lending agency
Day phone
Mailing address
Agent Day phone
Address
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be I~eld for pickup.
NOTE:
Individual well
Community well
Public water
If cornmunity well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72~J25 (Rev. 1191} 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.
NameofFirm ,~/~,~ /Y~'q'-/~4~.,1,~/V'~/ Phone t~,v-/-~'7~¢~(~
Address ..~Z~::~ /¢,/~,~-/./¢--~ ~/,/¢/~¢~/.~.,v~.:~ ,,x¢//_. ~-/~
Engineer's signature ~~ ~ Date
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date ,/2 -- 2 / -- ~'.¢
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.
72-025 (Rev 1/91) BSck MOA
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICFS
:-nvironmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Legal Description:
Health Authority Approval Checklist
Parce, ,.D.:__
WELL DATA
Welltype_ ,~
Log present (Y/N,
Total depth
If A. B. or C, attach ADEC leu[er. ADEC water system number
,A~ Date comDle[ea
· '~'~ ~ ~ Cased[o ~?~ ~ Casing height (above ground~
Sanitary seal (Y/N',
Wires properly protected (Y/N)
FROM WELL LOG
AT INSPECTION
Dste of test
Static water level
Wel production ~'~ g.o.m, g.p.m.
WATER SAMPLE RESULTS:
Coliform
Date of samole:
Nitrate
,r~,,"""~/~¢'~/ Other bacteria
Collected by:
B. SEPTIC/HOI. DING TANK DATA
Date installed ~/-~Z~?~_CZr/Tanksize /~-~'_.¢,"/, NumoerefCornpartments '~ Cleanouts(Y/N)
Foundation cleanout (Y/N) ~ Depression (Y/N) ~ High water alarm (Y/N) ~¢
Date of Pumping /~¢¢~¢ Pumper ,~¢,~
C. ABSOFIPTION FIELD DATA {'~,~,".- ~,¢r~ ~ ~om ~k~6,,~,~/¢. ~ ~,5~c> ~t{ .
Date installed ~'~//¢ ~ Soil rating g.p.d.~ or ~/bdrm) /, '~, System type EA,¢/~
~,~,
Length ~ / Widt~ ~. / Gravelthickness below pipe ¢~¢ ¢/ Total depth ~, ~ /
- ~,~. -
Effective absorotion area ~D s~ Monitoring Tube oresem (Y/N) ~ Depression~over field (Y/N)
Date of adeouacy test .//-/~ -' ~ Results (Pass/Fail) _ ~¢ ~ S For _ '.¢ bedrooms
Fluid depth in absorption field before test (in.); /~_ Immediately after ¢~Pgal. water added (in.):
F~.id d.pth / E" (ina) Minute~ ~te~: /%' Absorption ~te = //E~W .g.p.d.
Peroxide treatment (past 12 months) (Y/N) ~ If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed /'~,P/v' ~
Manhole/Access (Y/N)
High water alarm level at"
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot ,A/~ ~¢//~, ,,~ ~o ¢'
Absorption field on lot
Public sewer main
Sewer/septic service line
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at*
On adjacent lots '
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~¢', .~ ' Property line ,?..~ ! Absorption field /~L',
Water main/service line ~'¢ / Surface water/drainage ./'¢~ t¢~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /~ ~ / Building foundation ,/,~ / Water main/service line
Surface water ?~:~ "~ Driveway, parking/vehicle storage area ,~D
Curtain drain ~ ~/',./~ Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal record~ms are
in conformance with MOA~ H~C'guidelines in effec_~ on this date.
Signature ~c~1~~~ ~~:: "..~
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
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
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) _ ¢' ~0 ~/ .~/~/,~. .~'/~, /¢2~¢~-/¢,~--,,~¢c~
Properly owner
Mailing address.
Lending .agency
Mailing address
Agent
[:)ay phone
[:)ay phone
Address
o
· Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
_X
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ~ ~'¢~ ~,4~//,~-o --
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) F~onl 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 effec/t on the date of this inspection.
