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HomeMy WebLinkAboutNETTLETON ACRES #2 LT 4ANettleton Acres #2 Lot 4A #015-062-67 4 %'r� Municipality of Anchorage /.'` 6:-. �� Development Services Department i fsa Building Safety Division firs' �1 On -Site Water and Wastewater Program, 4700 Elmore Road �/ P.O. Box 196650 Anchorage. AK 99507 Page / 0133 www.ci anchorage.ak us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number. SW080055 PID Number: 015-062-67 blam ' Mary Shannon El Upgrade Address 6700 Lisa Ct., Anchorage. AK 99507 ABSORPTION FIELD Phone Number M B•bdams 4 0 Deep bench CI Shallow Trench a Bed CI Mound 0 Clew LEGAL DESCRIPTION Sod Ramp no change GPOfFe Total Depin nom engage Veda Ft. Bim` — Lot 4A svonr.'OI Nettleton Acres #2 Depth to ppe bottom Iran anginal Vide Fl. Gent &mei beneath pope Fl To.nrap Range S.cbon FM added above °Penal grade Ft Gram. Length Ft. Well: • New ■ Upgrade Gra of meet FI. Number et Inas WWW. brew Ines Ft CMmnubn (Pine•. A. B C) Total Daum Ft. Cued W Ft Total ebearpOon Mee pi: Pub Material ASTM D3034 Omer Date Drifted Static Malec levet Ft MtusM! A+ Home Services Dale ma—d 5/30/08 Y.te GPM Pump Bet et FI, Casing Heppe Above Ground Ft TANK SEPARATION DISTANCES El Septic • Holding CI S.T.E.P. ❑ Other: To Septic Tank Absorption Field Lin Station Holding Tank udtUPrrvate Sewer line "'al's".CapacityFrom Anchorage Tank Welding, Inc. 1500 Gs Wel 138 101 NA NA 130 Mani steel Number Of CmWrmrtte 2 Surface Water too•+ 100•+ NA NA LIFT STATION Lel tae 70+ 80+ NA NA Sae Gal Manfartur Fa^dabm 5 10 + NA NA 'Pump on '4vM at In 'Pump off level M m Wgn eater warm al It Caton Com HA NA NA'.'t'•� • - NA Pump Mane a Mata Etecb.ut NWaWns performed by RemarksBENCH No change to leach field. Old tank removed and buried on site. MARK Louwn and Descnpkon top of sonotube at northwest corner of deck Assumed Elevation 99.98 Ft .. Inspections performed by: Cindy W. Ellis Dates: 1" 5/30/08 Engineer's Stamp Qleb.di co. .... ed.q :b. ` •-..,� ' - *' 49TH / 2" 6/4/08 Development Services Department Approval Conditional Approval Date: 1 azyliy IV eta- • Chicly W. Ellis / CE-10577et • „ SSIOPti`t•. Reviewed and approved by: i „id_ - :ate: o 27- 0 q• tae. IM+nI / / / S 89°56'10"E LOT 4A Property line is 120 ft to the west. 1500 gal steel septic tank ST1 EXISTING 4 BEDROOM HOUSE A— ST2 DCO WELL 6700 Lisa Ct. GRAVEL DRIVE 0 FCO B DECK i C Permanent BM= top of sonotube QUMP Property line is 100 ft to the south. 0 / \ 1 Block 2 Lot 3 // Well radius=100' LISA COURT )4' Block 2 Lot 2 , Well radius=100' •0 5' SNOW STORAGE ESMT. AS -BUILT This is an engineering drawing, not an asbuitt survey. Locations are approximate. Nettleton Acres #2 Lot 4A Record Drawing of Septic Upgrade Mary Shannon Permit No. SW080055 Parcel ID:015-062-67 Watkins Engineering, Inc Cindy W. Ellis, P.E. lune 6, 2008 Scale 1 inch - 3011 P.O. Box 110443 Anchorage, Alaska 99511-0443 Phone: (907) 349-1851, Fax: (907) 349-1934 A 13 C ST1 24.0 10.0 ST2 30.0 16.0 DCO 33.0 18.0 SUMP 49.0 24.0 AS -BUILT This is an engineering drawing, not an asbuitt survey. Locations are approximate. Nettleton Acres #2 Lot 4A Record Drawing of Septic Upgrade Mary Shannon Permit No. SW080055 Parcel ID:015-062-67 Watkins Engineering, Inc Cindy W. Ellis, P.E. lune 6, 2008 Scale 1 inch - 3011 P.O. Box 110443 Anchorage, Alaska 99511-0443 Phone: (907) 349-1851, Fax: (907) 349-1934 rc0 FI\AI. CRAM: 98 81 Uro 1500 GALLON :rl'I:I:I.: F:I"rlc •i'ANK Benchmark = top of sonotube at northwest corner of deck = 99.98 AS -BUILT To I:xi:•lim; Ihtool old Nettleton Acres #2 Lot 4A Record Drawing of Septic Upgrade MaryShannon Permit No. SW080055 Parcel ID:015-062-67 Watkins Engineering,Inc -:` �C�- '''''''9S+ E;.. ; .5 49TH J " ,/� ,. 1 '1 /w ti- c' CINDY w. ECUS , `. `• /cE - 10577 , 9 •••` ' , .,.� .�"�' ' . Cindy W Ellis, P.E. June 6, 2008 No Scale P.O. Box 110443 Anchorage, Alaska 99511-0443 Phone: (907) 349 1851, Fax: (907) 349 1934 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 Permit Number: SW080055 Legal Description: NETTLETON ACRES #2 LOT 4A Design Engineer: 0844 WATKINS ENGINEERING Owner Name: MARY SHANNON Owner Address: 6700 LISA COURT ANCHORAGE . AK 99507 - Date Issued: May 21, 2008 Expiration Date: May 21, 2009 Parcel ID: 015-062-67 Site Address. 6700 LISA COURT Lot Size: 127713 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: ❑ Disposal Field 0 Septic Tank ❑ 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 ). g, 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. Received By: Date :r, --3Q -O /lyd. Date:0-00 Issued By. �1 l�rf l' ..`�JiC� Municipality of Anchorage Development Services Department Building Safety Division • On -Site Water and Wastewater Program 4700 Bragaw Street P.O. Box 196650 Anchorage, Alaska 99519-6650 www.muni.org/onsite (907) 343-7904 ON-SITE SEWER/WELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING Parcel I.D. 015-062-67 • Property owner(s) Mary Shannon Day phone Mailing address 6700 Lisa Ct. Anchorage Site address same Legal description (Sub'd., Block & Lot) Nettleton Acres #2 Lot 4A Zip Code 99507 Zip Code Legal description (Township, Range & Section) Lot Size 127,713 Sq. Ft. Number of Bedrooms 4 THIS APPLICATION IS FOR (® all that apply): THIS APPLICATION IS AN: Absorption Field 0 Initial Septic Tank Q Upgrade Holding Tank ❑ Renewal Privy 0 Private Well 0 Water Storage ❑ El 0 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. (iit eie Wald 16 (Signature of prop owner or authorized agent) Permit/Rush Fees: Date of Payment: Receipt Number: (Rev. 11105) J 2-0 p$ Waiver Fees: Date of Payment: /08910 Receipt Number: Watkins Engineering, Inc P.0 Box 110443, Anchorage, AK 99511 (907)349-1851 cwellis@gcinet May 20, 2008 Municipality of Anchorage Development Services Department Building Safety Division On -Site Water and Wastewater Program P.O. Box 196650 Anchorage, AK 99519-6650 RE: Nettleton Acres #2 Lot 4A Proposed Septic Tank Replacement To Whom It May Concern: Attached please find an application to install a new 1500 gallon steel septic tank at the referenced 4 bedroom house in Anchorage. The owner is aware that this tanlOs larger than the required 1250 gallons. The existing septic tank, installed in 1981, was installed Tess than 5 ft from the foundation. No work is proposed on the drainfield, as it appears to be in good condition. The old tank will be excavated and buried on site. The area will be compacted to avoid compromising the building foundation. Thank you for consideration of this permit application. If you have any questions or need further information, please call me at 349-1851. Sincerely, sq Cindy 0. Ellis, P.E. President 6 \ I •$t V • WELL 1 \ /L ' 3 V. / �o9 e0/ 5' I • WELL I \ / x \ Septic Area / \ WELLZO \ 1 \ ZO Q m Di to 4t t� j W 0 1 ¢S I— 01 QFI Wi I , i I \ \ / LISA CT. rn j - Proposed \ 6700 Lisa Ct. I septic Septic Area 0 _ tank \ ,J —i \\t\• Septic O Area / .