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Home My WebLink AboutCINERAMA TERRACE BLK 3 LT 2Cineromo Ter'r'clce Block 3 Loi- 2 # Municipality of Anchorage Page DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ~ [~/~ l0'~ ';~ '-~''' PiD Number: N~: ~ ~W~ Wastewater System: ~New ~ Upgrade Address:~O ~ ~ ABSORPTION FIELD ~,o~: ~- ~7 I"°'°'~m°m~: ~ Deep Trench ~ShallowTrench ~Bed ~Mound ~Other LEGAL DESCRIPTION so,,~ti.~: . ~ ~wsq.~. ~o~ O~,~ro~_~or,~i.~, r~: Block: Subdivision: -- Depth to pipe ~ttom from original grade: Gravel depth beneath pipe '°w~'i~N ~ ISec~l Filladded aboveoriginalgra~:~__ Ft. Grovel length: ~? ' Ft. WELL: ~New D Upgrade Gravel~ ~¢~Ft. Numberoflines:l Distan~tweenlines:~ Ft. Classification (Private, A,B,C): Total Depth: Oased TO: Total absorption area: ~¢~¢ Pipe material: Driller:A ~ p ¢ ~ Date Drilled: Static Water Level:Ft. Installer:~ ~ ~/-- ~1~'~ Date installe Yield: Casing Height Above Ground: SEPARATION DISTANCES ~eptio ~ Ho~Ui~g ~ S.T.E.P. From Tank Field Static. Tank Sewer Lin~ _ Well /~ ~0 Material: S~ Number of Cerements: Surface Water N/A N~ LIFT STATION Lot Size in gallons: ~ Manufacturer: Line ~O '~ ~ Cu~ainDrain ~ ~ 3ump Make & Model ~ Electrical Inspections pedormed by: Remarks: BENCH MARK Location and Descripti~ ~ ~h E~INEE~S SE~L Inspections performed by: ~S, DateS:2ndlSt e/~/~l~ ( ~o~~~'F~ -: ............ z~ , D~parlme.t of Hea es approval Reviewed and approved by: Date'. 72-013 (1/91} MOA 25 MoN~or 0 ~lde ?rench~ g' h4de 79'Long $' l)eep ~4 in o£ Septic Rock 3' mil~, £ovel"' ND SCALE 0 FBUNDAT10N CLEAN OUT TDB3EN SPURKLAND P.E, 203 W 15TH. AVENUE ANCH. AK. 99501 LOT 8, CINERAMA 1-ERR. R£2ERT HUNT I63£0 BLACK BEAR DRIVE SHEET~ 3/3 GRID, 3841 ~6Ft, LINE E,4$EI4E~IT TBBBEN SPURKLAND P,E, 203 W 15TH, AVENUE ANCH, AK, 99501 LB1- P_, 3LBCK 3 CINE£11Nll TERR RD3ERT HUNT 4101 ARCTI£ BL VD, OATE, DECEM3ER ]Z I9~ SHEET, £/3 arm3841 P A,~'~JE f. (.-iF' PE RMZ7 NUMBER: SW9:I. 0035 DESZGN ENG_T. NEER:TOBBEN SPURKL.AND~ (]~4NER NAHE:HUN]" ROBERT C)I,4NER ADDRESS: 4':I. 0':[ ARC'I"iC BL.D'.J. ANCHEiRAGE ,, ALASKA L.E:,E;AL. [)ESCRZP'T'i'di',i: ~INERAMA TERRACE BI...K :~ LT "FF!iS PERMIT 'J% FOP THE .... )NTR,_,.,, ~ .~ APPROVAL fGl~l.. ,.m...P [H,E:7'~ SY,~FEM M~,, NOT h..~,LEiE.[.~ ~.'"'._, ,., r~:r_"-r'~"T. FROM GRE!UND ~.~_..~-~.~. ~.,.,~J._UL.~,~ ~..~.~.t~..~ RECEIVED .~,5 ~,, 'x JUN '~"~' . r;~ ~, ,-7 19D1 - .~. .~. ,_ .- , .,~~ i,~.o/~f Ancho, a e ~.r~ 7~ ~,~._ ~ Dept. Health & Human Ser~ces ', Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST DATE PERFORMED: LEGAL DESCRIPTION; J..-~'-[' 1 2 3 4 5 6 7 8 9- 10- 11 13- 14- 15- 16- 17- 18- 19- 20- ECEIVED JUN 7 19Sl Township, Range, Section: WAS GROUND WATER ENCOUNTERED? s IF YES, AT WHAT ~3 DEPTH? p E Depth Io Water After Monitoring? Dale: SITE PLAN 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 PERFORMED BY: I CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES iN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERFORMED FOR: LEGAL DESCRIPTION: I 2 3 4 5- 6- 7 8 9 10 11 12 13 14- 15- 16- 17- 18- 19 2O COMMENTS Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST RECEIVED JUl',l 7 Iaa? :~pality of Anchorage & N~ma~ Servk~es Township, Range, Section: WAS GROUND WATER ENCOUNTERED? S YES, AT WHAT nL IF DEPTH? p E Oeplh te Water After Monitoring?' Date: SLOPE SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop %!o,, 7 - : l~ ~l ~ & ~ 0 PERCOLATION RATE __ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN ~ FT AND ~ FT PERFORMED BY: I CERTIFY THAT THIS TEST WAS PERFORMED iN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) PERFORMED FOR: LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST Township, Range, Section: I 2 3 4 5 6- 7- 8- 9- 10- 11 13- 14- 15 16 17 18 19 20 COMMENTS RECEIVED JUN 7 19 1 c~paliiy of Anchorage & Human Service WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH7 Oeplh to Waler After Mofliloring? Date: SLOPE SITE PLAN Reading Date Gross Net Depth to Net Time Time Water Drop 5~ io ~ ~y ; z.,> to 7 PERCOLATION RATE ~-~ (minutes/inch) I~ERC HOLE DIAMETER TEST RUN BETWEEN ~:> FT AND '~/~- FT PERFORMED BY: I ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. 72-008 (Rev. 4/85) CERTIFY THAT THIS TEST WAS PERFORMED IN DATE: CONSULTING ENGINEER TELEPHONE: (907) 279 3916 ~ ~ ~ ANCHORAGE, ALASKA 99501 CONSULTING ENGINEER TELEPHONE: (907) 279-3916 LBT7 LL~T .9 StiEET, ,t/.':~ 5F~I~ RECEIVED IdAR 1 § 1991 MunioipeJity ot Anehorege Dept, Health & Human ~e~loe~ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION ~Z~ PERCOLATIO~ TEST SOILS LOG -- PERCOLATION TEST PERFORMED FOR: "~7~ 'L I ~'~-~ · S~'OFE ' EITE PLAN WAS GROUND WATER/~J ENCOUNTERED? IF YES, A~L WHAT DEPTH? Reading Date Time Time ~K..I~ Water T:T Drop 18- 19- 20- PERCOLATION RATE ~ {minutia/inch) ¢ ~'~. FT TEST RUN BETWEEN , FT AND . ~T'~' ~/-~/ ~r~. ('-z./ · CERTIFIED 72-008 (6/79) .. PERFORMED FOR: LEGAL DESCRIPTION: Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST 3 4 6 7 8- 9- 10- 11 13- 16 ',,,, ! 17 ,;' - 20 COMMENTS ~),,¢~ ~ ~ I~/~'A,~ ~ERPO~MED BY: ~ --~ .. DATEPERF0~IEp: ~.~/~/~ Township, Range, Section: 'T [ ~ ~ SLOPE SITE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH7 Deplh to Water Alte.r~ Monitoring? IJ'l~ ~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~--1~'" TEST RUN BETWEEN" FT AND (minutes/inch) PERC HOLE DIAMETER -- FT ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/851 CERTIFY THAT THIS TEST WAS PERFORMED IN WATER WELL RECORD STA'tE Off ALASKA DEPARTMENT OF NATURAL RE$0URE$ Division of Geological El. Geophy~{ecll Surveys ......... ..~ ~' '/: ...... ~ Te~I Well ~ Other: ....... ......... ~, CA$fNG~ ~ Threaded ~;' ~un~clpatitY ? ~ ''~"' 'C I~, PUMP~ (if available) oepa'"'-'-''-'t:~e*~ HU~ ,an Se~t ~s ~".,,: ~'~ ~.~,~~I'~(,, ~ ~..A,~:,~,~x 27/: ~lgnad, ~,'c ....... ~.-"~/, /-'~%'~.-":1 Date; ';;~, ~ <~' _,- 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.# 1. GENERAL INFORMATION Complete legal description [_~"r' Z; ~-t~ct.~.- ~ Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address Day phone Day phone Day phone 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well ~'"~ ~(. Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OFWASTEWATER DISPOSAL: NOTE: Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025{Rev. 1/91) FronJ[. MOA~21 o 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. Name of Firm /~gA'7~5'~ E:'-~C/,,J~."~fz.~,,J~ Phone Address Engineer's signature DHHS SIGNATURE / Approved for ~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments ! 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 DHHS does this as a cou rtssy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of D HHS 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 p~'ofessional engineer's work. Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: A. Well Data Parcel I.D. Well Log present (Y/N) /v' Total depth Sanitary seal (Y/N) if A. B, or C. attach ADEC letter. ADEC water system number Date completed -~/~- ~"/~/ Driller Cased to ~"/ Casing height --l-- Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 FROM WELL LOG AT INSPECTION ~ g.p.m. ~'.~' g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~' /'~' / Absorption field on lot ~ Z-~ ~ Public sewer main ,~'//~ ~ Sewer service line ;> / ~ ; On adjacent lots ~ /~--~ / ; On adjacent lots ,> /~'-~ / Public sewer manhole/cleanout ~'~;,'/~ Petroleum tank ~/~/4~'' WATER SAMPLE RESULTS: Coliform o Date of sample: //,/~ ~'/~ Nitrate Z.-, ~, ~'//-- Other bacteria Collected by: ~ B. SEPTIC/t-14~.{~I~ TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping 7/~,/~ Tank size //z,~/~,¢~,,~ .