HomeMy WebLinkAboutEKLUTNA WEST LT 15Eklutna W st
Lot 15
#051-062-42
Municipality of Anchorage Page I 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: ~'/~'~° ~3. PID Number: ~5'-/ ~ ~ ~
Name: ~~ ~ ~t'$~ ~~ Wastewater'~tem: ~New D Upgrade
~d~,: ABSORPTION FIELD
Phone: INo, of Be~ooms: .~roeepTrench ~ShallowTrench ~Bed ~Mound ~Other
LEGAL DESCRIPTION SoilRating: /. ~ GPD/Sq. Ft. TotalDepth~o~originalgrade:
Lot~ Block: Subdiv~ion: Depth to pipe bottom from original grade: Gravel depth b~ea~ pipe
Township: I Range: I S~tlon: Fill added above original grade: Gravel length:
/, ~ Ft. ~ ' Ft.
I
I
WELL: c"'~"~e~ C Upg~ Gravelwidth: ~' Number of lines:
~t. / ~ Ft.
~ion (Private, A.B.C): ~' Cased To: Total absorption area: P pe material: [
~ / FL F~. ~ ~ ~ SQ. Ft. ~/~ t~ Y
Driller: ~ Date Drilled: Static Water Level: Installer: ~/~¢~ Date installed: ~_
Pump Set at: Ft. ~ C~ing Height A~v~ound:
~ GPM Ft. TANK
SEPARATION DISTANCES ~ptic D Ho,~g ~ S.T.S.P.
To Septic A~o~tion Lift Holding Public/Private Man, lecturer: ~ Capac[W in gallons:
From Tank Field Station Tank Sewer Lin~ ~,~, ~ / ~
Material: i Number of Compa~ments:
Su,ace ~ ......
w~.~ ~ ~--- LIFT STATION
Lot ~' i~' I ~ ' Size in gall°ns: I Manufacturer:~
Line
Foundation ~/ ]~f ~/ "Pump on" level at:~~' level at:'
~- i
CuAain Pump~odel ~ Electrical inspections pedormed by:
Drain ~ ..... -~ '~
Remarks: ~~r ~ ~ ~'~ BENCH MARK
Location and Description:
Elevation:
ENGIN~Ah:S SEAL
Inspections pedormed by: ~ ~ ~ ~' Dates: let ~-Z~ ~? ,,~/49'"~,- ~
Depadment of Health a~d Human Sewices approval 't~'~.~% ~"~'c.~
Reviewed and approved by: Date:/~ -~-~ ~
72-013 (Rev. 9/91} MOA 25
,I
Permit No.
$W980382 Page 2 of 2
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 Anchorage, Alaska 99519-665~ Telephone: 543-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description: Eklutna West Lot 15
PID No.: 05106242
SWING TIES
A-C =17.3'
B-C =12.1'
A-D =22.3'
B-D =44.3'
S89'26'49"E
178,40
PIT
ABANDONED
o
TANK
ABANDONED
S89°26'49"E
Approximete
Keybox
Location
255.28
ELEVATIONS
(NOT TO SCALE)
NE LOT COR REBAR
ASSUMED ELEV = 100.00
1000 GAL
SEPTIC
TH1
o~
o ~
1¸5'
ALL SEPTICS +50' [] - TEST HOLE
ALL WELLS +200' ° - MONITOR TUBE
o - SEWER CLEANOUT
+ - WELL
LEACHFIELD
EASEMENT
SCALE 1"-40'
10/5/98
ORIGINAL
GROUND
LEVEL AT:
N89.6
MUNICIPALITY OF ANCHORAGE
Department of Health and Human Services
On-Site Services Program
825 L Street, Room 502
P.O. Box 196650, Anchorage, AK 99519-6650
(907) 343-4744
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
Upgrade
Date Issued: Sep 24, 1998
Expiration Date: Sep 24, 1999
Permit Number: SW980382
Legal Description: EKLUTNA WEST LT 15
Design Engineer: 0024 Eagle River Engineering Services
Owner Name: Norma Louise Sharon
Owner Address: 204 Stan Key Road
Castle Rock, WA 98611-
Parcel ID: 051-062-42
Site Address: 021431 SETTLERS DR
Lot Size: 27841 SQ. FT.
Total Bedrooms: 3 Permit Bedrooms: 3
This permit is for the construction of:
[] Disposal Field [] SepticTank [] Holding Tank [] Privy
[] Private Well [] Water Storage
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
(907) 343-4744 ( 24 hours). ( Not required for a Water Supply Permit only ).
