HomeMy WebLinkAboutPROSPECT HEIGHTS #1 BLK 6 LT 10A
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
,~,~"5/(~.~.f5 /Az 1~/~ ~ Tn SEPTIC ABSORPTION
AddressF~0~ TANK FIELD WELL
Lot J ~lock J Subdivision
Township, Range. Section
AS-BUILT DIAGRAM (Show location of well, septic system, property lines, foundation,
~ /~ ~/Z ~ ~ ~ ~ driveway, water bodies, etc.)
TANKS N
~ SEPTIC ~ HOLDING ~ 7
Manulacturer Capacity in gaao~s
Material No. of Compa~ments
TYPE OF SYSTEM
~ TRENCH ~ BED ~. DRAIN ~ OTHER
Depth to pipe bottom Item Total depth from original grade
original grade FT
Fill added above original grade : Gravel depth beneath pipe
0 FT
Gravel
Gravel
width
~0 FT
Total absorption area :Distance between lines
~00 SQ FI
~PRIVATE D OTHER {Identifv)
Classification (A,B,C) Total Depth [ Cased to
REMARKS:
Inspections Pedormed by:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN.SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIFTION:
;ET}
1
2
3-
4
5
6
7
8
10
11
12
13
14
15
16
17-
18
DATE PE
Township, Range, S~fion: $ I ~ T I ~ ~1 ~ ~ iai
SLOPE
19
WAS GROUND WATER
ENCOUNTERED;'
IF YES. AT WHAT
DEPTH?
Gro~
Readi~J Date Time
SITE PLAN
I
De~th to Net
Wate~ Orol~
~0 - PERCOLATION RATE [mmute~nc~) PERC HOLE DIAMETER _
TEST RUN eETWEEN Fi' ANO, Fi'
AccORDANCE WITH A~ STATE AND MUNICIPAL GUID~NES IN ~FE~ O '
M U N I C I I::' A L ): T' Y 0 F A tq C H 0 R A G E
Depar"Lmer:,t of F.ieatt. h ~ Human Services
825 L. St. reet., Anc:l"~c~rage, Alaska 9950] 34:~;-.472;B}
F:' E R M I '1"
Owner Nam~.z.-': NO(ID DESIGt'~S :[iq
C)wner AddPe~[H~ '70~?. 1 DRIFTWO[)D F'L. ACE
ANCHORAGE, AK 9~518
Day Phone:
::5 49 -. 80 14
L. ot. l...ega 1 ',: Subd i v :i. s i on :: I:::'RL]SF:'EC 1' HE I t!'..)H"t'S ~ t t...c:H:. :: 10A
Sectic, n~ ].:]!; T'cx~nship:i 12N Rang~:.',~ 3W
Lcxl:. Size ?.~:3:1.~ (sq.,~'t.,. c~r' acres)
Max Be.',drooms.' Th:i.s Per. mit.: 4 f'oLal Capac:it.y: 4
B I ex:: k: 6
SEF:'T'IC; TANK: Minimum t. crLat set:::,t.:i.c: tank c:apac:[t.¥: :1.~250 gallons. Each sept:i.c
· l'..ank must. have at. least. 2 cc)mpa~tmenis'. Dept. h to t. op o¢ sept. ic: 'Lank (s) <
{(.---.',et r~'..'~quir'6:s insula'L:i.c~n ove.'.r 'Lank(s),,
WELL.',~ Log must. be subm:i.t, ted ti:) Munic:i. pal:i. Cy of' Anchc)r'age Del::~art. ment of' Health
and Human Se!r'vice-~ w:i.t, hJ.n :30 days o~' w,,~:.!!l comp!et, ion,,
INFORM D,1..J,,H.S., PRIOR TO :I. ST & 2ND INSF'Ei]:];T'IOIqS BY EIqGINIi~:E]:~, IF:
AF"T'I!iiJ::~ :::::::::::::::::::::::: HOURS, C~L..L :]!;4:3-'461!'JI AND I...Ei:AVIE A MESSAGE.
