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