HomeMy WebLinkAboutTANAINA VALLEY LT 8 MUNICIPALITY OF ANCHORAGE
DFPAR'rMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "[." Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELl. INSPECTION REPORT
Na,,e DISTANCES
~'~/~/~ S /A./ !~J'gD,O Z~ ~ Tn SEPTIC ABSORPTION --
AddressFllOM -""~ TANK FIELD WELL
-- LEGAL e~SCRIPTION LOT LINE
Township, Range, Secl~o~ ~S-BUILT DIAGRAM (Show Ioc~iion of well. septic system, properly hnes, foundation~
TANKS
~ SEPTIC ~ HOLDING ''~
TYPE OF SYSTEM
~ TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to pipe bottom Item To~al depth from original grade
°riginamgrade ~ F~__ ~ FI'
gill added above odgmal grade Gravel depth beneath pipe
~ FT ~ FT
WELLS ~ _ ~ ' - ~ - /
~ PRIVATE ~ OTHER (Identify)
REMARKS:
Inspections Performed by:
I /~'~ ~ ~o~OW --edily m., this inspec,,o, was pedor.ed accordln] lo all
zs &8
72-013 (3/85)
M U N I C :[ I::' A t., I T ¥ [3 F A Iq (] 1"4 O F/ A G Iii:
F~ng ineer, Designed
Ch,~r~ep Nam~;~: DEE~II:!HqS IN WDI]D
l)~y F'hl~ne ~
:~ 49...80 ~1. 4
L. crL I._egaln !~h.d:)d:Lvision,", TANAINA VAI...,LEY i..,c;t." 8
Sectic~r~ 4 'l'o~r~h~p~ ],22N Range~ 3W
Lot S:i. ze :];~796 (sq., ft. of acr'e~O
Max Bec:lpoomsJn Th:i.s I::'er'r~H.'L~ 4 Total
SI!H::'"I'IC "I'ANI.::.:: M:Ln:Lmur~ 'Lo'Lal sep'Lic tank capac:tty'.'
f i:?~}~ t p ~ ql,t :L P (~!~i; i r'l~ L.~ ], a t, J. C)l'l (:tv E:~ P '~,, a r~ k ( !!]~ ) ,,
Each s~pt :i,c:
t, ank (s) < 4,,()
II\IFOF?M D. H,, H,, ,"'3. PRIOR TC) IST &, :.*IxID INSPECTIDN~3 BY EN[~INEEF(,
AFTE[R OI=F*I[:;E I"IDLJR',~ CALJ... 343'""Zl, 6E~l AND LEAVE A MESSAGE.
CDIxI~gTFdJE;T PER EIqGINEERS ATTACHED AF:'F'ROVED DESIGN.
]"H I ~':J J::'El::dvl I 'f' EXF'I I~E:~Ei :L~?/3 :L/~8.
TH I S F~EF~M I'l VAI.., ~ D FOR ~ ~ I NDLI~: I:'~MI I..Y RE81DENCE ONLY,,
'[ F'
I CEI:(I'II='Y THAI':
1. ): am f'amilial~ with 'Lhe pel:JL~,PemerrL!,-] fDr' or'l-si'Le sewep~ and wells as set
[or"t'.h by the Mur~icil)a].J.'Ly o~' Anchorage (M[)~) and the g'L~t:e cH' A].a~ka,,
'~],, I ~n:i, 1]. ins'La],]. 'Lhe system in acc:or, danc~ with all MOA c:c~t:Je~i and pegu],at:i,c)ns,
and in ct:)rilp],J, arH::le wit. h {he clesJ, gr~ (:Pit~?pJ.a C]f this pepnli'L,,
3. I t~:i.].:l, adh~r'c~ 'Lo all M[:I~ and ~3tat, eaf t~lasl.,:a Peqt,.tipemerl~s f't:J" the set. back
~}~('~)~(:~P~;~g(':~) J~y~Bt,(~flJ (:')n th~,~ (~[x any adjac:ent
Z L.tricJel"5~]',ancJ tha'L this per'm:tt is
an] ~,nl,'~,'gemen.L~ ~ --]:1'1 r'equ:Lp~ addi'L:i.c~n~], pe~m:L'L. '
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG ~ PERCOLATION TEST
LEGAL DESCRIPTION:
5-
6-
7-
8
9
10
11
12
13
14
15
16
17
18
19
20
(z t~"A 1)
Township, Range, Section:
EITE PLAN
SI.OPE
WAS GROUND WATL"R
ENCOUNTERED?
