HomeMy WebLinkAboutATELIER #2 BLK 3 LT 5A Name Address Phone(s) mu,'~lt.,r,c~ul~ OF ANCHOr. AG2 MUNICIPALITY OF ANCHORAGE DEPf. C~ I~F--ALTH, & DE, ~TMENT OF HEALTH AND HUMAN SER ~IVIRONM, ENf.,~ PROTECT/ON Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-472Q' {..t i\l 0 ~ ~ ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INS REPORT Permit No. lNG Gl Bedrooms LEGAL DESCRIPTION Subdiwslon .or ,.¢ Township, Range, Section TANKS SEPTIC TANK ABSORPTION FIELD WELL WELL LOT LINE FOUNDATION ¥' ,,¢o + .¢~ AS-BUILT DIAGRAM (Show Iocahon Gl well, septic system, property hnes, foundat,on, driveway, water bodies, etc.) SEPTIC [] HOLDING Manulacturer CapacKy in gallons Material No. of Compmlments TYPE OF SYSTEM ~[TRENCH [] BED [] W. DRAIN [] OTHER Depth to p~pe bottom from Total depth from ongmal grade original grade '~. 0 FT //, ~J F1 Fill added above original grade Gravel depth beneath pipe l~),~ FI ~.,~ FI Gravel length Gravel width ~,~ ~' FT I. $ FT Total absorphon area Distance belween lines ~"'~-~ $0 FT -' F1 Pipe material Number of lines Soil rating /~ Sl} FT Installer Date Installed WELLS PRIVATE [] OTHER (Identify) (A,B,C) Installel 7otal Depth Cased to '~g FT Date Installed: REMARKS: Municip:l-and ga, guidelines ,. ellecl 0n this I:late: Health Department Approval: Scale: Date: certily that Ihis inspection was pedormed according to all Date: 72-013 (3/85) F:'ERM I T NO: DA]"E ISSUED'.' DFSI:::'AIRTIqEIxl]" ,... HI!i!:AL.]"H AND IEI',tV I RONMENTAI .... ~OTEC"f' I ON 825 I.... STREET, ANCHORAGE, AK 995()1 264.-4'72. C) 86()0'79 () 3 / 25 / 86 AI'"::'PI.... I CAN]": A D D R E S S: CONTP~[YT F:'HONE L. EGAL DESCRIP: I... lIT S I Z E' ~ MAX BEDRC)OMS :~ ANN GABLER 10461 HAMPTON ANCHORAGE, AK 346-1 I'70 99516 o U t. D I V I ,:~ .I. 0 N :: I ER SE:C'T'ION: 6 TOWNSHIP: :[2N 1.69A (SQ,, t:::'T. OR ACRI:i'S) 3 LOT: 5A RANGE: 3W BLOCI<." 5 L. is~ted belc, w ape the options available to you in designing your septic: system. Choose the opt:i, on that best Fits your site, DEt:::'TH 'TEl PIF'E BO'T'TOM (FT.) [::)F/AVli.:.':I_ Df.:!:F"T'H iF'T. ) 'T'OTAI ....DEPTH (F'T'.) GRAVEL WIDTH (FT,) ('31R~VIEL I....I.:![NB"f'H (I:::T,) GRAVI.']!:L. VOL. UME (CLJ. YDS. ) 'T'AI'41< SIZE (GAL, S) SOIl .... RATINO (SQ,,FI",, /BR) -IF R EE i'4 [].' ~-.41 :E~, E: D I~.,.I . I:), I::;;,". ~:-t ][ 5.0 6.0 5.0 6.5 0 ,, 5 3.0 1 1 ,, 5 6 ,, 5 8.0 2.5 21.0 5,,0 43. () 40.0 65.0 27.9 3:1. ,, 2 4.2.2 :1. 8:3 183 :1. 83 · ~..-i,f. TAI',II< MUS'T' HAVE A'I" I....E:AST TWO COMF'ARTMENTS I cert, ify that: 1. I am f'ami].iap with the requirements for on-.-site seweps anct wells as set ¢c, rtl"i by the Municipality o¢ Anchorage (MOA) arid t. he State of Alaska. 2. I will insta].l ti'he sys'Lem in accordance with all MOA codes and regulatic)ris~, and in comp ]. iance with the design c:r:i, teria of this permit. 3,, I w:i. ll adhere to all MOA and State ef Alaska requinement~ for the set bac:k distances fnom any existing ~ell, wastewater disposal system or publ:i.c sewerage system on this or any ad.:jacer'~'t:, oP neanby lot. 4,, I unclers'Land that 'l:.his per'mit :i.s valid for a maximum of 5 bedrooms ar'id any enlangemen{ wiZl r'equine an addit:i, or~al permit. IF: A I.,..IFT STA'T'ION IS INS'TALLED IN AN AREA COVERED BY MOA BUILDING CODES:, ]"HEN (1) AN E]...IECTRICAL. F'ERMIT AND INSPECTION MUST BE OBTAINli.:.':[); (2) AS-BUII....TS WILl .... N[]T BE AF:'F:'ROVED WITHOUT AN EI...EC'['RI[;AL.. INSF:'ECTION REF"ORT; Al,ID (3) "i"Hf.:~ EL. ECTRICAL WORK MLJS)~ BE Df3NE BY A L.]:i]E:I',ISED EL. ECTRICIAN. ,SIGI',IED ~/) ........... ....