HomeMy WebLinkAboutSHACKLETON LT 23A-572-013 (Rev. 3/78) - <11i_
MUNICIPALITY OF ANCHORAGE j
= DEPARTMENT OF HEALTH & ENVIRONMENTAL." PROTECTION
ENVIRONMENTAL ENGINE€RING DIVISION
-
82.5 L Street Anchorage, Alaska 91501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL_ SYSTEM AND/OR VVELL. [INSPECTION REPORT
NAMEr,
PHONE
� INEW
J�"..���j
/
/Y&%'�%J�'f �i���"-�D
❑UPGRADE
MAILING ADDRESS
wall- �ra
4AvA?4 � 5✓
LEGAL DESCRIPTION
Gvr 4,5
LOCATION
NO. OF BEDROOMS
12l"t����rf
U
DISTANCE TO:
Well
®
Absorption area
7
Dwelling
Jo
PERMIT NO.
e,4 fj j9•
y
azManufacturer
wF
/
46re
Material /
f��/
No. of compartments
�+
ti
Liq. capacity in gallons
IF HOMEMADE:
Inside length
Width
Liquid depth
y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
J0z
O z a
Manufacturer
Material
Liquid capacity in gallons
DISTANCE TO:
Well/��s Z
Foundation .�'
Nearest lot line
PERMIT NO.
g
Uj z
H w
No. of lines
Length of each line 1
� T.
Total length of lines
r
Trench width
® inches
Distance betwee lines
Z
Top of tile to finish grade
Material beneath the s>
r/
Total effective absorption area �G
r,9
74) /�y19iZfy.L� inches
60Z
Length Width
Depth
PERMIT NO.
w
a
Q F
Type of crib Crib diameter
Crib depth
Total effective absorption area
a4
Lu
w
`n
Well
Building foundation
Nearest lot line
DISTANCE TO:
-
�
Class Depth
�® s
Driller
Distance to lot line
PERMIT NO.
riv
/14 W 402y
Lu
Building foundation
DISTANCE TO: lc+r /
Sewer line J
IV1
Septic tank
%�z2-
Absorption area(s)
/U`!%` i Z.
OTHER
PIPES MATERIALS
SOIL TEST RATING
e el
Vr 4" 10 lj�
03A-7
INSTALLER4d>;r
C C-X e,
0`"
Z
i
VlkE ..�
�,�� oou00000j�pQ '
r 4 9
�� .. •-.9et•P000.00®
s
6 .o ren /i
�r �'f
CE • 1516 .' $I`
oo° CAF
ICIPALITY OF A.-
DEPT. OF HLF.11' • a
be
�/✓ Gr
ENVIRONMENTAL NZOTLCii
IZZ
AUG 1 'IC
APPROVED;p�q _ �AT€V LEGAL
72-013 (Rev. 3/78) - <11i_
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�������� �� ���" ���9� —~
[)�PH.-MlEt-47' OF HEALTH FIND ENVIRONMENTAL PROTECTION
825 L STREET/ HNCHORHGE/ GK 99501 .
264~4720
PERMIT NO:
DATE ISSUED
APPLICANT
HDDRESS:
�ONTHCT PHONE
LEGHL DESCRIP
LOT SIZE -
LOT LOCHTION
MHX BEDROOMS
840187
04/16/84
HERMHN C. KNOTT, JR.
8541 E. 1211-1 COURT
ANCHORAGE/ HK 99504
24]-2151
SUBDIYISION: SHHCKLETONLOT� 2]H-5
SECTION: 19 TOWNSHI� 12N RHNGE� ]W
12615 (SQFT. OR HCRES)
JOHN CT
]
BLOCK: 5
LISTED BELOW ARE THE OPTS H O YOU
IN DESIGNING
YOUR SEPTIC
S9STEM. CHOOSE THEOP
YOUR
--FTE.�������
������
1.4- �»�����][������
�' �d
DEPTH TO PIPE BOTTOM
e'
4.5
4.0
GRAVEL DEPTH (FT. )
0�5
].5
OTHL DEP TH (FT� )
5�0
7.5
GRAVEL WIDTH (FT. )
'19�0
5.0
GRHVEL LENGTH (FT� )
]6.0
49.0
GRHVEL VOLUME (CUYDS. )
25 3,
� ]6.2
TANK SIZE (GHLS)
1/000.0 **
1/000.0 **
SOIL RHTIN` (SQ.FT/BR)
150
150
-.+:,L: DEP-if--f TO PIPE BOTTOM MAY REQUIRE
H LIFT STATION
** TANK MUST HHVE
AT LEHST-OMPHRTMENTS
I CERTIFY THHT�
iI HM FHMILIHR WITH THE REQUIREMENTS FOR Ohl ---SITE SEWERS HND WELLS AS SET
FORTH B9 THE MUNICIPHLITY OF HNCHORHGE (MOH) AND THE STATE QF ALASKA.
