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HomeMy WebLinkAboutEKLUND LT A3 OF TR Ai~ 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 ~NSPECTION REPOFIT LEGAL DESCRI~ION ~ ]Well - [Absorption~ 'Dwelling ~. PERMITNO.~ ~ Manufacturer ~ p Materi~ No. ofcon~t~ents Liq.~agac}t~n gallons Inside Jengt~ W~th Liquid dept~ /~ ~ IF HOMEMADE: ...... ~ ~ DISTANCE TO: Wall Dwet ng PERMITNO, 0 ~ ~ Manufacturer ~ Well Foundation -~earest lot line ~ ~ P~RMIT NO, --~'~.. N°' °f line's,,,__ Length °f ease Total length :i~:'~. Trench width ~. ,~ rochesDistar'c~,r:en lines ~ ~ Top of tile to finish grade Material beneath tile Total eff~tive ab~r~tion area ken,th ~dth Depth ~E~MIT ~0. ~ ~ Type of crib mm DISUSE' TO: Well ~ Building fSundation Nearest lot line ~ Clas~. /~ ¢- Depth Driller Distance to lot line PERMIT NO. Building foundation L ,i.. s pt,c Abso, tio OTHER PIPE MATER ALS REMARKS __ _ APPROVED .,~ DATE LEGAL 72-013 O 8 E GEOTP_CHNICAL ~ DEVELOrMENT CO. Russell Oyster 694-277,4 Soils ~ Foundation." Perforra~d fora Box 90, Davis St., Eagle Riveh Alaska 99577 694-2774 or 688-2280 SOiL LOG Mailing Address: /~,, Z>, Z~¢x Earl Ellis 6~-22~ Land Development :-'~ 3'7 - ~//,-','- 0 3 5~ ].3 Ground Water Encountered: Yes No // If yes, wh~t deptiL_~_ Proposed ~nstallation: Seepage Pit ..... D~ain ~)d 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 APPL! **NY F LL$ OUT UPPER F ONLY Buyer / L:;,~ ~ Zip Code Address Lending Institution (. ~,. /~, ,' ~ '~ ~ ¢' ,: ~' Zip Address Phone Realty Co. & Agent Address Legal Description ) /;,~ ;i{ /~ 4;; Street Locati~ Type of Residence ~ Single Family ~ Multiple Family No. of Bedrooms ~ Other Water Supply '*~' Individual ~E~' Community F~ Public Utility Sewer Disposal .~ Individual '{-~ Public Utility [] Holding Tank ¢ TTACH WELL LOG. A well log is required for all wells drilled since June 1975. or wells drilled prior to that date, give well depth (attach log if available). Year Individual installed: ____ When Connected to Public Utility: NOTE: TNE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INll'IATED. Time Time Time Time Date Date Date Date Insp~tor Insp~tor Insp~tor Field Notes: ~,PPROVED BEDROOMSk ~'~5 ( ) DISAPPROVED ( ) CONDITIONAL Al ~L Inspector DATE Soils Rating Date Sewer Installed Well To Absorption Area Well to Tank 72-023 (3182) MUNICIPALITY OF ANCHORAGE MEMORANDUM DATE: October 12, 1992 TO: Accounting & Budget, DHHS FROM: On-site Services, ESD, DHHS SUBJECT: Request for Refund - Account ~2570-9426 The property called this morning and has made a request to pull the Health Authority Approval application. He informed me it was not required for his financing. Since this office has not reviewed the documents a refund possible. Please make the necessary arrangements to process the refund. Thank you. James M. Childers PO Box 140605 Anchorage, Alaska 99514 Amount $170.00 Receipt %24131/4294 Account %2570-9426 Tract A3 of Tract A Eklund Subdivision HA920665, PID %050-531-25 Laura J. Montgomery On-site Services cc: File Municipality of Anchorage DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Services Division Telephone: 343-4744 ON-SITE SERVICES FEE DOCUMENTATION OS- 2413i Date Paid: /~--~/-- N~.~e of Payer: (Name~or~ ~C,~he~ck) ,ing ^dd ess:/Off of che.c2 Legal Descriptionis): '~-~-~ Permit Number: Receipt#: .Check#: Type of Payment: (Indicate Amount Paid) '-tealth Authority: /-'~ '~ Excavator Permi't: Sewer & Well Permit: Well Permit: Sewer Permit: Copy Request: 72-034 (Rev. 10/87) Engineer Permit: Pumper Permit: Well Driller Permit: Tank Manufacturer: (Waste Treatment) DISTRIBUTION: WAIVERS: Lot Line: Well to Tank: Well to Field Field to Surface Water Tank to Surface Water WHITE--MASTER FILE CANARY--PROGRAM FILE Parcel I.D. # 1. 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 GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING NAA# Location (site address or directions) Property owner ~ Mailing address ~C, Lending agency C. ~ -T'r' Mailing address Agent ,¢~2 ,~ Ad dress ,5',~,,~ : Day phone Day phone Z-7-~ -- 0'7,%'/ Day phone z??