HomeMy WebLinkAboutASPEN RIDGE BLK 1 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 PHONE I [~NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION ~ NO. OF BEDROOMS~
~ D'STANCETO: Iwe'' //0' JAbs°rpti°nar~'~' Dwelling
~z ~.u~a.t.r.,Sr~tr Materialyt¢~/ No. of compartments 2
Liq, capacity in gallons Inside length Width Liquid depth
/~ IF HOME.DE: ~ ~
Well Dwelling PERMIT NO,
9~ DISTANCE TO:
Manufacturer Material ~ Liquid capacity in gallons
~= DISTANCE TO: Well /~., Foundation ~, Nearest lot line/~/ PERMIT NO~ ~ ~
~ ~~ No. of lines / Length of each line~, Total length of tine~, Trench width2 inches Distance between lines~.
~ ~ ~ Top of tile to finish grade ~ , Material beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth TotaJ effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ CJass Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS J
INSTALLER ~ ~ ~
A~PROVED ~ DATE LEGAL
72-013 (Rev. 3/78)
~WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of GeoIogicDI ~ Geophysical Surveys
Drilling Permit No.
LOCATION OF WELL (Please complete either la, lb or lc.) A.D.L. No.
lc.I DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS ~.. OWNER OF WELL:
Address:
FeefsurfoceBelow 4. WELL DEPTH: (final) 5. DATE OF COMPLETIO~
WELL
LOG
Material Type Top BOttom
,4, /~ ~., 9~;~ ~;.~;'"~ Auger ~ darted ~ Bored ~ Other:
~ .::, ~/,~.~r,~,,' =.,?T'/~{~;~? ~j~(~,, g ~ ~C~ g Irrigation g Recharge g Commerlcal
'~ / ~ ~ diam. ~,q- In. to '~,~-ft. Depth Weight ~) lbs./fl.
Type: Diameter:
Slot/Meah Size: Length:
Set between ft. and ft.
Backfilling Grovel pock
Date
~ Above or ~ Below land surface
Equipment used: ~J l ~ ~/r/~ /~
II. PUMPING LEVEL below land surface and YIELD
,~ 7 ft. after ~ hrs. pumping ~ , g.p.m.
ft. after hrs, pumping ~g'P'm'
I~.GROUTING Well Grouted',
Material: ~ Neat Cement ~ Other:
I~. PUMP: (if available) HP
Length of Drop Pipe ff. capacity g.p.m.
~ Subm. ~ Jet ~ Centrificol ~ Other
14. REMARKS:
16. WATER WELL CONTRACTOR'S CERTIFICATION:
15. Water Temperature ~o ~ F ~ C
I.
This well wos drilled under my jurisdiction and this report is true to the best of my knowledge and belief;
Registered Business Nome Contract License Number
'AuthOriZed RePresentative
Form O~-WWR (11/81) Copy Distribution; WHITE-~f~le D~GS~ PIN[-Orille% CANARY-Customer
RP[::'L. I CFff'~"F
L. 0 C: Ft T I 0 N
i,...EGFI[_
ID
L ::~ B.~. I::tSI::'EN F:: ~ DGE ~ L,O 1: t...L ~ e L.E 'F :5 Z ZE
T'¢F:'E OF: SO i L.. FiE;SOF..'PT I ON S"r'STEH 1' :S: TF.:ENCH
HF~XIMUH NUHBER 3F BE[:,ROC~MS = 3
SOIL RRTtNG ,::'.E;C.:! F'T,.-"BF.:)= 17'C~
THE' REF::!U i RE[:, :5 :[ ZE OF TblE SO I L.. RE:SOI:;.':PT I ON S'¢SI'.'EM i :5:
TF!E L. ENGTH [:,IMEN':i;ION IF..: THE LENGTFI (IN FEET) OF THE TRENCH OR DRF:III'.,IF:iELZ:,.
THE [:,EF'TH OF F! TRENCH (IR P!'.T I:~] THE D ISTFINCE ErET!4EEN THE SURFFICE OF THE
GF..:OUN[:, FIN[:, THE BOTTO!',t OF' THE EXC:FI'v'FI]"!ON ,:.'I!'.,t FEET).
