HomeMy WebLinkAboutBENSON LT 2
Municipality of Anchorage Page / of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~ ~1/ ~../~0 ~_~ PID Number: t~/' ~'~/'"~'
Name'. Wastewater System: D Ne~/5~/~ 0pgrade
Address:
~C ?Z z~ox 32~G, gHP&/HK ABSORPTION FIELD
Phone&5_ /~¢7 ~ ~ Deep Trench ~ Shallow Trench UBed ~Other
LEGAL DESCRIPTION so, Rating: GPD/Sq. Ft. Total~m original grade'.
to pipe bottom from original grade: ~el depth beneath pipe
Lot:
BJock:
Subdivision:
Depth
~ O~ .111 added above original ar~x Gravel length:
Town~ [ Range
~H..ra~e Grave~ d.pth: ~ Number of ,nes:
WELL:
/ Ft. Ft,
Classification (Private. A,B,C): Total Depth: Cased To: Total absorptio~ea: Pipe material:
Driller: , Date Drilled: Static Water Level: Install~ Date installed:
J Pum. Sot at: I Casing Height Above Ground:
~'~: /' ~ ~u ~SL ~t.I ~ ~,. TANK
SEPARATION DISTANCES ~ Septic ~/~}~Holding~ ~S.T.E.P.
To Septic Absorption Lift Holding ~ub~Prlvate Manufacturer: ~~ Capacity in gallons:
From Tank Field Station Tank Sewer Lines
Well /~/ ?~0/ ~/~ ~ /~Ot Mat~.._ NumberofCompartments:
Surface
Water ~/~ ~//~ W/A ~/~ W/~ LIFTSTATIO~~
Lot Size in gallons:~ Manufacturor:
~urtain ~ump ~'~ ~odo} ~ [Ioctrieal In~poetlon, poOormod
Remarks: ~ ~e// ~r~ BENCH MARK
Location and Description:
~ IA'sumed Elov"tiOn:
ENGINEEE'S SEAL
Inspections performed by: ~&t~~ Dates: 1st 0~/~/2~ "~ ~=~'" "~ ~
2nd ~' ,
~,, ~_ ~ L,'~ ~s ~,. ,3 er, ~' ~,'
Department of Health and Human Services approval ~¥ ~ '
Reviewed and approved by: Date: ~ ,~,..~=~ ~, ,~.:,.~:-
72-013 (1/91) MOA 25
Permit No. ~'g'~' ~'.xO~?3 Page
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Legal Description:
N 89°59'56' E / /
175,00
EASEMENT
PO' UTILITY & ROAD
15' UTILITY EASEMENT
.~.
~ EXISTING ~ELL
ABANDONED TO CODE
BENSON
LU~ 2 I '~ ~,~'
·
i 175,00 +
N 89°55'e7' ~/
:
:
ENGINEER'S SEAL
~ .. -y ,,
..~9TH~ '. ,~
72-013 A (2/91) MOA 25
JUN 1~ '~S 8:I1 FROM GEOSCIENCE-ANO 87£A PAGE.001
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.. MiliICL. INFORMAIION:
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW920073
DESIGN ENGINEER:EAGLE RIVER ENGINEERING SERVICES
OWNER NAME:DENNIS SAMUEL J
OWNER ADDRESS:HC 78 BOX 3235
CHUGIAK, ALASKA 99567
DATE ISSUED: 5/05/92
EXPIRATION DATE: 5/05/93
PARCEL ID:05128166
LEGAL DESCRIPTION: BENSON LT 2
LOT SIZE: 52500 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT:
THIS PERMIT IS FOR THE CONTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
Louis Butera, P.E.
Registered Civil Engineer
April 28, 1992
John Smith, P.E.
