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Home My WebLink AboutT12N R3W SEC 15 LT 135 MUNICIPALITY OF ANCHORAGE DE~ .tTMENT OF HEALTH AND HUMAN SER~, :S Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Address 3 37 - 5-q / $ TANKS SEPTIC [~ HOLDING TYPE OF SYSTEM [~'T'R E N C H [] BED ~j W. DRAIN [~ OTHER [Ota~ drplil frOm original grade FT /"~) "' [Si~ve~'deplh bonealh pd)e ':f ~dl absoqmo,/ .ie~ ...... [Distance bul,~e~n hnes WELLS ..... .~Z~'PRIVATE [] OTHER fldentifv) Classg~cabon (A,B C~ dotal DeptllFT Cased to RE~ARI(S: DISTANCES ~:~---"~'£ SEPTIC ABSO,PTION FROM ~- TANK FIELD WELL WELL '/~/Ot) · .~ /~0 LOT LINE /'-,~,D q- /~ /~ FOUNDATION ~/~ ~ ~ ~//o FF FT FT Inspections PeHormod by: , ___Lt~, /,,]-, J~/I.S ,9 ,4~) Municipal and Slate ogi(MUles ill efiect on lids date. 72-013 t3/85) !iF~:~'~/i:i.l ~.I l',l(:iIIi ii: ,, ) !4 ] l ! Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: LEGAL DESCR,PT,ON: 1 2 3- 4- 5- 6- 7- 8- 9- 10- 11 13 14 15- 16 17 18- 19- 20- DATE PERFOF Township, Range, Section: ?-I SLOPE SiTE PLAN WAS GROUND WATER ENCOUNTERED? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE __ (mmutesnnch) PERC HOLE DIAMETER __ TEST RUN BETWEEN FT AND FT COMMENTS ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON TRIS DATE DATE: McKay Well P.O. Box 557 Wesilla, Alaska 99687 Phone 376.5058 Well Owner--_ -- Well Location Size Casing . --Depth of Hole Static Water Level. / ~ ~.~_=__feet Date of Completion Well Test, ~,' '~ Gal per Minute for ~ Hours WELL LOG AUTHORIZATION TO DRII.L I hereby authorize McKay Drilling to proceed with the above work. Payment shall be mede in the following manner: Rig up Minimum .... feet. @ Balance due upon completion. per foot In the event it is necessary to insJtute legal proceedings to collect arty amounts due on this con- tract, I agree to pay an additional sum of fifteen percent (15%) of the original contract price, Plus attorney's fees, and cost for legal proceedings, Name Date _ Address -- ,, 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 GENFRAL INFORMATION Complete'legal description '7/;2 Location (site address or directions) ¢~"~.~' ~"/(7z/-7/~ '~- "- Prope~y owner ~/O~k, ~//2~ -~V~. Day phone I..ending agency ~' Day ~hone Maili~g address Agent Address.' Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ Day phone ¢ 'rYPE 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 tl~e 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 Ancho(age fifes 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 ¢o~-~T','~ucT/'x-~h ~;~J c~ i~,,-~ Phone Address ~/o/ ~u'Oz~rv' u~J-~'~.Jb-'--~ ~/'?-. ,,~Jc./-/~ /.'.'~//~t Engineer's signature '/'~:/'~ '/~t/~ Date o DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date The Municipa!ity of Anchbrage 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 DH HS does this as a courtesy to pumhasers of homes and theiHending 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. RECEIVED. Municipality of Anchorage /~JJ~ DEPARTMIENTOF HEALTH & HUMAN SERVICES MAR 1 0 199! Environmental Services Division : ANC C Ol 82!5 L Street, Room 502. Anchorage, Alaska !)9501. (907~¢r~. s~,v,c,s DIVISION Health Authority Approval Checklist LegalDescription: /-O7~/$5~1 5'/~ T'I'z.~t F~3~,o $~, ParcelI,D.: A, WELL DATA Well type '? Log present (Y/N) Total depth ..~ o o Sanitary seal (Y/N) FROM WELL LOG AT'I NSPECTION g.p,m. (,, 4- If A, B, or O, attach ADEO letter. Ar)EO water system number Date completed ?- / O ~- ~ '7 Cased to .~ O o Casing height (above ground) Wires properly protected (Y/N) Date of test Static water level I Well production WATER SAMPLE RESULTS: Coliform O Date of sample: Nitrate 4. z'~ ~ ~ o C)ther bacteria O g.p.m, Collected by: (4: uo ~ C,e, Bi SEPTIC/HOLDING TANK DATA Date installed 7- z - ~' 7 Tank size Foundation cleanout (Y/N), tV. Date of Pumping I-/"/'-~/ Pumper. 