HomeMy WebLinkAboutSPENDLOVE VIEW HEIGHTS BLK 3 LT 3
Municipality of Anchorage Page 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
Permit Number: -¢ b(-/ ¢] 7' 0,'~ E~c~ PID Number: _
Name: ~ ~ ~' 7~ C I~ ~ Wastewater System: ~ New ~ Upgrade
Phone: ~ ~ ~ . ~ ¢~ No. of ~¢drooms: ~ Deep Trench ~Shallow Trench ~ Bed ~ Mound ~ Other
Total Depth from original grade:
LEGAL DESCRIPTION SoilRating: O, ~ GPD/S%Ft. ~,~''
Lot: Block: Subdiv~ion: Depth to pipe bottom Irom original grade: Gravel depth beneath pipe
I
I
Number of lines: ~ Distance between lines:
WELL:D New Q Upgrade ~rave[ width; ~, ~ Ft. ~I I ~ Ft.
Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption area: Pipe materiah
Driller: Date Drilled: StaticWaterLevel:Ft. Installer:~l~ ~C~o~ Dateinstalled:~/7
Yield:GPM [ Pump Set at: Ft. ICasing Height Ab°ye Gr°und:Ft. TANK
SEPARATION DISTANCES ~ Septic ~ Holding ~ S.T.E.P.
TO Septic Absorption Lift Holding ~ubtic/Pdvate Manufacturer: Capacityin gallons:
From Tank Field Stat[on Tank Sewer Lines ~ ~O ¢~ ~ ~ ~
Material: Number of Compadments:
Sudace
w~t~ > ~oo, > ~o' - LIFTSTA'rlON ~.~,
LOt Size in gallons: ~ Manufacturer:
I
Cu~ain Pump Make & Modal I Electrical Inspections pedormed by:
I
Remarks' ~ m~//,~ ~ ~ ~ BENCH MARK
. ~,~ _
~6~ ~t¢~e~o,~ ~alu¢ ~e¢ t~1~¢ ~ ~ AssumedElevation:
Department of Health and Human Services approval
72-013 (Rev. 9191) MOA 25
PERMIT NO: SW970088 PAGE 2 C)F 3
PID NO: 02102111
C.O, "G"
M,T, "1-1"
C,O. 'T'
C.O, "J"
M.T, "K"
C.O. "L"
WELt_~
DRIVE
SWING TIES:
FROM: COR. "A"
TO:
S.T, C,O. "C"
S,T. C.O, "D"
DBL C,O, "E"
VALVE "F"
LOT 3, I
SPENDLOVE \
"BULL RUN"
DIV. VALVE
BDRM HOUS
DBL.
C.C.
COR."B"
42' 9.5'
44.5' 15.5'
45' 19'
60' 45'
45' 25.5'
67' 46'
101' 87'
36.5' 36'
70' 60'
101' 91'
p, 100'
,OCK 3,
FW HEIGHTS ,,
~- % "C" 1000 GALLON
~,~ SEPTIC TANK
DRAINFIELDS
LOT 3, BLOCK 3, SPENDLOVE VIEW HEIGHTS
SEPTIC SYSTEM INSTALLATION
AS-BUILT INSPECTION REPORT
FUA~OP T~C~[CAL S~V[C~S SCALE: 1" = 30'
]4530 ECHO S't'~T DRAWN BY TFM
ANCHO~G~, ALAS~ 995 ~6 AUGUST, 1997
PERMIT NO: SW970088 PAGE 3 OF 3
PID NO:02102111
2" RIGID INSULATION
OVER TANK, DRAINFIELDS,
AND PIPES
2' SOIL COVER
)VER ENTIRE
SEPTIC SYSTE"M
1000 GALLON INV.
SEPTIC TANK 101.9'
INV.
101.4'
BOT. GVL
ELEV. 100.4'
BOT. SAND
ELEV. 99.2'
T.H. #1 M.T.
WATER ELEV. -
96.3' ON 6/5/97
0.2' "BUMP"
INV.
100.t'
BOT. GVI..
ELEV, 99.1'
BOT. SAND.
