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HomeMy WebLinkAboutNORTH WOODS BLK 1 LT 1  ~._./ MUNICIPALITY OF ANCHORAGE ',~ / DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADDRESS ' II AbsorPtion ~ ~ Manufs~turer ' ~ ~ ~r~ / " ~m / No, of com/artment,2 Liq.~y in gallons Inside length Width Liquid depth i~,' ~l0 IF HOMEMADE: ~ ~ Well Dwelling PERMIT NO. ~ DISTANCE TO: Z~ ,'~. ~ Manufacturer [~ [ ~ z Material Liquid capacity in gallons ~ Well Foundation Nearest lot line PERMIT NO. ~ No. of lines h li.e TotaJ length of li~es 'Trench width Distance between lines ~ ~ _ inches ~ Top of tile to finish grade Material beneath tile Total effective absorption area ~ inches :,~ Typeofcrib Cribdiameter Cribdepth~ Totaleffectiveabsorptionarea DISTANCE TO: Well /~7/ h-' Buildin~nda~o~__ Nearest IdS line ~ Class Depth Driller Distance to lot line PERMIT NO. ~ Building foundation Sewer line Septic tank Absorption area(s) ~ DIS N OTHER PIPE MATERIALS SOIL TEST RATING~ . ~Z~~ .~ ~._. . ' ~,1~.., ~., ~ 4 ' r' "t. APP~OV~ / P/J % ......... DATE LEGAL - ..... . .... F!F'PLICF!NT :SKRE~GE; E:ONSTRUCTIOI',! P.O. BOX D., CEiUGIRE::] LOCRT)':ON NORTHHOOD:E; LE~]RL LOT ~. BL.K J. NORTHHOO[.',.~E; :~.;,,"B, LOT :F.;IZE T':r'PE OF E;OIL. E~BSORPTIO.~,! %?SI'EH IS: TREf,E:H l"!F'l;:'::.'[i'"ILIl"t M. I'iEE:[4: OF E~E[:,E;.:OOI"IS = Z-": SOIL ~..~' THE REf]:!U:[RED ',;:'.;:.~ZE: OF 'THE SOIL .RBE;ORF'TION %?STEH THE L_EN(::'TE-! E.'(£HENSI(]hl ].'S THE LE.i',!(:~TH '-'.'IN FEET) OF THE TF.:ENCH OF-: [)RF~INF.T. EL[). THE [:,EF'TH 0F f3 TRENCH (:IR F'IT .1:5 'THE DISTRt'.,IE:E BE'F!.,.iEEN THE ':7, URFRCE OF' 'f'l!E Gf-::.'.OLIND R.~.,![:, THE BOTTOH OF THE EXCR',,,'RTION ,'..'It'.~ FEET>. THERE iS NO SET HZE.',TH FOR TRENCHES. 'THE GRFI',..,'EL DEPTh! l'.::; THE t'ilNIi"lUi'4 DEP'T'H OF GRFI',,,'EL BETHEEi'.,! THE 0UTFRLL PIPE I:~ND '}'HE BO'TTOi'I OF THE E:4Cff,,,'RT!E;N ,.'.'IN FEET). F'ER['II T .... FIF'F't l' '":R~'.].T linE-''"-.':, THE: RESF'C!',!S IE:!t_ IT'T' TEl .T. f,!FOF.:i'i THIS F'-r.:'F:.. "4"r-.r,:.t"l. lEl'~.' ~"'I .r':,l ............ IP.4E";TRL. L_R'I,"Z("~f-,! .T~'-,IE;PE(:TIO!'-~S OF l~.i"~"'r' .Lt~.,....t..:, FIE:,.:rFK:Ei'-,iT TO Tt4.'T,=,, ..... ,~-'~"-F:'~.-c-'"r"',... ,.,,:., ~ tt.,..[, "FHE i'.,lL.Ir'lE~EE: OF RES I E:,EI'.,iE:ES THFIT THE HELL H T. LL. '5ER',,,'E'. E:RC:i.(F:tZLLI!'.,I~3 OF Rf'.,I"¢ :::;'-r'STEH .t,]ITHOt..IT F'.T.['4RL If.,!SF'EC:TIOi'.~ FiI'-~E:,:-c'"'-'-'-''-Ir-r,b..U, HL EH' 'TFi'~ZS B, EPRF.'.Ti'"iEf, ll" !.,IZLL BE 5LtE,'..IE(;:T TO F'ROLSEE:LiTIOt'.~. F!I!'.,I.'EMU!"I [)ISTRNCE 8ETHEEN R !.,.!ELL Rt'.,!D f:lf.&.' ON--SITE SEHRGE C, ISPOSF!L SYS'TEP! IS iE(; FEET FOR R F'RIYR'TE HEELL OR :!.59 TO 2E~8 FEET FROH R PUBLIC ~qELL DEPEh!E:,iNG UPOP4 I'HE T'.r'PE OF' PUBLZC HELL. H!bIIHLI!'1 DISTRI"4E:E FROf'1 R F'~:Ik,'R'TE HELL TO R PRI',/RTE 5EHER L.I!qE I5 25 FEET RhlD TO R C[]HHUNIT~' SEHER LINE iS 75 FEET. OTHER REIZ~UIREHENTS HR'¢ Ff'F'L'¢. SPECIFICRTZONS FIND COh!STRUCTION [:,IRGRF!HS !~RE R',,¢RILRBLE TO !NE;URE PROPER IhlSTRL. LRTZO~4. i CERTIF"¢ THE:IT :t.: I FIH FRH.I'LIR:F,.~ H.I'TH 'THE REQL.IIREi"IENT5 FOR ON4:;ITE 5EHERS RND HELL.:-; RS SE'.'F FORTH B"..-' THE tttNZC!F'FIL,1.'T'~" OF' RFIE::HORR(E, 2: I HILL .Tf.~E;'T'F!LL 'THE S':r'STEFI IN RCCORDF!NCE HITH THE CODES. ' ,.E:: I EJNDEE~:TRND THE:ff THE ON-5!TE '.'.:';E[,-!ER S"r'STE!i F!R"r.' RE--';!LL'[RE ENLRRGEi'iEP,IT iF' THE rES.ET [:,Ei'E:E I S F4'.EHOB, ELED 'f..'Cl I I'-.!F:LUDE HOF,~:FZ 'l-HRf.,! 