Manager, On-Site Services
Municipality of Anchorage
P.O. Box 196650
Anchorage, AK 99519
Re: Benson, Lot 2
Narrative
Dear Mr. Smith,
The proposed well upgrade will have very limited impact on adjacent properties for the
following reasons:
1. The area. has large lots allowing sufficient room for septic sites.
2. Immediate neighboring septic systems are all + 100' distance.
3. Reserve space is adequate, due to absorption capacity.
4. The upgrade is necessary due to high nitrates in existing well.
If you have any questions please call our office at 694-5195.
Sincerely,
Louis Butera, P.E.
P.O. Box 773294 · Eagle River, Alaska 99577 · Telephone (907) 694-5195 · Fax (907) 694-3297
N 89°59'56, E / J
~7s.oo t /
15' UTILITY EASENENT ~_ o~ o
SEPTIC PIPES
~EN~ON I~1
~ q~'T_D T 2
DF LDT 33
~ ~ LNEV YELL TO CODE
~1~ ~ .. / ~,~t
/~ ~ BENSBN
PIPES
o / LIN k LET 2 /
VACANT
~ ~ - TEST HOLE
· - MONITOR TUBE
o - SEWER CLEANOUT
~ - WELL
~:',~- PROPOSED LEACHFIELD
EASEMENT
W ELL S IT E P LA N
LEGAL: LOT 2, BENSON
DENNIS/SCHEN ~"~' .""
OWNER:
CONTRACTOR:
JOB ff 92-028 DATE' 04/22/921 SCALE 1" = 60'
EAGLE RIVER ENGINEERING SER VICES ~. ~_. ' · · .~
P.O. Box 773294 *.~z'.. ...'~
~A~ RIVBR, A~. 995??
(907) 694-5195 FAX; (907) 694-3297
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
NAME P NE
~,,.,~,.,~.~s~?. ~. ~ox /30/. P. ~, 4~.
LEGAL DESCRIPTIO~
~~~~.:: ~ . ~ ,o.o~,~oo,~
~~,~ctu~ ~~ ~X~e/,o.o,,~.
Liquid, lions IF HOBE~DE: I nsid~ I~ngth Width Liquid d~th
~ ~ ~ Manufacturer Material Uquid capaciW in
Q~ DISTANCE TO: Well/~__,, -- '__~ F°undati°nzx~''~- Nearest Iotlinx7 1.~,__
No. Of lines / Length o~lin¢ Total '~m oOin~¢ ~r~i~r
T°p°ftilet°fn~rade~ 7~ ~ Materi~L~neathtile /~ t' --~ i /~' )TotaleffectivX~~ar
Length Width ~ PERMIT NO.
~ Type of crib Crib di~ rib depth '
Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE yO:
~ 01ass Depth Driller Distance to lot line pE~MI~ NO.
~ Building foundation sewer line Sep~ic t~nk Absorption area(s)
~ DIsTANcE ~O: ~ j
OTHER
PIPE
MATERIALS.~/O- -- -- ~
72-O1 ~ Rev. 3~78)
OWNER OF LAND
ADDRESS
LEGAL DESCRIPT
DATE, - Started —
PERMIT NUMBER
KIND OF FORMATION:
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MISCL. INFORMATION:
by
DOC Co. dba
SULLI"N WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 • TELEPHONE 688-2759
Ended
DEPTH OF WELL
STATIC LEVEL OF WATER FT
DRAW DOWN FT.
GALS. PER HR
KIND OF CASING
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Ft. MUNICIPALITY OF ANCHORAGE
PT. OF HEALTH &
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Ft. ENVIRONMENTAL P,.VTECTION
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i l O 2 1980
Ft. AL
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DRILLER'S NAME
PERMIT NO.
r. ll_l~ I I~ ~[ r'.-~L I T~' I_--lF FI~-IC:h.~P..FIL]E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 "' L" STREET, ANCHORAGE, AK. _q._q. 5A'.~
264-4720
WELL FII%iC, CII"4--S ITE SE~,IEF..: F'Ei~-"I~ I f
( 800098 )
APPLICANT
LOCATION
LEGAL
TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH
69'?-~825
57750 SQUARE FEET
MAXIMUM NUMBER OF BEDROOMS
SOIL RATING <SQ FT?BR)= 85
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
[)EPTH= ? LEI~IGiTH= 4--*~- m3RFI%-'EL C-,EPTH= --*.'.:
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF 8 TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETWEEN THE OUTFALL PIPE
RND THE BOTTOM OF THE EXCAVBTION (IN FEET).