-- O7~"/' Unless otherwise requested, HA~ ¢ill be hel, d for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPL~,? ndividual Well ' %."/, Commun'it:~ Well Public;~ater ~' NOTE: TYPE OF WA~EWATER DISPOSAL: /i~ Individual on-site /Y Holding tank Community on-site If community well system, provide written confirmation from State ADEC attest- ing to (~e legality and status of system. ~ Public sewer NOTE: 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 5. S'~FATEMENT 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. NameofFirm dfT~P__..~ ~141LrJtsR£~ ?l¢.lV,4'rE E:,,,i~u4r=eR Phone Address 'F'~2 ~c,~, /~,¢,&,¢,~- /~ N(~,. Aid.. Engineer's signature ~ ;;~2. ~¢'~ Date · '",~r..' -- '..~4..~, ~.~.~ ....... ~.~..., ~...~ [isappr°ved' / [ J I  rov~ bedrooms, with following stipulations: Additional Comm~ The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approw~l Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DH HS 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 #21 '- ~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: "~-:r~Ac'r' A-:~, ~K, LJJ~4 P ~q~. Parcel I.D. / If A, B, or C, attach ADEC letter. ADEC watercystem number kogpresent(Y/N) '1/ Date completed 5"/1~/'7~,'~i?~' Driller Totaldepth ?--?-'r3 ~'T'. Casedto Z¢~ ~¢~, ?' Casing height Sanitary seal (Y/N) '~ Wires proper y protected (Y/N) FROM WELL LOG AT INSPECTION Date of test 5 [ lr= / ~7~ Static water level 100 ¢7 ~ P, oL~ .'75 g!~.m. ~ ¢% ¢ g.p.m. Well flow ~o4-- Pump level ~ ~' SEPARATION DISTANCES FROM WELL TO:' Septic/holding tank on lot l C;'~, F:~' ; On adjacent lots q-- Absorption field on lot ; t ~ ¢;t' ; On adjacent lots --b Public sewer main M / ~v , Public sewer manhole/cleanout " Petroleum tank ~/~ Sewer service line N /A WATER SAMPLE RESULTS: Coliform ~ Nitrate <; 3~1~ 1.- Other bacteria O Date of sample: °1. t~q` Iq`?,` Collected by: g~¢¢' B. SEPTIC/HOLDING TANK DATA Date installed ~ j ¢[ ~ ¥ Cleanouts (Y/N) High water alarm (~/N) ? Date of pumping' q. l ?-q [ q-?-- Pumper SEPARATIO~DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I O/~ P'C Onadjacentlots I IP~, F~'I' To property line + 2..~ F'f' Absorption field ,G PT Surface water/drainage I '~ 0 A. WELL DATA Well type Jn~ ~¥ i<~d ~. L Tank size. ~' ~0~ ~¢,on Compartments Foundation cleanout (Y/N) R, Depression (Y/N) Alarm tested (Y/N) Foundation I l Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Dale installed / __ __./~nufacturer Size in gal.o.~./ /anhole/Access (Y/.f~r Ver,, (Y/I~/_ . "Pump on" leve~ .... ".F~'rn p o,~e~el at ABfIORPTION FIELD DATA Date installed ~/q- I Total absorption area ~_0 Depression over field (Y/N) ~ Results (pass/fail) 1~ A-~' ~> Peroxide treatment (past 12 months) (Y/N) SEPARA ('ION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot I 16 ¢1' .On a6~iacent lots Soil rating 100 Gravel thickness Cleanouts present (Y/N) Date of adequacy test for __ System type '~y-sv~ _ Total depth Y ~ I~/~ _ If yes, give date To building foundation SuH:ace water ~'~ ~ Curtain drain. ~/A E, EN~.~INEI:'JR S CERTIFICATION Property line_~(2 t~1-' I?_-G ~1. /' To existing or abandoned system on lot -C~ibank--~© ~I¢+ Water main/service line. Driveway, parking/vehicle storage area. bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines this inspection. Engineer's Name Date HAA Fee $ . ~7~ Date of Payment Receipt Number /2-020 (Rev, 3/91) Back MOA 21 in effe~¢'~,~ of this ir ~.~.~'.~..~ ~ ~t~'.. . Waiver Fee: $ Date of Payment Receipt Number NORTHERN TESTING LABORATO 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 2505 FAIRBANKS STREET ANCHORAGE. ALASKA 99503 RIES, NC. (907) 456-3116 · FAX 456-3125 (907) 277-8378 · FAX 274-9645 Jim childers P.O. Box 140605 Anchorage AK 99514 Attn: - Report Date: 10/02/92 Date Arrived: 09/29/92 Date Sampled: 09/29/92 Time Sampled: 0730 Collected By: JC Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: A120722 Kitchen Water MDL = Method Detection Limit Flag Definitions B = Below Regulatory Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Method Parameter Units Result Flag MDL Analyzed EPA 353.3 Nitrate-N mg/1 <MDL 0.1 10/01/92 ~y ..~Su~nt a 1 Microbiology Supervisor