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HomeMy WebLinkAboutWAGERS LT 24DWager' Lot 24.D #015-141-56 mspecuon report i-i-:/.aoc Municipality of Anchorage Community Development Department Page 1 of 2 On-Site Water and Wastewater Program 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 - http://www.muni.org/onsite • (907) 343-7904 ON-SITE WASTEWATER INSPECTION REPORT Permit Number: OSP181357 PID Number: 015-141-56 ❑ New El Upgrade Name: Chad & Mary Irvine ABSORPTION FIELD ❑ Deep Trench 0 Shallow Trench ❑ Bed ❑ Mound Address 11150 Our Road ❑ Other Phone Number of Bedrooms Soil Rating ITotal depth from original grade 4 0.45GPD/SF 11.0 Ft. LEGAL DESCRIPTION Depth to pipe invert from original grade 7 Ft. Gravel depth beneath pipe 4.0 Ft. Subdivision Wagers Block Lot 24D Fill added above original grade 0.0 Ft. Gravel length 2@80 Ft. Township Range Section Gravel width 5.0 Ft. Beds: Number of Lines n/a Distance between lines n/aFt. SEPARATION DISTANCES To From Septic Tank Absorption Field Lift Station Holding. Tank Sewer Line Total absorption area 1600 Ftz Number of trenches 2 Dist. between trenches 8'+ Ft. Well 100'+ 25'+ TANK ❑ Septic ❑ S.T.E.P. ❑ Holding ❑ Other Manufacturer Ca Gal. Surface Water 100'+ Material Number of compartments Lot Line 10'+ NA Foundation 10'+ LIFT STATION Manufacturer Capacity Curtain Drain 50'+ Gal. Remarks Pump on level at Pump off leve in. High water alarm at in. Pump make and odel Electrical Inspections performed by Installer PIPE MATERIAL House to tank Tank to 3034 drainfield GLW Enterprises Drainfield 3034 Co/MT 3034 Inspector Pannone Engineering Services BENCH MARK (Assumed elevation) 100 ft Inspection5, dates: 10/15/18 3rd 10/16/18 2r' 10/16/18 4'h 5/31/2019 Location and description NW Bottom House Trim COMMUNITY DEVELOPMENT DEPARTMENT APPROVAL Engineer's Stamp Conditional Approval: Date OF TH •. Steven f�. f�annorie� CE 8149 law • .. aLAw Approved Date a 1�� mspecuon report i-i-:/.aoc DESIGN PARAMETERS UPGRADE SEPTIC SYSTEM NO. BEDROOM: 4(600 gpd) TANK SIZE: 1250g PERC RATE: 6-15 MPI SOIL RATING: 0.45 GPD/SF j AREA RQD: 1,333.33 SF SYS. TYPE: WIDE TRENCH 4.0' ED RF: 0.50 /ADJ AREA: 666.66 SF MIN LENGTH: 134 LF USED: A•00 (2EA) 80LFx5'Wx4.0' E.D., 11.0' TD,—_,.' TOTAL AREA: 1600 SF SHEDS GARAGE B TH-1 1993 � wE (E) 0 Z � 4 _ N )IV -- _ _ _— WELL (E) DRIVEWAY„ � BARN / 48R H SE p0, LLJ \ / TH-1 D rn I ! v O 24D i f , _ I DRY WELL FROM ROOF DRAIN E I INSTALLED DRAIN FIELD TH-1 1991 X —(2EA) BOLE x 5'W x 4.0'ED x 11.0'TD INSTALLED CO AND MT AT EACH END w_- _ w 10' UTILITY EASEMENT --__-__M _ �M E. 1 12TH AVENUE Z Oj A B DCO 31.2 55.5 DV 33.0 55.8 C 1 54.4 67.2 mi 55.9 68.0 C2 83.5 56.3 M2 83.7 56.7 C3 68.1 74.3 M3 70.2 72.4 C4 104.9 78.3 M4 102.9 76.0 O 24D i f , _ I DRY WELL FROM ROOF DRAIN E I INSTALLED DRAIN FIELD TH-1 1991 X —(2EA) BOLE x 5'W x 4.0'ED x 11.0'TD INSTALLED CO AND MT AT EACH END w_- _ w 10' UTILITY EASEMENT --__-__M _ �M E. 1 12TH AVENUE Z Oj j j q0 O O j nz z z wo w ry o tiU U U 0 pV >� C O.C./F.0. �� k lOD.OLi - —a 0 1250 g SEPTIC ` TANK CONNECTED To END OF EACH DRAIN PROFILE FIELD SCALE: NTS O Q O O' O NOTES: ��''�0''® Date RECORD DRAWING PANNONE ENG SVC, LLC �� t\t P.O. BOX 100217 ANCHORAGE, AK 99510 �� OF A�. t?, l� 11/15/19 Scale DRAWN BY: PHONE (907) 272-8218 FAX (907) 272-8211 .49 Mt0¢ 1"=50' ACP ' P.I.D. NO WAGERS, LOT 24D 15-141-56 Steven �R. ('onnome CHAD &MARY IRVINE ®PERMIT NO. S CE 8149c�lie®� OSP181357 11150 OUR ROAD c PLAN ANCHORAGE, A( 99516 4,t1�FFF�SSIONP���-* Sheet 2 OF 2 IJ 0 Q o C o soc 0 -x 4Jo- puolssada.� , 6l0Z/tZ/l l Aly L609 -S1 °® .a, !PIDISoO y /aalar d AN lo ®•...•.....{ ,... .• , 00 o b ; RI V AV �b JO • •i t «t t r t C i t t t t• t f ta• f t ,t. r ajvzsm LO -8L 'ON 8Or I "8"3 6LOZ/9L/* 9£9ZMs 3. 1 MID irgi,g-e-vZ 3NOHd L0966 e 'unst. tf'3 !i!71 i 311 'DNIAMuns .y i i ff T •S3dldaNVIS a"30 GTICIV 6LOZ/LZ/L L a3SIA3�4 nN3AV H1Z L l 1SV3 I ,96"66Z 1.09<L9068 S AS3 3sn oriand stria" oz avisq J,tn n .OL -- — — — — — — ———— ————--—— ————— — — — --_ _.