HomeMy WebLinkAboutBENITO BLK 1 LT 10
ri[ling
by
DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 272, GN-tUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND ,J/er? ~,.ZE,! ~
ADDRESS ]<~-~ ~,~'~;~ ,f'7 ~ /~
LEGAL DESCRI~ION ~ / O ~/< I ~ ~O
DATE-Started ~/~ Ended ~/~
~ND OF FORMATION: ' '
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DEPTH OF WELL
STATIC LEVEL OF WATER FT.
DRAW DOWN FT.
GALS. PER HR
KIND OF CASINO
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Ft. to . .Ft. ~ I ~ From~Ft. to . Ft.
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Ft. to Ft .... ~ ~ ~ , From Ft. to Ft.
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Ft. to--Ft, kY~,"OO ~/ ~~rom~Ft. to Ft.
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/
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MISCL. INFORMATION:
DRILLER'S NAME
i','l Ud t'-.i ][ C_-:: :]t: F' IFtl._ ]'. 'T* '-r" C:~ F F! l'-,i C: i-t ~.T) F-: R C..~ E
DEPRF.:TI"'IENT OF HERLTH FINE:, EN',,,'][F..'C~NFIEN]"RL PF.:OTECTION
825 L :STF.:EET., FtNCHOF.'.RGE., Ri.':: L-}.95F12L
264-4-728
PE.F.:M];T NO ·
r.;:,FITE 1:5:51...IE;[:,.
FIF'PI.... I CFINT '
H [.., [.,F..E.=,=, ·
3RhlE:5 t'l ELLI:5
:1..46 GENORFI
ERGLE R I VEF;;:., Ri,:.'
e.]94-.24.76
99.577
L...EGRL [:,E2..]CR I F' '
L. OT S l ZE '
L.C T L. OCRT Z ON '
SIJE:DI'v'ISION: E:ENITO
SECTION: .'1.;2: TOWNSHIF': 141'4
:t.."-;~'.'L27 (:SL::!. F'T. OR FICRE:5)
GENOF.:FI i:lN[:, E:FIRRNOF R'v'E
L 0 T · :L E~ BL. OCK ·
F.:FINGE · 2H
I CERTIF'¢ 'THFIT
t. I RM FRPIILIRF'. 1.4ITH THE REQUIREMENT:5 FOR ON-:SITE :SEP~ER:-]; FINE.:, NELL:5 II:5 :SET
FORTH B'¢ THE MUNICIF'FILIT'¢ OF FINC:HORFIGE (PIOFI) RND 'THE :STRTE OF FI L FI :5 K FI .
2. I NILL IN:STRLL THE :5'.r':5TEH IN F~CCOR[:,FINCE [4ITH RL.L hlOFI CO[:,E:5 FINE:, REGULFITIONS.,
FIND I N COI"IPL I FINCE 1.41 TH ]''HE [:,E:51GN CR I TER I Ft OF TH 1:5 PERPII T.
I glIL. L. FIE:,HERE TO FILL. PIOFI RN[:, SI'RTE OF FtLFt:SKR REC.!UIREr,IENT:5 FOR THE :SET BFICK
DI'_gTFINCE:5 FI~'.OP1 FIN'-r' E',:'-','I:STING 1.4ELL., HR:5]'EHFITER [::,I:SPO:SFIL S'¢:STEP1 OR PUBLIC:
:SEHERFIGE :5'¢E;TEP1 01'.,I ]'HIS OF.: FIN's.' FIE:,.J'FIC:ENT OR NEFIRB'¢ LOT.
:5 .T. ,.3 NEE:, ~~__.,~:~ ,_ _~//~ E:,FITFZ ·
HFF LI_.f N I (¢FINES hl ELL. I:5
PERr,!:[ T NC
DEPRRTHEh~ OF FIE:.IaL. TH RI'-,I[:, EN;,,' ! ROt'.,!HENTF:It... F'Fi:OTEC"i"101'-,t
825 '" L '" %TREET., F~i'.,ICHC~RF!G[[., FIK.
P-I! E.:.: L. E ....F- EC !F~L". h"~ :E "T'
RF'I:::'L t CF:INT
L O C t:::1T I C) !",1
LEGFII
Cf::I!_K ! F.t:'5 Ei",!TERPI-:;: ] SE!;'.:'.;
GENOF'.R L:.; T.