THEF::E I::2; NO :.:?,ET' I,.II[:,TH FOR TRENCHES.
THE ,GF'.FI'v"EL DEF']"H !:~, THE MIN!MUH [:,EPTH OF' GRRVEL BE'I".WEEN THE C,...ITFF~L.L PIPE
FINI} THE E',OT"FC I'.'. OF THE EX(]:R',/FFF t ON ,' I N FE:E'F).
F'EF. ff,ll T RPPL iCFINT FIFIS THE REI:~;F'ONS!E;IL I T'.? TO INFORH 'THI:'5 [:,EF'RR'TMENT DLtR tNG THE
!NSTF!L.L.F¥1"ION iNSPEC:'T!ONS 01::: FtN"r' 1,.IEL. L:'S RE:,JFICENT TO ]"!"'II'_=, PROF'ERT'¢ FtI",t[:, 'THE
NUME:ER OF RE'.::.:;iE:'ENCES THFIT THE t,.IELL t.4ILL SER',,"E.
.................... 'T lb..t! C') '::; ;2: ;::' :I.. !'",Il ~; P' E: C:: T' Z C, P..,i 5 R F;ii.'. IE [-R EE ~L.'::'~ IL.I! If.' ti:;,;;:: F..E !L":,,
E'~FIC:KF:[LLtNG OF' RN'¢ S'T'STEH NITHOUT F'INFtL tN'.'SPECTION FINE:, RPPRO',,,'RL B'.r'
[':,EPF!RTMENT i.,.!ILt.. BE SUBJECT TO PROSECUTION.
MINiML.tH DIS:;"I"FINCE BETt.,.IEEf.,I FI f,.fEL. L. Bf.,ID FIN"r' ON-SITE SEt,.tFIGE DISPOSFtl .... :i':';"r'STEM iS
::l..OEi F:'EET FOF'. F:! F'RI',,,'FITE f.,.!ELL OR ::t..5C~ TO 2(::tL:"~ FEET FF.:OI'"! FI F'UBL. tC I.,.IE!...L r':,EF'ENDING
U!:::'OI'.,! THE ]"'-?PE OF F'UBL:[C !.4ELL...
H!N!MUH [:,I:B'T'FIf.,IC'E FROH FI F'R!VFITE I.,.IELL TO Ft PRI',,,'FITE L:..;EI,.!ER L. INE IS 25 FEET FIN[:,
TO B COHHLtNIT'.? SEWER LINE I:.'5 75 FEET.
!.,.IEL. L.. LOGS RRE F::E(;:!UIRE[:, Rl'.,l[.', MUST BE RETURNE[:, TO THE DEPRRTMEr.,tT t.,.!ITHIt'.,1 :ZC~ [:'lgT'~i!;
(3 F:' T H E 1.4 E L. L C O I"IP L.. E"F :i: O !",1.
OTHEF.: F'.:E(;!U l RE:HENT:iii; f"IFF¢ RPPL"?. SPEC I F I C':FIT 1 O1",11.'-5, FIN[:, CONSTRUCT I ON [:, ! FtGRF:IHS:'; FIRE
I::IN,"t::i Z LRBt....E 'l"O I t'.,~5tJRE PROF:'ER l NSTFtLL. F:tT I ON.
t CERT i F:"r' '!"HRT
:i.: ! t::lt'"l F:FIH!LtFIF.': WITH THE RE(;:!UIRE!"IENTLE; FOR Ot",I-"-2;ITE tF.:;Et.,.IERF.'; FIND, t.,.IEL. L..~:'; f::IS :SET
FORTH B'?' THE HUN!E:IF'FtLIT"r' OF Rt",tCHORRGE.
;2' ! bITi. L. IN:.{';TFILL THE S'¢STEH IN RCCOR[:'FINC:E HiTH THE
]!:' ]: LIN[:,EF.':~.:;'T'F:IND THFIT THE ']t"I-F'.]'TF SEI,.!ER F;"r'STEM t"1R'¢ F'E'::~ III:;'E FI"ILF¥;r]EMENT IF' THE
F.':E:StDENCE IS REMODE:LE[:, TO I NCL. UDE HOI:;.:E THRN ~: BE[:,ROOHS.
