HomeMy WebLinkAboutPREUSS #1 BLK 1 LT 1
,. DEPART~?ENT 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
MAILING A~R ESS /
LEGAL D~SCRIPTION~
z No f--
Liq, ~c~gaHons IF HOMEMADE: Inside length Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material
~ --~ Liquid capacity in gallons
~ Well
~ DISTANCE TO: [~( Foundation ~ ~ Nearestlot/~/ PERMITNO~/~ ~--~
N-- ~ ~ TopN°' of lineS/of tile finish Length of%h~e[ Total le%o~nCs Trench %t~.inches Distance betw~ *
~ ~ to grade ~ ¢ Material beneath tile 7] inches Total e~tive abso~ area
~ Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
MAT RIALS
REMARKS
' ~ ,S25 "~ STREET., RNCHORFIGE., RK. ~S. ~ / /./ / ~
PERMIT NO. ( 818455 ::,/
L. EGRL LZ Bt PRE_SS LOT SIZE [28E~SE~ $QURRE FEET
'f"¢F'E OF %OIL RBSORPTZON SYSTEM IS: TRENCH
MRXIMUhl NLIMBER OF BEDROOMS = 3 SOIL RRTING (SQ FT,,"BR)= 125
'- ~- ' " '"'-T F"-F" '' '~ '-~'- '-'
THE REL.]Lt!RED :,I [HE :,IJ_L. FI_,:,JRFI ,T:,TEM I:,.
[:,EF'I-H= ¢ LE~"-J] _.~l ~'4--- $ _~F4. H -.- EL [:.EF'TH== ' .
THE LENGTH DIMENSION IS THE LENGTH (tN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENC:H OR PIT IS THE DISTRNCE BETWEEN THE SURFRC:E OF THE
GROUND FIND THE E:OTTOH OF THE EXE:RVRTION <IN FEET).
THERE I5 NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRRVEL BETWEEN THE OUTFFILL PIPE
RND THE BOTTOM OF THE EXCRVRTION <IN FEET::,.
PEF.:MIT RPPLICFINT HR'_-] THE RESPONSIBILITY TO INFORM THIS DEF'RRTMENT DURING THE
INSTFILLFtTION INSPECTIONS OF FIN'¢ WELLS F~DJRCENT TO TI4. IS PROPERTY FIND THE
NUMBER OF RESIDENCES THFIT THE 1.4ELL WILL SERVE.
BFICKFILLING OF RN'¢ S'¢STEM WITHOUT FINFIt_ INSPECTION FIND RPPRO',,,'RL B'?' THIS
DEPFIRTMENT WILL BE SUBJECT TO PROSECLITION.
MINIMUM DISTFINCE BETWEEN FI WELL RND RN'~ ON-SITE SEWFIGE DISPOSRL SYSTEM IS
tFiO FEET FOR R PRI',,,'FITE WELL OR 2LS(t TO 2~3E1 FEET FROM R PUBLIC WELL DEPENDING
UPON THE T'T'PE OF PUBLIC WELL.
MINIMLIM DISTRNE:E FROM R PRIVRTE WELL TO R PRI'¢FITE SEWER LINE IS 25 FEE]' FIND
TO R COMMUNIT'T' SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 3:El DFI'¢S
OF THE WELL COMPLETION.
OTHER REb']..UIREMENTS MR"r' RPPL'¢. SPEC:IFICRTIONS RND CONSTRUCTION [:'IFIGRFIMS FIRE
R'v'RILRBLE TO INSURE PROPER INSTRLLFITION.
F"EF.:~'4 ][ T E::-::F" I F:E:-]; [:.EE:Er'IE.:EF: Z~':l.. tL~:E:=t
I CERTIF9 THRT
&: I FIM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE '--]EWER'--] RND WELLS RS SET
FORTH B9 ]'HE MUNICIPRLIT9 OF RNCHORFIGE.
2: I WILL INSTRLL THE SSSTEM IN RCCORDRNCE WITH THE CODES.
~: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MR9 REQUIRE ENLFIRGEMENT tF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~ BEDROOMS.