COI',iSTi:~:LICT PER ENGItgEI}3~S ATTACHED APF:'ROVED DESIGN
't'HI,S PERMIT EXPIRES 12/3:~./89 AND VAL..ID F:'OIR A SINGI_E FAMII_Y
I CERTIF:'Y THAT:
:t.,,! am ~'ami:!.iar. w:i.t.h the ['equ:i. rement, s ~'cir c)n.....site sewe['~ and w~alls as set
~'orth by 'Lhe Munic:ipalit. y o~' Anc:h~r'age (MOA) and t.l"~e State o[' Alaska,
2., I will :i. nst. a].l t. he ~y~v[:.(-:e~n :i.r~ accor'clar~c:e) wi'Lin al! MOA (::odes and !"egulat. ions,
and in compliance ~,~,it.h the design cr:i.t, er'.:[a of th:i.s permit.,
::'.;~ I w:i. ll a(::lt"~e)re t.c) all MOA anct St. at.e o{ Alaska requ:i, rements ~'oP the set. back
distances f'r'c,m any existing wel:l.~ ~..~astE.~,,~at~m d:i. sposal symt. em oP put:)].ic
sew~e:,Page system o1-~ t. his ~1" any adjacent, or l"leaPby
4,, i undePst, and t. hat this permit is walid Fop a maximum
als(:) understand t. hat. the capacit, y o~' t. het. otal syst. em :i.s 4 beclrooms al'Id
any e:,niar-gemerrE. ~-~:i.].]. require a~ldit, ic:)nal pePm:i.t.,,
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
PERFORMED FOR:
DATE PERFORMED:
LEGAL DESCRIPTION:.~/~-- /~ ,~
1
2
3
4
5
6
7
8
9
10-
11
12
13
14
15
16
17
18
19
20-
COMMENTS
PERFORMED BY:
SLOPE
2:%
SITE PLAN
GROUND WATER S
)UNTERED? /b/'O ~
P
E
AT WH AT
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch)
FT AND -- FT
I
78. 45
50'
78.~2
05~
250.0E
N 8~o 53'25,, £ _ t320.2'~
Tom Fink, 825 "L" Street
Mayor P,O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
January 9, 1989
Sam Hill
7021 Driftwood Lane
Anchorage, Alaska 99518
Subject: Lot 10A Block 6 Prospect Heights Subdivision '~
Permit #880041, P.I.D. #015-092-20
A permit issued by this Department for an individual well
and/or on-site sewer system has expired as of December 31,
1988.
Permits are issued on a calendar year basis by authority of
Municipal Ordinance. A new permit must be obtained from
this Department for any well and/or on-site sewer system
not installed by the expiration date.
If you have drilled the Well, a well log needs to be sent to
this Department for documentation of the installation and to
close the permit. -
If a private engineer inspected the installation of the
on-site sewer system, the original as-built inspection report
(three-part form) must be sent to this office for review and
approval, and for documentation.
When applying for a new permit, the fees are: $90.00 for
an on-site sewer permit; $50.00 for a well permit; $140.00
for a combined sewer, and well permit.
If there are any further questions, please call this office
at 343-4744.
Sincerely,
Daniel J. Roth
Acting Program Manager
On-site Services Section
DJR/ljw
enc: Copy of Permit
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99S01 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED:
LEGAL DESCRIPTION:
1
2
3
4
5
6
9
I0
11
12
13
14
15~
16-
17
18
19.
20
SLOPE
SITE PLAN
WAS GROUND WATER S
ENCOUNTERED? ..~0 L
O
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND -- FT
250.02
EXISTING BRAss CAp
MONUMENT
EXISTING
B.L.M. ~RASS CAp MONUMENT
CURVE
NUMBER (SEE CURVE SCHEDULE Z~BOVE]
2-G~ xl
C81 /fie
9,4
2.05~
IoA
~ ~.5/A
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological A GeophysicolSurveys
Drilling Permit No.
LOCATION OF WELL (Please complete either la~ [b or lc.) A.D
I-~.lBorough d I-'~.I [/4qtr.. Section No. TownshlPNO Range EO Meridian
DISTANCE AND DIRECTION PROM ROAD ~NTERSECTIONS
3. OWNER OF ~LL:
WELL LOG Feet Below
Surface 4. W~LL~EPTH: (final) 5.~E OF COMPLETIO~
f .,~ Top 8ottom
~'~'~ ~ ~~/ ~ ~ 0Auger
· ~ ~Above or ~ Below land surface Date
12.GROUTING Well Groufed: ~ Yes/~ NO
Material: ~ Neat Cement ~ Other:
15, PUMP: (if available) . HP
15. Water Temperature o ~ F ~ C
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 AU'I~HORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete legal description
HAA #
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
.... · Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA wi/I be held for pickup.
NUMBER OF BEDROOMS: ~' ,~
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
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.
