HomeMy WebLinkAboutGREEN PASTURES LT 2Onsite File
Green Pastures
Lot 2
#051-283-33
MUNICIPALITY OF ANCHORAGE
On -Site Water & Wastewater Program
PO Box 196650 4700 Elmore Road
Anchorage, Alaska 99519-6650 Phone: (907) 343-7904 Fax: (907) 343-7997
http://www.muni.org/onsite
On -Site Wastewater Disposal System Permit
Permit Number: OSP221230
Work Type: Septic Upgrade
Tax Code Number: 05128333000
Site Legal Address: GREEN PASTURES LT 2 G:0753
Site Mailing Address: 15660 CHRIS CT, Eagle River
Owner: JOHNSTON JEFFERY A& KATRINA P
Design Engineer: NORTH RIM ENGINEERING
This permit is for the construction of:
Effective Date:
Expiration Date
Lot Size in Sq Ft
Total Bedrooms:
�oIR
enr
c, 5`r•
Oil
Department
7/25/2022
7/25/2023
40228
Q Disposal Field 2 Septic Tank ❑ Holding Tank ❑ Privy ❑ Private Well ❑ 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
6
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Special Provisions: C07257- I De- e, n c, 6t n e- d Ae. � h ► , he -(,y ✓o'u7 �'`�afer 9/ &
1. 7 day groundwater monitoring is required. Construction may proceed at your own risk before the 7 day
watermonitoring is complete. Please submitstamped and signed results with the As -built Inspection
Report. If the results require a design change,construction of the system will stop pending On -Site review
and approval.
2. The existing, 1984 trench is not drawn correctly on the septic design layout, there is a 20' "T" at the end.
Ensure that the new field meets the required separation from the existing trench.
Received B)
Issued By:
8/31/22
Date:
Date:
MUNMPAU Y OF ANCHORAGE
OE
Development Services DepartmentPhone: 907-343-7904
_ _
On -Site Water & Wastewater Section Fax: 907-343-7997
ON-SITE SEPTIC/WELL PERMIT APPLICATION
Parcel I.D. 05128333
Property owner(s) JOHNSTON JEFF
Mailing address 15660 CHRIS CT
Site address same
Day phone 696-3976
Legal description (Sub'd., Block & Lot) GREEN PASTURESLT 2
Legal description (Township, Range & Section)
Lot Size 40,228 Sq. Ft. Number of Bedrooms
APPLICATION IS FOR:
APPLICATION IS AN:
TYPE OF DWELLING:
(N all that apply)
Absorption Field
Fxj
Initial ❑
Single Family (SF) El
(w/wo ADU)
Septic Tank
0
Upgrade X
(D) E]
Holding Tank
❑
Renewal ElDuplex
Multiple Dwellings ❑
Privy
❑
(SF and/or D)
Private Well
❑
Water Storage
❑
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
<�Ei3
(Signature of property owner or authorized agent)
Permit/Rush Fees: #>,5 % 5
Date of Payment: (,�� 95 O.Q 2
Receipt Number: oci 5 y�
Permit No. D S LIP 21 2 3 0
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
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SteveEng.com '�� 8/31/22 = Green Pastures L2
SPECIFICATIONS & DESIGN GUIDELINES
Wastewater System Sizing: This is an existing 5 -bedroom, single family home. This is a
developed subdivision. A new trench is planned + new 2500 gallon STEP Tank, w/
concrete anti -floatation. The existing tank/trench to be decommissioned. No adverse
impacts are expected from trench/tanks upgrade. No conflicts to the other lots will take
place by this septic system construction upgrade. A new soil test reveals SM w/gravel.
An application rate of 1.2 GPD/FT 2. Trench Length = 625 FT2/(5'x 2) = 63' long trench,
4' effective, 5' wide. Tank to have anti -floatation ballast installed. Easements depicted in
the Plan view, private water wells serve these lots. If no foundation cleanout, add double
cleanouts prior to STEP tank. 5' trench depth requested due to recent soil test.
Specification Requirements: All components and work must comply with the
Municipality of Anchorage Specifications (AMC) & State of Alaska Drinking Water
Regulations and Wastewater Regulations.
• New 2500 Gallon STEP Tank, Steel. MOA -Approved.
• Decommission old tank/trench per UPC. MOA -Spec Material Under Tank.
