No preview available
HomeMy WebLinkAboutDUNCKLE LT 84A MUNICIPALITY OF ANCHORAGE DE ~TMENT OF HEALTH AND HUI~AN SEA iS Environmer~ts~ Hea~th D~vis~o~ ~25 "L' ~reeL Anchorage, Al~sk~ 995~, Telephone ~54-4'7~0 ON=S~TE SEWAGE D~SPOSAL SYSTE~ AND/OR WELL ~NSPECT~ON R~PORT Phone(s) ~No ~No of Be0rooms ~ELL Township, Range, Section ,~ SEPTIC [] HOLDING D~STANCES SEPTIC TANK ABSORPTION j FIELB WELL (Show location of well, sephc system, property hnes, loundabon, TYPE OF SYSTE~ ~;~...TRENCH ~ BEg ~] W. DRAIN LJ OTHER Depth [o p~pe bottom from ~ oral depth from ong~rlal gcade original grade '¢~"~ (~) F~ G~avel depth beneath p~pe Gravel w~dth ~-¢~s~ ~T~ FILl added above original grade (4~,© FT Gravel length Total absorphon area ~ , C,--) FT WELLS ,~x~' PRIVATE ~ OTHER Classlhc~hon (A,B.CJ ~ oral Deplh Cased to FT Inspections Per(or,ed by: 6edify, Ihat this }nspectb, was periermed a¢serding to a, ~unicipal and State guideli,es in effect 0fl ~is date: ENGli SEAL Health DepaHmen~ Approvel: 264-4720 850547 08/'29184 LE:GAL DESCRIP~ LOT SI Zlii'.~ MA X 'B E DR OOMS ~ ROBE:RT F:~ BROOKS 330'7- 1 () 4 ~ BON I F ACE ANCHORAGE:, AK 99504, SUBD I V :f: S I ON ~ DUNCI<LE SE:CTtON~ 8 TOWNSHIP: 4 L, OT~ L, OT 84A B[,,,I]CI<~ NA 15N RANGE~ the r,)pt, ions available to you in designing your~ septic the c~ption that be:si:. Fits your DEPTH T'O PIPE: BOTTOM (I:::'T.,) 4.0 E~RAVEL. DEF'TH (F'T~) 5,, 0 TOTAL., DEiF:']"H (FT.) 9.0 E)RAVEL W:[D'T'H (F'T.) 2,.f5 GRAVEL. LENGTH (F'T'.) 40,,0 GRAVE:L VOL, UME (CU,, YDS,, ) 2()~ 4 T'ANK SI ZE: (GAL, S) 1, :~ZS()~ 0 ~' SC)IL RATING (SD,,F'T~ /BR) 100 · ~'.~' TAIxtK MUST HAVE AT' LEAST TWO L,UMI-AE~IME:NI,:> :EF, Eli:: ZD 4,, 0 0 5 4 5 :[8 0 34 0 22 '7 250 0 '~'~ 100 ]: c: e ~" i:, i f y t h at, :~ t,, I am familiap wii:.h t. he r'equirements foF' c')n-.sit, e sewers and ~.~e].ls as set Forth by the Mun:[cipality c~f AnchcH~,ag~:~) (MOA) and the Stat.~ oF Alaska. 2,, t ~:[].1 install t, he system :i.n ac:cell"dance ~it.h all MOA ~:c~des and regulat.:Ec~ns, and :Eh compliance with the design crit, ePia oF this pePmi'L,, 3. I will. adhere to all MDA and St, ate c~f Alaska Pequi~emen'Ls for the set, back d.LstaF'H::es from any existing well, wast:e~at.e~, disposal sys{em or public 4. I under'stand that this peF'mit is w~lid For'. a maximum oF 4 bedr'ooms and any enlargement will require an additic~na~ permit. :IF A L. IF"T' STATION 1,::~ ,[N.~TALJ,.,.E,D IN AN AREA COVE:RE:D BY MOA BU:[LDING CODE:S, f'HEN (1) AN ~:.L,I.L, FR1CAI... F'ERMIT AND INSF:'EC]'ZON MUST BE OBTAINED; (~2) AS-BUII.,,,1.:~ NIL..L NO]" BE APF'ROVED NiTHOUT AN EL. ECTR]:CAL,. INSPECTION REPORT~ ~ND (3) THE EL, EC"FRICAL WORK MLIST BE DONE BY A L. ICENSED E:LE[TT]::(ICIAN. APF:'~ '[CANT~ ROBF'RT F. BROOKS Municipality o; Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502=0650 SO~LS LOG -- PERCOLATI~ON TEST SEAL) 1 2 3 4 5 6 7 8 9 10 11 DATE PERFORMED: Township, Range, Section: S Oc'p 7--/j'/~2 SLOPE SITE PLAN 12 13 ~ao '7-'~Z~ ~'t o¢'~* 15 16 17 18 19 20 WAS GROUND WATER ENOOUNTERED S IF YES, AT WHAT ~) DEPTH? p E Deplh to Water Alter ~oniloriflD? Oate: / Reading Date Gross Net Depth to Net Time Time Water Drop ~E~O~M~L~ ~V~ A~_~ __~, ~/ _ c~m~'~ ~uA~ T~S TeST WAS ~e~O~D~ ACCORDANCE WITH AEC'~A~'XND MUNICIPAL GUIDELI~ EFFECT ON THIS DATE. DATE: ,~//~/~ / 72-008 (Rev. 4/85) DOC Co. dba §ULLIV&I WATER WBLLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 ~ TELEPHONE 688-2759 OWNER OF LAND ADDRESS LEGAL DESCRIPTION DATE - Started ~ t PERMIT NUMBER ___ Ended ST ~TI(' LEVEL OF WATFR F[ I)RAI~ DOWN FT. GALS~ PER HR KIND OF CASING KIND OF FORMATION: From_~: ..... Ft. to 5 From '" From, 2L__Ft. to ,~ ~_Ft From ...... Ft. to-- From ....... Ft. to____ From ........ Ft. to From ....... Ft. to____ From ....... Ft. to __ From_____Ft. to .... From__Ft. to_ From .... Ft. to ...... FL Ft. Ft F~ Ft Ft From ..... Ft. to ..... Ft From ...... Ft. to __ Ft From _ __Ft. to .... Ft. From_____Ft. to .... FL From ....... Ft. to .......... Fl From Frmu From From From Ft. to .... From ..... Ft. to From From From From From. __ From MISCL INFORMATION: Ft. to. Ft. to Fl. Ft. to___ Ft. Ft. to Fl Fl. to___ Fl FI. to ..__ Fl .... Ft. to ...... Ft ____Ft. to ........ Fl. FL to ........ Ft.~ Ft Fl. Fl, to .... Ft. Ft. to _ Ft. __ ~Et. ut~ICIPALITY O- Ft. to regal .~ ~ , cCi'loN DRILLER'S NAME 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 Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) ApplicantName_~---~..~'.'?' ~¢'¢x3~'t"STelephone Home Applicant Address (c) Applicant is (check one): Lending Institution~; Owner/builder []; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family~ Multi-Family [] Number of Bedrooms ~ Other WATER SUPPLY Individual Wellf~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsite~ 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. Page 1 of 2 72-025 (11/84) ENGINEERING FIR~I 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 ~ ~..~_~_~. !o~_ ~::~'~ ~_~_l~ff Tel e p h o n e / Engineer's Seal Approved for _ ~¢~_)~_~/~_~ bedrooms by te Approved ..... .J</ 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 WELL DATA MUNICIPALITY OF ANCHORAGE (MO~.~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: MUNICIPALITY OF ANCHOI~A~I~ DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION ,lAN 2 ~ ~ ~'"~" ~" Gl:0uting Total Depth ~ Cased to __ Depth of Static Water Level ~-~ '~ Pump Set At "~.~ Casing Height Above Ground __~ ~ Sanitary Seat on Casing (Y/N) _ ~_ -- Depression Around Wellhead (Y/N) Electrical Wiring in Conduit (Y/N) Separation Distances from Well: TO Septic/Holding Tank on Lot ~/~"~ ~'; On Adjoining Lots TO Nearest Edge of Absorption Field on Lot ~_~70 ¢' ; On Adjoining Lots TO Nearest Public Sewer Line ~.~ TO Nearest Public Sewer Cleanout/Manhole _ ~~ ~ To Nearest Sewer Service Line on Water Sample Collected by ~ ;Date Water Sample Test Results Commonts B. SEPTIC/HOLDiNG TANK DATA Date Installed ~, ~__ _ Size --~-~L~~ NO. of Compartments standpipes (Y/N)" '~ __ Air-tight Caps (Y/N) _.~. -~-'~ __ Foundation Cleanout (Y/N) Depression over Tank (Y/N) ~:~ Date Last Pumped ...... Pumping/Maintenance. COntract on File (Y/N) ., ~, ' , ~, · for Holding Tank High-Water Alarm (Y/N) _. ~__ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ___~_!~ TO Property Line To Water Main/Service Line "7-~.~ Course ___~"'/~'~ ~ To Building Foundation / ~'. ¢' To Disposal Field /~) ¢¢ To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72o026(11/84) C. ABSORPTION F~ELD DATA Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Soils Rating in Absorption Strata ~/~ Type of System Design ----/~--~/~ ___ Length of Field Date Installed Width of Field ~'~ --~"¢Z,~" Depth of Field Gravel Bed Thickness . Standpipes Present (Y/N) Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot '"~¢'"1~=~ To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle. Storage Area Comments _~F'~_~_~ ~_ TO Property Line ~'* / To Existing or Abandoned System on ; On Adjoining Lots 7O~ To Cutbank (if present) ,____~¢~¢/~¢"'~.~,~ __ LIFT $~ Date Installed ~ Dimensions Size in G_al.!Qns ~__~Manhole/Access-% (Y/N) ~ "Pump High Tested Electri Comments ~- ~ ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I haveshec~ver~ied~cr conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signe~ate __~__._ Company ~ ,~'~¢~. MOA NO. Receipt No. "~_~_O__~, ~¢~ ! Date of Payment ] .- ~'"~SS ~ Amount: $ L~ ~-'~ Engineer's Seal Page 2 of 2 N ,~, 72-026 (11/84)