72-025 (Rev. 1/91) Front MOA #21
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 type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my inves_tLgation 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 ~0, ~ ~ ~/0 ? 7_J' ,~(~-.
Engineer's signature
Phone
Date
o
DHHS SIGNATURE
X' Approved for ~¢~-c- ~(/~/bedrooms.
Disapproved.
Conditional approval for
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
Legal Description: L,-."r' IO~.,~
A. Well Data
Well type/f/'~'~/~.-
Log present (Y/N) f
Total depth '~,~"/~
Sanitary seal (Y/N) ~
Date of test
Static water level
Well flow
Pump level1
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
~-,¢::;;~-;""~ Parcel I.D.
If A, B, or C, attach ADEC letter. ADEC water system number
Cased to /~7' ~ Casing height
properly protected (Y/N)
Wires
FROM WELL LOG AT INSPECTION
~ ~.p.m.
On adjacent lots
;
; On adjacent lets
Public sewer manhole/cleanout
Petroleum tank
SEPARATION DISTANCES FROM WELL TO:
Septic/ho!di.~g tank on lot
Absorption field on lot /0'7
Public sewer main
Sewer service line > ~',,4- /
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/~#~I#~:i TANK DATA
Date installed / ~//~-//~
Nitrate "~' ~ ~ Other bacteria
Collected by..'/~..,~,/~
Tank size
Compartments
Cleanouts (Y/N)
High water alarm (Y/N)
pumping ~,b ~//~3 Pumper
Date
of
SEPARATION DISTANCES FROM SEPTI~ TANK TO:
Well(s) on lot /~o On adjacent lots
To property line ~//,,9 / Absorption field ~
Surface water/drainage :>/¢-~'-~
Foundation cleanout (Y/N) /t'" Depression (Y/N)
Alarm tested (Y/N) /V'/~
Foundation
Water.-.~ei~service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
,~ __ Manufacturer ~ ~
Si ze in gallon~ Manhole/A~ ....
MOA electrical coHigh water alarm level des (Y/~
Meets
~ROM L I FToS::~IaOc: n: iOo:t s Surf~_~
D. ABSORPTION FIELD DATA
JJ
Date installed /o//,v~//,~.~ Soil rating (GPD/Ft2) Z ¢-- System type
Length .5-4:> / Width S / Gravel thickness ,~'" Total depth
Total absorption area 5-o (~ Cleanout present (Y/N) y Depression over field (Y/N) /v
Date of adequacy test ~./Z~/- Z,-~.~)~ Results (pass/fail) p~-~5~ for ~ Bedrooms
Water level in absorption field before test ~:> After test
Peroxide treatment (past 12 months) (Y/N)
/%/ If yes, give date '-----
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
!
Well on lot /07
To building foundation
On adjacent lots
Surface water ,~/~.~,
Curtain drain /V'/,~
On adjacent lots '>/~'~:~ / Property line
To existing or abandoned system on lot
Cutbank /V~¢-- Wate~r~'-;~J.~/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
date of this inspection.
Engineer's Name ,4/~)(M4A~,"l.=- '~ ,,4~J:O~,~"/1JOr~
Date ~/_~O /~'Z
HAA Fee $ ~ 043 ,- ¢
Date of Payment
Receipt Number
4381 - E
Waiver Fee $
Date of Payment
Receipt Number
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENTAL LABORATORY SERVICES
REPORT of ANALYSIS
Chemlab Ref.~ :93.4278-3
Client Sample ID :L10A B6 PROSPECT HEIGHTS SUBD.
Matrix :WATER
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 562-2343
FAX: (907) 561-5301
Client Name :ANDERSON ENGINEERING WORK Order :69968
Ordered By :ALLEN Report Completed :08/25/93
Project Name : Collected :08/22/93 @ hrs.
Project~ : Received :08/23/93 @ 11:15 hrs.
PWSID :UA Technical Director:S~EP~qE]~, EDE
Released By :~~
Sample Remarks: ROUTINE SAMPLE COLLEuT~U BY: A.H.
QC Allowable Ext. Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate-N 3.43 mg/L EPA 353.2/300.0 10 08/24 LLH
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
U = Undetected, Reported value is the practical quantification limit. LT = Less Than
D = Secondary dilution. GT = Greater Than
~,~,,,~'~ SGS Member of the SGS Group (Soci6t~ G~n~raJe de Surveillance)
ENVIRONMENTAL SERVICES IN ALASKA. COLORADO IITAI4 II I I1%11'51c~ ~11~ ~,,~AOVI