ELEV. 96.01
(SEE NOTE)
NOTE: GRADIENT OF WATER TABLE ASSUMED
TO BE PARALLEL TO SURFACE OF ORIGINAL
GROUND, THUS, THE WATER TABLE 18 4 FEET
BELOW THE BOTTOM OF BOTH DRAINFIELDS,
LOT 3, BLOCK 3, SPENDLOVE VIEW HEIGHTS
SEPTIC SYSTEIVl INSTAL[J~TION
AS-BUILT CROSS-SECTION
FLATTOP TECHNICAL SERVICES
14530 ECHO STREET
X_NCHORAGE, ALASKA 99516
NOT TO SCALE
DRAWN BY TFM
AUGUST, 1997
LOCATION OF WELL
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURCES
OIVISION OF MINING & WATER MGMT
WATER WELL RECORD
BOROUGH · SUBDI I ION ,, LOT eLOCK
LOCATION/SKETCH:
DEP'rHS MEASURED FROM:~]easing top []ground surface
BOREHOLE DATA: Depth
SECTION QTRS
SECTION
TOWNSHIP I RANGE
mN []E
[]w
WELL OWNER:
MERIDIAN
Material Type and Color
From To
WELL DEPTH: ? ,"'~ DATE OF COMPLETION
Depth of hole: '~r ' ~t ~r ~ ( ~ ' /
Depth of casing: . :, ~, ft - /
[] ground surface
DEPTH TO STATIC WATER LEVEL:
ft below [] top of casing
/ ,) () '}
Date: t:;~ / , / '.?
METHOD OF DRILLING: i[] air rotary [] cable tool
[] other
USE OF WELL: ;[] domestic [] irrigation [] monitor
[] public sopply [] other
CASING STICKs.U?:' ~ft. Diam: ~:'
Casing type: ..'* ,'.; :.: /,
in. to:: ~?ft
in. to.~ : ft
[] screened
WELL INTAKE OPENING TYPE: .;[] open end
[] perforated :D open hole
Depths of openings: to __ ft
SCREEN TYPE: Diam: in.
Slot/Mesh Size: Length:_ ft
GRAVEL PACK TYPE:
Volume used:
Depth t,o top:
GROUT TYPE: ·)-,,- =:<~¢¢Vol~me ¢'
Depth: from ' ft to ft
PMENT METHOD: 7 :~-",'
PUMPING LEVEL AND YIELD:
-,.% './ ft after ",Q hrs pumping..~',: ) gpm
INTAKE DEPTH: ft Horsepower: __
WELL DISINFECTED UPON COMPLETION? [] YES [] NO
CONTRACTOR INFORMATION:
Registered Business Name
Signature of Authorized Respresentative Date
REMARKS:
PLEASE MAIL WHITE COPY OF LOG TO:
DNR/DIVlSION OF MINING & WATER MGMT
3601 C St~ Su£te 800
Ancho~age~ Ak 99503-5935
ph(907)762-2538,Fax(907)562-1384
ZtK c'r&E Environmental Services
Inc.
CT&E Ref,#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
Sample Remarks:
994247001
Flattop Technical Srv.
I_3 Blk3 Spendlove View Hts
L3 Blk3 Spendlove View Hts
Drinking Water
0
Client PO// Pre-Paid Coils/NO3
Printed Date/Time 08/20/99 14:41
Collected Date/Time 08/18/99 13:20
Received Date/Time 08/18/99 14:50
Technical Director: Stephen C.'Ede
Results
PQL
Units
ALLouable Prep Analysis
Hethod Limits Date Date Init
Total Coliform
Nitrate-g
0 cot/100mL SM18 9222~
4.56 0.500 mg/L EPA 300.0
10 max
08/18/99 JOT
08/18/99 00/18/99 SCL
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH A/~D HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
~g~CHORAGE, ALAS[CA 99519-6650
PERMIT NUMBER:SW970088
DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES
OWNER NAME:JOHN TUCKEY
OWNER ADDRESS:3454 SAGEN CIRCLE
ANCHORAGE, AK. 99517
PARCEL ID:02102111
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT //3%LT ~,~.~
EXPIRATION DATE: 5/12/98
LEGAL DESCRIPTION:
SPENDLOVE VIEW HEIGHTS BLK
3 LT 3
LOT SIZE: 51216 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL 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 ALAS[CA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
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
RECEIVED BY: [ ~/~
DATE:
DATE:
- q "7
' -,NSTA'L"SPL,TTE / / o.o.