V4. 0
O & E ENgiNEERING & DEVELO~,-MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for.'
Legal Description:
Depth (feel)
0__
2__
3__
4
6__
7__
8__
9__
10__
11__
12 .
13__
14__
15__
16__
Name: /~,~
Mailing Address:
Soil Characferlstlcs
Earl Ellis
SOIL LOG 886-2280
~/,~ ~9~ ~-~,~ ~, ~J ~-~t,v Tel. N0 '~?,J- ~ ~,-,/~)
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit__
Comments:
No If yes, what depth.
Drain Field ~'
PLOT PLAN
PERC. TEST
by
DOC Co. dba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS ./;' >
LEGAL DESCRIPTION
DATE - Started ~ .' ;'
PERMIT NUMBER
~ ~ r :? ~J'' J? STATIC LEVEL OF WATER FT.
.?~',,.,~ / _J ~t?~ DRAW DOWN FT.
Ended :, /c~/ GALS. PER HR · ~ ~' ~'
KIND OF CASING ? ~' ~': ~ )
KIND OF FORMATION:
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.
From Ft. to.__Ft.
From Ft.
From Ft. to
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.
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
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
Parcel
1~'~"; GENERAL INFORMATION
;:.;. ;~, L~I~ (s te address or d~recbons)
. . .';: Agent::~: ; ; ~ ~ ~, ~' - "~":~Dayph0ne
.~. '..:. UnlesS.othe~ise requested,_H~ will be held for pickup
-=: 2. · NUMBER OFBEDROOMS:.,'-.' ....
..3. ~PE OF WATE~ SUPPLY: ..'. ~ '' '.-_' :._ _ -C .:=:&~?'-
~ "- - .... i~ II syste pro ide
.-. ~ ........ - NOTE: If commun we m, v n
_ . ing to the legali~ and status of system.~: .~.
..... 4,-~ ~PE OF WASTEWATER DISPOSAL: -'-:~ -.--: "'
. :;.. ;'- ~;. :.: ~: onL-,t~'--=.:
:~-.: _ ...~ ._ -.. _ Holding tank - ., : -.- .
.: .. _,~.: ~.~':':.-' ~-:¥..... . ...~:,_-,;::~
Community on-site-
NOTE:' If comm~hi~'~'
a~esting to the lega~i~ and status of syste~. ', ~-~'
~-~t~.~- ~ ~: ..... _ ..........
5. STATEMENT OF INSPECTION BY ENGINEER ' ': ' · '"~
Ag ,.=,+i~;-~ ~v ~'l ~ffix~ hereto and as of the validation date shown below,
investigation of this Health Authori~ Approval application shows that the 0n-stm water' ~P Y
an~or w~tewater dispo~l system is ~fe, functional and adequate for the numar of ~rooms.'.~'~:~
and ~pe'of st~a'ct~re indicated herein. I fuAher veri~ that based on the i~formatiOn 0btai~
the uun~Cipaii~ of Anchorage files and from my invest~ation andr J~sp~tion; the °n~it~:-~Ater?~??
' supply and/or wastewat~{ dispo~l system is in compliance With all Municipal and State codes,
.. ,.._ . Conditional approval for b~rooms; wit
%'~ ~' The MuniCipa]i~ of Anchorage Depa~ment of Health and H~ma Se~ices (DHHS) issues Heal~ Authori~
",'~/Appra~("~eAifi~tes based only upon the representations g~ven in paragraph 5 above by an independent
' profe~ional engineer re0istered in the State of A ~Ska. The DHHS do~ this as a cou~esyto purcha~ of hom~
and their lending institutions in order to ~tis~ ceAain f~e~l and state requirement. Employes of DHHS do not
- condu~ inspections or anal~e data before a ce~ificate is ~u~. The Municipali~ of Anchorage is not
responsible for erro~ or omi~ions in the profe~ional engin~¢s wo~. ~' .- .... . .
