HomeMy WebLinkAboutCOTTONWOOD HEIGHTS BLK 1 LT 16 ~UNICIPALITY OF ANCHORAGE
Hea and Environmental Prote~ )n
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
FROM .WELL jOO+ MANUFACTURER _ _ MATERIAL --%__ COMPARTMENTS _
INSI[}E LENGTH
INSIDE WIDTH
LIQUID DEPTH
LIQUID CAPACITYJO(~O GALLONS.
TILE DRAIN FIELD.'~-~-'~'~
SEEPAGE PIT:
Log Crib. Rings
BUILDING FOUNDATION__
DIAMETER __ OR WIDTH _ ., LENGTFt .... DEPTH
Crib Size: DIAMETER .... DEPTH ...... DISTANCE FROM: WELL
TOTAL EFFECTIVE
, NEAREST LOT LINE_ ABSORPTION AREA (WALL AREA)
SQ. FT.
Well ' I/
Class: %--~ · Depth: · I/
Well Distance To: Lot Line o~
Bldg: ~.~ Sewer. Line: , ~ ~
Pipe Ma~rials:~klk% ~
~ of Bedrooms:
Installer:
Remarks: ~%
~ U
L [.:.': I:]i I:::11 ....
i"'tF:I::-::'J'H ..IH l'.,ll...ll','ll!ii:l.:.'i:l.:it OF:' EJE:I:)FtCIOH:!ii; .... 2:':
'T'Hli!i: I....I!!i:I'.jE~ll"FI [::,.T. I"tEi"JS :[ O1",1 :[ S THE.:.'.' I....EI'.JE:J"r'H ,:: :[ N I::'[.ZET ::, OF:' 'THEE "I"F:.:E:NCH [::ti:;..'. I:::,I:~'.F:I :[ I',tF' :1: I.'.CL..I:::,.
'T'HE DE.:.:I:::'TH Ot..':' FI TF.:Ii.:::I'.,ICH C.}l-';i: F']:T ]::!.:.'; 'T'HE E:, :[ STFII'.,ICEi: E~E:'t"HEE:I'.,I TH[.:.': :.~i;I...ll:;i:l::'l:::l(.".:Ei: i::.'11::' 'I"HF.:i:
(:~iF.'.Ot...it'.,l[) I::11'.,11) THE [.:JCITTC. H','I 01::' 'T'HE [:J:',.'.~:CFI'v'F:IT]:[::ff.,I ,:: ]:1'.,I FEET).
THEt:;::E': :IS IqO :.:."-.;Ei:"l" I.,.1:[t::.',"1"1.-I I::'O1:;.: 'I"F~:E:t'.,IC':HE:!.:.';.
'T'I..-IE GF::F:t'v'E:L DEPTH .T.:i!i; THE:.': I','1:1:1'.,1:[I','11...11','1 E:,EF'TH OF' GF..:FI',,,'EL E~E'T'HEEI'.,I 7'l..-IEi: OI...rT'F'F:iL..L.. I:::' :[ F:'E
FiI'.,tE:, "['FIE: Ei[O"t"'!"OH OF::' THE E:.'.~:C:I:::t',,,'f:::I'T' ]: O1'.,I ,:.' ]: 1'-,I F'E:ET .':,.
]: C I.'C I:;;:'T' :1: I:::'":; '1" H F:I'T'
::L: :[ F:IH F:'FIH:t:L.:[F:I~'. I.,.t:I:'1"1'-I THlii!: t~i:E~:(i:!U]:I:~::E-:HE:NTL:i; F:'OF? ON'"":!.:.';:['T'I~!: :!:.;[.:.':H[ii:Fi::.'.:.; FIND !.,.IELL.:.:.'i;
F'OF;;:TH EP'r' THE: HUI",t :[ C :[ F'FIL ]: 'T"*r' l.":ll::' F:tt",I(.".:HO~:FIGE.
;;~:: ]: I.'.1 :[ t....t .... :1: NSTFtl....I .... THE S"r'STI'::.:H :[ N FtCCOI:~:E:'FtI',IC:E H :[ 'T'H 'T'HtF: CODES.