L.. J.. E~ B :1. E: E 1'.41 T O :.::;,.." [:,
M t 1',41 HI...IH [], I :]4;TRI'.,ICE E:ETHEEI'-,I Ft 14ELL. FII'.,ID FIN'¢ ON-:5 ! 'FE :SEI.,.iFtGE ,r.:, ! 5F:'OL'.:.';F:tl .... S'¢'.'~F.r!7!:H I :iii;
::l..EfEt FLEET F:'CIR FI PR I',,,'FITE !-,].ELL.; OF.:
:tS(i!f TO ;?.'Ei~'..} FEET FROM FI PLI[.3L ! C: !qELL [)EPEI'.,I[:, I NG LIPCd'.,I ]"HE T?PE OF' PUE!',t.. l C': F!Fi]...i ....
I.,.IELL L.O(:.:i:!.:.; FiRE F..'.EC4UIF.:E[:, FIND MI..IST 8E F.'ETLtRNED TO THE DEPFIRTMENT I.,.tITHIN
OF "['HE 1.4EL, L COMF'LETIOI'.4.
OTH[::];?. F.:EC!LI t I:~:EMEI",!TS MFI'T' FIPF'L.'T'. .%PEC t F' I CI::IT ! ONE; F~.i'-,ID C()N'..'i!;T,~;:LtCT I ON
F:i',,,'FI I L. FIE:LE TO I N::;URE PROPEF.: I N:!STFILL. I:¥r I ON.
:[ CERT I [:.-'.r' THF!T
::t..: :[ l.::lM FFIHILiFtF: I.,.!ITH THE RE(;:!UIREMENT:':~; F'OR ON-~5I'f'E
F'OR]"H EP.r' THE MUI'-,I t C ! Pr:IL I T'¢ OF FI!'.~.C:HOI:;.'.t::fGE.
;',ii:: I F.iILI .... IN:5'fflLl .... THE L:!;MST[.':_'H IN F~C:COR[:,FINCE HITF! THE CODE?:':;.
'F_:: I G N E [:, ' ..... ~ ...........................................
2 _~"1" CF[LK ! N'.5 E:NTEF:':F'R
E:,EPFIF;:'."f'HEN"I" HEF. tLTH FIND ENV I RCINI',IENTFII.. IOTECI"I ON
25J..El E. :LIDOR RD.., FINCHORFIGE., At:::.
276-222'1.
1.--I E g. L_ F" E: I:~." Ir-1 ]E_ 'l-'
( 7'64F17' :.',
FIF'F'LIC:ANT E[:,L,JRR[:, M NOF. ff'IFtN FO E:l'r,:.:; P,:-::-: EAGLE F.I, ER FIK .6S~4-9t4.4
LOC:RT I ON
LEGFIL. LiE) BfL BEN ITC. _ LOT :,I~E'-' '~" A. 9t27 'E;QURRE F'EET
MIN]:PIUt"I E:,I:,I~N_.E BET[,.IEEN
iEl~3 I::'EE"I" F'OF~: ~ PR~',,,'~TE PJELL FjR" 2C~C~ FEET FOR~ F'UE~[C: HELL.
"~ I " ~TO T~E
MEL. L LOGS; RRE F~:EQU~REE:,
OF' 'T'HE HELL CO~'IPLETZON.
.... 1 LL..ll .[L.H~].I..IN:, HNC., I_.UN:,T[.LIL.~[UN [.,ZHIJR~M ]RI [LHE, LE TO [N:,.LI~.E FROFER
]:
NST~LLRT~
ON.
1: I RI',I,,F'Rf,lZt..ZRR ~4Z'TH THE ~.EQUZREPI~T~ FqR ON-SZTE 5E~,IERS RNE:, PJELLS R2; SET
FI:3RTH E:,. THE r'IUNICIPRLITY ~F RNCHOR~GE~
2: ~ Ld~LL. ZNST~LL THE ~VST~r~ ~:~:D~E ~d~TH THE CO[:,E~.
S; I G N E E:,: ..............................
FIF'F'L I CRNT
NUN I
DEPSR. TMENT
2~i0 E. TUDOR RD., RNCHORRGE, RK 99507
b~LL P~R~liT
PER~IT N0. (76845)
~CHRRD L. EG~ BOX legl E.R. 6882217
iOCRTIbN~ .... GENORR STREET
LEGRL Lie Bt BENITO SUBD
LOT SIZE 190~0 ~QFT
MINIMUM DI~TRNCE FROM WELL TO RNV ~EPTIC TRNK/PRCK~ PLRNT OR ~OIL RBSORPTION
S~STEM I~ 188 FT FOR R PRIVRTEWELL RNb 28~ FT FOR R PUBLIC WELL.
