HomeMy WebLinkAboutSAND LAKE #2 BLK 2 LT 10pa Ali
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rrnuvru UAIL LEUAL
L, �, Jf z Alm-kz Lot]0
(Rev. 3/78)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
.0*
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
NEW
S_ � A E Inky, r f) r 15 e, /a V I f.4 U -il o n 5; lh
EJUPGRADE
MAI LING ADDRESS I t
L� 16 1 M'ir 4 r ve
LEGAL DESCRIPTION
5ana L4 to
LOCATION
'V
NO. OF BEDROOMS
ls� z 1
13
Well
Absorption area
Dwelling
PERMIT NO.
DISTANCE TO:
I
DI
19
[)D+
Q
z C)
2
<
LU I.-
Manufacturer
G re� 0_'r
Material
�5+ _I
Q
No. of compartments
2
Liq. caTW6 Ilons
I IF HOMEMADE:
Inside length
Width
Liquid depth
DISTANCE TO:
—
Well
Dwelling
PERMIT NO.
jaz
0 Z�
Manufacturer
Material
Liquid capacity in gallons
_j
DISTANCE TO:
-
Well
Foundation
Nearest lot line
PERMIT NO.
TZ 0 3 2 3
W12u
_j u. Z
of 11 es
0._
No. of lines
Length of each lin&3,
Total length of line�,.3
Trench width
Distance between lines
P: w
inches
j.-
Top of tile to finish grade
Material beneath tile
Total effective absorption area
13
�)
1'2C) inches
Length
Width
Depth
PERMIT NO.
LU
Type of crib
Crib diameter
Crib depth
Total effective absorption area
Uj
Lu
U)
DISTANCE TO:
Well
Building foundation
Nearest lot line
ss
s
Depth
Driller
Distance to lot line
MIT NO.
Lu
DISTANCE TO: I
Building foundation
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
Pvc,c 1:
SOIL TEST RATING 8
2- Bolin 6cir m
INSTALLER
r
ji
A 0 F�_ I
REMARKS
-P
1-47
All
L
rrnuvru UAIL LEUAL
L, �, Jf z Alm-kz Lot]0
(Rev. 3/78)
�T L-9 P-41 1: -1. F'" M L.- 3. _Y_ 13 F07 lot �����Fit ��B_
DEFF, HRTP! ENT HEHLTH FINE, ENVIF!8NM�NTHL T�CTION
STREET, ANCHORAGE/
264-4720
PEPMIT NO. ( 820]7] )
HPPLICHNT HULTQUIST CONST 4761 MARS DR
LOCHTION LrMKE
LEGHL 1-10 B2 SAND LAKE 42 LOT SIZE
TYPE OF SOIL HBSORPTION SYSTEM IS: TRENCH
6750 SQUHRE FEET
MHXIMUM NUMBER OF RHTING (SQ FT/BR)� 280
�
THE REQUIRED SIZE OF THE SOIL HBSORPTION SYSTEM IS�
������ �� ������7,5 -1- F, -ii c�ff,-�� ��
THE LENSTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRH1HNFIELD'
THE DEPTH OF H TRENCH OR PIT IS THE DISTANCE BETWEEN THE SLRFHCE OF THE
GROUND HND THE BOTTOM OF THE" EXCHVFITION (IN FEET). �
THERE IS NO SET WIDTH FOR TRENCHES
THE DEPTH IS THE MINIMUM DEPTH OF GRF*IYEL, BETWEEN THE OUTFHLL PIPE
HND THE BOTTOM OF THE EET).
��������
PERMIT HPPLICHNT HBS THE RESPONSIBILITY TO INFIORM THIS DEPARTMENT DURINIG THE
INSTALLATION INSPECTIONS OF HNY WELLS HDJHCENT TO THIS PROPERTY HND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE,
1:4 ;2! *,'.-- 3E K=� E_ 1: Kiv PA lot REH., 0:;;;� FF" :1 FT: FE V ~
BHCKFILL�NG OF 8NY SYSTEM WITHOUT FINAL AND HPPROVHL BY THIS
DEPHRTMENT WILL BE SUBJECT TO PROSECUTIOKi
MINIMUM DISTHNCE BETWEEN H WELL HND HNY ON-SITE SEWHGE DISPOSHL SYSTEM IS
100 FEET FOR H WELL OR 150 TO 200 FEf.T FROM H PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL
MINIMUM DISTHNCE FROM H PF--.'I1,/HTE WELL TO A PRIVHTE ��E14ER, LINE IS 25 FEET HND
TO H COMMURITY 5E1,!ER LINE IS 75 FEET.
