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HomeMy WebLinkAboutT12N R3W SEC 21 LT 32B ~ MUNICIPALITY OF ANCHORAGE DEPA.TMENT HEALTH A.D HUMAN SE.V, OES Environmental Health Division 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES DIAJ [ C-[-~,'~' ~ O~ N~ ~ ~ ~ Tn SEPTIC ABSORPTION WELL ~d~,~FROM~ TANK FIELD Phone(s) Permit No. No. of Bed ..... ' W~LL ~o~_ e 1BlOck Subdivision FOUNDATION Township, ~ange, ~tion IXD '~ AS-BUILT DIAGRAM (S,ow location of well. septic system, prope,y lines, foundation. I Iz driveway, water bodies, etc.) TANK~ ¢ SEPTIC ~ HOLDING Material No. of Oompa.ments TYPE OF SYSTEM ~T.ENCH ~ BE~ ~ W. ~RA~. ~ OTHER ~ / Depth to pipe bo,tom from Total depth from odginal grade Fill added above original grade Gravel depth beneath pipe Gravel length Gravel width Total absorption area Distance between lines Number of lines JSo~r.,ing Pipe matedal (4) Inst~le, ~% ~ ~t~ ~ Date Installed WELL~ ~ PRIVATE ~ OTHER (Identify) Classification (A,~,C) Total Depth ~ Cased to FT~ FT I~tall~ Date InstaU~d: REMARKS: Scale: t '~ = ~'~ ~ ~ ~ ~0 ,'~ .~ Inspections Pedormed by: ..... :.~,~, ,~:~ ..... Municipal and Slate guidelines in ellecl on this date: ~--~c~ ~ Health Depadment Approval: ~~ 72-013 (3/85) , v · ' I e, 000 ~ , ' · / I ~ .,.o°/ , I -- -I..~1~':<. ,- / ., ~"( , ~ , >' '. ~ l;,-.~--?-"k~.~: / - _/. ,,, nx ~ ~ ,,, ~0P.- · .. ~ ., ¢o / ~. ID- I ~u'~ - , -LOT I'/ ',L~.~ '. ,~ov.-:.-Lo-r:.az-AI ,, _TO"-~F7_ \ --~ ~ t > ./,,. I : Ukl DEVE' LOPED -'¢" $ Ib,'¢ ' ~F-LL _LOT ;~ ' LOT~. LO-I- t SYSTEM: ! ~"-""NATIVE FILL °*'"~4' PElF PIPE DESIBM: _. SENE R. FO ---'7' S~-NEE ROOF., ZIq£TA-LCL. 'C/O'AT.F__ACH- END OF-TEEKIC. N ¢ H0kl ITOP-./PIPE Z:ktSTALL l, Ooo GAL H.O.A,. APPROVED TAMK,, !-SEWER. SYSTEM'LOOATION-' PL^N .~.,~./..-~ ,.~. ,,¢ , ..... $21 T. 12. M l~3N ~. ,~ :,,.5,,,, ~ ~, PR~E~ ~RNERS, ~L~ AND ~PTIC DETERMINED BY ' ~ ~ ' -" .¢~ "-' ".' unic pality Anchorage Department of Health and Human Services 825 "L" Street Tom Fink, Mayor P.O. Box 196650 Anchorage, Alaska 99519-6650 January 8, 1990 Dwight Gosnell 3116 Glendon Drive Anchorage, Alaska 99504 Subject: T12N R3W Section 21 Lot 32B Permit #890166, PID #015-273-36 The subject permit, issued, by this office for a single family well and/or on-site wastewater system has expired-as of December 31, 1989. Permits are issued on a calendar year basis by authority of the Municipal Code of Regulations. A new permit must be obtained from this office for an well and/or on-site wastewater system not installed by the expiration date. If you have drilled the well, a well log needs to be sent to this office for documentation of the installation and to close the permit. If a private engineer inspected the installation of the on-site wastewater system, the original as-built inspection report (three-part form) must be sent to this office for review, approval and documentation. When applying for a new~ermit, the'~ees are: $90.00 for an on-site wastewater permit; $50.00 for a well permit; $140.00 for a combined on-site wastewaher and well permit. If you have any questions, please call this office at 343-4744. Sincerely, John Smith, P.E. Program Manager On-site Services JW/ljm: 200 enc: Copy of Permit "Kids Are Our Future" Oate issued~ 08/.~x~ U b.l I C I' F:' A L., I ]' Y 0 F A lq C H 0 R A G Ii!: Depart. merit. (:)¢ Hea!'i:.h & Human S(~)pv:~.c::es 825 L St.~eet., Anchor. age, A].a~d<a 99501 :~;4:5--4720 W E L L P E R M I 'T' Owr'.,e:,r' Name: DW:I:GHT GOSNIELL Address: :3116 GL.EIqDON DRIVE Day Phone 522-. :1.;?,; 11 F::'aP(:::el Id: 01 I...cri:. t....~.-'g a 1 ~ Sub cli v i s i on: NA L, ot ~ 32. B B Ioc: k ~ tq~ Sect. ion: 2:[ Town~hip: 12.N Range: 3W Lot. Size 43956 (sq,,¢'L. (:)p acres) Max Bedrooms~ ]'hi~ F;'ermi'{:~ 3 Total Capacity~ 3 ......... ! t.I.L, TAI'-.tK: M:J.r",,imum tc:d'.ai sel::)t, ic tar'lk, c:apac:ity:. .,.'~,O()C~ gallor~s,,. Each sept:J.c ..,~.!~:. must have at least ") cc, mpar'Lment, s~ Dept. h 'Lo tc)p oF sept.~c t. ank(s) < I/,JlZI...j_: 1..o9 if)L.tsBt, be subm:i.t.t, ed to Murlic::i. pal:i, ty c)¢ Anchopo. ge Depapt. ment. of Flea.].th arid Human S(-:i)r'v:i. cc.~!!, w:i. thJn .30 PIEI::i:MiT EXF'iRES OECEMBEF:;..' 3 ~., 1989. NOTIFY ;OHHS I]F INSF::'ECTIONS AT :%4.::5-zI. 744 OR ::543-4681. NA:!:NT'AI!q I¥1!f,.l~ :}.0 ' SETBACKS BE]'WE:EN ]'RENCH WAI_L.S AND LOT I_II',]E / F:'OL,q',IDAT I ON. t F CAV :l:r,.ll}.) EK;CUI::;:S AND SETE;ACKS CAN ' T BE: MA ~ N .... 'T'AI?,iED, SYSTli~:M MAY HAVE TO BiE MOVEB "F[i Ix!OFi:'T'H OF: :OWIEI_t_]:NG. L,::R i , F:Y ']"HA'Till :1.. I o.m '}'o. miJ.:i, ar' ~,,.~:i.'t:.l"l 'i:.[":s) r'e~(::lu:i.r'e?mer'YLs for' on-'s~t.e) ~e~(~.)p~ aw'id v, le~].s as ...... ¥c:,r't.h by t. he Mun:ilcipality of Ancl']of'a(:]6~ (MOA) and the Stat. e caf ~;.~,, I will inst. all t. he) !~iyst, Eqfl afl a~CI:::E)PdaFIC¢;) ~,*~:i.t.h a].l MOA ..... c~c.le....; ancl 0.1"ii::! ~.i'1 c:orfil:)].~ar'l!::Ee wit. h the desi(tn c:pit, eria of 'Lhis perm:i.'l:..,, :~;,, i i*]j.]..I, a(::lh~r'e t.c) &].'i M[)A and St. at.e of Alaska r'eclu:i.r'ement, s for' '!.l"~e ::,e'.L bac:l.:: - ~'" :b =~" ' ' ....~ ..,:,,.,.iii 01" 5~h~,*JeH'at~JG:, Sy~ili'l'.eem (::ll"l this or iany adjac:erU:. (::m rii. z.:,ar'by ]. c)'{'.. ,, t..l:,=,.. 'l'.his zs va.tid for a max:i, mum c ) ~ I :~; bedr, c:(::,ms,, a.r'Yy (.5:,r'iiar'(]ifg, mer'it ¥~;I.i require ar'i acldit, icirlal per'mit.~ (Own e r ) i}b~ I GH"f' t...: :: ........ , ~'S ~ U~ PEvELOPEP BOLE ~ ~Vv LOT 3 / LOTZ LOT I ~NA%IVE FILL ~' PElF PIPE ~-HONITOE PIPE MEAE CEMTEE. %MgTALL 1,00o CAL H.O.A. APPROVED TAMK. ~SEWE~. OYOTEM "LOOATION ~ PLAN- - JlJ %J~t ~ A~A~ OF L~ATI~ OF EXISTING DETERMINED BY USE OF CLOTH TAPE Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVIJ 825 "L" Street, Anchorage, SOILS LOG -- PERCOLATION (ENGINEER'S SEAL) PERFORMED FOR: I)NiANT _(_~.'r?.~;N.E- I l LEGAL DESCRIPTION:~.~IOu"T' Cji_ 6 7 -8 9 10 11 12 13 14 15 16 17 18 19 20- TownshiP, Range, Section: T 17_ N_[ ~ J~J .~2- t SLOPE SITE PLAN WAS GROUND WATER ENCOUNTERED? S L IF YES, AT WHAT O DEPTH? p E Oepth [o Water After _ ..,5.../~,.,/,.q9' MonitorinD? p~_y Oa,e: Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE __ (minute~mchj PERC HOLE DIAMETER __ TEST RUN BETWEEN FiT/AND __ FT 72~ (R~. RECEIVED JAN 1 6 t9~1 k.]u,-fic:paii~,y of Anchorage STATE OF ~T,~KA DEPART~ENT OF NAT~I~m~L ~ESOulkCES DIVISION OF GEOLOGICAL AND GEOPHYSICAL SURVEYS WATER WELL RECORD LOCATION OF WE'~pt' ~-]~381th & Human Services BOROUGH SUBDIVISION LOT BLOCK SECTION QTRS TOWNSHIP RANGE MERIDIAN ~ ~: / ~ o~ co~zo~: ~AS~ING POINT: ~top of casing Depth of hole: /7'~ ft ~ground surface ~other: Depth of casing: /~77 ft BO~HOLE DATA: Depth. STATIC WA~R LEAL: /~/ ft. Date ~'~ Material type and color From~ To ~ -~ ., . ~THOD OF DRILLING: ~ir rotary ->->~ - ~ 0 '2~ ~ca~Ze toot ~ocn.r: ~Z~ ..... ~_~ ~ ~/ 'USE OF WELL: ~domestic ~irrlgation ~monltor / / ' ' ~public supply ~other: ~ CASING: Stick-up '~ ft. Diam: ~ /~'~ in / ' / ~/z WELL INTAKE: ~. open end ~ screened ~/~'~ / .... ~,~/~9~ ~,/ ~~ perforated ~open hble / ' / ~/~ ' Depths of openings: to ft · / ~? ~ "~ ~. SC~EN TYPE: ~"~ .... Diam: in / ~ Set Between and ft -r~/~ ...... G~VEL PACK TYP~ · ~ Vol~e used: ~'~'~ .Depth to top: GROUT TYPE: ~ Volume: Depth: from ~ft~ to ft . Durag ~on: RE~S: OOOIMo9 uemnH 9 qtl~eH '~d~Q P~ING LEaL ~D YIELD: ~JoqouvJo/ll~d;o,.nsq ~J ft after ; hrs p~ping /~ gpm " ~6[ 9 L NVP ~ Z~ 'rD~l~:.__ ft Horsepower:. Date P~p Installed ~.~ ~ ~' ,~/? ~/~/ ~ Well disinfected upon completion? ~yes ~no Signature of Authorized Ra~esentatlve DGGS PO BOX 77-2116 EAGLE.RIVER, AK. 99577 Date i"l LJ h! [[ C ]Z [::' ~':~ L. ]] '[' Y 0 F ,,c~ [,;'. C l"f 0 I::;~ P~ Ei iii] DE, par. '[.merr[. i::~ f bh~:.~a ]. 't.h f!~ Ht..unar'~ Set- v :L ~25 L. ~.r'ee'[.~, ¢~r~zhc:,ra,~e~ r:~:[.:~uM.::,'~;t ?950:[ 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 '0i 5- - 30 HAA# F,qSO.Sq¢ GENERAL INFORMATION Complete legal description ,~¢--(~-~i.©~ Location (site address or directions) prOPerty owner.-~;:;b~d,. ~h.~ O~c~S~4, A./_/_ Day phone ;~ g~'i'6~'~'g~C} .... ~ Day phone rkMa~l ng address Day phone 3 L/?- ~ ::~ ~ Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: NOTE: Individual on-site )~ Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA#21 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 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 ~¢l(bCv2~ ~_~/A,C~'~ ~A.~_~,~'~i £~_~ Phone c~r~C~' '~ ~ ~ DHHS SIGNATURE / Approved for TH~ E'~' bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: ("~"'¢"~/" /~/" ~~ Date /'y/ The Municipality of Anchorage 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 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-o25(Rev, 1/91) Back MOA#'~I Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: ~C,~[ITcoQ,,~;{~ I~}i (~(.~c~.. ~J.) ParcelI.D.: 01~ '- ~7~-~- ~-~''~ Lo{- 3~b A. WELL DATA we, type Log present (Y/N) ~/~ IfA, B, or C, attach ADEC letter. ADEC water system number Date completed ~)- '~)- C~ 0 Total depth i ~ -1 ' Cased to I ~: ~ ' Casing height (above ground) Sanitary seal (Y/N) ye LL ~0 ~.~1. Wi res properly protected (Y/N) AT INSPECTION Date of test Static water level Well production FROM WELL LOG g.p.m. g.p.m. WATER SAMPLE RESULTS: Coliform Date of sample: / Nitrate Collected by: Other bacteria SEPTIC/HOLDING TANK DATA Date installed ~)" ~(~ ~q 0 Tank size Foundation clea[~0ut (Y/N) ~/'~ i~50 Numberof Compartments ~ Cleanouts (Y/N) Depression (Y/N) ,/~ 0 High water alarm (Y/N) Date of PbmPi'ng AasORPT ON FmLD Date insiali;d Pumper Soil rating~r fl~/bdrm) '~ ' If yes, give date Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* LengthI ,,.~ ~ I Wiath '~2 ' , Gravel thickness below pipe 'r7 Total depth I O Efec'tiVe'ab;o~'ption' ~.ea; ]5:'l ~ Monitoring Tube present (Y/")__~ Depression over field (Y/N) Date of adeqU;Cy iest' l a~ bi- Q~ ¢ Results (Pass/Fail) ?1~O'-:~ For ~ bedrooms Fluid depth in absorption field before test (in.); '~)-1 Immediately after..~-R gal. water added (in,): Fluid depth ~v (ins) Minutes later: //-/qo Absorption rate = <~ z~c:' .g.p.d, Date installed % J Size in gallons Manhole/Access (YJ.N~ "Pump on" level at* High wa~vel at* ~. *Datum Cycle/rested ~ E.SEPARATION DISTANCES "Pump off" level at* Septic/holding tank on lot Absorption field on lot Public sewer main SEPARATION DISTANCES FROM WELL ON LOT TO: tOO Sewer/septic service line I CO On adjacent lots On adjacent lots Public sewer manhote/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation iU{q ' Property line t0'4¢ Absorption field 6 Water main/service line ~(72 J~ Surface water/drainage I OO ~ Wells on adjacent lots F. SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Building foundation ~ O ~ Water main/service line IOOf' Curtain drain I 0 0 ~ ENGINEER'S CERTIFICATION Property line Surface water I certify that I have determined thru field inspections and review in conformance with MOA HAA guidelines in effect on this date. Signatu m~~'~ Engineer's Name Date t ¢//'~//'~ ~:~ Driveway, parking/vehicle storage area Wells on adjacent lots ~ 0 ~ '~ of Municipa/ rg~O~dS ~~s are HAAFee $ ~ Receipt Number Waiver Fee $ Date of Payment Receipt Number 72~026 (Rev. 3/96)* CCT-12-~8 1~:55 ;ROtaTE ENVIRONW~NTAL ~ OT&E Envlmnm~n~t ~rvi,',mm CT&I~ R~I.~ 985782001 Client Name P~none ~g. sm. ~ojmt N~m~ L32B T12N ~W 521 Cliff S~ple ~ Si~ Ho~ l;ib Mat~ Dr~g War~r Ordered By Clien~ PO# Printed DatedTime 10/12/~ 14:48 Coll~,~i Date~'t~ne 10/04/98 14;20 Received ~a~e/Time ~.0/05/98 09;40 T~hnic~l Dire~or: b-'lephen C. F. de 1.26 0.10D ~/L col/lOlL