HomeMy WebLinkAboutPOLLOCK HOMESTEAD BLK A LT 5LoN
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
82.5 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAI LING ADDRESS
LEGAL DESCRIPTION
DISTANCE TO: area
Manufacturer-- ~ /
y in
IF HOMEMADE: length
DISTANCE TO; Well Dwelling
er
DISTANCE TO;
No. of lines ,~0 /
line Total length of~
of tile to finish grade
.~ath tile
Type of crib Crib diameter Crib depth
DISTANCE TO: Well Building foundation
DISTANCE TO: Building foundation Sewer line
OTHER
SOIL TEST RAT~-~-
IPHONE j
FL--Y~ EW
[] UPGRADE
Dwelling
NO, OF BEDROOMS
NO.
No, of compartments --
PERMIT NO,
in gallons
lot line
width Distance between lines
inches ~
i~s4~es
tive absorption area
Nearest lot line
Distance to lot line
Septic tank
W~ROVED
72-013 (Rev, 3/78)
DATE
LEGAL
EiL~r,~ i 1 NO.
L OF;FIT I ON
DEF'FIRTFIENT L HEALTH RNB', EN","IRONHENTRL r ,40TECTION -,,'--'~ "L"' S]'REET, FINCHORRGE. Fit:.':. 99501
r,~ ~'-, q
'-',::0~- ,' 0 ::'
FE..rE_, DE',,,' INC
LSBLGF:KR POI_LOCK
692-7 OL[) SENRRD HIGHI.4R'¢ 99502 3:49-6692-
LOT :SIZE 999999 S[.:!UFIRE FEET
T"r'F'E OF S~Z~IL. RBSORF'TION S"r'STEN IS: TRENCH
MRXZMLIM HUME,'EF.: OF BEDROOMS = ~' '~3ZL RFIT~NG ,.'."_-'.;~ FT,."BR.."= 2-5C'~
THE RE .~ I ' ,
E6J...ZRE[.' -SIZE OF THE SO~L RBSORF'TZON $'T'STEP1 .IS:
THE LENGTH DI/"IENSION IS THE LENGTH "IN FEFT) OF THE TRENCH OR [:'RFIINFIEI_D.
THE DEPTH OF Fi ~REN_.H OR F'IT I.:, THE DISTFINCE BETNEEN THE SLIRFFICE OF THE
GRO[N[;, FIND THE BOTTOM OF THE EXI]:R","FITION (IN FEET).
THERE IS NO SET NI[."TH F'OR TRENCHES.
THE GRFI","EL [:'EPTH IS THE NININUM DEF'TH OF 6RFIVEI
FIND THE BOTTOM OF THE EXCRVFITION (IN FEET). .~ ,ET~IEEN THE I--~UTF'FILL F'IPE
F'EFRMZT FIPF'LZr:FINT HH.=, THE
.N=TRLLRTION ZN .... ~ ..... ,.- RE";PONSZBILIT'T' TO INF'ORM THIS DEF'FIRTMENT BUF'R~NG THE
",r b_. l l l..IN.~ OF AN"? [JELL._, RB..fFICENT TO THI-':, FRUFERTT FIND THE
NUNL:,'ER OF RESIDENCES THAT THE NELL NILL SEF.:VE. "' '"-" '"
L. LIN~ OF ANY 'E,"r'STEH HITHOUT FINFIL IN-,FEE. FION AND FIPF'RO',,,'FIL B"," THIS
DEPRRTMENT NILL BE ':: ''
-.,UB.]EL.T TO PROSEr-:UTION.
NINIMUH DISTFINCE BETNEEN Fi NELL RN£:, FIN? ON-SITE SEHRGE DISI-"OSAL 2;'T'STEf'I I=,
· ..,. ,'n~b NELL CF." 2.58 TO 2R0 P"EET FROM Fi PUBLIC NELL DEF'EN[:,ING
UF'F~N THE I"~'F'E OF F_IBLIE: NELL. .
MIN]~MUr,~ [:'~STFINCE F~...H FI PRIVFITE. NELL TO FI F'R~VFITE SENER LTNE IS '~.~ FEET FIN[:,
T~q R C:Or'IMUNIT~., SENEF.: LINE :CS 75 FEET. ':-'-
NELL LOGS RRE FREOUIRED FIND [dUST BE RETURNED TO THE DEPFIF..'TNENT NITHZN 2:0 DR"r'S
F~F THE NELL COP1F'LETZON.
OTHER RE~qt.IIREFIENTS NR"r' FIPPL"r'. '-'F'
='FE-.ZFICRT.IUNS RH[." CONSTRLICTZON F-:'ZFIGF.:F~HS FIRE
RVFIILFIBLE 1'0 ZN_IJRE FF..UFER N.=,FRLLHTZLN.