&
&:/~,
~.,2~
$
YES, AT WHAT
DEPTH? p
E
De~ I~ wa~' After
Mmliloring? /i/~ VJAT~[~'Dila
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE .-.-~? (m~nutes~inch) PERC HOLE DIAMETER ~"
TEST RUN BETWEEN -/7 FT AND ~.~ FT
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4/~)
¢- 2C
c-[-sw
3
,)0' E;i.~e. &
210.4I'
6
%/00'
14
15
16
13
Michoel E. Anderson
4381 -E
12
¢-$ lite
MUMC�PALETY OF
0 ''F
Development Services Department
On -Site Water & Wastewater Section
Parcel I.D. 011-051-83
Certificate of On -Site Systems Approval
1. GENERAL INFORMATION
Complete legal description TANAINA VALLEY LOT 8
Location (site address) 7070 LOWELL CIRCLE, ANCHORAG
Current property owner(s) JOHN & LINDA LOU THIES
Mailing address 7070 LOWELL CIRCLE, ANCHO
Real estate agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY:
Private Well
❑
Water Storage
❑
Community Well
❑
Public Water System
Public Sewer
Phone: 907-343-7904
Fax: 907-343-7997
Expiration Date: UGt,n
Day phone
AK 99502
Day phone
TYPE OF WASTEWATER DISPOSAL:
Private Septic
Holding Tank
❑
Community
❑
Public Sewer
❑
Waiver request for: Distance:
Received by: Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $ 412.501 COVID
Date of Payment I �''30''� 02 0
Receipt Number 71 b 3 z 3
COSA # OSC201701
Waiver Fee $
Date of Payment
Receipt Number
Waiver #
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation, based
on procedures outlined in the Certificate of On -Site Systems 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. I acknowledge that On -Site staff may visit the site to verify the information submitted.
Name of Firm FIRST WATER CONSULTING Phone 907-350-9566
Address 13030 SUES WAY ANCHORAGE AK 99516
Engineer's Printed Name CURTIS HUFFMAN PE Date 12/29/2020
Comments: This investigation was completed in compliance with MOA guidelines, regulations,
and best industry practices ( methods. The assessment of the condition of the well and septic
applies only to the conditions as of the day tested. The flow and absorption rates may change
due to subsurface conditions that may not be observed from the surface, changes in land use,
local soil characteristics, groundwater levels that may fluctuate during the year, quality of
construction (workmanship & materials), the water usage of the family being served by the
system and maintenance. The operational life of all well and septic systems are subject to
these various and dynamic characteristics and are outside the control of the evaluator of the
Therefore, how long function
o •�• e�
• • • • :1
�$
well and septic system. any estimate of a system will satisfactory
for current or future occupants or guarantee that no unseen encroachments, deficiencies or
�m'��4: • 9 !,
TH ••
discrepancies exist can be given by First Water Consulting & FWfS .
........
.:.
;V1.
®
6. DSD SIGNATURE
.�......;
. ....`..::
Curtis Huffman
System #1 Approved for bedrooms
�}�Fc/sT . 128991law
•CE
System #2 Approved for bedrooms
QPROF SSIONESSOP'"
��N0 �
Disapproved
Conditional approval for bedrooms, with the following stipulations:
By: Original Certificate Date: 5d�
g
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the
representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is
not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA Checklist
Legal Description: TANAINA VALLEY LOT 8 Parcel ID: 011-051-83
If more than 1 septic system on lot: COSA Checklist #
of
Structure served by this system
A. WELL DATA – PUBLIC WATER
Well log is filed with Onsite (or attached)
Date drilled
Total depth ft
Cased to ft
Sanitary seal is functioning correctly
Wires are properly protected
Casing height (above ground) in.