~LL L~S MUST BE RETURNED TO THE DEPRRTMENT WITHIN ~0 DR~ OF THE WELL
C~PLETION,
SPECIFICRTIONS RNO CONSTRUCTION OIRGRRM~ RRE RVRILR~E TO IN~U~ PROPER
IN~TRLLRTION.
ICERTIF¥ THRT I RM FRMILIRR WiTH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS
AS SETFORTH BY THE MUNICIPRLIT¥ OF RNOHORRGE RND WILL INSTRLL IN RCCORDRNCE
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 ~:) '"
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ~'~{Z-~J- ~.l...t.~-~ Telephone: Home (~>z:l~'~r' -'2./-~,~ Business
Applicant Address '~ [ z-~r'L~, . ~'Z(-.-~'7",.)f-.-'wr2~J~
Applicant is (check one): Lending Institution [] ' Owner/builder,J~ Buyer []; Other [] (explain);
(d) Lending Institution Telephone
Address
(e) Real Estate Company and Agent ~:~/~ ~'-~ ~-"V~,,__.4
Delephone t,~-lt'~- q ~ ~
(f) ~ the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well,;~]-- Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [] Public I~ 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 1 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 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 Telephone
Address
Date PH, 69~2979
DHEP APPROVAL
Approved for ~'~~ '
Approved _ ,/~
bedrooms by ~~-~ ~
Disapprove~/ ' -.~, ... Conditi°na?
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 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
.MUNICIPALITY OF ANO4ORA(~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~ r ~ 0
FJUN ? 19R
R &ElyED
WELL DATA
Well Classification
Well Log Presentl~N)
Total Depth ~ ~ t
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit~;)N)
Separation Distances from Well:
To Septic/Holding Tank on Lot I'Z//~*
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
If A, B, C, D~E.C, Approved (Y/N)
Date Completed ~'J ~-~/'~ Yield
Cased to + Depth of Grouting
[~::>~7.-- ' Pump Set At L~
Sanitary Seal on Casing
Comments
Depress,on Around Wellhead (Y~
; On Adjoining Lots
io//~ ;On Adjoining Lots
:'"/,.~ To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
~,~,~, ~ I/~¢=:~t.l~(.; ; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N) Air-tight Caps (Y/N)!
Depression over Tank (Y/N)' Al //
Pumping/Maintenance Contract on File (Y/N)J
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Welt
To Property Line
To Water Main/Service Line
Size No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Course
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
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 ~
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
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
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes (Y/N)
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.
Signed ~ .,~ ~ ~""~'"~',,~ Date
,,~ .~ ~'8'RB~"~198X ..... '""" MOA No.
Receipt No. ' ....... ~' .... 2g /
Date of Payment ~ ' ~ -~ ~-
Amount: $ ~ ~
Page 2 of 2
72-026 (11/84)
· DA~E RECEIVED'
TIME TIME TTME - -
D'ATE DATE ' bATE
"INSPECTOR INSPECTOR INSPECTOR
MUNICIPALITY OF ANCHORAGE JVlUNIClPAUTY OF AN_~H.OP. AGE--
! N PT OF HEAL
DEPARTMENT OF HEALTH & ENV RO MENTAL PROT;CTI~3~E ~4ENTAL PROTECTION
LTH&
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISIONOCT 3 :[ 1979
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SL~~I~[~S
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing.
1. P~ERTY~ I PHONE
PROPERTY RESIDENT (If different frET above) J ' PHONE
PHONE
2. BUYER
MAI LING ADDRESS
3.'"LENDING INSTITUTION ' ~ PHON~
4. R~LTOR/AGEN~
MAILING ADDRESS ~ ~ -
5, LEGAL DESCRIPTION
.~ SINGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS ' '
[] One ..~ Four [] Other
[] Two i--i' Five
[] Three [] Six
7. WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
PUBLIC UTILITY
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior tO that date,~i.ve,well
depth (attach Icg if available.)
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified.
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AR EA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OFBEDROOMS
[] THREE [] FIVE
[] FOUR [] SIX
[] OTHE~
Septic/Holding Tank
IAbsorption Area JSewer Line
Nearest Lot Line
5. COMMENTS
-'~"'" APPROV ED FOR g~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
;)ATE I BY ~.~
72-010 (Rev. 6/79)
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