Z F:ERTIF'.r' THAT
2-: I Fil"l F:'FINILIRF.: 1.4ITH THE REOLIIREI'ffENTS FOR ON-SITE cE, c ,=. .
-,-HER..-., AND NELLS FIS -,ET
FORTH B"r' THE MUNICIPFILIT'.r' OF RNCHOF..'RGE.
':" N=,TMLL THE S '-
-V-,TEN IN FICC:ORDRNC:E ['.IITH THE CODES.
Z-:' I UNDERSTAND THFIT THE ON-SITE SENER S'-P-"';TEr,1 MFi"r' RE-qUIF:-:E ENLFIRGEIdEr.,IT IF "rile
FRE_,I[:,ENCE IS RENODELED TO INCL.Ir..',E NOF.:E THRN Z-.': L-';EE:,ROONS.
V4. 0
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PF1OTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
~S LOG
PERCOLATION
TEST
7
8
9
10
11
12
13
14
15
16
17
18:
19
2O
SLOPE
SITE PLAN
Net
Time
Depth to
Water
Net
Drop
Reading
Date
~ -: PERCOLATION RATE__ (minutes/inch)
PERFORMED BY: ~ CERTIFIE'D BY: _ '
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological A GeophysicGI Surveys
LOCATION OF WELL (Please complete either la, lb lc.)
Drilling Permil No,
:~lBorough ~ubdv,~on Lot "~ock~ '/4,tre. Sec.on "o. Tow.eh~,NE
lc ~DISTANCE ANO,DIR?C~ ON FROM ~DAD INTERSECT ONS. 3. OWNER OF
Address:
2. WELL LOG Feet Below
Surface 4, WELL OEPT
Material Type Top Bolfo~. -,'~" ."
.,, :'/ ....... " 7. USE: ~ Do~
S~o~/~;sh s
' .: >, , ~ . I0, STATIC WATE
II. PUMPING LEV
~ Subm.
This we .was dri ed under
- ~ :' '~: : ~' ~ ~ ~ Dote: ,~,~
Aulhori'zed Repres'~nlof[~e ' '
[] Industry
[] Commoricel
A.D.L. NO.
wE]
tool []Rotary ~j Driven [] Dug
['~ det led ['~ Bored [~_'J Other:
Length:
-- ft. ond fl.
Grovel pack --
LEVEL: ~''5 tr. .2' /"'/
or ..[~ Below Ignd surface . Dote
below land surface and YIELD
after ~hr~. pumping ,~/ . g.p.m.
after __ hrs. pumping.. __g.p.m.
Well Grouted: [] Yes [] No
Neet Cement [] Other:
ovaHoble)
Pipe
belie!;
HP
- ft. capacity --_ g.p.m.
[] Centrifical [] Other
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
264-4744
Applicatio.n Date.
GENERAL INFORMATION fMUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 5~ Block A~ Pollock SubdivisZon
Location (add~ess'.or directions)
1533 I..' Pollock '~Drive
May 2, 1988
(b) Property Owner'J¢--~,ty. & Susan W.~nfr¢..YTelephone: Home 345-4975
Mailing Address. 15331 Pollock Drive, Anchorage, Alaska 99516
(c) Lending io~titutiog Commonwealth Mortgage Telephone
Mailing Address... 3553 'Pen¢/-_..,~ Street, #1100 Anchora,ge, Alaska
(d) Real Estate C0m. l~any.asd Agent 2001 ~EALTF/Susan OampbeZ1
Address '-1345'W&~t 9th Avenue, Anchoraqe, Alaska 99501
Telephone 276-2001
Business
99577
248-5300
(e)
Mail the HAA to the followina address: or: Check here ~ if hold for pick up.
