HomeMy WebLinkAboutT12N R3W SEC 27 LT 63 REM
MUNICIPALITY OF ANCFIORAGE
DEP rMENT OF HEALTN AND HUMAN SERV! 3
Environmental Health Division
825 %" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
TANKS
[.~' SEPTIC F~ HOLDING
' . , ,; ./~;~c)
TYPE OF SYSTEM
TRENCH ,~{~ BED [] W. DRAIN [] OTHER
WELLS
PRIVATE [] OTHER ¢ldentifv)
/
DISTANCES
~ SEPTIC ABSORPTION
TANK FELl] WELl.
WELL /
LOT LINE
FOUNBATION
72013 (3/85)
ENGINEER'S SEAL
lC
CE-1195
DIiF::'AF:~f'MI:i]',I1 OF:' tlE<AI.'1"I~ AND lii]',IV]]::;~OI'4MI~]qTAJ
2 ~:~.q '- 4
COhFI ¢~[;: I'
S t }i::l D ]: ',,/:[ ',:~ ]: O I'..h; NA
LiN: ,=. 7 'I'OWI',ISIq
:IC)EI"?C)O (SQ,, F::I ,, E]F:;: AE;F;:IES)
d O CK '.'
(~::)~"l.tl I:~y 'l:j'lv:~ i'.'h.u]:(c:~pa]:t't'y (::~( Arlcl"~c)rag('~ (M[)(~) arid ~hl.i~ ~P('a[e
2, ]: ~.4:il] :ir~s:H',a].:l. Lhc,, sy':!Ft-e:,m :i.n a(::cc)rdar~l:::~:! t,,,ci'f..h a].] MOA c;:(::l~::l~.:~!~ aild
~?,li(:J :il'l cc)mp],:iaJ~Ce with Lhc.., (;:l(::,~.~.J.(;jl'l c:;r'i'[c~p:i.a (:)~ Lhis pu.:,r'm:i.t.
:i!;,. [ p*:i;I] ¢dh~..)r'¢! t(:'l ,::\]] I'"ll]f'l ;~il(::l S't'at¢:, i:)~ ¢l]ask~,~ ~'c:.!qu:ir'c;nfic?r'rL!ii
]:S It',IS!Ai,i..ED ]]",i AI',.I AI:TE:A CC)VEI::,'.Fi:);) BY MOA BLI:[i.DII",tI.:} C(]DIES~
CAI. l:)JERidIl' AI",ID :[IqSI::'EC I :i]C}N Mt,IS t" l:(IE [)BtA]:I'qE.0; (2) AS' 'EJt
AI:::'Pt:~'.CiVI~:]} W]]'i'IIE]UI Al'4 I~:I..EL:)]F;'.]:(]Ai. ;l:t'~l~l::'~:l]','l ]:[]N I::U~]::'[]R'Jl; AND (3)
f'IL.JSI BE; DE}Iql;~: l:)Y A i.:I:Ci;~]'.IS[ED
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
7-//'?t.-'"'
PERFORMED FOR:
DATE PER FORIVlED: ~ ' ?r-'~ '~' ~'~ /
4-
.: ,7 --~5 -
6-
7
8
9
SLOPE SITE PLAN,],
10
11
12
13
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WPIAT
- Reading Date
CEJ195
Net
Time
Net
Drop
)N RATE (minutes/inch)
TEST RUN BETWEEN ET AND FT
COMMENTS ~ ~'~J ~" "-: ' ' '~ ' : ; '
CERTIFIED BY:
DATE:
72 008 (6/79)
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
PERCOLATION
TEST
PERFORMED FOR:
DATE PERFORMED: ~ -'~'~ ~ ~ __
7}/ ,:','
2
3-
.?,? 4
5
10-
11
13-
15-
16-
17-
18-
19-
20-
COMMENTS ' .' ~'
WAS GROUND WATER
ENCOUNTERED?
tx Reading Date Gross Net Depth to Net
Time Time Water Drop
~I .',".'.:;7 .'~-", :).. y~' .*,/./': /."."
