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HomeMy WebLinkAboutT15N R1W SEC 8 LT 52A 5'1- 0¢3 -o99 Municipality of Anchorage Page ~ of ~:~'~ 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 N~: ~/~i~ 1~/~ Wastewater System: D New ~Upgrade *~'~: ABSORPTION FIELD Phone: No. of Bedrooms: ~ ~ Deep Trench ~ShallowTrench ~ Bed ~ Mound ~ Other Total Depth from original grade; LEGAL DESCRIPTION so, Rating: I' Lot: Block: Subdiv~ion: ~epth to pipe boffom from original grade: Gravel depth beneath pipe  Fill added above original grad: Gravel length: Township: Range Secti Gravel width: Number of lines: ~ Distance be~een lines: WELL: New Upgrade Classification (Private, A,B,C): Total Depth: Cased TO: Total absorption aaea: Pipe material: Ft. Fl, Yield: ~)5 Pump Set at: I Caslng Height Above Ground: TANK ~ GPM Ft. Ft. SEPARATION DISTANCES ~s.pt~cu Holding ~ S.T.E.P. TO Septic Absorption Lift Holding Public/PrNat( Manufacturer: Capacityin gallons: From Tank Field Station Tank Sewer Lines ~C~ Material: ~ Number of Compa~ments: s.,~ce LIFT STATION Water ~ O l~ ~ Lot Size in gag°ns: I Manufacturer: Line ~ ~ ~ ~ "Pump on" level at: I "Pump offset: I High water alarm at: Foundation '7 ~' ~ ~ Drain I~ 0 ~[ ~ I Remarks: BENCH MARK Location and Description: Inspections pedormed by:~ ~ Dates: 1st Depadment of Health and Humag Se~ices approval Reviewed and approved by: Date: /2 72-013 (Rev, 9/91) MOA 25 iI STANDARD SYSTEM: SWING TIES 5-WIDE TRENCH AC-- 16.6 TOTAL DEPTH $.5 Fl' BC 25.4 TOTAL LENGTH 60 Fl' AD 24,5 EFF. ROCK 1.5 FT BD 28.5 INSULATED AE 55 1000 GAL SEPTIC TANK INSULATED BE 55.9 E ~- ABANDDN£D EXIST]NG TANK AND TRENCH Well D TOBBEN ~rPURKLAND P.E. 25 IL 50 75 100 SCALE: ]' : SO FT, 1£5 150 LOT 52A SEC 8, TISN, R1W 20616 OLD CRANBERRY, CHUGIAK BENCH t~ARK 80TTOM SIDING ASSUMED ELEVATIO I00,00 f SEPTIC SYSTE~P AS BUILT DATE: NOV, 30, 1999 SHEET: 2/5 GRID: NW1556 (907) 279-5916 II S~/990415 PID # 051 093-29 Monitor Cleon Cleon S~ondord Trenches; 5' Wide 30' L on9 ~5' Deep 1,5' Semer rock L~' Cover INSULATE ]ogg gal Septic '~onk ~ Z BOg FLZ}W SPLITTE£ Q ?Il. T ND SCALE FLOW/SPLITTER 95,0 9J. 4 NB SCALE 4" INSULATION 1000 SEPTIC TANK BENCH MAi~JC ]3DTT[IN SIDIN6 ASSUMED ELEV. JO0, O0 TBBBEN SPURKLAND P.E. 203 \415th Ave Anchorege Ak 99501 SEC, 8, HSN, 20516 DLD CBANBEt~2Y, CHUGIAK SEPTIC SYSTEM SCHEMATIC DATE: N~ ,~0~ ]999 gH£ET: 2/2G~IB: NW125~ PER'MIT # SW990415 PID # 0S1-093-£9 151852A$,J)W6 MUNICIPALITY OF ANCHORAGE Department of Health and Human Services On-Site Services Program 825 L Street, Room 502 P.O. Box 196650, Anchorage, AK 995'19-6650 (907) 343-4744 ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: Nov 22, 1999 Expiration Date: Nov 21,2000 Permit Number: SW9904'15 Legal Description: T15N R1W SEC 8 LT 52A Design Engineer: 0007 Tobben Spurkland, PE Owner Name: Fanni Mae Owner