List contact person and day phone number below. '
S & S ENGINEERING/694-2979
17034 Eagl~ River Loop Road, S~ite 204
Eagle River, Alaska 99577
ordered by Susan C~mpb~l~
TYPE OF RESIDENCE
Singie-Family.~
Number of Bedrooms
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 fRev 8/86t Fronl
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e~ep aZAleUe ~o suo!;oadsu! ~onpuoo ~ou op SHHQ ¢o seeAoldLu3 's;UeLUe~!nbe~ e~4s pue leJepe~ u!eHeo Xjs!;es o,t ~ep~o
u! suo!;nH;su! 5uipuel J!eq; pue seuJoq ,Lo sJeseqo~nd o~ ~seiJnoo e s~ siq~ seop SHHO eq/'~S~lV ¢o e~e;S eq; u! pe~@~s!Oe~
Jaeu!Oua leUO!SS@jo~d ;uepuedapu! ue Xq e^oqe ~ qde~§~Jed u! ua^iD suo!;e~ueseJde~ eq; uodn ~lUO peseq se;eo!,qMao
le^o~ddv /qi~oq~nv qHeeH senss! (SHHO) seo!^JeS ueuJnH pue qHeeH jo ~ue~uHedeo eSeJoqou¥ jo ,qHedfo!unl~l eq/
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peu!~qo uo!leuJ~o;u! eq~ uo p@seq jBql XIpa^ Jeqpn~ I 'u!e~eq p@~oipu! eJn~onJls ~o edXi pu~ SLUOOJpeq JO JeqLunu eq; Jo~
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qHeeH s!qi ~o UOi~O!lseAu! XLU ~eq~/gpe^ I 'MOleq UMOqS el~p uo!1epfle^ eqi ~o se pub ole~eq pexgj~ lees AuJ Xq pe!Hpeo sv
NOIJ. YIN~IO4NI (3NY ¥1¥0 'MC)BY:IS :Bl14 'S.LB=IL '~;NOIJ. C)~JdgNI 9NlalAOkldiNbll=l 9NII:IB~INIgN~
WELL DATA
'T~ o~MJ41NI~-,,~. 3'~ OF ANCHORAGE (MOA)
~u~\C~At ~I~I'~¥HORITY APPROVAL (HAA)
~O~' CHECKLIST- FEBRUARY 1984
1 264-4744
Legal Description. b~
Well Classification _
Well Log Present
Total Depth ~7
Static Water Level
Casing Height Above Ground
Electrical Wiring in Condui~YN)
Separation Distances from Well:
~...5'~"~. ~,__~ ~.[')t~,,~>./L~ If A, B, C, D,E,C, Approved (Y/N) _
7' Date Completed ~_~'¢~"t ¢ ~;~-'7~¢. d Yield
Cased to ~"7 t --
~/- Depth of Grouting
Pump Set At _ ~ ¢~
Sanitary Seal on Casing('(_~rN) _.
¥
Depression Around Wellhead (Y~Q~ __1--.3
To Septic/Fl'ok~ng Tank on Lot _ - \ ~ ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on .Lot ~ ~ ; On Adjoining Lots
To Nearest Public Sewer Line 1
Cleanout/Manhole r~/r/~ To Nearest Public Sewer
.~ -- To, Nearest Sewer Service Line on Lot
Water Sample Collected by 4~.¢~,~ ~..dtl...~h..;~_~/~ 'Date ,.._.%'--/~/,~¢2" -
WaterSample~stResults ~TI ~~o~ '~1~' ~
Comments ~'~ ~,~ ~ ,~ ~,~ ~ ~ .~ ~ .
B. SEPTIC,/ROL-DI..~_TANK DATA
Date Installed _~/-¢[ -'~"Z-- _ Size ~OO~) No, of Compartments
~tandpipes(~N) ~_ Air-~ght Caps CN)_. ~ Foundation ,Cleanout ~N) .
epression over Tank (Y/~ ~ ..... .Z¢
~ ~/ _ ua[e Las[ Humped __
Pumping/Maintenance Contract on File (Y/N) ~~ . .; for
Holding Tank High-Water Alarm (Y/N) I~/~ _ Temporary Holding Tank Permit (Y/N)
Separation Distances from SeptiC~ank:
To Water-Supply Well ~ ~ ~ ~' To Building Foundation _
Te P~epe~t~ Line ~-~ ~ To Disposal Field
To Water Main/Service Line ~ ~ f.~
Course ~ ~ ~-~
Comments ~ ~_..~
.-/
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72 026 (Rev 8/861 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed __~,~"'-~
Width of Field
Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ~, tCPE:~I
To Building Foundatio~.r~
Lot
To Water Main/Service Line \ ~ ~..-U
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present ~N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
Comments
LIFT STATION
Date Installed
Size in Gal~
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
~~ ud.~.~g__ Adequacy Test. Meets MOA
** 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.
17034 Eag'e El,~.atP04 '-¢'"//'~ > ~
Signed $ & S ENGINEEEING
Company r~,attle~.!¥m'; Alaska 99577
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 fRev 8/861 Back
ANALYSIS REPORT BY SAMPLE for Work Order { 6471 Date Report Printed: MAY 9 88 @ 10:26
Client Sample ID:L 5, B A, POLLOCK HOMESTEAD
PWSID :UA
Collected MAY ~ 88 ~ hrs.