PERCOLATION RATE / ~, /~ (minutes/inch)
TEST RUN BETWEEN ~" ~ FT AND ~::, r/ FT
CER ~-IFIED BY: DATE:
72-008 (6/79)
(a)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAt.
OF ON-SITE SEWER AND WATER FACILITY
264~4720
Application Date
GENERAL INFORMATION
I..egal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~¢~/~. 6'~ ,~/,/'~.~f' Telephone: Flome ~/:'¢'% / ~- ~ Business __'__:~%.%_ ......
Applicant Address ~'~r~'~/ ,,~?,,~,X¢,,'¢;'~¢~-"~.~¢''
(c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain);
(d) Lending Institution /z~z/-~''~'~ '/z'~,,,'~','¢E-/'¢1'2(= Telephone
(e) AddresSTelephoneReal Estate Company and Agent ~~~., .__ .~ ~
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family~¢ Multi-Family []
Number of Bedrooms ~'~
Other
WATER SUPPLV
Individual Well,.~ Community E] Public []
Note: If corn munity well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite,.~ Public [] 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-o25(11,8,1)
ENGINEERING FIRM PROVIDINg. ,~SPECTIONS, TESTS, FILE SEARCH, DA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, J verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional an*d adeq[~ate
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 h'om 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 ~ ~/~w~ ~,,..~ ~z//~/~/ ~ ~)~
Date 2 ~ ~/~
Conditional
DHEP APPROVAL
Approved for .zT./z~_,_t'-:,~'_ bedrooms by
Approved ~<'~- Disapproved
Terms of Conditional Approval
Engineer's Seal
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
72-025 [ I 1 ~84)
M.U,/',JtCIPALiTY OF ANCHORAGE (MOA)
~¢~u," '
· ,.~ O~' ~i~\ I~IEAJ~'yH AUTHORITY APPROVAL (HAA)
WELL DATA ~C~
Well Classification .~ / ~/~L~ If A. B. C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) ~ Date Completed / ~¢~ Yield
Total Depth /~-¢ Cased to /¢"~ Depth of Grouting
Static Water Level /~ ~ Pump Set At
Casing Height Above Ground ~¢ ~1
~ . Sanitary S~I on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) ~ ~'~7 ~f~round Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot /~/ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot /g~'~ ; On Adjoining Lots /~,
To Nearest Public Sewer Line /¢~'~- To Nearest Public Sewer
Cleanout/Manhole To Nearest Sewer Service Line on Lot
Water Sample Collected by ~, ~¢~ ;Date
Water Sample Test Results ~/c ~/~¢~*~ ~¢~/~¢~ ~/~ ~
Comments ~d5,/¢~ ~'~,~/y~ ~ ~,~' ~ ~c~' ~,
Date installed ~,Z~I -~
Standpipes (Y/N) )/
Depression over Tank (Y/N)
HOLDING TANK DATA
Size /~-~¢O
Air-tight Caps (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well //'2..~, w/'
No. of Compartments ',~ '
Foundation Cleanout (Y/N)
Date Last Pumped
; for '~'
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Property Line,
To Water Main/Service Line ¢'%'~'¢/'~- To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata ~"~"'~//~/~,
Date Installed ~ -,~3 -~'~ '"'
Width of Field ~ ,,~
Square Feet of Absorption Area ~7~¢~/' ~¢'¢'
Depression over Field (Y/N) A/
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Type of System Design '7'~
Length of Field ,~'- ~
Depth of Field ,:~ P"/C")"/,, /~Ct,,,~ ,, ~,~
Gravel Bed Thickness /~','~/~ ~""/~¢
Standpipes Present (Y/N)
Date of Last Adequacy Test /V~'/q
To Properly Line
To Existing or Abandoned System on
To Water Main/Service Line ~¢ ~ To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage ~¢~4~
To Driveway, Parking Area, or Vehicle Storage Area ¢~
Comments ~o ~504'~i~ ~ ~,~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test, Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection,
Signed Date
Company MOA No.