2. I WILL INSTHLL THE SYSTEM IN HCCORDHNCE WITH ALL MOH CODES HND REGULATIONS/
HND IN COMPLIHNCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
]IWILL HDHERE TO ALL. MOA HND STHTE OF HLHSKH REQUIREMENTS FOR THE SET BACK
DISTANCES FROM HNY EXISTING WELL/ WHSTEWHTER DISPOSHL SYSTEM OR PUBLIC
SEWERAGE SYSTEM ON THIS OR HNY HDJHCF`ll7 OR NERRB LOT.
4. I UNDERSTHND THHT THIS PERMIT IS VALID FOR H MHXIMUM^OF ] BEDROOMS AND
HNY ENLHRGEMENT WILL REQUIRE HN ADDITIONAL PERMIT.
IF H LIFT STATION IS INSTALLED IN HN AREA COVERED BY MOH BUILDING CODES,
THEN (1) HN ELECTRICHL pERMIT AND INSPECTION MUST BE OBTHINED/ (2) HS�BUILTS
WILL NOT BE HPPROVED WIT0UT HN ELECTRICHL INSPECTION REPORT/ HND (]) THE
ELECTRICAL WORK MUST BE DQ�� BY H LICENSED ELECTRICIHN� /
/` �
�TGNFD D�TF
HPPLICHNT: HERMHN CKNOTT, JRiy�
/ v
ISSUED BY DHTE:
v
SOILS LOG
gam,/F7
MUNICIPALITY OF ANCHORAGE
ae DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG — PERCOLATION TEST
� l1 1 ICAn.
PERFORMED FOR: L 1! �� b ' DATE PERFORMED: I
olyLEGAL DESCRIPTION: i�l�✓1C ll 61 1 '�5
SLOPE � SITE PLAN 1
1
2
3
4
5 r (�
6 r
a
7 i
8 r
10 f 0
11 C
r �
12
� 1
13
14-
15-
16-
17
4151617
18
19
20
COMMEN
5M.
5P.
ivarIIs .
WAS GROUND WATER S
ENCOUNTERED? L
O
P
IF YES, AT WHAT
DEPTH?
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
PERCOLATION RATE
TEST RUN BETWEEN FT AND
PERFORMED BY: aL 7[(r�,Y 1 1 tiicU'`�1 CERTIFIED BY:
72-008 (6/79)
(minutes/inch)
__ FT
DA
M -w DRILLING, Inc.
P.O. Box 10-378 • 10300 Old Seward Highway
(907) 349-8535
ANCHORAGE, ALASKA 99511
DRILLING LOG
Well Owner lif'ill3Ald IGIOTT
Location (address of: Township, Range, Section, if known; or distance main road
Lot. 2M5 .101ock 5 Sbhckleton Subd.
84-1
se of Well Dorae9ti_c
Size of casing bar Depth of Hole 107 feet Cased to Lo3.10 feet
Static water level 113 ft. (below) land surface. Finish of well (check one) open end (XXX );
Screen ( ); Perforated ( ).
Describe screen or perforation None
Well pumping test at -1.5 gallons per (1;onr) (minute) for---j----hours with 1 )0% f(.
of drawdown from static level.