OTHER MAY APPLY. SPECIFICHTIONS HWD CONSTRUCTION DIAGRAMS HRE
AVAILABLE TO INSURE PROPER INSTHLLHTION
KEEL F12 101 f '7- (T EE �1'1,1 F-31 E-_-,AF--e -_11111- _. ���__ ��
I CERTIFY THAT
i� I HM FHMILIHR WITH
THE REQUIREMENTS
FOR
HND WELLS HS SET
FORTH BY THE
TY OF HNCHORHGE,
2: I WILL INSTHLL THE
SYSTEM IN HCCORDHNCE WITH
THE CODES.
]� I UNDERSTHND MIT
ME ON~SITE SEWER
SYSTEM
MAY REQUIRE ENL�R�EME�T �F T�E
RESIDENCE IS REMODELED
TO INCLUDE MORE
THAN ]
BEDROOMS.
SIG- ED: ... ....
�~_
HPPLICMT T
V4.0
MUNICIPALITY OF ANCHORAGE PERCOLATION
DEPARTMENTOF HEALTHAND ENVIRONMENTAL PROTECTION 'ev
TEST
825 L. Street, Anchorage, Alaska 99501 2G4-4720
SOILS LOG - PERCOLATION TEST
PERFORMED FOR: e r el- t -re -DATE PERFORMED:
LEGAL DESCRIPTION:
Parcel I.D.#
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
HAA # 111V-1_1e(a1Z(Q
1. GENERAL INFORMATION
Complete legal description C, k
Location (site address or directions) 13133 -Seq
A P) C-11 0.� �q A la s t-, Q 9 5 5 cs 2 -
Property owner dr�? 7,1 Z- C 4*ZZ_'M'2 K. 1�16t_74�1 Day phone
Mailing address A141 ��S_eZ
Lending agency
Mailing address.
Agent
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3 "--
Day phone
Day phone
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State A DEC
attesting to the legality and status of system.
72-025(Rev.1/91) Front MOAN21
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 of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
NameofFirm A -4,,r_ G'�001010c, Phone 349-5/q��
Address 301 00,),,e�l St, 5u;
Engineer's signature
6. DIHHS SIGNATURE
Approved for 3 &�j bedrooms.
Disapproved.
Conditional approval for
Additional Comments
0
A I -L 9?,5 1 6 - 3
Date -
4
.i 7�," Cc!re
153
7353
X.
nc�
0 F E S 0,
bedrooms, with the following stipulations:
Date Z4�_lz �071_
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 intheStateof Alaska. The DHHS does this as a courtesy to purchasersof homes
and their lending institutions in order to satisfy certain federal and state requirements. Employeesof DHHSdonot
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.
72-025(Rev.1/91) Back MOA#21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Aloc-62- Parcel I.D. 113-J"I
A. WELL DATA
Wei I type L If A, B, or C, attach ADEC letter. ADEC water system number PLLJ,5 (0 4� 2 16 166
Log present (Y/(@ /U 0 Date completed
Driller —
I otal. depth — —Cased to � Casing heigh
Sanitary seal (Y/N) — Wires properly protected (Y/N) -
Date of test
Static water level
Well flow
FROM WELL LOG AT INSPECTION
MUNICIPALITY OF ANCHORAGE
ENVI NMENTAL SERVICES DIVISION
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot JW t
Absorption field on lot 1(�v +_
DEC 2 4 1991
9 -P.M. 9 -P.M.