3: E EE':,,E'OOi'iS RF'F'L ! CF¢.,FT' SKFI~BGS C(:~I'.,L'E;TF.:UCT I PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 7 8 9 10- 11 12 13- 14~__ 15- 16- 17 18 19 20 COMMENTS 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 SITE PLAN SLOPE WAS GROUND WATER ,~ SL ENCOUNTERED? IF YES, AT WHAT /~ E DEPTH? Ao Gross Net Depth to Net Reading Date Time Time Water Drop I ¢_..,~J"'~l 7;~o ~ /o %" ~-- PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN ~ FT AND ~'~'_ FT PERFORMED BY: 72-008 (6/79) CERTIFIED B ~///,~~ 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. # 1. GENERAL INFORMATION Complete legal description Lot I; Block I; North Woods Subdivision Location (site address or directions) 21617 Oberg Road Eagle River, AK Property owner Mailing address Lending agency Mailing address Doug Palmqu~t Day phone (414)89~-6450 C/0 Ptarmigan R~ Estate 12801 01d Glenn Hwq. Suite 9 Eagle River, AK 99577 Day phone Betty Fields/ PTARMIGAN REAL ESTATE Agent Address 12801 Old Glenn Hwy. Suite 9 Eagle River, Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 TYPE OF WATER SUPPLY: Individual Well Community well XXX Public water NOTE: Day phone 694-2321 AK 99577 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 NOTE: XXX 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 o 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 inves_ti_gation 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 Phone ~¢¢,'~-~'7/~ Engineer's s~gnatur~ D/~S SIGNATURE .~_¢ Approved for ~'~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: 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 mquiremen, ts. 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. 72-925 (Rev. 1/91 ) Back MOA Municipality of Anchorage /~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~.~o-~ ~ ~ ~- t~.' ~O¢----¢A ~ooc~Parce, 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 Driller Cased to Casing height Date of test Wires pro~ FROM WE.~~..~ AT INSPECTION Static water level Well flow~ Pump~vell SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot '7,.--0 o g.p.m, g.p.m. Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform Nitrate Date of sample: ; On adjacent lots '~--- ~ ~ ; On adjacent lots Public sewer manhole/cle~'''~'~- Petrolej~w~~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed °1 ~ ~ I Cleanouts ~N) High water alarm (Y~ Date of pumping Tank size \ ~ ~ ~-~ Compartments ~ Foundation cleanout ~ ~ Depression (,Y~[) ~ Alarm tested (Y/N) ,-[.1~. --' 2~ ~ ~) .% Pumper ' ~;)'~.~. ~_-,¢'J F'o O z_ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot '?-"D ~ ['~ On adjacent lots To property line I ~ Absorption field Surface water/drainage l ~ ~ Foundation Water main/service line 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) Manufacturer Manhole/Access (Y/N) _..~-~ "Pump on" level at ".~u~ at High water alarm level ~d Meets MOA electrical codes (Y/N) ~ SEPARATION DI~ FROM LIFT STATION TO: Wefi~on lot On adjacent lots Surface water D, ABSORPTION FIELD DATA Date installed Length "~ L. ~ Width Total absorption area ¥/~ 8o ¢ Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/~ Soil rating (GPD/Ft¢) '3--% '8 '~z~~ Gravel thickness Cleanout present (~/N) System type Total depth Depression over field (Y~j~ for After test If yes, give date Bedrooms Well on lot '¢~'~ To building foundation On adjacent lots Surface water Curtain drain SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots ~/~ Property line \ o ~ ¥' To existing or abandoned system on lot ~ ~¢-\ ~ Cutbank ~/~. Water main/service line \&,.- Driveway, parking/vehicle storage area E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conform~A and HAA Signature $ & $ ENGINEERING 17034 Eagle River Loo~~ Engineer's Na~l~ P!~er, Ai-:k~ ~3~ Date ~,~/.~ ~ " HAA Fee $ ~ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number 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 I n.f' I; BZoe. k I'; No,th Wr]od~ Suhdx'.vJ~x'on Location (site address or directions) 21617 0bc..Ag Road Property owner Mailing address Lending agency Mailing address Doug P~mqu~t Day phone Day phone 694-4200 72q)25 (Rev, 1/91) Front MOA 1¢21 Agent Virginia Kohfield RE/MAX OF EAGLE RIVER Day phone Address 16600 Cent~rfi~d Road #201 Eaql& Riv~, Ak. 99577 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 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 XX 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. 