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HomeMy WebLinkAboutT15N R1W SEC 4 E2NE4SE4NW4 G~:~TER ANCHORAGE AREA BORONS' ! HEALTH DEPARTMENT 327 EAGLE ST; ANCHORAGE, ALASKA 99501 279.2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM NAME LOCATION ADDRESS PHONE. SEPTIC TANK: DISTANCE FROM WELL LIQUID CAISACITY '72- / UMBER OE / MATERIAL COMPARTMENTS ~ 7,.~~ ': ~~ ' ~ LIQUID GALLONS. INSIDE LENGTH INSIDE WIDTh DEPTH ~ SEEPAGE SYSTEM: SEEPAGE PIT: -- ~,~ . · N U~ ~" b ~ ~ J Ts' ' l I : /' ~ ' OUTSIDE DIAMETER ~';¢*':":'' OR WIDTH ' ~.-Z, LENGTH / .DEPTH . NEAREST LOT LINE ' ' . TOTAL EFFECTIVE ABSORPTION AREA WALL AREA) · ' ~ SO; FT. . .- '~"~:.'~' --.'-''_ :-. .-- . . .: '.-' .'i:~/ :..-. -.-.}i<.--; :z-':-]' TOTAL. LENGTH--.X DISTANCE FROM-WELL · FOUNDATION ' ,--~" ,NEAREST LOT LINE' ' ~ OF LINES .. NUMBER(OF:~ LINES' ' · DISTANC~.2,EI'WEEN_~ -- ILINES .... - .~''. TRENCH WIDTH ~. - "' _ ~IN~ TOTAL EFFECTIVE bEPTH: TOP OF TILE TO FI ISH GRADE' ' DEPfH ~DF FILTER MATERIAL BENEATH TILE' ' - ' ' ";IN. ~BOX/E T'I],E":- ' W_ELL: TYPE~ DE~PTH''~ . ] .~/~t DJSTA~JCE FROM ~%~,&' WATER I / I J I J' ' J ~ J ~ ~ ~" , BUILDING FOUNDATION. ~'~ SAMPLE ~ ~ NEAREST ~ - ,~ NEAREST:;~ ~--'- SEPTIC .,~ ;~ ~ SEEPAGE ' ///~ ! ~--' OTHER LOT LINE SEWERLINE ~ J J .... TANK_ '- , SYSTEM .CESSPOO[ , SOURCES DISTANCES: li r, DIAGRAM OF SYSTEM ;~4A8.l'(Ji ('~1')~" ~.TER ANCHORAGE AREA BORC"" ...... HEALTH DEPARTMENT " 327 EAGLE ST, ANCHORAGE, ALASKA 27501 279-2511 --~ ~NSPECTIOhl REPORT ON-SIIE SEWAGE DISPOSAL SYS[EM ~ ~ u~/~ ~ /~ ',~hrr: ~'.'-C .~ - .' -~ ( PHOrqE ....... ~ z~/, , ~ , ~,,. , [OCAIIOP4 ......... 2~-/_/_~:?~"~, ......................... LEGAL ~ .( ~I' IO,d/.~_~z.~'..._~'_~._~'..:L~:~.~: ._~:/.~.~=~ DISIAN( F ~ RO/,~ WElL /' ~" MATERIA~ ....... ~ ~";' (~.z.~ <. '(_~. LIQUID CAPACilY_ .......... z~-~ f~ ....... oAclO~qS INSIDE LEI'JOIII .......... ~NSll)E WIDIII ............. DEPIH SEEPAGE SYSTEM: SEEPAGE plh ' ' '" · I ,~ -9 .... · '' .... ' i~LE DRAIJq FIELD: G]llEA EiI . ANCHOI{AGE AltLEA IlEAL'I'll I)EPAILTMENT 327 F,a le St. A.chorage, Ala~ul 9950 .g SEWAGE DISPOSAL SYSTEM - APPLICATION 279-2511 r~ ,, ~ J L! O & P E R/'P.I¥ LOCATION OF iNSTALLATION~ RE,~IOENCE ADDRESS LEGAL DESCRIPTION L: ';":~'~' APPLICA11DN 10 INSTALL: SEPTIC "fANK~' -. SEEPAGE PI'I'_ TO SERVE THE FOLLOWING FACILITY_ " ::' "':'"' FINANCED 'rttROUGH___-~: · ', ..... -!: ANTICIPATED DATE OF COMPLETION- PERCOLATION 'lEST RESULTS_ ' .... '" '? BELOW TO BE FILLED OUT BY tlEALTII DEPARTMENT Case No DRAIN FIELD_ , OTHER_ !1-'~ ~.;' ",,i',,-,/ ?":[:: {' , PERMIT TO INSTALL A '1 Ills IS TO SERVE AS--~:J ~ '%L_J.~'-~.~L~ ..... AS DESCRIBEI BELOW. SIZE OF UNII ID BE SERVED-- SEPTIC TANK SIZE L.,' ' ._TYPE '__.: ..... SEEPAGE AREA- ";".'~'- ..... TYPE --' DIAGRAM OF SYSTEM DISTANCES: .I) -,/-. O. t.,: i~.~ f ?'} ~' F' '":" .-~,~ ..... : ~' "', J- /4 '/ , ~" Health Authority I certify that Iarn familiar with the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that thc above described syste~n is in accordance with said code. ,',?.'_ ;,~' . :-/-..' APPLICANTS SIGNATURE- DATE--- DL Form 241 WATER WELL DRILLER LOG DO NO'£ FILL IN 8/66 Drilling Co. Permit No. Driller ;,/,~.-, ~0}J . f?//; 4~ 7~fi/e- 1.//<~ ~ Certificate No. Area fO ,'1,',~..,?.~:',~/ Use of Well..~ Well Owner ~J~?' :! ' ' Location (address of: Township~ Range~ Section, if known; or distance main road ~ ~'. :i"~ Size of casing ~'~ Depth of ttole__~j~C'' ..feet Cased to /?v~ feet Static water level //0. ft. (above) (below) land surface. Finish of well (check one) open end ( j~ ); Screen ( ); Perforated( ). Describe screen or perforation Well pumping test at ~' ~all~ns per (hohr) (minute) for ~ hours with ....... of drawdown from static level. Was casing collar sealed with cement grout ft. WELL LOG Depth in feet from Give details of formations penetrated, size of material, color, ~round surface and hardness. ,' :, TO /-, TO /" >' TO /5 u ..... Y, TO TO TO TO [7_.1 /. CC, rea!e;' Anchorage A: :,~ ;,,.,,,',t~,:i ~IUNICIPALITY 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 ParcelI,D,# 051 -042-20 GENERAL INFO RMATION Corn plete legal description T1 ~ N HAA# qlW SPt 4 FRnn' n{ N360' nf ~W4NW4 Location (site address or directions) 22469 Deer Park Dr Chuqiak £hugiak. Day phone AK 99567 Day phone 688-2910 Agent Add ress Day phone Unless otherwise requested, HAA will be held for pickup. ' 2. NUMBER OF BEDROOMS: 3 3. TYPE OF WATER SUPPLY: Individual well X Community well . Pub lic water NOTE: If community well system, provide written confirmation from State ADEC attest- tng to the legality and status of system. 4. ~ TYPE OF WAsTEWATER DISPOSAL: Individual on-site X , Holding tank :'" Community on-site . _ _ Public sewer ~ NOTE: If community '~ '~ ~"*" :':' ;" wastewater system, provide written confirmation from State ADEC. attesting'tothelegality and status o f system. .... ~ , :~, ;'-:;,,~,.~.?}??:.:?~::~.~:'~;~i.~. . 5. , STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I verity 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~ ~... ~ .. r* Name of Firm END Engineering Phone 696-6111 Address 20441 Ptarmigan Rlvd Fagl~ P, iv~r~ AK 99577 Enginee~;s signc;ture ' ~ . ~ DHHS SIGNATURE ~31~ro;ed for "--~ Disapproved. Conditional approval for bedrooms. b~edrooms, with the following stipulations: Additional Comments The Municipality of Anchorage Department of Health and Human Services (DHHS issues Health Authority Approval CertificatSs based on y upon the representat OhS given n paragraph 5 above by an independent professi,o, nal engineer registered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes and their lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not 'conduct nspect OhS 'o¢ 'analyze data before a certificate is issued..The Municipality of Anchorage is not responsible for errors or omissions in the professk~nal engineer's Work. ,;, .t :'.,' Municipality of Anchorage /~ Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST T15NRl['~ Sec 4 LegalDescription: E 300' of N 630' if SW4NW4ParceII.D. 051-042-:°0 A. Well Data Well type [ n d i v i d u a 1 If A, B, or C, attach ADEC letter. ADEC water system number N/A y Date completed ? / 4 ./.5 g Driller ~ W 1 5 0 ' Cased to ] 4 4 ' Casing height 9" Log present (Y/N) Total depth Sanitary seal (Y/N) y Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION Date of test 1 2/4/69 Static water level 11 0' Well flow 7 .g.p.m. 3.3 5 Pump level1 ,,n I~n SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 72' (MOA file) Absorption field on lot 1 f~ q ' + Public sewer main N / A Sewer service line 25 ' + ; On adjacent lots 1 00' + ; On adjacent lots ] 0 q ' + Public sewer manhole/cleanout N / A Petroleum tank N / A WATER SAMPLE RESULTS: Coliform Satisfactory Nitrate Date of sample: ll./3 ~nHll,/1FI,/qz[ 0.88 mg/1 Collected by: ~ N n Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed 11 / 6 / 69 Tank size 1 000 9 a 1 Compartments Cleanout~ (Y/N) y Foundation cleanout (Y/N) y Depression (Y/N) High,water alarm (Y/N)., N / A Alarm tested (Y/N) N / A Date'of puihpin{~' ~ '"~ ? ~ ~ii 94 Pumper sEpARA?iON DISTANCES EROM SEPTIC/HOLDING TANK TO: Well(s) on lot, 7 2 ( ~0 A f ~ 1 e~n adjacent lots To property line .5 0 ' + Absorption field Sanitamy Pumpers Surface water/drainage i 00 ' + N 100'+ Foundation 7' (MOA File) 43' (MOA) 'Watermain/serviceline 25'+ CONTINUED ON BACK PAGE 72-026 (3/93)* Front : : C. LIFT STATION Date installed Size in gallons Vent (Y/N) ~"Pump on" level at High water alarm level / Meets MOA elect 'r~al codes (Y/N) SwEEi~Oi~tl N~DISTANCE FROM LIFT ST~ TO: /'On adjacent lots D. ABSORPTION FIELD DATA Manutact er~ Man ~ccess (Y/N) ,~ "Pump off" Level at / