HomeMy WebLinkAboutSOUTHFORK NORTH BLK 4 LT 2Southfork
North
Block 4
Lot 2
#078-141-09
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program, 4700 Rimers Road
P.O. Box 196650 Anchorage, AK 99507 Page ,/of 3
www.ci.anchorage.ak.us (907) 343-7904
ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT 07 ,~'! L/!
Permit Number: O -~ iI:> / 0 / 0 ~'Z' PID Number: ~'"~~~
Name: A~ ~"' ~ ~ ~'~"~ ~ ~ Wastewater System: ~ New ~Upgrade
~~o ~. /~tv~¢ ,~t~ ABSORPTION FIELD~/~
Pho~¢¢__ ~517 Number~Bedrooms:~ = Deep Trench =ShaliowTrench ~Bed ~Mound ~Other:
Soil Rating: G
LEGAL
DESCRIPTION
Block~ Lot~~O~. Subd~ion:~o~ k ~*~ Depthto pipe bottom from original g~ Ft. Gravel depth b .... /thp~ Ft.
Township: Range: Section:
Fill added above original gra~ Gravel Length:~
/ Ft. ~ Ft.
Gravel width: ~ Numar of~s: I Distance belden lines:
Well: ~~ ~ NeWclassifi~tion (Private, ~ ~ Total ~,Depth: ~ Upgrade~~cas ~ Ft. / I Ft.
Total absorption ~ Pipe ~i~:
Date Drilled: ~c Water Level: Installer: / ~ /~ . Ce Installe~
Driller: ~ / ~~
Yie~ GPM PumpSotat: oight~oveGround;t' ~ <-;¢~¢~' TANK
SEPARATION DISTANCES ~pticD Holding D S.T.E.P. D Other:
~ ManCa~urer'~' ' ~3 ~ ~ Capacity:
TO Septic Absorption Lift Holding ~ublidPrivate
Tank Field Station Tank Sewer Line ~ ~ ~ ( ~ /~ ~ 0 Gal.
Material: Number of Compadments:
FoundationL°tSuda~ WaterLine /00/~/~/¢/m ¢ /~C>/O,~I O ,¢ U~~ ~WX ~ ~ "Pump on"Size: 'eve~/i'' "Pump ~' level at: ~'an~adurer:~T STATION~in.iHigh wats/~//in.
Cudain Drain ¢~ ¢~ ~ ~ Pum%Model Electri~l InsCs pedormed by: /
Remarks: ~ ~ % ~~ [~ BENCH MARK
J~ [~~ L°~t'°nand~cTi°~ ~ % ~" ~ ~ ~O.~m~vation:
Inspections pedormed by:,~, rr ~ Dates: 1'~ 0 ~'._~ 0; ~ ~,~ ..... ~,,.~",
2® ~-
Development Se~ices Depa~ment Approval ¢ ' .... '"" ..... ' '*'
Conditional Approval Date:
Reviewed
and
approved
by:
(Hey. 04/06) ~ - ~,~ .P"
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Permit Number:
Tax Code Number:
Work Type:
On-Site Wastewater Disposal System Permit
OSP101062
07814109000
Septic
MUNICIPALITY OF ANCHORAGE
Development Services Department
On-Site Water & Wastewater Program
4700 Elmore Road, PO Box 196650
Anchorage, AK 99519-6650
Telephone: (907) 343-7904
Upgrade
Permit Effective Dates: June 15, 2010 to June 15, 2011
Design Engineer: STEVE ENG
Subdivision: SOUTHFORK NORTH
Site LegalAddress: SOUTHFORKNORTH BLK 4 LT 2 G:0959
Owner/Address: HOELSCHER AARON M & DEBORAH A
2000 SOUTH RIVER DRIVE EAGLE RIVER AK 995779432
Lot Size In Sq Ft:
Site Mailing Address: 2000 SOUTH RIVER DR, Eagle River
Total Bedrooms:
J J,~eparlmenl
71836
3
This permit Is for the construction of:
N Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage
All construction must 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 Wastawater
Disposal Regulations (18AAC72) and Ddnking Water Regulations (18AAC80).
