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HomeMy WebLinkAboutPROSPECT HEIGHTS #4 BLK 1 LT 6 i.~_~~ 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 NAME . IPHONE J '~NEW MAILING ADDRESS LEGAL DESCRIPTION LOCATION /~ ~fe0~ "0. OF BEDROOMS JWel , / J DISTANCE TO: ] /~Z~ Absorption ar~ Dwelling / PERMIT NO. 0 ~ ~ ~anufacturer No. of line? Length of each line/ Total length of li~s Trench wide, , , Distance between~y~ ~ ~ ~ Top of tile to finish grade / Material beneath tile ~ ~ / Total effective abspr~area ~~ Width Depth PERMIT NO. ( ~ Type of crib Crib diameter ~ -- ~ Total effective absorption area ~ DISTANCE TO: Well Building foundation Nearest lot line ~ ~ DISTANCE TO: Building foundation Sewer line Septic tank/~ / Absorption area(s) OTHER PIPE MATERIALS ~J. ~/_L ~ ~]~] SOIL TEST RATING INSTALLER R EMAR KS ~ [ ,~, APPROVED DATE LEGAL MUNICIPALITY OF ANCHORAGE ~-~ DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Strut, Anr~ho~ge, ~ 99501 264.4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 4 5. 6 7 9- 10 11 12 13. 14 15 16 17- 18- 19- 2O COMMENTS SLOPE ~ ~UIL-"; LOG PERCOLATION TEST --/ DATE PERFORMED:_.'~Z .-./,~ --~ ~ SITE PLAN ~lt..T C, Reid, Jr.' No. 2251-E WASGROUNDWATE. ENCOUNTERED? E IF YES, AT WH~T DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE, TEST RUN BETWEEN (minutes/inch) FT AND ~ FT PERFORMED BY: 72-008 (6/79} CERTIFIED BY: SlX INCH WATER WELL DRILLED .......... OUT TO THE DEPTH OF 204 DRILLED aT The RATE OF $23.00 PER FOOT. C/~ ~ 200 1~ 7034 Sa4u,~ ~ ~ ' PROPERTY OWNER I~o~ ~, g~ ~.D.~ ~ ~ 27~-~17 ~47 ~ ~. LOCATION OF WELL SlTEJ~Jd~L. I S,,.fl% ,~,,~O~..~j. /~/'.o-J.q.h..L~ fiq~ DRILLER _ Bp_,,'z/'~/;~ C/m.*~ o,,,~ ~du~.prt~,/_ D,~/.L/~'~-~. ~.~.,.,~ WELL LOG: ~c.L~ IJe_J~ d4d. d2~ doo~ /9~or~ 44 ~ ~ 204 ~. S~~ ~ I O0 O0 S~ ~ ~ (116 ~ ~ $~.00 ~ ~: $2668.00) 7o~ co~_~ ~: $3668.00 Y~ g~ ~ ~ ~ o~ ~ 20 ~ ~ 44 ~. ~ ~ o~ ko~ ~,~ 5 3/4". ~ ~ ~ ~~ ~ ~~_ g~. T~ ~o~ ~ ~ ~ 204 ~ ~ ~e ~. 7~ ~ ~ ~ ~p ~o~ ou~ 5 ~ ~4 k~ ~~. (45 ~) ~04 o~ b~A~ ~ g ~ ~, ~~ ~ 166 o~ ~ ~ 204 ~. COST INCLUDES ALL LABOR AND MAT~RIAh ~ .......... ~ wU~ ~Ot/O~ WRIT~ CHECK PAYABLE TO RAMPART DRILLING WORKS VOR THE $~ THANK YOU VERy MUCH. BERNIE CLAUS OF RAMPART DRiLLiNG WORKS SERVICE CHARGEOF 1~0/. p~'~ ~i~m'l-m ~.~.~ , =~ . ............ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF iNSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lobatio~ (address or directions) IOZol D RoF (b) Applicant Name ~f¢+ ~ ~IL¢~ Telephone: Home 5~6-¢¢~¢ Business ApplicantAddress lO~/ S~OO~F ~E A~C~. 4K (c) Applicant is (check one): Lending Institution ~; Ownedbuilder~; Buyer ~; Other ~ (explain); Ac dress (e) Real Estate Company and Agent Address Te,ephone (f) Mail the HAA to the icl owing address: Telephone ~V/~' TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Indiviaual WellJ~ Community [] Public [] Note: If corn munity well system, must have written Confirmation from the State Department of Environmental Conservation attesting to the legality and status, 4. SEWAGE DisPOSAL ' OnsJte ~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Depadment of Environmental Conservation ~ttesting Fo the legality and statbs.. , the date of this inspection. Name of Firm Address I~) ~ ~,,~'~ Date I'~ ,'~, As certified by myseal affixed hereto and as of the validation date ~hOWn below', I verifY'that m~ in~estigation °f this Health ~ Authority Approval 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 fu~her 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 r wastewater disposal system is in compliance with all Municipal and State codes,.ordinancos, and regulations in effect on Telephone ~6/-~d Y~ 4Nc 'fin DHEPAPPRO' L ~ t /'~ Approved for ~ bedrooms ~rPrm~V~co nditi~o'~r ~Ap prova~isappr°v~f Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given n paragraph 5 above by an independent professional engineer registered in the State of Alaska. -[-he DHEP does this as a courtesy to purchasers of homes and their lend ng institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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. Page 2 of 2 WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal DeScription: /---~o' ~ J~JUNICIPALITY OF ANCHORAG~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION RECEI/ ED Casing Height Above Ground Electrical Wiring in Conduit (~N) Separation Distances from Well: Well Classification _ J~'~ ~'//'bd4 ~ Well Log Present ~N) Date Completed Total Depth Z¢-~//'~ Cased to q~' / Static Water Level ~_~, / Water Sample Collected by Water Sample Test Results _ Corn ments ~/2,'~ /;~-,~ Yield I / Depth of Grouting ~/ Pump Set At Sanitary Seal on Casing Depression Around Wellhead (Y/¢ If A, B, C, D.E.C. Approved (Y/N) To Septic/Holding Tank on Lot ~--~-" To Nearest Edge of Absorption Field on Lot ~2,~'" To Nearest P~Jblic Sewer Line q/I¢:]L To Nearest Public Sewer Cleanout/Manhole !V'//~' To Nearest Sewer Service Line on Lot · ~ K'~} "rc/-)/.Jc/~ ; Date 7//.~,/~ ; On Adjoining Lots ; On Adjoining Lots _ 1OO/"/' B. SEPTIC/HOLDING TANK DATA Date Installed_ ?/7 /-~"~' Standpipes (~/N) Air-tight Caps (~/N) Depression over Tank (Yi~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well TO Property Line ,2(~" TO Water Main/Service Line N/~:~ Course _ 100 ¢' '"t~ Size IZSD NO. of Compartments ~2- Foundation Cleanout CC)N) Last Pumped ~..~.~. Date ;for-- Temporary Holding Tank Permit (Y/N) To Building Foundation I 0 / To Disposal Field iii '~ To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026f11/841 LOCATION MHERE SAF~PLE WAS COLLECTED , . I'1 Not in proper container [] Leaked out [] Insufficient information provided. Please road Instructions on form. TYPE OF SAMPLE · t' ! (CHECK ONLY ONE THIS COLUMN) ~RINKING WATER / ' /CHECK TREATRENT []CHLORINATED [] FILTERED /~/)NTREATED OR OTHER [] RAW SOURCE WATER [] NEW CONSTRUCTION OR REPAIR5 [] OTHER(Specify) IS THIS SAHPLE A CHECK SAMPLE TO A PREVIOUS NON-CONFORMINq SAMPLE? [:]YES ~0 PREVIOUS COLLECTION OATE ANALYSIS ~EQU~STED (IF OTHER THAN TOTAL COLIFORM) SEND REPORT TO:(PRINT FUlL NA~,ADDRESS AND ZIP CODE NAME ADDRESS ANALYTICAL HETHOD: [~"I~'EHBRANE FILTER r-]FERI~HTATION TUBE Date & Time Started Time Completed ~////~"/~ Date & LABORATORY [-1 Other Bacteria ~ Test unsuitable because: [] Confluent Growth [] TNTC SATISFACTORY [~ UNSATISFACTORY [] BACTERIOLOGICAL WATER /U(ALYSIS RECORD FOR LAB USE ONLY ~'-1~ TOTAL COLIFORMS ~-~ FECAL COLIFOR~S ~-~ OTHER Membrane Filter: Direct Count Verification: LTB Final Membrane Filter Results Reported By,. 0 BGB Date Coliform/lOOml Coltform/lOOml Time A.M. P.M. READ SAJNPLE COLLECTION INSTRUCTIONS ON BACK OF FORM tll,./~ob/.{ r. IIVlF{UI~IIVII,.RI I/'iL CONTROL SERVI~'~, IN(:. 1200 West 33rd Aven~_, Suite B ANCHORAGE, ALASKA 99503 (907) 561-5040 SHEET NO. OF CALCULATES By CHECKED BY DATE SCALE ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed q / 7/-~2~'5'' Width of FielO Square Feet of Absorption Area ~" Depression over Field (Y/0 Results of Last Adequacy Test Separation Distance from Absorption Field: Type of System Design Length of Field ~7/ Depth of Field '~ Gravel Bed Thickness I / Standpipes Present (~/N) Date of Last Adequacy Test To Water-Supply Well To Building Foundation Lot N/ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Cours. e To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line - To Existing or Abandoned System on ; On Adjoining Lots ,~*O ~ '¢' To Cutbank (if present) N'//~ [ O0 / 10 LIFT STATION Date Installed _ Dimensions Size in Gallons Manhole/Acces~)C~---- On" Level at / / [ ~ ..,-~' Vent (Y/N) __- High Water Alarm Level at ~ [jJ' ~ ' PumpingCyc Tested for les during Adequacy Test. Meets MOA Electrical Codes (Y/lC) Comments ~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I hav~ GI3,e, cl~d, vc~rified/pr conformed to alIMOA end HAA g uidelines in effect on the date of this inspection. Signed Q ~ ½~,L~~ Date 7/! 7/¢*~2 Company ~'~ ~' [ [~t~- f MOA ,o. ~-¢'7OZ ¢ Receipt No. Date of Payment ~' {Q-~¢ '~ 72-026 (11/841