(Rev. 1/91 ) BaCk MOA 1121
Municipality of Anchorage
DEPARTMENT OF HEALTH 8, HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907)
Health Authority Approval Checklist ..¢~ ,.-~ ~.~o~
~=--1Descri*tion' ~ / ~ / /~,25 ~ Parcel I.D.: ~
Well ~e ~/~Y~/~ [f A, B, or C. attach ~EC letter. ~HC ~ater ~stem numb~
Log present (Y/N) ~"
Total depth
Sauitary seal (Y/N)
Date completed ,,t~,/~q ~, ~ ¢,¢ /
Cased to 6'49 '~/-F' ' ' l~asing height (above ground) ,~525 /-.<.A
Wires properly protected (Y/N) P/
FROM WELL LOG
AT INSPECTION
Date of test
Static water level
Well production ,.¥" g.p.m. ?~ ? g.p.m.
Co
WATER SAMPLE RESULTS:
Coliform '~ Nitrate ~ d ~ Other bacteria
D .... r .... · ,-'Ye ~ ,,,~_~ /5~¢~" Collectedbv -,'c'-'~a ~' ~ ~/~""e-~%'cYz'r-~)'/
SEPTIC/HOLDING TANK DATA ,~ ~ .-'
Date installed Tank size Number of Compartments /Cleanonts (Y/N)
FoundatiOn ~leanout (Y/N) Depression (Y/N) High. alarm (Y/N)
Date of Pumping Pumper Id/
ABSORPTION Fi~LD DATA
Date installed
Length Widtb
Soil rating ( 2g~Podrm)
~ravel thickness below pipe
Effective absorption area ,,/~Monitoring Tube present(Y/N)__
Date of adequacy test ////' Results (Pass/Fail)
Fluid depth~field before test (in.);
Flt~ __(ipe, roxid, e treatme~t (past nlsd)n~i2~t~t,'7; lTte/N~:
System Bq~e
Total depth
Depression over field (yfl,,r) __
For bedrooms
Immediately after gal. water added (in.):
Absorption rate = .g.p.d.
If yes, give date
D. LIFT STATION
Date installed
Manhole/Access (Y/N)
High water alarm level at*
Size in gallons
"Pmnp on" level at*
_---~-/ Datnm
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Pnblic sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ~
Building foundation . Property line Absorption field
Water main/service line Surface water/drainage ..B~-I~6~ adjacent lots
IST^ C ,OM TO:
Bnilding foundation .~'~ Water maitffservice line
Snrface water ~ Driveway, parking/vehicle storage area
~drain Wells on adjacent lots Property line
F. ENGINEER'S CERTIFICATION
.....
I certi~, that 1 have dete,'mmed th,'u field ,,,eect, ons and revtew of Municipal r~Z~. ~flat the~ov~ ~h are
in conJbrmance with M04 lt~, g ui&lines in effect on this &te.,~. . ~" . ~,. '.~{t.
Si w , ~ ~..: ........... . .r~
.............................................................................................................. '. x~~: .............
