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HomeMy WebLinkAboutNOLAN LT 55B ~ermit ~ Location: DepartmentI '~-H~aith and Environmental 'rotection 825 :~/ Street, AnChorage, AK. 264-4720 * * * HANDWRITTEN PERMIT * * * . WELL ~,.~ ..... ^~'~/~ ~;~ SL:~'~ PERMIT ~©&~ ~ ~ailing Address: ~7~ /~ ~?~J~ ~o~ ~'~3'~ Phone Number: Legal Description: }~S, ~ /O~ ~-~ L~ Size:: . TYpe of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: . ~ Soil Rating(sq.ft/br) The Required Size of'~the Soil A~sorption System Is: ' DEPTH.- ~/d~. .LENGTH ~/~ GRAVEL DEPTH /U//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 31, 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 residence is remodeled to include more that 3 bedrooms. Applicant ~ ~ Date: SWP/024(1/8i)~ ~ed Size of the ~i1 ~rption SiPTIC(HO~I~) ~ANK ~IXE b~ a well ~d ~ny ~-~i{~ sew~ dis~sa~ ~yst~m i~ 100 feet apply. ~e~ification~ a~ c~suuction the M~ioipa!iiy- Of Date; _:.._-- 2i{llO1) ,../ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geologiedl & Geophysicol Surveys LOCATION OF WELL (Please comp(eta either la~ lb or ]~.JDISTANCE ANO DIRECTION FROM ROAD INTERSECTIONS Street Address and Area of Wall Locotion Z. WELL LOG Materiat Type Grave3- fill 0 1 A.D.L, No. OW~gR OF WF.L~[r~ Wade Nolan Add ..... P.O. BOX 145 (final) ~ 5. DATE OF COMPLETION WEL~DEPTH: Gravel~ sand, silt o 37 Gravel ~ sml~ _Grave%~nd~ water __ ~ Y~ · R C EdVED 16. ;VATER WELL CONTRACTOR'S CERTIFICATION: 6. ~.~'J Coble tool ~,,~.J~otcJr~ [] Driven E] Duo [] Teat Well ~J Other: · . ..... . to / ft. Depth Weight 9. FINISH OF V/ELL: Type: Olometer: Length: ft. end Grovel pock ft. [~Above or ~De!ow land surface Il, PUMPING LEVEL below land surfaco and YIELD fl, after hfs, pumping.__ g.p.m. ft. after hrs. pumpinq ____g.p.m. 12.GROU1'ING VleII Grouted: ~ Yes ~ No Mcterldl: LO Neat Car, lent [] Other: - t3, PUMP: (if available) PIP ~3 .roctuct:gon o£ 20 GPM 15. Woter Temperelure ___o [-J F L--~ C This well was drilled under nly jurisdiction (]nd this report is true lo the besl of my knowledge and belief; Mag_nuson Drillin~i .... AA 5385 p.O. Box 77050~ Eagle River~ 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 SIN~ELLING' GENERAL INFORMATION Complete legal description Location (site address or directions) ~ L.~c~-----------------~'~/~ ~--~t~u.)A~ Property owner Mailing address Lending agency Mailing address ~-"~ 0 f~-, 3 ~[' ~~ ~ J~_ Agent ~ ~-Oiz.~-~ LC. Address-3~___ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Day phone Day phone Day phone 3. TYPE OF WATER SUPPLY: NOTE: Individual well Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: 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(Re¥.1/91) Front MOA#21 Address Engineer,s signature~~ ~ 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. Name of Firm _~zh-'~aU~'~-- ~t...A.$~,4 ~,L~I~---"L~--s ._ Phone _3 Date DHHS SIGNATURE X ' Approved for 'Tf']~-~-~ ~//)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 engineeFs work. 72-025 (Rev. 1/91) Back MOA ~21  Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~'4::>~- ,-~'~:~/. ~,,JC~,/~..~ O~'u~. Parcel I.D. A. WELL DATA Well type Log present (Y/N) "~---'-~ Total depth ~ ~ Sanitary seal (Y/N) '~ '~ If A, B, or C, attach ADEC letter. ADEC water system number Date completed ~mI- \~'~, c:~-~ Driller Cased to -~-~' Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG AT INSPECTION ~--O g.p.m. ~ -2r', ~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ~'//~ Public sewer main ~ ~c Sewer service line ~ ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~'~"'~'~\'~','~¥ Nitrate Date of sample: N.~c.~J ~, 1~ I B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Collected by: Other bacteria Tank size Compartments Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed ~k~,~ Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Ma'nufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed t~'"'~ ~ Length .Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) On adjacent lots Soil rating Gravel thickness Surface water System type Total depth Cleanouts present (Y/N) Date of adequacy test for If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots Property line To existing or abandoned system on tot Cutbank 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 guidelines in effect on the date of this inspection. HAAFee$ / ?0 ¢~ Date of Payment ///_ / ¢ ~ C~/ ~ Receipt Number ,~--,~ ,~ 3 ~' ('~ ~, ¢,~ 0 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEEP~'NG CO. TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518 Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER '~ PRIVATE WATER SYSTEM Name Phone No. ojQ,5'j/ Cily SAMPLE DATE: Mo. Day Year SAMPLE TYPE: I~ Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose ) [] Treated Water [~"'/Jntreated Water SAMPLE No. , LOCATION ~fJ:'Alic~C[ O.....~'E" 41 51 Time Collected Collected By I TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: patisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail, Date Received Time Received Analytical Method: Membrane Filter * No. of colonies/lO0 mi. Lab Ref. No. I I BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LSB Fecal Coliform Confirmation Final Membrane Filter Results Reported By "~ BGB Date Coliform/100 mi coliform/100 mi CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. Chant Sample ID:L$$B NOLAN S/D ?WSID :UA Collected NOV 13 91 ~ 16:30 h~$. Received NOV 15 91 @ 08:35 ?reserved with :AS REQUIHED Ana3ysi$ C:mpioted :NOV 15 9! Laboratory Supervisor :STEPHEN C. EDE 5633 B STREET ANCHORAGE, ALASKA99518 TELEPHONE ~0~ 562-2343 FAX:(907) 561-5301 ANALYSIS REPORT BY SA)~LE for WORKozder{ 40281 i)at, ~*port Pilntod: ~OV IS 91 ~ 1£:19 Client Name :CRITERIU~ AK EHGR Chont Acct :CEITESI BPO ! PO ~ NONE RECEiVEO Beq ! Ordered By :TED JOHNSON Send Report~ to: i)CRITERIU)( AK ENGR 2) Chemlab Ref ~: 9161~7 Lab Smpl ID: i Matzix: ~ATEE Allowable NITRATE-N 0.62 n~g/1 EPA 353.2 10 Sang, la ~OUTINE SA)(PLE COLLECTED BY: UA. JOB {91159. I Teats Perle)mad ' See Specaal Instructions Above UA-Unavn~hble ~/~- ~one Oecectod '' See Sample Remarks ~bow