-------------------, I �x Hr' x _ x -T x--- x---- x ---- x---- x x --- x---- x-7 !xf ! I (XdN) 30N33 x x x 1 W31SAS 011d3S � f x J I 1 s �cz N31S1,S 011d3S 40rn �O 40 . . , o2,ti� 1133M Q3NS 1:'o-:7 —`T- x—x—x--�x.-R.X._-_-__,_ �MO12>� I q �e t,� 3AIaC] 7"V 4 3AIW] 'O•d N n �i�./t� 3. V8V9 SNI-LSIX3 N W a o tr£ 03hiS 03H5 I I �.1 N .S'LO L j 1 1 L•ZO L ,6b bb6 3iMi,LaObO S *A'S O*Z`Lt, LZZ--bt *ON IVId 10/I 6/1g 6°11 oc,rnlirr MUNICIPALITY OF ANCHORAGE li°"� On-Site Water&Wastewater Pro ram ,,,,,,y).,)! PO Box 196650 4700 Elmore Road �� i Anchorage,Alaska 99519-6650 Phone:(907)343-7904 Fax:(907)343-7997 ,:: http://www.muni.org/onsite • ori; , 9MCHOP PG' On-Site Wastewater Disposal System Permit Permit Number: OSP181357 Effective Date: 10/9/2018 Work Type: Septic Upgrade Expiration Date: 10/9/2019 Tax Code Number: 01514156000 Site Legal Address: WAGERS LT 24D G:2636 Site Mailing Address: 11150 OUR RD, Anchorage Owner: IRVINE CHAD & MARY Lot Size in Sq Ft: 47242 Design Engineer: PANNONE ENGINEERING SERVICES Total Bedrooms: 4 This permit is for the construction of: 0 Disposal Field 0 Septic Tank 0 Holding Tank 0 Privy 0 Private Well 0 Water Storage All construction shall 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 wastewater code requires inspections during the installation. The engineer shall notify the Development Services Department per AMC 15.65. Provide notification by calling (907)343-7904 (24/7). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather shall be either: a. Opened and Closed on the same day, or b. Covered, sealed, and heated to prevent freezing 111 N Received : • ��� Date: ` °« Issued By: /) /0,.... LI, _ Date: /D©O ePutJS -RusI4 MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Division '- ! Fax: 907-343-7997 On-Site Water & Wastewater Program TR j s ON-SITE SEWEFVWELL PERMIT APPLICATION Parcel I.D. 015-141-56 Property owner(s) Chad & Mary Irvine Day phone Mailing address 11150 Our Road, Anchorage, AK 99516 Site address 11150 Our Road Legal description (Sub'd., Block & Lot) Wagers, Lot 24D Legal description (Township, Range & Section) Lot Size 47,242 Sq. Ft. Number of Bedrooms 4 APPLICATION IS FOR: APPLICATION IS AN: TYPE OF DWELLING: (®all that apply) Absorption Field E Initial ❑ Single Family (SF) ❑X (w/wo ADU) Septic Tank ❑X Upgrade Duplex (D) ❑ Holding Tank ❑ Renewal ❑ Multiple Dwellings [1 Privy ❑ (SF and/or D) Private Well ❑ Water Storage ❑ THIS APPLICATION INCLUDES A VARIANCE /WAIVER REQUEST FOR: Distance: I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit/Rush Fees: 7 /d/•4/0 Waiver Fees: Date of Payment: PiY1/7 Date of Payment: Receipt Number: O5-331167 Receipt Number: Permit No. 451,1F 1357 Waiver No. Permit App_.:-:• :L.,:c Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181357, Deb Wockenfuss, 10/09/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181357, Deb Wockenfuss, 10/09/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181357, Deb Wockenfuss, 10/09/18 Municipality of Anchorage On-site Water and Wastewater REVIEWED FOR CODE COMPLIANCE OSP181357, Deb Wockenfuss, 10/09/18 Municipality of Anchorage  Development Services Department ( · Building Safety Division On-Site Water & Wastewater Program, 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.cLanchorage.ak.us (907) 343-7904 Page I of On-Site Wastewater Disposal System and/or Well Inspection Report Permit Numbe~ SW090228 PID Number:, 015--141--56 Name:MICHAEL MARTIN Wastewater System: [] New ~ Upgrade Address: 11150 OUR ROAD * ANCHORAGE. AK * 99516 ABSORPTION FIELD NO. of Bedrooms: Ph°ne:(907) 748--6900 4 13 Deep Trench [3 Shoflow Trench · Bed [3 Mound Other LEGAL DESCRIPTION ~' "~: I'~' ~'~ ';~'~-~ - 24D WAGERS · ~ ~ _ - - ,/~? WELL: [] Hew I-I Upgrade ~ r, JOHNS EXCAVATION 11/6/2009 SEPARATION DISTANCES = sop~= n Holding [3 S.T.£.P. n other* Tank [~eld Station Tank S..