Waiver Fee $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
WATER & WASTEWATER UTILITY
3000 ARCTIC BLVD.
RECEIVED
OCT ~- 5 1995 VVASTEWATER
M..icipality o~Anchorsge CONNECT PERMIT
Dept. Health & Human Services
DATE OF APPLICATION
SCHEDULED COMPLETION DATE
PHONE: (907) 564-2762
BLOCK/LOT/TRACT BLK 1 LT
SUBDIVISION PREUSS #1
10/20/95
12/31/95
SINGLE FAMILY
[] MUTI-DWELLING No. APTS~
COMMERCIAL
TAX CODE 5057109 GRID t~56 AS-BUILT
STREETADDRESS 20019 EAGLE RIVER RD
OWNER MOORE ROBERT L & FRANCES H
MAIL ADDRESS EAGLE RTVE,A-K 995?7-8?46
PHONE
CONTRACTOR
[] Repair Existing Service
[] On Property Only
[] Hydrant Only
[] Main Tap - To Property Line Only
[] Main Tap & On Property Connect
[] Disconnect
[] R&R - Main Tap Only
CONNECT SIZE 4 "
REIMBURSIBLE
NUMBER
INSPECTION FEE $
PERMIT FEE $
$
DEPOSIT $
TOTAL $
[] City Tap
[] 50' or Longer
104.00
35.00
139.00
ASSESSMENTS
~ Main Line Extension
~ Have Been Levied
[] To Be Levied
Comments:
ISSUED BY CDF
[] PAID
INSPECTED BY
J---J CASH
J~J CHECK#
~.EMARKS
PERMITEE (Please Print)
PHONE
MAIL ADDRESS
SIGNATURE
POST IN A CONSPICUOUS PLACE AT THE JOB SITE
AWWU INSPECTOR
Original
SUBDIVISION PREUSS#1 BLK/LT/TRACT BLK 1 LT 1
_~, I INDICATE NORTH
I
I
I
I
SIZE MAIN: I DEPTAT MAIN:
CONNECTLOCATION: I ll~-$ ~& ££ ~o~ ~'~' COMMENTS
SULLIVAN WATER WELLS
P. Oo BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL DESCRIPTIOI~
DATE - Started
PERMIT NUMBER
~.~,..,,s,-~-~-t' DEPTH OF WELL _ ' '2 ' /
~'(.. fl? ~ ,~ STATIC LEVEL OF WATER FT. _r
DRAW ~WN ~. ~ '
Ended ~ GA~. PER HR "'
KINDOF CASING ..~ :~ c ,~
KIND OF FORMATION:
From" . Ft.
From ~ Ft. to .....
From ,::~ FL to . .
From , Ft. to ,.
From ~ ~" Ft. ~
From , Ft. to
From .... Ft. to ITt.
From Ft. to . , Ft..
From .. FL to .. FI,.
From ,,, Ft. to ,. Ft.
From Ft. to ,,, Ft.
From . .Ft. t~ Ft.
From ~Ft. t~ .__ Ft,
From Ft. to Ft.
From .... Ft. to Ft..
Froro Ft. to ' , Ft. _.
From ,, Ft. to ,. Ft..
MISCL. INFORMA'flON:
From Ft. to Ft.
From, FI. to Ft.
From~Ft. to , Ft..
From .Ft. to FI,
From .... Ft. to FI
From Ft. to Ft._
From ~ Ft. to Ft. _
From FI. to ..... Ft._
From Ft. to, ,, FI
From Ft. to ,,Ft._
From
Fro~__
From Ft. to , , . Ft.
~J DA"W~ RECEIVED
INS PECTI ON APPOI NTM ENTS ,~_.(.~:~j.~/~
TIME
TIME ~ .(~//(~/~(j~~/~.. TIME
DATE DATE , DATE
DEPT. OF H~ALTH &
MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL P,~:O;~CTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street - Anchorage, Alaska
99501
JUL g
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ~en (10) days for processing.
1. PROPERTY OWNER PHONE
MAILINd ADDR~S
PROPERTY RESIDENT (If different from~ab~ve) PHONE
2. BUYER PHONE
MAILING ADDRESS
3, LENDING INSTITUTION ~ PHONE
MAILING ADD~ES8
~ PHONE
4. ~ALTO~/Ag~NT
MAILING ADDRESS
5. LEGAL DESCRIPTION
o'T /3i /
STR E ET LOCATI ON
6, TYPE O~ RESIDENCE NUMBER OF~BEDROOMS
~ One ~ Four
~ SINGLE FAMILY ~ Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL* *ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach Icg if available.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** /~'d~/ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72 010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
F-I""~'S~iN G L E FAMILY E~ ONE E~-'~"I~H R E E [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL ,,.
[] COMMUNITY
DATE DRILLED.,.
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
F-I INDIVIDUAL/ON -SITE DATE INSTALLED
[~] PUBLIC UTILITY
Connection Verified INSTALLER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/Holding Tank IAbsorption Area Sewer Line I Nearest Lot Line
Absorption Area to nearest Lot Line
5, COMMENTS
I~APPROVED FOR '~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE
72-010 (Rev. 6/79)