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HomeMy WebLinkAboutHAMANN LT 23 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. ,~ MUNICIPALITY OF ANCHORAGE /DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONMENTAL ENGINEERING DIVISION ~825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE /~'NEW /-/~,..~, ~:,,~,.~ ~ ~. ~/-,2 72~ ~UPGRADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS Well Zbsorption area Dwelling PERMIT NO, DISTANCE TO: /¢ ~ / N- ~ Manufacturer Material No. of compartments Liq. capacity in gallons inside length Width Liquid depth /~-~ ~ IF HOMEMADE: ~ ~  ~ Well Dwelling PERMIT NO. DISTANCE TO: ~ ~ ¢ Manufacturer Material Liquid capacity in gallons E Well Foundation Nearest Iotline¢/., ~ PERMITNO. ~ ~ DISTANCE TO: / O~ I ~ / - ~m'l ~ ~ No. otlines ~ Length~/°f each~ ~,~/line f T~tal length of lines~ z Trench width~o inches Distance between~/~Olines ~ Top of tile to finish grade / .... ~ria[ beneath tile Total effective absorption Length Width ~)epth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area ~1 Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sawer line : Septic tank Absorption area(s} OTHER PIPE MATERIALS SOIL ~ST RATING ~ ~'~ INSTALLER ~ / ~/d / ~,, ~, ~ .... ~,,. ~. (LV ~5 - t /~- / ,.~ ~ " REMARKS ~ ~_~)~ ~ APPROVED DATE LEGALiZ~ ~) J!!id)iGl....Ji!] l::i'. ]i VJ!~i::I', i~ f/.]'iJ':]] 6 ? .;!-'"" 2 7 7 ('";?.::"!iVi!i]..,. )}!!!]:::'"?J'l (J'::'"J"~) 'T'O'T'AL !Z)El:::"l'l I (?'i" ~, ) GRAV~.!ii].... ~'0 ]] D'T'PI (l::'"J" ,, ) (!]J:::.'AV!!!!]... f...li!]',!(!]'TJ! (F't",~) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST ~ SOILS LOG [] PERCOLATION TEST LEGAL DESCRIPTION: SLOPE 7" lq ,,'J /~ SITE PLAN 10 11 12 13 14 15 16 -- 17 18 19 20 COMMENTS WAS GROUND WATER S ENCOUNTERED? /~O L O P E IF YES, ATWHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop P E--R-C-9 LAT~-~ N RATE (minutes/inch) TEST RUN BETWEEN FT AND FT PERFORMED BY: ,,~ ~' 3 )~ ~ gl ~ CERTIFIED BY: 72-008 (6/79) by DOC Go. dDa SULLIVAN WATER WELLS P.O. BOX272, CHUGIAK, ALASKA 99567 ~ TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started PERMIT NUMBER Ended DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT, GALS. PER HR KIND OF CASING KIND OF FORMATION: From Ft. to FI, From Ft. to Ft, From Ft. to___Ft, From____Ft. to____Ft._ From FI. to Ft. From__Ft. to_ Ft._ From.__Fl. to .Ft, From FI. to__Ft. From Ft. to __Ft. From Ft. to___Ft, From____.Ft. to Ft, From Ft. to Ft. From Ft. to Ft. From Ft. to Ft, From FI. to Ft. From FI. to Ft From FI. to Ft From Ft. to_____Ft. From Ft. to .... Ft From Ft. to Ft. From Ft, to___Ft, From Ft. to From Ft. to Ft. ~, · o,~ ~- F x~ ~(~ Fro,,,_____ FI. to t. --O~ . ' ~ From Ft. to Ft. ~'~(90~ From Ft. to~Ft. From_ _~Ft. to .... Ft. From Ft. to~_Ft. From _~Ft. to _ Ft From Ft. to~ Ft. From Ft. to Ft. From Ft. to Ft. From __Ft. to___.Ft. MISCL. INFORMATION: DRILLER'S NAME MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel i.D. # __(¢"~ ..~-¢-.~ ~ / ~ ~ \ - \ (~ HAA# ~=~\ ~--~ ~ (~.'~ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) LOT 23; Hamann Subdivision (b) (c) Location (address or directi, or)s) Wilma CirCe', Ea,qle' RiVer Property o~ner A.H.F.C.