"A" ;'> ~ CONSTRUGT 2 PARALLEL
~, 66' LONG X 5' WIDE SOIL
PLAN VIEW
SCALE: 1" = 10' - 0"
ABS. DRAINFIELDS WITH
12" GRAVEL BELOW PIPE
SECTION "A - A"
SCALE: 1" = 5' - 0"
-2' COVER MATERIAL
RIGID INSULATION
FILTER FABRIC
SEWER GRAVEL
(12" BELOW DIST PIPE)
FILTER SAND
MAXIMUM DEPTH OF
NOTE: THIS DESIGN REVISION IS NECESSARY TO
COMPENSATE FOR AN UNEXPECTED SEASONAL
HIGH GROUND WATER LEVEL OF 6.5~' BELOW GROUND
LEVEL. THE FILTER SAND IS NOT REQU RED BY CODE,
BUT IS BEING ADDED IN AN ATTEMPT TO ENHANCE THE
LONGEVITY OF THE SYSTEM.
THE SIZE OF THE DRAINFIELI:) IS BASEl:) ON A SOIL
ABSORPTION RATE OF 0.6 GPD/SQ. FT. WHICH FOR THIS 3
BEDROOM RESIDENCE REQUIRES (3 X 150)/0.6 = 750 SQ. FT.
THE REQUIRED LENGTH FOR A STANDARD 5' WIDE
DRAINFIELD WOULD BE 150', HOWEVER USING A LENGTH
REDUCTION FACTOROF 7/8 FOR 12" SEWER GRAVEL.
BENEATH THE DIST PIPE YIELDS A REQUIRED TOTAL
_ENGTH OF 132 F:EET.
L3, BLK. 3, SPENDLOVE, VIEW HEIGHTS
SEPTIC SYSTEM UPGRADE
REVISED PLAN AND CROSS-SECTION
FLATTOP TECItNICAL SERVICES
14530 ECHO STREET
ANCHORAGE, AK, 99516
SCALE: AS SHOWN
DRAWN BY: TFM
REV. JUNE, 1997
P. 01
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
FiX COVER LWI'TER
Subject:
From:
Total # of Pages (incl. cover letter)
CIVIl. & ENVIIIONMENTAL ENGINEERING * ENERGY CONSERVATION & ANALYSLq
THEODORE F, MOORE, P.E. 14530 ECHO ST.
PH: (907) 345-1355 ANCHORAGE, ALASKA 99516
April 28, 1997
M.O.A. DHHS
P.O. Box 19-6650
Anchorage, AK 99519
Dear Sirs:
The purpose of this letter is to provide the required design narrative in support of our application for
a permit to construct wastewater disposal facilities on Lot 3, Block 3, Spendlove View Heights, located
on Spendlove Drive. Soils logs, perc test results, a site plan, design drawings and specifications are
enclosed for your review.
The proposed system will be constructed in the vicinity of test hole # 1. As can be seen from the soil
log, the native material between 1.5 feet and 8' below ground level is a sandy silty gravel with a measured
perc rate of 15 minutes per inch. Using a slightly conservative soil application rate of 0.6 gpd/sq, ft., this
proposed3 bedroom residence requires a total absorption area of(3 x 150)/0.6 = 750 square feet. The
proposed design consisting of 94 lineal feet of soil absorption trenches with 4 feet of sewer gravel has a
total absorption area of 752 square feet.
The topography of the lot slopes down towards the southwest at 10%.
The proposed project will have no significant impact on present or future water supply and
wastewater disposal systems serving adjacent properties, nor will it have any significant impact on
reserved space-surface and subsurface, or on drainage.
Please give me a call at 345-1355 if you have any questions on this submittal.
Sincerely,
Ted Moore, P.E.
(~EXISTING
,,,~WELL
/
LOT 5, BLOCK 2- - -..
t
VACANT) -....
SPENDLOVE DRIVE
R 100'
PROPOSED
WELL SITE
lO% /
/
LOT 6, BLOCK 2 ,"
LOT 2
(VACANT -
EXCEPT FOR WELL)
INSTALL
SEPTIC TANK
CONSTRUCT
2 PARALLFL
47' LONG SOIL ~T.H.
ABS. TRENCHES #1
W. 4'SEWERGVL q.
?~. 10°~
SITE FOR /~.~.%
REPLACEMENT ~---~ ';. \ T H
TRENCHES
W. 6' SEWER GVL.
LOT 3, BLOCK 3,
SPENDLOVE VIEW HEIGHTS
10' UTILITY EASEMENT
UNSUBDIVIDED
WELL~
SEPTIC
LOT 4, BLOCK 3,
SPENDLOVE VIEW HEIGHTS
L3, BLK. 3, SPENDLOVE VIEW HTS.