~ U~. ANCHORAGE TANK 1250 We, lO0'+ - - - 25'+ STEEL 2 s~o=, wot,,1oo'+ .... LIFT STATION Cu~ain Drain NONE KNOW~ I ~ks: D~ ~ ~ ~ BENCH MARK ~ ~D~ ~ ~t~ TOP OF M~AL FOUNDATION F~HING e NW CORNER ~ ~ 100.00 Inspections performed by: GEG. Ltd. Dates: 2ndlSt 11/6/2009~..~..~.~%%~ ,rd ~'" ~.... -. [J .............. ,.:....; Conditional approvah Date: ( ~, :.' R~viewed and approved by: ~ / ~ ~ Date: ~-/~-/o '~', ,o,ess,o~ · AS BUILT DRAWING p[RU~T NUM.IFR: 015--141 --56 SW090228 - x / ~~....'~'L ~;.'?: ;~:'..-~;:"~"'.'7':~ ~">:,.'.~.~.' ~~. ~... .~ l ..... ..., ....... :,.... . ~~~" ;' ':'" . ~~' '"; ;': ......~'.... FCO 17.99 18.26 ST1 18.96 27.0 ST2 22.36 54.98 s DBL1 24.6 38.09 _ DB~ 24.91 38.53 ~L~CjlKLT DRAWING OF NEW SEPTIC TANK 1~/10/2009 P~.~auM..: AS BUILT DRAWING ..~o~,o .uM.~.: SW090228 - 015-141-56 ST1 TOP OF TANK ,-~ r:~ AT INLET = 95.45 ~-~ f NEW INVERT OF BUNG AT INLET = 94.80 1250 GALLON SEPTIC TANK FINAL GRADE = 100.23-100.34 ST2 TTOP OF K OUTLET TA~I¢. 5.45 '~INVERT OF BUNG AT OUTLET = 94.67 GARNESS ENGINE,~RING GRO~ -, CONSULTANTS & GENERAL CONTRACTORS ........ ~/'~'~' '"'"'~"~.'~'°'""°'"~'""~'""~'~'""'""~"'~'-="'"'~-~'"'""'-""'~.l~ ~'11 I/If I PREPPED FOR: PHONE NUMBS: P~E NUMB~~~'"/"":'""~ ~ ..~.,~o.: I"~w" WAGERS S/D; LOT 24D . ~TE: ~ ro f~'s~o~ ~?~:AS-BUILT DRAWING OF NEW SEPTIC TANK MUNICIPALITY OF ANCHORAGE Development Services Department On-Site Water & Wastewater Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Nov 04, 2009 Expiration Date: Nov 04, 2010 Permit Number: SW090228 Legal Description: WAGERS LT 24D Design Engineer: 0855 GARNESS ENGINEERING GROUI: Owner Name: MICHAEL MARTIN Owner Address: 11150 OUR ROAD ANCHORAGE, AK 99516-0000 Parcel ID: 015-141-56 Site Address: Lot Size: 0 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: E~ Disposal Field [] SepticTank Holding Tank E~ 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 DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 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. Date: ,:,ate: Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak, us (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. Property owner(s) WAGERS S/D; LOT 24D N/A Number of Bedrooms 015-141-56 MICHAEL MARTIN Mailing address 11150 OUR RD * ANCHORAGE, AK * 99516 Site address 11150 OUR RD * ANCHORAGE, AK Legal description (Sub'd, Block & Lot ) Legal description (Township, Section & Range) Lot Size Sq. Ft. Day phone Zip Code 748-6900 99516 THIS APPLICATION IS FOR ( [~all that apply): THIS APPLICATION IS AN: Absorption Field [] Initial Septic Tank [] Upgrade Holding Tank [] Renewal Privy [] Private Well [] Water Storage [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal codes. GARNESS ENGINEERING GROUP, Ltd. Permit/Rush Fees: Date of Payment: Receipt Number: (Rev. 11/05) Waiver Fees: Date of Payment: Receipt Number: GARNESS ENGINEERING GROUP, Ltd. CONSULTANTS & GENERAL CONTRACTORS November 4, 2009 Municipality of Anchorage Development Service Department On-Site Water & Wastewater Program 4700 Elmore Rd. P.O. Box 196650, Anchorage, Ak 99519-6650 (907) 343-7904 Reft Proposed Septic Tank Upgrade for Wagers Subdivision, Lot 24D, To whom it may concern: The existing 4 bedroom house is served by a private well and septic system. The 1250 gallon septic tank is collapsing and needs to be upgraded. We are proposing to install a new 1250 gallon septic tank as can be seen on the attached drawing. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assistance. SM~erely, '~ ,[effi'ey A. G~tness; P.E., M.S. President NOTE: Attached is a site plan drawing, a design drawing, which are all part of the design package for this septic system. (Contact G.E.G. Ltd. for 7page construction specification letter.) 