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Home My WebLink AboutTAIGA LT 2 =~ /~,~/ MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L ~Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE ~ --1J~'~ [2~ NEW A~k~Xi~I~[k'~A%X~~X Svein Bjornson 3 % ~UPGRADE MAILING ADDRESS LEGAL DESCRIPTION I Well , I Absorption area Dwelling I P E R ~~ ~ ~ Manufacturer Material No. of compartments Liq. capacity Jn gallons Inside length Width Liquid depth ~ ' DISTANCE TO: Well Dwelling Q Well Foundation Nearest lot line No. of lines~ Length of each line Total length of lines Trench width Distance between lines Topof Leng Width Depth PERMIT NO. ~ ~ Type of crib Crib diame -Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: ~ ~lass Depth~t~nA ]/~ Driller Distance to lot llne PER~ITNO. ~ DISTANCE TO: BuiJding fo i Sewer line Septic tank Absorption area(s) OTHERI I t., I I INSTALLER % ',%gl I L, ~6 ~ ~1~1'¢ ~ MI~NIC PAL fY AF CHC RAG APPROVED DATE LE6AL 72-013 (Rev. 3/78) ' ,' .... h:UNZC:RALITY OF ANCHORAGE "~' DEPARTNENT OF HEALTH AND ENVIRONMENTAL 2~4-472~ ,; CONTACT LEGAL DESCRIP: ; MAX ~EDROOMS: ON-SITE ;w~LL P PERMIT NO: 840368 r ' D.,Tc ISSUED~: 05/22/8~ : ~'~ ~V~ Bi~rn~so~ , ADDRESS: - ~541 ANCHORAGE, AK, .... ~9516 786-136~ ~UmDIV~SI~N: TAiG~ LOT: 2 SECTION: 6 TCWNSHIP: 12N RANGE: 2W 9959~ (SC.FT. OR .ACRES) ~LOCK: D! - LISTED ~EL~N ARE THE CP$ICNS AVAiLADLE TO YOU IN DC~SIGNING YOUR SEPTIC ? SYSTEM. CHOOSF_ TH~,. OPTION THAT ~ES_,__F]L:~ j~OURT - ~ SiTe. '" i.j ............. ~-- ~ '- .... '2~-~: .......... :' DEPTH TO PiPE 30TTOD~ (F'T.) 4.n,, V~.O .... : GRAVEL DEPTH (FT.) ~"-.: iL:ToTAL DEPTH (FT.) ~ :~ : 7;0 0.5 4.5 J~ ~GRAV~L ~IDTH (FT.) 2.5 ~.0 5.0 ''~ 'm GRAVEL LESGTH (FT.) 100.0 ** 41.0 ::~ .. GRAVEL VOLUF. E (CU.YOS.) 9.2 33.4 15.5 :~: TANK SIZE (GALS) ~,~.,0.0 ** 1,250.0 ~* 1,250.0 .... ?~ SOIL RATING (~Q.FT,/~3R) 150 t50 150 ** GRAVEL LENGTH > 75 FT. REQUI~ES FULTlPLE RUNS (NOT EXCEEOINS 75 ** TANK MUST HAV~_ Al LEAST ~0 COMPART~:ENTS ~ '.l - 1. I AM EAMikIAR NIlH THE REeUIREMENTS FOR ON,SiT.. S~W:RS AND WELLS NA FT. EAC AS FORTH ~Y THE MUNICIPALITY OF ANCHORAGE (~OA) AND THE STATE OF ALASKA. 2. I WILL INSTALL THE SYSTE~ !N ACCCRDANCE WITH ALL ~OA CODES AND ~EGUL~TI AND iN CCMPLIANC~ ~iTH THE D.;SIuN CRITERIA OF THiS 3. I WILL ADHERE TO ALL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET DISTANCES FROM ANY :XISTING NELL, WASTEWATER DISPOSAL SYSTEM OR PUBLIC - S£~ERAGE.SYSTE~ CN THIS C R ANY ADJACENT OR NE AR~Y LOT. 4. I UNDERSTAND THAT THIS PER~IT IS VALID FOR A MAXIMUM OF 4 ~DROC~S AND ANY ENLARGEMENT ~ILL REQUIRE AN ~DDiTIONAL ~ERMIT. IF A LIFT ~A~iO~ I~ INST,~LLED IN AN AREA COVEREO ~Y MOA ~.U:LDIN~ CODES, THEN (1) AN ELECTRICAL P~RMIT ........ · u ~ t~UST Gi~TATNE9, (2) AS~UZL~S .-WILL NoT 6E AEPROVED.~I~H~UT AN -FLECTRrCAL ..... INSPECTION RE~'~T'O AND (3) THE ELECTRICAL WO~',< MUST n~ DONE EY A ~r~ r ¢ ~ . --~.,, SIGNED ~%' ~ APPLicANTL EfART~ SU:INeJOR~;SSON ......... C .-ye-- . MUNICIPALITY OF ANCHORAGE * DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264"t720 SOILS LOG - PERCOLATION TEST SOILS [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10- 11 13- 14- 15- 16- 17 18 19 20 DATE PERFORMED: SLOPE SITE PLAN WASGROUNDWATER ~]~) ~ ENCOUNTERED? ~ E IF YES, AT WHAT ~ DEPTH? Gross Net Depth to Reading Date Time Time Water ~,~ / DEPT. OF ,EALTH & .; FNV]RONMEN~ pRO~ECT~ON PERCOLATION RATE /~' ~,! (minutes/in, I ECEt¥ ED TEST RUN BETWEEN COMMENTS PERFORMED BY: 72~08 (6/79) CERTIFIED BY: FT AND FT ~Tk[ ~,~k~D ~,tAU~, Cot4~,IST~%JT~_~I;:- MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99E01 264-4720 SOILS LOG - PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: SLOPE DATE PERFORMED: ~"'-~'~--- SITE PLAN 10 11- 12~ 13- 14- 15- 16- 17- 18- 19- 20- ENCOUNTERED? pO E IF YES, AT WHAT DEPTH? Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE (minutes/inch) TEST RUN BETWEEN FT AND FT COMMENTS ~/~;~ r,~e_~/ ~i /~or-,'/h~Z. ~,~ ~ ~ ~,~ J~/. ~ r~; ~ 72-008 (6/79) WATER WELL RECORD '~ STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of GeologicDI 8~ Geophysicol Surveys lb or lc.} A.D.L. No. /~- ~,~ ~T"/~ 1 6A ~_ .~f_ ot__o~- sE] wE] DISTANCE AND DIRECTION FROM ROAD INTeRSECTIOnS 5. OWNER OF WELL; Street Ad,res, and Are~ Of Well L0catlon ';-~. ~( ~' ~E~L LOG 5AAq)'F ~ LA'F (~l~'F I ~'D I 9 I 61om. in. lo fl* Depth Sflckup ft. gdLOJ2 ~I/AiV~A~ T'E ~ld~l-t ~ I~R[~ ~ l 91-- 9. FINISHOF WELL: ~/~ , /'/~ ~ T~ ~ ~ ~*(~ / Slot/Mesh SIZe: Length: E~IRONMENTAL PRC TECTION ' Material: ~ Neet ~ment ~ Other: J ~ ~ 14. REMARKS: 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 AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel i.D. 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent N, ~. ~JART~AR SVEINBJORM SSoN Day phone Ft~xF AI~/7 ~oF~c~ ~A~r¢;s Dayphone p.o. ~o~ ioo~o., ~o~, ~ ~'~o ( ~ ~ ~) Day phone 335.%~'3~c Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: L~ 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 commdnity wastewater system, provide written confirmation from State ADEC attesting to the 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 Anchorage files and from my inves!i_gation 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. NameofFirm [':L~TTO? T ¢H y'c s Phone Address I ~,~o ~C~/o ST ~NCH ~/c' ¢l~j.,~'/~ Engineer's signature DHHS ;.SIGNATURE IJ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments By: 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. 72-025 (Rev. 1/91) Back MOA #21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: LoT 2 Parcel I.D. A. Well Data Well type Log present (Y/N) Total depth 2 lo Sanitary seal (Y/N) Y If A, B, or C, attach ADEC letter. ADEC water system number Date completed 7/°J/g~ Driller W'.N. Cased to t'/3 Casing height Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test ~/~/~q ~/11~/':1~ ,~0 ~ Static water level I I fl 1 2.5' Well flow .5-' g.p.m. 3,-/ g.p.m. ~ ~' Pump level1 ~ ~ ~'7'~ ' ~r"rl c,,~ SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Ioo To (~,~ · Absorption field on lot Public sewer main :> /oo Sewer service line ~ 75 ' ; On adjacent lots ; On adjacent lots :> /ao Public sewer manhole/cleanout '~/oo Petroleum tank WATER SAMPLE RESULTS: Coliform (.~ cc,( /roo,~.E Nitrate /, ~? ,,~w,~'('~' Other bacteria Date of sample: r3/1~/5'-~ Collected by: B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) ')/ High water alarm (Y/N) Date of pumping Tank size 125o C~ Compartments 2 Foundation cleanout (Y/N) ~' Depression (Y/N) ,q' Alarm tested (Y/N) iq./~, Pumper 1S44¢~ N SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) onlot Ioo' F~o- (,o. On adjacent lots To property line ~o' Absorption field Sudace water/drainage ~ loc ' Foundation Water main/service line 72-026 (3/93)' Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" Level