Address: PO BOX 771522 EAGLE RIVER , AK 99577-1522 Parcel ID: 051-093-29 Site Address: 020616 OLD CRANBERRY DR Lot Size: 44981 SQ. FT. Total Bedrooms: 3 Permit Bedrooms: 3 This permit is for the construction of: [~ Disposal Field [] SepticTank [] Holding Tank [] Privy [] Private Well [] 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 Wastewater Disposal Regulations ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DHHS at least 2 hours prior to each inspection. Provide notification by calling (907) 343-4744 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: Issued By: ate: / / - 2 2 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN LOT 52A SECTION 8, T15N RIW 20616 OLD CRANBERRY, CHUGIAK Municipality of Anchorage Department of Health and Social Services 825 L Street Anchorage, Alaska 99501 November 2, 1999 We are submitting au application for the upgrade of the septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the septic system is subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: Ground Water at 7.5 1l. Use Standard 5 Wide Trench Soil Rating. From Testhole October 26, 1999 <1 min/in - 1.2 gal per sq.ft/day No. of Bedrooms 3 Required Areaper Bedroom: 150/1.2 = 125 sq.ft. Total area required: 125 x 3 = 375 sqfi Bottom Rock At 3.5 feet Top Rock At 2 feet Rock Depth 1.5 feet Trench Rednctioa Factor .78 Total Trench Length 375 x .78 / 5 = 58.5 fi. USE TWO TRENCHES EACH 30 LF SYSTEM CONFIGURATION STANDARD 5-W1DE TRENCH TOTAL LENGTH 60 FT TOTAL WIDTH 5 FT TOTAL DEPTH 3.5 FT ROCK DEPTH 1.5 FT COVER 2 FT INSULATE SEPTICTANK 1000 GAL INSULATE REPLUMB WASTE LINE IN CRAWL SPACE The installation of this well and septic system will not prevent development of adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. MunJ.:'ll:'ality of Anchorage DEPARTMENT O~ '~EALTH & HUMAN SERVICES 825 "L' Street, Auuhorage, Alaska 99502-0650 SOILS LOG- PERCOLATION TEST PERFORMED FOR: LEGAl. DESCRIPTION: L~ g t0 11 12 13 14- 15- 16 17 18 19 ~P 2O (ENGINEER'S SEAL) OATEPERFORMEO: Township, Range, Section: "'~ l'~'j',J ~ '~_ ~, ~'"t '~' CO`) SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? MoniLorino? Dele: Gross Nol Depth to Net f~eading Date Time Time Water Drop PERCOLATION RATE "~. t (minutes/tach) PERC HOLE DIAMETER TLST RUN BETWEEN ~:)- FT AND ~s~ FT DISCLAIMER: r~rnundwater c,~nditiens indicated are for the dates shown only. Past and future presence and/or depth of gro,,ndwater can not be predicted trom these ob~s_ervatlons. PERFORMED BY: /~-,~ I ~" ~ CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GblLELINESIN EFFECT ON THIS DAli:. DATE: / 72-008 (Rev. 4/85) 5O '5O 100 ~gM$ll 250 ~/££H AVENUE TO£££N SPU£1(LAND P.E. 205 W 15TN, AVENUE ANCN. AK. 99501 f907) 279-5916 LOT 52A SEC 8 T15N 20616 OLD ~RAN£~t?RY, CNUGIAK SEPTIC SYSTE~I DESIGN DATE; OCT. 26,1999 SHEEL' 1/5 GRID; N~/1556 PEI?N/T # SIF999XXX PID # YY 15/852A1,DI//5 STANDARD SYSTE&b 5-WIDE TRENCH TOTAL DEPTH 3.5 ET TOTAL LENGTH 60 FT EYE. ROCK 1,5 ET INSULATE I000 GAL SEPTIC TANK INSULATE [° A~A/VDLTN £XIS[IN6 ?ANK AND [ ~ I £5 0 100 IP5 150 TOBBEN I?URI(LAND P.E. SCALE; 1~ ~ SO FL LOT SEC 8, TISN, R1W 20616 OLD CRANBERI~Y, CHUG/AK SEPTIC SYSI'EI DES/ON DATE; OC~. 26.1999 SHEET: 2/5 GRID: NW1556 (907) 279-5916 PE£MIT # SW990XXX PID # yy IS!85£AR, Dl,/6 Monitor Cleon lTu Stand©rd Trenches, 5' Wide 30' L on9 3, d' Deep 1,? Setver rock INSU~TE © © 1000 9ol Septic 'tonk Z £00 FLOW SPL[T?'E£ ND SCALE FLOW SPLITTER NO SCALE 1000 SEP?IC TANK ~ENCN MARk~ ASSUMED ELE~ lO0, O0 'FBi}BEN SPURKLAND P,E. a03 W15th Ave Anchor'cge Ak 99501 LOT SEC. 8, TISN~ £0616 lYLD CRANBERRY, CHUdIAK SYSTEN SCHEMATIC DATE: N~V, ~ ]Q99 SHEET: 2/SGR]D: NW1255 PERMIT # SW990XXX PID # YY MUNICIPALITY OF ANCHORAGE DEPARTMENT OF NEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME MA,L,NG AODRESS l PHONE '-- Nr:w LEGAL DESCRIPTION LOCATION I I w. ~ / / I Absorptlcn ~e~ I uw,;~%Z Manufactur ~ ........ M ¢ --- ~' ~y~ailons IF NOMEMADE: Inside length I W,d,~ DISTANCE TO: ~ell I Dwelling Lerlgtll~ea(¢ ~e ~t~of~,~s ¢idth Ir Top of ti~e to ~is~ g~e ~th ti~ ~ /finches NO. OF BEDROOM~¢ No, of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMIT NO. Type of crib Crib diameter Well DISTANCE TO: Total effective absorption area Nearest lot line Class ~X., /~ ~_ Driller DISTANCE TO: Building foundation ~ .... " Distance tn ~- line PI PERMIT NO. ~ .... sorption area(si PERMIT NO. E ",' ' h~<OTEC:T ION DEPBRTMEN] HEALTH AND .N, IRONflENTAL .... ~b .=,TREET., RNCHOF~RGE., FIK. 264-4720 b41it_b Fl fqlg, ~Df'l--% I 'TIE S[Ebli~: i'i:Rfq I T 820805 ) RPPLICANT [.OCRTION LEGAL STAR GROUP CONST. T±SNRIW S8 LS~R INC 4i01 ARCTIC BLVD SUITE 20__.: 995 277-268t LOT SIZE _~995-4. SQURRE F'EET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH MR:dlMUM NUMBER OF BEDROGMS = Z SOIL RATING (SQ FT/BR)= 85 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: [)EP]-H:= D LE[',~G"TH = 26 G I~. RI "",,,' EEL ~.'" E I=" T' H;= 5 THE I_ENGTH DIMENSION IS THE: LENGTH (IN FREE].) OF THE TRENCH OR DRRINFIELD. THE DEPTH OF R TRENCH OR PI;F IS THE DISTRNCE BETWEEN THE'.' SURFRCE OF '[HE GROUND RND THE BOTTOM OF" TFIE EXCRVRTION (IN FEET). THERE IS NO SET WIDTW FOR TRENCHES. THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETHEEN THE: OUTFALL F'IPE AND THE BOTTOM OF THIS EXCRVRTION (IN FEE"T,). F;~EC-4L.I I F4E:D SEF~T I C: -rRt-~Kc .c_] I ZEE= _1_8(38 PERMIT FIPPLICPINT HAS THIS RESPONSIBILITY TO INFORM THIS I)EPARTMENT DURING THE iNSTALLATir'~ ~MCF)~,-.T~nMC nc: ,:::,~..~u ,.,~,¢ ~',~-.*," ...........................RTY RND THE NUMBER OF ...... T ,~!U I BRCKFILLIN p/...~.~f~ VRL BY THIS DEPRRTMEMT ~ MINIMUH DI ~¢ ¢ ¢ / tOO FEET F .g/,~.. ~_.,~/ ~2~¢-/¢2 / ' SFIL _,_TEM I=, '- ., . UPON THE T ( ~ ¢ fD~ WELL BEFENI..IN(~ MZNZMUM DZ ~ ~D~/~ ~-~C~ IS 25 FEET AND TO R COMMU OF THE WEL ~¢ ' - ,,' ' '~ - ~( ~t/ , e / ~ ON DIRGRRMS ARE FP,,'R I LRBt_E ~) ~. ¢~ F' E IF;-:.' M 982-~' I FORTH BY THE MUNICIPALITY GF RNCHORRGE. 2: I WII_I_ INSTRLL THE SYSTEM IN RCCORDRNCE WITH THE CODES. 3:: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MflY REQUIRE ENLRRGEMENT IF THE RESIDENOE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS. S I GNED: ....... ,x~r.~¢, RPPLICRNT STRR GROUP CONST. INC .... ............ 'YT-- ..................... .......... ',,'4. e CERT I I--"r' THAT I RH FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS :SET O E:~ E GEOI'[ HNICAL E~ DEVELO /tENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Earl Ellis 694.2774 S_0_!4,,!~.0_~ ~s.~8o Soils ~' Foundations Land Development Performed for: Hame:.__~r.,,, J, ,,C. Falco~?~._~ ........ ]'el, H0o.._2~72~.:~57 ,_ Mailtng Address:~l?_5. Wo 9th Ave° Ancb. or_~.~9~z_~A;Laska 9_ 9~.01~ Legal Description: Lot 2~A s~t~On 8 .~gN R1W S.~. ML - Silt topsoil with roots and organics° 275 Sqo ft./B~. GW - Sandy Gravel with cobbles to 12 inches. Very clean and :Loose. Overall very porous. ML - Silt. Very compact and tight° 300!sq. ft./BR. W~.t, er standing in pit at 13 feet° Dottom of pit. Ground Water Encountered; · "~ Pit measl.~red approxi~atel~ 3' x 15' in ~lan areao All ~i~ of the pit lo~ed the same. 0 Et E GEOTE HNICAL 8' DEVELO AENT CO. Box 90, Davis St., Eegle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster Eu~'l E//i$ 69,~-277, SO_.J L Lq~. Soils ~ Foundations Land Development' Performed for: Name:__.Dz~._ J..._..~C. Falconer Mailtng Address: 134~_~_Wo 9t______h Ave° A~c~or~ Legal Description:_ Lot ,,52-A Section 8 T15N R1W S.M. MD - Silt topsoi:L with roots and o~ganicso 275 Sqo ft./BfL GW - Sandy Gravel with cobbles to 12 inches, Ver~' clean and loose, Overall very porous. 85 S~o ~t./s~ ML - Silt. Very compact and tight° ~ Water standing in pit at 13 feet° · Bottom of pit. Ground Watar EncouRtared: Proposed Installation: of the it lo¢ e~_the smue, ~.~-- C ~ m ~ r- 0 0 0 ~) 0 ~ © '1' C 8 · 0 (O 0 0 ~ 0 ~) 0 ~J 0 d- 0 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.# ,L~ i- Ori%--:~ HAA # 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone Lending agency Mailin. g address Day phone Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well 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 on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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. - ' NameofFirm I~bbe,~ ,~<t,'~ ,~.~? ~. Phone ~7q-.~'~ ~- Address ~c~ ~ i~c, ~ ~c '~ ~%-~c~. /~ u~ ~-<¢S6[ Engineer's signature Date DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: ~/"~7/'~/q~ ~ ,/A~/~ 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 order to satisfy certain federal and state requirements. Employees of DH HS 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. Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division [N~oN~:~.',~ 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority ApproVal Checklist L-~']' 5:z-A :~...~.,~', 'TI3'~.I, ~i~' ParcelI.D.: ~)~51--~¢~J,~ IfA, B, crC, attach ADEC letter. ADEC water system number Date completed _~-' ;5 ~ ,- ~' ct Cased to ~'~ '~ FROM WELL LOG Date of test Static water level Well production WATER SAMPLE RESULTS: Coliform Date of sample: "/Jo a. SEPTIC/HOLDING TANK DATA Date installed ~/.,~'/~/~ Foundation oleanout (Y/N) Date of Pumping ~"~//~-~ C. ABSORPTION FIELD DATA Date installed II/~y/~ Length ,~ '/ Z~c) .Width Effective absorption area Date of adequacy test g.p.m. Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Nitrate ~'~ '7 ~ "'l Other bacteria Collected by: ~ ~ g.p.m. Tank size / ~'~"~ Number of Compartments ',~ Cleanouts (Y/N) . ~'/ Depression (Y/N) Pumper Soil rating (g.p.d./ft~ or fF/bdrm) Fluid depth in absorption field before test (in.); Fluid depth ~ (ins) Minutes later:. Peroxide treatment (past 12 months) (Y/N) Gravel thickness below pipe Monitoring Tube present (Y/N) "/ Results (Pass/Fail) ~/ System type I, ,~'- Total depth ~, Depression over field (Y/N) For ~ ~/gal. water added (in.): g.p.d, Immediately after Absorption rate = If yes. give date .bedrooms ,~ 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (WN) High water alarm level at* Cycles tested E. SEPARATION DISTANCES /~Size in gallons "level at* *Datum "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer/septic service line On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation 7, ~- Property line ,~ C) Absorption field ~'~ Water main/service line ) ,,'~ Surface water/drainage I"F~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~' ~- Surface water ~'~ I C~ Curtain drain i"~' I ~-~ Building foundation. ,~,2~ Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots '7 F. ENGINEER'S CERTIFICATION ' I certify that I have determined thru field inspections and review of Municipal re~ords that the above systems are in conformance with MOA HAA guidelines in effect on this date. Engineer's Name I ~b,~ ~ u r [<g[~'~ ~ Date I { ~ ~ ~/~- ~ '~ HAA Fee $ / ~ ~o.~'-- ~_ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number 12-05-99 t4:15 FRO~-CTE ENVIROE~ENTAL Zi~ CT&E Env,ror, nmn t~l Serv,eos Me $$15301 T-338 P,02/03 ~-478 CT&E Ref.