HomeMy WebLinkAboutBEAR PARK LT 12
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
LEGAL DESCRIPTION t"~t~
Well ~ AbsorPtion area Dwelling PER~T NO,
~ Z Manufacturer Material No. of compartments
Liq, capacity in gallons~ Inside length Width Liquid depth
[ ~ IF HOMEMADE:
~ ~ ~ DISTANCE TO: Well ~ /~ Dwelling PERMIT NO.
~ - ~ Manufacturer Material Liquid capacity in gallons
Well I Foundation I Nearest Iotl~ne PER~T~O.
~ :, Nc. of lines Length of each Icne Total length of lines Trench wide. Distancebetweenline~]A
~ :~ Top of tile to finish grade ~1 ~aterial beneath tile i Total effective abso~onll~area
~ Length Width D~pth PERMIT NO.
Tg~e of crib Crib diameter depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Clas~ ~ep¢~_ Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Buddmg foundation Sewer line Septic tank Absorption area(s)
OTHER
SOIL TEST RATING
INSTALLER .',
REMARKS
APPROVED. ~,~,8~ ~9~.~ ........ DATE LEGAL
72-013 (Rev. 3/78)
ENV: F'OI II IENTAL PROTECTION
DIEPAR'TMENT OF HEAL. TH AND I [ <'x~
8;25 I.~ S'I'REIET, ANCHORAGE~ AK 9950 J.
.... 4: ~,~ EE: L.L.. F:" E::E F;~ ~ ]:: T'
:'E R M I T 1'40:
~A'I"E ISSUED:
:},_,(..) 64.,J
10/0 :t./85
~PF'I.... I C'.ANT:
~DI) RESS:
',01'4 T A C'1" P H 0 N E:
:IRA KRUGER
% S&S ENGINEERING
~ -' ~ "" AK 99577
ANCIdOb~AbE.,
694-2979
.EGAL DESCRIF': SUBDIVISION: BEAR PARK LOT: 12
SECTION: 4 TOWNSHIP: t5N RANGE~ tW
.OT SIZE: '46563 (SD, FT. OR ACRES)
lAX BEDROOMS: 3
BLOCK:: NA
.isted be].c~w are the options available 'Lo you in designing yoLu' septic
~ystem. Choose the option that best fits your site.
.... r R ET: N C:] 14 B F2: [) W . D t? (4
flEP"I"H TO PIPE BOTTOM (FT.) 4.0
)RAVEI.. DEPTH (FT,,) 9. ()
'BTAL DEPTH (FI".') 1~,, 0
;RAVEl .... WIDTH (F]".) 2.5
)RAVEL LENGTH (F:'T.) 50.0
)RAVEl_ VOLUME (CU. YDS. ) 44,, 0
'ANK S I ZE (GALS) 1~ 000. o **
;C) IL RA"FING (SD:FT. /BR) 299
4.0 4.0
0.5 3.5
4.5 7.5
25. () 5.0
47.() 97.0 ~.*
43.6 '71.9
000.0 *~' 1.,00().0 **
2.57 2.99
.~..~. GRAVEL LEEt`4GTH > 75 FT, REQUIRES MUL"FIF'I_E RUNS (NOT EXCEE:DING '75 FT. EACh,)
· ~-~ TANK MUST F'IA',4'E AT LEAST TWO COMPARTMEN'TS
cert. ify that:
1,, I am familiar with the requirement, s for' on-site sewers' and wells as set
forth by the Municipal:i.'ky of Anchorage (MOA) and the State of Alaska.
2.. I will inst..all the system in accopdance with all MOA codes and r'egulations,
and in compliance wit. h the design criteria of this permit.
3. I w:~].l, adhepe to all MOA and State of Alaska requipements fop the set bacl-::
distance~ From any ex:i. sting well, wastewaten disposal system on public
sewer'age system on.this or any adjacent or ngar'by lot.
4. I understand that:, this permit :i.s valid f~)r a maximum OF 3 bedrooms and
any enlar'gemer~t will require an additional permit.
F A LIF'T STATION IS II`4STALLED IN AN AREA 'COVERED BY MOA BUILDING CODES,
HEN (1) AN EL. EC~L' PERMIT A~D INSPECTION MUST BE OBTAINED~ (2) AS-BUIL..TS
III...L.. NOT BEE AF:'F'~]VED/WITHOU'T AN EI..ECTRICAL INSPECTION REPORT~'AND (75) 'TIDE
:I...ECTRIC, AL"'W~'~D~/)(:~A I..ICE:I`4SED ELECTRIC:lAN. '
, ,,' ............ ...... .......... ........................................................ ..........
IF'PI.... :1: CAN'I" ~'""~~ '. '
........................................ ............