~ Compartments Foundation cleanout (Y/N) ,/~ Depression (Y/N) Alarm tested (WN) Pumper ,,.,~,~,¢, ~ SEPARATION DISTANCES FROM SEPTIC;j :~: P,:;-'~ TANK TO: Well(s) on lot ~ /¢~"/ On adjacent lots To property line ~' ~z~" Absorption field Surface water/drainage >' /o~ ~ Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer ~ Manhole) __ Vent (Y/N) "Pump on" level at ~ "Pump off" Level at High water alarm level ~ycles tested Meets MOA electrical codes (Y/N) .jr SEPARATION DISTA~ LIFT STATION TO: Well o~¢''~ On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~/~/~/ Length ~' Width Total absorption area ~¥ 5/ Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Soil rating (GPD/FF) Gravel thickness Cleanout present (Y/N) Results (pass/fail) System type .5.4~///~w' ?'~.~,~ Total depth Depression over field (Y/N) for .~ Bedrooms After test If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ ~,O-~ To building foundation On adjacent lots Surface water ;> /5-0 Curtain drain On adjacent lots > //-'~ ~ Property line To existing or abandoned system on lot Cutbank > 7~ / Water mai~/service line Driveway, parking~-ehicle storage area ~' ~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effeF, Ck~.~ tbe~c~a~te of this inspection. Engineer's Name Date HAA Fee $ Date of Payment Receipt Number Fee $ Date of Payment Receipt Number IC~') Parcel I.D. # 1. 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 O ~-'~ - O'~-~- ~ HAA# GENERAL INFORMATION Complete legal description Location (site address or directions) I'~0 Property owner Mailing address Mailing address· Agent Dayphone ~Y'¢- 6~"7 Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: NOTE: Individual well ,,/~ Community well Public water 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~)25 (Rev, 1/91) Front MOA#21 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. th'm.~spection. Name of Firm 'T'~ ~ .¢¢.-/ ~1~-~ Phone Address, ~O'% (~/ ~~ Engineer s signature ~ . Date ~t'., 0,k '-~ 6. DHHS SIGNATURE Approved for -.. /¢/ ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: . Date 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 orderto 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 engineer's work. 72*025 (Rev. 1/91} Back MOA#21 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST If A, B, or C, attach ADEC letter. ~z/ Date completed 1(o ~ Cased to /~ ADEC water system number ~, ~ ~[~3-o ~ ~ Driller ~-~ Casing height ~'~' Sanitary seal (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG Wires properly protected (Y/N) AT INSPECTION SEPARATION DISTANCES FROM WELL TO: Septic/,,~!d!.~, t~nk on lot i ~' ~)'- Absorption field on lot e~. '~O Public sewer main /~//~A~ Sewer service line ~ /c*-~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: .. SEPT,C/.O'D,.G T^.. Date installed ~/~ ~'/~' ! Cleanouts (Y/N) ~ ~ _ High water alarm (Y/N) Date of pumping Tank size /' ~q-~-O Compartments Foundation cleanout (Y/N) ~" ~ Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~/~'~-- On adjacent lots ~ / ~ To prOperty line .~"' 0 Surface water/drainage Absorption field t-///,k Foundation ~-. O Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed ~/"~& ~( Length '--] c~ Width Total absorption area Depression over field (Y/N) Results (pass/fail) ~)o~ ~ ~ Peroxide treatment (past 12 months) (Y/N) Soil rating L. &Gravel thickness ~.. L/ i~ Total depth ~(~ ~ Cleanouts present (Y/N) ,~ Date of adequacy test I"/'/~N- for "~ If yes, give dat~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: ;?~') Well on lot ~- ~ On adjacent lots ~ J88 Property line To building foundation 7 -~ To existing or abandoned system on lot Cutbank ["~//f:-~ Water main/service line Driveway, parking/vehicle storage area System type On adjacent lots Surface water Curtain drain /~//~ bedrooms E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Date HAA Fees /7D' Date of Payment Receipt Number 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number