~.....: ............................................... DATE: ........ Z...-.,.;~.,..--~ .................... 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: LEGAL DESCRIPTION: 3 4 7 8 SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O COMMENTS WAS GROUND WATER S ENCOUNTERED? ~ OL P E IF YES, AT WHAT 72-008 (6/79) 'Jl~,~R Gross Net Depth to Net ~ ,,'~,~eading. Date Time Time Water Drop , ~ DEPTH? PERCOLATION RATE ~ :'~, ~ (minutes/inch) TEST RUN BETW~EEN , 5 ~ FT AND ~-~' FT CERTIFIED BY: ~ ~ DATE:~ 51TE PLkN LOT 5~ BLOCK5 ATELIER MUI',IlCiFALJT¥ ©F ANCFI©RAO: DI~PT, OF HE/:,LTH & MUNICIPALITY OF ANCHORAGE ENVIRONM~:NTAL FROTECflON DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION j lJl'{ 0 ,nnn. DIVISION OF ENVIRONMENTAL HEALTH OE~TIFIGATE OF 'NSPEGTION FO" HEALTH AUTHO"ITY APP"OVA~ E C E j V ~ D OF ON-SITE 8EWEH AND WATEH FAOILITY . ~84-4720 Application Date (,:,-~- GENERAL INFORMATION (a) (b) (c) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ~/,J Cw-,e.~,_ t..l~ Telephone: Home .. Business Applicant Address Applicant is (check one): Lending Institution [] · Owner/builder,J~; Buyer []; Other [] (explain); (d) Lending Institution /)ore. Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA to the following address: TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual WellJ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE DISPOSAL Onsite J~ Public [] Community [] HolqJing 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 72-025 (11/84) 5. 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 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 ~,~ ~ .Z~'S,~c-./,~ Telephone Engineer's Seal 6. DHEP APPROVAL App~rp_v~e~ for J,-uc.~.~,~)bedrooms by  ~ Disapproved Terms of Conditional Approval Conditional Date CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHEP does this as ~ courtesy to purchasers of 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 the professional engineer's work. Page 2 of 2 72-025 (11/84) DEPT. OF HF~TH & jUN03 MUNICIPALITY OF ANCHORAGE (MO~-~ HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984 264-4720 Legal Description: ~r/~ MUNICIPALITY OF ANCHOP, AG;: DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 1988 Well Classification Well Log Present (Y/N) A// Total Depth '~' Cased to Static Water Level ~ Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Y Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line '""-' Cleanout/Manhole "-"- Water Sample Collected by Water Sample Test Results Comments If A, B, C, D.E.C. Approved (Y/N) '-"-' Date Completed ~1~'1~4,, ~,~,/ Yield Depth of Grouting Pump Set At G.~ · Sanitary Seal on Casing (Y/N) Y Depression Around Wellhead (Y/N) · On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ;Date B, SEPTIC/HOLDING TANK DATA Date Installed Standpipes (Y/N) Y Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) -- Separation Distances from Septic/Holding Tank: Size t~"~ No. of Compartments -'r'u.