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HomeMy WebLinkAboutRAYMOND TEDROW BLK 1 LT 9GRE/"F_R ANCHORAGE AREA BOI "'JGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME LEGAL DESCRIPTION SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER ~///i- LI. A-C ~ M A T E R i A LCO/J C~,-~-/¢~ NUMBER OF COMPARTMENTS INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY ]~Di0 GALLONS. SEEPAGE PIT: NUMBER OF PITS I DIAMETER H~g! OR WIDTH Ig[, LENGTH JZ! DEPTH LINING MATERIAL C)V~LUe~ CRIB SIZE: DIAMETERL~I DEPTH ~/ . DISTANCE FROM: TOTAL EFFECTIVE BUILDING FOUNDATION NEAREST LOT LINE__ WELL ABSORPTION AREA (WALL AREA) "~'~-'~')) SQ. FT. ADDITIONAL ABSORPTION WELL: TYPE _~-~R i'~.l~ J. BUILDING FOUNDATION __ CESSPOOL APPROVED CONSTRUCTION NEAREST LOT LINE OTHER SOURCES DISAPPROVED NEAREST SEWER LINE REMARKS DEPTH IO0'+ DISTANCE FROM: SEPTIC SEEPAGE TANK [',~'0t SYSTEM [~''~t)t DISTANCES: INSTALLED BY: PIPE MATERIAl LOT SLOPE: ~JeJff'~, REMARKS: Form No, LQ~031 DATE DIAGRAM OF SYSTEM MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL pi',OT ECTION NOV I ? 1981 RECEIVED ',~OBER [ A. SHAFER CI\/I[ EIx!GIN EER 694 2070 q'h(P soc}p~go p:ii: ?as fi:alii (~ ,.:~a'he] e]~d approx:iinal:elky 600 SRB 1967( EAC%LE RIVER, ALASKA 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 Location (site address or directions) /,/~g/z~//~/¢_~zC?~Z/_., ~---~ Property owner Mailing address Lending agency Mailing address Day phone Day phone Agent ,/~c~///¢/~¢E ~-~¢ ~,4¢,,z~ ~-~.~ Ad dress ~.~, r o/v, ('~z'JC,,u ~"'~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: .~ TYPE OF WATER SUPPLY: Individual well Y'- Community well Public water NOTE: Day phone NOTE: TYPE OF WASTEWATER DISPOSAL: 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) Front MOA #21 If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system, 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 furtherverifythat 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 Address Engineer's signature David R. Dayton P.E. 2o2i0 Dona~ar Si. Phone Chugiak, Alas?a~99567/ / o /HS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms, bedrooms, with the following stipulations: Additional Comments 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 IF21 Legal Description: Municipality of Anchorage Department of H~alth and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Parcel I.D. A. Well Data Well type J¢~ ~ '"¢'¢~ Log present (Y/N) Total depth ,/'/~'-¢" Cased to Sanitary seal (Y/N)// FROM WELL LOG Date of test Static water level Well flow Pump level1 /,~' ~'- Casing height Wires properly protected (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number ,,'V/ Date completed ? Driller INSPECTION AT ~ ~ ~ g.p.m. ~ g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /;~¢ Absorption field on lot / ~ ~ Public sewer main / ~;~ / Sewer service line /,¢' ~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: B. SEPTIC/HOLDING TANK DATA Nitrate ,, Date installed Tank size .~7~,,~ Other bacteria Collected by: :~Z~) Compartments Cleanouts (Y/N) High water alarm (Y/N) Foundation cleanout (Y/N) Date of pumping , SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on tot To property line Surface wateddrainage ,/V/ Depression (Y/N) "c'// Alarm tested (Y/N) '~'{~d Pumper '--~'~t"C/ZT'¢¢~' Y""*~,/¢¢'~' On adjacent lots /' ~ ~¢'H~ Foundation Absorption field ,z/Z Water main/service line CONTINUED ON BACK PAGE 72-026 (3193)* Front C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Meets MOA electrical codes (Y/N) Manufacturer 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 / Z~ Width Soil rating (GPD/Ft2) Gravel thickness System type .~¢¢¢?,,¢~ z¢ ,,,'~.,~' Total depth Total absorption area 'Z-¢¢ Date of adequacy test~'~//¢'~/', Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) Cleanout present (Y/N) Results (pass/fail) Depression over field (Y/N) for After test -~-'~,~' Bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~ ~-~ On adjacent lots //¢'~ "/- Property line To building foundation ~' ~'- To existing or abandoned system on lot On adjacent lots .%~'-~g-~'7/~ Cutbank A.,'/.~ Water main/service line Surface water ,/~/--- Driveway, parking/vehicle storage area Curtain drain ,g,/'~ ~ z~ E, ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to ali MOA and H/AA guidelines in effect on the date of this inspection. Signature Engineer's Name Date David R. Dayton P,E. 20210 Donalar St. ×/ / HAA Fee $ ~¢'-'~ , ¢/~ Date of Payment Receipt Number ...... ¢ ., :~ ', ...-' Waiver Fee'S Date of Payment Receipt Number 72-026 (3/93)* Back CT&E Kef.# Client Sample ID Matrix ClieutName Ordered By Proj eot Name Project// PWSID Commercial Testing & Engineering Co. Environmental Laboratory Services ~/~/~//~-~Z/~.~/Z:/~/~zZ/~Z~:~/ZT~//-~/z/~/z/~/z/z~z/~~ 94.340%1 L9 BLK1 WATER LABORATORY ANALYSIS REPORT DAVID DAYTON, P.E. UA WORK Order 80 180 Prh~ted Date 07/11/94 @ 12:14 hrs. Collected Date 07/06/94 ~ 14:30 In's. Receiv ed Date 07/07/94 ~ 12:15 hrs. Technical Director STEPHEN (2. EDE Smnple Remarks: Paralneter ROU'ITNE SAMPLE COLLECTED BY: D.D. Qc Results Qual Uuits Method Allowable Ext. Anal Limits Date Date Init Nitrate-N 3.6 ~ng/L EPA 353.2/300.0 10 07/08/94 CMR * See Special Instructions Above ** See Sample Remarks Above U = Undetected, Reportedvalue is the practical quantification limit. D = Secoudary dilution. UA = Unavailable NA =Not Analyzed LT = Less 'titan Gl' = Greater Than 5633 B Street, Anchorage, AK 99518-1600 --Teh (907) 562-2343 Fax: (907) 561-5301 ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA COMMERC:IALTESTING & ENGINEERING CO. David R. Damon P.~'~ ~hugiak, Alaska ~$67. D~;' 2 Treated Water ,n.. ~ $~"z.n!e Cvs: ],3 =" -~ ':~ ~?:"- ~-.. no: be ov.~: 48 h,sur~ Time Received >~ys~sS~ UOL 0 7 1~94 Client notified -- ,~-:¢:= ...... Phoned Spoke ~:h Da::: Tim:: Fecal Cdifo, ~m PART ONE OF TWO: REMAINDER TO FOLL0~ .,'MMERCIALTESTING & ENGINEERING CO. ,AVIRONMENI'AL LABORATORY SERVICES .............. Drfftkin= Water _Analysis R port for Total Coliform Bacteria ]LEAD AYSTRUCTIONS 0.,.5' REVERSE SIDE BEFORE COLLECTfNG SAMPLE 5533 B STSEET ANCHORAGE. AK 9951S TEL: (907) 562-2343 FAX: (907) 561-5301 MUST BE CO.'MPLErED BY WATER SUPPLIER PUBLIC ,¥ATER SYSTEM LD.# L /~ PRIVATE WATER SYSTEI~[ II ~Ionth Day Year S .-M¥'P LE TYPE: Routine ~ Treated Water Repeat S~ple (for routine sample ~ Untreated Water with lab ref. no. ) Special Pu~ose Time Collected S.~ LE LOCATION ColIected By Date Received Time Received _ Analysis Began TO BE COMPLETED BY Lg~OR-A. TORY Annlysis shows this Water SA}vWLE to be: ..~ Satisfactory [] Unsatisfactory Sample over 30 ho~-s old. re~alts may be unreliable Sample too long in transit; sample should not be over 48 hours old at exam2nadon to indcate reliable res',=ks. Please send new sample via specie2 de!ive,'y mM!. ~'JUL 14 1994 Analytical Method: ¢ Membrans [] Number of colonies/100 raj. Lab Ref. No. Result* Jun Client notified of unsatisfactoo' results: .-tn, ah'st Phoned Spoke vdth Date: Tiros: Yaxed © Faxed BACTERIOLOGICAL WATER ANALYSIS RECORD 3'L%~O-SCUG Result: Total Coliform E. Coli Membrane Filter: Direct Count Colonies/100 mi Verification: LTB BGB C O LEFIRaM Fecal Coliform Confirmation Co rp~rQei~[~: Final Membrane Filter Resu~7 Reported By ~_2_'U/y/& Date 7' l'~'~) ¢ Time Coliform]100 ml PART ONE OF TWO: REi'IAINDER TO i:8LLO~/ · -'-LOT BLOCK- .... SUBD q / ~.,;,.~ 7~,~P.. ' .. ~, - NO. BEDROOMS SYSTEM TYPE SOILS RATING '- - ' NOTES:' ~'.~ ~ ~ =~~' '. · TIME' MI~ WATER DEPTH ~ WATER PLOW GALLONS'' START AT ZT D FT ~D. ZD M~TER GA~. Z GAL GAL/~. ~L'ABS LeO ~ .--~m~ . .. " '~'~ ~ i'