HomeMy WebLinkAboutBARCLAY CITY LT 5
i 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
~.."../' ,~ .',.'//J~ 2._ . ,~, / ,,~"'~ ..C. ,~ ~ [] UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
IWell IAbsorptionarea ~.~ Dwelling PERMITNO,
DISTANCE TO: //'/ ~ , / .) ' ~ _4-k..~ oo 2-
I- ;~ Manufacturer Material No. of compartments
u~--
Liq. capacity in gallons Inside length Width Liquid depth
IF HOMEMADE:
I~. ~ ~ DISTANCE TO: Well ~""'~ Dwelling PERMIT NO.
~O _z ~ Manufacturer Material Liquid capacity in gallons
Q Well Foundation ,/~' / Nearest lot line/~ / PERMIT NO.
~ DISTANCE TO: /.~7 ' ,~ ~ ~-~ u~
m ~ Z [ ~ No. of lines / Length of each line / Total length of lines , Trench width Distance between lines
~ ~ ~ ZZ ~ ~ ~ inches ~
~ ~ Top of tile to finish grade , Material beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diamete~ Crib depth Total effective absorption area
~ Well ~ Building foundation Nearest lot line
~ DISTANCE TO: /
Class Depth Driller ~/ ~/~ Distance to lot line PERMIT NO,~o~
~m DISTANCE TO: Building foundation~¢ , Sewer line /o / , ~ Septic tank /// / Absorption area(s) ff~/ '
OTHER ~
PJPEMATERIALS ~ ~.,,P ~ ~ 5~C ~ ~.
SOIL TEST RATING ,%1 ~X
/~'~
INSTALLERj ' /' 5m12~-~ /~
~EMARKS ~~ ~5~.' ~ ~. .
~/4~ ~.~,'~/~: ~- 1~-~ '-~.
.~?r,~ ~ ~~o~.' ":.,--' 7- ~ ~ ~.,,
APPROVED - ~~ DATE LEGAL
72-013 (Rev. 3/78)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geologicol ~ GeophysicolSurveys
Oritlin9 Permit No.
No
LOCATION OF WELL (PIDDle complete either ID, lb or lc.) ~'~/'~" "~' '
Subdivieion Lot Block I/4(Itre- Section No.I Townehip N['~ Range E[]! Meridie~
DISTANCEAND DIRECTION FROM ROAD INTERSECTIONS 5. OWNER OF WELL: /::
Addr.ss: c~- '
Street Address Qnd Arid of Will Loceti~fl
Fief 8elo~ 4. WELL DEPTH: (flflol) ~ 5. DATE OF COMPLETION
2. WELL LOC Surfoce ~'C, L-~,.ft.
Motlriol T~I Top Bottom
~ :'-: ,:>.~ e. OCable tool ~otary ODriven ODug
.~ ,,~ ( ~' 8. CASIN2: ~ Threoded ~ Wlldld
Type: ~ /
Set befweee fl. end fl.
Bockfilling Grovel pock
Equipment
~ ' ..,~ II . PUMPING LEVEL belo~ lend surfece end YIELD
ft. offer
- Matertat: ~ NIOI Cement ~ Othlr:
*'-- Length of Drop Pipe ' (/~ ~. capacity _ ,~. g.p.m.
16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Temperoture ,,o ~ F ~ C
T~is wetl ~as drilled under my jur~sdi~lio~ and this report is true to the best of my knowledge and beltef~
Address; ' -
~' Authorized Representolive
Form 02-WWR (11/81) Copy Dislribution; WHITE*State D~GS~ PINK-D~ilIIr, CANARY-Customer · ,
SOILS 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: i'Z--
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
SITE PLAN
10
11
12
13
14
15
16
17
18
19
2O
A, Sharer
No.
S
IND WATER ~_~)_ 0L
P
E
· i'YES, AT WHAT
:-PTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN
PERFORMED BY:
72-008 (6/79)
FT AND ~ FT
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D.# 05'0 --~fW[ --~33.
1. GENERAL INFORMATION
Complete legal description
Lot
5; Bar~aV C,(~V S~$-d~vision
Location (site address or directions) Mi~ 14 2
Property owner $~z~ Alford
Mailing address HC83 Bo~. 2449
Lending agency.
Ma iling address
~Road
Ea_~£~ River, AK
Day phone
Ea le RZve~ AK 99577
Dayphone
694-5354
Agent
Address
'Day phone
e
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: $
'TYPE OF WATER SUPPLY:
Individual well
Comm unity well
Public water
NOTE:
If community well system, provide written confirmation from State,ADEC arrest_
lng to the legality and status of system. ' ( / ~ ~
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-0'25 (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 '
Eagle Ri~mr, Alaska 99577
Address
Engineer's signature Date
'6. DHHs sIGNATURE
.... ~' APProved for
....... ~ DisapProved.