# Client Name Project Name/tt Clieat Sample ID Matrix Ordered By PWSID sample Rcma~s: 9964,74001 Tobben Spurklanfl P,E, Lot 52A S~ 8 Lot $2A Sec 8 Drink~g Wa:er 0 0.744 Client PO# '~re-Paid Colis/NO3 Printefl Date/Time 12/02/99 11:16 Collected Date/TLme 1t/30/99 10:30 Reeeivefl ~ate/Time 11/30/09 11:40 T~hfficM Dlceetor: Stephen C. Ede __ Rel~s~~ ~ eol/lOOmL $M18 9~228 m~/L EPA 500.0 12-03-99 14:16 FROM-CTE ENVIRONMENTAL 5615301 T-335 P.03703 F-478 Zt~ CT&E Environmental Services Inc. ~ Laboratory Division Drinkinfl Water Analysis Report for Total Coliform Bacteria READ INSTRUCTIONS ON REVER~ ~IOE B~FQRE COLLECTING SAMPLE 200 W. Po~er Anchorage, AK 99818-1605 MUST BE COMPLETED BY WATE~ SUPPLIER /~PUBLIC WATER SYSTEM PRIVATE WATER SYSTEM Tel: [907) 562-2343 Fa,,:. f907) 561-5301 TO RE COMPLETED BY LAB'~:)RATORY ZSy$1S $i~ows U~S Water ~AMPLE [o be' ~= unsaastac~ A naly~tc~31 Me,heel: MMO-MuG Lab Ref No SAMPLE DATE' SAMPLE TYPE. i~'Routine Repeat, Sample (refer to lab · Special Purpose' from. Treated Water ~)Untreated Water Time Collected ¢ollec~d: by {in~t~all: EIEIEi4?4 Sent to ADEC, Date. ANC FSK JUN Client notifie~ of unsatisfactory results; Time. BACT E RIOI..OGI~A'IZ'WAT E R ANAySIS"RE~ORD MMQ.MUG Result: Total Coliform Verification. LTB Fecal Coliform Confirmation: Final Memorane Fd~er Reponea By' ~"~ ,.__~..~.~.~.-.~ ~. Cell CoIo~ie~l100Hll COLIFORM Cohfermll OOml MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONME~C.?AL DEPAFffMEW~ OF })EA~iFH AND E~VIRONMENTAL PR(IrEC~7. ION APPLICATION FOR HE. AL'I~ AUTq{ORITY APPROVA_L CERTIFICATE (a) r~gal Desc~ip. tion (iD~l. Ude Iot, bleck, subdivision, section, t(~nship, range) ',ocation (ad.ess o~ dJeect'ion~) Applicants Ad,ess Buyer C:I~ Othsr ~----~ (e,.lain), (c) (d) (e) :tending Institution Address Address Te].ephor~ ~/f.~_ of N~siden~ ingle-Family Numb~.~ of Bedr~x~ms Multi.-Family~_-~_,. Other 3o Water Individual Well.~..~ Cc~,munity [l~ Public [~ Note: If ~n:[ty v~ll system, must have %~it~n ~nfh~tio~% f]r~ ~%e State ~pa~nt of ~3virom~ntal Conservation attestiRg ~o t~ legality and status. Is tho ~11 adequate fo~ the nt~r of t'~dr~:mq st~cified in this ~ 4. ~{ewa~al Is th~ wastewate~ dis~sal system adequate f~ the numar of ~dr~P [Page 1 of 2] 2-15-84 Date (ENGINEER SEAL) 6. DHEP A~2.roval Approved for ~-- b~dr:, ocrrs Approved [~. Disap~,oved ~_~ Te~ms of Conditional App,.oval %he Municipality of Anchorage Departur~nt of ~alth and Enviroc~ntal ]?~.otection does not ~a~antee the c~ntinued satisfactory pe~fo~manc~ of t~ wate~ supply and/o~ the wastewater disposal system° ~lhis approval indicates that, as of t~ validation ¢~te shown above, based on tt~3 data and information furnished by an e~;ineer ~egiste~ed in the State of Alaska, the wate~ supply and wastewater disposal system is safe and func~ tional for the numbe~? of bedroc~ ~ld type of structure indicated. ( DHEP SEAL) 7. Mail the HAA to the following address: KB2/d5/s [Page 2 of 2] aJ MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (~[~A) CHECKLIST - FEBRUARY 1984 MUNICIPAI.I1¥ OF ANCHORAGE I)EP'r. OF HFALTH & ENVIRONM[~NTAL PROI'ECHON' /.7--.. Total ~p~ ~.3 Cased to Static Water Level /~ / Pump Set At Casing }{eight Abow; Ground/-~.