HomeMy WebLinkAboutPOLLOCK HOMESTEAD BLK B LT 9Onsite File %62, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT I PHONE ~-~ NEW DISTANCE TO: MAI LI Well Liq. ca! DISTANCE TO: Manufacturer Inside length IF HOMEMADE: Well Dwelling Dwelling Material Width DISTANCE TO: No. of lines Top of tile to finish grade Foundation ~_~. ~.~.f Length Type of crib Total length of lines Material beneath tile Width Depth Crib diameter Crib depth PERil7 NO. 2 ' /-14 n~' //J/F / No. o'f compartments-Z_ Liquid depth PERMIT NO. Material Liquid capacity in gallons Nearest lot line 3~--/ I~,~'',:%'~-~:1 Tren¢~ w~clt,~// ! -ine~e~ Distance between line Total effActiv~ aL~orp.Qon area inches /, ff:'l" PERI~IlT NC). ' Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line PERMIT NO. DISTANCE TO: Building foundation Sewer line Septic tank Absorpt on area(s) OTHER SOIL TEST RATING I NSlT~A L LE/~ APPROVED , ~ DATE LEGAL Permit MUNICIPALITY OF ANCHORAGE Department ~ Health and Environmenta3 ~rotection 825 ~ Street, Anchorage, AK. ~9501 264-4720 * * * HANDWRITTEN PERMIT * * * Applicant: Location: WELL AND/OR ON-SITE SEWER PERMIT '~') 8 d [:./o ,L¥~1.~4,~' Mailing Address: Phone Nu~er: Legal Description: Lo~ ~IK~ llo, Z Lot Size: TYpe of Soil Absorption System Is: Trench: ~/ Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: ,3 Soil Rating(sq.ft/br) ~/O7 ~ The Required Size of the Soil Absorption System Is: ' O,/ GRAVEl_ DEPTH ~,'~/ DEPTH /~ LENGTH ./"f-~ WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~©',?.].) GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 1 9 $ 3 * * * I certify that: (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 codes. (3) I understand that the on-site sewer system may require enlargement if · the ~esidence is remodeled to include more that 3 bedrooms. Signe~~~~///~~~ Issued by: ~_~'7/~,~/C~, Applicant / Date: g/Z9/~-~ ¢ ~ SWP/024(1/Sl) SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST 1 3 4 5 6 7 8 9 SLOPE 10 --11 12 13- WASGROUNDWATER ^ *--/\/'/'~ S L ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? 'Bloo LB SITE PLAN 14- 15- 16 17, 18- 19- 20- PERCOLATION RATE /b¢~'/--t~.~ TEST RUN BETWEEN CO ENTS ,300 c;/r/ Gross Net Depth to Net Reading Date Time Time Water Drop 't /0/2//2 ?, · ' (--5~O (minutes/inch) ,-J~-,~-.~--~--~' F T A N D ? FT CERTIFIED BY:__ DATE: 72-008 (6/79) WATER WELl_ RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological ~ Geophysical Surveys LOCATION OF WELL (Please complete either Io~ lb or lc.) B,bdi.eio. Let :',:~' 7 <~: ~ I_of_ of__o~ -- ~ DISTANCE AND DIRECTION FROM/ROAO INTERSECTIONS Street Address and Area of Well Location WELL LOG Feet Below Surfoce Material Typo Top Bottom Cril[iilg Permll No, A.O,L. No. Sect[on No. Townghip NC] SE] OWNER OF WELL: 6. ,~Cable tool []Rotary [] Driven E~ Dug L~ A,,er ~detfed E~BoreU E} Other: 7. USE: ~'Domeslic ~ Public Supply ~ I~dustry ~ Irrigation ~ Recharge ~ Commerlca~ ~ Test Well ~ Other: 8. CASING'. ~ 'rh,?