RECEIVED
_; On adjacent lots
; On adjacent lots
Public sewer main 10 0 —Public sewer manhole/cleanout 10c" -
Sewer service line 004- Petroleum tank 1 00
WATER SAMPLE RESULTS:
Coliform Nitrate o, K, Other bacteria 6. K,
Date of sample: I Z, �.Z, C) /4 � — Collected by: Klyk�
B. SEPTIC/HOLDING TANK DATA
Date installed 12 G, /a Z, Tank size to 00 qc� I Compartments Z-
Cleanouts (ON) Yes Foundation cleanout (ON) V65 — Depression (Y/Q) A-) a
High water alarm (YO AJO Alarm tested (Y/N)
Date of pumping )'2- 1 //6 1 lq! Pumper A-,- vfom;5 5t-mtt5 (Nc-
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot On adjacent lots 100t
To property line
Surface water/drainage
f
—Absorption field I Z
too I—
Foundation 2- Z
-Water main/service line /00
72-026 (Rev. 7191) Front CONTINUED ON BACK PAGE
C. LIFT STATION N
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N),
Manufacturer
Minhole/Access (Y/N)
"Pump off" level at
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots
Cycles tested
Surface water
Date installed (, /Z 6 /&Z_ — Soil rating �f 80 1311/pC111" System type De-e.a 11'e -o -A
Length 53 1 Width Gravel thickness 10 t - Total depth 1
Total absorption area - 1050 Cleanouts present (ON) ye -c
Depression over field (YQ Wo Date of adequacy test I Z-/// /4 /
Results (pass/fail)
for
Peroxide treatment (past 12 months) (Y/& lU CJ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wel I on lot I On adjacent lots — 10 0 —Property line (0,
To building foundation I Z To existino or abandoned system on lot
On adjacent lots I q
Surface water oc) i /
Curtain drain
E. ENGINEER'S CERTIFICATION
Cutbank
--Water main/service line—,
Driveway, parking/vehicle storage area so
04- 1
bedrooms
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
Date )d q+) co
C-- Y
0�
HAA Fee$ — /70
Date of Payment A V- q1
Receipt Number olpz
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $ —
Date of Payment
Receipt Number
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
FOR: Arctic Slope Consulting Group
December 24, 1991
PWSID # 216156
WALTER J. HICKEL, GOVERNOR
(907) 563-6775
My review of the records on file in this office reveals that Lots 7-12, Block 2, Sand Lake
#2 Subdivision, Class "C" Public Water System, is in compliance with the provisions of 18
AAC 80.200, State of Alaska Drinking Water Regulations.
BR/cf
Sincerely,
X�/� 4��-
Byron Roys
Environmental Engineer
V ec"'CL:(" p;�Jpcl tj Y
A+ HDME SERVICESP INC.
-f4 COO
T A PULL LL -
HOME SERVICE 3
S, INC
1-5900 Fra"Cesca Drivo.
Anchorage, Alaska ggsi6
345-1890 or 345-2444
CUSTOMER
a
LJOL [I IL Ur
Blook _ Lot
14S P02
INVOICE# 6039
0
OR
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
TYPE OF RESIDENCE
Single -Family E@
Number of Bedrooms
3. WATER SUPPLY
Individual Well[] Community[R Publicn
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite CR Public El Community 11 Holding Tank
Note: If community well system, must have written confirmation from the State Departmentof Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (Rev 8/861 Front
Application Date j:cn e- 196 7
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a)
Legal Description (include lot, block, subdivision, section, township, range)
c 1-r S'eZ AV( 4a
Location (address or directions)
8f 33 _�'ece ,; e�
(b)
Property Owner Ra� PC" le d r_r Telephone: Home N. A.
Business
Mailing Address 9 3-1-- IV i -a *% il� e k)6 AO (" h -L , #-T
(c)
Lending Institution NaPI 84hic 004 hlaxf�,q Telephone
2 of 7
Mailing Address 30( W, No r A er,? I-,qA /r
(d)
V
Real Estate Company and Agent Mt �-r Ae�" /7 am ( C -.c AT �-e_
j=trAef-
Address — 290Y W. �(4,rkerl2_ I-VA/zr S /&k-<
C-40 n9V �95-*.7
Telephone s 't '9 - 2-'9 0 1/
(e)
Mail the HAA to the followina address: or: Check here 1Z, if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single -Family E@
Number of Bedrooms
3. WATER SUPPLY
Individual Well[] Community[R Publicn
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite CR Public El Community 11 Holding Tank
Note: If community well system, must have written confirmation from the State Departmentof Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (Rev 8/861 Front
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MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
JUN 9 1987
RECEIVED
A. WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth —
Static Water Level
Cased to
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Description: t- & 01- (0�0 G (oc k- 2 ) S'Ctnct 4,ake 42
If A, B, C, D.E.C. Approved (Y/N)
Date Completed Yield
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Man hole
Depth of Grouting —
Pump Set At
Sanitary Seal on Casing (Y/N) —
Depression Around Wellhead (Y/N)
On Adjoining Lots
_; On Adjoining Lots
— To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Water Sample Collected by r -I -E&, nec'4 socr — ; Date d'14- e & 7
Water Sample Test Results Sa ks A, AP!7A� IV, CO (L4 a
Comments r) Ec
Cer- kf,*-,zAe +H -.k cA d
B. SEPTIC/HOLDING TANK DATA
Date Installed r�t M/9 P- Size 1000 �r Q( No. of Compartments a
Standpipes (Y/N) r Air -tight Caps (Y/N) r Foundation Cleanout (Y/N)
Depression over Tank (Y/N) IN Date Last Pumped 61-19 / C77 a a C -f L�
Pumping/Maintenance Contract on File (Y/N) ri, A. ; for IV, A.
