No preview available
HomeMy WebLinkAboutT12N R3W SEC 15 LT 116 --- 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 Narno: ~)D/'/N/VD ,~E/u'/¢ (~',4',qM~ Wastewater System: )~New [] Upgrade Phone 3~_~~~,~_O~ IN°°fBe~°ms: ~DeepTrench FJ Shallow Trench [~Bed [~Mound [~Other ' ' Soil Rating: Total Depth from original grade: LFGAL DESCRIPTION ¢¢~me:/.~) /'°& ~PD/Sq PI Lei /~/~_~ Block: /~/4~ S u b di~,~) Depth to pipe boltom lmm original grade Gravel depth beneath pipe 4.7 -. 42 I I Fill added above original grade: G ave length: WELL: ED New.I I/- "~-_.[] t, Jp-¢l rede/_ ~ Grsvel w,dth:~/f~f~/~:¢~,. ~,,,~¢' ~3 ,~?¢~ Ft. Number of lines:~/R Disla,lce belWeen lines:/~/.~ Ft~ Classification (Private A,R C): I~ Cased TO: Total absorption area: Pipe Date Drilled: Slatic Waler Level: Installer Dale installed: i I : [Casing Heigllt Ab°ye Gr°und: TANK SEPARATION DISTANCES ~ Septic L] Holding L~ S.T.E.P wou ..... SI'EEl_ SLirface Wator /V,~ ,/,v/,g) ~,~ ,,v4 Nfl /V/:,)- LIFT STATION - Curtain BI=NCH MARK Location and Description:$ . Department of Heal nd Huma rvices appro~a '~,'"'",,,¢~-~ ''~ ... Reviewed and approved by: Date: ~/~) 72 013 (Rev 9/gl ) MOA 25 Permit No. ~,.~¢~/7'~ Page ~., of Municipality of Anchorage DEPAR'rMENT OF HEALTH AND HUMAN SERVICES ENVIFIONMENTAI. SERVICES DIVISION P.O. Box 196650 ® Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewster Disposal System and/or Well Inspection Report Legal Description: ~///-o 7""/Z/V' ,~3J~V' ~E'C. /~ _ PID No.: /oo', ~/20k¢ ~o7~ //TLx ,1111~ /; ~../7. S. .SE E f~TT~CH~L~ ~HT. .5/eY "1 THI~E£' Permit No. ~J~J~_L~ Page ~ of ~ _ 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: ~17'//~ 7-/2/v/~3~/~E'C./;~ PID No.: ~/"~.~_~____ .... ~r~c. ~-~ ~ .~ .... ..... 5YST~N PLAN ~'~ ~ TANK DETAIL r KND TRENCH ~Lr.v/~ ~ 72-013 A (1/93) ' 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 AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW930176 DESIGN ENGINEER:SKLH CONSULTANTS OWNER NAME:CRANE DONALD L OWNER ADDRESS:4711 E. ].01 ST ANCHORAGE AK 99516 DATE ISSUED: 6/23/93 EXPIRATION DATE: 6/23/94 PARCEL ID:01548404 LEGAL DESCRIPTION: T12N R3W SEC 15 ]bT ].16 LOT SIZE: 32200 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1 2 3 4. REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING THE FOLLOWING SPECIAL PROVISIONS. THE ATTACHED APPROVED DESIGN. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL (18AAC80). SPECIAL PROVISIONS RECEIVED BY: / / ISSUED BY: DATE: DATE: £07'//Lo ,sec. /5/ 'T/2A./, ~3~./ I/ LOT LOG PP~gPE. F~ TW IHP~oV£- M~MTS ~ER LO~TED ~ pROt~RT~ 140~ LOT jOT --~ £. IOl~~ AV£. A~I' TIqIS TIRE / / WELL LO~' 116 50' \ LOT t40 / / / / / ? aJ""~'a~ I LOT llG, 5EG. I5. TiZN, R3W, ~F. VILED ~-ZB'-'P~ - PPO?o3ZD WELL (_OCA.,T;O~ l" -' I00' EF. ISTI KIG P~OFE~Y !t~VE BE~N LO~TEP Wl~ ~ H~VE NOT [~MSURVEyED FIE. Lb ~ADI LJ~. CLEA_tJOoT 4' 4u PE¢.~ PIP~ LAI~ r~A APPR6q£D CE.I~IC ROCK ELEVATION t/ /~ ~ ~.:, ,,~ ~//~ MOTE: 5ECOMD C~POUT ~4 wtTu~~ ~ = f ~MT ~MD C,O. .~P TOP5 .~P ~l?e n~d, (O~5T~UCTEO ~r ~ 5W~P ~ouuP B~I~LL ~4t' CAe EMD ~E TIH~ A~ O~I&IM~L 4-'-I~J PCP..F. LAID L~:UEL FULL P~-CT"I4 OF' £~..?l]C ~NbTH e. QUAL T'O I~CIC6T 5ECTIOIq LOTI.t&, SEC. I5,TlZN, RS'W, 6. M. 25,36 Municipality el Anchorage DEPARTMENT OF HEALTH & HUMAN SFRVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION 'I"ES'I' PEREOR E EOR: LEGAL DESCRIPTION:__ 1 4- 5- 6- 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Township, Range, Section: SLOPE T IZ N: R3'W, &.M. ecl5 SITE PLAN .. ueplh to Waler ADer .. (~/X~C.L. ~'4onilarinfl? _ ~./O/)P~. Dale: Reading Date Gross Net Depth to Net Time Time Water Drop 4) ,> ~/-?; o(5'~$ & ..... ~/ ~ol ~.,,,,, 7 7/, / ,~£*~O;//,)A/.