~pd ~ Welded I0. STATIC WATER LEVEr.: '~::~. '; / ft. . ?' Dote ~ Above or ~ Below lend ~ur~o~e I2,GROUTING Well Grouted: ~ Yes ~ NO Materiel: ~ Neet Cement ~ O~her: 16, WATER CONTRACTOR'S WELL CERTIFICATION: 15. Wafer Temperature o '[~] F LJ c This well was drilled~nder m j'urisdlclion (]nd ibis report is true Io the besl.of my kno~edge end belief /~ ?., ~j"Registered Business N-'--edm ( ~' ~ ...... Contract License Number Address; Signed: A u t her [ze:d Represenlativo Form O2-WWR {11/81) Copy Oistribulion: WHITE-SIoIe DGGS~ PINK-Oriller~ CANARY-Cuslomer 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, 17--/);~'-3~ 1. GENERAL INFORMATION Complete legal description Lot 9; Block B; Pollock Homestead Location (site address or directions) Property owner Mailing address Laurie Johnson 15320 Pollock Drive Anchorage, AK 15320 Pollock Drive Anchorage, Day phone AK 99516 345-3493 Lending agency Mailing address Agent Address Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 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 o n-site Public sewer NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rey. 1/91) Front MOA~21 STATEMENT OF INSPECTION BY ENGINEER. As cer[ified 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 ,5' £ _,C ~¢,-c'-f,,~,~,,¢C. Phone Address /?o ~,~ i,~c,-~ ,~,v~.;e 4¢¢ ~.¢,~/ ¢. £, ~¢,~ ¢¢'~£7~ Engineer's signature "~//.~Z. ~. Date //~, /'/'? DHHS SIGNATURE · ¢ Approved for T'~--~~) 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 DHHS 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 engineer's work. 72-025(Rev. 1/91) Back MOA#~I r_NViRONMi:NT^L St!P..VICE,S DIVISION Municipality of Anchorage JAN 0'7 DEPARTMENT OF HEALTH & HUMAN SERVICES ,.) ........ Environmental Services Division 1~. ~:~ ~ ~ ~ V 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: Health Authority Approval Checklist A. WELL DATA I..o'1' ~ ,~. 6,1.ce.V_ e~ .~ t°o~.ecv. Parcel .D.: Well type Log present Total depth Sanitary seal (~YN) (P~a',l~'r~- If A, B, or C, attach ADEC letter. ADEC water system number ~i~ Date completed ci .,~t Cased to 5.~ t Casing height ~bove ground) Wires proper~y protected ~) Date of test Static water level Welt production FROM WELL LOG AT INSPECTION /"J g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform t~) Nitrate Other bacteria Date of sample: Collected by: ~ '~ '~ ~t~Gt~,=~:l~ (; B. SEPTIC/HOLDING TANK DATA Date installed iZ./6/$3L Tank size Foundation cleanout i~N) 'CE.r` Date of Pumping {z j 00 ¢_~ Number of Compartments ~4'~ Cleanouts (t~N). "¢E~' Depression (Y~ /4 o High water alarm (Y/~ /~ o Pumper A 'f' ~d,'~(~t ~ (. C. ABSORPTION FIELD DATA Date installed 1'7./g Length ,.~. ~ t Width Effective absorption area ~cI {~ I~ Date of adequacy test I'Z--7.'1' Fluid depth in absorption field before test (in.); Fluid depth /V//~I (ins) Minutes later: Peroxide treatment (past 12 months) (Y/t~) 72-026 (Rev. 3/96)* f~ ~','~ ~,,'/,b~ 4- T rating~ ~ or fF/bdrm) J O _ System type Soil C 'ZffI Gravel thickness below pipe ~ ~ota~ aep~n Monitoring Tube present {~q) 'Y'E.~; Depression over field (Y~I~) ~4~ Results (~ail) J;:)t~$, For ~ bedrooms Immediately after -~2~ gal. water added (in.): J.~ __ Absorption rate = ~'t ~- 0 .-f~ g.p.d. V--¢o~# If yes, give date LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level a...t~--~'~ Size in galion~....~__.~  "Pump off" level at* *Datum E. SEPARATION DIsTANcES SEPARATION DISTANCES FROM WELL ON LOT TO: ~[~holding tank on lot ~ ol Absorption field on lot ~ O°'~ '"}" Public sewer main t4 /~ Sewer/septic service line ~+ On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM~SE~HOLDING TANK ON LOTTO: Foundation ';Zot4. Property line '7 Water main/service line Io~ 4' Surface water/drainage I'oo~'P SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line I o t -Ir' Building foundation Surface water i o o~ t- Curtain drain ~ Absorption field Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots ~ 0 ~ t+ F, ENGINEER'S CERTIFICATION I certify that lhave determined thru field inspections and review of Municipal recor~._;~..~'.t~l¢i ~/~ecS~,~,te, ms are Signature ~ ~' -~~ //' ~ ~ "' "" %` Date / / 6 / ~ '7 ~47~', CE: 880 i /? ~ HAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* HEALTH AUTHORITY N)PROVAL8 SEWER & WA'[ER /../, ROBERTC. COWAN, RE. ROBERT A. SHAFER, RE. CLIENT: ADEQUACY TEST FORM LEGAL DESCRIPTION: Lei' # OF BEDROOMS: ;Z.-3 TYPE OF ABSORPTION SYSTEM; CIVIL ENGINEERS (907) 694-2979 FAX (907) 694-1211 EPTIC TANK/FIELD'SEPERATION TO WELL: io I ' ~E/~ SEPTIC TANK SIZE: j ~ cc) ABSORPT ON FIELD DATAj Depression over field SEPARATION DISTANCE FROM ABSORPTION FIELD T Driveway, parking/vehicle storage area: Curtain drain: Foundation: SEPTIC DATA: Date of pumping: 1'7.-Ze-q~, Foundation cleanout ~N): ~ ,LIFT STA'rlON: "PUMP ON" level at: High water alarm level: Depression "PUMP OFF" level at: METER OALLONS LIQUID LEVEL I"IME READING ADDED COMMENTS (TOTAL) S,T. M.T. M.T. I~ ': ~ o 7~oo - '--' ~ ' "-" 1~oo 7qco l,~/~ __ ii- f j~li ~ p,~r, I .; 0 0 p,~ ~ i~" 7 ,~,~ ~'.~,~,~ RESULTS: PASS/FAiL: EXPLANATION: TESTED BY: ~ THIS SYSTEM IS NOT GUARANTEED AGAINST SUBSEQUENT FAILURE 17034 NORTH EAGLE RIVER LOOP · SUITE 204 * EAGLE RIVER, ALASKA 99577 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING 1. GENERAL INFORMATION Complete legal description Lot 9; Block "B"; Pollock Location (site address or directions) 15320 Pollock Anchorage, AK Property owner Mailing address Lending agency Mailing address Dav~ B~n~sch & Sally B~ckwith 15320 Pollock Anch0~g¢, AK Day phone 344-0844 Day phone Agent Rocky Kuv~k/ VISTA REAL ESTATE Address 3000 "C" Str~t, Suit6 101 Day phone 562-6464 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 2 TYPE OF WATER SUPPI. Y: Individual well /(/Community well Public water NOTE: XXX 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 Holdin9 tank Community on-site Public seW'er NOTE: XXX If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 s~uewwoo leUO!~!PPV / :suoijelndRs 6UIMOIIOJ eLt~ Lt~!M 'SLUOOJpaq .~oj leAo~dde leUO!T!puoo re, eCl 'peAoJddes!c] 'SLUOOJpeq ~ JOJ .peAoJddv ~ ~]I:ln.LYNOI9 SHHa 'uoRoedsu! s!ql jo e~ep eq~ uo ~oejje u! suo!~elnSeJ pue 'seoueu!pJo 'sepoo e~e~S pue led!o!unv, l lie q~iM eOUe!IdLUOO U! S! uJe~sXs lesods!p jm, eMejSeM ~o/pue Xlddns Je~eMe~is-uo eq~'uo!~oedsu! pub uo!~e6!jsa^u! XLU LUOJJ pue sel!J e6eJoqouv jo X~!led!o!unR eq~ LUOJj peu!m, qo uo!leuJ]oju! aq~ uo peseq ~eq), Xjpe^ Jeq~Jnj I 'u!eJeq pa~eo!pu! e]nlonJ~s jo ed/th pue SLUOOJpeq ~O JeqLunu eq~ JoJ e~enbepe pue leUO!~ounj 'e~es s! LUe~SXS lesods!p ~m, eMe~SeM ~o/pue Xlddns Je~eM e~!s-uo eq~, ~,eq~, SMOqS uo!~eo!ldde le^oAddv X~,poq~,nv q~leeH s!qj jo uo!~eSp, se^u! XLU ~eq~ Xjpa^ 'Moleq UMOqS m, ep UO!lep!leA eq~ Jo se pue o~e]eq pex!jJe lees Xgu Xq peij!lJeO sv '9 I-I=I:INI!DN=I X.G NOI10=IdSNI 40 IN=IIN=I.LVIS Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.¢'T A, Well Data Well type /~ Log present~) ~'~ Total depth -~-~- Sanitary seal Y~) C.k/' r (- C 0 c¢1 Paroel I.D. If A, B, or C, attach ADEC letter. ADEC water system number Date completed ¢/2.£/~o5 Driller Cased to .~-.~--- r Casing height Wires properly protected (~) Date of test Static water level Well flow Pump level1 FROM WELL LOG /'" AT INSPECTION ;On adjacent lots _ ; On adjacent lots SEPARATION DISTANCES FROM WELL TO: Septic/~l~l~ank on lot /(~ 1" / Absorption field on lot /00 Public sewer main Sewer service line Public sewer manhole/cleanout Petroleum tank ,,'J,,,~,~ WATER SAMPLE RESULTS: Date of sample: Nitrate /' Of'/O '///~ Collected b~' B. SEPTIC/I-I~iI~I~TANK DATA Date installed //'~/~/~-'~ " /O < r" Tank size rO~;~ Compartments Cleanout,~) _6("...