Conditional approval for
bedrooms.
b~rooms, with the following ~ipulations:
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
DHHS does this as a courtesy to purchasers of homes
professional engineer registered in the State of Alaska.The .
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.~5(Re~.l/gl) aac~ MOA~21
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L,.~ 7- ~ 8,~£c,-e?, C-,r~, J/O Parcel I.D. 0 -~'0 -w~/ - -3 ~
A. Well Data
Well type
Log present (~I~/N)
Total depth
Sanitary seal {~N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed '3 /I '~ /~ (~ Driller p
Cased to ~ ~"~ Casing height
~/E. 5 Wires properly protected {~/N)
FROM WELL LOG
Date of test ~' //~] / ~ (,
Static water level ! ~ ~
Well flow ~
Pump level1
SEPARATION DISTANCES FROM WELL TO:
/
g.p.m.
AT INSPECTION
MUNICIPALITY OF ANCH(J,.. ....
~'4VIRONMENTAI,- SERVICES D ~,,_.
2 7 1995
RECEIVED
Septic/holding tank on lot I I
Absorption field on lot
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform O Nitrate
Date of sample: (, J t ~- / ~ ,~'"
B. SEPTIC/I-I~L-I;NN~ TANK DATA
Date installed ~ / ~ 4
Cleanouts (I~N) Y~- -~
High water alarm (Y/N)
Date of pumping
)./
Collected by:
Tank size / 0 ~,~ 0
Foundation cleanout f~/N)
/~
¢~ ~ c Compartments
¥ ,~.5 Depression (Y/~
Alarm tested (Y/N)
Pumper $.
Other bacteria
~_ & $
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
SEPARATION DISTANCES FROM SEPTIC/~ TANK TO:
Well(s) on lot I 1 t On adjacent lots /
To property line I0 ~'t- '-I-
Absorption field
Surface water/drainage / ~ (~ ~ '/--
Foundation
Water main/service line
lO/.../-
72-026 (3~J3)* Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level /~ested
Meets MOA electrical codes (Y/N)
S:elA RAT~~j':c~ r~o:t s
Manufacturer /
Manhole/Access (Y.~)./
~uump off" Level at
Surface water
D. ABSORPTION FIELD DATA
/
Date installed ~ /~" ( Soil rating (GPD/FF) t ~0
Length ~ ~ ' Width ? ~'" Gravel thickness
Total absorption area L/(~ 2. ~,~ Z Cleanout present (Y/{~ ~v c
Date of adequacy test ('/~" / c~ ~ Results (~fail)
Water level in absorption field before test ~
Peroxide treatment (past 12 months) (Y/N)
z/I,~ ~. System type T g ~- ,,~ · ~
!
7 Total depth ! ~
Depression over field (y/~ ~v C~
for ~ Bedrooms
After test ! '
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot / o 0
To building foundation
On adjacent lots
Surface water /
iO
/ _/...
On adjacent lots / o o Property line
To existing or abandoned system on lot
/
Cutbank $- o ~ Water main/service line
Driveway, parking/vehicle storage area 5- ' '/"
Curtain drain
!
I o --/-
/O
/o -/'-
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effects inspection.
Signature
Engineer's Name
~'~.. ': ,.: ::,:: ~',t'.'. '.:."' '
HAA Fee $ ~ ~, ~ Waiver Fee $
Date of ~agment ¢-~ -~ ~ Dato of Paymont
~ipt ~umbor ~ ~ ~ ~] Bocoipt ~umbor
72-m6 (~93)* ~ck
06×26×95 14:56 COMMERCIAL TESTING ~ 9075941211 N0.735
Matrix
Client 9ample ID
CT&E Environmental Services Inc. 'I?'
[aboratory Division ~=_-:L__=:_ -------=--'~.--- '_'___~ .... _-_-_=_-_-_-_-_-__-___~ .... ~
..2.7-~ Laboratory Analysis Report
WATER
LS BARCLAY CITY SUED, KITCHEN FAUCET
PWSID UA
Technic,1 Directo=
STEPHEN C. EDE
Sample R~marks: SAMPLE COL~ECTEDEY: STEVE
OC Allow&hie Ext. Anal
Parameter R$~Ul%S ~ual Unit~ Metbo4 Liml~ Date Da~e Knit
Nltrate-N i.1 mE/L EPA 35~.2 10. 06/~1/~$ OAA
See SadDle R~ma~ke Above
t~dete~ed, Ze~orted value lo the ~ractical quantific&tlon limit. LT - ~. ~
Soconda~ dilu=io~. ~T - ~reater ~
2~.-W. P~ter Drive, Anchorage, AK ~g618-1605 -- Tel: (907) 562-2343 Fex: (gO7) 561-5301
[NViRONMENTA[ FACILITI~ I~ A~KA. CAUFORNIA. FtORIDA. iLLINOIS. MA~Y~NO, MICHIGAN. MI~SOURL N~W JERSEY, OHIO, WE~T VIRGINIA
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 ,,~- ~'--~.~ 4;.