Date of completion .,larch 2, 19€ 4
WELL LOG
Depth in feet from
ground surface Give details of formations penetrated, size of material, color and hardness
0 TO 2 Casting sticku)
4. TO 240 Bro-vrn sand
ko TO 5�
55 TO
60
6o TO
n0
90 TO
Loll
1o4 TO
107
TO
TO
TO
TO
TO
TO
TO
TO
Brom-i sand b Bret
Broirn sand- clay wet
Gray sanely clay _, tre"t
Gray sandy clay with gravel wet
t-laterbearing pxxavel
Certificate Nds. 814 & 973
3 — CONTRACTOR
- RD rIJ T^lk I F=- L~I-
PERMIT Nn. 84006]
DATE I����D`~ 0]/21/84
CAt-.jT:
ADDRESS: 8541 E 12TH
HN1'..HHORH6E, HK 995(_4
CONTACT PHONE: ]]7�1190
LEGHL DESCRIP: SHHCKELTON
SECTION:19 TOWNSHIP: 12N
LOT SIZE: FT. OR ACRES) ^
\
LOT: 2] H-5 BLOCK: NH
RANGE: ]W
I CERTIFY THAT:
1.I HM FHMILIHR WITH THE REQUIREMENTS FOR ON-SITE SEWERS HND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE (MOH) AND THE STATE OF HLHSKA.
2STTHSTEM IN HCCO�DHNCE WITH HLL MOH CODES AND REGULHTIONS/NHS
HND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
] I WILL ADHERE TO HLL MOHAND STATE OF HLHSKH REQUIREMENTS FOR THE SET BACK
DISTANCES FROM HNY EXISTING WELL, WASTEWATER DISPOSAL. SYSTEM OR PUBLIC
SEWERHGE SYSTEM ON THI� OR ANY ADJACENT OR NEHRBY LOT.
SIGNED DATE:
APPLICANT / KNOTT
^
ISSUED BY DATE:
Department 0f Health and ftvirormental Protection .
V. $25 �t.reet, Anchorage, 9,1-11kal o
264-4720
$3 06q% HANDWRITTEN PERMIT
- WELL PERMIT
it cant Kailing Addressc RV VL� ._42 '&�f
la s r1� €ia 1 Phone Number. S-
1 Description-.
rAW �t4 L# 7 1 Lot 5iZa:
of sail Absorption System Is
wench.- Drainfield: , Seepage Recd! Holding Tanki
,lam. Number of Bedro e- soil ting(sq..ft/br)
The Required ;size of the soil Absorption System Is:
t'f `
LENGTH l GRYE DEPTH_ WIDTH�`
,:,length dimension is the length(kn feet) of the trench or grainfield. The 1
,►16h of a trench or pit is the distance between the surface of the ground and
t: bottom of the excavation (in feet) • There is no set width for trenches a
U_ -gravel depth Js the minimum depth of gravel between the autfall, tip� and
i, bottom of the excavati n(in feet).
REQUIRED SEPTIC(HOLDING) TANK SIZE r � GALLONS
#:t: applicant has the responsibility to info this department during the
i31atior, inspections of any wells adjacent to thi* property and the neer
l;adences that the well will serve.
Two(2) INSPECTIONS ARE REQUIRED 4P
ia:lling of -any FBytVa � Is ����`= ��crrsa�� a�•pyozpaT` b ���-�eP��ni��
e subject to prosecution, - Amdistancedistance between a well and any on-site sewage disposal system is I00 fee
(''private well. or 150 to 204 feet from a public well depending upon the typq
"clic well. minimum distance from a private well to a private 88wer line -
I feet: and io a community surer line i 75 feet= Well logs are required
-
line-
-
be returned to this department within 30 days- L Of the well completion.
�:xeguarements may apply. Specifications and construction diagrams are
able to insure proper installation,
PERMIT EXPIRES DECEMBER 31, 1 9 3 3
artiy than:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage,
(:2) I will install the system in accordance with csudes a
(3� I understand that the onsite sewer system may require enlargement if
the residence is xetnod l d to include more that 3 bedrooms.
s _Issued by; &_ g
s `�
Date: �
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A
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date —26Z
(a) Legal Description (include lot, block,/subdivision, section,l township, range)
Location (address or directions)
1-r-�-� � e" ✓��" :� 1:moi
(b) Applicants Name /�c'fiyj �� /� ®ate d�i� Telephone = Home,4f,�!�4
pusiness
Applicants Address
(c) Applicant is (check one) Lending Institution ; Owner/builder ;
Buyer [::I ; Other F�] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
Telephone
(f) Mail the HAA to the following address:
2. Type of Residence
Single -Family
Number of Bedrooms
3. [dater Supply
Individual Well
Multi -Family
FA
Community
Other (describe
Public
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 Public I j Community E::l Holding Tank
iioce: ZY v_11 system, must nave m Itten confirmation from the State
Department of Environmental Conservation attestidg t'0 the IP -241 Y MId 9t9LUV3-
[Page 1 of 21
5. Engineering Firm Providing Inspections, Tests, File Search, Data and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify that my investigation of this Health Authority Approval shows that the on-site
water supply and/or 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 regula-
tions in effect on the date of this inspection.
