HomeMy WebLinkAboutDRAKE BLK 1 LT 6
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
Carl De Board I 333-8628 L-~UPGRADE
MAILING ADDRESS
P.O. Box 3-364 Anchorage, AK 99501
LEGAL DESCRIPTION
Lot 6 Block 1 Drake Subdivision
LOCATION NO. OF BEDROOMS
Driveway off Mallard Ave 3
DISTANCE TO: ] Well I Absorption area Dwelling PERMIT NO.
_u~ 124' 41 Not built 780150
Z Manufacturer Material No. of compartments
~ Greer , Steel 2
Liq. capacity in gallons Inside length ~ Width Liquid depth
lO00 IF HOMEMADE:
~,r~ ~ DISTANCE TO: Well Dwelling PERMIT NO,
~O _Z ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundat'ion Nearest lot lioe PERMIT NO,
,,~, ~- DISTANCE TO: 175 I 15'
~ ~ ~ No. of lines Length of each line Total length of lines Trench width Distance between lines
-, 2 26+66 92 48 inches Right angles
~' ~ ~ Top of t?le to finish _grade Material beneath tile Total effective absorption area
m 5 to 7' 24 inches 368 S.F.
Length Width Depth PERMIT NO.
<~ I- Type of crib Crib diameter Crib depth Total effective absorption area
uJ Well Building foundation Nearest 10t line
u~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
I~1
Cast to drain field - Perforated P.
SOl L TEST RATING
100 S.F./B.K.
' NSTA L LER -
Glacier Excavating
REMARKS
West end of east-west drain line
at test hole location. Ground-
water 4' below washed gravel in
... .....~ n .~ lXl v,[.
drainfield trench. ~.~ '<! ...... ~ _
DATE LEGAL
72-013 (Rev. 3/78)
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Performed
Leoal
This
'°One t~n ts worth a thousand opinions"
C 2204 CleVelancl Anchorage, Alaska 99503
For ~ ~ BO~ Date Performed
~escrintion: Lot ~ Block ,~ Subdivision ~m~
~orm Re.orts Soils Lo, ~ Percolation
Test
~enth
Feet
~)~.~_~ ~, Soil Characteristics
6
16--
18__
20--
i
Was Ground Water Encountered?~ d'Yoo
I¢ Yes, At what Denth?,,
Readinq Date Grnss Time Net Time Depth to H20 Net Dron
Percolation Rate Hinute
Prnposed Installation: SeenaQe Pit
Deoth of Inlet Denth
CnM~ENTS' /00 ~, ~'+ ~ra.,4.~4.~_~_
I1', /
Test Performed By '~~~_ Data
Drain Field
To Bot Or Trench
~) o[~f Pit
Certified By: ~(~
Date:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
' On-Site Services Section
P.O. Box 198850 Anchorege, Alaska 99519-8e50
343-4744 ..~
Parcel I.D. #
CERTIFICATE OF HEALTH AUI'HORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
017-461-04 HAA#
.1.. GENERAL INFORMATION.. . · ~ ..... .... . . ~ ..
Complete legal.description T.ot 6, Block 1, Drake $/D
Location (site address or directions)
2901 Merqanser
Property owner' Ernest
Mailing address
Lending agency
Mailing address
& Cindy LoVe Day phone 345-3342
AnchoraGe, Alaska 99516
: -' Day phone
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2, 3
e
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well x×
..... Community well : ;.~..
Public Water
If community well system, provide written confirmation from State ADEC attest-
NOTE:
. lng to the legality and status of system. ~,' 'i, '.~ I:)/,I ?,
_ . . ..' ~.',',,". , - ."
4. TYPE OF WASTEWATER DISPOSAL:,, "
/ :'~ ~' ,~, ', ...~
,~?- ..... ~ Individual on-site _ ~x.
.=~..:.~ ..... .~ ;~ 'commUnity On'site ___ ·
~ . ' / ~ .?. ~.~;;-:-: .
NOTE: If community Wastewater system, provide written confirmation from State ADEC '
attesting to the legality and status of system. '
72~25 (Rev, 1~1) Front MOA~I
Sa
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.ti_,qation 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. .
NameofFirm Steven R. Pannone, P.E. Phone 274-0308
Address P.'-o. Box 142025, Anchoraqe, Alaska
Engineers signature-.----~~~- J
DHHS SIGNATURE
~' Approved for
bedrooms.
9~514
Date
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
#
· :The M[mci,~ality of Aj~horage Department of Health and Human Seduces (DHHS) issues Health Authority
',, Approval Certificate. I~ased only upon the representations given in paragraph 5 above by an independent
% ,,. ; .,.~ ,(~.',y . . . .
prote~.,on, al er~gl~e~r reg mtered m the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
"/. ' [ ~' I %,\" -" . , . .
the,i:l~ndin.[~ institutions in order to satmfy certain federal and state requtrements. Employees of DHHS do not
and
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the profe~ional engineer's work.
72-02~(Rev. 1/911 Back MOA#21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
LegalDescription: Lot 6, Block 1, Drake S/D Parceli.D. 017-461-04
A, Well Data
Well type ;Private
Log present (Y/N) Y
Total dePth 55 ' 5-~"
Sanitary seal (Y/N)
~,OT~: We I 1
Y
is artesian and also
FROM WELL LOG
5 ' 5%"
15-20
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 5-25-78 Driller Cook
Cased to 40 ' + Casing height
Wires properly protected (Y/N) Y
has plug inside casin9.
AT INSPECTION
5-25-7~ 10-8-94
Date of test
Static water level
Well flow
Pump level1
50'
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot +110 '
g.p.m.
See note above
6ol
50'
; On adjacent lots + 100 '
Inlet Water
24"
g.p.m.l~3wler ,~-4~'~ h~s
~ C
Wells
Absorption field on lot +.L 10 '
Public sewer main MA
; On adjacent lots + 1 0 0 '
Public sewer manhole/cleanout NA
Sewer service line + 2 5 '
Petroleum tank ~,,
WATER SAMPLE RESULTS:
Coliform '-'~
Date of sample:
Nitrate 2 .~, ~
~'~/~ ~ Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed 5-30-78
Cleanouts (Y/N) Y {2)
High water alarm (Y/N) ~A
Date of pumping 9-16-9 4
Tank size 1000 Gal. Compartments 2
Foundation cleanout (Y/N)Inside fndn Depression (Y/N)
Alarm tested (Y/N)
Pumper Rotorooter
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot + 1 .t. 0
To property line +50
Surface water/drainage
On adjacent lots
Absorption field
+100 '
+100 '
42'
Foundation 9 ' to cleanout
Water main/service line + 25 '
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date ~ Manufacturer
Size in gallons ~ Manhole/Access (Y/N) J
Vent (Y/N)_ __"Pum~.~_ ~t ~
High water alarm level ~s. tested
Meets MOA electrical codes (Y/N) _.~/~ ~
SEPAR~TATION TO: ~
W_C-oClot On adjacent~....Iots Surface water
D. ABSORPTION FIELD DATA
Date installed 5-30-78 Soil rating (GPD/Ft2) 100 System type Shallow trench
Length ;Z6 + 66 Width 4' Gravel thickness 2' Total depth 7.5 - 9.5'
Total absorption area 36 _9 ? F Cleanout present (Y/N) ¥ Depression over field (Y/N) N
Date of adequacy test 10 - 8 - 94 Results (pass/fail) T~ a s s for 3 Bedrooms
Waterlevel in absorption field before test Below latera]_ ** Aftertest Below lateral
Peroxidetmmment(past12months)~/N) ~o If'yes, givedme
**NO monitoring tube reqrd in 1978; during entire test water remained below
SEPARATION DISTANCEFROM ABSORPTION FIELDTO:level of lateral pipes. System was
injected with 607 gallons of water.
Well on lot + ] ] 0 ' On adjacent lots + ± 00 ' Property line + 20 '
To building foundation 58 '
To existing or abandoned system on lot
On adjacent lots + ± O 0 ' Cutbank + 1 ~) 0 '
Water main/service line + 25 '
Surface water + ] n r),
Curtain drain +100 '
Driveway, parking/vehicle storage area +.5 0 '
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect orLt~e.d~e of this inspection.
Signature
EngineeesName Steven R. Pannone, P.E.
H~ Fee $ ~. ~ Waiver Fee $
Date of Payment
Date of Payment
Receipt Number ~d/(~¢/¢/ Receipt Number
72-026 (3/93)* Back
SINCE 1908
CT&E Ref.#
Client Sample ID
Matrix
Commercial Testing & Engineering Co.
Environmental Laboratory Services
94. 6297-1 LABORATORY ANALYSIS REPORT
LOT 6, BLOCK 1 DRAKE/2801 MERGAHSER
WATER
Client Name PA_NNONE ENG SRV. WORK Order 11623
Ordered By S. OSWALT Printed Date 01/03/95 @ 11:29 hrs.
Project Name Collected Date 12/28/94 @ 10:05 hrs.
Project# Received Date 12/28/94 @ 13:00 hrs.
PWSID UA
Technical Director
STEPHEN C. EDE
Sample Remarks: SAMPLE COLLECTED BY: S.O.
QC Allowable Ext. Anal
Parameter Results Qual Units Method Limits Date Date Init
Nitrate-N 2.64 mg/L EPA 353.2 10. 12/30/94 CMR
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
ii~U Reported practical quantification LT = Less Than
Undetected,
value
is
the
limit.
~iD = Secondary dilution. GT = Greater Than
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLAND, NEW JERSEY, OHIO, UTAH, WEST VIRGINIA
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
d"~//7- /-//~'//-"~)/-/ NAA# ~.~ O~..~_ (~'~'"~
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lOt, block, subdivision, section, township, range)
,//,
Location (address or directiOns)
(b) Property owner [~-~t <~'>'~'~Y~. Telephone' (home)
Mailing Address .~--~, ~/' '/~*~-,
(c) Lending Institution ~'-.~.~,',~>t~.~, ,-~z-~//'~, ~ ~/,~. Telephone
7
Mailing Address
Business-~'3-- ~ ?,,¢ /
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here r-i, if hold for pick up.)
List contact person and day phone number below:
TYPE OF RESIDENCE
Single-Family}~2~ 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 th legality and status.
SEWAGE DISPOSAL
On-site J~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. 7/88) Page 1 of 2
5. 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. 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 ? L-'--C 5 --~-~¢ Telephone
Date
6. DHHS APPROVAL
Approved for ,-~' bedrooms by
Approved /~_ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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, 7/88) Back Page 2 of 2
~ MUNICIPALITY Of ANCHORAGE (MOA)
(,*~J~'~,l , Health Authority Approval (HAA)
m~NiOp^U~~ol~^O~- CHECKLIST - FEBRUARY 1984
ENVIRONMENTAL 5'"~-'",,~R',C]ES DIVISION 343-4744
iiiii::';~J 9 ~9~8 Legal Description: L
^. w.,,, R E C E i V E D
Well Classification f:::¢'(" I U~'/~
Well Log Present(~) Date Completed
If A, B, C, D.E.C. Approved (Y/N)
5"'-',/,,,~ ~-,,"/,75~'' Yield
Total Depth
Static Water Level ~'. ~z / /
Casing Height Above Ground / /
Electrical Wiring in ConduitCN)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot /
To Nearest Edge of Absorption Field on Lot
.~-5";5-C~ased to 5~J;~. Depth of Grouting //(,Z,..-o,~-...
Pump Set At ~
Sanitary Seal on Casing
Depression Around Wellhead (YL"N~
/ 75
; On Adjoining Lots ~/oo
; On Adjoining Lots
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results 1~
Comments
To Nearest Public Sewer Cleanout/Manhole
,,~ Zo/
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed S~-/.z~/?¢' Size
Standpipes (~N)
Depression over Tank (Y/~
Pumping/Maintenance Contact on File (Y/N) /U/,/~
Holding Tank High:-Water Alarm '(Y/N)
/ nO O No. of Compartments
Air-tight Caps ~'~N)
Foundation Cleanout (Y~
Date Last Pumped .5//7/*~
; for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTAN. CES FROMSEPTIC/HOLDING TANK:
To Water-S.uppl~'Well ' .
To Property Line
To Water Main/Ser:vice Line
To Stream, Pond,-Lake or Major Drainage Course
To Building Foundation
To Disposal Field ~'7
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
/
Length of Field ~ ~
Depth of Field ,J-- ;7
Gravel Bed Thickness
Square Feet of Absortion Area _.~? ~;,~ ------._ ..Statndpipes Present ~N)
Depression over Field~~/z//____~_/~'__~_~_ .~Date of Last Adequacy Test
Results of Last Adequacy~ ~-~Test ~/~ ~,~ ~-'~' ·
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation
Lot N e
To Water Main/Service Line
/ ~"( To Property Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
To Existing or Abandoned System on
; On Adjoining Lots .~ 7_c~
To Cutback (if present)
Comments
D. LIFT STATION
Date Installed Dimensions
Size in Gallons Manhole/Accel_
"Pump On" Level at "Pur04a'Off" Level at
High Water Alarm Level at r ~''''"' Vent (Y/N)
Tested for N ~[ ~/..)...........~~~..Jr"~/~ ' Pumping Cycles during Adequacy Test,
Meets MOA Electrical Codes (Y/
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have che~Gked, verified, or conformed to all MOA and HAA gui~Jim1~il~ ~[fect on the date of this
inspection.