at .Cycles tested SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed 2/' Length ~-G' Width 3 Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) NoNE Soil rating (GPD/FF) Gravel thickness Cleanout present (Y/N) Results (pass/fail) System type T¢£~cH Total depth 12 -- 8 Depression over field (Y/N) N for H' After test L,~ -~" If yes, give date N,A, Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water >- On adjacent lots ~ /oo Properly line To existing or abandoned system on lot Cutbank H ,/~' Water main/service line Driveway, parking/vehicle storage area 3o Cudaindrain No~£ OBS~f~vg'~ 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. Signature,~~ -~, ~ '" ' ~' "* '' ' Engineers Name Date Wmver Fee $ ' HAA Fee $ '~¢)D / r/D Date of Payment Receipt Number Date of Payment Receipt Number .~~MMERCIALTESTING & ENGINEERING CO. a~,,I~__~._~RONMENTAL I. ABORATORY SERVICES Chemlab Ref.~ :93.4071-1 Client Sample ID :L2 TAIGA Matrix :WATER REPORT of ANALYSIS RIGHT SIDE HOSE BIB 5633 R STREET ANCHORAGE, AK 99518 TEL:(90~ 562-2343 FAX:(90~561-5301 Client Name :FLATTOP TECHNICAL SRV Ordered By : Project Name : Project% : PWSID :UA WORK Order :69526 Report Completed :08/16/93 Collected :08/13/93 @ 17:00 hrs. Received :08/13/93 @ 17:25 hrs. Technical Director:ST~P~ENZC~ EDE Released By : ~~~ Sample Remarks: ROUTINE SAMPLE COLLECTED BY: CHRIS. QC Allowable Ext. Anal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 1.29 mg/L EPA 353.2/300.0 10 08/16 LLH * See Special Instructions Above UA = Unavailable ** See Sample Remarks Above NA = Not Analyzed U = Undetected, Reported value is the practical quantification limit. LT = Less Than D = secondary dilution. GT = Greater Than ~S~'~S Member of lhe SGS Group (Soci~t~ G6n~rale de Surveilla.ce) ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH, ILLINOIS, OHIO, MARYLAND, WEST VIRGINIA, NEW JERSEY, SOUTH CAROLINA +~ ~ MUNICIPALITY OF ANCHORAGE DIVISION OF ENVIRONMENTAL HEALTH DEPARTMENT OF HEALTH A/CO ENVIRONMENTAL PROTECTION APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. Geaeral Information Application Date (a) Legal Description (include lot, block, subdivision, section, township, range) Location, (address or directions) (b) Applicants Name ~f fC~ ~f'.~' ~ "~Tele hone ~ Home Business Applicants ~dress (c) Applicant is (check ope) Lending Institution ~ uyer 0 her< plain); ; (d) Lending ~nstltUtion Address (e) Real Estate Co. & Ageng ~ Telephone Owner/buflder~; Telephone (f) Mail the HAA to the following address: 2o ~¥pe of Residence Single~Family~ Multi-Famlly~ Number of Bedroome.~ 3. Water Supply Other (describe) Individual Well~ Communi~y~ Publtc~-~ Note: If community well system, must have written confirmazien from the Sta~e Department of Environmental Conservation attesting to the legality and status. Sewa~=e Dis: osal Onsi~e ~ Public ~ Communi~y ~ ~olding Tank ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality amd status. [Page 1 of 2] 5. En$ineerin$ Firm Providin$ Inspections~ Tests~ File Search, Data and Information 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 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 informati0u obtained from the Municipality of Anchorage files and from my inVestigation and inspec~ion, the om-site water supply amd/or wmstewater disposal system is in compliance with all Municipal and State codes, ordinances~ and regula- tions in