• 10' minimum between the tank trench, tank to house. 10' to property lines,
• 3of cover or insulation is required for trench; 2" Minimum thickness for insulation
can substitute for I' cover.
• Tank & solid pipe must be set on well compacted, stable soil.
• 4 inch diameter cleanouts with airtight caps are required I' to 4' from foundation
wall, prior to any 90 degree bend in 4 inch line, in each tank compartment, and two
adjacent opposing cleanouts between the tank and the absorption field, not more than
10' from the tank positioned to provide cleanout access towards the tank and towards
the absorption field.
• All cleanouts must extend to at least ground level.
• In solid pipe runs, ASTM D-3034 may be used in lieu of cast iron.
• Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock.
• Drain rock to be 1/2" to 2" screened, distributed uniformly throughout the trench.
• Force main to be 1.25" Schedule 40 PVC or equal.
• Distribution pipe to be 1.25" Schedule 40 PVC w/ 1/8" orifice @ 18" on -center.
• Silt barrier (filter fabric) to be installed above the drain rock.
• Smeared trench sides must be raked or scarified before drain rock placement.
• The finish grade must be mounded to promote drainage away from trench.
• Insulation must be placed over any pipe installed under driveways or parking areas.
• Approved pipe materials include cast iron, PVC ASTM D3034, PVC ASTM F789,
ABS ASTM D2661,
• Sewer Service Line is minimum 2% slope.
• Septic Tank to be pumped every two years or when required.
0 Insulation board to be extruded direct burial polystyrene (Dow Styrofoam HI/equal)
LJ CJI VIN IVU I CJ.
1. Total Depth of Trench is 5'.
2. Sewer Service Line minimum 2% slope.
3. Schedule 40 PVC Pressure Force Main.
4. Decommission Old Tank/Trench Per UPC.
5. Insulate Trench + 2' Cover.
6. Measure Required Separations Prior To Construction.
7. Double Cleanouts Before Tank If No FCO.
8. Insfall Anti— Floatation n ee lank.
9. Recommend Survey Prior To Construction.
X10^Install Protective Bollards On Driveway Siddef Septi
Septic
Area
NOR THRIM
ENGINEERING
SteveEng. com
PO Box 770724
:ogle River, Alaska 99577
90 7. 694. 7028
Well
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Driveway
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20' BLM Easement
Almdale Ave \Conflic
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GREEN PASTURES
LOT 2
WASTEWATER
UPGRADE SEPTIC
System.
New 2500 Gallon
STEP Tank
Steel w/Concrete
Anti -Floatation
Decommission Old
Septic Tank/Trench
PER UPC
eway
Lot 115 Well > 100'
1" = 40'
DESIGN
LAYOUT
8/31/22 12 of 3
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Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP221230, Rebecca Carroll, 07/25/22
S❑ILS
�IGIINEERING
Perf ormed For: Owner
Legal Description: L2
DEPTH
(FEET)
1 -
2 -
3 -
4 -
5 -
6 -
7 -
8 -
9 -
10 -
11 -
12 -
13 -
14 -
15 -
16 -
17 -
18 -
19 -
20 -
Organic
SM Silty Sand
LOG - PERC❑LATI❑N
L-� C �,
TEST
Date Perf ormed; 8/29/22
T,H, Location: See Attached Test
Boring Location Map
W/ Groundwater? No
Depth --
Gravel Water Depth
After Monitoring, None Date; R/'�1/PP
#
I Date
Gross Time
Net Time
Depth
Net Drop
1
8/31
0
--
6"
--
2
8/31
10
10 min,
4/1
2"
3
8/31
10
--
6u
--
4
8/31
20
10 min,
4//
2"
5
8/31
20
--
6"
--
6
8/31
30
10 min,
2//
4"
7
8/31
30
--
6"
--
8
8/31
40
10 min,
2"
4"
9
8/31
40
--
6"
--
10
8/31
50
10 min,
2"
4"
11
8/31
50
--
6"
--
12
8/31
60
10 min,
2"
4"
21 - Percolation Rate 2,5 min/in Perc Hole Diameter 6"
Test Run Between 3' & 4'
Comments; Measured To The Nearest 1/16",
Performed By NorthRim Eng, I CERTIFY THAT THIS TEST WAS
Performed in Accordance with All State/Municipal Guidelines in Effect
ON THIS DATE, DATE;
NOR THRI M
ENGINEERING
SteveEng. com
PO Box 770724
Eagle River. Alaska 99577
907.694.7028
49�� GREEN PASTURES
. LOT 2
M-4=TESTH❑LE LOG
� 8%31%22++
GE❑TECHNICAL
TH2
8/31/22 12
Carroll, Rebecca M.