~ Foundationcleanout Y~N) 'Z'¢'.,) Depression (~_.~..2,-/o High water alarm (Y~).,,'~-~ ~ Alarm tested (Y/N) ,/'L///)~ Date of pumping - G / P--'"'¢ / f~ ~ Pumper 4¢ //r..¢44 ¢'~ SEPARATION DISTANCES FROM SEPTIC/I"J¢~ii~III[~ TANK TO: Well(s) on lot. /O / ' ~ On adjacent lots /(~ To property line r'~O ~z_ Absorption field ~' Surface water/drainage /6'/O~-/'¢~' ~'~C~7'--// - Foundation Water main/service line /0 ¢/'' 72-026 (3/93)* Front CONTINUED ON BACK PAGE Date installed %. Manufacturer Size in gallons ~ Manhole/Access (~ Vent(Y/N)__ __"Pump~l~t.. ~p 0fi" Level at High water alarm level ~cles tested __ Meets MOA electrical ~ ~ W.~.ett~n lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed /'~.. / ~,~ / ~ -~ Soil rating (GPD/Ft Length '~- ~¢' Width ~. ~ Totalabsorptionarea (/"¢~ ~ Cleanoutpresent~) t"(/(-.-~ Date of adequacy test ~/'~' ¢'~//~ Result~il) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) System type Total depth ~-, Depression over field (Y,~ for ~ Bedrooms After test ~.~ ~ ~(~ . If yes, give date /,(..,)/,~r- SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots /O~'% ~- Property line .-'~'/~ To existing or abandoned system on lot ,,,¢/0¢M( Cutbank ,.,<--f.-,%'~'~¢/~Water main/service line ~...~ Driveway, parking/vehicle storage area /~...) 7' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to al~ MOA and HAA g Signature S & $ ENGINEERING E ' ,., 17034EagleRlverL&)OpR. e'adNo, 204 HAA Fee $ / '7 D~' ,'27,) Date of Payment ~,~, Receipt Number date ~f'th2s inspection. Waiver Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back APPLI¢ NT FILLS OUT UPPER HA[ ONLY Maili~ng Address Zip (;ode Lending Institution ~eally Co. & Agent Legal Description ~¢~ Type of Residence .,~ Single Family Multiple Family [] Other Water Supply ~E~(Individual ~ Community [] Public Utility Sewer Disposal  ,~ Individual Public Ulility 61 Holding Tank No. of Bedroorrks ~_. ) Phone Phone ,r. . '~ -...7::X5"'.~ Phone ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. For wells drilled prior to that date, give woll depth (attach Icg if available). Year Individual Installed:__ When Connected lo Public Utility: NOTE: THE INSPECTION PEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Date Date Date Inspector Inspector Inspector Field N°te~: I' '~ *~/ (~ ~_~, h Time Cb, I, I~NVJRONM"NrAL PROI'~CIION ~;:'~ ) APPROVED BEDROOMS ) DISAPPROVED Soils Rating Date Sewer Installed Well To Absorption Area Well to Tank _Well Log Receivedo- Septic Ta~k Size ALASKA E F1UIROFIFIqeFITAL COF1TROL S RUICeS, linC. ~n§in¢¢rir,,:] 8 ~r, uir-or, mer, tal Sm,:ljes December 16, 1983 Municipality of Anchorage Department of Health & Environmental Protection 825 L. Street Anchorage, Ak. 99501 Re: Health Authority On December 13, 1983 our company collected a water sample from the house located on Lot 9 Block B Pollock Homestead Subdivision. The property owner is Chris Fejes. The water analysis was satisfactory. A copy of the report is attached. The well is located 100 feet from the septic tank and 100 feet from the leach field. The electrical wires are encased in conduit. Ail the standpipes are capped. The well casing stands 2 feet above ground and has a sanitary seal. 1200 LU¢sI 33rd Au¢.u¢. $ui1¢ B "J)mchoro§¢, J~loska 99503 · (907) 276-1361