Company ~~~- -
..,,
~,,~ ~ ~f,,~*'"~/~ngineer's Seal
Date ,/~_ ~ /?¢~ ~ ~ ~~:
MOA No.
Receipt No.
Date of Payment ~.~ -?~ ~ Waiver Fee: $
Amount: $ /~ O- O0 Date of Payment
72-026 (Rev. 7/88) Back Page 2 of 2
CHEMICAL & GEOLOGICAL ORAIORIES OF ALASKA, INC.
~,,,,~'L~;O;~/O2, E~S~ FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order S 10555
Date Report Printed: NOV 28 88 ~ 19:32
Client Sample ID:L6, Bi DRAKE O/S TAP
PWSID :UA
Collected NOV 18 88 ~ 12:30 hrs.
Received NOV 18 88 ~ 15:00 hrs.
Preserved with :4 DEO. C
Client Name : AECS
Client Acer : AKECSRP
P.O.! NONE REC'D
Req t
Ordered By :
Analysis Completed :NOV 21 88 Ser~ Reports to:
Laboratory Superyl~or~:~TEP~N C. ~DE I)AECS
Speclal
Instruct:
Chemlab Ref t: 3496 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result/Un, ts Method Ll~ts
NITRATE-N 1,3 m~/1 EPA 353,2 10
Sample ROUTINE SAMPLE
Remarks: SAMPLE COLLECTED BY A. WIEN.
I Tests Performed ' See Special Instructions Above DA-Unavailable
ND- None Detected '* See Sample Remarks Above
NA- Not Analyzed LT-Less Than, ST-Greater Than
~ ' ' DEPARTMENT OF HEALTH & ENVtRO~I~L' -'
\\~'~ ~ll~,~}/ ENVIRONMENTA~ ENGINEERING DIVISION
s
DIRECTIONS: Complete all pa~s on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
Carl W. DeBoard " - ~ ] 337-3191
608 Klm Place, Anchorage, Alaksa
PROPERTY R Esi 6ENT (If different from above} ' ~
Ronald D. Smith 349-1425
MA L NG ADDRESS .
c/o 7590 Briarwood, Anchorage, Alaska
3,"LENDING INSTITUTION ...... ~ PHONE
Coast Mortgage Co.
MAI LING ADDRESS ......
P.O.~ Box 1200, Anchorage,' Alaska 99510
Cloyd Moser
MAILING ADDRESS
4467 Business Park Blvd., AnchOrage, Alaska 99503L
Lot 6, BloCk 1, Drake Su division
STREET LOCATION
llard Avenue
E
[] One [] Four [] Other
~ SINGLE FAMILY-
[] Two [] Five
'[] MULTIPLE FAMILY ~ Three [] Six
.Y
~ INDIVI DUAL* * ATTACH WELL LOG A well log s required for all we Is dril ed
[] COMMUNITY Since June 1975. For wells drilled prior to that date, give we I
[] PUBLIC UTI LtTY depth (attach Icg if available.) '
s. SEWAGE DISPOSAL SYSfEM " '
[] INDIVIDUAL ON SITE** If nd v~duat/on-s~te, g ve nsta lat on daze 1978
If system s over ~wo (2)years o d an adequacy test s required
[] PUBLIC UTIL TY b ~his De artment
NOTE~ T.E,NS"ECT, ON 'FEE MUS~ ACCOM.ANY EAC.-REOUES~ .~FO.E P"OCESS, NG CA. BE ,N,T,~T~.
72-010(3/78) ....... ~ .~
.... THIS SIDE FOR OFFICIAL USE ONLY ~..,~
DATE RECEIVED
INSPECTION APPOINTMENTS
FIME TIME TIME
::)ATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
NUMBER OF BEDROOMS
1, TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SIX
[] OTHER
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTI LITY
Connection Verified
[]Septic Tank or i-]Holding Tank
Size: If Tank is homemade
give dimensions:
TYPE OF TANK
TOTAL ABSORPTION A'R EA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
MANUFACTURER
MATERIAL
Septic/Holding Tank
Absorption Area ]Sewer Line
INearest Lot Line
~ APPROVED FOR ~' BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
(Title)
LEGAL DESCRIPTION
72-010 (Rev'. 3/78)