#108811 Mailing Address 520 East 34th ~Av6nue Lending ~nStitution ' Mailing Address ' ' Telephone:(home) Anchorage, Alaska 99503 Telephone Business (d) Real Estate Company and Agent JACK WHITE COMPANY ATTN: Kathi O~,stead Address 10928 Ea_~l~ River Road Ea_~le River. Ak. 99577 Telephone 694-~500 (e) Mail the HAA to the following address: (or check here,~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle Ri~er Lo<)p Road Ne; 204 Eagle River, Alaska 99577 2. TYPE OF RESIDENCE Single-Family ~X Number of bedrooms 5 3. WATER SUPPLY Individual Well EY~ Community [] Public [] Note: If community well system, must have ~vritten confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site,Y~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 78-025 (Rev. 7/88) Page 1 of 2 '>tJOM s,Jeeu!eue leuo!ssetoJd eq~ u! suo!ss!uJo Jo s Jo.JiB Joj elq!suodseJ lou s! eSeJoqou¥ jo/~!led!olunl/~ eq.L 'penss! s! aleo!lp,~eo e eJoleq e~ep ezXleue JO suoRoedsu! ~,on puoo ~,ou op SH HQ jo see,~old uJ3 's~ueLueJ!nbeJ m,e~s pus le~epet u!m, Jeo/,ts!~es o~epJo u! suo!~nlRsu! 5u!puel J!eq~ pu~ SeLuoq JO s~eseqoJnd o), ,{sm, Jnoo e se slq~ seop SHHQ sql 'e~iSel¥ jo e~e~.S sql u! peJe~s!eeJ ~eeu!eue leUO!SseloJd ~.uepuedepu! ue/,q e^oqe G qde~BeJed u! us^!6 suo!~elueeeJde~ eq~, uodn ,{lUO peseq pe~ea!Jpeo le^oJdd¥ ,~.poq),nv q~leeH senss! 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O:IdSNI IDNlalAOl:ld INi:II=I IDNII:I=I~NIeN~I '~ MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: A. WELL DATA Well Classification _ /),', d ¢¢ f(¢_, if A, B, C, D.E.C. Approved (y/N) ~t.]/~ / Well Log Present (Y/N) ~ Date Completed /'i/ ~ Total Depth~.-.-~oO Cased to_L,-%"",2 ' Depth of Grouting Static Water Level //--¢ Casing Height Above Ground _ Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot ~ ~-~ "ff Water Sample Collected by .~ ~ ~ ~¢',,-~? t,.J eecu,~ ~ / Water Sample Test Results .~ ~ ~/~ .4, ~c/F~ c. ~o/'/~ -- Comments To Nearest Public Sewer Cleanout/Manhole ~//:1 B. SEPTIC/HOLDING TANK DATA Date Installed ~(~ -~/-/-P--~-Size Standpipes (Y/N) F _Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) No. of Compartments 2 F Foundation Cleanout~.'.'.'.'.'.'.'.'.1~N) ~ ,., .- ! , Date Last Pumped __ 2~:~ /~. ~!~:? ~/(F} ;for - Temporary Holding Tank Permit (Y/N) ~J/ (~ SFPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well / © --~ To Property Line /o To Water Main/Service Line /O To Stream, Pond, Lake or Major' Drainage Course Comments To Building Foundation 'Fo Disposal Field 72-026 (Rev 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed (_o ~ ,,2Z/~ ~ Width of Field ~o Square Feet of Absortion Area Depression over Field (Y/N) Results of Last Adequacy Test Type of System Design Length of Field Depth of Field / ~__ Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: /.f- To Water-Supply Well / OO To Property Line To Building Foundation '-/O Lot /,)~ ¢ ~ ; On Adjoining Lots .'~ o To Water Main/Service Line / O ¢ ¢- To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course ¢90tO ¢ To Driveway, Parking Area, or Vehicle Storage Area / LO ~ ~ To Existing or Abandoned System on / Comments D. LIFT STATION Date Installed % Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) "% Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed $ & $ ENGINEERING Company _. - ,_ '17U~ ~'~ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SM4PLE Eot Work Order ~ 17940 Date Report Printed: NOV 2 89 @ 18:07 Client Sample ID:L23 HA},~NN S/D PWSID :UA Collected @ hrs. Received OCT 31 89 ~ 15:20 hrs. P~eserved with :AS REQUIRED Client Name : S & S ENGR Client Acct : SNSENGP P.O.