HomeMy WebLinkAboutT12N R3W SEC 15 PARCEL 13C
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
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
~"AME '' PHONE [~NEW '
MAILING ADDRESS
~G~L DESO~IPTIOM
LOCATION NO, OF BEDROOMS
o,sTA~o~,o:i~l~/"lO't'i /' '~,7
~ Lq. ca aciW riga o s H MEMAD~ Insidelen~th WiSth Liquid depth
¢5 ~ ~ DISTANCE TO: Well Dwellin'g PERMIT NO.
O ~ ~ Manufacturer Material ~iquid capaciw in
-- ~ Well Foundatio Nearest 'o[ ~e
.~ No. of)inosI Length of each[jne Total length of lines Trench width ~ Distance between lines
Material beneath tile
[:~ Top of tile to finish grade t/ICi ~)D in~h~
Lengd~ Widtb Depth PERMIT NO.
~ p Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
Distance to lot line PERMIT NO,
~ ~ Class .-~ ~ S Depth JlZ DriJler V~ 6m
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO: N~'F I~J M/~
OTHER
PIPE MATERIALS
dZ-/As ~
SOIL TEST ~ATING
INSTALLER
~ '.. JU~lE 2a, 1911 .. ;.
',' ~N ~1 ~ ~
72-013 (Rev. 3/78)
DEPAR"FMEIxlT (:IF: HEAL. TH AND ENVIRONMENTAL I'"'ROTECTION
825 L STREET, ANCHCIRAI,"]E, Al< 99501
R64'-'47RO
PERMI'T'
DA'YE I SSLIE[D."
8406o0
07/2.0184
APPL I CANT:
ADDRESS:
CONTACT PHONE."
I:~OSS CONSTRUCTION
10560 SCHNEITER DRIVE
ANCNORA(~E, Al< 99516
346-272~2
I_E.]L:~AI_ DESCR I P:
LOT St ZIE:
LOT LOCATION:
MAX BFDIROOMS:
SUBDIVISION: NA Lo'r: PARC
SECTION: 15 TOWNSHIP: 12N RANGE: 5W
19800 , (SQ.FF. OR ACRES)
],04TF.I OFF BIRCH TX CODE 015-291-06
4
15C BLOCI<: NA
L.,isted below ape the Ol.~ttons available to yeu' in clesigning youm' septic
system. Choose the option that best Fits your site,,
DEPTH TO PIPE BOT'I'OM (FT.) 4.0 4.0 4,, 0
GRAVEL DEF'TH (F'¥,) 5.0 0.5 .3.5
TEITAL DEF""¥H (Ff.) 9.0 4.5 7.5
GRAVEL WIDTH (FT.) 2.5 1%,0 5.0
GRAVEL I_IENGTH (FY.) 44,, 0 55.0 48.0
BRAVEL VOLLJME (CU. YDS.) 22.4 24.6 35.5
'T'AI~I< SIZE (GALS) 1~250.0 ** 1,250.,0 *,~(. 1~250~0 *~.
SOIL. RATING (SQ.FT./BR) 1!0 1:LO 1lO
** '¥ANI< MLJST HAVE AT LEAST T'WO COMI:'ARTMENTS
I c:eptify that:
1,, I am familiar'
2.
5 ,,
with the requir, ements {or on-site sew~ and wei].s a:i~ s~:-L
[orth by the Municipality o~ Ancho~'age (MOA) and the State oF Alaska.
I will install the syetem in accordance with all MOA codes and pegulations~
and in cempliance w~th the design g~iteria o~' this per'mit.
I will adhere to ~11 MOA and State of' Alasl<a requir'ements far 'Lhe'~:~m~, back
dietances rr, em any existing well, wastewater d:i. sposal system or pgd:)lic
sewePa6je system 01'1 '[his OP any ad.jaEent er neaPby lot.
~ understand that this pepmit is valid ~o~a maximum eF ~ bedrooms
any enlargem~nt will ~'equi~'e an additional permit.