3. The wastewater code requires inspections dudng the installation. The engineer must notify the Development Services
Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours).
4. From October 15 to Apdl 15, a subsudace soil absorption system under construction during freezing weather must either:.
A. Open and Close on the same day.
B. Covered, sealed, and heated to prevent freezing.
Special Provisions: Fill is to be added to the pond in order to meet separation distances to the
absorption field.
Received By:
Issued By:
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 Elmore Road
P.O, Box 196650
Anchorage, Alaska 99507
www. muni,org/onsite
(907) 343~7904
ON-SITE SEWER/~VELL PERMIT APPLICATION
FOR A SINGLE FAMILY DWELLING
Parcel I.D. O "~ ~3. _ 1,~,// . 0
Property owner(s).,'~v' o ~1
Mailing address 2~3 430 ~oo./~-~
Site address
Legal description (Sub'd., Block & Lot)
Legal description (Township, Range & Section)
Lot Size -'7/°0'"~' Sq. Ft. Number of Bedrooms
Day phone ~-'~'.Z/- ~¢:',.~"/7
Zip Code ? 7 ,-q' 7' "7
Zip Code
THIS APPLICATION IS FOR ([~ all that apply): THIS APPLICATION IS AN:
Absorption Field [] Initial []
Septic Tank ~ Upgrade ~
Holding Tank Renewal
Privy []
Private Well []
Water Storage []
I certify that the above information is correct. I further certify that this application is being made for a
Single Family Dwelling and is in accordance with applicable Municipal Codes.
(Signature of property owner or .ad~j~r~ed agent)
Permit/Rush Fees:
Date of Payment:
Receipt Number:
(Rev. 11/05)
Oq 'c/g c
Waiver Fees:
Date of Payment:
Receipt Number:
I E.?. ,.G.~E ERING
Southfork North, Block 4, Lot 2
~PECIFICATIONS & DESIGN GIIIDEI,INES
Wastewater System Sizing: This is an existing 3-bedroom, single family home. The
septic tank failed. A design is submitted for a new septic tank. The existing leach field is
functioning, but within 100' of the constructed pond. The leach field also requires
additional cover material. The neighboring lots are undeveloped except across South
River Drive. The old tank will be removed or properly abandoned in place. The water
well is drawn on sheet I. Other water wells are not impacted. No adverse impacts are
expected from septic system replacement. No conflicts to the other lots will take place by
this septic system construction. The easements are located on the drawing and are not
encroached upon.
Specification Requirements: All components and work must comply with the Municipality
of Anchorage Specifications (AMC) & State of Alaska Drinking Water Regulations and
Wastewater Regulations.
· Two compartment, 1000 gallon septic tank. Watertight couplings on inlet & outlet.
· 5' minimum between the tank and bed. 10' to property lines.
· 3' of cover or insulation is required for trench; I" insulation may be substituted for one foot
soil cover.
· Tank & solid pipe must be set on well compacted, stable soil.
· 4 inch diameter cleanouts with airtlght caps are required I' to4' 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 lleu ofcast iron.
· Trench to be placed level, minimum of 4' to groundwater, 6' to bedrock from drain-rock.
· Drain rock to be ½ inch to 2 ½ inch screened. Drain rock to be distributed uniformly
throughout the trench.
· Perforated pipe to be installed level with perforations down.
· Silt barrier (filter fabric) to be installed above the drain rock.
· Smeared trench sides must be raked or scarified before drain rock placement.
· Backfill over drain rock must not be less than 36", 24" with I' insulation.
· The finish grade must be mounded to promote drainage over the 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 Linc is minimum 2% slope.
· Septic Tank to be pumped every two years or when required.
· Insulation board to be extruded direct burial polystyrene (Dow Styrofoam Ill or equal)
· Old Septic Tank to be removed or pumped, filled with sand/gravel, crushed, & buried.
· Any area of Pond within 100' ofwastewater system must be filled with clean fill
n
(~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
A~ ~ ~~ SEPTIC ABSORPTION
~ FRO~ TANK FIELD WELL
Phone(s) Permit ~o.