~ NONE RECEIVED Req ~ Ordered By : S & S ENGRS. Analysis Completed :NOV 1 89 Laboratory Supe~vi~or,:~TEPHgN C. EDE Released By : .x~ /~. ~ Send Reports to: 1)S & S ENGR 2) Special Instruct: Chemlab gel ~: 8328 Lab Smpl ID: 5 Matrix: ~ATER Allowable Paramete~ Tested Result/Units Method Limits NITRATE~N ND(0.10) mg/1 EPA 353.2 10 Sample ROUTINE SA~LE Remarks: SAMPLE COLLECTED BY RJS. 1 Tests Pc=fo=mod ' See Special Instructions Above UA:Unavailable ND: None Detected "See Sample Remarks Above NA: Not Analyzed LT:Less Than. GT=Greater Than NtUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONIVtFNTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) _ /-/~ ~-,-,~., ~ ,o _ (b) Applicant Name ~'_/~,hf.~: /~-'~'-"¢'-'%' _Telephone:Home ~.-~o5-~ Business ~¢~-z/¢~ ApplicantAddress ~ ~c) ~ p~ .~ ~. ~ ~,~'Ze /~ ~'/~ ~'~7 (c) Applicant is (check one): Lending Institution ~ ¢'Owner/builder~; Buyer D; Other D (explain); (d) Lending Institution Address Telephone (e) Real Estate Company and Agent (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family_,,~ Multi-Family [] Number of Bedrooms '--% Other WATER SUPPLY Individual Well~, Community [] Public [] Note: If commLmity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsde~." Public D Commueity EJ Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ' .... * As certified by my seal affixed hereto and as of the validation date shown below, I verify that my irwestigation of this Health Authority Approval 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 ail Municipal and State codes, ordinances, and regulations in effect on the date .of this inspection. Name of Firm EAGLE RIVER ENGINEERING SERVICES Telephone FA(ILE RIVER, AK 99577 Address Date __~/;:'-/~//~ Y- 694-519§ Engineer's Seal Approved for ~'~ bedrooms b "E~ate Approved '~--~/ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional enc~ineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST ~ FEBRUARY 1984 264-4720 Legal Description: ,~o 7~ ,NoIID.] t Oa.d ]VJ. NTWNO~IAN:I B~)"C~OHDNV ~.0 /,.&IIVdlDINNW WELL DATA Well Classification ¢O~_¢,¢ Well Log Present (Y/N) Y Total Depth '.~o o Cased to / %- D." Static Water Level / 5' / ' Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances from Well: If A, B, C, D.E,C. Approved (Y/N) Date Completed z7"/'~ s'- Yield Depth of Grouting /v'./.../ Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by _ ~'~'~ ¢'~e~ ~'' Water Sample Test Results ,-~ 7 Comments ; On Adjoining Lots / }~ / ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date g'//-¢',~'~' B. SEPTIC/HOLDING TANK DATA Date Installed ~-~"~ / ?,~;'~_ Size /¢-oo _,74 / No, of Compartments ~ Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) /.v Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) '4"//~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well /~ :~ To Property Line /,~ ''/- To Water Main/Service Line /0 Course Date Last Pumped //-/~ ; for _ Temporary Holding Tank Permit (Y/N) / To Building Foundation "~/ To Disposal Field ~ 2 / To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~'~'~ ¢ /~&~ Width of Field :~ "~ Square Feet of Absorption Area //~' Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well /00 To Building Foundation '~O / Lot /1~ cr,,-,.~__ To Water Main/Service Line ,/O '/- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field -,Y¢~' ,P Depth of Field /2 / Gravel Bed Thickness ~ / Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line /o / To Existing or Abandoned System on ; On Adjoining Lots 3o o'- To Cutbank (if present) /,/Mc,._(_ Comments LIFT STATION ~ Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all M CA and HAA guidelines in effect on the date of this inspection. Signed~''¢'~~ Date Company ~_5Z¢ Receipt No. ~ Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) Engineer's Seal