REQIJ I REC) SEPT I C TRr-IK: S
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TI-dm] <2) I ~SPECTIID~-IS FtRE REQLIIRE[:,
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
±00 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL. DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ~0 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
RVRILABLE TO INSURE PROPER INSTALLATION.
F"ERIr.1 I T E:~-~iF' I I~:ES [-~ECEr-IBER _-Z4~l_., 198E~
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2~ I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3~ I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN ~ BEDROOMS.
=.IGNE .....
APF'LIE:AN~ PETER J. BENSON
. ,
ISSUED Bz/_~z~_~__~_=~~_~____DATE_ ',.'4. 0
SOILS LOG
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99B02 276-222~J
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
/" SLOPE '~ z SITE PLAN
1
2
~ - 3
'-'---'4
~ 7
10
12
14
17
20
.5'IL 7"/7'Z~f 5o/ L
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
/~o 7~ ~o ~iA
Gross Net Depth to Net
Reading Date Time Time Water Drop
~Ih-.
/
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN
f /
COMMENTS f'~S~' ? Tr~IC I ~)?~
72~006 (7/76)
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. # 051-281-66
HAA # ~o~ ~F~ t-~(~l
GENERAL INFORMATION
Complete legal description
Benson, Lot 2
T15N R2W Section 25
Location (site address or directions)
18040 Kamkoff Avenue, Chggiak
Property owner Samuel J. Dennis
Mailing address HC 78 Box 3235, Chugiak, AK 99567
Lending agency N/A
Mailing address
Agent N/A
Address
Day phone 265-1669
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 ~
TYPE OF WATER SUPPLY:
Individual well ×
Community well
Public water
NOTE:
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:
x
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
J2-025 (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 River Engineering Services Phone 694-5195
Address P.O. Box 773294, Eagle River, AK 99577
Engineer's signature
DHHS SIGNATURE
~ Approved for
DisapProved.
./--~. ~"_ ~/' ~ .') bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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 engineer registered 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 & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~/VSDA/ ~::)7" ~
A. WELL DATA
Well type /D/~//,/,,~'~ If A, B, or C, attach ADEC letter.
Log present (Y/N) ~/~ Date completed
Total depth ~'~ ~) /
'"- Cased to
Sanitary seal (Y/N)
" FROM WELL LOG
Date of test /~ ~./~'~-
Static water level
Well flow t/~' ~-~
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/b, e4~g tank on lot /,P-~ /
Absorption field on lot
Parcel I.D.
ADEC water system number
~/~ ;Z. Driller
~::>~o ~a / ~ Casing height ~ / .~-~ ~,~,~-'
Wires properly protected (Y/N) ""/'~ '~"-'~
g.p.m.
Public sewer main
Sewer service line
AT INSPECTION
h h
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
/00 '
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate L /~Z~)~-. ~-- Other bacteria
'-- Collected by: ~'~/~/~//~'~",~_ "~
B. SEPTIC/HOLDING TANK DATA
,Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size /~-~ ~¢t Compartments
Foundation cleanout (Y/N) ,Y '~ Depression (Y/N)
'~'~ Alarm tested (Y/N)
/1 ~ / Pumper ,.7'/~ 5'
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /,)~v' On adjacent lots
To property line '~$' ' Absorption field
Surface water/drainage /~ ?,'~
-f-/~o ~ Foundation /~' ~'"'"'(
~' ~-~,"~ ' :Water main/service line '~/o '
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION /VA
Date installed
Manufacturer
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
sEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD D~TA
Date installed //~R~
Length /'/¢' / Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
Soil rating E'¢- ~/~,¢e System type
Gravel thickness ? / Total depth ~'-'
Cleanouts present (Y/N) )/
Date of adequacy test ~'///~-/~'-~
for -?