4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather
must be either: A. Open and closed on the same day.
B. Covered, sealed, and heated to prevent freezing.
Received B~ ~ ~ Issued By: :?¢~"/-~-"/~ ~
Date:
Date:
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
September 21, 1998
Jim Cross, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re:
Eklutna West Lot 15
Narrative & Permit Application
Dear Mr. Cross:
We are applying for an upgrade permit for a dwelling where the old undocumented leachpit has
collapsed and has to be replaced as soon as possible. We are applying in advance of the 7 day
monitoring period with the intent of the permit being issued as soon as the ground water table is
confirmed. The test hole is 18' deep with no water at this time and the system is designed at a
total depth of 8'. The proposed septic upgrade will have very limited impact on adjacent
properties for the following reasons:
1. The surrounding lots are large, allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all +30' distance.
3. Drainage will not be affected and is not a major consideration in our design,
4. The entire surrounding area utilizes a community waster system which results in
sufficient reserve area for all lots, soil is excellent.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
\ 1998\98-068-NAR
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED: '~-- /oc~-- ~'~
LEGAL DESCRIPTION: ~'"k//~7-~/~: J4,~-,57'- /_.~,-/- /..C-- Township, Range, Section:
SLOPE
SITE PLAN
1
2
3
4 ;,,'r ~,-~
5
6
7
8
9
10 - WAS GROUND WATER
ENCOUNTERED?
11
IF YES, AT WHAT
1 2 DEPTH?
kth to Waler Alter
13 - Monitoring? /~
gate:
,tV'o
S
E
14-
15
16
17
18
19
20
Gross Net Depth to Net
Reading Date Time Time Water
I ~/- ~/-,/~ I~-.'~? ~I ~'I~
t Io,.,..,
~ i I~.'o/ ~ 7 ~l/~
PERCOLATION RATE __
TEST RUN BETWEEN __
~o 5'"' (m~nutes,'inch) PERC HOLE DIAMETER
Z2/ FT AND ~- FT
COMMENTS
PERFORMED BY: -"~,'~ Z:~ J'" I .~_~---~ ~z~'-~--~'~ CERTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~;7~ ~ ,~---~.-~-,oc,
72-008 (Rev. 4/85)
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street. Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED:
LEGAL DESCRIPTION: ~C"/</~, 7-~.~ /,~-~7" Z~?- /~'- ToWnship. Range. Section:
1
2
3
4
5
6
7
8
9
10
'11
12
13
14
15
16
17
18
19
2O
COMMENTS
T
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED? ,~/'(3
S
IF YES. AT WHAT ~.,'~A (~
DEPTH?. p
E
Depth to Water After
Monitoring? . Dote:.
Gross Net Depth to Net
Reading Date Time Time Water Drop ~'~.~
PERCOLATION RATE ~° '?' (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN Z/' FTAND -~- FT
PERFORMED BY; ~'"~' ~ -'f'' I -~'~"~ ' CERTIFY THAT THIS TEST WAS PEI~FORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE; ~-
Eagle River Engineering Services
Louis Butera, P.E.
P.O. Box 773294 (907) 694-5195 tel
Eagle River, AK 99577-3294 (907) 694-3297 fax
LEGAL:
A.
1.
2.
3.
SPECIFICATIONS FOR ON-SITE SEPTIC SYSTEM
Eklutna West Lot 15
9/21/98
GENERAL
The septic plan is for a single family residence only.
The drawing and or site plan shall be a part of this specification.
All materials and workmanship shall meet the Anchorage Department of Health and State
Department of Environmental Conservation requirements.
4. All soil tests are advisory to the design and are to be verified or modified in the field by the engineer.
5. All excavations and depths are advisory and are to be verified in the field by the contractor to meet
Municipality of Anchorage, Department of Environmental Conservation requirements.
6. It is the responsibility of the owner to obtain all necessary permits or easements and to locate any
adjacent multi-family wells.
7. The excavation is to be exactly in the area shown on the site plan, any deviation requires engineer
approval.
8. It is always recommended that a surveyor locate the nearest lot line position and the location of any
easements.
