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HomeMy WebLinkAboutTELEMARK HILLS LT 2 Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVIOES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report N.m~: ~~O ,' ~ ~ ~ Wastewater System: ~New U Upgrade 5et ~Rou~ &V~ ABSORPTION FIELD Phone'. 77-°'°°m': ~DeepTrench USh,,IowTrenoh OBed OMqund OOther LEGAL D ESCR I PTI O N so,, Rating: t ~ Total Depth from~ orl~lnalo grads: . ~ GPD/Sq. Ft. Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe I e~ I Section: FIll added above original grade'. Gravel length: Township: Rang WELL: ~New B Upgrade Gravel ~: ~¢~ Numberer lines: ~DBt~nc~tweenllnes: Classification (Private. A.B.C): To,al Depth: Cased To; Total absorption area: Pipe material: Date Drilled: Static Wsler Level'. Installer: Date install d: SEPARATION DISTANCES ~ septic u Holding ~S.T.E.P. TO Septic Absorption LiS Holding Public/Private Manulacturer: Capacity in gallons: From Tank Field Slatlon Tank SewotLInes ~ . t ~ ~ J Well q30 ~5 ~(~ ~ --- Material: ~ ~ Number°fO°mpartments: Surface N ~- LIFT STATION Water ~ ~ Lot Size in gallons: Manufacturer: "Pump on" level al: I "Pump olf';v~at: I High w~;rm al: Foundation T ~' 5 ~ Remarks: BENCH MARK Inspections performed by: t%~, Dates:let._, .O/?¢' ~,% '_ Department of Health and Human Services approval O. ~, % ,~' 72-O13 (1/91) MOA 25 4O Monitor °l Cleon Out Stondord Trench 3' [Olde 40' Long 10' ~eep 7' Sewer rock 3' Cove~' NJ7 SCALE 15~0 Gal STEP I06 Mlro£! 140 99 7 £t o£ Septic Rock TDBBEN SPURI<LAND P,E, 203 WlSth Ave Anchorage AR 99501 . Cleonout.~ ~ Monitor / NO £CALE 93 STEP Tonk BENCH MARK BBT, SILTING ASSUME]) ELEV, lO0,O0 L[TF 2TELEMARK HILLS MARK SPRAND STEVE/JANICE TDWER SEPTIC SYSTEM AS; BUILT '])ATE, JAN, '~8, 1994 · ~' ' STATE OF ALASKA DEPARTMENT OF NATURAL RESOURCES LOCATION OF WELL DIVISION OF WATER WATER WELL RECORD BOROUGH SUBDIVISION SECTION QTRS SECTION I TOWNSHIP r~s RANGEr~w[~F I MERIDIAN LOCATION/SKETCH: WELL OWNER: DEPTHS MEASURED FROM:[-lcasing top I-Iground surface BOREHOLE DATA: Material Type and Color Depth From To RECEIVED MAR 6 1993 M~t ~olpality ct Anch..ora! He~lth & Human ~er~ WELL DEPTH: DArrE OF COMPLETION Depth of hole: o~'~ ft Depth of casing: ~:s"/ ft ~ / '"~' ~'~/_ /~'~ DEPTH 'ro STATIC WATER LEVEL: / ~e~ ft below [] top of casing Date: ._~. J c:~ ¢ / ~"~' J~ground surface METHOD OF DRILLING: .'[~ir rotary [] cable tool [] other USE OF WELL: J~domestlc [] irrigation [] monitor [] public supply [] other. CASING STICK-UdB:.~_~ ft. Diam: ~C--~ in. to ~-~ft Casi.ng type: ~-)-~o..~'/ '~. to ~---'~ft WELL INTAKE OPENING TYPE: ~open end [] screened [] perforated [] open hole to ft Depths of openings: SCREEN TYPE: ----.. Diam: in. Slot/Mesh Size: Length: ft GRAVEL PACK TY-REL. Volume used: ~ Depth to top: GROUT TY P E.---~-.~ ~, Volume: Depth: from -" ft to ft DEVELOPMENT METHOD: ~'L~. Duration: P~NG LEVEL AND YIELD: ft after ,?/' hrs pumping ~-~) gpm PUMP INTAKE DEPTH: ft Horsepower: WELL DISINFECTED UPON COMPLETION? [~..YES [] ~-O ~ CONTRACTOR INFORMATION: ~agisterdd ~usi~ess ~ame REMARKS: PLEASE MAIl. WHITE COPY OF LOG TO: DNR/DIVISION OF WATER PO BOX 772116 EAGLE RIVER AK 99577-2116 Signature of Authorized Respresentative Date H, D]MOND BI. VD, ANCHORAGE~ ALASKA 995(12-3904 (907) 279-3916 i'qur~icipality o.F Anchorage !)ivisimn o~ E]nvironmen[al Heal'Eh Departmen~ o-F Ft[~alth and Social Services 820 I Street Anchorage~ Alaska 99501 Sub j ec: k: F'ermit :!