~ '~ LE~13D~(¢ ~ NO. or, rooms ~WELLLoT LINE
I ~ CAN~ ~ ,~,i .... y. waterboOies, etc.)
~ SEPTIC ~ HOLDING
Manu cturer Capacity in gallons
TYPE OF SYSTEM 'I
~ TRENCH D ~ W. DRAIN O OTHER
Depth to pipe bottom from Total depth from original fade
~ FI ~ FT
Gravellenglh ~ FT GravelwiOth ~ FI
Total absorption area Distance between Jines
IVATE ~ OTHER (Identify)
Cla~ifl~on~[~~(A.B.C) Total Depth IT Cased to FI ,.
/
72-013 (3/85)
/ /
8;?/,'.';J I.... S'Li"~'..H:., F~r~l::h{2r. age:, ¢.~im-ska 99501 :.T:;zi.:::.!;.'-q.'720
F:'ar (:::E-~ i :[ d r, 0'7E),,,~ :1.4. !.....09
.... (... L I....~:2~:j a I ~ .::~.~.:~l:l ] v i sili i:~n z~ SC!L!1"H F (..)lq'.... NDi:VTH t_cH:. ~~..°
,SE, c: 'L i c:n x z!./9 'To~,m ,:.~.~h i l::i [ I ~?~',.E!;N i:['.an g E:, ~
L..c:,t..'.:i!~:i.z~.~ '7:i.E!:]!;,':':~ (?.!~':::I,, ft .'.::n" a~:::!~!~)
:81 cx:: !< x xi.
1 ~-'~
Day
:i)E:V:I:~q'F]:C~N F:!::~:(::)H (..'..'F:'F'F::~i3VE::O ENE~]:NIiEEF?.~S D[ES:[C')N I::~Iii~:L~!LJ:[[RE:E~ DI-h""F,E; AF:'F:'F.",'OVAL.
I:::'i::~ :[ (::il::~ 'lC:) C:E!N!i~TI::~LIC'T :[ C]N ~ NC]'I' :[ i:::'Y ~:)H!'"IE~ EUZI:=C)[?E: A~i...L.. i NSF:'E:C'T :[ E)NEil ,, Fq..J ....
E:Xi:f;~.W.'-'::C!']:C)N!!:~ HUS'I )'3E: [.)F:'EEIqE~:)/C;L..[)~E::0
N ! (:':')t"-I'!' ~, T'H :I: 8 t:::'!i!i:l::d"l ]: ] :1: E~ H'C)F~ (.:'~ 5 I:(Eii. D!':.','E)EIH E~F:' F~!!!!:Ei~ :!: ]:)l:ii:NC:li!!: CiNI..Y ~, F:~ND lie X .....
i:::'i F?.E]E: !iN 17./:3 :I./"?O., E:X :[ E?[' IhK'}
I...:(I='T' ST'~.~T']:C)N F~E:[;!LIIF;EES THE: ~:'q:::'F:'F;,'E)I='F':.'I,'.'.'C!'E:
i C:E~:F:',"[' ]: F:'¥ 'I'H&YI" ~
]: am tam:i. Zl.:i. ar'. ~4:J.'Lh 'LhE.~ P~.~qL~J.r'em~r'~t.~i .fcH" c)n-~i'Le ~EYz~(~.:.H":~ and (,,~(~.:.):!.:l.J[il a~i~ ~i~.::~'L
Fcm'i.h by 'LI':~ !'"]u.r~ic:ii:)aii'Ly oF F~nc:l-~cmage~ (HC)P~) and Chez, E~t.a'LE:, c:){
2,, ]: ~i:1. I :Lr'H~-La:!.i 'LI'~.:~ s~y~'L(-~xn ir'l ac:c:c)r'dan(:::e ~,,~:i.'Lh ali ["IChq (:::(::)d~::.:,~: and
~;,, ]: r,~:i.].l adl"l(:erra 't'..D a11 HCiB~ ar'icj E?t:.a't:.(.~ (::,.f ;~:l. as~H.,:a r'(?¢qu:fr't~men'LE~, f(::n" 'E.h(.;e
%ev~E:~r'a~](.:=) %y%'L(am'~ (::)i-~ 'Ll"~:i.~[[~ cH" any ,:;'[~d.jac:,:+:.)nt. oP r'~,~:.)arby
f(+?6:,'L r,:.xF..~:Lr'(.:~)Ei :ir'~!~n.~]a'L:J.'an ,'::)v(.z.:r 'Lanl< (~) .