:'51: GNE[:, · .~~
V4.. 9
SOl LS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED: '7~ ~ - ~ 7~
3
C~/~ ~,,..'ry, ~^~v
5
SSLOPE ~
-
SITE PLAN
lO
12
13
14
15
16
17
18
19-
2O
COMMENTS
PERFORMED BY: ~ (.
WAS GROUND WATER S
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time/i/[jj%] Water ~' T Drop
PERCOLATION RATE //. / (minutes/inch)
TEST RUN BETWEEN &t/ //''~ FT AND ~)"' FT
3,0 "/~ 50/'v CERTIFIED BY:--"-----'----'-I'~ "" v
72-008 (6/79)
Parcel I.D.# OJ '7 --
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
C E I V E D
JUL 2 ~ 1997
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions) ~ '7 tq ( f~ _~ /oc~ ,~, bO-6
~" "Pi°'pe'rty' ....... owne[-~-,~'"'~'" ~ z' ~o¢,],~ /Lo / s "~0 ~/~.L ~ Day phone
::,, ,, u~i!ing,address v q r b ~'/e ~ ~, 0 ~ ~ o/n c~ ~ ,
,Lending agency, Day phone
"Mailing address:'
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
m
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.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
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
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 s & $ ENGINEERING
]70,~4 F. agJe klver Loop ROad No. 204 Phone. ~ o~ ~ _ ~ '7 ':> ~?
Address Eagle River, Alaska 99577
Engineer's signature '/~~~ :~/--~.~_ Date 7/~,1/~?
DHHS SIGNATURE
· ~ Approved for .~-
Disapproved.
Conditional approval for
bedrooms.
bedrooms,
with the following stipulations:
Additional Comments Je~ /~+ ~e.~nL
By: - (~'" '~ /'~~"'"~ Date
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 ~
MUNiCiPALiTY OF ANCHORAGE
Et~ii~3~AL,SFr. EVIC:~ DI¥~J,S_I_QN
Municipality of Anchorage 1~)~)~
DEPARTMENT OF HEALTH & HUMAN SERVICES _ ;IUL 21
Environmental Services Division 3r~ t-/., ~ i ~/lJ:]lil'i~~;j~4~!, r-- I V ~'~=''-''
825 L Street, Room ,502 · Anchorage, Alaska 99501 · (907) 34
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Well type
Log present (~N)
Total depth
SanitarY seal
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed c~/~.~j/~ ~,
Cased to '~'.-~ /
Casing height (above ground)
FROM WELL LOG
Date of test
Static water level
Well production [
WATER SAMPLE RESULTS:
Coliform Nitrate
Date of Sample: ?-/I ~/~
B. SEPTIC/HOLDING TANK DATA ·
g.p.m.
Wires properly protected (~N) ~,~ AT INSPECTION
' , ; '
0,'"/
g.p.m.
Other 'bacteria O
Collected by: ~ S & $ ENGINEERING
17034 Eagle River Loop Read Ne. 204
Eagle RiVer, Alaska 99577
~ Number of Compartments ,Z, ' Cleanouts(~_'~._
High water alarm (Y/N)
-/ .
Date installed /9~2-- Tank size
Foundation oleanout (~N) ?~ Depression (Y~ /Jo
Date of Pumgirt~ '.?/'- ~ ~ 7~ Pumper 15 ~ 4 c J
,~ ?-- . · I
C. ABSORPTION.FIELD DATA ".." ~
Date ins~lled .... i ~ ........... il rating (g.p.d./ff~ or ~/bdrm) System ~pe
Length ~ ~ z ,. Width;' _~ Gravel thickness bel~ pipe ~ Totnt depth ///
Effective absorption area , ~~. Monitoring Tube present ~)~ Depression over field (Y~
Date of adequacy test .~I~/~T Results (Pas~Fail) ~ AS~ For T~e bedrooms
Fluid depth in absorption field before test (in.); ~ ~ Immediately affer~7 gal. water added (in.):. ~ ~o"
Fluid depth 3 (ins) Minutes later: ~ ~ Absorption rote = ~ ~O ~ g.p.d.
Peroxide treatment (past 12 months) ~/N) ~h~_ K~ If yes, give date
72-026 (Rev, 3/96)*
LIFT ST~~..~~~.
Date installed Size in gallons
Manhole/Access (Y/N) "P~i~n" level .at*
High water alarm level at* *Datum~'""'"-~.
Cycles tested
E. SEPARATION DISTANCES
"Pump off" level at*
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot ~D0~ '~
Public sewer main ~ '~
IOO~+
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Sewer/se ptic service line
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation .5' ~ Property line $ ' ~ Absorption field ~
Water main/service line IO' I- Surface water/drainage loft)/+ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line I0.'+ Building foundation ~0~ + Water main/service line
Surface water Driveway, parking/vehicle storage area
Wells on adjacent lots
Curtain drain I~I A
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal rec
in conformance with MOA HAA guidel~es in effect on this date.
Signature ,~f~J ~/~- ~--~
Engineer's Name //t~ ~ ~ ~ ~ ~ ~- ~o ~ ~ ~
Date ~ / ~ / / ~ 7
Waiver Fee $
HAAFee $ ~c:)'
Date of Payment ~/7/?-,'J / ~ 7
Receipt Number
72-026 (Rev. 3/96)*
~0'~-
a~
Date of Payment
Recei pt Number
MUNICIPALITY OF ANCHO~GE
MEMORANDUM
WATER WELL ADVISORY
HEALTH AUTHORITY APPROVAL NO.
During a recent Health Authority Approval on-site inspection
and test of tile potable water supply well on Lot ~
Block ~ of ~ ~i~6 Subdivision, the well's
produc%ivity was determined to be gallons per minute.
The minimum well productivity required by this Department
(AMC 15.55) for a ~ bedroom residence is ~ gallons
per minute. Although the subject well currently exceeds this
minimum requirement, all parties concerned are advised that the
production capacity of the well may fluctuate. Restriction
of non-critical water uses such as washing cars and watering
lawns and gardens may be required.
This advisory must be attached to all copies Of the subject
Health Authority Approval.
JUL-~5-1997 10:1~ CT&E ESI ANCHORAGE 90?5615501 P.03×11
j~t~ CT&E Environmental 5ervioes
CT&E Ref.# 973901002
Client Name S & S Engineering
Project Name/# N/A
Client Smnple ID Lot 8 elk l A~pen P, idse
Matrix Drinking Water
Ordered By
FWSID 0
Client PO~
Printed Date/Time 07/23/97 09:19
Collected Date/Time 07/16/97 12:15
Received Date/Time 07/16/97 16:00
Technical Director: Stephen C, Ede
Siu~piO-'Remarks:
Parameter ReBait ts PaL Unt ts Hethod
Nitra~;e-N k o.loo U O.lO0 ~/L
Yotat CoLiform 0 cot/lO0~
A~toNabte Prep AnaLysis
Limits Date Date Init
SH18 4500-1;03F 10 max
$H18 9222B
, ~:,
07/~B/97 J~J
07/1&/97 TMW
APPLIC ~IT FILLS OUT UPPER HAl oNLY
Realty Co. & Agent _.,...,__~~ ~ ~ Phone
Address ~// , Zip Co. de.
Type of Residence
Single Family
'~l~ Multiple Family No. of Bedrooms
[] Other -
Water Supply
..!ndlvldual ATTACH WELL LOG. A welt log Is required for all wells drilled since June 1975.
Community For wells drtlled prior to that date, give well depth (attach log tf available).
[] Public Utility
Sewer D,sposa,
--4ndivldual Year Individual Installed:
';[] Public Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Field Notes: ~_ ~ ~UNIClPALI~ OF
~,~::~' 2 - I982
. R[C[IV[D
*CONDITIONS OF APPROVAL
( ) DISAP~OVED
( ) CONDITIONAL APPROVAL*
DATE ~-- /~ -- ~ ~
Soils Rating Date ~wer Installed Well To Absorption Area / ~ ~ Well Log Received
/ 7~ /~.. ~ ?~¢~" WelltoTank //~ Septic T~k Size
72-023 (3/82)