$ SW92E 201 Sprano~ Hark S Elizabr~th B Felemark Hill,s Lot=~ AL g _ ~- ~ ~ I 993 On ,]u]y :79~ 1993 S & A Contractors ~as on site c:lear~tg the area ~or the Scl]tic: system~ stockpiling materials and providing access to the site. The tank was on site. The f:irst and ~econd inspec-' tion was on July 30~ 1993. 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:SW920201 DESIGN ENGINEER:FLATTOP TECHNICAL SERVICES OWNER NAME:SPRANO MARK S & ELIZABETH B OWNER ADDRESS: 301 WAREHOUSE AVE. ANCHORAGE, AK. 99501 PARCEL ID:01523188 LEGAL DESCRIPTION: TELEMARK HILLS LT 2 DATE ISSUED: 7/29/92 EXPIRATION DATE: 7/29/93 LOT SIZE: 77178 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: THE ATTACHED APPROVED DESIGN. 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 (iSAACS0). THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: TNIS ONSITE SYSTEM MUST BE APPROVED ENGINEER'S DESIGN DATED7/92. RECEIVED BY: / INSTALLED IN ACCORDANCE WITH THE DATE CIVIL & ENVIRONMENTAL ENGINEERING · ENERGY CONSERVATION & ANALYSIS TItEODORE F. MOORE, P.E. 14530 ECHO ST. PH: (907) 345-1355 July 21, 1992 ANCHORAGE, ALASKA 99516 M.O.A. DHHS P.O. Box 19-6650 Anchorage, AK 99519 Dem' The purpose of this letter is to provide the required design nm'rative in support of our application for a permit to construct wastewater disposal facilities on Lot 2 of Telemark Hills S/D, which is accessed from Moose Road. Soils logs, perc test results, a site plan, design ch'awings and specifications are enclosed for your review. The proposed system will be constructed in the vicinity of test hole # 1. As can be seen from the soil log, the native material between 2' and 12' is a sandy gravel with a measured perc rate of less than 1 minute per inch. Because this material is underlain by 4 feet of sand (sample enclosed) no additional filter sand is needed. Using the soil applicatiou rate of 1.2 gpd/sq, ft. specified in the wastewater ol'dh~ance for soils with a perc rate of less than 5 minutes per inch, this proposed 4 bedi'oom residence requires a total absorption area of (4 x 150)/1.2 = 500 square feet. The proposed 50 foot tong soil absorption trench with 5 feet of sewer gravel has a total absorption m'ea of 500 square feet. Because underlying sm~d was not encountered in test hole #2, the designated replacement system is configm'ed as a bed and sized on the basis of 0.7 gpd/sq, ft. for filter sand. The topography in the proposed construction m'ea in the southeast corner of the lot slopes to the northwest at approximately 10%. This corner of the lot is well di'ained. Much of the remainder of the lot is'lower lying and poorly di'ained. Because the suitable area on this lot is limited, it is necessary that the south edge of the proposed residence be no mom than 100 feet south of the north lot line, in order to preserve adequate area for a replacement system. Although suitable soils were found at a shallower depth than utilized in this design, the distribution pipe was placed at 7' below the the ground elewttion at test hole #1 in order to allow gravity distribution of effluent from the residence. The proposed project will have no significant impact on present or futm'e water supply aud wastewater disposal systems servh~g adjaceut properties, nor will it have auy impact on reserved space/surface and subsurface, or on drainage. Please give me a call at 345-1355 if you have any questions on ttfis submittal. cc: Mm'k Sprano Sincerely, Ted Moore, P.E. eLEANOUT -)of F)LAN VIeW CLEANOuT IIIII SECTION A-A ~XcAVATIoN J',, ~, .