effect on the date of this inspection. Approved for ~Z/. __ bedrooms By Approved Disapproved Conditional CAUTION THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION (DHEP) ISSUES HEALTH AUTHORIT~ APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT~ ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER I~EGISTE3J~D IN '£~ STATE OF ALASKA. THE DHEP DOES %RtIS AS A cOuRTESY TO PURCHASERS OF HOMES AND T~£R LENDING LNSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE- MENTS. EMPLOYEES OF DHEP DO NOT CONq)UCT INSPECTIONS OR ~MALYZE DATA BEFORE A CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT tLESPONSIBLE FOR ERRORS OR OMISSIONS IN THE PROFESSION!~L ENGINEER'S WORK~ (DHEP SEAL) RR4/eJ/D18 [Page 2 of 2] 7 -19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH ALVfHORITY APPROVAL (HAA) 0EC 2 ~ CHECKLIST - FEBRUARY 1984 ~7~.~2~U ~' A'ec ~(~ WELL DATA __ ~I/~ Off Well Classification ~/~//f~f~ If A, B, Or C, D.E.C. Approved(Y/N) Well Log Present ~) Date Completed ~/~,/6~ ~ield ~ ~/~/ Total Depth ~O /~'f. Cased to /?F /~'T. Depth of G~outing ~//~ Static Water Level · //~ /~ Pump Set At ~//~'~ Casing Height Above Ground ~ ~7~ Sanitaz~ Seal on Casing Electrical wiring in Conduit ~) Dep~sss~0n A~ound Wellhead SeParation Distances f-fca ~11: (/~C~/~ /~-~#/~T / To Septic/Holdin~ Tank on Lot /~ ; On Adjoining Lots /~D To Nearest Edge of Absorption Field ,on Lot. //__~__~ .; On Adjoining Lots /~ To Nearest Public Sewer Line ~/~ To Nearest Public Sewer C~eanout/Manhole J//~ To Nearest Sewe~ Service Line on Lot Wate~ Sample Collected By ~. f~F/R~/;If~F~A ~'~/?f;~ Date /~/~//f/. , Wate~ Sample Test I~su!ts e¢{/~'~¢ C~i~ients ~7-~/~/~ ~J/~/~ /~79/~/ ~f~.J ~7~£~j ~J£zz ~ SEPTIC/HOLDING TANK DATA Date Installed ~///~// Size /~_5"f3 Standpipes ~) Air-tight Caps Depression ove~ Tank (Y~ Date Last Pumped No. of Cc~ps~tmmnts ~,~ Fcundation Cleanout Pumping/Maintenance Contract cn File (Y~N) ~/~' ; for Holding Tank High-Wate= Alarm (Y/N) ~///~ Temporary Holdin~ Tank Pern]it (Y/N) ~/~ Separation Distances from Septic/Holding Tank: (f~ ~$~f To Building Fcundaticn 3F~3/z To Disposal Field '~o 2-- To Stream, Pond, Lake, cr Majo~ Drainage To Water-Supply Wall To Property Line /O '~' To Water Maip~.Se~vice Line course Receipt 9 Date Paid: Amount: [Page 1 of 2] 2-15-84 Soils Rating in AbsorDtiDn St=ata Date.Installed ~,///~ Width of Field ~(o// Square Feet of Absorption A~ea Depression over Field (Y~ Results of Last Adequacy Test E]v-/~k? Type ofSystem~/Design Length of Field Depth of Field //~ Gravel Bed Thickness 7 / ~'~ Standpipes P~esent ~) Date of Last Adequacy Test ~///~ Separation Distance from Absorption Field: (~r~ To Water-Supply Well //~ w To P=operty Line. To Building Foundation ~, 7 w To Existing or/~bandor~d System cn Lot /j/~ ; Oa Adjoining Lots To Water Main/Service Line . To Cutbank(if present) To Stream/Pond/Lake/c~ Majo~ D~ainage Ccurse To D~iveway, Pa~king Area, c~ Vehicle Stc=age Area D. LIFT STATION Date Installed Size in Gallons High Water Alarm Lavel at ~ Tested for ~%~/~ Electrical Codes(Y/N) ~-~ Dimensions ~ Manhole/Access ~ "Pump Off" Level at_~,~____/~ Vent (Y/N) Pumping Cycles du~ing Adequacy Test. ~ets MOA Counts Check Permitted Bedroom Rating A~ainst HAA Request certify that I have checked, verified, or conformed to all MOA HAA Guidelines in effect on the date of this insp~'ction. Signed ~"--F /~/~ Date [Page 2 of 2]