HomeMy WebLinkAboutALYESKA #3 BLK 22 LT 13000
Date Drilled:
'FELL LOG
Cerv~ l~ circle
Cird~ood, Al<.
Static Water Level ~, r'r,.-nr:e feet
Gallons Per Minute
Draw Down N,fA feet
Total Feet of C~sing cased to 32.
Type M~terial Drilled:
0 feet
to 3Q $i].tv qravel
30 feet
to ~1.0 Bedrock w/w,~ter
to
to
¸to
to
Drilling /~
S.R.A. Box 1553 H
Anchorage ,Alaska
99507
..,u ,;i'..im,-:ll'W C'F ANCHORAeE
IX'7~'f. OF HEALTH &
ENVIRONMr'JNTA- PROTECTION
RECEIVED
M~ICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK ~9501
264-4?20
m-iN--_~ I TE L-JELL PERF~ I T
PERMIT NO:
DATE ISSUED:
840262
0572i784
APPLICANT:
ADDRESS:
CONTACT PHONE:
GEORGE R MCCOY
P 0 BOX
GIRDWOOD, RK 9958?
~8-6058
LEGAL DE$CRiP:
LOT SIZE:
SUBDIVISION: RLYESKR #2
SECTION: i6 TOWNSHIP:
i54~2 (SQ, FT. OR ACRES)
LOT: t5
RANGE: 2E
BLOCK: 22
I CERTIFY THAT:
i. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
SEWERAGE_SYSTEM ON THIS OR ANY ADJACENT OR
APPLICANT: GEORGE~A McCOY' ~
RORTH BY THE MUNICIPALITY OF ANCHORAGE <MOA) AND THE STATE OF ALASKA.
I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH ALL MOA CODES 8ND REGULATIONS,
AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT.
I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK
DISTANCES FROM ANY EXISTING WELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC
NEARBY LOT.
M~JNICIPALITY OF ANCHORAG~
DIVISION OF ENVIRONMENTAL HF<H
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
i. General Information
Application Date
(a) Legal Description (include lot block, subdivision, section, township, range)
Location (address or ~irectioRs)
.~ ~ O~.o5 ~_
(~)
Applicants
Nam~
(c) Applicant ~is (check one) Le~in~ Institution
Buyer ~ ; Other ~ (~plain);
(e) Real Estate Co. & Agent
Address g'.~ (
2. T_~e of Residence
Single-Family~
Number of Bedrooms
3. Water Supply
Multi-Family
Other ~(describe)
Well 75 ¥' Community Publi 51l
Individual
Note: If commu 'well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4..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 status.
[Page 1 of 2]
g,n~ineerin~ Firm Providin$ Inspections.~ Tests~ File Search~ Data and Informati.on
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 ipziicated 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 wastewa~er disposal
system is in compliance with all Municipal and State codes, ordinances, and regula-
tions in effect on the dace of this inspection.
Name of Firm_
Address //
/ // 'o ....... . ,
Approved
for
//'
Approved ~ D~sapproved ¢'~ Co~t~on~
Terms of Conditional Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES mZALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAI~ 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 ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE ~FUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7-I 9-84
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
Well Log Present (Y/N) ,
Total Depth / ! O Cased to~- 3 ,9__
Static Water Level _q ~ ~ ~L~ ¢ ~ PureD Set At
Casing Height Above Ground ~
Electrical Wiring in Conduit (Y/N) y,~
Sepa~ation Distances f=cm Well=
To Septic/Holding Tank on Lot
MUNIQPALIZY OF
DE?L OF
[NVIRONMENIAL i-;,;~ '~
FEB [o 885
/
If A, B, c~ C, D.E.C. Approved(Y/N) ~//
Date Completed F-2 ~ '-~ y , Yield
~pth of ~outing ~/~
Sanit~ ~al on Casing (Y~)
~essi~ ~nd ~l~ead (Y~)
; On ~djoining Lots,
To Nearest Edge of Absc~pti~o~n~etd on ~t
Water S~le Test ~sults
SEPTIC/HOLDING TANK DATA
Date I?stalled Size~/ ,/ ~o. of Ccmpa=tmsnts
StandD1pe. (Y/N) Ai=-ti~ ~p, (~)// / Foundation Cleanout (Y/N)
Depression o~r Tank (Y/N) /D~Las/P~d%' ~
Pureeing/Maintenance Con a on File ¢ fo=
Holding Tadk High-Water Alarm (Y/N) --Temporary Holding Tank Permit (Y/N)
Separation Distances f~cm Septic/Holding Tank:
To Water-Supply Wall To Building Foundation
To P~operty Line To Disposal Field
To Water Mair~Se=vice Line , To Stream, Pond, Lake, c~ Major Drainage
Course
2-15-84
C. ABSORPTION FIELD DATA
De
Soils Rating in Absorption St=ata
Date .Installed
Width of Field
Squa=e Feet of Absorption A=ea
Depression over Field (Y/N)
I~ssults of Last Adequacy Test
~/~ Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P=esent (Y/N)
Date of Last Adequacy Test
Separation Distance f=cm A~sc=ption Field:
To Water-Supply Well To P=operty Line
To Building Foundation To Existing or Abandoned System cn
Lot ; On Adjoining Lots
To Water Main/Service Lin~ ~--0 ~--' To Cutbank(if present)
To Stream/Pond/Lake/c= .Major Drainage Course
To Drivew~ay, Parking Area, c~ Vehicle Stc~age A=ea
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Din~nsions
Manhole/Access (Y/N)
"Ptm~ Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Ccn~ents
** Check Permitted Bedrocm Rating Against HAA Request
certify that I have checked, verified, c=. confc=med to all MOA HAA Guidelines
on the date of this inspecti°n.
Signed ~ Date~~'-
c any z ANo.
KB1/d5/s
[Page 2 of 2]
2-15-84
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