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
{"Z..
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
18
19
20
Township, Range, Section:
SLOPE
WAS GROUND WATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E
Depth to Water After
Monitoring? Date:
SITE IJLAN /
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE__~' (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~ FT AND ~ FT
COMMENTS, ~
72-008 (Rev. 4/85)
CERTIFY THAT '~HIS TEST WAS PERFORMED IN
DURbiN Dmt[i~c Co.
I./t,J I~LII I1 L/II, I LLI Ilt
Time Drill Lo~I Casinc~ Mile 1.2, Lucas Road
P.O. Box 871348
Wasilla, Alaska 99687
(907)
Name:
Address:
City:
Job
Location:
· Crew: ~.~- ·
·
Date:
Notes:
Depth Well Lo~
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
(~--L~\ _ {.~..~,~ _ -~ ~¢. NAA #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner ~t-,-,~-~ ~-1, ~',. ,~
Mailing address
Day phone
Lending agency
Mailing address
Day phone
Agent
Address
Day phone
Unless otherwise requested, HAA will 'be held for pickup.
NUMBER OF BEDROOMS: ~ ",/
TYPE OF WATER SUPPLY:
Individual well ~/
Community well
Public water
NOTE:
MUNICIPALITY OF ANC-.HOEAGE
ENI/IROI~91ENTAL SERVICES DtVI$1ON
JUL 0 7 1996
RECEIVED
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
5. 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.
Nameof Firm [ o ~b~l c ~/-.-l~,~ -~ ~-- Phone fl-:7~ ~ ~ / ~
Address ,~; ~ ~' / ~-~ ~ ~
Engineer's signature ' I~,LckC~~I ' Date ~'//~
/
DHHS SIGNATURE
Approved for 3
bedrooms.
Disapproved.
Conditional approval for .. bedrooms, with the following stipulations:
Additional Comments
By:
Date 7- ~z/_... -~'~
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 engineerlregistered 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 #21
Municipality of Anchorage
DEPARTMENT OF HEALTH & H_U. MAN SERV~iwiC~?U~
Environmental Services uivision '~O. ~/~fl.N/.N. 2_ ,, 0~~
825"L" Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4.7.43/" ~RVlc~$
Health Authority Approval Checklist
LegalDescription: /,!#7' I~t ~au( ~OU~,- ParcelI.D.:
A. WELL DATA
Well type
Log present (Y/N)
Total depth /
Sanitary seal (Y/N) ..
FROM WELL LOG
Date oftest
Static water level /
Well production
RECEIVED
If A. B. or C, attach ADEC letter. ADEC water system number /,~ m m
~/ Date completed ~ /~"_~
- >1211
Casing height (above ground) ,
Wires properly protected (Y/N)
AT INSPECTION
§.p.m, ,~, g,p,m,
WATER SAMPLE RESULTS:
Coliform'~ ~/~/a~/~ Nitrate ~. ,'~ ~' i't~- Other bacteria
Date ofsmnpl~: Coll~oted by: ~ ·
B; SE~IC~OLD~G TANK DATA =
Foun~fion cle~out fire) . ~ Depression ff~ ~ m~gh water ~ ff~
Date of Pumping ~ /~4~Pumper ~ ~ $
C. ABSOR~ION'~LD DATA
Dateins~led ~W~ Soilrating (g.p.d./~2orfl2~) ~ ~ System~e
I/
, , 0 '
LenVh ~O~ Width3b / E
Effective abso~tion ~ea ~ Me,toting Tubepresentff~ ~ Depression over field ff~
Date of adequa~ test b~V/~ Resffits ~ass~l) ~ For ~ b~ooms
Fl~d dep~ in abso~on field before-test (in.); ~ ~ l~ately ~r/~g~. wat'dtaaded (in.):
Fluid depth ~(ins,) Minutes later: ~w~ Abso~fioarat~= ~'~ g.p,d.
Peroxide ~ea~ent ~ast 12 months) (Y~ , ~ ff yes, give
Date installed
Manhole/Access.([./N)~,
High water ala~'m !e~/e'l at*
1
Cycles tested
SEPARATION]
SEPARATION D
}ISTANCES
Size in gallons
"Pump on" level at*
*Datum
Receipt Number
Rev. 8/95 OSS: haa.v}k.doc
"Pump off" level at*
STANCES FROM WELL ON LOT TO:
!
Septic/holding ta~ k on lot ] O flo ; On adjacent lots .~'
Absorption field ol lot ] [ ~ I ; On adjacent lots
Public sewer mmn~ ~ ~A Public sewer manhole/cleanout
Sewer/septic semi ce line ~ ~ ~ / Lffi station
s~~ON ~Sr~NC~S ~O~ S~mC~O[~INa r~N~ O~ [Or ~O:
Building foundatk ~n ~ ~ t Prope~ line ~ O / Abso~tion field
Water mai~se~i~ line ~ ~ I
Surface water/dr~nage N Wells on adjacent lots
SEP~A~ON DiSTANCE ~OM ABSOR~ON ~E~ ON LOT TO: I
Bulling foun~t~n ¢ Water m~se~ice line
]NI Driveway, p~hnffvehicle storage area
Cu~aindrain [ ~ ~ Wells on adjacent lots ~/~O ]
ENG~ER'S ~ERTIFICATION
I certi~ that I h~e determined thru field inspections and review of Municipal ~ ,~ dhat
in confortnance ~th MOA ~ guidelines in effect on this date. '
"
Signature ' I -~
Waiver Fee $
Date of Payment
Receipt Number
CT&E Environmental Services Inc.
La b o r a t o ~ D iv i$ ion r_~'.~,~"~'.~'~'~'~'~-~-~,.~,.~-~r~-.~,,~..~.~.tjt~jjjjjjtt~jjjj~~.
Drinking Water Analysis Report for Total Coliform Bacteria w..otter 0rive
A~chorage, AK 9951 8-1 605
READ INSTRUCTIONS ON REVERSE ~IDE BEFORE COLLECTING SAM'PLE Tel: (907) 562-2343
Phone s~umber
I'a:~ ~'~umber
Cay
State Z~p Code
~ ;end Result~ ~3 Sendlnvolce
~;omp~ny Name C~ ~e
Code ,
Fax: 1907) 561-5301
BE COMPLE'TED BY LABORATORY
Analysis shows this Water SAdMPLE to be:
~ SatisfactoO'
UnsatisfaCtory
[] Sample'~ver 30 hours old, results may
be unreliable
[] Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received
Time Received
Analysis Began
,~,,,.,^dd,., Analytical Method: ..lia-"'Membrane Filter
r~ MMO-MUG
* Number of colonies/100 mi.
Lab A~,.
Ref. No. Result*
~ Routine , Q Treated Water Sent toA.D.E.C.. (~). Fbks Jun []
[] Repeat Sample (for routine sample ~ Untreated Water Faxed
with lab ref. no. ) Date: ~--)q Time:
[] Special Purpose
Time' Collected Client notified of unsatisfactory results:
S A~LP L E LOCATION Collected By [] []
L~}6 ! 2 B{~Cl.f' ~r k .I :35 4Cltt"~ Phoned Spoke with Faxed
Pit,sc Print Date: _ Time:
Comments:
BACTERIOLOGICAL WATER ANALYSIS RECORD
MMO-MUG Result: Total Coliform E. Coil
Membrane Filter: Direct Count (~ Colonies/100 mi
· Verification: LTB BGB COLIFIRM
Fecal Coliform Confirmation
Final Membrane Filter Results/., ---, -- Coliform/100 mi
Reported By /'~-b Date 6'~-~[' ~c~ Time. (::)c~/ hrs
T,'VTC · Tt., Numer,tu.~ ro Ct,unt
CT&E Environmental Services Inc.
Laboratory Division
Laboratory Analysis Report
CT&E Ref.#
Client Sample ID
Matrix
962484.962484001
Lot 12 Bear Park
Drinking Water
PWSID 0
Sample Remarks:
Collected Date 06/20/96
Technical Director: Stephen C. Ede
Parameter
Nitrate-N
Total Coliform
Results
2.33
0
QC
Qual
PQL Units
0.200 mg/L
0 col/lOOmL
Method Allowable Prep Analysis Init
Limits Date Date
EPA 353.2 06/24/95 Elizabeth
SM18 92228 06/20/96 TAV
U - Undetected
LT - Less than
GT - Greater than
D - Secondary Dilution
J - Below the calibration range
200 W. Potter Drive, Anchorage, AK 99518-1605 --Tel: (907) 562-2343 Fax: (907) 561-5301
3180 Peger Road, Fairbanks, AK 99709-5471 -- Tel: (907) 474-8656 Fax: (907) 474-9685
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST 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 //~ /- ~'""
1. GENERAL INFORMATION
(a) Legal Description' (include lot, block, subdivision, section, townsh~ipj range)
Location (address or directions)
(b). Applicant Name ItT..~. I~[-/-~.)d.~,~YL~., Telephone: Home '2v~- ~..~i~'
Applicant Address
Business L.~ - ~-~ ~[~_p
ENGINEERING FIRM PROVIDING ..,SPECTIONS, TESTS, FILE SEARCH, DAT, ,ND 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 alt Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm ~ .................. Telephone
. SRB 196X.
