HomeMy WebLinkAboutT12N R3W SEC 15 LT 128GRE
,:R ANCHORAGE AREA BOP JGH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
DISTANCE //~
FROM WELL
INSIDE LENGTH
MAILING ADDRESS
~, ~,~ NUMBER OF
__MANUFACTURER ' Y/~-~/~ MATERIAL~'O ]1 C //~) COMPARTMENTS
INSIDE WIDTH__ LIQUID DEPTH LIQUID CAPACITY /'/~'~GALLONS.
SEEPAGE PIT:
NUMBER OF PiTS __! DIAMETER ___
LINING MATERIAL
BUILDING FOUNDATION_
ADDITIONAL ABSORPTION
OR WIDTH/j'~,
DIAMETER
NEAREST LOT LINE
DEPTH ~/¢_ DISTANCE FROM: WELL
TOTAL EFFECTIVE
ABSORPTION AREA (WALL AREA) ~ '~'~ _SQ. FT.
WELL:
BUILDING NEAREST
FOUNDATION LOT LINE
CESSPOOL
OTHER SOURCES__
APPROVED___ __DISAPPROVED__
OEPT,
....... DISTANCE FROM:
NEAREST SEPTIC SEEPAGE
SEWER LINE TANK SYSTEM
_REMARKS
D,STANCES:Z = I/ 1
DIAGRAM OF SYSTEM
PIPE MATERIAL_:
LOT SLOPE:
REMARKS:
Form No, EQ-031
[)ATE ~'- ~/7--
G.A.A.B.
GRea, ER ANCFiORAGE AREA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY
333{) "C" STREET ANCHORAGE, ALASKA 99503
TELEPHONE 2~4-4561
PERMITNO,
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PERMIT
INSTALLATION OF: ~EPTIC TANK ~EEPAGE PIT , DRAIN FIELD , ~, OTHER
COMPLETION DATE ANTICIPATED
FINAL INSPECTION: 24 HOUR NOTICF' REQUIRED. BACKFILLING OF ANY SYSTEM WITHOUI' FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION,
DIAGRAM OF ~Y~TEM
MINIMUM DISTANCE;S, RI~QUIREMENTB
SEPTIC TANK TO ~EEPAGE PIT WALL
DRAIN FIELD ·
., DRAIN FIELD
· SEEPAGE PIT
WATER MAIN TO SEPTIC TANK! '
.: DRAIN FIELD --
,'
~IEPTIC TANK, /~ -- SEEPAGE PIT,
Performed for_/~)~u . ~.
L.~g~ ~ Description:
~)i.~ fat'c} reports:
Bg~- '~R ANCHgRAGE AREA BOROUGH
Oepar :nt ot~ Em;irr, nmental Quality
3330 "C" Street
Anchorage, Alaska 99503
Soils log
Date performed
Percolation test
Dapch
Feet
: ,~-~'as grouad
i'.. ~:;adin9 Date
~ If~yes, at what depth?
Gross Time
Net Time
Depth to H20
i!et Drop
I
~ ','~ -.-~- ~,~,9.c~]l.a~.IO~.; Se,~ag~ Pit... ~ . ·
,'.,,', '"-v, .'.:Dr~ll:O, b',l <.i.d,-
.' - ~q,e% i.i3pth ~'o J)OttoT:; of pit Or
G' I'ER ANCt!ORAGE AREA BOROUGH
Department of Environmental Quality
3330 "C" Street
Anchorage, Alaska 99503
erformed For ~ ~}~ ~,c-;-~ hc-
--~ '--~ ~o~ ~ Date performed
Legal Descr~ptlon. ~.~ ~ ........ _
~nls Tor reports: So'ils log __~_~.~__~] Per~'~on test
Depth
Feet
5-
7-
8-
lO-
ll
12-
das ground water encountered?
If yes, at what depth?
Reading Date Gross Time ' Net Time Depth 'to 1120 Net Drop
.............. -"-T J], :L_- _/:..-Z]Z]T_'].-_Z]] --.:]~
Pefco'la'[.ion i ate ............. ~llillUi:e
P,~ ........ d ir, ,: la~. on: S~::r:x,>]e F~ llr~in Fi~ld
RECEIVED
MAY '1 915)96
Muhio~j)ahty OI Anchorage
Dept. Health & Human 8ervioes
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. # __0 15 '~ L1/(~ 2- I 5"-
1, GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Pr°perty°wner_ ~1~1~>
Mailing address
Lending agency
Mailing address_
Agent _
Address
Day phone. ~L'~I -~Ofl ! .
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: .~-~' ~/
TYPE OF WATER SUPPLY:
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
lng to the legality and status of system.
\,,'
i~, ..:.~,'
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev, 1191) Front MOA ;;21
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 verifythat 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 ~vith all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
NameofFbm ~/ - -~~ Phone
Engineer's signature ~ (~*-~ ~ Date
/
DHHS SIGNATURE
X Approved for -~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
3'he i~t~ni,clpality 9!,~,n,c'horage Department of Health and Human Services (DHHS) issues Health Authority
':ACproval 'Certifiei!t~ based only upon the representations given in paragraph $ above by an independent
profe~onal cng neer rog stored ~n the State of A aska. The DHHS does this as a courtesy to purchasers of homes
and their lending msbtutions in order to sabsht certain federa and state roquirements, 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 profsssional engin~r's work.
Municipality of Anchorage
Department of Health and Human Services
HE;AL. TH AUTHORITY APPROVAL. CHECKLIST
Legal Description:
A, Well Data
Well type
Log present (Y/N) '7/
Total depth I
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to __ I {o ~ Casing height
Sanitary seal (Y/N) '"/
/
FROM WELL LOG
Pump level1 '~ o 'f/;q] c--'-¢d
SEPARATION DISTANCES FROM WELL 'FO:
Date of test
Static water level
Well flow
Septic/holding tank on lot
Absorption field on lot !
Public sewer main
Sewer service line
Wires properly protected (Y/N) '~ ~
g.p.m. ~- ~ g.p.m~ ~ % ~~% %
; On adjacent lots _ ~ t (pC
; On adjacent lots )'~ { ~
Public sewer manhole/cleanout ~'~/'/,z'~
Petroleum tank ~'NI / ~
WATER SAMPLE RESULTS:
Coliform
/
Date of sample: ~'/[ ~"/
Nitrate
_ ~/ ~ L-/ Other bacteria
Collected by:
B, SEPTIC/HOLDING TANK DATA
Date installed _~-,///'? / ~ L-/
Cleanouts (Y/N) y
High water elarm (Y/N)
Date of pumping
Tank size _ / ~ Compartments
Foundation cleanout (Y/N) _ /k/ Depression (Y/N)
Alarm tested (Y/N) __
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
we,(s) on lot __ / I
To property line ~>'~ /
Surface water/drainage
On adjacent lots '~'~ lO'Co Foundation
Absorption field ,'~ O Water main/service line
CONTINUED ON BACK PAGE
72-026 (3/93)* Front
C. LIFT STATION [ ~-,,/.~
Date installed
Manufacturer
Size in gallons
Vent(Y/N)
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" Level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Sudace water
D. ABSORPTION FIELD DATA
Date installed
Length ) ,~
Total absorption area
Date of adequacy test
Width
Soil rating (GPD/F¢) ~-~¼ ~
Gravel thickness
Cleanout present (Y/N) '"/
Results (pass/fail) ~
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
System type C P---I
Total depth / ~/z._,
Depression over field (Y/N)
for ~ Bedrooms
Aftertest ~ ~ ~/.~ ~
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot /~'O ~
To building foundation
On adjacent lots
Surface water /%-]/
Curtain drain
On adjacent lots ~ /~ Property line
~ D -'~ To existing or abandoned system on lot
Cutbank ~ o ~t .~. Water main/service line
Driveway, parking/vehicle storage area ,~.
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidefines in effect on the date of this inspection.
Engineer's Name
Date
HAA Fee $ ~.~
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number
CT&E Environmental Services Inc,
Laboratory Division V~,Z~,~,~__Z~~~~~
CT&E Ref.~ 95.1868-1
Matrix WATER
Client Sample ID POTABLE FROILAND
Laboratory Analysis Report
Client Name TOBBEN SPURKI~kND, P.E. WORK Order 14661
Ordered By TOBBEN SPURKL~LND Printed Date 05/16/95 ® 08:49 hrs.
Project Name Collected Date 05/12/95 @ 11:30 hrs.
Project~ Received Date 05/12/95 ~ 12:00 hrs.
PWSID UA
Technical Director STEPHEN C. EDE
Released By ~--'~ ~,~
Sample Remarks: SDJ4PLE COLLECTED BY: T.S.
QC Allowable Ext. Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate N 5.94 mg/L EPA 353.2 10. 05/12/95 CMR
==__=====__--==___~-=== .... ====================== .... ================================================================
See Special Instructions ~Joove UA - Unavailable
See Sample Remarks ~Joove NA - Not ~]alyzed
Undetected, Reported value is the practical quantification limit. LT - Less Than
Secondary dilution. GT = Grea[er Than
200 W. Potter Drive, Anchorage, AK 99518-1605 Tel: (907) 562-2343 Fax: (907) 561-5301
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