HomeMy WebLinkAboutFOUR WAYS BLK 1 LT 3
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
Stephen Syverson
MAILiNG ADDRESS
E. 99th (off Homestead)
344-8549 T E]UPGRADE
LEGAL DESCRIPTION
L3 B1 Fourways S/D
LOCATION NO. OF BEDROOMS
Absorption area PERMIT NO.
781041
Well
DISTANCE TO: 100'+
Manufacturer Sunset
~ Plastics
1250 F HOMEMADE
DIST,~NCE TO' Well
Manufacturer
IWell
DISTANCE TO: I 115' +
No. of lines ~ Length of each line
I 54'
To. o¢ tU. to ~ini,h ~.
2~ - 5~ feet
L~th Width
TO~ w~,~
I~s Depth
~[ 10: Buildino founOation
Inside length
I Dwef[ing
15'
Material
Fiberqlass
Width
No. of compartments
2
Liqaid depth
Dwelling PERMIT NO.
Liquid capacity in gallons
Foundation
40'+
Total length of lines
54'
Material
Nearest lot line
15'
Trench widt] 36 inches
48 inches
Material beneath tile
Depth
PERMIT NO.
781041
Distance between Ii nee
Total effective absorption area
432 S.F.
PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line PERMIT NO,
Sewer line Septic tank Absorpt on area(si
OTHER
PIPE MATERIALS
4" C.I./ 4" Hancor Plastic Perf,
SOILTESTRATING
Clean Sandy Gravel -- 100 S.F./Bedroom
INSTALLER
H & M Excavating 344-0013
REMARKS
Soils consisted of brown clean sandy
gravel - GW to bottom of trench
-~PPROVED
DATE LEGAL
11/3/78 L3 B1 Fourways Subdiv.
F:'Ef;;:M ]: T l'.,IO.
F:tI:::' P L. I E: I:::tlq 'T'
[.. [)1;7:1:;:I T ;[ I~.l
99'['H E~I':T: I".IE~htE:STEI:::I[:, f::lt'.4[:,,-."Cff;i: I-'IF:I.'[NTi';dEE
[..~: EI;;t. FZOl..IF~:l.,ff':l~'r'S z,. [
I,..O'T :5IZE
I','ll::t;:.:;:[ivlLttvl 1'.41...1t',1[)[~.[;;: ()F:' Ei:E[:,F;::OOMS ......
THE t:;;:E~;:!I...I]:F?.ED S:[2:[E OF THE: SC;IL. FIE'-E'::I:~'F:'TZZt'.t
THE L...ENGTI4 [::, :[ I'"IENS I ON I S THE L.EI'.,I(:~iTH ,:: I hi FEET :) OF THE 'Tr;dENE:I I OR I::,1:~:1:::1 :i: I'.,IF I El..[::,.
THE [::,EI:::'TH Ot:::' I::1 TF;:EhlC'H Of;?. F']:T :[:ii!; 'I"FII:::.' D ZSTI':INCE E~E'I"HEE:N THE :.'.:.;UI;i:F.'F:IC:E [31::' TI-IE
di[4:E~LIN[::, Ftl'.,l[::, TI.-IIF~ IE,::)'T'TOPt O1::' THE EX(:::f::i'v'FiTZEff.,I ,:: :[1'.4 FEET::,.
TI--IEI:;i:E :I:'.E; NO S[:::T I.,.I :[ [::,TH I::'OI.;;: TF;:EI'.,ICHES.
'lHI.i: G[;i:I:::I',,,'I.:!:I... [)EF'-FH Z:E; THE: MI I'.,I:[HUM DEPTH OF G[;:FI',,,'EL [:~]ET.~,.IEEN THE: OIJ"I'I::'I:::IL.I.
FINI) TIq[E I:i~OT'f'EiM Eli::' THE E::.O.'::F:I'v'FTT :[ CiI'.,t ,:: I N I:::'EIET ::,.