2!:: ]: LINE:'EF;::'.E;TF~I'qI:.':, THI::IT THE: Ot",I'"":i.:.';]:TE :iii; E l.,.I E: Fi: '.:.~:"r".'.-'.';"l"l.::~t"'l HFI'T' F.:E(i:!I...I:[i:;i:E: E:I',!LF~F?.GEi:Hliii:I",IT ]:F:: 'T'HE
F'-"'.tiES :1: t:::'EI',tCE: :[ :i'..:;, I:;i:E:HO[::,EI...li.:.':E:, 'T'O ]: I",tCI....LII:::,E I"IOI;:'.E THFIN .?~: EH.:.Et]:'I:;.':OOH'.!.:.;.
................................................................
I'RF:'F'I.... ]: CI'RI'-,IT H ]: I....L :[ F:II'"I F:'I....I..Jt'.,It-:::
OE~E
GEOT~CHNICAL Et DEVELC'°MENT
Box 90, Davis St,, Eagle River, Alaska 99§77
6~4-2774 or 688-2280
Russell Oyster
694-2774
Soils Et Foundations
Performed for:
Lega'l
,SO)~. LOG,
Name: ,P~//-/-///~ ,,~:>, /¢~/./N~ ,Tel.
~tllng Address: ~/- ~2 ~ ~~
Depth (feet)
$Qll Characteristics
CO.
Earl Ellis
688-2280
Land Development
No. 'Z~ e- ~/~'~
o
6
10 ....
11
12_
Ground Water Encountered: Yes
No /~ If yes, what depth
Proposed Installation: Seepage Pit Drain Fle~d,,,
Comments: ...
DRILLING I.OG
WILLIAM D. PLUNK DOM.
Well Owner Use of Well
Location (address of: Township, Range, Section, if known; or distance main roars
LOT 16 BLK 1 Cottonwood Heights
Size of casing 611 Depth of Hole 127.5 feet Cased to 128.61 feet
Static water level 1 1 R ft. (a;'; (below) land surface. Finish of well (check one) open end (xx ) ;
Screen ( ) ; Perforated
Describe screen or perforation_ N/A
Well pumping test at 5 gallons per 0 (minute) for 1 hours with 100% XR.
of drawdown from static level
Date of completion_
WELL LOG
Depth in feet from
ground surface
0
110
TO
110
117
TO
117
TO
118
118
TO
118.75
118,
125
125
125
TO
127.5
TO
TO
TO
TO
TO
TO
TO
TO
TO
tions penetrated, size of material, color and hardness
1
511ty sand anis gravel fractured rock fragments
1 —CUSTOMER
/Vi-W I.; KI LLI IN%.~,
Well Owner
Location (address of:
}]lock 1
DRILLING LOG
Use of Well
Township, Range, Section, if known; or distance main road
ilot i6 Cottonwood H ..... ,~'' '
Size of casing
Static water level
Street{ ( ); Perforated ( ).
Describe screen or perforation N/A
'12
Well pumping test at gallons per
of drawdown from static level.
.Depth of Hole 110 feet Cased to 110 feet
9 0 ft. (~) (below) land surface. Finish of well (check one)
(minute) for 1 hours
with
open end ( '~ );
Date of completion 6 / 2 / 7 7
Depth in feet from
ground surface
TO
,TO
TO
TO
.TO
TO
TO
.TO
· ' ' WELL LOG.
Gi,v.e,.details of formations penetrated, size of material, color and hardness
Organics t~
~ rav~ i
(wet)
Loose'-pea gravel
Sandy gravel
TO
.TO.
TO.
TO.
TO
,TO
60
lob
Sand
Loose gravel, sandy ~
San, dy ~f~a~e_~,, wet
, .TO
2 -- STATE
Ff:[i'.,t):~'"ti..,ll"l [>iSTF:INE:E BE:.]"!.,.iEEN F:! HEL. i .... F~N[:, I::~Bi'¢ (31'-,I.-,';5):TE :E;Et,.iFIGt.:.!:
:j..t~i)E~ F'EE'T' FOR F:! PRiVFiTE WELt .... C. IR 2Ell:3 t::'EET FOR F1 F'UE&,tC MEL. t
t4E~]...i .... LOG:iii; I:II;i'.E F,..:E(..]U:!:!'.;i:EI.) I::ltql} t-,'itj'.!i~'Ff' E',E RE]"UF. fi'-,IEi.} TC! THE
OF THE MIFJ_i..~ COi"!F'LET ;i: O!",i~
':T.-;F"EC ]: F :t: CI::!T ! Ot'-,tL'-'.:; FIN[) E:OI'.,ISTF.".UC:T ! ON [:: !. FIGRF~HS F1F.'.E F!',,,'FI ! L.. RBi....E TO
:i; N:5 T P,I,..L,. F! T ): 0!'.,i.
I. CERT :[ F".¢ ]"HFIT
::L: :[ F:ti'i F:' I:::!. H :[ L. tF:IF4'. N I'T'H '/'HE I:;i'.E(;:!U:[f~'.[.:.:MENT".Z, F'(]I:~: [)l'-,l-::~;.~Ti!ii: '.:.::.';Ekit!F_R:!!i; F!t'.,I[)
t::.'Eit:;i:TH 8'.,.' 'T'HE t'"it. Ji'4 :[ C': Z PFtL t: 'l""r' (IF' F~NC:HOI:;:F:IEili!::.
2: .[ i.,.t ].: L..L :i: N?FF:IL..L 'Ft...tE :5'¢?TEI'i ]: N F¢.':.':C:[]~:[.':,RI'..-iI.'-::E t4 ]: 'TH THE
flf:::'F:'L. :1: (:::F:!NT t4:1: Lt,.. ]: I::~1"i t}- PLUNK
MUNICIPALITY oF ANCHORAGE :;'
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section --
P.O. Box 196650 Anchorage, Alaska 99519-6650
" ......... '" ....... "" ' ..... - CERTIFICATE OF H~LTH AU~HORI~
. ~:, - APPROVAL FOR A SINGLE FAMILY DWELLING
:~-:~. ,-. - '...~; :?C~ .~ .:
owner?;' William & Christa' P D~'~h0ne!:,-::-,~ 696-2243-:~.;:' ';;";L-,-:--:~.'~
address .... 20332 I~Uqhlin street ;:.C~fi~iak'~;~:-/~-%::99567]::: ;:;--'i:F'::...''' ' '.~?;
addr~;'S':; 16635 Cente~ieid'~ive';C ~gle'" Ri%6;~]~":'~%~":9¢~7~?~::.' ' ' ='' ;:'"
..... ~ Cmme/R~-,of ~qle ~v~ ..... .Day phone.`.: 694-4200
.., ... ~........ '../...~: ':. ~ . ~-, .~
-:~'~ Unless othe~ise requested, H~ will be held for pickup. ' '
2. _. NUMBER OF BEDROOMS: 3 s
' ' ' -x~,~' · '
..... _ .......~' Individual w~ll x
....... : ~ommuni~ w~ll ..
~OT~: If commum~ ~ll ,~m, ~row~ ~r~.n confi~at~on from Stat, AO~
.... · . ~ .......... _~5.. .. ~, ,,.
...... -,,,-~ ..... ' ".~.-?' Individual on-site---..-,-. ,~:.-. - ............... ~.?:;-,~;~.::;:::?~. ,i-~,-..~ - ,- , .:
................. ~ ¢ h''-~
Holdin_g tank ....... ~ ...... ~:,'~ ~,-;',. .~- if,, , -
on-site
uommum~y . ,~:;- ._ :_. .~, .
Public
sewer
NOTE:If communi~ wastewater system, proWde wri~e~ c~nfi~mation from State ADEC
a~esting to f~e legali~ and s~atus of
~(R~.I~I) Front MOA~I
STATEMENT OF INSPECTION BY ENGINEER
As certified b~'-'~ny'seal affi~d hereto and as of the Validation date shown below, i Verify that my
investigation of this Health Authority Approval application shows that tl~e 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_gation 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 c~f this inspection. .
Name of Firm :Eag:].e P~.ve~: :Eng±eee~'.i.ncj Se~-,~.ces ' Phone" 694-5:L~)5 .... ' ';' '-
Engineer'ssionature '~ ~'F-~' ~ Date'*' O5//S~/
,.'.~ . :.~. . '., ~..:,
DHHS. SIGNATURE ~
~ . . ..' ..... !'.~ ;: ......... ,:. - .-~ .... :: '~'.~::, .::,:.., :. ~.. · ._: ....
Conditional approval for -~ ""-~ ' ~rooms, with the 'follo~ng stipulations:
Additional Comments
The I~i~Jnic'ipality of/~r~cl~orege Department of Health and Human Services' (DHHS)issues Health Authority
~"~'~Approval~.~ertifi~e~'~ed only upon the mpr~entations given in paragraph .5 above by an independent
;3r~)fessional en~i~r registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and th~lend~ ~nstitufi-ons ~n order to ~t~s~y certain f~deml and state requirements. Employes of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality_of Anchorage is not
responsible for errors or omi~ions in the profe~ional engin~r's work. ' ' ' -
............ ., '.,-., ..;- ,;~.?:.! ~, ;
724325 (Rev. 1/91) Back :MOAI~I
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A, Well Data
Parcel I.D.
¢5/- 5,
Well type
Log present (WN)
Total depth /?.,'~ ·
Sanitary seal (Y/N)
FROM WELL LOG
Date of test 0 ~/,' /""//'¢ ,¢
Static water level //~
Well flow
Pump level1
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ ~/1~'/72 Driller
Cased to /~.~"~ / Casing height
Wires properly protected (Y/N) Y,~
SEPARATION DISTANCES FROM WELL TO:
Septic/~g tank on lot
Absorption field on lot
Public sewer main
Sewer service line
/,//,4
'/- 50'
g.p.m.
AT INSPECTION
70
r1"'1
....<
/00 /
0
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
Date of sample: O~/~ ~/c~ _~
Collected by:
Other bacteria
B. SEPTIC/i'JE~t;B~G TANK DATA
Date installed /0/? ~
Cleanouts (Y/N) )/~,~
High water alarm (Y/N)
Date of pumping
Tank size
Foundation cleanout (Y/N)
! !
Compartments
Depression (Y/N)
Alarm tested (Y/N) ,~//~
I
Pumper .~-.$
SEPARATION DISTANCES FROM SEPTIC/~ TANK TO:
Well(s) on lot l'~ Y / On adjacent lots
To property line -/- ~0 1 Absorption field
Surface water/drainage ,/V/,/,~
Foundation "/- ~ /
Water mafn/service line ~ /~) /
/"N/'NKI?IKII I1"1'% /'NKI E3A!~V
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
"Pump on" level at
High water alarm level _/
Meets MOA electrical codes (Y/N) /
SEPARA~ LIFT STATION TO:
WaiSt On adjacent lots
Manufacturer ~
Manh~
~ "Pump off" Level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed / D/~ ~ t
Length 2--/- ~ !
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Soil rating (GPD/FF) ¢~ ¢//~/¢-. System type .~--~
Width --~ / ~, 5 /
Gravel thickness .~ / Total depth
~ "] D / Cleanout present (Y/N) )/~ Depression over field (Y/N) .
O S/~C~ / ~ S Results (pass/fail) ~/~ SS for --~ Bedrooms
.~" After test ~
.~///~ If yes, give date /~///~
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ¢'//0
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots 'Y~ / 00 ! Property line
To existing or abandoned system on lot
Cutbank /V//4 Water ~eiWservice line
Driveway, parking/vehicle storage area -V-/~ '
+ $0'
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on
inspection.
Signature ~~
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
72-026 (3/93)* Back
Waiver Fee $
Date of Payment
Receipt Number