Receipt No. '~O~) l
Date of Payment
Amount: $ 3,-~
Page 2 of 2
72-026 (11/84)
~2
I,~ol PIJMP LOG
Date tested; 6/21/86
?/e!l owner: Paul Sines
V/ell ]ocotion: Lot 63,
Well dot)th: 159'
Casing dooth: 159'
I)2 ameter: 6"
Static water level: 123'
'.'/et] tested by pumping:
bol. ow ground love]
1 2: Dg~P.M.
1 : 18 PoMo
1:28
Rate( .P.H.)
G
5
2.25
2.25
Water Love]
12_3'
156'
156'
2
2
1:58 P.N. 2 156'
2:28 i~oi'"l~ 2 t 56'
2:58 P ~ i'.i. 2 156'
5:28 P.Mo 2 156'
5:58 P.N. 2 156'
Ii: 28 P"
,~ jurisdiction and thSs renorL is true
']'his well was te~;~ pumped under ,~y
to the best of my kaow]edye aha
1 56'
156'
Foss Drilling;
Dale C,, Foss:
wJ ML LABORAT ~IES, INC, ~ LA~ ~TORY ].O. ~ ~
(907')344-8551
BACTERIOLO6ICAU WATER ANALYSIS
TO BE COHPLETED BY WATER SUPPLIER ....
DATE ~LLECTED J TmE COLLECTE~ I TYPE OF~. ~,YSTEM
1
MONTH DAY YEAR [3 PUBLIC,~INDIVIDUAL
I.D. N0. (PUBLIC SYSTEMS) r, TRCLE CLAS~
NAME OF SYSTEM TELEPHONE NUMBER'"~'='~_-=
ZIP CODE
? ~.' ,/~
[]]CHLORINATED
F'IFILTERED
~[~-REATED OR OTHER
SYSTEM ADDRESS
LOCATION WHERE SAMPLE WAS COLLECTED
~YPE OF SAMPLE
(CHECK ONLY ONE THIS COLUMN}
~RINKING WATER
~CHECK TREATMENT
~W SOURCE WATER
D NEW CONSTRUCTION OR REPAIRS ~
[] OTHER(Specify)
IS THIS SAMPLE A CHECK SAMPLE TO A PREVIOUS NDN-CONFORMING SAMPLE? [~) YES ~' PREVIOUS COLLECTION DATE
A~A~YSI~ REQUESTED ~IF OTHER THAN TOTAL CO~IFO~M~
,~.~ ~,~ /~/,~H ,.¢ ~-/.'-~" ~", 1< /~-,/ '~ "~-"~ /'"'~"'~ ....
~ REPORT TO:(PRINT FULL NAME,ADDRESS AND ZIP CODE
ADDRESS ~'F~/ ~.~ // '.','~.'~ ' .... -
CITY/~/x~//', %~'/~' .~ STATE f*~. ZIP
FOR LAB USE ONLy
[] RESUBMIT SAMPLE
Sample rejected because:
CHECK ONE OR MORE
[] Sample too long in transit.
Sample should not be over 30 hours.
[] Sample received too late in week
[:]Not in proper container
[:]Leaked out
[] Insufficient information provided.
Please read instructions on form.
[:]Other (Specify)
I,~EIVED FROM ~,~,e.o
DATE ~/~'(~ TIME
At~i~I'CAL METHOD:
Im~EMBP, ANE FILTER
I=)FERMEflTATION TUBE
LABORATORY RESULTS
Analyst~~
[] RESUBMIT SAMPLE
Test unsuitable because:
[] Confluent Growth
[] TNTC [~
SATISFACTORY UNSATISFACTORY []
BACTERIOLOGICAL WAllER ANALYSIS RECORD
FOR LAB USE ONLY
COLIFORMS
[-~ FECAL COLIFORMS
Membrane Filter: Direct Count
¥~rification: LTB
Final Membrane Filter Results
Reported By
READ SAMPLE COLLECTION INSTRUCTIONS ON BACK OF FORM
BGB
Date
Time
Coliform/lOOml
Coliform/lOOml
/
,//
:/