Tom Fink,
Mayor
N unicipality Anchorage
Department of Health and Human Services
825 "L" Street
P.O. Box 196650 Anchorage, Alaska 99519-6650
January 8, 1990
Aaron & Debra Holesher
% S & S Engineering, 17034 Eagle River Loop Road, Suite 204
Eagle River, Alaska 99577
Subject: Lot 2 Block 4 South Fork North S/D
Permit #890196, PID #078-141-09
The subject permit, issued by this office for a single family
well and/or on-site wastewater system has expired as of December
31, 1989.
Permits are issued on a calendar year basis by authority of the
Municipal Code of Regulations. A new permit must be obtained
from this office for an well and/or on-site wastewater system
Dot installed by the expiration date.
If you have drilled the well, a well log needs to be sent to
this office for documentation of the installation and to close
the permit.
If a private engineer inspected the installation of the on-site
wastewater system, the original as-built inspection report
(three-part form) must be sent to this office for review,
approval and documentation.
When applying for a new permit, the fees are: $90.00 for an
on-site wastewater permit; $50.00 for a well permit; $140.00 for
a combined on-site wastewater and well permit.
If you have any questions, please call this office at 343-4744.
Sincerely,
John Smith, P.E.
Program Manager
On-site Services
JW/ljm:200
enc: Copy of Permit
"Kids Are Our Future"
M U N I C :[ F:' A L.. :I: T Y 0 F' A lq C H [] R A G E
De p a r' t m~-~.:.n'L o ~' Hea :I. t. h & I"'lu ma n S e i" v :i. (::: e~..
(:~',~!5 L. Str'e,?L, Anchc~r'-a(je, Alaska 9950:[
0 N ..... S % T E S E W E R F' E R H :1:T
Per'm :i.'L Number' ,: 890 :[96
:(}E:~'~. E, ]: ~H~iI..IE.~(:J ',I O?/() :I./~9 En g i n ~:.'..)(.~ r' Des :i. gried
I]bm.,'.;,,~' Ac:h::l~'ess: 1703,-".1. EAGL..E RIVER RI:),,
EAGLE R!VE:R, AK 99577
Day J::'h()rte~
694'"-2979
!,...c,t L..e(:lali: Subd:i. visic~n~: :SOUTH FORE Ni]R"i'H Lot: 2
Sect J.c)r'~: 419 'l"(::~tr'~sh J.p ~ :[3N Range:
Lc:r('.. Size '7:1.8::t~;6 (sq,, {t,, (:)r' acr'es)
Max Bedr.,:)oms~ 'l"his F'er'mi'L~ ::S Total []apac::ity~
Block.~ 4
SEPTIC TANK~: M:i.n:i. mum '(:.otal septic tank c:apac:ity: ~.,()0() gallons,, Each s(.~pt.:i.c:
t,ar',k must haw.~, a!:. least 2 compar'tmen'Ls,, Depth to top c,~' sep'Lic 'Lank (s) <
{ec~t r'equ:i.l".es il"H~M].~V['..~.(::)i"~ (:)VE')H" 't:.aF~k (~),,
]"Ff:I:S SYSTEM 'f'(] BE ]:NS"FAL. L,.IEi:D :I;A ACCORDANCE W:i:'t'!,..I '!"HE APPROVE:D
ENGINEE:R'.':3 DES:i;GN. DFIHS MUST BE NOTII;:!E:D PRIOR TO AM.... ):NSPECT. ....