IF A LIFT STATI[]I9 IS II~STAI...LED IN AN AREA COVERED BY MOA BUILDING []ODES.~
THEN ~1) AN ELIECTRICAL. F'ERMIT AND IN~PECTION MUST BE OBTAINED; (2) AS-BUILTS
WILl.. N[]T BE APF'ROVED WI'Il-lOUT AN ELECTRI[)AL INSPECTION REPORT; AND (5) THE
EL. ECI"R:~CAL. WOFd<~ DONE BY A LICENSED ELECTIRIC:I:AN.
APPI_ICAN'I'~ ROSS C~N~TIRUCTION
SSUED
BY
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Slreet, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
LEGAL
-, /). q. SLOPE
1
2
3
4
5
6
7
8
9-
10-
11
13
14
15
16
17
18~
19
20-
COMMENTS
PERFORMED BY:
0 R,¢~,Ad",q I C
PERCOLATION
TEST
DATE PERFORMED:
WAS GROUND WATER
ENCOUNTERED? N o
IF YES, Al' WHAT
DEPTH?
SITE PLAN
I
Gross Net Depth lo Net
Reading Date Time Time Water Drop
PERCOLATION RATE
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geologicol ~ Geophysicol Surveys
I
.-- of-- of--of -- s [] w~]
ROAD INTERSECTIONS 3. OWNER OF WSLL: ~'~OSS C, onst
iO~3g&Ggd gX/r~ ~, SlOt/Mesh SIZe:~ Length:
~' s D~i].li~ & ~nt Ak3327
Street Anchorage~ Alaska 995~
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geologicol & Geophysical Surveys
Anch 1 ..........
' S~-s SE~;s N~:~
Range ~W, Seward
_gr_ave 1_ y_ till
s~lty till brn
silt gra~ brn
:$_~ ty_ gravel
_. I-~O _..~_g~_ would
s~lt~ sand~H~rave ].- se e
gray silt
cemented silty gr
.:~ented bgn .s~_~y
.. gra~ q~y~d silt
2 gpm at 322'
Alaska Now-Well~
ROAD INTERSECTIONS B. OWN£R OF WELL: :[:~OGS
not c].eaI .~ ~ Te,f Well ~ Olher:
-seep d:Lrty_ 1~8 161 9. FINISHOF WILL:
Vel seep 178 200 S~o,/~.h S,~.:
Dote
- - ~ Above or ~ Below lan~ surface
Equip m ont use,: ~~~_
~e~ ~p II, PUMPING LEVEL below Io~d sorfoco and YIELD
~ F ) Length of Drop Pipe fl. capacily g.p.m.
14,~EaA~S: 200t_2~ heav~ seep
.... ' .... 2 gpm at ~22'
,n Stmeet Ancho~age~ Alaska 99~16
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARTMENT OF ['~ALTH AND ENVIROnmENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a)
(b)
Legal Description (include lot, block, subdivision, section.~ tovmship, range)
Location (address or directions)
Applicants Name ~.~ Co_;q.~=i~_T__el__ej~hone - Itome
Applicants Address
(c) Applicant is (check one) Lending Institution ~--71 ; Owner/builder ~ ;
(d) Lending Institution Telephone
Address
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the HAA to the following address:
2. I~yj~_e__o~f~Residence
Single=Family V~-'~
Number of Bedrooms
3. Water SuE~_!
Individual Well ~[]
Multi-Family
Other (describe)
Community 1.--~[ Pub[Lic Ii~
Note: If community well system, must have written confi~0.ation from the State
Department of Environmental Conservation attesting to the legality and status°
4. ~S~wa~_~p~spo s al
Onsite ~ Public ~_~[ Commualty ~ Holding Tank l~--~
Note: If community wall system, must have written confirmation from the State
Department of Enviromnental Conservation attesting to the legality and status°
[Page 1 of 2]
Firm ProvidJ.~jg~I;.as~e~.ct__l~ons, .T_es__ts_z ]?ile Search~, Data and Information
As certified by my sea]. affixed hereto and as of the validation date showo below, I
verify that my investigation of this Health Authority Approval sbows 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 obtains1 from the ~nieipality of Anchorage files and frsm my
investigation and inspection~ the on-site ~,mter supply and/or wastewater disposal
system is in compliance v~th all Municipal and State codes, ordinances, and reguia~-
tions in effest on the date of this inspection.