~ ~nchorage, Al~s~c[ 995 Flattop Technical Serv~es 14530 Echo Street, Anchorage, AK99516 Phone (907) 345-1d55 Lot 2, Telenlark Hills accessed from east end of Moose Road Wastewater disposal system installation Specifications 1.0 General: 1.1 The scope of file project consists of the installation of a 1250 gallon septic tank followed by a 50' long by 12' deep soil absorption trench containing a total of 5.5' of sewer gravel. 1.2 Construction shall be as depicted on tile approved site plan and design drawings. Minor deviations from these drawings may be 'allowed or requked by the engineer conducting the inspections. All c. onstmction procedures and material specifications shall confom~ with Municipal and State requirements. All separation distances shall be in conformance with Municipal requirements, unless specifically waived. 1.3 The contractor shall be responsible to obtain auy necessmy utility locates, and to work around any bm'led utilities. 1.4 The contractor shall provide adequate cover material and rough grading over all system components to ensm'e that proper drainage is achieved after settlement and that there m'e no msiduaI depressions. Insofm' as possible the contractor shall miniofize damage to trees. 1.5 Unless specifically agreed otherwise, the homeowner shall be responsible for finish gradiug after the soil is compacted, tls well as placemem of lopsoil aud reseeding all areas distm'[x:d by the cOnSlruction. 1.6 Due to tile necessity to preserve tile 10' utility easement, prior to start of work tile homeowner shall arrange to have t/land smweyor mark the south property line at 25' intervals in the viciuity of the proposed soil absorption treuch. 2.0 Septic Tank: 2.1 The 1250 gallon septic tank shall be Municipally approved with two compm'tments, and shall be set level on undisturbed soil. Each compm'tment shall be equipped with a watertight manhole cover and a 4" cleanout. If the tank is buried less than 4 feet, it sllali be insulated with 2 inches of approved burial type, rigid insulation. 2.2 All pipe connections to the tank shall be equipped with waterproof mechanical couplings. The waste line from the residence to the septic tank shall have a minimum slope of 1/4'" per foot, and the waste line between the tank and the soil absorption system shall have a minimnm slope of 1/8" per foot. A cleanout shall be installed within 5 feet of the building foundation, and a double cleanout shall be installed within 5 feet downstream of the septic tank. The tank shall be no closer than 5 feet from either the building foundation or the soil absorption trench. 3:0 Soil absorption system: 3.1 The soil absorption trench shall be constructed by excavating a level trench to a depth of 12 feet below the origiual ground level in the vicinity of test hole # 1.. The contractor shall verify that gravity flow can be achieved fi'om the proposed residence; if not an approved lift station will have to be installed. 3.2 No portion of the trench which runs parallel to thc south property linc shall Dc no closer tlan~ 10 feet from the property line as located by a land smweyor. 3.3 A total of 5.5 feet of approved sewer gn'avel shall be placed in the bottom of the excavation with the perforated distribution pipes laid level such that the pipe inverts are no less than 60 inches above the bottom of the sewer gravel. Sewer gravel shall be 0.5" - 2.5" screened gravel, with less than 3% passing the #200 sieve. 3.4 Monitor tubes and cleanout pipes shall be of 4" diameter and installed in the locations shown on the design drawings. The portion of the monitor tube extending threugh the sewer gravel shall be perforated. 