Name of Firm 2~/z.,~ //.,Z,/¢-,.~.~/~-t ~/~c/ Phone Z ¢I -?9 ¢ ~
Address ~¢//-/E~ ~,~.~L/--~_~//~ ~,~/ //~_~_~Z'~.,....,.~¢.~- ~ ¢¢~-/~
Engin~¢s signature Date //~ ~d -- ¢ ¢
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By: Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The D H HS does this as a ¢ourtesy to purchasers of homes
and their lending institutions in orderto 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.
untclpality o~ Anchorage
DEPARTMFNT OF HEALTH & HUMAN SERVICES
'Environmental Se~ices uivision '
- : 825 L Street Room 502. Aqchorage Alaska 99501 ·
: ' · Health Authority Approval Checklist
~e'll tyP~ ¢~'~. ,~ 'lf~8, Or'C, a~ach ADEC leEer. 'ADEC
Log present (Y/N)
·, Total depth.,;:-,,~,,--:.' ......... ::.. ........ base~ to ~'~'~ '~-' ........ ',, Casing
,:,- Samtary seal (,Y/N) -~' ~.~ ....~:..:,..: ........ ,, ~,,,,.,,,~L~, ,..~,. ........ ,,, ,.W~r,e.s properly protected
4' .;.~;~ ......... ~,.-~,~ ,~:~:-,,,,~*~:--,- ':'~'r' i~l FROM WEEL !2OG ..e .... .............. AT INSPECTION
B. SEPTIC/HOLDING TANK DATA
:~!,~>~i-~O a. t e,.i.~i~t .a!fe ~ .,~,,~,:.,, ,',, '-,~.~ :-.~ ,?Tg r!~
~,~t~:.::? Foundation cleanest (Y/N) .~':.:"t'.:¢,~&'~'~?:.~¥:Depresslon (Y/N) ':~'?~'.~ m:~'~-?High wateralarm':{~),,
C, ADSORPTION FIELD DATA
Date installed //,.~/q W Soil rating (~ or ft'/bdrm)_ ///¢.~,,,-3,System type ,5'/?-'¢/~Ag
....) /
Length /'wD Width ,~ / Gravel thickness below pipe ~3~ ¢/ ·: ~Total depth _-,~.~:-~=:;~::::-:., ..
....... Effective absorption area ,.-.~-e ~,sr~ .Monitoring Tube present (Y/N): ~")(". Depression over;field (¢N)
: Fluid depth in absorption field before test'(in,)~ '--Z~.T Immediately after--gal, w~ter:[~ded :(in~);
,:-Fluid depth, .../..~- .- .(ins) Minutes qatbr:?-~,~u/~' --,. Absorption rate.=-'~>"~'r"'--':~:~'¢X'g'PJd""'~(~r'¢f¢:~{~¢~i~
Peroxide treatment (past I2 months) (Y/N) ' ~ If yes, g~ve date
72
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
"Pump on" level at*
"Pump off" level at*
High water alarm level at*
*Datum
Cycles tested
Septic/holding tank on lot
Absorptio~ field on lot
Public sewer main
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Sewer/septic service line /
Property line
Surface water
Curtain drain /L////~
/
F. ENGINEER'S CERTIFICATION
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station /'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Property line ~ ~' / Absorption field
Water main/service line ~'/'~ Surface wateddrainage .,, Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
//~', ~ Building foundation / ~' ( Water main/service line
Driveway, parking/vehicle storage area
Wells on adjacent lots ,/'1-~///~
I certify tibet I have determined thru field inspections and review of Municipal records that the above systems are
in conforman~~~idelines in effect/~is date.
Signature ~.¢¢...~.~ ~/.~ -
Engineer!s Name ,,~,,2_,~/~',,¢~-/z.O /'~..///,9-,,,~.~,..~/~/
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
SHEET NO, / OF
o^~o~^TEOSY t~O Z-/ O^T~ //-I~
CHECKEDBY__ DATE
S H E b'~' NO. -- t/ OF.
CHECKED BY- OATE
/
q.,. ec
SHEET NO ~ OF
CHECKED BY DATE
SCALE
SHEET NO '~ OF
CHECKE~ BY. DATE
SCALE
':.:..~ ~ ,!., .
P.O. Box 196650 Anchorage, Alaska 99519-6650 !::v~ i;'<, ,. i.
343-4744 ' :: .:r ', ~;::,, ,! ·
CERTIFICATE OF HEALTH AUTHORITY ,..
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. i* ~-21/ Z. 2. Z. ~-~'~
1. GENERAL INFORMATION
Complete legal description
HAA# 90-7 J
Location (site add,ress or directions)
Property oWner /~
Mailing address .72-
Lending agency
Mailing address.
Day phone ~2.1'~-.~-c_/~. ¢ 7f-¢
Day phone _
Agent Day phone
Address
h,-:' Un!ese otherwise requested, HAA will be held for pickup. ~,:~:
2. NUMBER OF BI"DROOM$: ~
3. TYPE OFWATER SUPPLY:
Individual well
Community well
Public wa~er
!f commumty well system, prowde written confirmation from
- - N?~.T.E: , ~"" ' '
:: ".i ":" ' ' ~ng to the legality and status of system. ' '
-
NOT~: /f communi~ wastewater'~ystem provide wri~en
, . confirmation from State ADEC
a~esting to the legafi~ and ~tatus of sy~m.~
, :.,. %- ', Individual on-site
.... ,,. , Holding tank :
.... ' - Community on site
5. STATEMENT OF INSPECTION BY ENGINEER
i~ : r AS cert f ed .bymy sea 'afl Xed hereto and as of the validation date shown bellow, i ver ~y tnat my
~ investigatioh 'of~thiS Hea th 'A'uth0r ty Appro,v.a app ;cation shows that the on-s te water supp y .~: ~
and/or wast~water d sposa ·system·is safe fu~ ,c. tiona .a.r~d 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 inves.ti, gation 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 2~PO (-O~57'- 3-~,--~- A~-
6. DHHS SIGNATURE
......... ~ Appr0~;ed: for
............. Disapproved..
-bedrooms.
Conditional approval
':" ' ~ bedrooms, .with the following' Stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human servi(~es'(D'HHS) Issues he~lih Adth°rity
Approval Certificates based only Upon the r0presentaflons given in paragraph 5 above by an indep0ndent
profeSSional engineer registered in the State of A aska The DHHS does th s as a courtesy to purchasers of homes
and the r end ng nst tut ons in order to ~afisht certain federal and state requirements. Empl0y~os of DH~S do nbt
:: con;du~t inspections or analyze` ~ta b?,fore a certificate is issued. The Municipality of Anchorage is riot
·., ~?: .~; .;;[~).~.~;,{!~,,', : ; .,,. ,,.:~ ,::, . ;, :~:, ~. ~ ~; ,l~'~!~.~ ';,~.~?.~;v~'?.'!,.'.~. ~> .: ~::: .t':: ':
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL. CHECKLIST
LegalDescription:__/_,~T 4'A ~/~/V~I I~E-/~¢~-5 ParcelI.D. (.2 // ? 2_2. dL--O
A. Well Data
Welltype /5¢/)/~: ~__
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
-- Date completed -- Driller
'-- Cased to -- Casing height
-- Wires properly protected (Y/N) --
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main --
FROM WF. LL LOG AT INSPECTION
g,p.m.
; On adjacent lots
_; On adjacent lots
Public sewer manhole/cleanout
Sewer service line
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate -- Other bacteria
Date of sample:
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed 1 2-/2-// ¢ +
Cleanouts (Y/N) _ y'
High water alarm (Y/N) ~.~- Alarm tested (Y/N)
Date of pumping _ I 2~/2- C~/¢ '~ Pumper
SEPARATION DISTANCES FROM SEPTiC/HOLDING TANK TO:
Tank size _/_?-,.~--~ ~- A-- L_ Compartments 2..-.
Foundation cleanout (Y/N) _ 7' Depression (Y/N) _ /~v/
Well(s) on lot ~( / fY On adjacent lots _/v'/,A-- Foundation_
To property line _ .~ ~ / Absorption field i ,~ r Water main/service line
Surface water/drainage / cOO ~
72.026 (3~3). Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed --
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer --
Manhole/Access (Y/N) --
"Pump off" Level at
.Cycles tested --
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot. -- On adjacent lots --
Sudace water
D. ABSORPTION FIELD DATA
Date installed I Z./2~ / / ~ ~ soil rating (GPD/FF) /,
Length ~' ,~-- / Width ~ / Gravel thickness
Total absorption area .~ ~D~7, fy--, Cleanout present (Y/N)
Date of adequacy test /~//~ Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N) /y"
System type 'T/~ ,t~-/v'c.
Total depth ~. ~
Depress~n over field (Y/N)
for ~ Bedr~ms
After test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
line
Well on lot /Y/Z-Y- On adjacent lots Property
To building foundation
On adjacent lots ~ C' ~ Cutbank / f2,'2 "/- Water main/service line 2-..,~
Surface water /
Curtain drain
E. ENGINEER'S CERTIFICATION
I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in
Signature ~//_~/¢//~s'S~
Engine~N~r~'e ~ ~'(./27~ ~ ~ {.~ ~/~f~ ~
Date J~/~ '~/~
CE ~84t :;,
HAA Fee $ i'~'
Date of Payment ,/'~--
Receipt Number ~.2-.
72-026 (3/93)' Back
Waiver Fee $
Date of Payment
Receipt Number
APPLI(* NT FILLS OUT UPPER HAl
Phone
Mailing Address ~:[-% ~ ~ [~ ~[ ~/; ~4. ZiP Code
Address ~'~ [~ ~x ~ (~ ~ ~. [ ~ { ~ Zip Code
Lendinglnstitution ~:~-~ ~.~]-X~, L. I~[ ~-~.~L:.~.t( ~;cr~ : ~'. ~[[d Phone
Real Co.&Agent d~ .~, ~ ~ , .~ ~ (-Y'(~ ~;~,~/ [~,c/~ ~[~ 2c~(~_~-~-~ ~i-L~ Phone
~ Individual ~ ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975,
Time Time Time 'rime
Date Date Date Date
Inspector Inspector Inspector Insp6ctor
Field Notes: MUNICIPALITY OF ANCHORAGE
~ ~~ ~ DEpT, Of HEAt. TH &
~'"' ',~' ENVIRONM~N'fAL PROTECflON
) MAR 1 0
RECEIVED
('~) A~P~OVED BEDROOMS 'GONDITION8 OF APPROVAL
( ) DISAPPROVED
( ) GONDITIONAL A~P~OVAL'
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
~,:~,.., ) ~,.,, Well to Tank Septic T~k Size
ALASKA ,UlmOIlmEnTAL
~TROL SE. ]iCES, IRC,
3/ll/83
' //Vo~·'
· SELLER -- YANACAVA BUYER-
SUBDIVISION-SANDI,HEIGHTS ~
BLOCK-1 LOT-4A ,
ADEQUACY TEST FOR SEWER SYSTEM
THE TYPE OF ABSORPTION SYSTEM IS A CRIB WITH AN ~JtEA OF 288 SQFT,
THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 675 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IlS ACCEPTABLE FOR A
3 BEDROOM HOME.
THE SEPTIC TANK WAS PUMPED ON 3/11/83 .
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF
THIS 3 BEDROOM HOUSE.
]000 IS ADEQUATE FOR
1200 Wesl 33rd Aucnue. SiJo¢ ~ · Anchoroqe, Alosko 995o3 · (907} 276-1361 .........