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
Location (address or directions)
/'.,.'c-~- ~-"-~/,2 o ~' ~-'->,Pc'-c~= /~,~--~ /~' ~'.
Applicant Name ~,-~'f-~,,'t-~--'= Z.. ,~/~:)z~ Telepl~one: Home
Applicant Address /-~-'~ Z l ~ ~ ~j ~~= /~ , ~ ~
Business
(c) Applicant is (check one): Lending Institution []; Owner/builder,~ · Buyer []; Other [] (explain);
(d) Lendinglnstitution [.J['='~ .~ ~'~([9~(,~._C--~IP-~{'~ ~,A/,-L~ele'~one "~_'~_o --~'C.~.
/
(e)
(f)
Address ~, ]~. E'£1; b
Real Estate Company and Agent F/~:~'
Address
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [~ Multi-Family []
Number of Bedrooms '~'
Other
3,¸
WATER SUPPLY
Individual Well.J~ 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 ~. 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 I of 2 72-025 (11/84)
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
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and aclequa~
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information obtaine~
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect
the date of this inspection.
Name of Firm .~>~--~i-t~'~-z/~,~ ,~'~ ~-.~ ~,-~L~ Telephone _'~4; Z --P--i~- / ~'
Address _~-.~,.~ ,'SL~'~,~ I~,~.~ :;~-~'-E~ _~ A,,~-~/-/,.~,,'~-~-~ ~ ~"~..)'~ ~
Engineer's Seal
DHEP APPROVAL
Approved for '/~""~-'"
Approved
bedrooms by
Disapproved Conditional
Date
Terms of Conditional Approval
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 a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspection~ 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)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MO,-.
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ,~c~' ,~-
MUNICIPALITY OF ANCHORAG~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
APR ] 0 1986
Well Classification /~t~, ¢"/~,'-'~-~'" If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) Y Date Completed ~'- / -~ - ~ ~ Yield
Total Depth ;~--~"'~ Cased to
Static Water Level / ~ 2_
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Depth of Grouting ~
Pump Set At ~-- '~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Nearest Edge of Absorption Field on Lot /o/
To Nearest Public Sewer Line ~
///' ' On Adjoining Lots ~-'
t
· On Adjoining Lots
To Nearest Public Sewer
Cleanout/Manhote ,--' To Nearest Sewer Service Line on Lot '--'
Water Sample Collected by ¢-¢../. ,~-/-~-r.,~ ~ ' Date ~--/
Water Sample Test Results ~,..~ ~ ~ ~---~.¥2 ~
Comments ,,,~z'~-/~ ,,9-~,~,,~ ,,,.¢,~. /,¢-~.f--¢..~/.~ /-f,~,,.~ ,,~- 7-~,~.
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (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:
To Water-Supply Well ///
To Property Line /~,"'; .5"
To Water Main/Service Line
Course /
7-/,2-~.>''' Size//¢''c~ ~"~'"¢'~-~' No. of Compartments
Air-tight Caps (Y/N) Y Foundation Cleanout (Y/N) ~"
Date Last Pumped
'~ · for
Temporary Holding Tank Permit (Y/N)
To Building Foundation /o
To Disposal Field 5 /
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABS'ORPTION FIELD DATA
Soils Rating in Absorption Strata
MUNICIPAUTY OF ANCHORAG2
DEPT. OF HEALTH ,&
ENVIRONMENTAL PROTECTION
Date Installed 7-/~-~'"
Width of Field ,ftt'
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ,,/o
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
Type of System Design
Length of Field -~ ~ /
Depth of Field ~ ""/"
Gravel Bed Thickness ~'"
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /_~.S
To Existing or Abandoned System on
· On Adjoining Lots
To Cutbank (if present)
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.
Compan~'~h'L~r.; -'~ ~$'~ . MOA No.
Receipt NO. 3'") ? ~__ ~"~/
Date of Payment
Amount: $ (-..¢
Page 2 of 2
72-026 (11/84)
Engineer's Seal