]:ONS,, INSTAL.L..AT Z ON OF A L.t FT S]"A'T':[ON REQU:I:RES TFIE AI'.::'F:'F~OPRI ATE
ELEi:C:TI:R:[CAL I NSF'ECT:I: :I:ON,, ]'FIE EX ]:S'I' ]:NG I..EA[:;H F I EL.D MUST BE PRE)F'
ERLY ABANDONED ,, T,'-.I:i: E PiEF~M :!: '1" :I: S F[:)F:~ A 3 BEDF;'.OOM S I NGL.!il; F.'AM :!: L.Y
F;,'ES :!: D!i~:IxlC!i!i: OI~IL..Y, AND EXF' :I:I:"II~ES ON :i.i;:'. 13:1. 189,,
i: CERT:I:F:'Y THA'I"~
I, I am Fam:i:l. iap with 'r-.he l"ecluir.~men'~.s £op c)n-s:i, te se~iei"s and we:!.:l.s~ as set
l'oi"th by 'l'..he MunJ. c:ipa].:i, ty of' Arichor. ag~.~ (MOA) and 'Lhe Statce ciF Alaska,,
2,, I ~.~:i.:!.l :i. nsta:!.l the syst..~.:~.~m in accor'dance Nit. h a].l MOA i::cicles
and in compliance wit. h the design c:r'i'Le~:i.a oF th:is
3,, I ~,~i].l adhel~c.~ t.o all MOA arid State o{' Alaska r-equ:i.l-em(~:.~r!ts i'c:m the set back
distarl(::es Fl".ciin arly ex;i. stJ. rig W~:,],].~, waste~,~at.e~" disp(ssa], system of pub:Ilo
:!: unde)"s'lt, ar'ld 'Lha'i:. 'Lh:i.s per'mit is va].i.d {'oi". a maximum
a:l. sc) ui"!d(.:.::,i'~st.,:~;tr'id tha't, the capac:i, ty of 'f. he total sys'L~:.:em :i.s ::.~; !:)i~(:]l'~cicims arid
ai"iy v~ntat'gement ~,,;:i.:l.l p~::~,q~.z:i, pe an add:i, tic)na~l
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LE ^, DESCR,PT,ON: Z2
5
6
7
8
9
10
11
12
13
14
15
16
17,
18-
19-
20-
DATE
PERFORMED:
,~ ~/~'/~,~,Township, Range, Section: /.~,/~,/ .' /~/,~0~ ~t~zE-)~/r
SLOPE SITE~PLAN '
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
Monitoring?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
FT AND ~"~ FT
COMMENTS ~
..... · .,~-~l~.I/~. ~ / ~ /
....... ' Eaale River, Alaska 99577 ' ~// ~ ~ CERTIFY THAT ~HIS TEST WAS PERFORMED IN
A....uANCE WITH A~ STATE AND MUNICIPAL GUIDEL~CT ON THIS DA,E. DATE: ~/~¢~ ~
72-008 (Rev. 4/85)
MUNICIPALITY OF ANCHORAGE
DE,,.__/:ITMENT OF HEALTH AND HUMAN SER:, ES
* Environmental Heallh Division
, \_, 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
Add .... TANK FIELD WELL
Permit .o. "O. O' %rooCs WELL /~}
Lot 8lock Subdiwsion
% ~ ~.~ ~ ~ FOUNDATION '
%[~ ~ ~ , 5~~ ¢¢I drweway.AS'BUILT DIAGRA" (Show location of well. septic system, property iwater bcd,es, eto. J ..... loundat,o..