From: Wockenfuss, Deborah M.
Sent: Monday, July 18, 2022 10:44 AM
To: Carroll, Rebecca M.
Subject: OSP221230 Green Pastures Lot 2
Nick Curtis with Property Appraisal called to say he checked out the living space above the garage. He said it is one big room
with exercise equipment and hobby stuff. No plumbing, no closet. His number is #6789 if you need more information.
Deb Wockenfuss
Onsite Water and Wastewater
Municipality of Anchorage
343-7906
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~/~ ~----~, MUNICIPALITY OF ANCHORAGE
~'~ ~1~ ~1/ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
I ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
IPHONE
~AILINGADDRESS
D 0
LOCATION I NO. OF BEDROO
Iwell , Absorption area , Dwegingz 3 P E~ ,~$~,
~ ~ ~ DISTANCE TO: /O 2 ~'~ "
~ ~ Manufacturer
~ Ma ' No. of compa~ents
I ~gallons Inside length Width
/~ IF HOME,DE: ~ Liqui0 depth
.~¢~ DISTANCE TO: ~ PERMIT NO.
O ~ < Manufacturer
:C -- ~ g'~ Material Liquid capacity in gallons
DISTANCE TO: Well ~/ ~ , Foundati~ . f Nearestlg~li,~ ( PE~IT~.~
~ ~ No. of lin% Lengd, o' e~o~ine_' Total len~¢:Y~ Trench~d~;¢O
~ TOPLengthof tile to finish ~de(width DepthMaterial beneath tile ¢ ¢ 'f ...inches Total ~'(¢~ef~ctive abso~ion~ area
m PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ DISTANCE TO: Well Building foundation Nearest lot line
M ~Class Depth ' Driller Distance to lot line PERMIT ~O.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
INSTALLER
REMARKS ,~i) , ~
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TI-.IE:]',I ( 1 ) AN li!!:L.I!~:C'I'I:~ ]: CAL.. I:::'ERM I 'T AND ]: NSPE:CT :[ (IN MUS'T' )::?,E: (]ECl'mA ]: NIZD; (2) A!!!F...BU :1: LTS
W:I:LL t',IC)T BE AF::'F::'RC]VED WI'T'HC)LFI' AN EIJ~i:CTR]:CAL :I:I',ISPI!ii:C:'/T']:ON RE!I:"OFUI"i~ AND (3) THE:
MUNICIPALITY OF ANCHORAGE
DF'PARTMENT OF HF-ALTH AND ENVIRONMENTAL PROTF'CTION
825 L. Stroet, Anchorage, Alastcn 99B01 264.472(I
SOILS LOG- PERCOLATION TEST
'E~ALDESC.,PT,ON: /~ //F: ~'dc Z.5' 7--/J-/'-J
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18,
19-
20-
SLOPE
[] SOl LS LOG
PERCOLATION
TEST
SITE PLAN
R,.~b.~,d A, 5ha~er
No. 1457-~
ENCOUNTERI
Reading Date Gross
Time
PERCOLATION RATE
Net
Time
TEST RUN BETWEEN
COMMENTS ' ..... ~ ~'~i[~- ~"~' [~'~I~
~ ...... -.-- "~ - ~ ' ~R'FIFIED
72.008 (6/79).
Depth to
Water
Net
Drop
__ (minutes/inch}
FT AND FT "~
DOC Co. dba
SULLIVAN. W TER WEL $
P,O, BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
~WNER OF LAND
DDRESS
,..j (','/.7 I:7 'd,:', ~'Y,,~,.fv'Q ,,~,/ DEPI'I] OF WELl, ~ 0 ,,) Q~
, 7? '5 s'r,vnc LEVEL OF WATER FT. ,~; 0
,EGAL DESCRIPTION '~'
)ATE - Started i 6 ,.'
'ERMIT NUMBER
DRAW DOWN FT.
KIND OF CASING
~IND OF FORMATION:
'rom c ~ Ft. to~'? .--Ft. (:~ ~.;t!'~;',_.~ 0 i; ,-J From Irt.
'rom -,~Ft. to~' ~ Ft. ..2/A i I 3~, From Ft.