3701 E. Tudor Road, Suite 101 * Anchorage, AK 99507-1259 Ph: (907) 337-6179 * Fax: (907) 338-3246 * Website: www.garnessengineering.com I I I WAGERS S/D; LOT 24B I I I I I I L ] I I × ~ I / I / I I / \ I I WAGERS S/D;/ L01 24C ,,..7, I X / / IN // iN I I / SCALE: I k ~" lOO' I ~ /I/ = % E. 112TH AVENUE lOO' WELL ~DlU~i // _ A _%__ c I // / X ~PT~C 0 / o WELL RADIU~ o ~100' WELL ~DIUg I / / ~ /GREEN~ND S/D; / GREEN~ND S/D; / I ~ / ~ / BLOCK 1, LOT ~/ BLOCK 1, LOT 1 / ~ % / / /// --% [ ~ ~100' WELLi XGREEN~ND S/D; x / / / % ~ I BLOCK 1, LOT 4 ~ / GAYNESS ENGINEERING GROUP, Ltd. CONSULTANTS&GENERAL CONTRACTORS MICHAEL .ARTINI eo,- s-egoo I1 OF 2 ~~fr~ LEGAL DESCRIPTION: BRAWN BY: ~%- "U CE77~5' ." ~~ - ~ WAGERS S/D; LOT 24D A.J.O. DESIGN FOR NEW TANK 11/4/2009 (Rev. O'd05) GEG, Ltd. HAS A 7 PAGE SPECIFICATION LETTER THAT PERTAINS TO THIS DESIGN. TO OBTAIN A COPY OF THE LETTER CONTACT GEG. BY PROCEEDING FORWARD WITH THIS INSTALLATION, THE ENGINEER, WELL DRILLER, CONTRACTOR AND PROPERLY OWNER AGREE THAT THEY HAVE READ THESE SPECIFICATIONS AND AGREE TO ACCEPT THE TERMS AND CONDITIONS OUTLINED. WAGERS S/D; LOT 24C ITANK UPGRADE ONLY GARAGE : : "~ ~__: EXISTING 1250 GALLON SEPTIC- TANK IS RUSTED AND BEGINNING TO COLLAPSE. TANK IS TO BE REMOVED AND REPLACED WITH NEW 1250 GALLON SEPTIC TANK. INSTALL FLOW SPLITTER TO BE LEVEL. INSTALL DOUBLE CLEANOUTS \ / EXISTING HOUSE SCALE: I I 1" = ,30' ...... ,o,: ~PHONE NUMBER: [ PAGE NUMBER' ~.~..2,./,/~...~ .... ~ J ~jre Gar ess A ~ DRAWN BY ~ ~ GE=7~" -' W,OERS S/D; LOT 24D A.J.O. kq~,; I wPE OF WOaX: I OATE: ~k~o f e ~ ~o ~ -/ DESIGN OF SEPTIC TANK UPGRADE [ 11/4/2009 (Rev. 01/05) Municipality of Anchorage Page / of DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~/¢g ~/~- PID Number: Name://,~?//'<.~//¢,4? /~? /~2~Z' ./¢:,. ,¢ Wastewater System: ~New U Upgrade Address: Phone: ~ NO. of Bedrooms; I,~ ~Deep Trench ~ Shallow Trench ~ Bed B Mound ~ Other LEGAL DESCRI PTIO N so, Rating: Total Depth from original grade: Lot: ~ Z/~ Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe Number of lines: Distance between lines: WELL: ~New ~ Upgrade ~raveldepth: ¢' ¢ Ft. 2 /Z' /TFI. Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material: Driller: Date Drilled: Static Water Level: Installer: ~ I I ~ Date installed: Yield: Casing Height Above Ground: SEPARATION DISTANCES ~Septic D Holding U S.T.E.P. TO Septic Absorption LiR Holding Public~ Manufaclurer: Capacityin gallons: From Tank Field Station Tank Sewer Lines ~Z:~ /~ ~ 0 Well (/~' 15~' /~ ~ Q ~/ Material: ~,L ~-~-/_ .... Number of Compartments: Water ~, o ~] s / ~,¢.n ~~ LIFT STATION / / , "Pump on" level at: I "P~p~~ lev~t~ I High water alarm at: Curtain ~- Remarks: BENCH MARK LocaEon and Description: T Assumed /00 Elevation: ~NG~'S S~L Inspections performed by: ~AI, ~c~ DD~-~ Dates: 1st /o/9/ql '-~¢C Department of Health and Human Services approval ~;% .~,.%,~ 72-013 (1/91) MOA25 Permit No. d~//~ ,.~,/,~ Page 2~ of ~ Municipality of Anchorage DEPARTMENT OF HFALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/er Well Inspection Report Legal Description: PID No.: 72-013 A (2/91) MOA 25 Permit No. ~V~/ ~lc2~l~~''~ Page_~ of ~ Municipality of Anchorage 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 Legal Description= [-~¢'FC'dr~Pl '~-~-~1'~i~~ ~.~1,~2~. PlO No., M~R ~6 '9~ 14:00 POL~RCONSULT 00~ PERFORMI-;D FOR: Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Ancl~orage, Alaska 99,502-0o§0 8OILS LOG -- PERCOLATION TEST LEGAL 13ESCRIPTION~ ~e'J¢ "~ ~/~ ~,.,',~,~, Township. Range, Section; 1 2 3 4- 10 11 12 13 14 16 19- SLOPE SITE PLAN WAS GROUND WATER ENCOUNTER ED? 6:.LO ~;'. e," PERCOLATION RATE 7.~'~ {mlnute~/mch) PERC HOLE DIAMETER ~_~ . 'rEST RUN BETWeeN ~ T AND FT PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW910312 DESIGN ENGINEER:POLARCONSULT OWNER NAME:WAGERS MARIAN M OWNER ADDRESS:2642 COTTONWOOD ST. ANCHORAGE, AK 99508 DATE ISSUED:10/01/91 EXPIRATION DATE:10/01/92 PARCEL ID:01514156 LEGAL DESCRIPTION: WAGERS LT 24D SEC 22, T12N, R3W, SM LOT SIZE: 47242 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD / 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 ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (iSAAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: PERFORM ADDITIOAL SOIL TEST AT REPLACEMENT SITE. MAXIMUM DEPTH OF TRENCH MAY NOT EXCEED 6', UNLESS SM LAYER PERCED A~OVAL ~//~A~NTED BY DHHS. DATE: DATE: polarconsult alaska, inc. ENGINEERS · SURVEYORS · ENERGY CONSULTANTS Department of Health and Juman Services 825 L Street Anchorage, Ak. 99501 September ~, 1991 Lot 24D, Wagers Subdivision On-site Septic and Well Permit Mike & Patrice Higgins Dear Sir/Miss: Please find attached an application for an on-site septic system and well. The proposed septic system is a seven foot deep absorption trench. The proposed system and reserve is located on the back half of the lot. The proposed well will be installed on the front half of the lot. This arrangement is consistent with other wells and septic systems on the adjacent lots and will not impact, nor hinder the development of, adjacent lots. Sincerely Yours Michael D. Dahl Staff Engineer MUNICIPALITY OF ANCHORJ~OE ~.NVIP, ONMENTAL SERVICES DIVISION SEP 5 1991 RECEIVED 1503 WEST 33RD AVENUE · SUITE 310 · ANCHORAGE, ALASKA 99503 PHONE (907) 258-2420 · TELEFAX(907) 258-2419 L5-3320 RIO0.O0' BASIS OF ELEVATION 100' 102 10' I I~ TRENCt 74150' 40NITORING :-MENTI RIO0.O0' ]fAELE V. CE-1393 102'- I MANIFOLD ~ROPOSED 14 BR HOUSI FF 97.0' RIO0,O0' PROPOSED WELL OUR ROAD :ROPOSED 1 GAL. SEPTIC TANK FUTURE :ARAGE LEGAL: LOT 24D WAGERS SUBB SCALE: 1" = 4d' [ SEPT 18, 1991 SHEET 1 OF 6 PERFORMED FOR: LEGAL DESCRIPTION= 1 2 3 4 5- 6- 7- 8- 9- 10- 11 13- 14--- 16- 17- 18- 19- 20- Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Township, Range, Section: SLOPE WAS GROUND WATER . t ENCOUNTERED? S IF YES, AT WHAT DEPTH? p Depth to Waler After ~/~{?1 t.fL E OF. % DATE PERFORMED:~[ ~O1~~ SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ tminutes/mchl PERC HOLE DIAMETER TEST RUN BETWEEN ___ FT AND _ ACCORDANCE WITH ALLSTATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) FT CERTIFY THAT THIS TEST WAS PERFORMED IN PERFORMED FOR: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SE"VICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~ ~ ~ ~. Township, Range, Section: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED7 IF YES, AT WHAT DEPTH7 Deplh lo Water AJter r~tonitoring? Date: Reading Date Gross Net Depth ~. Net Time Time Water Drop PERCOLATION RATE ~ tm~nules/mch) PERC HOLE DIAMETER TESTRUNBETWEEN _till'r.~- FTAND COMMENTS PERFORMED BY: ~. file' I t%~cw,~,- ~¢,,~\ ~.~ CERTIFY THAT TRIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST LEGAL DESCRIPTION: ~T ~ ~ ~. Township, Range, Section: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTR? Depth to Waler Alter Monitoring? Dale: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN -- (minutes/tach) PERC HOLE DIAMETER __ FT AND _~3J~_ FT PERFORMEGBY:~' J~'~'(,~(~ I K{I¢~A~ ~D~ CERTIFY THAT THIS TEST WAS PERFORMED IN 72-008 (Rev. 4/85) Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: ~-,~'1 1 2 4 7 ~0 14- 19- 20- COMMENTS DATE PERFORMED: Township, Range, Section: SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? SITE PLAN Depth to Water Aller __ MoflilerinD? Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~_-' l- {minutes/inch) PERC HOLE DIAMETER TES*RUNeETWEEN $~-- ~T^ND_ ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED iN RIO0.O0' R100~ O0~ BASIS OF ELEVATION 100'- I02' APPROX. 16,000 SQ. FT. RESERVE AREA EXISTS. --4 MONITORING TUBE PROPOSED TRE SOLI MANIF( ~ROPOSED BR HOUSI FF 97.0' 74,50' TUBE III :OPOSED SEPTIC TANK FUTURE SARACE 125( GAL. SCALE: RIO0.O0' PROPOSED WELL OUR LEGAL.: LOT 24D SEPT 18, 1991 WAGERS SUBD. SHEET 1 OF 6 BASIS OF RIO0. O0' -~I,,.--~L~,-ll?'"~.Z-------- ELEVATION RIO0.O0' R100.00' ] I 102' 102'~ FARPPROX. 16,000 E SE R VE~.~E A l'P I SQ. FT. 15.00' MONITORIh l~'~ TUBE 74.50' ,~ITORING TI :oTUeE,1 1 -- S~FTI~ IFUTURE I 'ROPOSED ~OARAGE BR HOUS FF 97,0' RIO0.O0' PROPOSED WELL GAL. OUR ROAD SCALE; 1"= 4d' LEGAL: LOT 240 WAGERS SUBD. SEPT 18, 1991 SHEET 1 OF 6 From : ALPIN~ DRILL S07 345 0~0~ Deo. 31. 