9. Any remaining open test hole excavations shall be filled.
B. SEPTIC TANK
1. Septic tank shall have a minimum capacity of 1000 gallons and shall be of MOA approved design.
2. Existing septic tank and leachpit to be pumped and filled with native earth, abandoned in place.
C. TRENCH
1. The trench is to be located as shown on the site plan.
2. The bottom of the trench excavation shall be level, plus or minus 1.5".
3. The total depth of the trench excavation is not to exceed 8' at any point.
4. The sewer line is to replace the existing sewer line that leads to the existing pit with plumbing
routed under the trailer to exit the front of the building. The effluent line within the trench shall be
laid level within 0.03'.
5. The trench gravel is to be covered with typar fabric material.
6. Soil or combination of soil and extruded board insulation to a depth of 3' or equivalent is to be placed
over the leachfield.
7. The area over the trench is to be finish graded to prevent ponding of surface water runoff.
8. The septic tank and leachfield must not be closer than 100' to any existing private well, 150' to any
Class "C" well, or 200 feet to any community well.
RECOMMENDED LEACHFIELD DIMENSIONS:
TOTAL DEPTH = 7' min. or 8' max
TRENCH LENGTH = 38'
SOIL RATING = 1.2 GPD/fi2
SEPTIC TANK = 1000 gallons
GRAVEL DEPTH = 4' under pipe, 2" over pipe
TRENCH WIDTH = 5'
BEDROOM CAPACITY = 3 Bdrm
Twenty-four (24) hours notice required for all inspections.
\1998\98-068-spc
EAGLE RIVER
ENGINEERING SERVICES
P.O. Box 773294
Eagle River, Alaska 99577
(907) 694-5195
ERES Project No.: 98-000
Calculated By: LB
Date: 9/22/98
Legal: Elkutna West Lot 15
Single Family 3 Bedroom Dwelling
TEST HOLE
Shallow Trench Subsurface Wastewater Disposal Field
Water use at 150 gallons per bedroom =
Percolation rate =
Wastewater application rate =
Required absorption area =
Trench width (W) =
Grovel depth (D) =
450 gallons
1.5 minutes per inch
1.2 gallons per day per square foot
375 square feet
5 feet
4 feet
Required length = Shallow trench factor * Required absorption area / W
Shallow trench factor = (W + 2) / (W + 1 +2 D)
Shallow trench factor = 0.50
Total Excavation Depth = 7.0 feet
Required length = 38 feet
EKLUTNA.xls 8:38 AM9/22/98
SINGLE FAMILY ON-SITE WORKSHEET
ERES PROJECT NUMBER: 98-000
LEGAL DESCRIPTION: Elkutna West Lot 15
NUMBER OF BEDROOMS: 3
WATER USE PER BEDROOM: 150
PERCOLATION RATE: 1.5
DEPTH TO GROUNDWATER: 18
DEPTH TO IMPERMEABLE LAYER: 18
ANTICIPATED DEPTH OF COVER: 3
MOUND OR BED SYSTEM
CALCULATED BY: LB
WASTEWATER APPLICATION RATE:
ABSORPTION AREA REQUIREMENT:
MINIMUM BED LENGTH
12 FEET WIDE BED
15 FEET WIDE BED
TRENCH SYSTEM
WASTEWATER APPLICATION RATE:
ABSORPTION AREA REQUIREMENT:
SHALLOW TRENCH OPTIONS
5 FEET WIDE TRENCH
GALLONS
MINUTES PER INCH
FEET
FEET USABLE SOIL STRATA
FEET TOTAL USABLE DEPTH:
USABLE SOIL STRATA DEPTH:
0.8 GAL/SQ.FT
563 SQ.FT
12
9
47 FEET
38 FEET
1.2
375
GAL/SQ.FT
SQ.FT
DEEP TRENCH OPTIONS
3 FEET WIDE TRENCH
EFFECTIVE REQUIRED TRENCH EFFECTIVE REQUIRED TRENCH
DEPTH (FT) LENGTH (FT) DEPTH (FT) LENGTH (FT)
1 66 4 47
2 53 4.5 42
2.5 48 5 38
3 44 5.5 34
3.5 40 6 31
4 38 7 27
8 23
9 21
10 NA
DESIGN SPECIFICS
FIELD SYSTEM: S
GRAVEL DEPTH: 4
TRENCH OR BED WIDTH: 5
LENGTH:
TOTAL
EXCAVATION
DEPTH: 7.0
(B=BED, S=SHALLOWTRENCH & D=DEEP TRENCH)
FEET
FEET
FEET
FEET
EKLUTNA.xls 8:38 AM9/22/98
,J
S89'26'49"E
178.40
' O
.,,4.% ~qS/ ABANDON EXISTING oTANK !~--n ~ % ] %
/~-~ . ' S89'26'49"E ~ 5'X58' TRENCH
kEYBOX 235.28
ALL SE?TICS +30'
LOCATION ALL WELLS +200'
[] - TEST HOLE
ALL SURROUNDING LOTS · - MONITOR TUBE
ON COMMUNITY WATER o - SEWER CLEANOUT
'4,- - WELL
EASEMENT
NO SURFACE WATER PROPOSED LEAOHFIELB
NO KNOWN CURTAIN DRAINS I...i.- EXISTING LEACHFIELO
S E PTI C S IT E P LA N
LEGAL: EKLUTNA WEST LOT 15 ~.
CONTRACTOR: N A ~ ~ ,~-~ --~'~ · ..
A EAGLE RIVER ENGINEERING SERVICES ,~.g .,,GU,SA. BUT~RA,*
EAGLE RIVER, AK. 99577 "0;~"¢ ' ....
(907) 694-5195 FAX.. (907) 694-3297
Municipality of Anchorage
Development Services Department
Buitding Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.a k.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 05'1- 0~2- q-2
1.
GENERAL INFORMATION
Complete legal description ~gk ~ a ~'na [V'~ 5 ~ . ]- 0 ~
Location (site address or directions) .~1'~'31 .~e~ef'5 Dr,,. ~d~ial~
Current Property owner(s) ~e~ ~ IH~en~ T ma. ~ Day phone
Mailing address ~0. ~0A 102 17~/ ~,r4~e ~ ~K qq~lO
Lending agen~ ~ I/x F~ ,, ~ ~-~r~r~ Day phone
Mailing address ~t~ ~ ~¢Z.~.~
Real EstateAgent V;~a Xe~( Esf,~e Dayphone
Mailing Address ~A~I ~ ~free f
Unless ethe~ise requested, H~ will be held by DSD for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class /4 Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single family on-site wastewater disposal and/or water
supply system. DSD also issues H4As upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days o!d. (Certificates may be reissued for a period of up to one year with
valid water samples.) Certificates are valid for one year for properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional
engineer's work.
4. 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,
based on procedures outlined in the Health Authority Approval Guidelines for this appIication, shows that the
on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of sb'ucture indicated here{n. 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(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Address n0, E,~,~
Engineer's Printed Name
DSD SIGNATURE
p'"' Approved for
Disapproved.
Conditional approval for
Phone
Date
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Adviso~
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
(Rev.
Original Certificate Date:
M-nicipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
w~vw.ci.anch(xage.ak.u s
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
AD
Legal Description: E~: ]~! ~'n a
ff A. B, or C pr~e ~SID
OM WELl. LOG
Date of test
Static water level
Wall pr~uction ~ g.p.m.
WATER S~PLE RESULTS:
~:,te~f~ample~ Coll~ by~~
Percel ID:0S/-
Well Log (Y/N)
Wires properly protecled (Y/N)
Casing height (above ground)
AT INSPECTION
in.
ft.
g.p.m.
Other bacteria
colonies/100 mi.
B. SEPTIC/HOLDtNG TANK DATA
Tank Type/Material 5 t~ I
Tanksize /000 gal. Number of Compertments
Foundation cteanout (Y/N) Y~5 Depression over tank (Y/N)
Date of' pumping ~:~ -' ! - ¢~
Date installed I/2
Cleanouts (Y/N) Y~.5
High water alarm (Y/N)
Pumper ~ ~,~ ~,~ ,:A
C. ABSORPTION FIELD DATA
Date installed ~/~ ~/~ ~ Soil rating (g.p.d./~ or ft=/bdrm) ]. ~
Length ..I~'/ ft. Width .5-/ fl.
Total depth ~' ' ft. Eft. absorption area $ 0 ¥ ft2 Monitoring tube
Date of adequacy teat ~'/.21/o,?, Results (Pass/Fail)
Fluid depth in absorption field before test I,C, .,c in. Wale~ added~[~'0 gal.
Elapsed Time:/_//.._min. Final fluid depth ISrff in. Absorption rate >=
Any rejuvenation treatment (past 12 mo.) (YIN & type)
System type 5J~.llO~ 7ra.cJ
Gravel below pipe ,~- ' ft.