TANKS i
MaRulacturer Capacity ~n gallons ~
~aterial No. of Compartments ~¢'
TYPE OF SYSTEM
-~;pthor,ginaltOgradePlpe bottom from %' OFT Total depth fro~ original grade ?, OFT ~
Gra~'i~gth Gravel w~dth
Total absorption area Distance between lines / ~
Installer Date Installed /
PRIVATE ~ OTHER [Identify)
Class,ficahon (A,B,C) Total Depth ~T Cased to ~ ~. ~
I ~ ~ J ~ cedify that thio inopection was pedormed according Io all
Health Depadment Approval: ~ O~ Date: / /
72 013 (3/85]
DEF'AI::(TMEEI'.tx~"OF ' ""~' '"""
ri.:.,.-, .. "~ AND ENVIRONME:N'T'~' F'RO'I"EC'I"ION
825 L STREET, ANCHC)RAGE, AK 995()1
2.64-'472()
F'ERMIT NO:
OATE :f .E~S ~ED:~
860 :L 58
06 ?04/86
APPL I CANT
~..~DDR E.~::~,:::,:
CON't"A. CT F:'HONE:
SOLJ"rl--J F'OF;.:K CONST.
I'"':'. 0. BOX 770567
EAGLIE RIVEF;:, AK 9':?5'77
694-4:~;5 :t.
.'."3LIBB I V I S I ON ~ SOLJTH FORK NOR"FH
'L:;E[:;T ]: [)lxl: 4&9 'f'OWNSH I F:': :[ 3N
'7:1.836 (:SC;!,, FT. OR ACRES)
L LOCI- .... 4
LJ:]T:~=."'" q "'"
RANGE: 1W
..... Jsted bE.?].ow ar'e 't:he? Ol:)'Lic)ns available 't:.o you in des:i, gl]iJ](:; y(]t..tP sep'L:Lc
system. Choose the optic)ri tha'l:., i::~<~:est., fits yc:~L.(r' '''
DEPTH 'T'O F'IPE BOTTOM (F:T.) 4.0 4.0 4,,()
GRAVEl.... DEPTH (F"f'~) 4.'0 0,, 5 3.5
'I"OTAL. DIEPTH (F:"T.) 8.0 4,, 5 7,, 5
GRAVEl,.. W]:D'f'H (F"T'.) 2.. 5 25.0 5.0
GRAVEl.... LEIqGTH (FT.) :t..1.3.0 '~"~ 47,, 0 97,, 0
GRAVEl.... VOLLJMtE (CU. YDS. ) 47. :[ 43.6 '71.9
]"ANK SIZE (GALS) ].,000.0 ~'~' 1,000.0 '~4, 1,()00,,0 ~'
SOIL. RA'I"ING (SQ~F"'T. /BR) 299 257 299
7= F'T. EACH)
~'* GRAVEl,_ LENGTH > 7'5 I::'T. REQtJ]:RES MUL. T]:F'I...E Rt..]I'4S (NOT EXCEEDING .... ~
..... E.A.~: I ]'WO COMPARTMENTS
'~.'."¢.' TANK idlJST HAVE A'T' ~ ''' ' ......
c:er"L:i, fy that:
:l.,, I am Fam:i.].iar' wit. h the r. equirement, s For' on-site ~ewer's and we].:Ls as set
Fop'Lb by the f'iLtC~:Lc:ipa].~.~y O{ Anchor'age (JvJOA) and the State c:,F A].aska.
2,, I ~.~J.].]. :Lnsta11 the Sy~'~:.E)Ei ~r) acc(:)l'd~d'lc:e ~,*~J.t.J'i ali. MOA cc]de~ and
and ~r'l comp].iariEe t,,]i'(..h the cJe~J.g~3 cpJ, t. el"~:a o¢ 'f. iqJ. s per'mit.