PROP. WELL AND SEPTIC SYSTEM
SITE PI.AN
FLATTOP TECHNICAL SERVICES 1 INCH = 50 FEET
14530 ECHO STREET DRAWN BY TFM
ANCHORAGE, ALASKA 99516 _. APR., 1997
NOTE: THIS IS NOT A SURVEYED PLAT.
ALL LOCATIONS SHOWN ARE APPROXIMATE.
INSTALL 1000 GAL.
SEPTIC TANK
~ MONITOR TUBE · '
-
D3034PIPE / I/ / 47' LONG A~S. TRENCHES/ ASTMF-8~0
~,4""SUMP~- I/ / SPAOED~5APART / PE~FP~PE
PLAN ViEW
SCALE: 1" = ~10' - 0"
CLEANOUT
MONITOR TUBE
MOUND BACKFILL
12" OVER TRENCH
DIA. D-3034 PIPE W. 4" "BUMP"
3
FABRIC
:. PIPE
BOTTOM OF EXCAVATION
SECTION "A - A"
SCALE: 1" = 5' - 0"
L3, BLK. 3, SPENDLOVE VIEW HEIGHTS
SEPTIC SYSTEM CONSTRUCTION
PLAN AND CROSS-SECTION
FLATTOP TECI~qlCAL SERVICES
14530 ECHO STREET
ANCHORAOE, AK, 99516
SCALE: AS SHOWN
DRAWN BY: TFM
APRIL, 1997
Flattop Tochnical Services
14530 Echo Street, Anchoraoe,/ 1( 9951§
Phone (9(17) 345-1355
Lot 3, Block 3, Spendlove View Heights S/D
Spendlove Drive
Wastewater disposal system installation
Specifications
1.0 General:
1.1 The scope of the project consists of installation of a 1000 gallon septic tank followed by two
parallel 47 foot long soil absorption trenches with 4.5 feet of sewer gravel in each. Care shall be taken in
laying the pipes to keep the distribution pipes as shallow as possible.
1.2 Construction shall be as depicted on the approved site plan and design drawings. Minor
deviations fi'om these drawings may be allowed or required by the engineer conducting the inspections.
All construction procedures and material specifications shall conform with Municipal and State
requirements. All separation distances shall be in conformance with Municipal requirements, unless
specifically waived.
1.3 The contractor shall be responsible to obtain any necessary utility locates, and to work around
any buried utilities.
1.4 The contractor shall provide adequate cover material and rough grading over all system
components to ensure that proper drainage is achieved after settlement and that there are no residual
depressions. Insofar as possible the contractor shall minimize damage to trees and existing lawn areas.
1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish grading after
the soil is compacted, as well as placement of topsoil and reseeding all areas disturbed by the
construction.
2.0 Septic Tank:
2.1 The new 1000 gallon, 2 compartment septic tank shall be Municipally approved and shall be set
level on undisturbed soil. Each compartment shall be equipped with a watertight manhole cover and a 4"
cleanout. If the tank is buried less than 4 feet, it shall be insulated with 2 inches of approved burial type,
rigid insulation.
2.2 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The
waste line from the residence to the septic tank shall have a nfinimum slope of 1/4"' per foot, and the
waste line between the tank and the soil absorption system shall have a minimum slope of 1/8" per foot.
A cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be
installed within 5 feet downstream of the septic tank.
3.0 Soil absorption system:
3.1 The soil absorption system shall be constructed by excavating 2 parallel 47 foot long trenches in
the vicinity of test hole # 1 to a total depth of 8 feet below ground level.
3.2 The bottom of the excavations shall be level within each trench, but the bottoms of the two
trenches will not be at the same elevation. Any compacted or smeared surfaces shall be raked to allow
proper infiltration. Sand for leveling or serving as filter material shall comply with Municipal
specifications.
3.3 A total of 4.5 feet of approved sewer gravel shall be placed in the bottom of the excavations with
the perforated distribution pipes laid level such that the pipe inverts are no less than 4.0 feet above the
bottom of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing
tbe #200 sieve.
3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on
the design drawings. The portion of the monitor tube extending through the sewer gravel shall be
perforated.