1991 05:13 PM P01 D~PA~[~TM~NT OF NATU~L DIVXS~0N OF GEOLOGICAL AND G~OP~IY~ICAh WATER WELL RECO~ ~OROUG~ SUBDIVi'~';ON Dg~ound surface BO~HOLE DATA: ~top of casing othe : ......... ~ ~LL DEP~I{; [ DAT~ O~ CO~L~T~ON: Depth o~ hole:~/ Depth STATIC WATER LE~: ft, Date METHOD OF.DRILLING: ~ir rotary ~oabl e tool ~othcr: USE OF WELL: ~'domo~ti¢ ~irrlgation ~monito~ CASING: Bttek~u ft. Diam:_~=n NELL INTAKE: ~ open end ~scmeen~d ~- per~or~tsd ' ~op~n hole Depths of openings~ SC~EN TYP~;: Diam~ .in Set BDt. ween ~ f~ '".. GRAVEL PAC~ TYPE: vo .u, e ............ GROU~ Dat~ Pump InstalleO WATER CI[EMISTRY SAMPLE TAKEN? ~o W~i]. disin£eoted PLEASE MAIL'WItITE COPY OF LOG WITHIN 45 DAYS TO: DGGS PO BOX 77-.2116 EAGLE RIVER, AK. 99577 Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www. ci.anchorage.ak.us (907) 343-7904 . CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A $1-NGLE P'AMILY DWELLING Parcel I.D. 1. GENERAL INFORMATION Complete legal description ~)-.~,S,~ Location (site address or directions) Expiration Date: L Current Property owner(s)",..JE)h r~ Mailing address il. i..~O Lending agency ,~' ..~/ Mailing address Real Estate Agent Mailing Address Day p~one Day phone Day phone Unless otherwise requested, HAA will be held by DSD for pickup. NUMBER OF BEDROOMS: Z/ TYPE OF WATER SUPPLY: · Individual Well [] Individual Water Storage [] Community Class ~ 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 4 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 HAAs 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. (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 enginee(s work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seat affixed hereto and as of the validation date shown below, I verity that my investigation, based on procedures outlined in the Health Authority Approval Guidelines for this application, 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 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Nome of Firm ]~af~e l;~re~. ]~nl~[ueerb~ S~ Pi,U.8 - p.o. Bo~ :Z~, F_.~I~ I~, ~ ~)5~.~ Address Engineer's Printed Name ~ ~.~ .~- ~~ Date DSD SIGNATURE ~ Approved for Disapproved. Conditional approval for bedrooms~ ~,. bedrooms, with the following stipulations: Additional Comments WATER AND WASTEWAI bK PROGRAM Attachments: HAA Checklist Septic System Advisory Well Flow AdVisory Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date: (Rev, 01]02) Development Services Department Building Safety'Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.ancho[age.ak.us (907) 343-7904 HEALTH.AUTHORITY APPROVAL CHECKEIST -:A. WELL DATA Well type Date completed ,/o-/~, Total depth /4/ ft. . : ParceHD: ~:3/5- -/',' / Cased to ~'/J'- ff. f¢¢f': - FROM'WELL LOG ?~-/~,_ ?/ ft. g.p.m. AT INSPECTION gr0undl ~&) in. g.p,m. Arsenic: //,4 rog.II. B. SEPTIC/HOLDING TANK DATA Tank Type/Material S'/~ Tank size ! -~ ~'~ gal. Foundation cleanout (Y/N) Date of pumping c~-c~' Nitrate ng./I. Date of sample: 5--~/-,¢.~ Number of Compartmer~ts __ Date installed Cleanouts (Y/N) Pure ~ Eft. absorption area /zFC'¢ft~ Monitoring Date of adequacy test ¢ - 3. i- ¢,.? Results (Pass/Fail) Fluid depth in absorption' field before test O~/.a~atl. Water added ~'-?~ gal. ! /~', 5"/' Elapsed Time: ~?~ min. Final fluid depth _TL_ in. Absorption rate >= Any reJuvenation treatment (past 12 mo.) (Y/N & type) colonies/100 mi. For z./' bedrooms New d n. ¢' ¢'J"'~ g.p.d. /" /,,4 If yes, gi~e date D. LIFT STATION Date installed ,.,.-~ize in gallons "Pump off" level at Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: in, Septic tank/lift station on lot Absorption field on lot Public sewer main '~/~ Sewer/septic service line 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 SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundation /~ ~ Water main ~ ,n//4 ~ Wells on adjacent lots. ¢-/~¢* ~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property, line 7'/~" Water service line Absorption field.. /¢" Surface water ¢-/¢~" Building foundation Water main N ~ Surface water -/-/wa / Driveway, parking/vehicle storage Wells on adjacent lots ~-,'¢'~ / Property line /-/,¢ Water Service line Curtain drai~ F. COMMENTS in, G. ENGINEER'S CERTIFICATION I certify that I h.a. ve.determinedthrough field inspections and ............ · ;ords that the above systems are in · ' 4 HAA guidelines in effect on this date. Engineer's Printed Name ,;¢-., ~ ~, ~ /~/~r ~ Date ~'- 5' -~ ~ Date of Receipt Number (Rev. 12/01) Waiver Fee $ Date of Payment Receipt Number I///~I0' ~ EASEMENT '~ N 89~r57'50'W ~98.92' 10.2' X 7.,9' Ct.E~OUTS 8.0' X 8.0' WOODEN LOT 24D 47,,23~ $ 8~e~7'~O"E L~99.90' PUBLIC USE EASEMENT- R=20' EAST 1 12TH AVENUE (aeavEL) PLOT PLAN ASBUILT ~ SCALE I" · 50' GRID 26~6 Project No. 03-170 L~n~ ~ Aeen~,;nf-~e tn,- 11500 DawI Avenue, ~chorage, Naska 99515 KegisTerea Lana ~u~eyo~ (907) 522-4625 Fax ~ ~, w~ SUB~I~ ~-' ~-~ ~e R~lng ~d~ ~lka, and ~ ~ l~m~ ~ ~.' mean am w~in ~ p~ ~ a~ ~ ~ ~h ~ h ~ ~.~...~'~ ..... ~i~d ~e~ ~ ~ ~~ ~ ~e p~ ~ adi~ 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 ,~,f,.~-iql-_,.',.',.',.',.',.~(~ NAA# ~,~ ~°~E,3 ~) ,~ ~ 1. GENERAL INFORMATION Complete legal description Location (site address or directions) /[ ~._~ c~¢4_ ~¢~ Property owner Ct¢~//~f._ ,¢~4,~,,-~_~ Mailing address ///,.5-c~ ~u,,~ ~.~ /. A/¢c{~ Lending agency "~ ¢~4~-.,,L ~,4c~'"ch.,x'~ c,~ Mailing address Day phone Day phone Agent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Comrh'unity 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 Cornrnunity 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) Fronl 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 structbre 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'-"~,o~,u~ ~-, .¢ Vc~ Phone Address ~--:~, ~ ,Go'~ /~?~ ~.,~-- /t-,,,~'g f /'A F- Engineer's signatur~ ...~----- - Date DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: 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. IVlunicipality of Anchorage DE DEPARTMENT OF HEALTH & HUMAN SERVIL~d'S Environmental Services Division 825"U' Street. Room 502 · Anchorage, Alask~ 99501e (9071 34~4~ Municipality o~/-~, , Dept, Health & t4ttman $~rvme~s Health Authority Approval Checklist Legal Description: /.o-r zqD A. WELL DATA Well type q'0AOAT~, Log present (Y/N) Total depth //, ( Smtitary seal (Yhxr) Parcel I.D.: _~ IfA, B, or C, attach ADEC letter. ADEC water system namber Date completed Cased to ! ~, I FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform ~ cD .~- Date of sample: B. SEPTIC/HOLDING TANK DATA Date installed Foundatimt cleanout (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Date installed Length /~ Width Effective absorption area Date of adequacy test to -t Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Nitrate g,p,nt. ~, ~q- g.p.m. ¢P. IB,~ Other bacteria '--O - Collected by: 5,9._.c~A,~ ~a,~ ~ Tank size / Zs-o Nmnber of Comparttnents ~ Cleattouts (Y/N) 'lv "( Depression (Y/N) ,,,,d High water alarm (Y/N) .x,,[t4 Pumper Fltfid depth in absorption field before test (in.); E 6" Fluid depth _'~" (tbs.) Minutes later: t't(tto Peroxide treatment (past 12 months) (Y/N) ~ 0 Soil rating (g.p.d./fi2 or fi%drm)_ o. q ~ System type 35 ~ Gravel thickness below pipe q Total depth Monitoring Tube present(Y/lq) "Y Depression over field (Y/N) Results (Pass/Fail)?rq ~-..q For ~ bedrooms ImmeAiately allerb¢O gal. water added (in.): Absorption rate -- -[-:~tg~> {,,tzO g.p.d. If yes, give date D. LIFt STATION Date installed Manhole/Access (Y/N) · /[ "PU~F' .~.~sted Size in gallons _ .__--- "Puml~ off' level at* E. SEPARATION DISTANCES SEPARATION DISTANCES FROM %rE, LL ON LOT TO: Septic/holding tank on lot I I ~5 t Absorption field on lot _ 1 3Z' Public sewer main ~' evo 4~ _; On adjacent lots /avo '*- _; On adjacent lots Public sewer manhole/cleanout r' ~o Sewer/septic service line Lift station _ ,/0,9 SEPARATION DISTANCES FROM SEPTIC/HOLDING 'rANK ON LOT TO: Building foundation l ~':P~ Property line fo ~ ' Absorption field /O t Water main/service line. ~o'* Surface wateffdralnage too'~ Wells on adjacent lots f ~o ~' SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Boilding foundation 'z.~ t Property Line /.5" Water main/service line Surface water ~ oo"r Driveway, purking/vehicle storage area .~- v Curtain d~aln l~o + Wells on adjacent lots ,'cPO"- F. ENGINEER'S CERTIFICATION I cergfy that 1 have determined thrufield inspections and review c in conformance with MOA HAA guidelines in effect on this date. Signature~ _...~q~ .~ Engineer's Name Date _ ~t~ HAA Fee $ ~)(~-~ ~c>O Waiver Fee $ Date of Payment Receipt Number Date of Payment Receipt Number Rev. 8/95 eSS: haa.wk,doc 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 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcell.a.~ ._~\ ~/-~-' /~'\\- ~[zD NAA# 1. GENERAL INFORMATION Completelegaldescription LoT 2_~ /~ UL~,~-,F_[-~ .%L/L~.O, Location (site address or directions) Property owner Mailing address Lending agency Mailing address_ Agent Address Day phone Day phone Day phone 2, NUMBER OF BEDROOMS: 3, TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well Community well Public water If community 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-O25 {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 Municipal and State codes, ordinances, and regulations in effect on the date of this inspection, Narne of Firm //~ b~"'lZ~'O,J /:-"'"""J ~;, ~J ~.%~-?~ ~J ~ Phone Address BO, ~'o/- z.,,/077~ ,,~ c~-,~ ,t,~F/,.e '~ ,zlrl/-- Engineer's signature ~,--~,J~- (~,l,,ue,/,,,------~ - Date DHHS SIGNATURE X Approved for bedrooms. Disapproved, Conditional approval for 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 DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Em ployees of DHHS cio 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. 72~72§ (Rev. 1/91) Back MOA ¢21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: & ~L~.D ~,UAE-~P~5 %6) i~ ParcelI.D. 0£~'- A. WELL DATA Well type p/~lUAT ~ Log present (Y/N) Total depth Sanitary seal (Y/N) _ If A, B, or C, attach ADEC letter. ADEC water system number k/ Date completed /E)- (~/-~/ [ Driller._~L.?/~d -~_ /~' / Cased to /~' / Casing height Z_ ' ~/ Wires properly protected (Y/N) y FROM WELL LOG AT INSPECTION Date of test /~- / "/- ? / ~r~ ~,~: Static water level Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot //~¢' Absorption field on lot Public sewer main ; On adjacent lots ; On adjacent lots /¢~ Public sewer manhole/cleanout Public sewer service line Petroleum tank WATER SAMPLE RESULTS: , ~/~,~/,~ ~"' Coliform ~~~ Nitrate Date of sample: B. SEPTIC/HOI. DING TANK DATA Other bacteria ~ Collected by: (~.7'A~v~$ S~t-F~-I - ¢~o/,~fz ~o~$¢cT__ Date installed /¢ ' 6'- ~// _Tank size /.Z_ 50 Compartments Cleanouts (Y/N) }/ Foundation cleanout (Y/N) ,V Depression (Y/N) High water alarm (Y/N) /V/,4 Alarm tested (Y/N) Date of pumping IOE'~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ] / ~' On adjacent lots I0O' ¥' Foundation /0 ¢ To property line ~--5'/ _Absorption field /0' _Water main/service line ~'¢2/ Surface water/drainage 72-028 (Rev. 3/~1) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level _ "Pump on" level at Manufacturer. __ Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D, ABSORPTION FIELD DATA Date installed /O- ~ '- ~ I Length /(cE>' Width Total absorption area Depression over field (Y/N) Results (pass/fail) _ Peroxide treatment (past 12 months) (Y/N) Soil rating · '~5~ __ Gravel thickness Cleanouts present (Y/N) _ Date of adequacy test for System type Total depth If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 132~' To building foundation _ On adjacent lots fo~' + Surface water /0~ / C- Curtain drain No,qF ~ ~,1 On adjacent Iots__~_ Property line. To existing or abandoned system on lot .Cutbank ~Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CFRTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Engineer'sName /V~,6,f~/-.44,~. i~ //~1.0C¢1¢.[0,,) HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/91) B~ok MOA Waiver Fee: $ Date of Payment Receipt Number