--\ / Existing N\ . Existing olo ,s 5\oPi......4. septic tank PC \ / 0 io c� y\ / 10010 I j WELL-I N -----W 4BR House .0.! .' y�� • WELL I 42- 03 • WELL J \ I \ / 4A Septic Area 6 \14 i WELL I 1 cP i I I I% Undeveloped �I I Septic Area Septic Area ..--- V / \ 1 I / I . WELL 15 / i 9 , I 8 . 7 WELL: Nettleton Acres #2 Lot 4A Site Plan for Septic Upgrade Mary Shannon Watkins Engineering,Inc Parcel ID:015-062-67, of 4. :•. ��• .7 . C. 49 TH���4, /I Cindy W. Ellis, P.E. P.O. Box 110443 Cindy May 20, 2008 Anchorage, AK 99511-0443 Scale: r = 100' Phone: (907) 349-1851 Fax: (907) 349-1934''• e •.coca WusnIs ; S 89°56'10"E LOT 4A 6700 Lisa Ct. Proposed 1500 gal steel septic tank 5 ft from any foun- dation and 5 ft from drainfield Install DCO Existing Septic Tank (1981) 1250 Gal. Steel - to be removed and buried on site. Property line is 120 ft to the west. o WELL Property line is 100 ft to the south. \• V 5' SNOW STORAGE ESMT. Block 2 Lot 3 hie Well radius=100' Block 2 Lot 2 , N.. Well radius=100' LISA COURT Based upon a survey by Jeffery A. Gataldi. LS -6091 February 17, 1997 Nettleton Acres #2 Lot 4A Proposed Design for Septic Upgrade Mary Shannon Parcel ID:015-062-67 Watkins Engineering, Inc. Cindy W. Ellis, P.E May 20, 2008 Scale 1 inch = 30 ft P.O. Box 110443 Anchorage, Alaska 99511-0443 Phone: (907) 349-1851, Fax: (907) 349-1934 • Jv W ELUS CE' '0577 ,/¢.~-~,~...= MUNICIPALITY OF ANCHORAGE {'~ ~"~'~\~ DEPARTMENT OF HEAl.I'll ~ ENVIRONMENTAL PROTECTION ENVIRONMENI'AI. ENGINEERING DIVIRION 825 I. Stre~t- Anchorage, Alaska 99501 'relenhone 264-4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELl_ INSPECTION REPORT MAILING ADDRESS EEGAL OESCRIP~.ION , L. OCATI O/N DISTANCE TO: I $'~'~ "l "~t' Absorption area Dwelfin. g a I Manufactarer /, ~ [Liq. capacity in gallons ~--. ..... hlside length ISTANCE TO: Dwelling ~a~ .... -[Material ~ ~ g DISTANCE TO: Foundation ~ ~ N Y~ of lines I Length of each~ ~ ~ ~ Top of tile to finish grade Material beneath tile ~ ~ype of crib I Crib diaOleter Crib depth _ ~~ -- I DISTANCET~: :ell BuilOingfoundadon OTHER PIPE MATERIALS NO, OF BE~_,~OOMS PERMIT NO. No, of compartments Liquid depth PERMIT NO. Liquid capacity ir) gallons PERMIT NO, Distance between IhleS inches T t lff- ~//~1 o a e ectiv~ absorptjon area PERMIT NO. arest lot line stance to lot lithe PERMI'F NO. SOIL TEST RATING INSTALLER REMARKS APPROVED 72-013 (Rev. 3/78) DATE LEGAL Z 0 o ~5 © 0 0 0 O © © O © © © © © © © 0 0 0 0 0 0 0 0 o! ~,,'!I ~..._~ ~"*,~ % C: % F. F:::~ L.. % "F *-,-" ~(;Z* F::: f::a~ I!',a *Z:: ~---~ ...... ~;~: ~::~ ~ZFa ~ ~E: *~[~e~ ~ ~ E,EPFIR'FHEN'!" Cfi::' HEFIL. TFI F:lh![:, EN, :[ROhff"IENTF:IL. PI;:OTE'C:'T'~ON /~S~ 2 G ,:1. -'- 4. 7' ;2 El ~..4 EEC L.L. F~I ~'-,~ E:, C, ~'..4 ....... :~:; % "'T" ~EE ~E;; ~JE ~..,,.~ EEC ~;~: F' EE F:: ~'"11 :E ""~ .... ,:: ',~?,:]..EK;' ~3 :L L. CIT E;IZE: 55(:~1~3EI E;~;:!I..IF:tRE FEET 'THEE L. ENG'T'H [:, I P'IEI',tE; I 01'.,! :!:. S THE L. ENGTFI ,:: ]: N F'EET > OF THE 'TRENCFI OR DF;.'.FI :[ NF ]: EL.I>. THE I.')EF:']"H [:IF Ft TF.:IENCH OR F'IT :IS THE E:,~STFd",ICE BETHIE:EN THE IL:;LIF.:FFIC:E OF THE[ GROUND IqND THE BO'I"TI:'3H CIF THE Ek0L':FI',,,'FIT .T. ON ,:: :[ N FEET ). T' H E: 'IF ~:~." tEC ~'-,1~ C: ~-.