__ Depression over field )V,)
For .~ bedrooms
New depth 1(.5- in.
/.-/5'0 g.p.d.
If yes, give date
D. LIFT STATION
Da"~t~stalled
"Pump ~ in.
Datum
E. SEPARATION DISTANCES ~o~wm~,/;31.~, h/~'e~'
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absorption field on lot /~//~q
Public sewer main ~
Sewer/septic service line
Size in gallons
'Pump off' level at
Cycles tested
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
in.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ,~'
Water main
Wells on adjacent lois
Property line + I._._~".>
Water service line
Absorption field '~' I 0 /
Surface water +100 /
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 'J'
Water Service line
Curtain drain
Building foundation -~ 10'
Surface water '~ 160~
I
Wells on adjacent lots ')' dQ
Water main 1' ~,$"
Driveway, parking/vehicle storage
F. COMMENTS
ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name ~/0/4~$
Date _~/,~ I/~) 2
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
75, o,e
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)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Agent ~C~.~
Address
Unless otherwise requested, HAA will be held for pickup.
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
'NOTE:
4. TYPE OF WASTEWATER DISPOSAL:
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.
NOTE:
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 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 Munici 3al and State codes,
ordinances, and regulations in effect on the date of this inspection.
- Phone
Name of Firm ~-,a~]e ~{~.vez' ~ngJzzeez~
Address P.O. ~,~ ~_~_a29~:' ~., .....
Engineer's signature ':"~:7,~; .-:~:-~.7-" Date
DHHS SIGNATURE
~' Approved for .~
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 CerUficates 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 enginee¢s work.
72-O25(Rev. 1/91) Back MOA~21
Well-type ~',~ s~ ,,~ IfA, B, crC, attachADEC letter:~ADEC Water system number:-~9;~::~v~'~'~,:'.~ · :--
'Log present(Y/N) '/~/~ · Date completed, · . ~' - - -
Total depth - CaSed'to :'. , · . Casinghelght (above,ground) · · ~'. ' ::
· / '~' ~ ~ Wires properly prOtected (Y/N) *'
Sanitary seal (Y/N) -
. ' · . 'FROMWELELOG ..... · . 'AT .INSPECTION - · - ' . ; '
Date of~est.-? -... , ; : - '-' ~ ': · ~ . -~
Static wate~ level~.~ ..... · ,, .~- ,. _ :-. - :
Well production:. - ; . ' g,p.m.- * - ' '' - , . ' g:P'~1:~ r~ ~:~.i-
wATER 8AMP~E-~IE~uLTB: ., .:.. -
Date of sample: , Collected y. ' , ,
Date i
, present (Y/N) ~' - DepressiOn over field (Y/N)
Fluid depth/n absorphonfield before test (in.); -. . Immediately after,..-~ gal. water added· (in.).- , , :~_-. - .
· · ~ ~ · - . _ ' . ~ ~-~
F u d de th (ins) M nutes later:. :Absorption rote = . ' - ,,, , . ,g~p.d.-
72;"026:(Rev. 3/96)* · · '- : ,-'-- -' '-~'-~' :'~' -': :' ';-"'~' '~-: ~" '""
· " " ' ' · .. ' . - : - ·" - ". .
LIFT STATIO~
Date Installed '~
Manhole/Access (Y/N)
Size In gallons
"Pump on" level at*
*Datum
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septio/holdlng tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation ~ / Property line /-'//~'
Water main/service line 7~/a / Surface water/drainage ~'/a~ '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Absorption field
Wells on adjacent lots
Property line '/5' /
Surface water "~/'~ /
Curtain drain /~/~
Building foundation Y,f' · Water main/service line
Driveway, parking/vehicle storage area /5' /
· We Is on adjacent lots ~- D.~ ,, ·
R ENGINEER'S CERTIFICATION
in conformance w/~ MOA HAA guidelines In effect on this date.
Signa~m ~ . ~
EnglneereName ~,~-~ , ~~ ~
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
~3-~7-L::~2 ~:221:~ FROrl E.R. EnBtneer~n~ ~cs.
249'?84? p.l~t
ASBUILT-NO CORNER~; SET THI~ DATE. ..
I HEREBY CERTIFY .THA~ I HAVE S~D THE ~ :" .'"
FOLLOWING DESCRIBED~ PROPER~ ' '." //'~' ' ' / ·
ARY
TOl'(qL P.~I