HomeMy WebLinkAboutNORTH WOODS BLK 4 LT 9/ ~ MUNICIPALITY OF ANCHORAGE ~
/ DE tTMENT OF HEALTH AND HUMAN SER', ES
/ Environmental Health Division
/ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
Address ' ¢ TANK FIELD WELL
Pbone(,)J I P~rmi, No, No. ~edrooms WELL %¢,/
LEGAL DESCRIPTION LOT LINE ¢/~ / /0
Township, Range, Section
AS-BUILT DIAGRAM tShow location of well, septic system, property hnes, foundabon,
TANKS i
TYPE OF SYSTEM r~
~ TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to p~pe bottom from Total depth from original grade
ongmm grade ~ /¢ ~ / F~
Fill added above orig,nal grade Gravel depth beneath p~pe ~ H
~l'~ngt h Gravel ~th
Total absorphon area Distance between lines J ~
Installer Da,e installed ,
WELLS ,
~ PRIVATE ~ OTHER (Identify) ~
~ FT J /
REMARKS: ~' - 7~ ~
Ins e rmed b :
I , , cedily that this inspe~ion was pedormed according to all
Municipal and State guidelines in effect on this date:
72-013 (3/85)
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Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
I
2
3
4
5
6
7
8
9
10
Township, Range,
SLOPE
WAS GROUND WATER
ENCOUNTERED;) '~ [ ~-'~
11
12
IF YES, AT WHAT
E
DATE PERFORI
Date:
Depth to Waler After
13 Monitoring?
14
15¸
16-
17-
18-
19
2O
PLAN
Reading Date Gross Net Depth to Net
Time Time Water Drop
'5 ~,..,~,~ ~,~., ~ t(,~.,,
PERCOLATION RATE
(minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND "~ FT
PERFORMED BY: L,'I'/ /,~'/' ( / CERTIFY THAT THIS TEST
72-008 {Roy. 4/8.5)
WAS PERFORMED IN
SCALE
' r S~ALE
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
~t 9i Block 4; North Woods Subdivision
Location (site address or directions)
Property owner
Mailing address
Lending agency
Kim Le man
22445 McManus Drive
Chugiak, AK
Day phone
22445 McManus Drive Chugiak, AK 99567
Alaska HOme Mortgage Attn: Carla Day phone
561-5534
563-3033
Mailing address
Agent
471 W, 56~h Suite 100
Address
Anchorage, AK 99505
Day phone
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
NOTE:
3
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.
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!Lgation 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
Address
Engineer's signature
$ & $ ENGINEERING
1703~ .~ P,;ver L~p ~oaci ~0, 2U4
Eagle River, Alaska 995~7
o
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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 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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and 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. ADEC water system number
Date completed Driller
Cased to C~
Wires properlg~ (Y/N)
FROM WE~AT INSPECTION
Date of test
Static water level
Well flow ~
Pump'l~el 1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot "2,~>c:> ~ ~'
g.p.m, g.p.m.
; On adjacent lots
Absorption field on lot ~/...~ t-~ ; On adjacent lots
Public sewer main Public sewer m~
Sewer service line PetroJeum't'Enk
WATER SAMPLE
Coliform Nitrate Other bacteria
Date~ Collected by:
fib
B. SEPTIC/HOLDING TANK DATA
Date installed ~ ~ % 1
Cleanouts ~'~N) '~
High water alarm (Y~_J~
Date of pumping
Tank size t"/-"~- ~ Compartments
Depression (Y~)
Foundation cleanout (~1) ~/' ~'l
~ Alarm tested (Y/N)
~ ~-" ~"~ Pumper -..~,..~, ~'¢~5%? ~ ()
Well(s) on lot
To property line ~
Surface water/drainage
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
~--oo ~'*'~ On adjacent lots ~'~ ~
Absorption field '7.--'P ~
Foundation
Water main/service line
"'7
72-026 (3/93)* Front CONTINUED ON BACK PAGE
Manufacturer
C. LIFT STATION
Date installed
Size in gallons
Vent f~N) ,~/ "Pump on" level at
High water alarm level /I~/'{
Meets MOA electrical codes~.~N) /
Manhole/Access (~)
~c~ '~ "Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot ~-~ z;) ] ~ On adjacent lots
Surface water
Date installed
Length ,4-'5" /
Total absorption area
D. ABSORPTION FIELD DATA
Width
Date of adequacy test J
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y~)
Soil rating (GPD/FF)
~ J Gravel thickness
Cleanout present ~_~)N)
Result~ail)
System type
Total depth
Depression over field (Y/~)
for --~ Bedrooms
After test
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~ t~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots ~//~ Property line
To existing or abandoned system on lot
Cutbank /J//,~ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
/certify that/have checked, verified, or conforme~ HAA guidelines ineffect on the date of this inspection.
S & S ENGINEERING / /
17034 Eagle River Loop Road NO)~'~//'~/
Signature ~ -
Engineer's Name ~
Date ~
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Parcel I.D. #
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
051-731-14
~MIPALITY OF ANCHORAGE
ENTAL SERVICES DIVISION
OCT 2 5 i991
RECEIVED
GENERAL INFORMATION
Complete legal description
Northwoods , Lot 9, Block 4
T15N R1W Section 4
Location(siteaddressordirections)
22445 McManus Drive, Peters Creek
Property owner Ronald Todd & Pamela Ekberg Dayphone 261-3050 (PE)
Mailing address 22445 McManus Dr., Chugiak, AK 99567
Lending agency
Mailing address
Day phone
Agent Mark Soquet/Soquet Realty
Address 4155 Tudor- Center, Suite
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Day phone 229-0045
208, Anchorage, AK 99508
X
Public water
If community well system, provide written confirmation from State ADEC attest-
, lng to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
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.
NOTE:
72-025 (Rev. 1/91) Front MOA #21
5. STATEMENT OF INSPECTION BY ENGINEE~R
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 Eagle River Engineering Services Phone 694-5195
Address P.O. Box 773294, Eaqle River, AK
Engineer's signature ~
99577
Date /¢/,..~-, C'//'~ /
DHHS SIGNATURE
7z~- Approved for ~-
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
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. 1/91 ) Back MOA #21
Municipality of Anchorage ~i~
DePartment of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: A/~,~7'~'oO.O$ #/ /..~)~' ~ z~ .~
A. WELL DATA
Well type ,~
Log present (Y/N)
Total depth .
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Parcel I.D. 05/ - ¢3/./Z/
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to
FROM WELL LOG
Driller
Casing height
Wires properly protected (Y/N)
g.p.m.×/
Pump level T :~~~
SEPARATION DISTANCES FROM WELL
Septic/holding tank on lot .../
AT INSPECtiON
; On adjacent lots
· MUNIcIPALiTY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
g.p.m.
OCT 2 5 1991
RECEIVED
Absorption field on lot
Public sewer main
Sewer service line
WATER SA~ESULTS:
; On adjacent lots
Public sewer manhole/cleanout
./
/
Petroleum tank
Nitrate Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed / ? ,?"~
Cleanouts (Y/N) Y
High water alarm (Y/N)
Date of pumping
Tank size /~O A~./'Z./~'7' Compartments 2
Foundation cleanout (Y/N) ~' Depression (Y/N)
Alarm tested (Y/N)
/(~/,~/c] / Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /)///4 -/
To property line ¢'/~
Surface water/drainage
On adjacent lots
Absorption field
Foundation
Water main/service line.
' ~" ' CONTINUED~ON BACK PAGE
72-026 (Rev. 7/91) Front ~ -,
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level .Z/Z/. J*
Meets MOA electrical codes (Y/N)
"Pump on" level at
Y
Manufacturer. ~/VCH. '7--~WK
Manhole/Access (Y/N) Y
--~0 ~ "Pump off" level at
Cycles tested 7
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot /q/~ On adjacent lots
!
Surface water
D. ABSORPTION FIELD DATA
Date installed /c]~?
Length Z/5 ' Width ~-/-/'
Total absorption area //~) ;2~
Depression over field (Y/N) /t/
Results (pass/fail) ,~z¢ $5
Peroxide treatment (past 12 months) (Y/N)
Soil rating ~Z,~ ~r~ System type
Gravel thickness ~ 'J Total depth /
Cleanouts present (Y/N) Y
Date of adequacy test
for -.~
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
~/.
Well on lot ,A/,//?
To building foundation
On adjacent lots
Surface water /'7//~
Curtain drain f- /¢~
On adjacent lots ~' 2.¢D ' Propertyline /~ '
To existing or abandoned system on lot "/- ~
Cutbank_ .A//.4 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.
Signature ./J..~4~
Engineer's Name
Date /~/~ '&~/'~
HAA Fee $ / ~?~, _Z~_...
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
SENT DY:ADEC ANCHORAOE
;10-24-91 ; 15:57 ;ANCHORAGE/WESTERN D0~
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
3601 "C" STREET, SUITE 322
ANCHORAGE, ALASKA 99503
WALTER J. HIOKEL, GOVERNOR
563-6775
Ootober 22, 1991
FOR: Eagle River Engineering '
PWSID ~213001
My review of the reoords on file in this office reveals that the Northwood Subdivision
Class "A" Public Water System, Is In compliance with the routine coliform bacteria samples
requirements listed In Table C, and with the inorganio sampling listed in Table B of
18 MC 80.200.
Sincerely,
Byron Roys
Environmental Engineer
Eagle River Engineering Services '
11940 Business Blvd, Suite //205
694-5195
Fax 694-5297
'P.O. Box 773294
Eagle River, Ak. 99577
Legal:
Owner: ' /'~
Type of test:
El Well Flow TeSt ~ Septic Test Only El Well & Septic Test
Date:
El Other:_ , -
Meter Monitor Well Tank
Time Reading Level Level Level
GPM PSI
Remarks
?;,z ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ,L~ ,~. ~ ~.~ "~ ~
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ~ //~/ /¢~/
GENERAL INFORMATION
Legal Description (include lot, block, subdivision, section, township, range)
NORTHWOODS: LOT 9, BLOCK 4~ T15N~ R1W~ SECTION 4
Location (address or directions)
MCMANUS DRIVE, PETERS CREEK
(b) Applicant Name CAROLYN MCPH'RE Telephone: Home NA Business 694-5500
Applicant Address 10928 O~D GT,~N' HIGH~AY~ gAGLB ~_.~, AK 99577
(c) Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other ~ (explain); IR~J~R
ALASKA HOUSING AUTHORITY
(d) Lending Institution
Address P.O. BOX 10120, ANCHORAGE, AK 99510
(e) Real Estate Company. and Agent JACK WHITE COMPANY
Address 10928 OLD GLENN HIGHWAY, EAGLE RIVER,
Telephone 694-5500
(f) Mail the HAA to the following address:
HOLD FOR PICKUP BY EAGLE RIVER ENGINV~,RING SERVICES
Telephone 694-2979
AR'IN: CAROLYN MCPHE, F,
AK 99577
2. TYPE OF RESIDENCE
Single-Family~ Multi-Family [] Other
Number of Bedrooms ~
3. WATER SUPPLY
Individual Well [] Community~[~[ Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite[~ 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.
Page 1 of 2 72-025 (11/84)
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MUNICIPALITY OF ANCHORAGE
ENVIRONMENTAL SERVICES DIVISION
SIP 2 3 1987
RECEIVED
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: "'~-'~'/'
Well Classification
Well Log Present (Y/N)
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring ~n Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Man hole
Water Sample Collected by
Water Sample Test Results
Comments
"~" ~ If A, B, C. D.E.C. Approvecl (Y/N)
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed /~E~'~ Size /..).~'-o ~"/~:/'No. of Compartments
Stanap~pes (Y/N) Y Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N) ~ Date Last Pumped
Pumping/Maintenance Contract on File (Y/N) ,,v,/~ ; for
Holding Tank High-Water Alarm (Y/N) .'~"/~' Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~'~
To Property Line ~'/~"
To Water Main/Service Line ¢'/~' /
Course
To Building Foundation
To Disposal Field
To Stream. Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed .j~,~ ¢--- / ¢,¢¢
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 .,/-..~o ~
To Building Foundation '~¢
Lot --/--..7~ /
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /,d'
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ,¢¢f~4:-'~-~ ~'~,~,4.¢;~/~, ~,.~.,~¢-~//_~¢¢" ¢~,.,.~,,¢~ /~¢.~,.~7- ~- ~--..~"~'
D, LIFT STATION
Date Installed /~',::¢'~ Dimensions
Size in Gallons ,=1,%~"~ ~,¢¢,¢~',-~ ~ /-'~-,A,- Manhole/Access (Y/N) ~
"Pump On" Level at ~>~ '" "Pump Off" Level at ~ ~ ¢
High Water Alarm Level at '¢~'¢/ /~
Vent (Y/N) .~'
Tested for '//~//~ Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
Comments ,'~*'~
** 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 -~~ Date
Company F/*~"/~-~"--'-~ MOA NO.
Receipt No. /OC:) / ~:30 ~
Date of Payment ~/~ ~/~7
Amount: $ ~ ~
Page 2 of 2
72-026 (11/84)
3601 "C" STREET, SUITE 1334OFFICE /
ANCHORAGE, ALASKA 99503
STEVE COWPER, GOVERNOR
563-6775
DATE: _~Bi~m~£_22~_l~Z
PWSID #: _21~QQ1 ............
To Whom It May Concernt
According to the records on file in this office, the _~UU~8~
U!!Li!!ESL~QS!UWQQQ~. Water System is in compliance uith the
State of Alaska Drinking Water Regolations,
Sincerely,
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