3, ! wi].1 adher'e 't:.o all MOA and State o( Alaska pequir'emer~t.s {'(:,p the set back
sek,~6.H"ag~ system c)n 'Lhis cm any adjac:en{z c)p neapby
· 4. '.[ urld~Pstand that th~.~5 pepr/'l~'.. :i.s v~.],id [c~i" ~t m~x:i.r~iL.Uil c~{7 3 bedr'aom~ and
ar]y (.?ri].aPg~)merlt NJ.].J. r'E:,qL~fPE, an additic~na], p~Pm:Lt,,
:IF A I...IFT STA'T'I:ON IS INSTALl_ED :IN AN AREA COVERED BY MOA BUiL. D:[NG CODES,
]"HEN (1) AN E:LEE;TRICAL. F'ERMIT AND INSPECTION tdUST BE OBTAINED; (2) AS-'BUIL. TS
W:i:L.L. NOT BIE A~ ~ED Wt'T'HOU-f' AN ELEC"FRICAL !NSF'E:CTION RE:F'DRT; AND (3) THE
E:L.I::CTIR]:E;AL. W Mt~IS"F BE DONE BY A LICENSED EL. ECTRICIAN,,
S ]: G lq E D
CAN]": SOU" '
1 .:::: UE..L BY
PERFORMED FOR:
1
2
4
5
6
8
9
10-
11
12
13
14
15
16
17
18
19-
20~
Municipality of Anchorage ~'~ .... / ~
DEPARTMENT OF HEALTH & HUMAN SERVICES ~~~.~.~.
SOILS LOG -- PERCOLATION TEST ~~.
Township, Range, Section: ~ ~ ~ ~N~
SI 'E PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? . p
E
Oeplh to Water Alter
Monitoring? \"~! Dale: ~'
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE '~"~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~' FT AND ~ FT
COMMENTS 'RB ']',X /"'¢-~ /~ ~ ~/ CERTIFY
S & S ENGINEERING
PERFORMED BY: /~f.,~_.- ~ TH~,~T;,~-J-II,S3T~S~,.~$ PERFORMED IN
ACCORDANCE WIT~H A~LLL[EST~AJTYJ~J~'J~J~C~d"J~'UIDEL~IN EFFECT ON THIS DATE. DATE: '¥'1~' ~ C~
72-008 (Rev. 4/85)
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
ADDRESS )~,) /5:.~?:
LEGAL DESCRIPTION
DATE- Started ,%;
PERMIT NUMBER
DEPTH OF WELL
STATIC LEVEL OF WATER FT. f? '~
DRAW DOWN FT.
GALS. PER HR
Ended
/
KIND OF FORMATION:
From · Ft. to '
From !~) Fi. to
From ~* Ft. to Ft.
From ~ ..... Ft. to ~:-}(~' Ft.
From ~']~"~ Ft. to '~ { Ft.
From Ft. to Ft.
From ~Ft. to ~
? ? Ft.
From__Ft to Ft.
From / 17 Ft. to.¢ / Ft.
From__Ft. to Ft.
From Ft. to__Ft
From Ft. to Ft
From__Ft. to Ft.
From Ft. to , Ft
From Ft. to__Ft.
From__Ft. to__Ft-
From Ft. to____Ft
From Ft. to Ft
From__ Ft. to Ft.
From__ Ft. to Ft.
From Ft. 1o ..Ft
From Ft. ~o Ft
From__ Ft. to__.Ft
From__Ft. to__Ft
From__FL to__ Ft.
From,~Ft. to Fl
From__Ft. to Ft.
NIUNICIPALI'I~'r~:~fi ANCHOl~.~o__ Ft
DEPT. OF HEALTH &
JhIVlRONMr:~L~J-To~ PROTECTII~.to '; Ft.
}d~l~o~ loC. Ft. to__Ft
. From~.~F.t. to ! Ft
RE ,IV F,.
From__Ft. to Ft.
From Ft. to Ft.
MISCL. INFORMATION:
DRILLER'S NAME
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 ~'~ - ~ '~' ~-~(~
GENERAL INFORMATION
(a) Legal Description~..¢ (include~ Iot,.~L~A/-'-bl°ck' subdivision,~ section,~.l~ltownship,h~::::C::~CZ.4~range)
Location (address or directions)
(b) Applicant Name ~'~-~-'~'~ ~'~ Telephone: Home
Applicant Address '~'~"~' ~ q'"l~:~"'~'"~ ~-~,~.,
(c)
Business .J~ Of-. ~
'7'7
Applicant is (check one): Lending Institution D; Owner/builder~ Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms ~'~
Other
WATER SUPPLY
Individual Well~i~ Community [] 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 -.,
OnsiteJ~ 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.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDII~-~NSPECTIONS, 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 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 regulations in effect on
the date of this inspection.