12.,.¢""0 Number of Cornpartrnents Z-.-- Cteanouts (Y/N) ~' Depression (Y/N) /¢ High water alarm (Y/N) C= Soil rating (-~1~ or fl=/bdrm) /.¢~3 System type "'/-~ EX) C. 1"/ Gravel thickness be ow p pa. ~ ' _Total depth /o ' Monitoring Tube present (Y/N) )"' _ Depression over field (Y/N) Results (Pass/Fail) /¢~$'.S For_";J~ ~ ABSORPTION FIELD DATA Date installed 7- Z.- ~' 7 Length_ ~'5'- ' Width '~' ~ Effective absorption area .~ F e Date of adequacy test Z-ZT- ~ 3 Fluid depth in absorption field before test (in.); Fluid depth O (ins) Minutes later:. Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Immediately after 4'~/('gai. water added (in.): Absorption rate = "f- 4.~ c~ g.p.d. If yes. give date bedrooms D. UFT STA'T Date installed ~ ' ' Manhole/Access (Y/N) "Pump off" level at* Cy~c~e~..t~High water a~ *Datum ~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot '~ / o o Absorption field on lot "/' ~ e o Public sewer main -~ /o ~ Sewer/septic service line ~ .~o On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation I '7 Property line + 5-0 Absorption field Water main/service line +~'-o Surface water/drainage + / o o SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO: Property line ¢ / 5" Building foundation + ~ o Surface water '¢- ! o o Curtain drain .f-/o o Wells on adjacent lots ENGINEER'S CERTIFICATION I certify tha in conformance with MOA HAA guidelines in effect on this date, Signature /~/~' ~f" ~ Engineer's, Name '4~' '~' dC.)/c.5'6~J - ~'~$~,, ~Jg? Date ¢7 - ¢' - ¢ ~' Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area -+_co HAA Fee $, - Date of Payment _ ~-~:~ '--/~ '-- .?./~ Receipt Number Waiver Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* NORTHERN TESTING LABORATORIES, INC. Constructing Engineers 9601 Buddy Werner Drive Anchorage, AK 99516 Attn: Hem'y Wilson Client ID: Lot 135, Hose Bib Client Project Il: Source: NTL Lab//: A160194 Sample Matrix: Water Cormnents: Method Parameter. SM 4500 NO3 E Nitrate-N Units Result Report Date: 3/9/99 Date Arrived: 3/1/99 Sample Date: 2/28/99 Sample Time: 12:30 Collected By: ** Legend ** MRL - Method Report Level MCL = Max. ContaminantLevel B = Present In Method Blank E - Estimatefl Value M = Matrix haerference H Above ivlC L D = LostTo Dilution Date Date MRL Prepared Analyzed mg/L <MI1J. 0.10 3/5/99 Reported By: Stephanie K. Cowling Chemistry Supervisor NORTHEF]N TESTING LABORATORIES, INC. 3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456 3125 8005 SCNOON STREET ANCHORAGE, ALASKA 99518 (907) 349 1000 · EAX 349 1016 POUCH 340043 PRUDHOE BAY, ALASKA 99734 (907) 659 2140 · FAX 659 2146 DRINKING WATI::R ANALYSIS REPORT FOR 'rOTAL COLIFORM BACTERIA Constructing Engineers 9601 Buddy Werner Dr, Anchorage, AK 99516 [3ate Received: 3/1/99 Time Received: 16:25 Date Analyzed: 3/1/99 Time Analyzed: 18:00 [:)ate Reported: 3/4/99 Time Reported: 13:36 Next Sample Due: Comments Phone Number: S = Fax Number: U = POS = Collected by: HW ND = TNTC = Sample Type: Private water Systems CG = Method of Analysis: Membrane Filtration (SM 9222 HSM = B) SA = Comments: Old = Satisfactory Unsatisfactory Positive Test Result None Detected Too Numerous To Count (>200 Colonies) Confluent Growth Heavy Sediment Masking, Results May Not Be Reliable Sample Age >30 Hours But <48 Hours, Results May Not Be Reliable Sample Age >48 Hours, Too Old For Analysis R = Resample Required NT = No Test * # Colonies/100 mi ** # Colonies/mi Sample Sample Total* Fecal Other* HPC** Date Time Coliform Coliform Bacteria Result Lab~ Location Comments 2/28/99 12:30 0 ND 0 NT AC11194 LOT 135 HOSE BIB Satisfactory Sherri L. Trask Environmental Analyst Northern 'resting Laboratories, Inc Anchorage, AK 3/4/99 Op ?07A~