Address ~ ._ ~. ....... ,,-.. , .,~.~-.~
Date
DHEP APPROVAL
Approved for ~/'~'~"' bedrooms by ~
Approved ~ Disa~oved
Terms of Conditional Approval
Con~/~nal -'
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval c(~rtificates 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 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)
WELL DATA
Well Classification
Well Log Present~/N) Date Completed
Total Depth [~/'~'~; Cased to ~'~.('~' ~ Depth of Grouting
Static Water Level ['"~ ~
Casing Height Above Ground
Electrical Wiring in Conduit~)/N)
Separation Distances from Well:
.u.,c,...,. o;..c.o..o;
HEALTH AUTHORITY APPROVAL (HAA)
264-4720
Description:.. '..
Legal ~
~------~ [~ ~'~ If A, B, C, D.E.C. Approved (Y/N) ~/~
Yield
Pump Set At |/~ /
Sanitary Seal on Casing~N)
Depression Around Wellhead (Y~)
To Septic/I-~31~mg Tank on Lot ~. ~ ~- ; On Adjoining Lots
To Nearest Edge of Absorption Field or) Lot 1 [ ~, ~.----; On Adjoining Lots
To Nearest Public Sewer Line ~ [~' To Nearest Public Sewer
Cleanout/Manhole ~/,~ '
Water Sam pie Collected by
Water Sam pie Test Results
Comments
To Nearest Sewer Service Line on Lot
,~-'~1'~--'~ ~:::~~r'-~ ;Date !l~'O~ ~
B. SEPTIC/HeL-131/~I3 TANK DATA
Date Installed /~ '~"~y"~iSiz; I. ~ No. of Compartments ~-
Standpipes(~N) Air-tight Caps(~N) Foundation Cleanout I~N)
~a~;~Last Pumped ~'--~ ~
Depression
over
Tank
(Y~GD
Pumping/Maintenance
Contract
on
File
~. , ; for ' r,3 /
(Y/N) F'3/'~/ Temporary Holding Tank Permit (Y/N) .~_
Holding Tank High-Water Alarm (Y/N)
To Property Line
To Water Main/Service Line
Course
Separation Distances from Septic/He~lm~ Tank:
To Water-Su pply Well
L~·
!
To Building Foundation
To Disposal Field ~.
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIEL
Soils Rating in Abso
Date Installed
Width of Field
DATA
~tion Strata '~_~1 ~
~==,- ~ -~
Square Feet of Abso ation Area
Depression over Fiel (Y~
Results of Last Ade( acy Test
Separation Distance from Absorption Field:
I
To Water-Supply Wlll
To Building Foundal~on ,
Lot / ~[~
To Water Main/Servibe Line
To Stream/Pond/La~ ~/or Major Drainage Course
To Driveway, Parkin
Comments __
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Le
Tested for
Electrical Codes (Y/I~
Comments
** Check Permitted
I certify that I have c
Signed ~
Co m Da~;~[.E
Receipt No.
Date of.Payment ,
Amo~nt:$ ''
Page 2 of 2
72-026 (11/84)
Type of System Design
Length of Field ~L
Depth of Field ~ ~-'-~ ~
Gravel Bed Thickness ~ ,.~.~ [4
V
'-'"'~ Standpipes Present CP/N)
Datepf Last Adequacy Test 4~.I~--~"~.~-~
Area, or Vehicle Storage Area
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cu~tbank (if present)
vel at
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
edroom Rating Against HAA Request **
cked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
' ~HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC~
' TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENTEF~
5633 B Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
I.D. NO.
Water System Name
(*) See h on back
Phone No.
Mailing Address
State
City
Mo. Day Year
Zip Code
SAMPLE TYPE:
E3"-Routine
r-I Check Sample (for routine sample
with lab ref. no.
El Special Purpose
~ [] Treated Water
- ,~- Untreated Water
SAMPLE
NO.
1
2
3
4
5
LOCATION
I
Time
Collected
I
TO BE COMPLETED BY LABORATORY
I
Analysis shows this Water SAMPLE to be:
/J~Satisfactory ~ [] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received
Time Received
Analytical Method:
ID Fermentation Tube
ID Membrane Filter
Co,acted Lab Ref. No. Result* Analyst
! r-r-J
i FT'1
I r-r-1
j FT'I
*No. O! colonial/100 mi or NO. of Posture ~OrllOnl
_. READ ~ tUCTIONS
VlPLE
o~'~22o
Rev. 1983
BACTERIOLOGICAL WATER ANALYSIS RECORD
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By ~,"'~/~-~ ~
BGB
Date
Time:
TNTC = Too Numerous To Count
Coilformll00ml
Collformll00ml
p.m.