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, ;] <~' ,-) ?~ ;-4 4 ,c ,~ · ¢: , ,.-, F
'rom.~- Ft. to-~::~Ft.- ~' ' ~.:,~_ ~ From
:rom "/~L Ft. to ," ~' Ft.. ~ '~:'"~(_ _iL_:,' .... Jd~'= '''' From Ft.
:rom. ,) ~'~t't. todz, / FC ,~; . ~>':- z'--"' i !~ / From .... Ft.
'rom .... Ft. to__ _Ft.
q'om~/<; [ Ft, to_ Ft.
~rom itt. to _.Ft,
:rom______Ft. to ..... Ft..
h'om__ __Ft. to___Ft,
~rom .... Ft. to ..... Ft. __
:q'om_ __Ft. to_- .Ft.
;:rom Ft. to ..... Ft.
;:rom Ft. to Ft
From Ft. to ...... Ft,
,/d ¢-' 4,~ .; ~:~, /'-- Froln__
From
Ft. to .... Ft,
.Ft. to ...... Ft.
Ft. to_ __Ft
From Ft, to .... Ft.
From ......... Ft. to ____Ft,
From ........ Ft. to ..... Ft
From Ft. to ..... Ft .....
From 1"¢. to ..... Ft,
From Ft. to Ft.
From Ft. to ........ Ft
vlISCL. INFORMATION:
DRILLER'S NAME
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. # _ O~\ - ;~.&~-.~ HAA#_
1. GENERAL INFORMATION
Complete legal description
Lot 2; Green Pastures
Location (site address or directions) 17941 Chris Court, Chugiak, Alaska
Property owner ~hnstr)n Day phone 344-1079
Mailing address 2010 Colony Loop, Anchorage, Alaska 99507
Lending agency
Mailing address
Agent
Address
GHAC
Day phone
Anchorage, Alaska
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well xxx
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 IRev. 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/orwastewaterdisposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein, lfurtherverifythatbasedontheinformationobtainedfrom
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
5 & 5 ENGIN~;:R!N~
Address '7034 Ea:lle River Loop Road No. 204
'~.,-.:le River, Ala¢'.a 99577
Engineer's signature
DHHS SIGNATURE
Approved for ~f~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By:
Additional Comments ~+~: m,~ ..... ~ ~ ¢'~"' *~4 ....... * ..... ~-° existing
State and Municipal Codes. There are nitrates present. It is
sug~est~--~~riodic testinguu'-- per~z-m~d LO i~sure thu w~ils
continued suitability. Nitrate concentration is 7.2 mg/1. EPA
maxmmum concen~rat±on Ls 10.0. mg/1.
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 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 enginee¢s work.
72~25 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~.-~" "~ (--~¢,~ ~/%Sl-OF-.E,~, Parcel I.D.
A. WELL DATA
Well type
Log present (~/N)
Total depth /'pO ~ ~'"
Sanitary seal ~/N)
If A, B, or C, attach ADEC letter. ADEC water system number ~/,/~
Date completed ) 0 ~ ~!~,~r Driller /--~Og.~, ~ ~3
Wires properly protected (~N)
FROM WELL LOG AT INSPECTION
Date of test
Static water level '~o
Well flow
Pump level
Casedto
SEPARATION DISTANCES FROM WELL TO:
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
Septic/holding tank on lot
Absorption field on lot I ~"~
Public sewer main
Public sewer service line ~ !.~
WATER SAMPLE RESULTS:
/_. c, ~,¢,,'/ ,~
Coliform ~ /'~'0~ J~.
Date of sample: (,.~- I"'~-~/
Et, SEPTIC/HOLDING TANK DATA
Date installed [I-'~.~,-' ~
Cleanouts (~N) N/I
High water alarm (Y,(~i)
Date of pumping
Nitrate
Collected by:
Other bacteria
Tank size ~,3..,~c~ Compartments
Foundation cleanout ~/N) ~ Depression (Y~
/"/ Alarm tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot I C~'2~-~ On adjacent lots. I ~ ~ ~'' Foundation
To property line IO~
Absorption field '~" Water main/service line
Surface water/drainage ~::~0, ~ ~
72-026(Rev. 3/91) Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level ~
Meets MOA electrical co~d (etON) .
