HomeMy WebLinkAboutT12N R3W SEC 33 LT 149
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAI~PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchora~.le, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL: INSPECTION
REPORT
NAME
P, NONE
~UPGRADE
LEGAL DESCRIPTION
L~CATION
NO. OF BEDROOMS
Well )rich area
PERMIT
DISTANCE TO: [Well /~'0 P°undadf) O
No. of I,nesi l I_~rl~ ti, ~j~,~ 'l'otai lengtl~ of lines',~"',~
PERMIT NO.
Manufacturer ~i_iquk~ capacity m gallons
PERM, O//
Distance t)etwean lifles
Top of tile to finish~gradel
Width
Crib diameter
[M~[erial
Trench wid t~-~
Matelial beneath til~
PERMIT NO,
Distance to ici line PERMIT NO,
Septic tank ea(s)
Length
DISTANCE TO:
Class Depth Driller
Building foundstion Sewer line
DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING
I NSTALLE~L~ ¢
REMARKS
APPROVED
DATE LEGAL
4/'la,
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:
4
5
SLOPE
DATE PERFORMED: Z 7.&/
SITE PLAN
11
12
13
14-
15-
16-
17
18
19-
20-
ENCOUNTERED?
P
E
IF YES, AT WHAT IO I
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
~ / / TES~T/~UN BETWEEN
COMMENTS II~l,/~ ~. Jl"~ t~l.'~ k~" ~ l,~ ~/~ °~
PERFORMED BY: ! ~~,~ CERTIFIED BY:
FT AND FT
72-008 (6/79)
MUNICIPALITY OF ANCHORAGEi ~
Department of Health & Human Servi(~es
DIVISION OF ENVIRONMENTAL SERV!CES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Parcel I.D. # ~-~\. ,-.
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township; range)
Location (address or directions)
IqglO IX-C~ld~n
(b) Property owner I,z.,A ¢ H~au~y ~ Telephone: (home)
(c) Lending Institution ~4, ,4. Telephone
Business A'-¢'q ' t '/aq
29...4- ¢ a
Mailing Address
(d) Real Estate Company and Agent . ~.~1 E.c,~J'~ O(~ I,m,l~.~
Address
Telephone ~ US- - ~11~
(e) Mail the HAA to the following address: (or check here ~, if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY
Individual Well I~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site t~ 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
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, J verify that my investigation of this
HeaJth 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 all Municipal and
State codes, ordinances, and regulations in effect on the date of this inspection.
Name of Firm
Address _
Date
6. DHHS APPROVAL
Approved for_ ~' bedrooms by
Approved ,~ Disapproved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of H'ealth and Human Services (DHHS) issues Health Authority Approval
cerificated 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 professiona engineer's work.
72-025 (Rev 7/88} Back Page 2 of 2
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744
Legal Description:
If A, B, C, D.E.C. Approved (Y/N) --
Well Log Present (Y/N) ~ _ Date Completed _ 6,f-¢1/":
Total Depth ','~-¢.i'5~' Cased to ~ ~5-~ Depth of Grouting _ /xh/J-.
Static Water Level ,¢ E, ~ Pump Set At
Casing Height Above Ground ¢~ o"
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot I
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
¢,0, ; On Adjoining Lots _'~ IO0'
To Nearest Edge of Absorption Field on Lot '~ I I ~' ' ; On Adjoining Lots ___"~ f cO '
To Nearest Public Sewer Line ~ tOO ' T_oNearest Public Sewer Cleanout/Manhole ~ ¢oo '
To Nearest Sewer Service Line on Lot .~'~. ff Z '
Water Sample Oollected by ~'~P T'¢c~ .¢'~cr ;Date_/O/~//¢~.,, I~
B, SEPTIC/HOLDING TANK DATA
Date Installed o~/¥ /~_/Size ~OOO~l _No. of Compartments
Standpipes (Y/N) ~
Depression over Tank (Y/N) N
Pumping/Maintenance Contact on File (Y/N) __
Holding Tank High-Water Alarm (Y/N) ~l,
Air-tight Caps (Y/N) __ ~' Foundation Cleanout (Y/N)
_ Date Last Pumped ~fl / ~'
; for
Temporary FIolding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well ~' ,~h¢~ ¢- ¢. To Building Foundation
To Property Line __ ';~ '57~ - -%1 To Disposal Field
To Water Main/Service Line '~' ~o' '
To Stream, Pond, Lake or Major Drai~a~ Course ~ I~o'
Comments
72-026 (Rev z/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field 5-
Square Feet of Absortion Area
~7
Depression over Field (Y/N) __ /x/ __
Results of Last Adequacy Test ~'~,~x~z(~f' z~r
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well I I ~' ~
To Building Foundation _
Lot ~ 30 '
TO Water Main/Service Line ~ f¢,¢' '
To Stream, Pond, Lake, or Major Drainage Course __
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field .~"~'
Depth of Field
Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line ~ lc ~
To Existing or Abandoned System on
; On Adjoining Lots "~ ;~0 '
To Cutback (if present) I~, .,~.
D. LIFT STATION N,/~,
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at _
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at __
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA g.~¢lj~.eS,,if~effect on the date of this
inspection.
Signed ~~ ¢ ~
Date ~0¢ ~ )~¢~ ~ . __ . ...... ¢ EngmeersSeal
Receipt No. ~2 3¢% ¢¢ ~( Receipt No.
Date of Payment ~/~ .~ ~ ~' O
Waiver Fee: $
Date of Payment
72-028 (Rev 7/88) Back
Page 2 of 2
A
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
$633 B STREET · ANCHORAGE, ALASKA 99518 o TELEPI~ONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440 ~
e
2}
/
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAl,. PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAl.
OF ON-SITE SEWER AND WATER FACILITY
264..4720
Application Date _ - --
GENERAL INFORMATION
(a) Legal Description (iaciude lot, block, subdivision, section, township, range}
Location (address or directions)
_~. Telephone: Home
Applicant Address /¢¢/¢
Business
(c) Applicant is (check one): Lending Institution []; Owner/builder O; Buyer []; Other.~ (explain);
(d) Lending Institution
Address
_ TelephOne
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the Fl~,~/to the following addres~s:
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms "~
Other
WATER SUPPLY
individual Well ¢ Community [] Public []
Note: If coremunity well system, must have written confirmation from the State Department of Environmental Conservation
attestin9 to the legality and status,
4. 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
ENGINEERING FIRM PROVIDING INSPECTIONS, TES'¢G, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validatiOr~ date shown below, I verify that my investigation of this Health
Authority Approval shows that the omsite 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 ihTostigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Mumf.~pal and State codes, ordinances, and regulations in effect on
lhe date of this inspection.
Name of Firm .~ (~ ~. _ _ Telephone ,5~ / - ~J~ ~ .......
Approved for _:~ ~.C~ . bedrooms by
Approved "./' Disapproved
Terms of Conditional Approval
cAIJTION
The Muncipslity of Anchorage Depariment of Health er,d Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representation~ given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DFIEP dC,mC this as a courtosy to purchasers of homes and their lending
institutions in order to sahsfy certain federal and state rn ~¢~rements. Employees of DHEP do not conduct inspections or
analyze data before a cert.hcate is issued The M( n cipal¢ 1 of Anchorage is not responsible for errors or omissions in the
professional engineer's v, ork.
Page 2 of 2
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ,,~.~ T
Well Classification /~,/~/d~ ~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (ye (,:i~¢t~"~z~fr.."Date Com plated ~/./~/~'~.4/; ~ield
Total Depth ~ Cased to ~// '~ Depth of Grouting
Static Water Level ~, ~/_~- ~ / ~ Pump Set At
Casing Height Above Ground ~ /~ ~ Sanitary Seal on Casing~N)
Electrical Wiring in Coaduit~N) Depression Abound Wellhea-- d (Y~
Separation Distances from Well:
To Septic/Holding Tank on Lot ~_ /¢//¢ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot _ //~' /~; On Adjoining Lots
To Nearest Public Sewer Line _ ~ To Nearest Public Sewer
Cleanout/Manhole ~¢ To Nearest Sewer S~rvice IJna on Lot ,~
Water Sample Collected by __~~-~ ; Date /0~
~Water Sample Test Results ~R%f~ 'F/¢¢: ~ ~ ¢
B. SEPTIC/HOt. DING TANK DATA
Date Installed
Standpipes~N)
Depression over Tank (Y/~
Pumping/Maintenance Contract orr File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well __
To Property Line
To Water Main/Service Line .~
Course
Comments
Size / O~;' No. of Compartments
~ Cleaner'S)
Air-tight Cap (~.~'N) _.Date Last iF°undati°n Pumped /0//~/~L~''_
/¢/~ Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72 026(11184)
C. ABSORPTION FIELD DATA
· Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design
Length of Field ,.~--~:~
Depth of Field _ ~,'~-
Gravel Bed Thickness ~.~
Standpipes Presentd~)
Date of Last Adequacy Test
· .~ Square Feet of Absorption Area
Depression over Field
Results of Last Adequacy(~Test ~/~¢'~'~
Separation Distance from Absorption Field:
To Water-Supply Well /'/~/
To Building Foundation 7~'
LOt ~ /~.2~z ~L ; On Adjoining Lots
To Water Main/Service Line ¢~ ~,~- ' ~' To Cutbank (if present)
To Stream/Pond/Lake/or Major Drainage Course .,~
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~/¢~¢---~- ..~¢¢-'~-t
/
To Property Line
To Existing or Abandoned System on
:/-_--3 ,¢
D, LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
~ .~~....~..~..~/Ma~e./~.ess (Y/N)~~
/
Vent (Y/N)
Electrical Codes (Y/N) J
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I ~he checked~erified, or conformed to all MO.,~ an/d NAA guidelines in effect on the date of this inspection.
Signed [/~l'~'7"¢'%~¢¢'/]'4"c'~'~1'~- Date
Company ~,'//~('~_~' ~_ MOANo,
ReceiptN~l/ ~ ~) ~ ~ ~
Date of Payment I 0 ~ ~-~
Amou.t:
Page 2 of 2
72-026 (11/84)
M-W DRILLING INC.
P.O BOX 110378
ANCHORAGE, ALASKA 99511
PHONE 349-8535
DATE ,/~--'--
AMOUNT
MATERIALS
LEGAL DESCRIPTION
SERIAL. NUMBER
DEPTH
SETTING
SCREENLENGTH
&TIC LEVEL
TOTAL MATERIALS
LiNER/SCREEN
AMP RATE
DESCRIPTION OF WORK
~ .
All charges shall be paid fi~ full withfi~ ten
prior to drilh'ng Tile custo~ner shall pay in-
pay may result fil a lien against the property,
DATE
oUT
RATE
ALASKA 811dlBoIqm I1TAL COIqTBOL S FtulCSS, InC.
CURT KUTIL
14910 WILDIEN
ANCHORAGE ALASKA
SELLER-JACK WHITE CO
OCT 7 1985
WILL PICK UP FROM OUR OFFICE
50675
LEGAL:Ti2N R3W SECTION 33/LOT 149
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST DATE-OCT I 1985
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 308 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 690 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
3 BEDROOM HOME.
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1000 IS ADEQUATE FOR
THIS 3 BEDROOM HOUSE.
TIlE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON OCT 3 1985
FLOW TEST ON WELL
WELL FLOW DATE-OCT I 1985
A FLOW TEST WAS PERFORMED ON THE WELL. 690 GALLONS OF WATER WAS
PUMPED AT A RATE OF 4.5 GPM OVER A DURATION OF 2.5 HOURS.
THE DRAWDOWN WAS 1 ' WITH A RECOVERY TIME OF 10 ~MINUTES
AND THE STATIC WATER LEVEL WAS 80 FEET.
THE WELL FOR THIS 3 BEDROOM HOME.
,PPOINTMENTS
TIME ~/~
DATE --
~-S~CTOR ~~
MUNICIPALITY OF ANCHORAGE
T). :RECEIVED
TIME
y, --~ , DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT OF
~ X 925 L Street - Anchora~le, Alaska 99501 ENVIRONMEMU,, ~)l ~CTION
ENVIRONMENTAl. SANITATION DIVISION ,)~".F~ t 5 ~981
Telephone 264-4720
REOUEST FOR APPROVAL OF INDIVIDUAL WATER A"D SEWtI~ ~&El~& D
DI :{ECTIONB: Complete m oarts on page 1. Incomplete requests will not be orocessed. Please allow ten [10} days fo process ng
MAI LIN~, RESS ·
4. REALTOR/A EN'[
MAILING ADDRESS
_ PI-lONE
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDEN(~E
NUMBER OF BEDROOMS
~ One :_- Four E~ Other
[~=]~ SINGLE FAMILY
~ Two E-- Five
[] MULTIPLE FAMILY ~] Three ~ Six
7. WATER SUPPLY
I~1~1~1~1~1~1~1~1~1~ NDIVl DUAL ' - ATTACH WELL LOG. A well loft is requlrea for all Wells drilled
[] COMMUNITY since June 1975. For wells drillec ~rlor to that Bate, give wel
[] PUBLIC UTILI-Y aeptn (attach log if availabl¢.l
~, SEWAGE DISPOSAL SYSTEM
~/r NDIVIDUAL/ON'SFfE*~ YEAR ON-SITE SYSTEM WAS INSTALLED.
[~ ~UBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REOUEBT BEFOI:{E PROCESSIN~ CAN BE INITIATED.
1. TYPE OF RESIDENCE / ' ,": , ' , /
[] SINGLE FAMILY [] OTHER
MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL DEF ,~ ~;,, ,~-, -, : ~
DA'
COMMUNITY
I~] PUBLIC UTILITY
Connection Verified LO(
3, SEWAGE DISPOSAL SYSTEM ,
~ INDIVIDUAL/ON -SITE DA'
~PUBLIC UTILITY ,
Connection Verified INS
~Septic Tank or ~HoldingTank ~ .~ ,
Size: If Tank is homemade SOl :/ ~ < ( ,
give dimensions: '
5, COMMENTS.(~,~ ',~ ,,,f., ,.~ Z('~ ;,~ ,<r .
a~ escrowed to ~ave t~e ~o~Zo~g ~o~ oom~Zeted by Ootobe~ 23, Z98~
~L~h >~he 100 ,~.~ d~ce requSromen~ me~:' between ~he new sewer
sys~om and oxSs~n~ wollM~Co~Y of porm~ a~ached. ~he ~nspec~on
~ed by ~ho~ one,neet w~ll need ~o be submitted ~o Chis
~ APP~OVfiO FOB B~DBOOMS o~co ~or
~ CO~BITIO~A~ A~BOVAL {letter must accompan~ certificate}
)RAGE Al
;!tPi fi 1 1 I
September 18, 1981
Floyd A. Garrison
Star Route A Box 4018
Anchorage, Alaska 99507
Snbject: T].2N R3W Section 33 Lot 149
Approval for the individual
cannot be granted until the
completed:
sewer and water
following items
fac] litJes
have been
' (1)
'['he water analysis report needs to be submihted to
this office from hhe Chem Lab, 5633 B Shreet, for
(2
The well casing extended twelve(12) inches above
ground level.
(3
The distance between the well and the sewer system
is only thirty-nine(39) fleet; the required dlstance
Js ].00 feet. Either the sewer system or the well
will need to be moved.
(4
The septic tank pumped with a receipt submitted to
this office.
(5)
An adequacy test needs to be performed on the existing
sys'tem. This test will determine if~the system is
adequate according to National Standards. A listing
of private firms performiug the test[is enclosed. This
report needs to be submitted to this office fe~ our
review.
Floyd A. Garrison
September ]8, 1981
test, the foil_owing
A soils test will need to be performed in the area the
new sewer system will be installed so that design criterla
and specJ, fications can be made.
If the sewer system fails the adequacy
items will need to be completed:
~b k~2) A permit obtained from this office to install the new
sewer system.
Please notify this department for a reins~}ectJ.on when the noted
descrepancy has been corrected. If there are any further
questions, please call this office at 264-..4720.
Sincerely,
James S. Roberts
Associate Environmental SpecJa].ist
JSR/ljw