~ e Foundation Cleanout (Y/N) Date Last Pumped /)e~J ~ ' for '- Temporary Holding Tank Permit (Y/N) To Water-Supply Well To Property Line To Water Main/Service Line Course To Building Foundation ~ To Disposal Field ~" To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026{11/84) C, ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Type of System Design Length of Field '~ Depth of Field //. ,~ Gravel Bed Thickness ~..,-~' Standpipes Present (Y/N) Square Feet of AbsOrption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: Date of Last Adequacy Test To Water-Supply Well JO~ To Building Foundation '-~ Lot ~ To Water Main/Service Line -'--- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Property Line ~'e '~' To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) -- 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 choked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Sgned _..~Nt~.._ / _~1~ Date MOA No. Receipt No. Date of Payment Amount: $ ~~ gg* :,~ ~ ¢~ ~ ~'" ~"~"~ %. '~'&~ ~ Engineer's Seal Page 2 of 2 72-026 (11/84) Alpine Drilling & En*erprises Domestic -- Commer tc. Pump & Water Systems N o i~.o Box 110496 Jab Name / Loca,t4e~ horage, Alaska 99511 LO-lc' 5; .-~.~k ~ INVOICE 2028 QUANTITY DESCRIPTION AMOUNT LABOR HOURS ~RATE AMOUNT TOTAL ~ATERIAL TOTAL LABOR WORK ORDERED BY DATE ~MP TOTAL LABOR PAY THIS AMOUNT ~ ~ Thank You (I Hereby Acknowledge the Satisfactory Completion of the Above Described Work,) TERMS: ACCOUNTS PAYABLE AT lOTH OF MONTH FOLLOWING PURCHASE. SERVICE CHARGE AT RATE OF 1.5% PER MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS. TIME TIME TIME ' DATE DATE DATE MUNICIPALITY OF ANCHORAGE D~PT. OF HEALTH~ & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTE~ON~ENTAL ENVIRONMENTAL SANITATION DIVISION Telephone 2644720 R E C E 1V t D B~U~ST fOb APPbOVAL O~ INDIVIDUAL WAT~B AND 8~W~B FAOILITI~8 MAILING ADDRESS PROPERTY R ESl DENT (If different from above) PHONE 2. BUYER PHONE MAILING'ADDRESS 3. LENDING INSTITUTION I PHONE MAI LING ADDRESS 4. REALTOR/AGEN~ ~ PHONE I MAILING ADDRESS 5,' LEG.~L DESCRIPTION ~ , / STREET LOCATION 61 TYPE OF RESIDENCE [~""SI N G LE FAMILY [] MULTIPLE FAMILY 7. WATER SU~.PLY INDIVIDUAL* NUMBER OF~B EDROO__~ [] One [~' Four [] Two [] Five [] Three [] Six [] Other * ATTACH WELL LOG. A well log is required for all wells drilled [] COMMUNITY [] PUBLIC UTILITY since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY /q7q 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 RESIDENGE [] SINGLE FAMI _Y [] MULTIPLE FAMILY 2, WATER SUPPLY [] INDIVIDUAL ~ [] COMMUNITY ~ [] PUBLIC UTI LI;.,TY Connection Verified 3. SEWAGE DISPOSAd SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tan~ or [] H~lding Tank Size: /ab..--c-) If Ta~k is homemade give dimensions: , TYPE OF TANK ] TOTAL ABSORPTION AR~A 4. DISTANCES WELL ~O: Absorption Area to nearest iLot Line NUMBER OF BEDROOMS [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SlX [] OTHER PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED SOl LS RATING MANUFACTURER MATERIAL Septic/Holding Tank Absorption Area lSewer Line Nearest Lot Line 5. COMMENTS ~;~.~,APPROVED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAgPROVED DATE ~ [ BY~/~ 72-010 (Rev. 6/79)