Name of Firm '/�-
- E-L;"Lf Telephone L.->
Address 3pi/. fVk--7 "5-7�J
Date *�%1%"�✓
(ENGINEER SEAL)
6. DHEP Approval
Approved for bedrooms
Approved __�4- Disapproved
Terms of Conditional Approval
CAUTION
'C'OF
Ate,
sr�67�.N.'Y c a•r y
3 ¢ JAMEO 0 nouiaffe (
P°�<�•' ¢.pry°€�`te•`b�`wGy.._ /,� •`-���
Conditional
THE HUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 REQUIRE-
MENTS. 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.
(DHEP SEAL)
RR4/ej/D18
7-19-84
[Page 2 of 2]
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
A. WELL DATA
Well Classification ,:�,..�� , If A, B, or C. D.E.C. Approved(Y/N)
Well Log Present (Y/N) Y' Date Completed Yield Yield yrj
Total Depth /407 _ _ Cased to j®2 Depth of Grouting
Static Water Level ¢ 3 Pump Set At
Casing Height Above Ground ?"o Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) Depression Around Wellhead (Y/N)
Separation Distances from Well: / 3f0 J,
To Septic/Folding Tank on Lot Z ; On Adjoining Lots /®5' ks r -**4
To Nearest Edge of Absorption Field on Lot On Adjoining Lots 1,o7 An&e,-�g
To Nearest Public Sewer Line /C/144 To Nearest Public Sewer
Cleanout/Manhole &,d&A To Nearest Sewer Service Line on Lot
Water Sample Collected By AAI -a V,a� ; Date
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed i4Avr/;W Size 1,qNo. of Compartments
Standpipes (Y/N) }/ Air -tight Caps Y/N) Y Foundation Cleanout (Y/N) Y
Depression over Tank (Y/N) W Date Last Pumped des/
Pumping/Maintenance Contract on File (Y/N)Gfor y�
Holding Tank High -Water Alarm (Y/N) Temporary Holding Tank Permit (YIN),-Y,44-
Separation
Y/N)iYi4Separation. Distances from Septic/Holding Tank:
To Water -Supply Well /�j:Z,'Z To Building Foundation 27
To Property Line /'3®� _ To Disposal Field 7 J
To Water Main/Service LineTo Stream, Pond, Lake, or Major Drainage -�14
Course
Comments
�y
[Page 1 of 21
-0 2��1�)')
�_C_ s�(
T,ks
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 16' 1;> g��, %� Type of System Design
Data InstalledLength of Field ¢ 3'
width of Field Depth of Field
Gravel Bed Thickness Jrii
Square Feet of Absorption Area 5,e9 ? ��_ Standpipes Present (Y/N) _
Depression over Field (Y/N) A/ Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Whll Ipa, To Property Line ,rp, ze
To Building Foundation 5'. ' To Existing or Abandoned System on
Lot Aj t� ; On Adjoining Lots
To water Main/Service Line 41 To Cutnarle(if present)
To Stream/Pond/Lake/or Major Drainage Course �aeye 14
To Driveway, Parking Area, or Vehicle Storage Area
D. LIFT STATION
Date Installed
Sire in Gallons
"Pump Or." Level at
High water Alarm Level at
Tested for
Electrical Codes(Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at _ --
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conforTm d to all MOA HAA Guic)el,i es in effect
on the date of this ins ion.Ur N
Signed: Date7 ,9 ¢ .s`j�' �-
STNo° �.
Company MOA No. 5/ _ee/� ,:�.:. 1,GzrSEF 4n
RBl/d5/s
(Page 2 of 21
JAMES B ROBERTS
CE . 1516NSF
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