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HomeMy WebLinkAboutDENSIL THOMPSON LT 137BDEPARTMENT 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 I,'ONE LOCATION NO. OF BEDROOMS~ ]Well t I AbsorPtion are~ Dwelliug / PERMIT NO. ~=~ Manufacturer ~ ~f~ .... Mat~_ ~ ~°' °f c°moartment~__ Liq. capacity in gallons IF HOMEMADE: Insid~ Width _ Liqui~depth ~ DISTANCE TO: Well ~ ~welling PERMIT NO, ~ -- ~ Manufacturer / A Material Liquid capacity in gallons C Well 1~ Foun~.~ Nearest, lot li~, PER~ ~ ~ ~ No. of lines / ~en~th o~ lige Total length of ;ines~ ~ Trench ~i~_ inches Distance b.tween linos Total effective absorption area ~ ~ ~op of tile to finish grade ~ I Material beneath tile ~2~ inches 744 Length ~ Width ~ Depth PERMIT ( ~ Tvpe of crib Crib diame{er /~ Crib depth Total effective absorption area ~ Well Building foundation Nearest lot line m DISTANCE TO: ~ Clas~ ~ ~/-- ~. Depth Driller Distance to lot line PERMIT NO. ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOl L TEST RATING INSTALLER ~ REMARKS 72-013 (Rev. 3/78) A F::' 1:::' L.. I C A N'T': A D D R IE S S :: t..,Ol,! 1 mC T F:'HONEi:: A M E R I C A I',I [ii: X C A V A T' ]: O N % S&S l!!!:r,,IG I I',!E:IER ]: I',IG EAGI.._E: R I VliEl::i'., Al< 99577 ~z ,'";,: ,'.', ,'"',..'r ,~::, ..,,n'::: r)..,..,.'r V ]: S :1:0 I",I :: NA SEC'T ;[ lIN: 8 'TOHI',IE!;H I F:': ! A (S(.";!, I:::T ,, (:IR ACF::'.IES ) DEF::"T'H 'l"O F:' ]: F::'E .Bo"r"l"Eff4 (F::T ,, ) GF:;'.AVEE] .... D-Ei]:::"T'H (I!::'T' ,, ) "I"OTAI ....DEF:'TH (F'T,,) GF:i'.AVEi:I.... ' I,,,j I D'I"H (I:.':"T' ,, ) GRAVli!!;I .... L. ENEFI"H (F:'T',) GF:;'.AVEI .... VOL..tJME ((.]: ..... Y'()S ,, ) 'T'ANI< SIZE (GALS) !iF;(::) ]:1 .... RAJ" I I',IG (SI'.,'! ,, F'T' ,, /BF;.'. ) ,,,. I C A N T': [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAl_ PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST LEGAL DESCRIPTION: ~-~--~'r I'?~q'8 ~-~ ~ 2 8 9 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTtI ,.% ENVIRONMENTAL PROTECTION SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O COMMENTS r~WAS GROUND WATER R E C E i V E L~ou~,-r~.~o? . b~bert A, She{mr No. 14,57.E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop ~ ~-~q-eq IO',.oo/~ '---- ~ '-'-- , 72-008 (6/79) PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) ~ FT OWNER OF LAND ADDRESS Drtlli tg.:,,Zog by DOC Co. db~ SULLIVAN WATER WELLS P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 LEGAL DESCRIPTION 41 ' " :, Ended -.. DATE.- Started PERMIT NUMBER DEPTH OF WELL STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING KIND OF.FORMATION: From ": Ft. to 'i' Ft. From '~' Ft. to ~ :" Ft. From ,,?:'., Ft. to ' c" Ft. From "v'Ft. to .,c.!,'. Ft. From : ,'??r Ft. to ' ." '~ Ft. From From Ft. to _Ft. From ..... d Ft. to ~;: Ft. From."; ' Ft. to Ft. From ':":' 'Ft. to Ft. From" '" Ft. to Ft From: From · '~ 'Ft. to ~ Ft.' ,~' From Ft. to Ft. From Ft. to Ft. From Ft. to Ft. From Ft. to Ft From From From From From From MUNICIPALITY OF ANCHORAGE Ft. to DEPT. O~-~I, EALTH & ENVIRONMENTAL PROTECTIO~ Ft. to Ft. FEE t Ft. 'o Ft. ~to "£ I. }/E D Ft. to,. Ft. Ft. to Ft. From Ft, to Ft. From.' ' ' Ft. to Ft. From' Ft. to' : Ft. From. ,' .... Ft. to, ' Ft. From ' ' Ft. t°.`. :~Ft. DEF:'AR'I"MI~N'I' OF' HEAL]'H AND ENVIRONMENTAL F::'ROTE:CTION 8.=:...J L STFREE"r', ~N[;I. JORAGiiEi:, AK 99501 264-4'720 F:'EF:;:H I 'T' NO: DATE ISSUED: 840940 ]. 1 / ()'7 / 84 A F:' F:' I.... I C A N T: A D D R [il] S S: COIqTA[$'T' F:'H[)NE: L CALVIhl STE[.~LIL: 2900 BONIFACE F"I<WY .t~680 ANCHORAGEE, AK 99504 2 '7 6 - 4 2. .q. 6 LEC']AL. DESCF~II:::': SUBDIVISION: DENSIL. THOMPSON LOT: 137B SECTION: 8' 'I'OWNSHIP: i[5N RANGE!i: '.I.W Li.O"I" SI ZE: 4568C) (SQ. FT. OR AE;RES) LOT LI")CA'F I []N: B I RCHWOOD LOOF:' E. L..L,[J... II i\lA 1. I am fami].i, ar' bui'Lh 'Lhe requir'emen'Ls for C)l"r..