3.5 Approved filter fabric shall be placed over the entire top sm'face of the sewer gravel before backfill with unclassified soil. The top surface of the cover material shall be raised a minimum of 6 inches higher thau the sm'rounding terrain to allow for sabsequent settlement, and shall be graded to smooth contom's. Fill slopes shall be no steeper than 3:1. 3.6 After the installation is complete, tile owner shall be responsible for ensuring that all m'eas distm'bed by the construction m'e covered with 4 inches of topsoil and seeded to promote rapid revegetation. 4.0 Inspections: 4.1 A total of 4 engineering inspections will be required during the course of the pi'oject: (1) initial stakeout with the contractor to establish the location of the system and to discuss the plans, specifications and construction procedures, (2) after the native material has been excavated to expose the infilu'ative surface to ensure that it is level and at the right elevation, and coafonns with the soil test information, (3) after the sewer gravel is iu place and the distribution pipes have been laid and connected up to the septic tank, but prior to placement of insulation or filter fabric, and (4) after final backfill and grading is complete. The septic tank requires one inspection after it is set level and the piping connectexl, but prior to backfill. This inspection may be incorporated with any of the above inspections. 4.2 The installer shall coordinate tile timing of the inspections with the engineer sufficiently far in advance to ensure the availability of the engineer. Plcdtop Technlccd Services 14530 Echo Slreet Anchorcrcre, Alcmkcr 99516 Munlcll~allty olAncnorage DEPARTMENT OF HEALTFI & HUMAN SERVICES 825 %" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST -i-. g. ~t I:R.ORM.D POR . N1/ X 6PR&NO LEGAL DESCRIPTION: ]OT 2, T£LE ~1/~ R ~ 1 2 3 4 5 6 7 8, 9- 10- 11 12 13' FS 14 · ·15 16 17 18, ~9- 20- ~T SM REDDISI~I 5ANb¥ ~ ILL~ Township, Range, Section: SEC :23 SLOPE B f'?o~N 5 Cl G HTL,/ SILT'( 5ANbY LOAt.1 WAS GROUND WATER Gross Time CLAS~IFIE'b COMMENt'S .HA?E~IAL Date -'~ Net Time PERCOLATION RAJE ~"<~ ._ utes/inch) PERC HOLF 1~' , RUNBETWEEN ~.~ Ii AND '7 _FY "rile ~,Hhlg F,%~ I,E ~ I~ ~L~H~fl~HER~ Depth to Net Water Drop R (0LO~ ~ ~lb CON~ENT. ~CT ~OLE SIDE~A~L~ ~E~E SrA~LE, UNbE~Ly~. ~oucb ~LLo~ _INST~(~T/O~ FLATTOP Fc5. CERHFYTHATTHISTESTWASPERFORMEDiN AOOORDANOE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE, DATE; ~/~ /~ ~ 72-~8(Rev. 4/85) oF TRENCg ~VPE 5YST6~. --' PERFORMED FOR: · Flattop Techn[ca! Services 14530 Echo Street Anchoracm, Alqska 99518 MunlcllSality olAncnorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0850 SOILS LOG -- PERCOLATION TEST T.H. ~2 LEGAL DESCRIPTION: 1 2 3 4 5 6 7- 8- 9 10 11 12 PT ~L (~ R',~'{ SANby SILT 13' 'lownship, Range, Section: .~EC 23 SLOPE CLEAN sANDY ~',~,AVEL L~NSE~ OF GI~AV&LLV 5AND~ q , ~'~ WAS GROUND WATER ~ A~5~ ' ~ ENCOUNTERED7 14 I~-~o '15, 16- 17- 18-¸ I9 2O IF YES, AT WHAT OL DEPTH? 1~.7~/ -- p Oeplh lo Water Aller ,, G/2 ~//~Z ~ MonlloriaD? ~.7 Dale: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE _ --- (m,nuteshnch) PERC HOLE DI,AMETER TEST RUN BETWEEN .... FT AND __ FT COMMENTS ._N.ATERIA C 5ANb STRATu~ THe D~6~ WIC~_ .~._~__ ~E~T~__~.sA~ FILTEr. PER~ORMEDaY: ¢~A'[;~ %~'Cg ~(:5 ~ ~ ~ CER~ffY'rlIA}TrlIS~ESrWASFERFORMEDiN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFEC] ON 72-~8 (Rev. 4/85) P.[at~op Technical Services 14530 .Echo Street Anchorac~e, Alqska S9518 Munlcll~allly olAncnorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0550 SOILS LOG -- PERCOLATION TEST T.H, ~ PEREO, MED LEGAl DESCRIPTION: SM REDDISIq SAnDy ~P SANb¥ GF~FEL. ML G;~A'f SILT ,Lo,q M 1 2 3 4 Townshqa, Range, Section: ~EC 2 3 SLOPE Oeplh Io Water Alter ~)~'f _ 14 15 16 17, 18- 19- 20 Reading Date Gross [ Net Depth to Net Time Tired Water Drop PERCOLATION RATE ..... (mmuloshnch) PERC HOLE COMMENTS '~T£~'I/~L LESS SUITABLE .._T_~_A~_ _7~Z. ~.~T~__~ t1,'~ To SILT LE~St'~ C~uSIHG ~ERC~IF~ ~_, ACCORDANCE WITH ALL STATE AND MUNICIPAL GUiDELINES iN EFFE01 ON THIS DATE. DATE: ~_./~ Parcel I.D. # 1, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICE& 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 DWEL LING " ©~ 5 ~ 7.3 - I~'~' HAA# ~. ~)_~L~,(~ GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address ~,u / )c~',,e r- 6 Day phone _..~c~'- Z / 7-, ~L· ~or,~C,~,'~'/' F~mn m Day phone ',' Day phone Unless otherwise requested, HAA will be held for pickup. 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: 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. 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(Rov, 1/91) Front MOA#21 ')IJOM S,JeOU]~U@ F~uO!SSO~.oJd GH~. U! SUOIb%'ILUO JO S JO J J@ JOJ elqlsuodseJ lOU s! eBeJOtlOuV ,~o Xi!l~d!o!unl~ eqI 'penes! s! eleo!,t!14ao ~ eJojeq eleP ezXleue Jo suo!1oedsu! lonpuoo lou op SHH(3 ,~o seeXoldU~a 'slueu~eJ!nbeJ e3~ls pue leJ@pe,t u!e~Jeo ~s!l~s oj Jap Jo u! suo!lnl!]Su! t~u!puel J!eql pue SeLUOq ~O sJ~s~qoJnd o] XselJnoo ~ se s!qi s~op SH HQ eq/'~>lSelV,tO e~elS eq] u[ peJe~,s!6eJ J@~u!l~ue l~uo!sseJoJd ),uepu~depu! ug Xq o^oqg g qdeJaeJBd u! us^!8 suo!]91ueseJdeJ aq~ uodn XIUO p@s~q s~]~o!t!PeO Ie^oJddv X~!joq]nv qll~aFI sanss! (8HHO) seoFueS u~u~nH pu~ qll~H Jo lueu4p~dac] aa~Joqouv ~o ~!l~d!o]Un!AI eq.L s~uaLuuJoo IgUOp,!ppv :suo!~glndR9 6u!A~OllO~ e4~ 4~!/~ 'awoo~peq Jo~ leAoJdd~ IgUO!~!puoo 'peAoJddes!O '~'?"; 'aLUOO~peq ~ JoJ pe^oJdd¥ ~ 3~I3.LYNOIS SHHO '9 eJ n~,euais s,Jeeu!§u=l ~/.f_-~.~' / 02, sse~pp¥ · uo!~oadau! 9!q~ jo e~,gp eq~ uo ~oajJ, e u! suop, elnaaJ pue 'seoueu!pJo 'sepoo e~g~9 pue Igd!o!unlA~ I1~ q~!A~ eougHduuoo u! 9! uJe~aX9 Igaoda!p Ja~gA~e3ag/~ Jo/pug Xlddn9 Je~gA~ m49-uo eq), 'uo!~oadsu! pug UO!~gap, SeAU! XUJ uJoJJ pug Sel!J eagJoqou¥ Jo ~!lgdio!un~ aq~, tuoJ~ peu!g~qo uo!~guJJoju! eq~ uo peagq ~,gq~ XJ!JeA JaqlJn;t I 'u!eJeq pe~eo!pu! eJn~onJ~9 jo ed/q pue sLuooJpeq JO JaqLunu eq1 Jo~ e~gnbepe pue lguol~ounj 'ejgs s! uJe~9/~9 Igaoda!p JeleA~e~sgt~ Jo/pug Xlddn9 Jm, e~ e]is-uo eq~, 3eq~ st~oqs uop, goHddg IgAo~ddv/q!Joq),nv q~leeH s!q3 jo uo!~ea!~ae^u! XuJ ~gq~ ~!JeA I 'A~oleq u~oqs e~gp uop, gp!lgA aq~, Jo 9g pug o~eJeq pax!~g Iga9 ~uJ Xq pe!J!lJaO 9¥ M:::I~INI~)N=1 AG NOIJLO:IdSNI -I0 .LN~IlN~J. VJ.S Municipality of Anchorage Department of Health and Human Services HEALTH AUTHOFIITY APPROVAL CHECKLIST A, Well Data Well type ~rO~c~_~ Log present (Y/N) Total depth Sanitary seal (Y/N) Parcel I.D. If A, B, or C, attach ADEC letter. ADEC water system number y Date completed I1/¢"7/~ Driller j'~/F/.~, /',¢ '~,_ Cased to z¢~ Casing height y Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION ~ ¢ g.p,m, g,p.m~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot I o O + Public sewer main I 0 ~ '-~ Sewer service line I O oq' I o~q- ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~,~ Nitrate _ ~. '~ '7._ Date of sample: /~-/~0/ ~ '-~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~/ Iq { q "~ Cleanouts (Y/N) "/ High water alarm (Y/N) Date of pumping Tank size I ~ c~ ~ Compartments Foundation cleanout (Y/N) 7 Depression (Y/N) _ -- Alarm tested (Y/N) '--- .~'~ ~ -~- c'~r/~, Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / p c, ~ On adjacent lots To property line .