HomeMy WebLinkAboutCHUGACH PARK ESTATES BLK 2 LT 8
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
MAILING ADDRESS
LEGAL DESCRIPTION /
LOCATION
DISTANCE TO: ]
I
Well
-1/o
Manufacturer ~
[Liq.,capacity in gallons
IDISTANCE TO' Iwell
I' I
Manufacturer
I We ·
I DISTANCE TO: I
No. of hnes ~ Length of each
Top of tile to finish grade
Length Width
/Y/
I Type of crib Crib diameter
I DISTANCE TO:
]Class .---. Depth
DISTANCE TOT' ~ut'ldin~ ~oundation
PHONE
,j~N EW
[] UPGRADE
NO. OF BEDROOMS
IAbsorptionarea,lL/Z,~ Dwelling lt..~'"7 I PERMITNO. --
Material.~/~__~ ~ ~- No. of compartments
Inside~length Width - Liquid depth ~
PERMIT NO.
Dwelling
Foundation:.~ ~' '7
Total length of li~nes
3~,- +
Material beneath tile
Material
Nearest lot line, c, ~) !
inches
Depth
Crib depth
Liquid capacity in gallons
PERMIT NO.
Distance between
Total effective absorptio.~,area
PERMIT NO.
Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line PERMIT NO.
Sewer line
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
DATE
LEGAL
_MUNICIPALITY OF ANCHORAGE.-
' Department ~ Health and Environmental ~rotection
- 825 ~ Street, Anchorage, AK. ~9501
264-4720
~---,['--LJ'-J~, * * * HANDWRITTEN PERMIT * * *
Permit
W~ON-SITE SEWER PERMIT
Address:
Location: , . Phone Number:
Legal Description: ~~ ~~Y~~ Lot Size:
Type of Soil\~sorption System Is:
Trench: ~. Drainfield: ._ Seepage Bed: Holding Tank:
Maximum N~ntber of Bedrooms: ~._ Soil Rating(sq.ft/br) /~
The Required Size of the Soil Absorption System Is:
DEPTH 0
WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall Pipe and
the bottom of the excavation(in feet).
· * REQUIRED SEPTICCI:DD-L-D--I-NG-) TANK SIZE = /dO0 GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this departmeni
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 feel
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
· * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I wi~nstall the system in
(3) I u~der~t~d that the on-site
th~ re--ce/~ r~modeled to
S igne~
~~-ica~
accordance with codes.
sewer system may require enlargement if
include more t~~ed~~
Issued by:
Date:
SWP/024 (1/81)
IC:I;-~LIT~' ~)F R[-~C:P-~E:RGE
DEPRRTMENT '~. HERLTH RND ENVIRONMENTRL ..~OTECTION
825 ~L~ STREET., 8NCHORRGE., RK. 99501
264-4720
~.~ELL PER~I IT
PERMIT NO. ( 810098 )
RPPLICRNT LEE ROBBINS
LOCRTION PETERS CREEK
LEGBL
SR BOX ?149 CHUGIRK ~ ~ ~] 688-]:010
L8 B2 CHUGRCH PRRK ESTRTES LOT SIZE _~SOURRE FEET
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SEWRGE DISPOSRL SYSTEM IS
t00 FEET FOR 8 PRIVRTE WELL OR 150 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET 8ND
TO 8 COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MRY RPPLY. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
8VRILRBLE TO INSURE PROPER INSTRLLRTION.
PEE:r4IT E>~F'IRES [)EC:E~IBER 31. I 981
I CERTIFY THRT
1: I RM FRMILIRR WITH THE RE&-~.UIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
2: I WILL INSTRLL THE SYSTEM IN R~RDRNCE WITH THE CODES.
8F'PL I CRNT LEE RCBE:I~
'v'4. 0
January 4, 1982
Lee Robbins
SR Box 7149
Chugiak, AK
99567
Permit ~ 810098
Subject: L8 B2 CHUGACH PARK ESTATES
A permit issued by this department for a well and/or sewer
system has expired as of December 31, 1981.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log should be sent to
this department to document the installation date.
If an engineer inspected the installation of the on-site
sewer system, please have them send us the as-builts for our
files.
If there are any further questions, please call this office
at 264-4720.
Sincerely,
Sewer and Water Program
Enclosure: Copy of Permit
by
DOC Co. {~ba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 668-2759
OWNER OF LAND
ADDRESS ~ ~f
LEGAL DESCRIPTION ~' ~'~
PERMIT NUMBER
~O/~/~t ~.d -~ DEPTH OF WELL
~,"'o ~ '7 / 4/~: ~ ~d ~/~' STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
Ended ~/~/ GA~. PER HR
OF CASINO
KIND OF FORMATION:
From {~ Ft. to I Ft.
From ~ Ft. to ~ Ft.
From ~ Ft. to Iq Ft.
From I ~ Ft. to--Ft.
From~ Ft. to Ft.
From o~_~' Ft. to~Ft.
From. ~o), Ft. to "'] t~' Ft.
From '7~'
From
From ~ 7
From [ r0 -~
From
From
_ Ft. to ~'7 Ft.
Ft. to Ft.
Ft. to ti3 ~} Ft.
_ Ft. to /~ Ft. 7'16,,~7'
,Ft. to Ft. ~'/-.. ~I'F
~ oa.g' Ft. to ! 4~) Ft. d_/. ~ }*
From / ~'0 Ft. toi & ! Ft.
From [/~ I Ft. to ~._/_~__~Ft.
From Ft. to Ft.
From~Ft. to I~'~ Ft.
From i~¢~ Ft. to [ VO Ft.
From Ft. to Ft.
From__Ft. to.___Ft
From__Ft. to_ _Ft__
From .... Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft.
From__Ft. to Ft
From Ft. to__Ft.
From Ft. to Ft.
From . Ft. to Ft
From Ft. to Ft.
From__Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
MISCL. INFORMATION:
DRILLER'S NAME
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
DATE PERFORMED:
LEGAL DESCRIPTION:
2
3
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
SLOPE
WAS GROUND WATER
ENCOUNTERED?
SITE PLAN
P
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
! ~-'~:':Reading Date Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN . 'FT_ .,~/~ ~ FT
72-008 (6/79)
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
CERTIFICATE OF HEAl'TH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~'"~\ - L\ c~.~ _ {,- '~
GENERAL INFORMATION
Complete legal description
Lot 8; Block 2; Chugach Park Estates
Location (site address or directions)
19320 Chugach Park
Chugiak, AK 99567
Property owner
Mailing address
Lending agency
Mailing address
Lori H~de.n Day phone
P.O. Box 671022 Chuqiak~ AK 99567
261-3681
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual well XX×
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:
X^X
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. 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
Address
Engineer's signature
S & S ENGINEERING
Eagle River, Alaska 99577
Phone
Date 3 //q/~,
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 #21
Municipality of Anchorage ~
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825"L" Street, Room 502 · Anchorage, Alaska 99501· (907) 343-4744
MUNICIPAl. Ii I *or Al
~NVIRONMt~NTAL ~ERVIC~:$ DtYi~tON
Health Authority Approval Checklist
Legal Dcscriptiou:
A. WELL DATA
Well type
Log present {~q)
Total depth
Sanitary. seal
Date of test
Static water level
Well production
[~v-- 7_. ~t:OM.t~rt.~~ }P&4--$-Parcel I.D.:
FROM WELL LOG
If A. B. or C, attach ADEC letter. ADEC water system number
Date completed t_[ _ ~, ~ ~ Jr
Cased to I Del J Casing height (above ground)
Wires properly protected Oq)
AT INSPECTION
15'2_.'
4,O g.p.m. Z,q
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. ~OLDING TANK DATA
Nitrate O, I o Other bacteria /__)
Collected by:
S & S ENGINEERING
i7~4 Eagie River Loop ~[oad No. 204
Eagle River, Alaska 99577
Date installed 4"--~ 3 Tank size /* 0 o Number of Compartments 2_ Cleanouts (.~ZN) ~
Foundation cleanout {~lqq) ~/ Depression (YFI~ ~J High water alarm (Y/N) ~/¢
Date of Pumping Z-14 ~q {, Pumper -~7.~~ /~Otv//'t,Ottt
ABSORPTION FIELD DATA
Date installed e~9 Soil rating (g.p.d./fi2 or fl2/bdrm) 12-5'n~/~g.- System type '7'~/Lff~ 4-/'4
Length ~ & ' Width ,,2,6'- ~ Gravel thickness below pipe 6'- ~ Total depth ~ t
Effective absorption area ~l O fz:,et~, Monitoring Tube presentOq) 5t Depression over field (Y~j)
Date of adequacy test "~' /'ff'~'f 6. Results ~fFail) ~,a~'5 For ~ bedrooms
Fluid depth in absorption field before test (in.); t9 Immediately aftert/(7o gal. water added (m): t/~/
Fluid depth ~ (ins.) Minutes later: ~ Absorption rate = ~,3~ 4- g.p.d.
Peroxide treatment (past 12 months) (Y~]~ ~/~d~. I~tJ~l~)lfyes, give date
D. LIFI' STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at*
High water alarm level at* ~
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
~holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
· On adjacent lots
[C>e~ t4r ' On adjacent lots
~/~ Public sewer manhole/cleanout
,Z.%~ t $~ Lift station [ C> e> ~' 4--
SEPARATION DISTANCES FROM~~OLDING TANK ON LOT TO:
Building foundation I O ~ Jr Property line I o I * Absorption field
Water main/service line /o ~ ~ Surface water/drainage /00 t ~ Wells on adjacent lots
/oo tO-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation I ID x Jr Water main/service line ~ c~ ~ '~
Surface water ~ o O ~ Driveway, parking/vehicle storage area '2~ I Jr
Curtain drain ~ I~ Wells on adjacent lots l'~0 ktr Property line [ 15
F. ENGINEER'S CERTIFICATION
I certify that I have determ/ned thrufield inspections and review of Municipal record~.~&~b'b~~e
in conformance witO 5~,~ ~ guidel~s in effect on this date.
