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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