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot Y' /~'~
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots //'-~ ~'~¢- / x/_) Propertyline
To existing or abandoned system on lot
Cutbank ~'?,~ Water main/service line ¢/¢ '
Driveway, parking/vehicle storage area ~' / z2~-;,,~.,:,~ .-,~--~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or confor.rned to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date /
HAA Fee $ /?~) 0
Date of Payment ~ -~ O--~~~¢¢)
Receipt Number ,~".~ ~c~oL/
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date November I0~ 1987
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 2; Benson Subdivision (E~; Lot 34; Section 25;
TI5N; R/W; SM)
Location (address or directions)
(b) Property Owner
Mailing Address
P~'::e Benson Telephone: Home 688-3867
Business
(c) Lending Institution Home' Savings ~; Loan As.~ociat,~Liphone
Mailing Address Anchorage, Alaska/ATTENTION: Robin
(d) Real Estate Company and Agent FORTUNE ~OPERTIES/Margar~t Goch~
Address ~000 A Str&~ S~t& I01~ Anchora~&~ Alaska 99503
Telephone 562-1653
(e)
Mail the HAA to the followina address: or: Check here [~, if hold for pick up.
List contact person and day phone number below.
S & S EN~INEERIN~/~94-2979
Eag£.P. I~Ju~_~; fl~a qq577
ordered b~ Margaret Goche
TYPE OF RESIDENCE
Single-Family [~
Number of Bedrooms
WATER SUPPLY
Individual Well I~ Community [] Public []
Note: If community well system, must have written confirmation lrom the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite [~ Public [] Community [] Holding Tank I--I
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 ~Rev 8/86) Front
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 alt Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm
Telephone
Address S & $ ENGINEERING
17034 Eagle River Loop Roid No. 204
Date ;>eR!v~-"~ _A.l=.~ka 9957~
Note: The well for this property meets
codes.
it is suggested that periodic testing be performed to
insure the wells continued suitability. Nitrate
concentration is 7.7 mg/1. EPA maximum concentration
10.0 mg/1.
DHHS APPROVAL
Approved for ~ bedrooms by
Approved_ c.~. Disapproved
Conditional
is
Terms of Conditional Approval
CAUTION
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 engineer
registered 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.
Page 2 of 2 72-025 fRev 8/86) Rack
WELL DATA
MUNIQPALITy OF A~MJ INICIPALITY OF ANCHORAGE (MOA)
..ROWL
,~o oi~KLiST' FEBRUARY 1984
rVOV I987 264-4744
Legal ~cription: ~
Well Classification
Well Log Present ~)N)
!
Total Depth ¢~ ~
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit~N)
Separation Distances from Well:
To Septic/I-I~Idrrl-g Tank on Lot
If A, B, C,/D.E.C. A/oproved (Y/N)
Date Completed (.z~/~- / /~O Yield
/
Cased to ~ ~ / Depth of Grouting -'--'
~'~F ' Pump Set At t.~.~-.