3.5 Approved filter fabric shall be placed over the entire top surface of the sewer gravel. A minimum
of 2 feet of soil cover is to be placed over the filter fabric. If the soil cover thickness is less than 3 feet,
two inches of rigid, burial type insulation is to be placed over the entire top surface of the gravel, in
addition to the filter fabric.
3.6 The top surface of the cover material shall be raised a minimum of 6 inches higher than the
surrounding terrain to allow for subsequent settlement, and shall be graded to smooth contours. Fill
slopes shall be no steeper than 3: 1.
3.7 Unless specifically agreed otherwise the homeowner shall be responsible for arranging to have
the site finish graded after the backfill material has stabilized, and for placement of adequate topsoil and
seed to promote rapid revegetation of all areas disturbed by the construction.
4.0 Inspections:
4.1 A minimum of 4 inspections will be required during the course of the project: (1) initial stakeout
with the contractor to establish the location of the system and to discuss the plans, specifications and
construction procedures, (2) after the native material has been excavated to expose the infiltrative surface
to ensure that it is level and at the right elevation, and conforms with the soil test information, (3) after
the sewer gravel is in place and the distribution pipes have been laid and connected up to the septic tank,
but prior to placement of insulation or filter fabric, and (4) after rough backfill and grading is complete.
The septic tank requires one inspection after it is set level and the piping connected, but prior to backfill.
This inspection may be incorporated with any of the above inspections.
4.2 The installer shall coordinate the timing of the inspections with the engineer sufficiently far in
advance to ensure the availability of the engineer.
TEST HOLE
FLATTOP TFCHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:__ Lot 3, Bloc~_Spendlove View Heights S/D
DATE PERFORMED: October 1, 1996
PERFORMED FOR:
DEPTH
(feet)
Jolm Tuckey
Pt.
SM Sandy loam
GM Sandy silty gravel
Less silt, but tighter above 3 feet
GM/ML Silty Gravel
Hard digging
Maay cobbles
Sidewalls do
SLOPE
Depth to Groundwater Date
No Groandwater 10/1/96
~Mo~n~o~r ~be dry 10/9/96
~V'~rO 15~" q"' q//K/~7
SITE PLAN
SPENDLOVE DRIVE
#2
COMMENTS:
Clock Net Time Percometor Not Drop
Date Reading Time (minutes) Reading (Inches)
10/1 12" Presoak
Slart 11:27:45 23 3/8
#1 11:42:45 15 22 5/!6 1 1/16
Add water 11:43:30 __ 23 3/8
#2 11:58:30 15 22 3/8 1
Add water 11:59:15 23 3/8
#3 12:14:15 15 99 1/4 1 1/8
Add water 12:15 2~ 3~{.8~
#4 12:30 15 22 3/8 1 ·
Add water 12:30:30 __ 23 3/8 __
#5 12:45:30 15 22 1/4 1 1/8
PERCOLATION RATE 15 (minutes/inch) PERC HOLE DIAMETER 8"
TEST RUN BETWEEN 5.25 FTAND 5.75 FT
Recommend treecb desiga in this area be based on slightly conservative application rate of 0.6 gpd/sq, ft.
PERFORMED BY FLATTOP TECIqNICAL SERVICES, I ,~..,~.,,,~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES iN EFPECT ON THIS DATE. DATE: [0/2~'/~,,~ ¢'//'/~',/~ 7
Il'EST HOLE# 2
LEGAL DESCRIPTION:
DATE PERFORMED:
PERFORMED FOR:
DEPTH
(feet)
1
FLATTOP TECHNICAL SERVICES
14530 ECHO ST.
ANCHORAGE, ALASKA 99516
SOILS LOG -- PERCOLATION TEST
Lot 3, Block 3, Spandlove View Heights S/D
Oclober 1, 1996
John Teckey
Pt.
GM Sandy silty gravel
Tightly bound
GM/ML Silty Gravel
Siltier than T,H, #1
Increasingly cohesive w. depth
No distioct sirata change
SLOPE
Depth to Groundwater Date
No Groundwater 10/1/96
Monitor l!!be dry 10/9/96
SITE PLAN
SPENDLOVE DRIVE
15--
COMMENTS:
Clock Not Time Percemeter Net Drop
Date Reading Time (minutes) Reading (inches)
10/2 Presoak
Start 12:34:45 23 3/8
#1 1:04:45 30 22 13/16 9/16
___ _ Add water 1:05:45 23 7/16
#2 1:35:45 30 22 7/8 9/16
Add water 1:36:15 23 3/8
B.H. #3 2:06:15 --- ~ 30 - 22 13/16 9/16
PERCOLATION RATE 54 (minutes/inch) PERC HOLE DIAMETER 8"
TEST RUN BETWEEN 4.5 FT AND 5.0 FT
Trench design in this area should be based on 0.45 gl)d/s_ch ft.
PERFORMED BY FLA~-rOPTECHNICALSERVICES. I ~-_~..,..,~ ~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE:
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
ParcelI.D. #
CERTIFICATF OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA # ~'~ ~ Or?% (¢~
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
/ ~ 3-5-/
'l~&iliilg ad'dress
".:.-'Lending agency
Mailing addi~ess
Day phone
Day phone
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: -~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. 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
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 thi~ 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 flies 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.
Engineer's signature
DHHS SIGNATURE
~ Approved for
Disapproved.
Conditional approval for
'T E E bedrooms.
bedrooms, with the following stipulations:
Ad(Jitional comments
The Municipality of Anchorage Department of ·Health an~ Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations'~iven 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.
Municipality of Anchorage
DE:PARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 ·
Health Authority Approval Checklist
'LegalDescription: /, /'~/ ~/oc~r~ 5/~,,~dlo~'~ ///.~//.,'TParcelI.D.: 0~./-0~-/ -/(
A, WELL DATA
Well type ?~' /'
Log present (Y/N) Y'
Total depth _ $C, '
Sanitary seal (Y/N)
IfA, B, or C, at~ach ADEC letter. ADEC water system number
Date completed
Cased to b'- '7 '
FROM WELL LOG
~'/2o/? 7
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Date of test
Static water level
Well production
~'/~o/? 7
g.p.m.
g.p.m,
WATER SAMPLE RESULTS:.
Coliform ~r,)
Date of sample: ZY//~ /~
B, SEPTIC/HOLDING TANK DATA
Date installed
Nitrate _ ~J',--~(~ Other bacteria _ ('~
Collected by: _
~'/.5- / ~) '7 Tank size _L.O c)~,,,2
Number of Compartrnents ~- Cleaneuts (Y/N)_ '7' -
Foundation cleanout (Y/N) _
Date of Pumping _ N,4
C. ABSORPTION FIELD DATA
Date installed ~'/5-/ 9 7
Length _ I Z g..,c' Width
Effective absorption area
Date of adequacy test_ M.
Fluid depth in absorption field before test (in.); __
Fluid depth (ins) Minutes later:.
Peroxide treatment (past 12 montl~s) (Y/N)
72-026 (Rev. 3/96)*
Depression (Y/N) /V High water alarm (Y/N) A/. ,4.
. Pumper N.
~' ~e-oc-ge..c~ occ~;,,'~-( I~,,c_r /-~,~ I )/ec~ ~'-
Soil rating (g.p.d./ft~ or fF/bdrm) ~_ System type
,~ o' Gravel thickness below pipe. /, o' Total depth ~.,5' '
Monitoring Tube present (Y/N) 'r" _ Depression over field (Y/N) ,~'
Results (Pass/Fail) For .bedrooms
Immediately after gal. water added (in.):
Absorption rate =. ~' ?.~-O __g.p.d.
If yes, give date
D. LIFT STATION /k/.
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
I10'
I ~-5'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ¢" Preperty line ,5-5''
Water main/service line '>/~' Surface water/drainage ~ too'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
I,s~' Building foundation ~--~'
Property line
Surface water
Curtain drain
On adjacent lots
On adjacent lots
"Pump off" level at*
HAAFee $. ~,~, .¢,o
~ I~'O '
Public seWer manhole/cleanout
Lift station /V. 4.
Absorption field.
Wells on adjacent lots
Water main/service Dine. ~ /~ '
Driveway, parking/vehicle storage area ~ /Y~ '
Wells on adjacent lots ~ ~d.,o ,
Date of Payment
Receipt Number
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal records
in conformance with MOA HAA guidelines in effect on this date.
Signature ~ ~
Engineer's Name _ ~A ~ ~o ~ ~. ~oo ~
Date ~p ~ ~ ~ /~e~
Waiver Fee $