~c~ 4- Absorption field Sudace water/drainage I O O -P- Foundation Water main/service line 72-026 (3/93)" Fron~ CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level z¢ ~," Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer /~/V¢-~, r~..~ ~/~/d ~.~ ~.~ ~)_ Manhole/A~ess (Y/N) ~ "Pump off" Level at ~" ~ / t Cycles test~ ~ ~ ~C~Dr ~ SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot I ~o-'P On adjacent lots leo'F- Surface water ( Oo D. ABSORPTION FIELD DATA Date installed ~-- 1 ot - ¢1' "~ Length ~-'O Width Total absorption area I ~O O ~ .-F Cleanout present (Y/N) Date of adequacy test ~Results (pass/fail) Water level in absorption field before test '--- Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/Ft2) O. Gravel thickness ¥ System type /'4,~u I Total depth ~ Depression over field (Y/N) for -- After test If yes, give date -- Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Sudace water I Curtain drain On adjacent 10ts / 0 0 -~ Property line ~43 ~ TO existing or abandoned system on lot Cutbank / ~ o 4- Water main/service line Driveway, parking/vehicle storage area ! 0 E, ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effectO~"i~"e~'ie:6Hhi$ inspection. Signature ~.~~ Engineer's Name HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)° Back 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) PrQperty owner Mailing address Lending agency 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 ,/ 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#21 5. STATEMENT OF INSPECTION BY ENGINEER As certified bymy 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 wasteweter disposal system is safe, functional and adequate for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. NameofFirm "-~b~ Sp~'c~-L,~~:2 "~-~. Phone ~/-~¢rlG, Address ~12.O..~ t.¢/ /.~/--~ ~'~ ,¢4~ Engineer's signature ~ ~ Date l1 z~/,~ ~{ DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Munlcil~ality of An. cborage 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72~25(Rev, 1/9~) Back MOA#21 Municipality of Anchorage Department of Health and Fluman Services HEAl_TH AUTHORITY APPROVAL CHECKLIST LegalDescription: L.¢'/: ~ -T"c~,/,~.~4,c,,ck ~,;~,l.s ParcelI.D. 01~5 - ,¢-~/'-~A A. Well Data Well type '~ Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~/¢' ¢/~ ~ Driller Cased to ~ ( Casing height FROM WELL LOG Date of test ¢~"~Y [~ ~ Static water level I ~ Well flow ~ Pump level1 '~o ~/'¢' ~,4 SEPARATION DISTANCES FROM WE"LL TO: Septic/holding tank on lot LC Absorption field on lot Public sewer main Sewer service line Wires properly protected (Y/N) AT INSPECTION g.p.m. .g.p,m. ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ~ ~ Other bacteria Collected by: '~-'~'~ ~ lB. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) "/ High water alarm (Y/N) Date of pumping Tank size / ~-6~¢,,) Compadments ~ Foundation cleanout (Y/N) '-/ .Depression (Y/N) / 1"'//'/~ Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot /7/%0 To property line ~0 Surface water/drainage 72-026 (3/93)* Front On adjacent lots Absorption field Foundation Water main/service line CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) '"J "Pump on" level at High water alarm level Meets MOA electrical codes (Y/N) Manufacturer A~ ¢-.~ Manhole/Access (Y/N) ~z 22 "Pump off" Level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot z~ ~ On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 'Z'/~,4> z/~ .~ Length ~ C) ~ Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Width Soil rating (GPD/FF) Gravel thickness Cleanout present (Y/N) ~ Results (pass/fail) -~ System type 7/t.