Date of flow test for COSA
Static water level at beginning of test ft.
Well production at time of test gpm
Water storage tank volume gallons
Well disinfected for coliform test? Yes No
Coliform bacteria is Negative
Nitrate mg/L Nitrate less than MRL (ND)
Arsenic ug/L Arsenic less than MRL (ND)
Collected by
Date of Sample
Comments __________________________________________________________________________________
B. TANK DATA
Age of tank(s) 5 years
Tank type/material SEPTIC / HDPE
Measured operating fluid level in septic tank 48”
Standpipes/foundation cleanout per record drawing
Date of pumping 12/17/2020
C. LIFT STATION
Required maintenance completed
Age of lift station years
Lift station material
Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 5/22/2015
ALL standpipes present per record drawing
Total measured depth from grade 10.9 ft (max)
Measured depth to pipe invert from grade 5.9 ft (min)
N/A – pressurized field
Monitor tubes go to bottom of effective. If not, state
depth into effective
Code-required soil cover over field
System presoaked
(Required if vacant for greater than 30 days prior to
date of test)
Gallons introduced gallons
Adequacy test date 12/29/2020
Results Pass For 4 bedrooms
Fluid depth prior to test 5 in
Water added 640 gal
New depth 15 in
Elapsed time 90 min
Final fluid depth 5 in
Absorption rate 600 gpd
Any rejuvenation treatment (past 12 months) N
If yes, enter date
Comments/Deficiencies: Tested west trench only. East trench 4” of fluid / sludge.
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well) NA PUBLIC WATER
Septic Tank/Lift Station on Lot > 100’
Yes if No
ft
Neighboring Tank > 100’ Yes if No
ft
Absorption Field on Lot > 100’ Yes if No
ft
Neighboring Absorption Fields > 100’
Yes if No
ft
Community Sewer Main > 75’ Yes if No
ft
Community Sewer Manhole/Cleanout > 100’
Yes if No
ft
Private Sewer/Septic Line > 25’ Yes if No
ft
Holding Tank > 100’ Yes if No
ft
Animal Containment > 50’ Yes if No
ft
Manure/Animal Excreta Storage > 100’
Yes if No
ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10’ Yes if No *5+ ft
Property Line > 5’ Yes if No
ft
Absorption Field > 5’ Yes if No
ft
Water Main > 10’ Yes if No
ft
Water Service Line > 10’ Yes if No
ft
Surface Water > 100’ Yes if No
ft
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No
ft
Community Wells > 200’ Yes if No
ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10’ Yes if No
ft
Property Line > 10’ Yes if No ft
Water Main > 10’ Yes if No
ft
Water Service Line > 10’ Yes if No
ft
Surface Water > 100’ Yes if No
ft
If absorption field is under driveway comment below
Wells on Adjacent Lots:
Private Wells > 100’ Yes if No ft
Community Wells > 200’ Yes if No
F. ENGINEER’S COMMENTS
*PER CODE AT TIME OF INSTALLATION.
G. ENGINEER’S CERTIFICATION
I certify that I have determined through field inspections and review
of Municipal records that the above systems are in conformance
with MOA COSA guidelines in effect on this date.