·. ~3 r, Electrical Wiring in Conduit((~/~0 Separation Distances from Well: TO Septic/}{olding Tank ~n Lot /~O '~ TO Nearest Edge of Absorption Field on Lot/~_~P __ Sanitary Seal on Casing~Y~ Depression A~ound Wellhead (_~ ; On Adjoining Lots /~ ~ ; On Adjoining Lots TO Nearest Public Se~ Line /~3- /~'~ To Nearest Public Sewer Cleanout/Manhole /4J //v~ TO Neagest Sewer Service LiJ~.· on Lot / :,L Wat~.r Sample Cells ~ted By'r Water Sar~ple Test Results ~'~/~ B. SEF£IC/HOLDING TANK D~rA StandpiF~(~,~ ~<~A~r-t~ght Cap~Y~ _ Founda~tion, Cleanou~J~Y?~) Pumplng/MalntenaD,, Contzact (~ F:Lle ~:'/te ' fo:, --~ __. Holding Ta~ High-Wate~ Ala~ (Y~/~/$ ~q~p~a~. . Hotdi~ Tank Per~t (Y~) ~p~ation Distan~s fm~ ~p~:ic~{olding Tank: TO Water-Supply ~11 _,/~. ~ -TO ~ilding F~ndation__ -~:~ / TO Property Line / ~ TO Water ~4=ni~R/Service Line Co~se Coma~nts To Disposal Field. [/~ /'~ ~L TO Stream, Pond, Lake, c~ Major Drainage [Page 1 of 2] 2~15--84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Length of Field Depth of Field .~' Gravel Bed Thickness Depression over Fzeld (~.' Date of Last Adequacy Test Results of Last Adequacy Test ~6~' ///~ ~ Separation Distance from Absorption Field: To Water-Supply Well /~?~Q ~z~ To P~operty. Line To Building Foundation ~/~ .~ ~ To Existing or Abandoned System on not Adjoining TO Wate~-M-~.-~.~./Se~vice Line ~q~ ?L. To Cutbank(if~Pre'sent) /~Y ///~ To Stream/Pond/Lake/o~ Majo~ D~ainage Course ~/~ .///~ TO D~iveway, Parkin~ Area, o~ Vehicle Storage Area ~'/~// Co~vents De LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions 'yanho~/Access (Y/N) /. / "Pum~ O~Level at Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA ~%~quest I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect on the date of this inspection. Signed Company KB1/dL/s [Page 2 of 2] / Date ~ No./ I 2-15-84 APPLIC ,,rr FIILLS OUT UPPER HAL ONLY Zip Code ~,;~2 / ~ Zip Code ¢' ~'r~ ¢ */ Phone Phone Zip Code ~ "'5z ¢¢,/~/C' Type of Residence [~ Single Family [] Multiple Pamily No. of Bedrooms [] Other Water SuPply .[~' Individual (~)¢'~ ~J~l~)~. ATTACH WELL LOG. A web Icg Is required for all wells drilled since June 1975. [] Community 1_~4:~ L~)/~ £~qq -~. ~ For wells drilled prior to that date, give well depth (attach Icg if available). ~ Public Uglily Sewer Disposal / .~ Individual ~,E)~),~ /_t~S"~ ~',~t~'~ Year Individual Installed: Public Utility Whee Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RI-'_QLIEST BEFORE Pf:IOCESSING CAN BE INITIATED. me Time Time Time ate Date Date~ Date sp~tor Insp~tor Insp~tor Insp~tor MUNICIPALITY OF ANCHORAGE CCT 2 2 1982 RECE!_V_I D ( '~,-~-¢,PPROVED BEDROOMS ) DISAPPROVED (DATE) ~I,~___OON BITIO AL ~[PPROVAL '~.or~ 'CONDITIONS OF APPROVAL Well Log Received Septic Tank Size Soils Rating Date Sewer Installed Well To Absorption Area (~'~ ( '~-~'"~-- Well to Tank