-.1~ IL,,-~ .'.E E"_'.'., 'T' ~'-,~ % :ES;; ~2~. ~:TE.~ C.E, ~.:.E, F' ES E: T'. THEE GRFI',/EEI... [:,EF'TH I:E; THE I"I]:I',IIMLJH E:,EPt"H OF GRFI',,,'EI... E:E'f'HEEht THE OUTF'F!L.L PIPE FII",IE:, THE DOT'T'OH OF:' 'T'HE E::.:',CFff,,,'FIT I Ot',1 ,:: I N FEET >. F'ERH I 'T FIF'F'L. :[ CFII'.,IT HI:IS '['FIE: RES;F'ONS 1' Er T L. 1' T"r' TO l I',IFORM "f'l'"l i 5 E:'EF'FIR-i'MEI",tT [:'LIR I NG THE .'[ t",ISTFILLFIT]: Oiq ]: N5;F'EC:T ]: ON".E; OF FII",I"¢ 14[FL.I._S FII)J'FICENT 't"L-I 'f'l'"l 15; PF.'.OF'ERT'¢ FIN[:' THE I'.,IIJtdEdEF~'. 0!::: RE::J;]:E:,ENE:E'.:5 'TFIFIT THE HELL. HIL..L. E;EFWE. [!i;l::tl3'f:::l::' ]: LL..'Ii l",l(.:i OF' FIN'¢ :S"r'E;'TEt'"I I.,I .I' 'I"HOLI"f' F':[ IqF]L I NSPEC:T I OIq FIN[) FIF'F'RO',,,'FIL E:'¢ 'T'H :[ E; f?.'IF3::'FtRTHENT H Z LL E:E ZUEL]'E'C:T TO I':'ROSECI..IT ]: 01',1. I"I:[NIHUH [:' :[ S'TFINCE~: BE:THEEI"4 I::1 I,~EL.L F]i",tE:' FIN"r' ON'-'S]:'TE SEI.,.tF1GE D ISPOSRL Sh"S"f'EH I:..:.; ::LE~Ei F:'E:ET F'OR I::1 F'F. iI',,,'FI'TL:~ I.,-!E:L.I.~ OF4'. :J..58 TO L-':'~]:.~i~ F'EET' FROH P, F'I..t[~:L.:[C 1.4EL. L [:'EF'IEN[:']:i",IG UPON THE 'T'¢F'E OF PIJE:L. IC HELL. i'q :1:I",11 I'"11...11"1 D I STFINCE F'ROH Fl F'R I ',,/FI'T'E F.IFi:LL T'O I:::f F'[(: Z ',,,'I::ITI:E SE:I,.IEF~:: L .1: NE I E; ;?.5 FEET FtI",!E:' 'T'O FI COHHIJI",II]"'¢ SJ[~:I,.I[:ZI:;.: LII",tE IS 75 FEET. I.,.IEL. L. l...Ol:]i~:: FIRE REXT.!LIIRE[> FIND I"II. jST BE RIETI...IRNED '['0 "rHi;:'. [:,EPFtR'T'HEI',I]' !.,] ]: 'T'H :[ N .'~:O [:,F:I'¢S OF' THE HELL. E:Ot'IPL. ET.I:ON. OTHEI:;.". F:'.E3:::!U :[ REMENT'.:~; MI::tY FIPPL'.¢. E;i::'EC Z F:' ]: CFIT 1' Oi'.,IS F¢.~D COI'.,1E;TRUCT ]: ON E:, I FqGRF~h'!E!; Fi',,,'R :[ L..I.':IE~LE TO I I'.~I...I[~:E F:'ROF:'EI~'. ]: NSTF~LL..FI]' I' I CERT' ]: I::'Y THF:IT :L: I I::I1'"1 F:Fff'ilLIFiR t,.tlTH THE REL::.!IJIF'.EMENTE; FOR ON--L:,I'T'E E;EHEF:.:E:: RI',IE:, HEL. LE; Fiji]; SET F'Of(:TH B"¢ THE HL.IN I ii: I F'F:tL. ]: T'¢ OF' FINC:HCtRFIGE. 2: ]: H :[ LL I N:i];TI:::IL.L. THE E;"r'E;TEH ::ii:: I UN[:,ERS'TFINE:, THFtT 'T'HE ON-'-::/,]:TE E;ENER :.T.','¢S~I"EH I"'IFI'¢ F::E~;!LIIRE Et',II...FIRGEHEI',IT IF:' THE RES I[:'ENC:E I:'5 REHO['."EL.E:[:' TO ]:i",tE:L. IJDE r,IOF::E THFtN q. _4 F:IF'P L~'1 J~:J"['~]: CFINT ' / ,, I ~;:~;I...I E D Bb.'. ............... E:,FITE ......... SOILS LOG MUNICIPALITY OF ANCFIORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: ,~'~ &/ 2 3 5 7 8 9 10 11 12 13 14 15 16 17 18 19 20 PERFORMED BY: !~--,.~,t5~ SLOPE SITE PLAN WAS GROUND WATER ~/~_.l~ , I~ ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND -- FT DATE: 72-008 (6/79) 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 Parcel I.D. 1. GENERAL INFORMATION Complete legal description L. CFr Location (site address or directions) Property owner Mailing address Lending agency Mailing address (o7O L.r_, Day phone Agent Address Day phone 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. 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 ~f21 . S~UeUJLUOO leuoB!pPY :suoBelndBs I~U!MOIIOI eq~ q~,!M 'sguooJpeq Joj le^oJdde leUO!~!puoo 'pe^oJddes!a 'SLUOOJpeq Joj pe^o,~ddv ~- ~anJ.¥NglS SHHa 'sepoo e~e~S pue ledp!uny~ lie q~i~ eoue!ldLUoO u! s! uJe~s/,s lesods!p Je~e~e~se~ Jo/pue ,~lddns Jete~ m,!s-uo eq~ 'uo!toedsu! pue uoBeSBse^u!/[LU LUOJ¢ pue Sel!~ eSe~oqouv jo X~!ledp!unlhl eq~ uJoJb peu!e),qo UOBeLUJObU! eq), uo peseq ~,eq~.Xbpe^ Jeq~Jnj I 'u!eJeq pe),eo!pu! eJ n;onJ),s jo ed~ pue SLuooJpeq bO ceqLunu eq~ ~oj e~enbepe pue leuo!~,ounb 'ejes s! ~ue~sXs lesods!p Je~e~e~se~ Jo/pue Xlddns Je~e~ e~!s-uo eq~ ~eq~ s~oqs uoBeO!ldde le^oJddv ,~,poq~nv q~leeH s!q~, bo uoBeSBse^u! Xu~ ~eq~ Xb!Je^ I '~oleq u~oqs e~ep uoBep!le^ eq~ bo se pue o~aJeq pex!~je leds Xgu Xq Pe!b!ueo sv '9 I:EI~INIDN=~ ),8 NOI.L~)~dSNI 40 .LN~IlN=LL¥.I.S !;  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LL¢I ~,~-~ I.~ ~¢~4 ~ t,4.,z~ Parcel I.D. Legal Description: f~ v~2. A. WELL DATA Well type ~, Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. yDate completed Cased to ? FROM WELL LOG Date of test Static water level Well flow Pump level ~-~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line ~,¢,.~..,Z.'.'.'.'.'.'.'.'.~ ADEC water system number ~f///--~ '-///~ ¢~/~,/ Driller Casing height Wires properly protected (Y/N) g.p.m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ Nitrate / Date of sample: ~ '~¢"' High water alarm (Y/N) Date of pumping B. SEPTIC/HOLDING TANK DATA Date installed -/,/~'/~ / Tank size '¢~-,%~O Compartments Cleanouts (Y/N) ~ _ Foundation cleanout (Y/N) / Depression (Y/N) . Alarm tested (Y/N) ~//~- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I c~ To property line ~:~ / Surface water/drainage On adjacent lots Absorption field /k~¢ H~__~ Foundation. Water main/service line 72-026 (Rev. 7/91)Front 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 '7/ Length Y ~ Width Total absorption area Depression over field (Y/N) ~ Date of adequacy test Results (pass/fail) r.~ for ¢ Peroxide treatment (past 12 months) (Y/N) /%'¢ C) If yes, give date Soil rating ~ ~ System type Gravel thickness ,/¢¢-.- Total depth ~& ~¢..~'/l~)Cleanouts present (Y/N) ,,~/ bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots ~ / ~'O Property line To existing or abandoned system on lot Cutbank /~ 4(- Water main/service line Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature '~' ~ Engineer's Name ~-'-¢_~b,~p-/ HAA Fee $ Date' of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEP~R~iENT OF H>iA~TH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Io General informa~ion (a) Legal Description (include lot, block, subdlvision~, section, township, range) Location (address or _,directions) (e) Real ~sta~e C',o, & Agent ~f~ )t:i(~_:~ ....... Address Telephone Mail the ILAA to the following address: 2o T~pe of Residence Sing].e~Fa~ily~[ Number of Bedrooms 3, W~a_~e~r s_. uRpl_X Multi-Family~ Other (describe) Individual Well,~[_ Community :~[ Public ~ Note: If community well system, must have written confirmation from the State Department of Enviro~nnental Conservation attesting to the legality and status° Note: ~f community well system, must have written confi~nation from the State Department of Environmental Conservation attesting to the legality and status° [Page 1 of 2] E~ineerin~. Firm ProvidinL~___Ins pections~__ Tests~File .... Search,~__~ Data and Information As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health Authority Approval shows that the on-site water supply and/or vrastewater disposal system is safe~ functiona3~ and adequate for the number of bedrooms and type of s~ructure indicat~ herein.- I further verify that, based on ~he info~ation obtain~ from the ~%nicipality of ~chorage files and from my investigation ~d tnspection~ the on-site ~mter m~pply and/or ~stewater disposal system is in compliance wi~h ~1 M~micipal and State codes~ ordinances~ and regu!a~ ~tons in effect on the da~e of this inspec~:ion~ ~ ' A ~ '~'~ ',~ ~.~:'~ ';' , "".~ ' ~ :) ~ / ~ [ >~ ~ < ~'~ D~P A~i~roval .... ~'~ c'~% ..... ' Approved ~_ Disapproved Condi~iom~d. Terms of Conditional Approval CAUTION TIlE MUNICZPALITY OF ANCHORAGE DEPARTMENT OF t~LTH AND ENVIRONMENTAL PROTECTION (DttEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT= ATIONS GIVEN IN PARAGRAPH 5 ABOVE, BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTEtlED IN THE STATE OF ALASKA° 'I~IE DHEP DOES THIS AS A COURTESY TO PI~RCHASERS OF HOMES AND THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDEIhLL AND STATE REQUIRE=" M~NTSo EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A CERTIFICATE I$ ISSUED° THE MUNICIPALITY OF ANCHORAGE IS NOT ILESPONSIBLE FOR ERRORS OR OMISSIONS IN TITJZ PROFESSIONAL ENGINEER'S WORK° (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7 ~-1 9 =84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 IViUNK:IPALITy OF ANCHORAGe: DEPT. OF HEALTH & F'NVlRONIvi~NTAL PROTECT/oN WELL DATA Well Classification Well Log P~esent (Y/N) Total Depth / () Cased to If A, B, or C, D.E.C. Approved(Y/N) Date Completed 3-~/~/ Yield_~_~_~ Static Water Level . ~_J Casing Height Above Ground t~. '.~ Electrical Wiring in Conduit (Y/N) ~ Separation Distances f~cm Well: To Septic/Holding Tank on Lot /[/~) ~ qq' Pump Set At Depth of Grouting n~ _~ Sanitary Seal on Casing (Y/N)~ Depression Around Wellhead (Y/N)~_ ; C~ Adjoining Lots /~/~'~ To Nearest Edge of Absorption Field on Lot._~ .~ ; On Adjoining Lots /~7'~) To Nearest Public Se~ Line. ;k~./.~ To bkea~est Public Sewer Cleancut/Manhole__. /%7,//~ To Nearest Sewe~ Servi~ Line on Lot Water Sample Collected By ~7, ~/~Lc.~7 __; Date~ //- ~ ~._~ 'Wate~ Sample Test Results ~ .~/~ t/~ B. SEPTIC/HOLDING TANK DATA Date Installed_ ~-//~/ Size /~_..~-~) No, of C~a~tm~nts .~.. Standpipes (Y/N) ~/ Ai~-tight Caps (Y/N) ..~ Foundation Cleanout (Y/N)~ Depression over Tank (Y/N) ~ Date Last Ptur~ed ~_ //~ 2 7 ~ ~ ~ Pumping/Maintenance Contaract on File (Y/N).f?//t ; for Holding Tank High-Water Alarm (Y/N) /b;/?t Temporary Holding Tank Permit (Y/N) Separation Distances f~cm Septic/Holding Tank: To Water-Supply ~11 To lh~operty Line / To Water Main/Service Line co=se Co~nts To Building Foundation_. ~ ~ f~ To Disposal Field ~ To Stream, Pond, Lake, or Major D~ainage [Page 1 of 2] 2~15-84 Soils Rating in Absorption Strata Date Installed ~7~.//~/ Width of Field 72 ~' Square Feet of Absorption A~ea .... ~,~ Length of Field ~/~ ~ Depth of Field ~ ~ Gravel Bed Thickness /2 ;~ Standpipes P~esent (Y/N) Type of System Design Depression over Field (Y/N) /%J Date of Last Adequacy Test Results of Last Adequacy Test _~D~-~//tT~ Separation Distance f~om Absorption Field: / TO Water-Supply Well ~-~ ~ To P~operty Li~ /~ To Building Foundation Q. ~ (q~ To Existing or Abandoned System cn Lot.. /~/~/~ ; On Adjoining Lots ~ ~)~ To Wate~ Main/Service Line /~<f: To Cutbank(if present) /~//~ To Stream/Pond/Lake/c~ Majo~ Drainage Course To Driveway, Parking A~ea, o~ Vehicle Storage A~ea /~/~ Co~ents De LIFT STATION Date Ins'tailed Size in Gallons "Ptu~ On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Din~nsions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Corm~ts ** Check Permitted Bedroom Rating AEgainst HAA Request I certify that I have checked, verified, o~ conformed to all MOA HAA Gui on the date of this inspectj~. . S igne~/~~~/F~/ ~Date //-~~ [Page in effect 2-15-84 MUNICIPALITY OF ANCHORAGE DIVISION OF EN~RONMENTAL HEAL'I~ DEPARTMENT OF HEAL~{ AND ENVIRONMENTAL PROTECFION APPLICATION FOR [~3kLTH AUTHORITY APPROVAL CERTIFICATE 1. General Infornmtion Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (add~ess er directions) Applicants Address__~_~J~_j~L~jff. Z._ A.l&C./~/lJzz3(,-~,, A~. (c) Applic, ant~is (chec~ a~) Lending Institution ~; CXmar/builcier ~ ; Buyer ~ ; Other [~ (emplain); (d) Lending Institution _~ A I/H ~?_~..{?_/'~ 0~f2_'T ~l ;,~- T. ele~o~~ (e) Raal Estate Co. & Agent _J~,/Z~.~ Adcl~ess Tele phone 2o _%ype,. o_f ~sidence Single-Family~.~ ~alti-Family ~ Other (describe Number of ~edrooms 3. Water Su_j~.. ]individual WelL~_~ Corm~nity ~ Public ~--__~ Note: If ~nity ~ell system, must have ,~ritten confirmation fr(]n the State Departr~nt of Environmental Conservation attesting to the legality and status. Is the well adequate fo~ the number of bedrc~ns specified in this HAA (Y/N) '~. 4. ~sal ' ~ ~'~ (Y/N) y Is the wastewater disposal system adequate for the number of b~ck'ocn~ [Page 1 of 2] 2-15-84 5. E.~ineerin~ Fiknn Providi_;3~ Inactions, %%sts, Data and Information I certify that I hav~ checked, w~rified, or confc~m~d to ali. MOA HAA Guidelines in effect on the. date of this~ir~sna~e't'[,on. · //,~ /~" / ' " ~ .,-,-,. ~ ..... .~,~ 6..~.HE_P ,%p_~rova 1 Appr o".~ d for Approved [~ Disapp~o~d ~ Conditional~-~-[ Term~ of Conditional Approval q~e Municipality of Anchorage Department of Health and Enviror~m~ntal Protection dces not guarantee 'the continued satisfactory .performance of the wate~ supply and/ct, the wastewate~ disposal system. This approval indicates that~ as of th~ validation date shc~n above, based on the data and inforraation fu~-nished ky .an er~ir~.er registered in the State of Alaska, the ~ter supply and wastewater disposal system is safe and func- tional for the number of bedro{~ns and tyl~.~ of structure indicated. (D~EP SEAL) 7. Mail the HAA to the following address: KB2/dS/s [Page 2 of 2] 2-15-84 ae MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Well Classification Well Log P~esent (Y/N) Total Depth (06 ' Static Water Level Casing Height AbOve Ground lg.J'+ .. Electrical Wiring in Conduit (Y/N) ~/ Separation Distances f~cm Well: To Septic/Holding Tank on Lot 1 C~O e ¥ Cased to '~61d~O~;Nr)Pump Set At MUNICIPALITY OF ANC~QR613~g DEPT. OF H~'~LTH ~ i -- IF NVI RONM E NTAL'~I~OT,~CrlON MAR 2, .2, oo,, RECEIVED If A, B, o~ C, D.E.C. Approved(Y/N) b~.//% __ Date Corap. leted 7'- ~ ~ - ~ I Yield'.. r~. = ~' Depth of Grouting k,t)u~ . Sanit~y ~al on Casing (Y~)~ ~ession ~ound ~l~ead J,Y~)~ ; On AdjoiniJg Lots_.[O~) To Nearest Edge of Absorption Field on Lot I 0-0-~' ; On Adjoining Lots To Nearest Public Sewer Line Iq/,'/k To Nearest Public Sewer Cleancut/Manhole J~.//~ To Nearest Sewer Service Line on Lot water Sample Collected By ~J~. ~ AV.J L~.~f' __; Date_ ~ ~J 6 ~ ~5 '~ Water Sample Test Results. ~-F~I~AC~T'¢¢&~ B. ~~OLDING TANK DATA Date Installed 7-.