~ ' Sanitary Seal on Casing (~N)
Depression Around Wellhead (Y/~[~)
/
/ ~20 ; On Adjoining Lots
To Nearest Edge of Absorption Field on LOt /o2... ~ ; On Adjoining Lots
To Nearest Public Sewer Line d/~ To Nearest Public Sewer
Cleanout/Manhole ~/A To Nearest Sewer Service Line on
Water Sample Collected by /----~/~,. ~ _'~-~,~. (~!~r'"~C-~ ;Date
Water Sample Test Results ~,~ ~"/'~ ~ I
Comments .~, ~ ~ ~'J~f.//~ ~"7~.~ ;.,~ "~-~-"~'1"' ~:),~/~
SEPTIC/I:~-D1RG TANK DATA
Date Installed '"7/1/~0
StandpipeS)
Depression over Tank (Y~
Size
Air-tight Capsd~)
Pumping/Maintenance Contract on File (Y/N!\ ,/
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/l:b:d=l~g Tank:
/
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Comments
No. of Compartments '~'
Foundation Cleanou.t (Y/~
Date Last Pumped
b'~/J~'~ ; for ----'--
Temporary Holding Tank Permit (Y/N)
I
To Building Foundation ~"~-.~
I
To Disposal Field ~
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026 (Rev 8/86} Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed "7 '~
Width of Field
//
Type of System Design
Length of Field
Depth of 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
Gravel Bed Thickness
Square Feet of Absorption Area 'Z--"~ ~ ¢ Standpipes Present ~N)
Depression over Field (Y/I~ Date of Last Adequacy Test \\
Results of Last Adequacy Test _~::~, ~ ~'~
Separation Distance from Absorption Field:
~ C;"Z..~ To Property Line \
To Fxisting or Abandoned System on
: On ^dioining Lots t¢
/ c~ To Cutbank (if present)
Comments
LIFT STATION
D~t~ '; Dimensions
Size in Gal. l. ons ~ ' Manhole/Access (Y/N)
"Pump On" Level at ~ "Pump Off" Level at
High Water~Alarm Level at
Tested for
Electrical Codes (Y/N)
Comments
Vent (Y/N)
ring Adequacy Test. Meets MOA
** 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.
· & $ ENGINEERING
17034 fag~ , . ...~ .......... ~' / -_
Receipt No./(~-.~/ O007
Date of Payment
Amount: $
Page 2 of 2
72-026 fRev 8/86/ Back
c~t~ ECT~i oN~A-p~p; i~N'-T M E NTS
TIME TIME
DATE DATE
INSPECTOR INSPECTOR
DAT=~RECEIVED
TIME [
I NSPECTORF~
MUNICIPALITY ~F ANCHORAOE
MUNICIPALITY OF ANCHORAGE DEPT. OF H;ALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTI~NVIRONMENTAL F;:,CTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION AUJ~ 2 5 lgSO
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERTY OWNER
MAI LING ADDR ESS
PROPERT9 RESIDENT (If different froqDfa~)v6)
2. BUYER
MAI LI NGA 0 bh E~S
' I PHONE. ~'~' ,.J~
PHONE
PHONE
3. LENDING INSTITUTION
MAILING ADOt~ES~ .---. '
777_
4. REALTOR/AGENT
MAI LING ADDRESS -
IS. '~=GAL DESCRIPTIbN i ,
Goo caf
J STREET LOCATION
1 6. TYPE~F R~IDENCE
~INGLE FAMILY
i--I MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One [] Four
[~Two [] Five
Three [] Six
[] Other
7. WATER SUP.~I~Y
[3~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
8, SEWAGE DISPOSAL SYSTEM
[~INDIVI DUAL/ON-SITE**
[] PUI~LIC UTILITY
ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
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 RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
~ I NDIVI DUAL/ON -SITE
[--]PUBLIC UTILITY
Connection Verified
'~Septic Tank or F-IHolding Tank
Size:~ If Tank is homemade
give dimensions:
TOTAL ABSORPTION AR EA
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OF BEDROOMS
[] ONE ~ THREE [] FIVE
[] TWO [] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE iNSTALLED
INSTALLER
SOl LS RATING
MANUFACTURER
MATERIAL
Septic/Holding Tank IAbsorption Area
Sewer Line
[] OTHER
¢,., o//,¢;, ¢, /,,
Nearest Lot Line
5. COMMENTS
DATE
~PPROVED FOR ~-~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)