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 typeofstructureindicated herein. I fur[herverifythat 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. Phone ¢' ¢ ¢' Name of Firm ., .... .: .......... :-:-,,; 'J ¥034 ;:.~4j~.:~ qivr. r Loop Road No, 204 Engineer's signature DHHS SIGNATURE ~ Approved for bedrooms. Date Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ',./0 t4-1''J. ~..~'f~ tTl~ 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 1191) 8ack MOA ~21 Legal Description: Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to ADEC water system number Driller Casing height Wires properly protected (Y/N) Date of test · Static watei' level Well flow Pump level FROM WELL LOG g,p.m. AT INSPECTION Iii g.p.m. < SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot "~-¢, o ~ e- Absorption field on lot '~o~ ~'~ ; On adjacent lots On adjacent lots Public sewer main Public sewer manhole/cleanout Public sewer service line Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate Other bacteria Collected by: B. SEPTIC/HOLDING TANK DATA Date installed c~. ~ \ Cleanouts t~)/N ) ~/ High water alarm (Y~ Date of pumping '~" I''cll Tank size I oOC:) Compartments Foundation cleanout (Y/~' r-J Depression (Y/~ Alarm tested (-Y-R~) ~J~.4- Well(s) on lot To property line ! ~ Surface water/drainage SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: '~> '~ On adjacent lots Absorption field Foundation Water main/service line 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Manufacturer Manhole/Access (Y/N) Vent (Y/N) High water alarm level Meets MOA electrical codes~ SEP~FROM LIFT STATION TO: Well on lot On adjacent lots "Pump on" level at _ ..-~PffCd-~ff" level at ~~~Cy~ es tested Surface water D. ABSORPTION FIELD DATA Date installed ~ ~'[ Length ¢2L¢~ Width Total absorption area Depression over field (Y/~ Results~/fail) Peroxide treatment (past 12 months) (Y,~ Soil rating System type . Gravel thickness O,¢' /~¢'~¢-Total depth ¥ Cleanouts present ~/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 IoO Curtain drain ~ On adjacent lots ¢ I,~ Property line I o ~4- To existing or abandoned system on lot Cutbank ¢1,~. Water main/service line Io~'~ 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 HAA Fee $ L" '7 ~-~ ~ O Date of Payment ? -~"~ ¢~'~/' Receipt Number .:~- .;-~ ~ ? ~ 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number DEPT. OF ENVIRONMENTAL CONSERVATION ANCHORAGE DISTRICT OFFICE 3601 C STREET, SUITE 322 ANCHORAGE, ALASKA 99503 June 5,1991 WALTER J. HICKEL, GOVERNOR 563-6775 FOR: S & S Engineering Ray PWSID 213001 My review of the records on file in this office reveals that the Chugiak Utilities, Northwood Subdivision Class A Public Water System, is in compliance with the provisions of 18 AAC 80.060, State of Alaska Drinking Water Regulations. Sincerely, Keven K. Kleweno Lead Engineer ~:~ printed on recy¢i,..'d ~af)~r b y 0,~ I Time ~,,_,'s Time ' Date Date Date .i~_×~. _~/ Inspector Inspector Inspector Comments ~ ~ Conditional Approval ~NICIPALITY OF ANCHO~G~: DEPT. OF HEALTh4 % .~JvIRONM~NTAL '~ .... ' ........ DEC (: ,:: ! gECEIVED Date Sewer Installed Permit No. Septic Tank Size / ~?.~_ (~--j Holding Tank Size Soils Rating Well To Absorption Area Well Log Received ~- Well to Tank APPLICANT FILLS OUT LOWER HALF ONLY Property Owner -'~"~tiO/~y''cc)~L=''~ ~' ~~ ~'' d~ __~ Phone Address Lending Institution ~ ~¢~ ~ ~/~/ ~~ Phone Address Realty Co. & Agent. Phone Address Legal Description AU% i i, Type ~sidence ~ Single Family ~ Multiple Family No. of Bedrooms ~ Other Water Supply ~ividual A~ACH WELL LOG. A well Icg is required for all wells drilled since June mmunity 1975. For wells drilled prior to that date, give well depth (attach Icg if Sew~gCsposal j - ~ Individual Year Individual Installed: ~ Public Utility When Connected to Public Utility: B Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.