~..-~l Size I.~O No. of Cc~n~azrtments ~ Standpipes (Y/N) y Air-tight Caps (__Y~ Foundation Cleanout (Y/N)y'_~ Depression ove~ Tank (Y/N) ~ Date Last Puntced ~- g_O'~ q Pumping/Maintenance Contract on File (Y/N)~.//~ ; for Holding Tank High-Water Alarm (Y/N)~L././~. Temporary Holding Tank Permit (Y/N) Separation Distan6es fnzom Septic/Holding Tank: To Water-Supply Well_ ~O0 ~ To lh~operty Line _ t0 ~ To Water Main/Service Line Course ~./~ Couuents ~ To Building Foundation_L~+ To Disposal Field___~/+ To Stream, Pond, Lake, or Major D~ainage [Page 1 of 2] i c. ,' 2~15-84 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed 7~ 1 {- %~ ~ Width of Field 7 ?.'t Square Feet of Absorption A~ea Depression. over Field (Y/N) Results of Last Adequacy Test ~',~/~-~O Type of System Design Length of Field ~ ~ ~ Depth of Field ~ ' Gravel Bed Thickness I ~." Standpipes Present (Y/N) Date of Last Adequacy Test ?~-Q Separation Distanoe from Absorption Field: To Water-Supply Well %00~ To P~operty Line % O ~ To Building Foundation q O ~ To Existing or Abandoned System cn Lot ~./~ ; On Adjoining Lots ~O ~ To Water Main/Service-Line ~0 ~4- To Cutbank(if present) To Stream/Pond/Lake/or Major D~ainage Course 100 ~% To D~iveway, Parking Area, or Vehicle Storage Area Co~ents D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Din~nsions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating A~ainst HAA Request I certify that I have checked, verified, or confor~ed to all MOA HAA Guidelines in effect on the date of~ this i~sD~ion./~ Signed ~Date'~ ~/~ ~ ~ Company ~ MOa No. ,<~-~9~/ \ / KB1/d5/s %~/ [Page 2 of 2] 2-15-84 DATE RECEIVED -' INSPECTION APPOINTMENTS DATE (.-~ DATE DATE INSPECTOR ~ I NSP ECTOR INSPECTOR ..q (3~c~_~..~_c,t~'-v,~l L..~:¢~.?\ MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Aachorage, A~aska 99501 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE-:R FACILITIES DIRECTIONS., Oomplete all parts o~ page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER I PHONE .~__.(..~ . · Il .z MAILII~ ADDRESS -,~ PROPERTY RESIDENT (If different from above) PHONE 2. BUYER l\3f,~ PHONE MAILING ADDRESS 3', LENDING INSTITUTION I PHONE I MAILING ADDRESS 4. ~ALTORIAGENT MAILING AD DR E~S,,) V S. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE [~"SING LE FAMILY [~ MULTIPLE! FAMILY NUMBER OF~BEDROOMS [] One ~--J Four [] Two [] Five I~' Three F-I Six [] Other 7. WATE R~UPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL I.OG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSp, L SYS~ I::M ~I/ INDIVl DUAL/ON.SITE*~ [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] .JS~IGLE FAMILY [] ONE .,.[]t THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED ~J~(.. -~ 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER (~. I--]i'NDIVIDUAL/ON -SITE DATE iNSTALLED 7- / /' E~ PUBLIC UTILITY · Connection Verified iNSTALLER [~'eeptic Tank or [] Holding Tank ~ize: ~ ~- ~ O If Tank is homemade SOILS RATING ~- give dimensions: ~' TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA %~ .,~/ ~.~ MATERIAL .~'~' f.~ ~ 4. DISTANCES Septic/Holding Tank Absorption Area ISewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line · ,! .,~ 5, COMMENTS ~]'/' APPROV ED FOR EDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [~ DISAPPROVED 72-010 (Rev, 6/79)