~jL ~£a/~//dl~// PERCOLATION RATE _ (mmules/mch) PERC HOLE DIAMETER 7~,:V~%' ~d?' ~Q~,//¢¢c.%O, TEST RUN BETWEEN -~ FT AND ~t ~ _ F} COMMENTS ~/~[~ /d~ ]/~f~Sd ('~.(.~/, , ~/j~ /)[~C~-- ~/L~' /(~/)L/)';(V 1~/ ~ ~::~,S'~" PERFORMED BY: ~ - "k/~:~ ~ ~ /~,¢~ ~-~ CERTIFY ~AT ~HIS TEST WAS PERFORMED IN / ACCORDANCE WITH ALL STATE AND MUNICIPAL 6UIDELINES IN EFFECT ON ~HtS DA~E. DATE: ~, 72 008 (Rev 4~85) Tom Fink, Mayor Nlunicipality of Anchorafle Department of Health and Human Services 825 "L" Street P.O. Box 196650 Anchorage, Alaska 99519-6650 ENGINEER BULLETIN 91-4 September 12, To: Subject: 1991 All Engineers Designing and Inspecting On-site Wastewater Disposal Systems Owner Installation of On-site Wastewater Disposal Systems AMC 15.65.035 requires that any person engaged in the business of installing or excavating an on-site wastewater disposal system must be permitted by DHHS. Recently we have received several as-built inspection reports which indicated that systems were installed by the property owner. Upon inquiry we have found that several of these "owner installed" systems were actually installed by contractors who were not permitted by DHHS. In situations where a property owner truly desires to install his own system, we will require that the owner obtain prior approval from this office. The owner should submit a letter with the permit application that indicates that the system will be owner installed. The letter should specify the anticipated extent of owner involvement during construction and should also include a list of proposed subcontractors. Approval for owner installation will be indicated under the Special Provisions portion of the permit. As-built will not approval. inspection reports which indicate owner installation be approved unless the owner has received prior Please contact our office at 343-4744 if you have any questions. Sincerely,j~tl~h' ~ Program Manager, On-site Ser ices cc: Lee Browning, P.E., Manager, Environmental Services GREA', , ,NCHORAGE AREA BOR¢'" Department of Environmental C~uality 3500 Tudor Road Anchorage, Alaska 99507 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: MAILING ADDRESS. ~O/~ -"~ LEGAL DESCRIPTION NUMBER OF DISTANCE F* ~ ~¢~ - ' COMPARTMENTS ~.~ FROM WELL ?gb ~ ('I~¢'L)[J. MANUFACTURER" ~¢O('JE' '~'( ~'~ MATERiAL]_t',/_~: I~'~/~1 G INSIDE LENGTH INSIDE WIDTH_ LIQUID DEPTH-- .LIQUID CAPACITY_- /¢?¢'h? SEEPAGE PIT: NUMBER OF PITS- // DIAMETER-- OR WlDTH~-Z , LENGTH -~C~', DEPTH'~/frd LINING MATERIAL ~)~O~D~JA] CRIB SIZE: DIAMETEROOz'~ -DEPTH~- ~ D~STANCE FROM: WELL_ TOTAL EFFECTIVE BUILDING FOUNDATION ~O~, NEAREST LOT LINE?0'f ABSORPTION AREA (WALL AREA) "~/~'~) _SQ. FT. ADDITIONAL ABSORPTION TYPE '~1~/~O~¥~ CONSTRUCTION-- DEPTH _ DISTANCE FROM BUILDING NEAREST NEAREST SEPTIC SEEPAGE FOUNDATION LOT LINE SEWER LINE TANK -- SYSTEM CESSPOOl OTHER SOURCES__ APPROVED_ DISAPPROVED. REMARKS. DISTANCES: INSTALLED BY: /tt/~'t'~(l" PIPE MATERIAL: LOT SLOPE: ~F~n~e£ : DIAGRAM OF SYSTEM APPROVE[) i_-')L2'~.z_~!~. (). /2'~,,~'g'/~'z~c'-- G.A.A.B. Form PW-026 GREATER ANCHORAGE AREA BOROUGH SEWAGE DISPOSAL SYSTEM -- APPLICATION AND PER,kAIT COMPLETION DATE ANTICIPATED ,.,~,_,. ~o ~.~,~ -...,~ --~ 4'° -~. ~.~ ~,~ WATER MAIN TO S~PT'C TANK ~.~ SEEPAGE PIT /o DRAIN FIELD ~ TYPE DEPAR1HEIII' OF EI=IWiROH~Ei'iif, L O/Al 3500 TUDOR RBAI) ANCtlORAGE, ALASKA 99502 CASi: # Performed For___~L__~-O~__~N~(~ Date Performed ~'~_,C) -') Leoal Oescrip~tion: L6~ ..... Block Subdivision '~=,c~ [.~_~l'}i~N'.~~.!, This Form Re~orts Soils I_oq ...... ~ Percolation Test qe~th Feet Soil Characteristics 5-- 6-- 7-- 8-- 9-- 10 I i Was Ground Water Encountered? Ie Yes, At what )enth? Readinq Date Gross Time Net Time Oenth to H20 Net Drool Percolation Rate Proposed Der) th of M i n u t e I n s t ~-i-l-~Tf o n: $ e c ~, ~, ~ e Inlet g,]te: ....................... t~ATER WEL' RILLERS LOG Area Location (addr~s~ of: To.ship, Rang~, ~ S~ction (if kno~); distance from road Size of Casing ~ Depth of Hole~O/ ~e~t. Casod to ,~ ~.1 _ Des~ib~ screen or perforations: Dr ~T ~ILL IN .~Depth in feet from ground surface Give details o~ formations penetrated, size of material, color, and hardness. to tO to to to RECEIVED ' to tO October 26, 1972 TO WHOM IT MAY CONCERN: SUBJECT: On-site sewer and water system, N1/2, W1/2, El/2, NWl/4, NWl/4, NWl/4, Section 25, T12N, R3W, S.M. The on-site sewer system at the above location is approved by this Department. A water sample will be obtained by this Department, this date and the results will be available by Monday or Tuesday of next week. The well 'is of approved construction and is 250' Carrol Sue McKechnie Environmental Control Officer mb ® Municipality of Anchorage On -Site Water and Wastewater Program (907) 343-7904 s Certificate of On -Site Systems Approval Parcel I. D.015-484-04 1. GENERAL INFORMATION: Expiration Date: 7, j `^-zl Complete legal description T1 2N R3W SECTION 15: LOT 116 Location (site address) 4720 East 102nd Avenue *Anchorage, AK Current Property owner(s) Don Harrison Mailing address Real Estate Agent 2. TYPE OF DWELLING: M Single Family (w/wo ADU) ❑ Duplex ❑ Multiple Dwellings (Single Family and/or Duplex) 3. NUMBER OF BEDROOMS: 4 Day phone 907-230-1803 Day phone 4. TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL: Individual Well M Individual M Individual Water Storage ❑ Holding Tank ❑ Community Class_Well ❑ Community ❑ Public Water System ❑ Public Sewer ❑ WaiverNariance request for: Distance: Received by: Date: COSA to be released to the engineer, unless otherwise requested by the engineer. COSA Fee $ .550 LLQ Date of Payment _�L� Z i Receipt Number 017 3Z COSA # OSG 2. 1117 Waiver Fee $ Date of Payment Receipt Number Waiver # of 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, based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application, shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) in compliance with all applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation. Name of Firm: Garness Engineering Group, Ltd (GEG) Phone: 907-337-6179 Address: 3701 East Tudor Road, Suite 101- Anchorage, Alaska 99507 Engineer's Printed Name: Jeffrey A. Garness Date: In conducting this evaluation, GEG provided an engineering evaluation of the well and/or septic system in accordance with the guidelines and regulations established by the Municipality of Anchorage and industry practices. The reported results describe the condition of the system/s on the date/s of the evaluation. Separation distances were measured to readily identifiable features. Hidden defects or encroachments may exist that were not identified during the evaluation. The operational life of all wells and septic systems depend upon a variety of variables, including but not limited to, soil conditions, groundwater levels (that may fluctuate during the year), quality of construction (materials and workmanship), and the water usage of the family utilizing the system/s. These conditions can vary, and are outside the control of GEG. Satisfactory test results do not guarantee future performance of the system/s; therefore, GEG makes no warranty (express or implied) regarding the future performance of the well or septic system. GEG makes no representation whether an alternative well or septic system can be installed on the property in the event either of the current systems fail to perform adequately in the future. The content of this report is for the sole benefit of the person/party that retained GEG to perform the evaluation. Reliance upon the information provided in this report by any other person or party (including subsequent property purchasers) is not authorized, nor will it confer any legal right whatsoever. 6. DSQ SIGNATURE System #1 Approved for bedrooms System #2 Approved for Disapproved Conditional approval for bedrooms bedrooms, with the foil G� OF 41 Jess., j CEI.793 G ��4Pd Pin ressl00000 #AECC884 OF �J ON -S/ IN TE W u tER ND m �'AST�- 11 ,V AEE? A A4 B Original Certificate Date: The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. ATTACHMENTS: COSA Checklist _ Nitrate Advisory Septic System Advisory Arsenic Advisory Well Flow Advisory OtheT�� r A0j0t4i UVy S pc ( 'f+o Legal Description: l T12N R3W SECTION 15 LOT 116 If more than 1 septic system on lot: COSA Checklist # of A. WELL DATA ® Well log is filed with Onsite (or attached) Date drilled 10/1/93 Total depth 246 ft Cased to 241 ft © Sanitary seal is functioning correctly FE -1 Wires are properly protected Casing height (above ground) 12+ in. Date of flow test for COSA 4/5/21 Static water level at beginning of test 203.1 ft. Comments B. TANK DATA Age of tank(s) 28 years Tank type/material 5EPTIC TEE Measured operating fluid level in septic tank 51 ❑® Standpipes/foundation cleanout per record drawing late of pumping i 1 - A D. ABSORPTION FIELD DATA Parcel ID: 015-484-04 Structure served by this system Well production at time of test 4.6+ gpm Water storage tank volume N/A gallons Well disinfected for coliform test? ❑ Yes. ® No [Coliform bacteria is Negative Nitrate mg/L FM� Nitrate less than MRL (ND) Arsenic ug/L ❑ Arsenic less than MRL (ND) Collected by AAROW WELL AND PUMP SERVICE Date of Sample 3/22/21 C. LIFT STATION ❑ Required maintenance comp Age of lift station s Lift station mater' Comm Which system tested (date installed) 6/27/93 Adequacy test date 4/5/21 X ALL standpipes present per record drawing Results ❑✓ Pass For 4 bedrooms Total measured depth from grade 9.9 ft (max) Fluid depth prior to test 10 in Measured depth to pipe invert from grade 3.8 ft (min) Water added 697 gal ❑ N/A — pressurized field New depth 25 in ❑ Monitor tubes go to bottom of effective. If not, state Elapsed time 120 min depth into effective '5.33 ® Code -required soil cover over field Final fluid depth 19 in ❑ System presoaked Absorption rate 600+ gpd (Required if vacant for greater than 30 days prior to NO Any rejuvenation treatment (past 12 months) _ date