~.c4r ~-~ 7 Total depth Depression over field (Y/N) ~,-/ for L/ Bedrooms After test If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ ~ To building foundation On adjacent lots _'~ Surface water /'~ Curtain drain /~/ E. ENGINEER'S CERTIFICATION On adjacent lots /% /0¢.4~' Property line To existing or abandoned system on lot Cutb~nk /,~' '~ Water main/service line Driveway, parking/vehicle storage area I cedify that I have chocked, verified, or conformed to all MOA and HAA guidelines in effect,~r~ th¢,clate.o..f.this inspection. Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back From : I~LPINE DRILL 90? 345 02~12 q PO3 Jan. 16.19.4 10:48 PH  cOMNIERCI -- ENVIRONMENTAL LA .......... . ...... ~- ' .... ' ........ ' ..... "ri REpoRT of ANhLYSIS ^NoHOR^eE,^~5~ ,'~ ker~t Sample ID :11600 MooSE/LOT 3 LILWORI( ltlI,LS ,,HATER Name : At,¥'~[NE DRILLING Ol:'dex~ed By %'ro~ect~ ........ ' .... -- ~ ,cTED BY. A,D. · ~e Remarks: ROUI'INI~ S~tltq~E cOLLF., ~ORK order :74554 Report Completed :01/04/94 Collected ~/30/93 ~ 16~48 Technical Direc~O Released By : ~,~__,;x~ ~_~_ Qc ReSUltS Q~]al u~its Parameter ................ .... 3.72 mg/L EPA 353,2/300.0 lq it['ate.'-N Method Limits Date Date 10 01/03 See Special Instructions Above NA = Not Anal~ ,, See S~mple Remarks Above nna~e~ete~, Reported value is the practical quantification limit., LT = Less Thai GT = Greate~ ' ENVIRONMENTAL LABORATORY SERVICES Drinking Water Analysis Report for Total Coliform Bacteria .99 8 8TR E* ANCHORAGE, AK 99518 READ INSTRUCTIONS ON REVERSE SIDE BEFORE COLLECTING sAMpLE TEL: (907) 562-2343 FAX: (907) 581.5301 [] Send Results [] Send lnvoice [] Send Results [] Send lnvoice SAMPLE DATE: Month Day Year SAMPLE TYPE: '¢, Routine [] Treated Water [] Repeat Sample (for routine sample ~ Untreated Water with lab ref. no. ) [] Special Purpose Time Collected Collected By SAMPLE LOCATION TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: Safisfactmy Unsatisfactory [] Sample over 30 hours old, results may be unreliable [] Sample too long in transit; smnple should not be over 48 hours old at examination to indicate reliable results. Please send new sample via speci,al ~elivery mall. Date Received Time Received __ Analysis Began Analytical Method: r~embrane Filter [] MMO-MUG * Number of colonies/100 mi. Lab Ref. No. Result* ,'4.0:31_-,3 .~ ~ I h~l Sent toA. D.E.C. dAm:k) Fbl~ Jun Cllent notified of unsatisfactory results: Phoned Spoke with Analyst Faxed Faxed Date: Time: BACTERIOLOGICAL WATER ANALYSIS RECORD i~VfO-MUG Result: Total Coliform E. Coil MembraneFilter: Direct Count ¢ _ Colonies/100~ml Verification: LTB BGB COLEFIRM Fecal Coliform Confirmation Final Membrane Filter Results Reported ByF/~ ~L~//~'] Coliform/100 mi Date / ~Z/~' ~c~L Time /~t~) hrs ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MAR PART ONE 0F TWO: REMAINDER TO FOLLOW C].l. un[;" d, ,,.Ill/b-([1) *[,2 Tt'[,lgr'lhR( H~LI,,L,S Commercial Testing & Engineering Co. Environmental Laboratory Services ~r~r~.~,~r~j-~sr~,~-~,-~r~.~J~2qr~-~~~ RI;',POR'P oF hlqhlLY~Ji,~3 5633 B Street :94.0303 i Anchorage, AK 99518-1600 Tel: (907} 562-2343 Fax: (907) 561-5301 OYOered By ~TOBBE~q 13PURKE,ANi) R,~po~fl. CompZol;ed ~01/25/94 P~7)jeet:~ : RoteS.red :01/1.9/9d I~ VI:00 h~:~;. fi~)f~p].e Ro~a t'k~;: ROUT'II'Ii): BA[IPLE; COI',LgCTt.;D BY: ',P. g. / ' ll ::; IJt'ld'~'e" c,d Repot'bed va].ue :ira l:ho [)ra(:;[;J.(:ol "" .... ' ~ ' . lin ',~I D :: gf}eOrt(I/:li?V (]J.JA1;:J. OY/, G'.[' : (~1(.''' tl'(.'l' ~ ~1)~ Member of the SGS Group (Soci*tb G~n~rale de Surveillance) ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA