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HomeMy WebLinkAboutDELUCIA LT 34'~' ' DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ',~ ~'.~ 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAIU~G ADDB[SS LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS Well [ Absorption area Dwelling PERMIT ~ ~,S~A.C. ~o: ~ ~ ' ~ ~ Manufacturer Mator ~o. of compartmen~ ~ ~ ~i~. ca0aciW in Callons Inside length Width ~iquid depth ~O~ O- IF HOMEMADE: ~ ~ Well Dwelling PERMIT NO. ~ ~ Z DISTANCE TO: O ~ ~ Manufacturer Materiat Liquid capacity in gallons D Well Foundation Nearest lot line PERMIT ~ ~ DISTANCE TO: ~ I-~ ~m~ No. oflines / Lengthofeachlin~. Totallengtho~li~es, Trenchwid~ Distancebetweenlines Length Width Depth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption aFea ~ Well Building foundation Nearest lot line ~ DISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO. ~ Building faundation Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: OTHER I SOlE T[ST B[MA~KS I I _ I APPROV /~ DATE LEGAL -013 (Rev. 3/78) Russell Oyster 694-2774 O & E ENG,,4EERING & DEVELO~ ,¢IENT CO. Performed for: Name: i/: ',~ z'_ Mailing Address: Legal Description: ~ ~> 7~ :; "'/¢' Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 888-2280 SOIL LOG Tel. No. Earl Ellis 688-2280 Depth (feet) Soil Characteristics 0 1 6__ 7__ 9__ 10__ 11 12__ 13__ PLOT PLAN PERC. TEST 14__ 15__ 16__ Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No /"'~- If yes, what depth Drain Field Performed by: Date: 'rHF'C,c- i~; NO SET !4[D'FH FO? TF:E%CHE O & E ENG,NEERING & DEVELO~ ,VIENT CO. Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 Russell Oyster 694-2774 Performed for: Name: SOIL LOG Tel. No Mailing Address: Legal Description: /-~' Earl Ellis 688-2280 Depth (feet) 0 3__ 4__ 5__ 6__ 7__ 8__ 9__ 10__ 11 Soil Characteristics 12 13__ 14__ 15__ 16 Ground Water Encountered: Yes Proposed Installation: Seepage Pit Comments: No~ ~"/,,~ ' If yes, what depth Drain Field.__ PERC. TEST Performed by: RETURN TO: Dtvislon of Geological and 300t Porcupine Drive (Tel~ Anchorage, Alaska 99501 ~ystcal Surveys (DGGS) 277-66]5) WATER WELL RECORD Drilling Company Name STATE OF AI~SKA DEPARTMENT OF NATURAL RESOURCES U.S.G.S. Local No. Drilling Permit No. LOCATION OF WELL J Please complete either la, lb, or lc. M.U.L. la. ~orough Subdivision Lot I Block lb. Fraction Section No. Township Range Meridian 1c. Distance and Direction From Road Intersect;ohs 3. OWNER OF WELL: Address: S~reet Address and Area of Welt Location ,, 2. WELL LOG Feet BelOw 4. WELL DEPTH: (completed) Surface Elevation Date of Surface Completion Material Type Top J Bottom ft. I 6. USE: r~Domesti¢ ['-'~Public Supply [-']lndus:ry I r-1 irrigat~oo K-lRecharge ~co~i~, ~T~s~ ~ ~O~h~r: J 7. CASING: ~Threaded ~Welded in. to ft. Depth Weight lbs/Ft. [ i ~n. to ft. Depth - 8. FINISH OF WELL: l  Slot/Mesh Slze: Length: ~ Set be~en ft. and ft. ) -- Fit:Engs:  9. STATIC WATER LEVEL: ft. ~A~ve ~Below land surface Type of Measur~nt: 10. PUMPING LEVEL below land surface ft. after hrs. pumping g.p.m. ) ~ ft. after ~ hrs. pumping ~ g.p.m. 11. WELL H~D COMPLETION: ~ In Approved Pit ~Pitless Adapter ~ inches ~bove grade 12. GROUTING: Well Grouted: ~Yes Materl~l: ~Neat Ce~nt ~ Other: 13. PUMP: (if available} HP Length of Drop Pipe ~ ft. ca~city ~ g.p.n Type: ~Sub~rsible ~Reclprocating 14. REMARKS: 5. WATER WELL CONTRACTOR'S CERTIFICATION: Thls well was drilled under my jurisdlctlon and this reoort is true ~o the best of my knowledge and bellef: Registered Bus;ness Name Contract License Number Address: Signed: Date: Authorized Representative Form O2-~R Copy Distribution: WHITE - State DGGS, PINK - Driller, CANARY - Customer MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTIOt~ DiViSION OF ENVIRONMENTAL HEALTH CERTir,CATE OF ~i;:.:r E .~T O., FOR HEALTH AUTHORITY APPROVAL ., ~N-ol L .t. ;Li' F.h,D WATER FACILFFY 264-4720 A~pi~cat~on Date ~_~%~__::~:'. GEI'4ERAL INFORMATION TYPE OF RESIDENCE : ' 'd :.-,,-~'"'T .1, , WATER SUPPLY ~i.: . ~; '.: ~d, '~,;:-r; ...' ~., :_,~ [:'.,',ir t~ [tt{.~ - [.',. '- . ;:: ', .:~': '. , ' .'. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, F~LE SEARCH, DATA AND iNFORMATiON · .- ~ ~., ,o,¢, ~ L',3!ow, I \'erif7 that ray 'w~3t ~h,.~n. cd lms Hea~th ; s c¢:;-t f:ed by ~ sea: ~ffix~d herc'to and as of the vahdat~on date ~''~ ~'~ 5, ~, h or t/A ;c p~' L,.'a 5h ~:ws that thc ~L: r,.-s~te w&ter supply and,,'o~' wastewater d sposal s},ste m is safe, func~iona', and adequate ~ ,~,,~ ~.c~ n,_;~'; t~e: c~ :~eCr,3oms and ~;/~'~ of structure ~' ~: :' '~' herc;;n. I further vea:y tha~ based on the u'ffoi'm~:~t~on obtaineo t':'c~ the M;:,c~,aht/ of Anchorage ~es and from ;'r,y :'"~' ....... ' ' , ~od~a~,on and inspE~ct~orh U'~(e on-s:,te water supply and,,'or :,a~e,,~ater c:2;..o_.a~ ~),~tem ,s ~n compliance w~th ail t~unt~p~ and State ..... ,~.~ o-~ ,--~ ....,.. ,.~_,u~ o, ~., ~: k. eo, arid ;'egulaticns in effect on ~ ~-- - -f'eiephone CAU'Tq Or.4 . .- ..... :---.- ~ :-, ::' sc',¢qy :;[:,::n the '.r' ....... . CHEP .... " . ':~': . ir . .' ~ ; : 'L A WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: Well Classification Well Log Present ~,~N) Total Depth ~--,~-~-"- ' Cased to Static Water Level ~ -~ ' Casing Height Above Ground Electrical Wiring in Conduit~N) Separation Distances from Well: To Septic/I ',o',dlng Tank on Lot To Nearest Edge of Absorption Field on Lot \ ~"~ ~'~ To Nearest Public Sewer Line _ , Cleanout/Manhote Water Sample Collected by ~.~ ,¢,r If A, B, C, D.E.C. A~proved (Y/N) Date Completed ~"//(~ ! Yield ! Depth of Grouting Pump Set At Sanitary Seal on Casin~;~J~/N) Depression Around Wellhead. ,¥~1) Water Sample Test Results ' On Adjoining Lots · On Adjoining Lots To Nearest Public Sewer r~ /A __ To Nearest Sewer Service Line on Lot c224~(', t/'~ ~z ~_~(-, Date Comments B. SEPTIC/~TANK DATA Date Installed 'U~,/1:¢., I Standpipes~N) Depression over Tank (Y~ ~//~ · for Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) m'~//4.? Separation Distances from Septic/J~ Tank: Size / ~_:'z~C:? No. of Compartments Air-tight Cap.s~) Foundation Cleanout Date Last Pumped To Water-Supply Well ____/.~--z~ To Property Line ~/b ~'Y~ To Water Main/Service Line Course /,~ Temporary Holding Tank Permit (Y/N) /~/:~ To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(1~,,84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~/'~ Width of Field Square Feet of Absorption Area Depression over Field (Y/~). Results of Last Adequacy Test Separation Distance from Absorption Field: Type of System Design Length of Field "~ Depth of Field I ':Z- Gravel Bed Thickness '7 Standpipes Present. N) Date of Last Adequacy Test To Water-Supply Well To Building Foundation Lot ¢'J/,~ 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) j,~l "/~ m P Off" Level at A 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 checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~, ~ E' ~",~C,:N'-~:''~' Date Company ~: ............ ,,, ,~--,~,,,~ ~;.~ . Page 2 of 2 Receipt No. Date of Payment Amount: $ 72-026 (11,84) MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE Genera/ Information Application Date . //,~/~>cf / (a) Legal Desc~iption (include lot, blogk, subdivision, section, township, range) Location (address or directions) ./z , 6 Z~.':~ o Buyer ~ ; Other ~-~ (explain); tution ?-~ ; (d) Lending Institution ~ !2 ~ l 6'c.~u Telephone Address (e) Real Estate Co. & Agent Address Tel,ephone (f) ~-~a~iq the HAA to the following address: 2. Type of Residence Single-Family~ Number of Bedrooms Multi-Family Other (describe) 3. Water Su~i . .. Note: If community well system, must have written conf~rmation from the State Department of Environmental Conservation attesting to the legality and status. 4. pewage Disposal Onstte~ Public ~ Community ~ Holding Tank ~-~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th& legality and status. [Page 1 of 2] E__n~ineering 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 w~astewater 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 obtain~ from the M~anicipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all ~nicipal and State codes, ordinances, and regula- tions ~n effect on the date of this inspection. Name of Firm Address Date D_HEP Approval Approved for ~z~/"~Jbedrooms '~ Disapproved Approved telephone Date / ,? - ~/ '~-~/ Conditional Terms of Conditional Approval CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRO~NTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT- ATIONS 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 REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ,tNALYZE DATA BEFORE A CERTIFICATE I$ ISSUED. THE M[~ICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK. (DHEP SEAL) RR4Iej/D18 [Page 2 of 2] 7-19-84 ae WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 Legal Description: MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION OEO(; RECElYED.. z:Pe/ c, Well Classificat~ S F Well Log Present~) Total Depth 2 ~- ! Cased to Static Water Level ~ ' Casing Height Above Ground ~ ~/~' Electrical Wiring in Conduit ~Y~) Separation Distances from Well: ! TO Septic/~4~3--Tank on Lot /'~ ~- If A, B, or C, D.E.C. Approved(Y/N) Date Completed ~/~/ Yietd~r~. ~ 2 ~Z~'- Depth of Groutinq ~ ~t At ~ ~ Sanitary ~al on Casing ~pression ~ound ~l~ead ; ~ ~joining Lots /~ ; ~ Adjoining Lots/~ To ~est Public ~r To k%arest Edge of Absorption Field cn Lot/~b TO Nearest Public Sewer Line /J / # Cleanout/Manhole /3 / ~ To Nearest Sewer Service Line on Lot Water Sample Collected By ~ .~ ~%~ .Water Sample Test Comments SEPTIC/HOLDING TANK DATA Date Installed ~~/~ / Size //~Q~D C) No. of Compartments ~__ Standpipes !Y~/~ Air-tight Caps~ Foundation Cleanout (Y/N) Depression over Tank (~ Date Last ?umped /~/~/~ Pumping/Maintenance Contract on~/File (Y/~/~f- ; for Holding Ts nk High-Wate~ Alarm (Y~/J/~- Temporary Holding Tank Permit (Y Separation Distances from Septic/F~R~l{~3 Tank: To Water-Supply Well /450 To Property Line /D To Water Nm~n/Service Line Course To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Receipt ~ Date Paid Arno un t: ,. [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~//~ / Width of Field ' ~ ~ ~ ~ Type of System Design //~./~ Length of Field ~ / ~p~ of Field /2 ' Gravel ~d Thickness ~ ~' Square Feet of Absorption Area Stalndpipes Present (Y/N) Results of Last Adequacy Test ~'~,~ ~r; ~ ~,~c ~-o~/ __ Separation Distance from Absorption Field: To Water-Supply ~!1 /Z~O /~ To Property Line /fP To Building Foundation ~ ~ ~ To Existing or Abando~.~d System cn Lot /c~ ~ ~J ~ ; OD. Adjoining Lots ~ TO Water Mmi~n/Se. rvice Line c~0 ~ To Cutbapk(if present) TO Stream/Pond/Lake/ct Major Drainage Course /~; O ~_7 To Driveway, Parking Area, or Vehicle Storage Area ~ Conn~nts /{/ ~ ~'~ ~ D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes(Y/N) Dimensions MapJ%ole/Ac~ess (Y/N) "~f"/Level at __ VVe~'~/N) Pumping Cycles cl~ring Adequacy Test. ,~ee ts MOA Con~nents ** Check Permitted Bedroom Rating A(jainst H/~R Request I certify that I have checked, verified, or cc. nf©rn~d to all MOA HAA C~aidelines in effect on the date of this i~pection. Signed Company KBi/dL/s [Page 2 of 2] 2-15-84 .~ C~.'~ ~)~ '~"~"~. ,~:~L . RECEIVED , I~P~CTION APPOIN~M ENTS ~ ~,~:~ ~ c%~ (~ ' ~ C~ ~v~' - ~- -~ ~ ~ ~--' DATE ~ DATE [ / DATE INSPECTO~ , I J ~UNIClPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH ~ ENVIRONMENTAL PROTECTIO~ 825 L Street - Anchorage, Alaska 99501 MUNidrA_~ , CF DEP[. J ENVIRONMENTAL SANITATION DIVISION ENVIRONMENT:,L ~,~,cC,,ON Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER ~HONE MAILIN~ ADDfiES~ PROPERTY RESIDENT (If different frbm above) / PHONE 2. BUYER ~ / MAI LIN~DDRESS/ MAILING ~DRESS 4. ~EALTO~/AGENT I PHONE MA~UN~ ADD~eSS' ~ / STREET LOCATION 6. TYPE OF RESIDENCE ~ NUMBER OF~BEDROOMS [] One I---I Four ~' [] Two [] Five SINGLE FAMILY [] MULTIPLE FAMILY ,J~ . Three [] Six [] Other 7. WATER SUPPLY  I NDIVIDUAL* COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since dune 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM /E~] INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM []INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [~]Holding Tank Size:- /~)~ If Tank is homemade give dimensions: [] ONE [] TWO PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED NUMBER OF BEDROOMS PERMIT NUMBER [] THREE [] FIVE [] FOUR [] SiX DATE INSTALLED INSTALLER SOILS RATING TYPE OF TANK MANUFACTURER TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line [] OTHER Septic/Holding Tank IAbsorption Area ISewer Line INearest Lot Line 5. COMMENTS FOR -,C% BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED DATE 72-010 (Rev. 6/79)