12/30/2020
4 -
P'4E•
,rte Municipality of Anchorage BL•
1_ On-Site Water&Wastewater Program 0z
(907) 343-7904 3 = 6 7a , sA .Y
CERTIFICATE OF ON-SITE SYSTEMS AP ". VALOR 2�'9
k
o G
Parcel I.D. 011-051-83 Expiration Date: l
1. GENERAL INFORMATION
Complete legal description TANAINA VALLEY; LOT 8
Location (site address) 7070 LOWELL*ANCHORAGE,AK 99502
Current Property owner(s) JOE MORAN Day phone 907-440-0891
Mailing address
Real Estate Agent Day phone
2. TYPE OF DWELLING:
El Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 4
4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:
Individual Well ❑ Individual On-site
Individual Water Storage ❑ Individual Holding tank ❑
Community Class Well Community On-site ❑
Public Water System Public Sewer ❑
WaiverNariance request for: N/A
Distance:
Received by: Date:
COSA to be released to the engineer,unless otherwise requested by the engineer.
COSA Fee $ 55/ Waiver Fee$
Date of Payment q/5119 Date of Payment
Receipt Number O7 ?O 8(7 Receipt Number
COSA# 06C/90615- Waiver#
c
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation, based on procedures outlined in the Certificate of On-Site Systems 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.
Name of Firm GARNESS ENGINEERING GROUP, Ltd. Phone 337-6179
Address 3701 E. TUDOR ROAD, SUITE 101 *ANCHORAGE,AK, 99507 rr��
Engineers Printed Name JEFFREY A. GARNESS, P.E. Date -1 h/i
9
Engineer's Comments:
In conducting this evaluation,GEG provided an engineering evaluation of the well and/or septic system in accordance with the �oloisli•11%4,
guidelines and regulations established by the Municipality of Anchorage and industry practices.The reported results describe the ...•�G OFr 4.♦
condition of the system/s on the date/s of the evaluation.Separation distances were measured to readily identifiable features. .��P .�
Hidden defects or encroachments may exist that were not identified during the evaluation.The operational life of all wells and septic •C,.' •• •• v. •
systems depend on a variety of variables including,but not limited to,soil conditions,groundwater levels(that may fluctuate during `) ••• e
the year),quality of construction(materials and workmanship),and the water usage of the family utilizing the system/s.These = *z• A ; '....1‘ ••:* ��
RI
conditions can vary,and are outside the control of GEG.Satisfactory test results do not guarantee future performance of the % • ,,,, 0
system/s:therefore,GEG makes no warranty(express or implied)regarding the future performance of the well or septic system. •
• •
GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the ,
current systems fail.The content of this report is for the sole benefit of the person/party who retained GEG.Reliance upon the • • • •r' s' .
information provided in this report by any other person or party,including but not limited to subsequent properly purchasers,is not • 0 t• C V' 1
authorized.In short,GEG disavows any legal duty to anyone other than the person/party who paid for this report. .tP Or,• \a;
6. DSD SIGNATURE ••�N tWOOFE 1�C�P�, +
LICENSE 4h E�`��44
#AECC884 ,,",,
1 System#1 Approved for LI bedrooms.
System#2 Approved for bedrooms.
Disapproved. , ,t_,
Conditional approval for bedrooms, with the following stipulatibns:O _S1�E �Gc'
5 wp,SER p,N� z
,„‘Np,TFRn
o`1) pROGRrM o
.70Iii`krr Sol\i\C'
4 By: ( , /M. r- Original Certificate Date: Li rfiO-11
The Municipality or Anchorage Develop,emt Services Division(DSD)issues Certificates of On-Site Systems Approval(COSA)based only
upon the represenatations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTCHMENTS:
COSA Checklist ?C Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
(Rev.10/12/121
COSA Checklist
Legal Description: TANAINA VALLEY; LOT 8 Parcel ID: 011-051-83
If more than 1 septic system on lot: COSA Checklist# of Structure served by this system
A. WELL DATA (kj)()1:1 vv
❑ Well log is filed with Onsite (or attached) Well production at time of test gpm
Date drilled Water storage tank volume gallons
Total depth ft Well disinfected for coliform test? ❑ Yes ❑ No
Cased to ft ❑ Coliform bacteria is Negative
❑ Sanitary seal is functioning correctly Nitrate mg/L ❑ Nitrate less than MRL (ND)
❑ Wires are properly protected Arsenic ug/L ❑ Arsenic less than MRL (ND)
Casing height(above ground) in. Collected by
Date of flow test for COSA Date of Sample
Static water level at beginning of test ft.
Comments
B. TANK DATA C. LIFT STATION
Age of tank(s) 4 years ❑ Required maintenance completed
Tank type/material Age of lift station years
■❑ Standpipes/foundation cleanout per record drawing Lift station material
Date of pumping—71i e J f Comments:
D. ABSORPTION FIELD DATA
Which system tested (date installed) 5/2015 Adequacy test date 3/26/19
❑■ ALL standpipes present per record drawing Results ✓❑Pass For 4 bedrooms
Total measured depth from grade 9.5+ ft(max) Fluid depth prior to test 3 in
Measured depth to pipe invert from grade 5+ ft(min) Water added 655 gal
❑ N/A—pressurized field
New depth 4 in
❑ Monitor tubes go to bottom of drainfield. If not, state
depth into effective 525 Elapsed time 75 min
❑■ Code-required soil cover over field Final fluid depth 3 in
❑ System presoaked Absorption rate 600+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment(past 12 months) N/A
date of test) N/A
Gallons introduced N/A gallons If yes, enter date
Comments/Deficiencies: TESTED WEST TRENCH ONLY
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot> 100' Community Sewer Manhole/Cleanout> 100'
❑Yes if No ft 0 Yes if No ft
Neighboring Tank > 100' DYes if No ft Private Sewer/Septic Line > 25' DYes if No ft
Absorption Field on Lot > 100' ❑Yes if No ft Holding Tank > 100' ❑Yes if No ft
Neighboring Absorption Fields > 100' Animal Containment> 50' ❑Yes if No ft
0 Yes if No ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' 0 Yes if No ft DYes if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No 6 4- ft Surface Water> 100' 0 Yes if No ft
Property Line > 5' 0Yes if No ft Driveway/Parking > 0' D Yes if No, comment
Absorption Field > 5' 0/ Yes if No ft Wells on Adjacent Lots:
Water Main > 10' 2 Yes if No ft Private Wells > 100' 2 Yes if No ft
Water Service Line > 10' ['Yes if No ft Community Wells > 200' 0 Yes if No ft
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10' 0 Yes if No ft Driveway/Parking > 0' 2 Yes if No, comment
Property Line > 10' 2 Yes if No ft Wells on Adjacent Lots:
Water Main > 10' ❑✓ Yes if No ft Private Wells > 100' 0✓ Yes if No ft
Water Service Line > 10' 0./ Yes if No ft Community Wells > 200' 0 Yes if No ft
Surface Water> 100' 0 Yes if No ft
F. ENGINEER'S COMMENTS
*5'+ MET CODE AT TIME OF INSTALLATION
0o600vp
0 F ''r1 ���a0
G. ENGINEER'S CERTIFICATION o� 9s��
I certify that I have determined through field inspections and reviewIQ
of Municipal records that the above systems are conformance with '. / T I %�*06,
MOA COSA guidelines in effect on this date.
v VA
VA
0 /' ,
/O ••J:'f ey ness.
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COSA Checklist yellow sheet 4�%%\-\ �p�Oo
#AECC884
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4/6.71?49+Gp.
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13 WATER(/NE EASEMENT /
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N 81 58
48-w 8539 oi
/ AS-BUILT SURVEY 1" = 30'
a
v
LJ )RrLFS sE"T,-IS C.,-E
/
0000OOOp� I HEREBY CERTIFY THAT I HAVE PERFORMED A SURVEY
�' OF A 4'4% OF THE FOLLOWING DESCRIBED PROPERTY
LOT 8, TANAINA VALLEY SUB.
Q n�P `11� 4410o0 ANCHORAGE RECORDING DISTRICT, ALASKA, AND THAT THE
�Gj 49 TH %0
GID VISIBLE IMPROVEMENTS SITUATED THEREON ARE WITHIN
,,�� /7�`��A THE PROPERTY LINES AND NO VISIBLE ENCROACHMENTS
foitS,f/. ,DTHE INFORMATION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SHOW ANY
CONFLICTS BETWEEN EXISTING STRUCTURES AND PLATTED LOT LINES AND/OR EASEMENTS; AND ISEXIST OTHER THAN NOTED.
0y SHANEA.HOLT X00 NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES, IMPROVEMENTS, OR FENCELINES. DATED AT ANCHORAGE,ALASKA THIS _ 2 ND DAY OF
00�• LS-6914 y4 40 EASEMENTS OF RECORD, OTHER THAN THOSE APPEARING ON THE RECORD PLAT , ARE NOT SHOWN ED) _APRIL , 2019
44prOfeasfona‘_bc NOTE: FENCELINES THAT HEREON ( UNLESS TMAY APPEAR ON THIS DRAWING ARE NOT TO BE USED TO DETERMNE
�k0PO4o� PROPERTY LINES OR POSITION ADDITIONAL IMPROVEMENTS. HOLT LAND SURVEYING
ANY PAVING SHOWN HEREON MAY BE APPROXIMATE DUE TO EXCESSIVE SNOW AND/OR ICE. 600 HIGHVIEW DRIVE
12815 FB 169-57 195-60 ANCHORAGE,AK 99515
345-5513
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF r.'NVIRONMENTAL SERVICES
343-4744
Parcel I.D. # _
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Telephone: (home)
~OL.4c~
Telephone
Location (address or directions)
(b) Property owner Z~E%i,~./d$ ?z./
Mailing Address '7~ ~- ( L~,'~! F7'-IWQo,D
(c) Lending Institution
Business ~,i?-~0 /.Cz
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here [:~qlr hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY
Individual Well []
Community ~ Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Coaservation attesting to th. legality and status.
4. SEWAGE DISPOSAL
On-site,j~ Public [] Community [] r Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 IRe¥.7/88) Page 1 of 2
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MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description: Lz~7~ ocr'
A. WELL DATA
Well Classification
Well Lgg Present (Y/N) Date Completed
Total Depth . Cased to. __ Depth of Grouting
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments ~F~--
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B, TA., DATA
Date .nsta,,ed Size
Standpipes (Y/N) __~/
Depression over Tank (Y/N) _
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) _ ~/,//-
SFPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
/,'~4:~ No. of Compartments _
Air-tight Caps (Y/N) ~/ F:oundation Cleanout (Y/N) _ //
Date Last Pumped ~.c)
/~ -~¢z~oO c"'_c~ >q%7- ; for
Temporary Holding Tank Permit (Y/N) .~/~
To Building Foundation
To Disposal Field ~'
To Water-Supply Well ,:~0 /
'To Property Line ~/'
To Water Main/8ervice Line __ ,~'?
To Stream, Pond, Lake or Major Drainage Oourse
Oomments
72-026 (Rev 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed /o- z :~ ~
Width of Field
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well ~ '?0 '
To Building Foundation ~- 7'
To Water Main/Service Line ~ ?
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Size in Galions~
"Pump On" Level at ~
High Water Alarm Level at ~
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pomp Off" Level at
Vent (Y/N)
~ ~ycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
S gned
Company //~J~ ~7~-~O
/0/~ 5'~/~ ~ Engineer's Seal
Date
MOA No.
Receipt No.
Date of Payment
Amount: $
72-026 {Rev 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORA6E/UESTERN DISTRICT OFFICE
3601 C STREET. SUITE 133d
ANCHORAGE. A[ASKA 99503
STEVE COWPER, GOVERNOR
563-i77s
To tJhom It May Concern:
Accordinq to the records on File in (his oF?ice, the
~,x.~ _L-:~_~d.%~.._kc~,,~,t~,~x~Ldater System is in compliance uith the
qtafe o¢ Alaska Orinkinq IJater Requlations.
Sincerely.
Environmental Field Officer