Name of Firm Telephone ,
SRB 19~X
Address
A1(995:7 JUL I I 198 ,
[}ate
Approved t/er (~.~.¢~¢_., Date
bedrooms by o
Approved /~¢*
Disapproved
Terms of Conditional 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 [}HEP 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.
Page 2 of 2
72-025 (11/84)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
i~,"JIqicIPALITy OF ANCHo,r~AG~
DEPI'. OF HEALTH &
ENVIRONMENTAL PROTECTION
Legal Description:
.
WELL DATA
Well Classification
Well Log Present (~)/N)
Total Depth
Static Water Level
~.~"),~ k/~ ~.~/>%~- ifA, B, C, D.E.C. Approved (Y/N)
Date Completed '~'-/'~/¢ Yield
Cased to '~O lb/'
Casing Height Above Ground
Electrical Wiring in Conduit(~/N)
Separation Distances from Well:'
To Septic/J=b:44~J'T.ank on Lot
To Nearest. 15dge'of Absorptiof~ Field on Let
Nearest P~Jbifc Sewer Line /~/
To
Cleanout~Manhole
Water Sample Collected by
Water Sample Test Results
Comments
Depth of Grouting
Pump Set At
Sanitary Seal on Casing ¢~N)
Depression Around Wellhead (Y/,_~
~ '7,~¢¢ [ ; On Adjoining Lots t ~::~¢ ~r
; On Adjoining Lots ~L~ ~ t~
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot '2'~-~ ~J¢
B. SEPTIC/I=I~L'Dfl~G TANK DATA
Date Installed '"~..--'~. ~ ~l~ Size
Standpipes~/N) Air-tight Caps dC~'N)
Depression over Tank (Y~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/,~ Tank:
To Water-Supply Well I "~'+
To Property Line ~'-~'
To Water Main/Service Line .)
Course
Comments
No. of Compartments '-2-
Foundation Cleanoutd~/N)
~..%__/~ Date Last Pumped
; for
/.
Temporary Holding Tank Permit (Y/N) /~/,~1
To Building Foundation
To Disposal Field' :-
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata '~.--~ =~'lle0---
Date Installed "~--~:~ ~ ~
Width of Field '¢-.-, ~' '~
Square Feet of Absorption Area
Depression over Field (Y/~j:)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field "~
Gravel Bed Thickness
Standpipes Present ~:~:'N)
~.~///~ Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot ~'~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Property Line
To Existing or Abandoned System on
Comments
; On Adjoining Lots
To Cutbank (if present)
/,¢0
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
anhole/Access(Y/N)
"Pump Off"Vent Level (Y/N)at
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify ~ ~4~j~,~;~j~ed, or conformed to all M CA and NAA guidelines in effect on the date of this inspection ""~
SignedS~ B ]?~X Date
Compar~t'~l I: Dl~/c~ A ~,, ,,~,,~=-~..-/ MOA No.
R ceiptNo. _
Date of Payment '~ - ~-~
Amount: $ ~%,~
Page 2 of 2
72-026 (11/84)
'CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
Anchorage, Alaska 99518
Drinking W~ter Analysis Report for Total Coliform Bacteria
Mailing Address
City
TO BE COMPLETED BY WATER SUPPLIER
.~ PRIVATE WATER SYSTEM ~
Name
SAMPLE DATE:
State
Day Year
Phone No.
Zip Code
SAMPLE TYPE:
[~Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
.) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
4 I
5 I
Time Collected
Collected ¢
I
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[~ Satisfactory
[] Unsatisfactory
[] Sampletoo long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Timei Received
Anal,Ytical Method:
Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No.
I
I
I
BACTERIOLOGICAL WATER
Result*
ANALYSIS RECORD
Analyst
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Filter Results
TNTC = Too Numberous To Count
OB = Other Bacteria
BGB
Date
Time:
Coilform/100ml
Coilformll00ml
Ix.co ..m.
p.m.
x~/) ',. 9_~TM \¢-~:., 9