-.si'Le sewer's and wells as se'L f'c)r'th by the Municipali'Ly oF Ar)chc)rage (MOA) and 'Lhe State of' Alaska. 2,, I w:i. ll ins'Lall 'Lhe sys'Lem 'in accordance with ali. MOA c::odes ar'id r, egula'Lic)n.;~;, and ~r'l cc~mp].i~nce with 'Lhe de~$gn criteria of' thi~ penmit,, 3,, I ~i].]. ~dher'e tm all MO~ and State mf ~:Lasl.::a r'eqLtil-ement~ f'cH" the set back distances from ~ny existSFIg wel].~, N&s'Lev~ater d:i.~posal ~ys'Lem of pul:~tic sewer'age system on 'LI]J.s (:)r any adjac:e)rl'~L (:)f' I"~ear'l:)y ].ot. APF'L]CANT: I... CAI....VIN GTEEI...E 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 AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 137 B; Densil Thompson Subdivision Location (site address or directions) 19958 Birchwood Loop Road, Chugiak, Alaska Property owner f'l~l vi n ~-,=¢.1 ¢, Day phone 688-5009 Mailing address 19958 B±rchwood Loop Road, Chug±ak, Alaska 9956? Lending agency Mailing address Agent Address FIRST NATIONAL BANK OF ANCHORAGE Day phone ATT~3~!~N: Ro~ M~Tnt~re Day phone m Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well xxx 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: xxx 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 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 investigation 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 $ 3, S ENGINEERING Phone 17034 Eagle River Loop Road NO. 21~4 Address Eaqle River Alaska 99577 Engineer's signature DHHS SIGNATURE '/--- Approved for Disapproved. Conditional approval for bedrooms. 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 DHHS 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 It21 ( Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~ \?"~ ~ '~.~v-"'~'~-~Yt~l~arcel I.D. A. WELL DATA Well type Log present {~/N) Total depth Sanitary seal ~)/N) ADEC water system number ~\-' ~ Driller Cased to ~:~D~ Lo~' ' ~L,'.12.' Casing height Wires properly protected~.~YN) ~ AT INSPECTION V'L.- tl If A, B, or C, attach ADEC letter. Date completed FROM WELL LOG Date of test t,~--(~ Static water level L~ ?... Well flow \C). O g.p.m. Pump level ~,.~L.- SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot \ Absorption field on lot \ Public sewer main Sewer service line "/.-~' ~ ~'' ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform C:> g"°"'/~,~o~, iL. Nitrate Date of sample: I~. ~ \ ~-'~'t"~. B. SEPTIC/HOLDING TANK DATA Collected by: Other bacteria ~._~ o ,.~, Date installed ~' '~ ~ ~ ~, 5'- '~ Tank size ~ Cleanouts ~v.~/N) ~ Foundation cleanou~YN) High water alarm (Y~ ~ Alarm tested (Y/N) Date of pumping \ '~- ~ Y'] --- ~'Z- Pumper SEPARATION DISTANCES FROM SEPTIC/HOLDING~'ANK TO: S & S ENGINEERING 17034 Eagle River I-oep ~ea~i Eagle River, Alaska 99577 Compartments '7.- Depression (Y~ Well(s) on lot I [_~ To property line I c> Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at High water alarm level Meets MOA electrical codes (Y/~)-~'''''~~ SE~ROM LIFT STATION TO: W~on~lot ' On adjacent lots Manufacturer Manhole/Access (Y/N) ~ f~ff" level at ~ Cycles tested Surface Water D. ABSORPTION FIELD DATA Date installed ~' "'~ - ~ /' Length L~1~ ( Width Total absorption area Depression over field (Y~) Results ~;~/fail) Peroxide treatment (past 12 months) (Y~ Soil rating 'Z,'Z.~" ~/~:~¢- System type "T~---~ -~' Gravel thickness Cleanouts present ~YN) Date of adequacy test /Z. ~ ! ~5 - ~'2._ for "['~A ¢~¢¢_¢... ~ I/-./J o ¢ ~ If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots Surface water Curtain drain Well on lot /'~ ¢ To building foundation E. ENGINEER'S CERTIFICATION On adjacent lots /~o ~ ~ Property line /~/~- To existing or abandoned system on lot Cutbank '~/~-~ Water main/service line Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection: Signature Engineer's Name Date S & S ENGINEERING 17034 Eagle Rh'ar Loop Road Eagle Rive~'. Ata;t<a YY577 HAA Fee $ /'~7'¢ Date of Payment 72-026 (Rev. 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number CHEMIC, AL & GEOLOGICAL LABORATORY A~A{,¥~I~ {%~$~;Y~ for IMVOIC~ { ~Z7t6 Colle~to~ : 12/15/92 I 1.3;~0 {Us, BPO{ : ~l~Otved : {2/17/92 { 13~$0 h~. ~q$ : NIT~k2E-N 3.~ ~/1 EPA TST.Z/~OO,D 10 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE (DF iNSPECTION FOR HEALTH AUTH©RITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-472O Application Date GENERAL INFORMATION (a) L';gal Ee/scription (include I~., block, subdivision, section, township, range).~ Location (address or directions) (b) Applicant Namer,s.. Z,~.¢~ ~--~-~_ Telephone: Home/.-¢)~7/-~'- /~'~ -"2?__ Business (c) Applicant is (check one): Lending Institution [] · Owner/builder,,~; Buyer []; Other [] (explain); '' //~,~ .,~ ..,¢~:'.-~ ~' _~"/~~~"/~,~,~-6! I e hone (d) Lending nstitution(.~¢4~¢¢ . ~. · v . ,~,~_.,. p Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family,J~/ Multi-Family [] Other 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. 4. SEWAGE DISPOSAL Onsite/~ Public [] Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation attesting to the legality and status, Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ~- ~,. 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 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, l further 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 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 Telephone Address ;:-,iL;', i..i;' :' Approved ~_ __ Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending 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 72-025 (11/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 25 Description: Well Classification ~, ~ Well Log Present ~N) Total Depth ~C~' ~ ~ " Cased to (~:2~ ~ Static Water Level ~' ~ ~ Casing Height Above Ground ~' ~ ~ Electrical Wiring in Conduit (~N) Separation Distances from Well: To SeptJc/,Netdh'~j Tank on Lot //.c, To Nearest Edge of Absorption Field on Lot .//'~ ~ To Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C. Approved (Y/N) Date Completed //- ~ Yield Depth of Grouting -'-'-- Pump Set At Sanitary Seal on Casing4~9'N) Depression Around Wellhead (Yi~ ; On Adjoining Lots ; On Adjoining Lots '~ ~ To Nearest Public Sewer ~/,d To Nearest Sewer Service Line on ~,'i~' ~ ~__..~J~/~~~ ; Date B. SE PTI C/I:IOEBff~ TANK DATA Date Installed Standpipes ~)~/N) Air-tight Caps Depression over Tank (Y/~;) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Hel~li~j Tank: · To Water-Supply Well //~ To Property Line /~ ~' lot.,- To Water Main/Service Line Course · ~"'" Z.-~' Size ~ ~ No. of Compartments ~" Foundation Cleanout tG~N) E~ate Last Pumped ~ ~/,,a · for '---- Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field I,~' To Stream, Pond, Lake, or Major Drainage Comments page 1 of 2 72-026(tl/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~"- ~ - ~,~" Width of Field Type of System Design Square Feet of Absorption Area Depression over Field (Y/~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well //--~ ' Length of Field ~ Z- Depth of Field /c~ ' Gravel Bed Thickness "7 Z. Standpipes Present ([~:)'N) /_~Aate of Last AC equacy Test To Building Foundation ~'"' /'~ Lot ~ ~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on · On Adjoining Lots ~ /~ To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checkeC, verified, or conformed to all MOA and HAA guidelines in effect on the date of this i'nspection. ~-~ ~:. ,GiNE,~I~ Date Signed ~; ?' ~ ~'~ ~' ''~ "~'"" Compan~ .... ,~,, ~t~,,~,-~, ,--~L~,;,~ ~-~, MOA No. Receipt No. ~ ~t-~ ~ Date of Payment Il I ~l~ Amount: $ ~ ~ ~ Page 2 of 2 72-026 (11184)