I:::'IEF;'~:I'I I ] I:::tI::'F:'L I C:I::II",IT I'-I1:;:1!~; 'T'HE( I.[ . ; , [" I" I ~ :' ]I [:1 '[ ti''i I[ t r 'TEl 7( I'''IF:'OI;?'M 'f'l''l I '.::i; I::'EI::'F:II:;:TMEI",IT I.::,1...11:;i: :[ I",lEii TI:'IF!;
]: t",l'.'~i; T'FII~.L.FIT I ON T 1"4'.-2 F'F:'. ": "[' I' ': Nc OF' FIf',t"r' 14[;I_L.'.~; FI[)J'I::If.';:[(NT TO TH I '."!; F:'I:;i:OF'I:(RT"r' I::11",11:::' THE
iql..IHIE~E:F~'. Eft::' Fi:ESIDEI",IC:[~:S THFt"I- THE I,.IEL. L. I.,.III...L 9.;FZF.:'v'E.
M I f',l I f"ll.,.IFI [)I '.::;TRf',IC:IE BE'I"I.,.IEEi",t t::I I,]EI..L. I::tlqC, F:lt',l"r' ON-'iii; I TE :i::;[!~l,.IF:l(~iE
:I..E~O F'IiEI~ET F:'EIF:: I:1 [;"F.'.]~,/I::IT['~; t.,.IfELL.; Ed;i:
:L'.:'!,EI TO 200 FF:ET FROM 'Ft PI...IE:L :[ C: I.,.IEI....L. DE'F'Ei"4DII",IG IjPON TH[E 'F'¢F'[!~: EIF F'I...IE'd...ZE: I.,.l[i!:l..t
I.,.IEI...L LOG:'2; l:::ff~'.[!~ f~:EO]:!UZf::'.E[) F:II",t[:' I'"ILIST BI/ I:;~:LETI..tF~ff'4EI]:, 'FO TI"IEi: [;:,Ei:F:'F:II:;i:TI'"IEI",IT I.,!ITHII",I
Cfi:' "I'I*IE~ I.,.IEL. I.. C:f::IP1F'I...ETI ON.
OTHEEI;?. f4'.E%!U I f;?.EMEI",Ff'S f"lF~"r' I::IF:'F:'I...."r'. :E;F'EE: Z F Z CFFI" ]: Ot",IS FIND COI",I'.:5Tf4:LIC:T
I:::I',,,'F:I I L.F"IE:t...Ii~ TO I Iq ':'.:; LI F4'. E: PF,:'.C~F'IEFi: ~ I"4STF1LL. FIT I ()i",l.
[4.". T I I-: "d T H I:::1T
FIi"I FFIMZI._.:[FIFi: I.,.IlTFI "l'l-lEE [~':EZ-ERJlt~'.IL::r,'IE!:i'.,IT:5 F:'OIE: ON"'"'.E;ITE; 9.';l:F].,.IEE[;?.!ii; FIN[::, HF£1..L.:i!; FIS SET
FC~fE:'['I'4 E:','.d THE [,'ll..Jf.,I Z C: I F'FIL. I T'¢ O[:'
I 14 .~ LL. I I'.~'~TFII...[. THE '.'-~;'~"..'E;"I"Ei:I,'I I I'.,1 F:iE:C:EdE:[::,F¢,ICI:E t,.I :[ '1"I.-I THE
I..II'.4[)(.:E[;::E:71'Fii'.,I[) THI::IT THI:E ON....S Z TE: SEEHEf;?. S'¢'.E;TE:FI f'll:::t'T' P.':E:L.-.K.I Z F;'.I:~ [i:[',~,l[..l::lE~GEii:h'lt!d'.,IT t I:::' 'l"l .IE
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
17-
18
19
2O
COMMENTS
PERFORMED BY:
[~ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTIV1ENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Al~ka 99502 276-2221
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
D-lO
I
DATE PERFORMED:
WAS GROUND WATER /~/C/,,1 S .... : , , :
L
ENCOUNTERED' O Z¢-~/~'-//.cr;t..,/'/'~_~/ ~":
E
IF YES, AT WI-IAT ; . :
DEPTH7
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BE,TWEEN %~ FT AND FT
U.~¢. ~,~-1~'fl,--¢vo,--¢', %' ¢o 4::'o,.' ?' '
· i
DATE:.
72 008 (7/76)
SIX INCH WATER WELL DRILLED AND CASED OUT TO 'THE DEPTH OF
DRILLED AT THE RATE Of ~19o00 PER FOOT.
PROPERTY OWNER --./~2~
LOCATION OF WELL SlTF £~
DRILLER /~_4~.
WELL LOG:
24 .....
102-.-166~
233 7ee~,
-8549
~z~ve,L. 30% c2m~. Sea~eaw~ ,~,~t.L
Sa~ q;uwe.L. 20~ _cLaq, ,b'_,Lp, d.e,'t,.. $o~e g,,zace_4 of_. t~ro..Le.,'~ ~ 1'02
Co4Z; o~. ged, L: ~$4427o00
Co,oX: o~ lg~,L 8ezt,L: $22.00
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF ~'444._Q=00
THANK YOU VERY MUCH.
DATE
BERNIE CLAUS OF RAMPART DRILLING WORKS
SERVICE CHARGEOF 1V~% PER MONTH be ASSESSED ON PAST DUE ACCOUNTS.
Jui 08 "S. 01: 6p Anoho,age \,V i; & Pun-ip "Seer 9072430742 p.2
Develcrpn-,ertf Services f>c-pa.rtmen't
Building 513; eiy bivisior,
t C}n Site 1'VQte & VVaarewafer Program °
4700 Elmore Sfren;
P.C. Boy: 196650
Alark Anc hornge, A1: 39515-6550 s
MaYt"' s'dwN.m�r;i.ur^„lorgite
Pump(90',0343-@790
d ump In tafation Log
Well Drilling Ye: Inir Number:
Datc of Issue -
Parcel Identification Number: Of 5.
4 Legal Description i 1310ck i•a# k'rap,
rty Owner Marne & A.ddxytss:
0� '?i t`- A e,
l'aamp%mst-tllatron fiat `7
Pump Intake Depth 13(-JOW TOP of Well Casin-: � : �' fret
-Pump N'Ianti fa:ctul•er's Name -C. t
P"In , Model. __75 C-3xi r_JU !RSt �
Pump Size ___. wlI ._._hp
Pi%less Adapter Purial Depth: - r7�feet
Pitless jkdaptt:x 1112nafacturer's :Name:
I'itless Ac3Rpcer Installer:
j W'ell Disinfected Iiporx Coolpletkul? ,`' Yes _Nc,
Method of Disinfection:. -
Comments:
Pump rustaller Name:P�KAw"Kk_
Cerrlpany: n G�tii✓A- ��
s ”
4'iarliaxp, Address: � �� ?'���^ �tr`r....•
City: ��?G CYG� ti;_ State: .74k Zip: &76S 2'
attention: the plump installer shall Provide i:sstallatian log to DSD within 30, days of p,ar..a}? ir.& llati;�n,
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
l~) ?~.¢::), - (~,~ NAA# /~1,~ct \ C3
.1, GENERAL INFORMATION
Complete legal description
Lot 3; ~ Ways Subdivision;
Location (site address or directions) 6700 East 99th
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Mayron & Gene Schutte
O%¢.gq~
Day phone
Day phone
Camellia Busc'~an FORTUNE PROPERTIES Day phone 562-7653
3000 A St~e~ #101 Anchorage, Alaska 99503
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4
TYPE OF WATER SUPPLY:
Individual well
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:
XX
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Rev. I/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/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein, l furtherverifythat 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 $ & $ EN~d-NEERJNG
Address ] 7034 Eagle Ri,Yet Loop Road No. 204
Eagle t<Jver, Alaska 9~577
Engineer's signature
DHHS SIGNATURE
X Approved for ~ bedrooms.
/
Disapproved.
Phone
Date ~/~/~, mc//
Conditional approval for
bedrooms with the following stipulations:
Additional Comments
By:
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.
72~325 (Rev. 1/91) 8ack MOA ¢21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L_¢~ ~ j /4 LU¢~ ..%~_~, Parcel I.D.
A, WELL DATA
Well type ~lf A, B, or C, attach ADEC letter·
Log present (Y/N) ~,
Totaldepth '"xc ,~. ~g-
Sanitary seal (Y/N)
ADEC water system number
~-I- '~ ~ _ Driller
Date completed
!
Cased to .2_ ~ ~ ' Casing height
Wires properly protected (Y/N)
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
g.p.m.
AT INSPECTION
g.p.m, co
SEPARATION DISTANCES FROM WELL TO:
/
Septic/holding tank on lot ~ ~ ~-
Absorption field on lot ! 042 ~
Public sewer main /,,)/~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout.
( 00'~
Public sewer service line
Petroleum tank ¢OOA)~ ~OV,2IO
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B, SEPTIC/HOLDING TANK DATA
Date installed / I ~ ~ - ~ ~ Tank size
Nitrate _~.¢,,-?-~,E/)C~?~¢'~ (A), ~_~Other bacteria
Collected by:
Compartments
Cleanouts (Y/N) l_1 Foundation cleanout (Y/N) /'1 Depression (Y/N)
High water alarm (Y/N) k.)/ (A Alarm tested (Y/N) ¢,2/J~
Date of pumping R - -"~ -~'~'J ~/Sf ff- ~0¢A¢--- -~eC'¢~Oc~--~g
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot <~ Onadjacentlots (OO '~ Foundation
To property line {00' Absorption field / (¢ Water main/service line_
Surface water/drainage J CO P
72 026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) '"'~ump on" level at
High water alarm level
Meets MOA electrical codes (Y/N) %
SEPARATION DISTANCE FROM LIF ION TO:
Well on lot On adjace'~ots
D. ABSORPTION FIELD DATA
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
Date installed l I - '~ - -'~ ~ Soil rating /
Length ~--~ ' Width ~ (o ~' Gravel thickness
Total absorption area /--/ ,~ 2, ~ Cleanouts present (Y/N)
Depression over field (Y/N) /k~ Date of adequacy test
/')(~ .~, -.~ for
Results (pass/fail)
/
Peroxide treatment (past 12 months) (Y/N) ~/~ If yes, give date
System type
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ! O0 /1~
To building foundation ~O
On adjacent lots
Surface water
Curtain drain
On adjacent lots ! 062
Property line
/
To existing or abandoned system on lot
/
Cutbank t',) P, Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in
$ & $ ENGINEERING
Signature 17024 Eagle Ri,vet Loop Eoa¢l
Eagle River, Alaska 99577
Engineer's Name
Date ~-/~ -~/
~e date of this inspection.
HAA Fee $ //"-/~,'
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301
a)
Member of the SGS Group (SociCt6 G6n~rale de Surveillance)
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
TELEPHONE (907) 562-2343
5~.'.33 B Street
Anchorage, Alaska 99518
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D. # ~
~,, PRIVATE WATER SYSTEM
Narn~
Mailing Address
Phone No.
ENGINEERING
~i~ ~.a~jie RiYer Leap ~,oaa No, ~
~ver, Alaska 99577
C~y
Mo. [)ay
SAMPLE TYPE:
Routine
Check Sample (for routine sample
with lab ref. no. )
[] Special Purpose
Slate Zip Code
Year
[] Treated Water
[] Untreated Water
SAMPLE Time
No. LOCATION Collected
31 I
41 I
51 I
Collected
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
/.~atisfa~tory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Time Received
Analytical Method: Membrane Filter
* No. of colonies/lO0 mi.
Lab Ref. No, Result* Analyst
% 47115
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS Membrane Filter: Direct Count
Coliform/100 mi
BEFORE
Verification: LSB
Fecal Coliform Confirmation
BGB
COLLECTING SAMPLE
Final Membrane Filter Results
Reported ay~ ~'~-,
Date
TNTC = Too Numerous To Court
OB = Other Bacteria
PART ONE OF TWO
REMAINDER TO FOLLOW
Coliform/100 mi
/ _%7~' -~' - a .m.
p.m.
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
Application Date May
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
m~ ~,~T
Lot :~ Four Ways ,Subd; Sec° iLt~ J.J._~ ~.~,'~'~
Location (address or directions)
~00 E o ~ Ave.~ A~cho~age~ ~'L
~ Leo i,;. Carl. son - Business 522-1030
Applicant ,,ame ............ - ..... _ ........ Telephone: Home
Applicant Address ~'~00 =,, 99~ Ave,, CmcAo~%e, Al(
(b)
(c) Applicant is (check one): Lending Institution [] ; Owner/buiider [] ; Buyer [] ; Other [] (explain); __~ .
(d) Lending Institution
Address
I?cr:,ax Healty, ~nco
(e) Real Estate Company and Agent
Address ].O00 ~_':,o Dfimond B!vd, ~ Anchorc:;_{~_ AK
(f)
ES C I{',','/,_$ A ~'i:; CO Telephone 522-~!188
1~00 i!',. Dimond Blvd., Ancb. or:.U~;~
Telephone
Mail the HAA to the following address:
t!o]_d for pickup
TYPE OF RESIDENCE
Single-.Family [~ Multi-Family
Number of Bedrooms Four
Other
WATER SUPPLY
Individual Well ~ Community [_1 Public ~
Note: I~ community well system, must have written confirmation lrom 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 slatus.
Page 1 of 2
ENGINEERING 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 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 tile 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&taska Soil ..eo~,3_ng ~nd EngJ.neeril~g Telephone 56]'"'~L~55
Address 6100 A.. Street ~ Anchorage, A~'{ 99.502
Date May 8~ 1985
ST85-;260
-/~-".'~"~a~-. Date
Approved for ~o b~'~; bedrooms by ¢ / __ f~¢%~
Approved ~. Disapproved Co n d itio rYal~.-~
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (E)I-IEP) issues Health Authority
Approval certificates based solely upon the representations 9wen in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers et 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 tile
professional engineer's work,
Page 2 of 2
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
~JxlVIRONMENTAL PROTECTIORI
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) [, ,/ ',~ }
CHECKLIST- FEBRUARY 1984
Legal Description: Lot ~
Sec. 1~., T12I~, R~W, S.M.
WELL DATA
Private
Well Classification
Y
Well Log Present (Y/N)
If A, B, C, D.E.C. Approved (Y/N)
Date Completed 12-1-78 Yield 9gpm, Well log(Ref. Cm.]_)
Depth of Grouting
Pump Set At _ 225 ft.
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
Total Depth 2~/~ ft. Cased to 2~"z ft.
Static Water Level 101 £t. (5-6-8.5)
Casing Height Above Ground 12 inches
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well: Ret'. Cornment 2.
To Septic/Holding Tank on Lot 9h ft. Well-S.T.C.O. ; On Adjoining Lots 1~? ft.
To Nearest Edge of Absorption Field on Lot 101 ft o ; On Adjoining Lots l/l-O ft.
To Nearest Public Sewer Line 100+ .ft. To Nearest Public Sewer
Cleanout/Manhole 1OO+ fft~ To Nearest Sewer Service Line on Lot .~O ft.
Mark Holum, P.E.
Water Sample Collected by ; Date
Water Sample Test Results ,Satis£acl;ory
Commentsl)Well yield confirmed at 600 gal/day per 2/-I` hour drawdown test 5~6-85.
2)Refer ADEC separation waiver attached.
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (WN)
N
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) N/A~
Holding Tank High-Water Alarm (Y/N) N/A
Size 1250 gal. No. of Compartments 2
Y Y
FOundation Cleanout (Y/N)
Date Last Pumped 5-7-85
; for
Temporary Holding Tank Permit (Y/N) N/A,
Separation Distances from Septic/Holding Tank: Ref. Comment
To Water-Supply Well 9LF ft. Well-S.T.C.O.
To Property Line 60 ft,
To Water Main/Service Line 1}+ ft.
Course 100+ ft.
To Building Foundation 16 ft.
To Disposal Field 16 ft. (~Lnsp. Rpt.)
To Stream, Pond, Lake, or Major Drainage
Comments Refer ADEC separtion waiver attached
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 11-3-78
Width of Field 36 inches
100 ft2/bdrm(Insp' Rpt)
Type of System Design
Length of Field
6 z/2
Depth of Field
Trench
fl;. to 9 1/2 ft.
Lt ft.
Gravel Bed Thickness
Square Feet of Absorption Area /f~2_ £t2 Standpipes Present (Y/N) Y
N 5/6-7/8,5
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test Satisfactory (Absorp1;ion rate appro×. 8.50 gal/day)
Separation Distance from Absorption Field:
To Water-Supply Well lO1 £t. To Property Line 10+ £t;.
To Building Foundation ~O £t. To Existing or Abandoned System on
Lot ~/A ; On Adjoining Lots .50 £t ·
To Water Main/Service Line ~O+ ft · To Cutbank (if present) N/Az
To Stream/Pond/Lake/or Major Drainage Course 1OO+ £t;.
To Driveway, Parking Area, or Vehicle Storage Area 10 Ft.
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
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 //?'.///~--~' ,..-/~--~/~ Date
Company Ak. SoJ1 Testing & E~g~oA No.
Receipt No. ~ '~ ~ /
Amount: $ ~¢O
72-026 (11/84)
BILL SHEFFIELD, GOVERNOR
ANC!tORAGE/WESTERN DISTRICT OFFICE
437 "E" STREET, SUITE 303
ANCltORAGE, ALASKA 99501
274-2523
May 21, 1985
Alaska Environmental Control
Services~ Inc.
1200 W. 33rd Avenue, Suite B
Anchorage, Alaska 99503
SUBJECT:
Dear Sir:
Waiver ltorizontal Separation between Well and Septic
Tank, Lot 3, Block l, Fourways Subdivision,
Anchorage, Alaska (8521-WA-167)
The Department has reviewed the subject waiver request and hereby waives
the horizontal separation between the well and septic tank to 95 feet
on the subject property for a 4 bedroom single family residence only.
Sincerely,
District Engineer
SWE/msm
APPLIC iT FILLS OUT UPPER HA[ ')NLY
Mailing Address Zip Code
Lending Institution ~_~.~ ¢,. ¢~ ¢/~) Phone
..- ',A./ t]
Street Locati~
Type of Resi~nce
.~ Single Family ~/
~ Multiple Family No. of Bedrooms
~ Other
Water Supply
~ Individual ATTACH WELL LOG. A well Icg is required for all wells dritled since June 1975.
~ Community For wells drilled prior to lhat date, give well depth (attach Icg if available}.
~ Public Utility
Sgw~ Bisposal
,.~-Individual Year Individual Installed:
~ Public Utility whe~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 Inspeclor Inspector Insp6ctor
Field Notes:
~- ~.~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
( ) CONDITIONAL APPROVAL'
Soils Raling Date Sewer Installed Well To Absorption Area Well Log Received
72.023 (3182)
ALASKA eF1UIROFImeI I'AL COFll'ROL $ RUIC $, IF1C.
~n~inecrin§ $ ~uir~m~nl~l $ludi~s
July 26, 1982
Municipality of Anchorage
Department of Health & Environmental Protection
825 L. Street
Anchorage, Ak. 99501
Re: Health Authority
On July 15, 1982 our company collected a water sample from the
house located on 4 Way Subdivision, Block 1 Lot 3. The
property owner is Mr. $chutte. The water contained no
coliform bacteria.
The well was located over 100 feet from the septic tank. The
electrical wires are encased in conduit annd the well seal was
adequate. The well casing stands are 1 foot above the
ground.
Ail cleanout pipes had caps.
A copy of the report is attached.
MUIxIIC P~LITv OF
:, ,~--: ..../,NCHORAGE
E~'V!,. ~: i ,.
RECEIVJ2D
1220 LUcsl 25th/~uenue ,, Anchor(t§e, /~lask~ 99503., (907) 276-1361
DATE RECEIVED
INSPECTION APPOINTMENTS
'-~'AT E DATE DATE
T~SP E CTOJ;~ INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE PF;~I'. C-, , ' '~ &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT ON"" ' A~ ;:,C, iEC[ION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page 1. Incomplete reqeests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER ~) ~ PHONE
I G ADDRESS
MAILING ADDRESS
4. REALTOR/AGENT PHONE'
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6, TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF,,BEDROOMS
E] One [] Four
I~] Two E~] Five
~ Three E~ Six
Other
7. WATEI~ S~PPLY
,~'- INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* ATTACH WELL LOG. A well log is required for all wel[sdrilled
since June 1975. For wells drilled orior to that date, g~ve well
depth (attach log if available.)
8. SEWAGE DISPOSAL SYSTEM
~ iNDiViDUAL/ON.SiTE~.
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev, 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL I DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
13
· SEWAGE DISPOSAL:SYSTEM : PERMIT NUMBER
[] INDIVI DUAL/ON -SITE DATE INSTALLED
Connection Verified INSTALLER
[]Septic Tank or [~] Holding Tank
Size: 1~'~._~?-~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER,
TOTAL ABSORPTION AREA MATERIAL-- ~--- ~.~..t~C~.t~ ~
4, DJSTANCESwELLTO: Septlc/HoJdingTank Absorption Area lSewarki.e IN~arsst Lot Lin~
Absorption Area to nearest Lot Line
5. COMMENTS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
~ DISAPPROVED
/ /