Holding Tank High -Water Alarm (Y/N) N, A. - Temporary Holding Tank Permit (Y/N) N. 4.
Separation Distances from Septic/Holding Tank
To Water -Supply Well > IrO' To Building Foundation 20,
To Property Line 6' To Disposal Field 12
To Water Main/Service Line :> 10' To Stream, Pond, Lake, or Major Drainage
Course > (00 '
Comments
Page 1 of 2
72-026 (Rev 8/861 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 260 0'18c(rm Type of System Design Qeg;e rre�s,6
Date Installed S, iles / 6 2 — Length of Field S-3 , t --
Width of Field
Depth of Field is-'
Gravel Bed Thickness to ,
Square Feet of Absorption Area 1 0 5'0 � Standpipes Present (Y/N)
Depression over Field (Y/N) N Date of Last Adequacy Test 5
Results of Last Adequacy Test &d_epaie r,& r- becer&0mv I-,
Separation Distance from Absorption Field:
To Water -Supply Well -
To Property Line 45--s-
To Building Foundation 12 To Existing or Abandoned System on
Lot N, A On Adjoining Lots 19
To Water Main/Service Line �t to To Cutbank (if present) N. 4.
To Stream/Pond/Lake/or Major Drainage Course > (00
To Driveway, Parking Area, or Vehicle Storage Area so.
Comments 9Xc I-#" ,�,(r I V et f c Atr � c, oc I-mt
D. LIFTSTATION fv,A
Date Installed —
Size in Gallons -
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
** Check Permitted Bedroom Rating Against HAA Request **
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
I certifythat I have checked, verified, orconformed to all MOA and HAA guidelines in effect on the dateof this inspection.
Signed 154� Date 6'1,9 le -7
Company rk�* r"* S-&'cr MOA No. 70X 2
Receipt No. o 0 Z —(no
Date of Payment (e — OF A4
Amount: $ Z,:g 0 e Engineer's Seal
Page 2 of 2
72-026 (Rev 8/86) Back
*..'49TH
01
00 ..................
THEoDOR F *'* * * a *:' ..
C . RE -
CE - 358
.1.1 AV
0
0 iva"
E An L hj-Ai-- S 9 ARA STEVE COWPER, GOVERNOR
DEPT. OF ENVIRONMENTAL CONSERVATION/ Telephone: (907)
Address:
ANCHORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303 274-2533
ANCHORAGE, ALASKA 99501
DATE:_ june go 1987
PWS I.D.# Class C
To Whom it May Concern:
According to records on file in this office the Lot 10, Block 2, Sand
Lake #2 Water System is in compliance with the State Drinking
Water Regulations
Sincerely,
(��alRes C. Allen, RS
Regional Sanitarian Supervisor
Time
APPLIC'NT FILLS OUT UPPER HAL ONLY
Property Owner
5 15! , -1fic.
Time
Phone
Mailing Address
a-
Zip Code
Date
Buyer
Q L
Inspector
Address
Zip Code
Lending Institution
C' "C'/
1OLF01CIPAU'ry OF
Phone
Address
Zip Code
Really Co. & Agent
U 0 e! 198,9
Phone
Address
Zip Code
-3) APPROVED BEDROOMS
Legal Description
I DISAPPROVED
Street Location
) CONDITIONAI� APPROVAL -
Type of Residence
BY:(Q--
Single Family
Soils Rating
Date Sewer Installed
Multiple Family
No. of Bedrooms
Septic Tank Size A)00
11 Other
Well to Tank
Water Supply
11 Individual
ATTACH WELL LOG. A well log is required for all wells drilled since June 1975.
5� Community
For wells drilled prior to that date, give well depth (attach log if available).
EI Public Utility
Sewer Disposal
Individual
Year Individual Installed:
Public Utility
When Connected to Public Utility:
0 Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Time
Time
Time
Date
Date
Date
Date
Q L
Inspector
Inspector
Inspector
Inspector
1OLF01CIPAU'ry OF
Field Notes:
P!�PT ANCHORAGE
C—
ENViR t P.
E
-0 4
U 0 e! 198,9
RECEIVED_
-3) APPROVED BEDROOMS
*CONDITIONS OF APPROVAL
I DISAPPROVED
) CONDITIONAI� APPROVAL -
DATE
BY:(Q--
Soils Rating
Date Sewer Installed
Well To Absorption Area
well Log Received
Septic Tank Size A)00
Well to Tank
72 023 (3182)