V,7~II on Ici On adjacent lots
Manufacturer
Manhole/Access (Y/N) ~
~ "Pump off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~\ -/~\ ~ ~
Length ~J~ ' Width '~c:~ ~'
Total absorption area L¢O~
Depression over field (Y/~ /~
Results f~/fail) ¢/~¢~'~
Peroxide treatment (past 12 months) (Y~
Soil rating ~ ~'- o ~
Gravel thickness
Cleanouts present (~N)
Date of adequacy test
for
~2//---- If yes, give date
System type
Total depth
¥
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot \ \"/~
To building foundation
On adjacent lots -z_~¢~
Surface water ~ c~
Curtain drain
On adjacent lots / c:'° "¢ Property line
~-~L"~ To existing or abandoned system on lot
Cutbank ~J~"- Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certif7 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's
Date
HAA Fee $ _ ! 70
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE sEwER AND WATER FACILITY
264-4720
Application Date ~
1. GENERAL INFORMATION
Location (ad/d~ress or directions) ~ ,
(b) AppticantNaF~e~~:z~7~-,~~ Telephone;Ho~e ;ef-~ Business
(c) Applicant is (~6h'eck one): Lending Institution U; Owner/builder~; Buyer D; Ot~er ~ (explain); __
(d) L~nding Institution~/~)~d/.,~
(e) Real Estate Company and Agent
· /'-"~:~ ~ ]relephone
Address
Telephone
(f) ~'1 t~e HAA to the following address:
2. TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms · V
Other
WATER SUPPLY
Individual Well~' Community L-] Public []
Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SI"WAGE DISPOSAL
Onsite/[~' Public [] Community [] Holding Tank [] ,'
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025(11/84)
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA, ,~ AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this I'tealth
Authority Approval 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 ail Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm ~ ....... ,,,~,,~.¢. Telephone
Date ~1 ~-~
Approved for ~/~t¢~ bedrooms by te
Approved ~ Disapprove~J. Conditional v
Terms of CondJtio"naJ Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
.engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
le 2 of 2
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
MUNICIPALiTy OF ANCHORAGE
DEPT, OF HEALTH &
~:NVIRONMENTAL PROTECTION
J. 9 1985'
Le/gal Description: ~-~-
Well Classification
Well Log Present (~4)
Total Depth fr.Z~
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit gi~/N)
Separation Distances from Well:
To Septic/He~ift~j Tank on Lot I
To Nearest Edge of Absorption Field on Lot __
If A, B, C, D.E.C. Approved (Y/N)
Date Completed tO ¢ ,E~/-' Yield .
Cased to ~.¢~..~" '~
Depth of Grouting
Pump Set At ~O, ¢~
Sanitary Seal on Casing
Depression Around Wellhead (Y/~J~
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer I_ine .,,i~/I/~! . To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot '"~"'~'~
Water Sample Collected by .~ ~ ~ ~ rr.,xa'(~¢:=~ ; Date
Water Sample Test Results
Comments ~ ,¢-/'-~,¢---~ '~=¢.~-~.¢~<~=*~ ~IL~¢~. Z~"~"'1'7-:>
B. SEPTIC/~ TANK DATA
Date Installed I1-~-I -
Standpipesg:igN) Air-tight Caps ¢~N)
Depression over Tank (Y/~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/I-let~i-m~j Tank:
To Water-Supply Well ~ c~"~. ~
To Property Line '~ c~
To Water Main/Service Lin~ '~ Cb, I
Course ~ / ~
Size t "Z-.~"'tE:~ No. of Compartments __
Foundation Cleanout ¢5~N)
Date Last Pumped
'4//3,/ ; for -'
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field ~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed I 1 -~ I -~ %6,
Width of Field ~"~:::;~"'
Square Feet of Absorption Area
Depression over Field (Y/~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present ~)N)
Date of Last Adequacy Test
To Building Foundation
Lot
To Water Main/Service Line ~ ~ I.~
To Stream/Pond/Lake/or Maior Drainage Course
¥o Driveway, Parking Area, or Vehicle Storage Area
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To~tbank~5 (if present)
~c>J ~
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to all MOA and H.A.C,.guidelines in effect on the date of this inspection·
Date ~'~ ~ ('~' ~'g&'
· ned .'~ ~ ~ ~,~,~r ~ ~-,,~ -,
Amount: $ ~ ¢ ¢~ ~ _ ~~~r, (;~
Page 2 of 2 ~ ¢% '.. .",~b'~
72-026 (11/84) ~ %~