Name of Fir~ ~~; - ~%~d~
Approved for .... bedrooms By
Approved Disapproved ~--~"T- Conditional
Terms of Co itional Approval
CAff~ION
THE MUNICIPALITY OF ANCHORAGE I~PARTiENT OF t~ALTH AND ENVIRONb~NTAL PROTECTION
(DHEP) ISSUES I~ALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ~ASKAo THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTSo E~PLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ~NALYZE DATA BEFORE A
CERTIFICATE IS iSSUED o TI~ M~tICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
MUNICIPALITY OF ANCHORAGE (MOA)
HF~LTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
WELL DATA
We].]. Classification ~
Well Log P~esent (Y/N) ~
Total [~.~pth I1~, Cased to 114
Static Water Level ~J5 ]Pump Set At
Casing Height Above Ground ]c~ '~
Electrical Wiring in Conduit (Y/N) ~/
Separation Distan?es f~.om Well:
To F~ptic/Holding Tank on Lot ~ ~ ~
To Nearest Edge of Absorption Field on Lot /~
To Nearest Public Sewer Line ~O~L~
Legal Description: ~__A~(.~
If A, B, or C, D.E.C, Approved(Y/N) ~/~
Date Completed _ ~/~,/~.~/ Yield
Depth of G~outing
Sanitary Seal on Casing (_Y/N) '7/
Depression A~ound Wellhead (Y/N)
; On Adjoining Lots [ DO
; On Adjoining Lots /(.70
To Nearest Public Sewer
Cleancut/Manhole_ ~ ~/~ To Nearest Sewe~ Service Line on Lot
Wate~ Sample Collected' By '~-~. ~. ; Date ~ .~
Water Sample Test Results ~e~7/~/~c./~c ~/
Coramnts
B. SE~rIC/H~(~ TANK DATA
Date Installed ~/~o/~ .~/ .
Standpipes (Y/N) -~O
Depression over Tank (Y/N)
Air-tight Caps (Y/N) '~
~ -- Date Last pumped __
No. of Co p t nts
_ Foundation Cleanout (Y/N) ~'
Pumping/Maintenanne Contract on File (Y/N) ~//~ ; for
Holding Tank High-Wate~ A].a~m (Y/N) h//~ Temporary Holding Tank Permit (Y/N)
Sepauation Distan~s from Septic/Holding Tank:
To Water-Supply Well ~D +
To P~operty Line ~O ~
To Water Main/Service Line
cour N o a
Co~nts
To Building Foundation ~ 7
To Disposal Field ~0 ~
To S~eam~ Pond~ Lake~ c~ Ma~or Drainage
Receipt #
Date Paid:
Amount: .
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils P~ting in Absorption Strata
Date Installed ~/~O/~ .~
Width of Field ~l
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field ~/4/
Depth of Field q '
Gravel Bed Thickness 5 ~
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-SupplyWell
To Building Foundation
Lot NoNE
TO Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Cor~n~nts
On, Adjoining Lets ~ 1u
~ ~ To Cutbank(if present)
To P~operty Line I~)
To Existing er Abandoned System on.
De
LIFT STATION
Date Installed
Siz~ in Gallons
Dimensions
__Manhole/Access (Y/N)
"Pump O~" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Meets MOA
Con~ents
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, o~ conformed to all MOA HAA Guidelines in effect
on the date of this inspection.
Signed Date ,~. O.~..~. ~,.~
Company %. ..
KB1/d5/s
~ $~s', 'JUNE 25, ~97J .'
. .;
[Page 2 of 2] i,,, .... ,,,. ~,';.
It,;-.~.r~,,,~, ~;~ .7'
2-15-84