Signature ¢~ d. :
Engineer's Name /~ ~ z5 ~,t ~ ~ . k o ~,q ~
...................................................................................................... >:~.k~
HAA Fee $ ~eOO ~ ~
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
Rev. 8/95 OSS: haa.wk.doc
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
1. GENERAL INFORMATION
Complete legal description
Lot 8; Block 2: Chugach Park Estates Subdivision
Location (site address or directions) Corner of Chugach Road and Platzek
Prope~y owner ~ori Hyden Day phone 688-4959
Mailing address P.O. Box 671022, Chugiak, Alaska 99567
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
3
NOTE:
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ~'~Y
Holding tank
Community on-site
Public sewer
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 ft21
5. 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.
S & S ENGINEERING
Name of Firm 17034 Ea§ltl ~i~J' kldep Read Ne... ~ Phone
Eagle Ri~ar~ AlaSka ~E]~F~'~
Address
Engineer's signature
DHHS SIGNATURE
Approved for 5
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 D HHS 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 ~Y21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ ~ ~¢..~Z..- /--t-~.Sf.~--~.-~ Parcel I.D.
A. WELL DATA
Well type
Log present ~J~N)
Totaldepth
Sanitary seal (~(N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to \ ~
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
ADEC water system number
~ - L.~ -~t Driller
Casing height
Wires properly protected ~.~N)
AT INSPECTION
g.p.m.
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~:;> c~ '"'t, o o .~ --0-,/ Nitrate
Date of sample: ~'
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~'" ~'~
Cleanouts ~YN) ',~
High water alarm (Y~
Date of pumping
Other bacteria t~ ~ ~ ¢---
S & S ENGINI;;L:IaI~ ~!~_.
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Tank size ~, c>c, c~ Compartments
Foundation cleanout (~N) ~ Depression (Y~:)
~ Alarm tested (Y/N) ~
.-'7..- --~ '7~ Pumper ;;:~_~-_ ~E.--~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot \ o~ ~ On adjacent lots \~O
To property line ~c>t'¥'' Absorption field
Surface water/drainage \ L~
Foundation
Water main/service line
72-026 (Rev. 7/91)Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent (Y/N) "Pump on" level at ' ~mp off" level at
High water alarm level J ~ Cycles tested
Meets MOA el~__
SEPARA~.~.J~ISTANCE FROM LIFT STATION TO:
w'ell on lot On adjacent lots · Surface water
D. ABSORPTION FIELD DATA
Date installed ~'~--
Length '~'~ ~'~ Width
Total absorption area
Depression over field (Y~
Result~fail)
Peroxide treatment (past 12 months) (y~..~l
Soil rating \'Z.-~'
Gravel thickness
Cleanouts presentd[~YN)
Date of adequacy test
for
~=~ ~ ~ If yes, give date
System type
Total depth
bed rooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~ c:~ ~'" On adjacent lots \ o o ~'' Property line
To building foundation ~..o ~" To existing or abandoned system on lot
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
HAA Fee $ //70 ," ~ Waiver Fee:,
Date of Payment / ~ --?/-- ~7 ~ Date of Payment
Receipt Number Z_~/Z-~:~/'[') (~--//_?/'~) Receipt Number
72-026 (Rev. 3/91) Back MOA 21
APPLIC '-NT FILLS OUT UPPER HA[-'ONLY
Property Owner j~zf ,,d/i~,':-: 7'~/.~ j..~i -? ./i ' /~.~c: I~J/¥ z./22> Phone
Mailing ,~,ddress / ~. ~.~, ~
Address ~:'0 .
Lending Institution / ~ /~ :, ~ /L,'~ ~ .... Y ' ' ' Phone
Address ::,~ 2~,/' (;~ ~j~ ~L~-/-~ ~~f~ ~ zip Code
Phone
Realty Co. & A~nt
Address Zip Code
Legal Descript~n ~
Street Locati~
Type of Resi~nce
~Single Family
~ Multiple Family No. of Bedroo~
~ Other
Water Supply
~divid~l A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal
~n~,v~u.~ ~e~r ~n~v~ua~
D Public Utility When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
( J~ ) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
Soils Rating Date Sewer Installed Well To Absorption Area / O--~-~-" Well Log Received
/ .% ~'- 1:;~' ~-'-' :~ O ' <~ ,.~ Well to Tank //' ~) '/- Septic Tank Size
72-023 (3182) ~'