of test) N/A Gallons introduced gallons If yes, enter date N/A Comments/Deficiencies: EAST TRENCH SURCHARGED UPON ARRIVAL; TESTED WEST TRENCH ONLY; FCO NOT PRESENT -DOUBLE CLEANOUTS BEFORE TANK "WEST TRENCH MONITORING TUBE COSA Checklist yellow sheet 11 E. SEPARATION DISTANCES From Private Well on Lot to: (Please enter distances if less than required or if community well) Septic Tank/Lift Station on Lot > 100' ❑ Yes if No Community Sewer Manhole/Cleanout > 100' []✓ Yes if No ft C]✓ Yes if No ft Neighboring Tank > 100' 0✓ Yes if No ft Private Sewer/Septic Line > 25' M Yes if No ft Absorption Field on Lot > 100' r✓ Yes if No ft Holding Tank > 100' F/ Yes if No ft Neighboring Absorption Fields > 100' Water Main > 10'✓ -1 Animal Containment > 50' 121 Yes if No ft ✓Q Yes if No ft Water Service Line > 10' ❑Q Yes if No ft Manure/Animal Excreta Storage > 100' comment below Community Sewer Main > 75' 0✓ Yes if No ft✓71 Yes if No ft From Septic/Holding Tank on Lot to: (Please enter distances if less than required) Building Foundations > 10' ❑ Yes if No *5'+ ft Surface Water > 100' Yes if No ft Property Line > 5' F71 Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓Q Absorption Field > 5' 0 Yes if No ft Private Wells > 100' Yes if No ft Water Main > 10'✓ -1 Yes if No ft Community Wells > 200' F✓ Yes if No ft Water Service Line > 10' ❑Q Yes if No ft If septic tank is under driveway comment below From Absorption Field on Lot to: (Please enter distances if less than required) Building Foundation > 10' El Yes if No ft If absorption field is under driveway comment below Property Line > 10' 0 Yes if No ft Wells on Adjacent Lots: Water Main > 10'✓Q Yes if No ft Private Wells > 100' ❑✓ Yes if No ft Water Service Line > 10' E✓ Yes if No ft Community Wells > 200' 0 Yes if No ft Surface Water > 100' ✓0 Yes if No ft F. ENGINEER'S COMMENTS *MET CODE AT TIME OF INSTALL **NO RECORDS AVAILABLE FOR TI 2N R3W SECTION 15 LOT 117. MEASURED 125'+ TO SINGLE SEPTIC PIPE IN BACK YARD. SYSTEM TYPE/DIMENSIONS ARE UNK G. ENGINEER'S CERTIFICATION l certify that I have determined through field inspections and review of Municipal records that the above systems are in conformance with MOA COSA guidelines in effect on this date. COSA Checklist yellow sheet #AECC884 Septic 'Tank Advisory Certificate of On -Site Systems Approval #OSC 211179 Subdivision: T12N R3W Sec 15 Lot 116 Starting at 20 years of age the MOA issues Advisory's for steel septic tanks. The septic tank for this property is 28 years old. Typical replacement costs range from $8,000 to $11,000 This advisory must be attached to all copies of the subject Certificate of On -Site Systems Approval. This is an example of what the metal of a 20 -year-old steel tank MAY look like. Mailing Address P O Box 196650 *Anchorage, Alaska 99519 6650 *www muni org 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 AUTNORITY APPROVAL FOR A SINGLE FAMILY DWELLING ~ Parcel I.D. # ~')~5- L~-\ - i~U\ HAA # ~.\ ('~o~ ~--If(") It"'~("') 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address. /007? ~.7'/;'.'.'2,7')~. Day phone 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: 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 statbs 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 App,:oval 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 ,~,/¢'//-7/ ~'~,¢'LZ,/~']~'~ Phone Address /~. ~). ,/~O'~C:' //~),/~,,/~ ,/¢ /~/?~',~¢7-¢~.E7~?/ /~/~ ,~,~,~// Engineer's signature .~.~.'2~.~.~ ~ _ .../ / ,/ Date DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval C?rtificates based only upon the representations given in paragraph 5 above by an independent profes~)9nal 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: Parcel I.D. A, WELL DATA Well type /DFC- Log present (Y/N) Total depth ~-///m Sanitary seal (Y/N) If A. B. or C, attach ADEC letter. ~ ,~-,¢rF,¢C//~ Date completed Cased to Z// FROM WELL LOG Date of test Static water level Well flow /"~"~ Pump level ~3~) ADEC water system number ,,/Y'/~ /O ~/-,~ Driller ~1~--/'~),'5 ,/~/"/'//'/'1~ Casing height properly protected (Y/N) Wires g.p.m. . SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot /-~'~ Absorption field on lot Public sewer main _ Sewer service line ___ ; On adjacent lots ; On adjacent lots Public sewer menhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate ~0 .-'4~.// __ Other bacteria Collected by: ~ / B. SEPTIC/HOLDING TANK DATA Date installed _ 7-/Z -~ Tank size Cleanouts (Y/N) ~J High water alarm (Y/N) Date of pumpin~ Compartments Foundation cleanout (Y/N) ~' Depression (Y/N) /V Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well (s) on lot /-~ / On adjacent lots /~ ~ ~ 1-o property line /.,~ Absorption field /'~ ~ A/o/ye Surface water/drainage Foundation ,~ _Water main/service line 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION ~alled Size in gallons'~'~ Vent (Y/N) ~ High water alarm level Manufacturer Manhole/Access (Y/N) Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot Qn adjacent lots "Pump off" level at Cycles tested D. ABSORPTION FIELD DATA Date installed 7-/Z Length ~'¢' Width Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating /.Z~?P/51¢ System type Gravel thickness ~ '£D Total depth _/,'~ Cleanouts present (Y/N) Date of adequacy test /(J'~ for 4~' bedrooms ~ If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots /'-~O ' Surface water Curtain drain /'V/r;'.'.'.'.'.'.'.'.'~CP~ On adjacent lots ~Z~3 ' Property line // · ~'('~, ' To existing or abandoned system on lot /V/.~ Cutbank /'M',o/') ~ Water main/service line DrivewaY, parking/vehicle storage area /',¢~ ~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. HAA Fee $ v~(~E~) ..' (-~ 4:%) Date of Payment Receipt Number 72-026 (Rev 3/91) Back MOA Waiver Fee: $ Date of Payment Receipt Number ~ell Owner ~onald L, Crane 'I2N R;$W SEC 15 LT 116 .ocat4on Of ~/oll PERMIT ~' $W9~0 !,~_ora~ ......... '-"]-" I ...... Is/...[ W I/oll Log FL, Below Surfaco Well Depth (ft) Date oF CempleUon MIterlel Type Top Ilar. tern [ 246] [ 10/1/93] Uae Il, gravel,/ 0 15 ~n silty.sa.nd, tlngt fi'om 25' 15 -aive~y, hard 35 47 ~rd pan, brn, damp on top" " 47 88 N~.pan, gray __ 8B · ~y milt, hard,~_ gB ~r~ oan, ~b~ly 129 170 m, sandy UII .......... 170 ;~nd~y ~HL.damo 210 221 ~n, sandy till, 8esDaOe 221 231; -n hard pan, lenses ~ra~,/water, 5gpm 23~ 241 'n hard pan, lenses gr~yg.I./..~a~er, lB+gpm 241 'at~r clearing~ Cast Drilling Method [r tar:¥ ] [welde . ] Diameter (In.) I'" , .~ ~oj ~o Depth (?t,) Weight, (lbs/fO Type Diameter Level (ft.) Date Pumping Level Below T of' C (ft.) After (hfs) Puml~/no.(~o~.m) t~routln§ Yes~ IqaLer'tal Pump H,P, CapaclW Sattlno (ft) Remark~ Type Jsubrn~rutblu 'his well wee drilled under my Jurisdiction end thle report 18 true Lo the best of my knowled~e~ ~u~horl~od Roprooont~tlvo 7