Received MAY 4 88 @ 15;00 hfs,
Preserved with :4 deg C
Analysis Completed :MAy 6 88
Laboratory Supervisor :DANIEL d. BACON
Client Name S & S ENGINEERING
Client Acer SNSENGp
P.O,{ NONE REC'D
Ordered By : R. SCHAEFER
Send Reports to:
Released By : ,~ ~IS&S ENGINEERING
Special ~ ' .................................................................................................
Instruct;
Chemlab Ref {: 9924 Lab Smpl ID: I Matrix: Water
Parameter Tested Result/Units Allowable
Method Limits
NITRATE-M ND(O 10) mD/1 EPA 353 2 10
Sample ROUTINE SAMPLE.
Remarks: SAMPLE COLLECTED BY R,J,S,
I Yests Performed ' See Special Instructions Above UA-Unavailable
ND= None Detected *' See Sample Remarks Above
MA- Not Analyzed LT=Less Than, GT-Greater Than
ACHE3//ICAL & GEOLOGICAL LABORATORIES. OF ALASKA, INC.
TELEPHONE (907) 562-2343 5633 13 Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUB,,c WATER SYSTEM ,.,.,
~ PRIVATE WATER SYSTEM
Name " Phone No.
S & S ENGINEERI~(~ ;
Mailing AddJeY~g~14 Ea!..'l~ ;~i', er Loop R'ea~l No. 204
Eagle River, Alaska ~..~__~J.
City Stale Zip Code
Mo. Day Year
SAMPLE TYPE:
dS~ Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
.) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
4 I I
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
Date Received
Time Received
Analytical Method:
is shows this Water SAMPLE to be:
isfactory
[] Unsatisfactory
[] S~mple too long in ti'ansit; sample should
not be over 30 hours old at examination
to ihdicate reliable results. Please send
new sample via special delivery mail.
Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result* Analyst
I EF]
I FI-]
I I-1-1
BACTERIOLOGICAL WATER ANALYSIS RECORD~,'~J
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
TNTC
OB
Membrane Filter: Direct Count
Verification: LTB
Final Membran~ %: ~su~/~,,
Reported By ~ ~~
BGB
Time:
= Too Numberous To Count
= Other Bacteria
PART ! OF Z RE:MA1BtDER TO FOLLOW
Coilform/100rnl
Coilform/100m I
p.m.
APPL, Ir
Property Owner ~/~,( ~' ,, k-.;.'L~,~.; ~ 'i i ~ ', ('- ! '
Mailing Address i ..!.'
Zip Code
Lending Institution i' '-
',NT FILLS OUT UPPER HA' ' ONLY
i ;
Zip Code
Really Co. & Agent'S; -t( ,, , · ___ Zip Code
' ' ...... I ,'!',.,~,, .
Type of Residence
Phone
Phone
':: '¢'%
.:,~;~JS in g le Family
[] Multiple Family No. of Bedrooms
[] Other
Water Supply
'~"~ Individual
[] Community
[] Public Utility
ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
For wells drilled prior to that date, give well depth (attach Icg if available).
Sewer Disposal
~-~- ,Individual
[] Public Utility Year Individual Installed: / '~2 ~;: ,dL,-
[] Holding Tank When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time
Date
Inspector
I:ield Notes:
/J~ o
Time
Date
Inspector
Time
Date
Inspector
Time
Date
Insp6ctor
~) APPROVED BEDROOMS
) DISAPPROVED
. _
'CONDITIONS OF APPROVAL
Soils Rating / Date Sewer Installed
;'2-023 (31&?.)
Well To Absorption Area
Well to Tank /
Well Log Received
Septic Tank Size ./' d3 O0
()ctoi:}e: F.t} ~ i9{.{3
APPLI¢ NT FILLS OUT UPPER HA[ ONLY
Property Owner/~,~ · ,.~ ~ ........
Phone
Address A" ,- ~')
Address / :'? '
Legal Oescript~n ~
Street Locali~ ~'~
Type of Resl~nce
S
ingle Family
Multiple Family
~ Other
Water Supply
~J~ Individual
Community
[] Public Utility
Sewer Disposal
Phone
Phone
ATTACH WELL LOG. A well Icg Is required for all wells drilled since June 1975.
For wells drilled prior to that date, give well depth (attach fog if available).
,~. Individual
d' Public Utility
[] Holding Tank
Year Individual Installed:_ A~
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
Time Time Time Time
Date Date Date Date
Inspector Insp~tor Insp~tor Insp~tor
Field Notes:
)'/'z 0 FNVIR ,~' ~.' :. :'_rlON
R . EIVI b
'(~") APPROVED BEDROOMS 'CONDITIONS OF APPROVAL
) DISAPPROVED
2.: . _.,. -
Soils Raring Date ~wer Installed Well To AbsorpHon Area ~-~ * Well Log Reoeived
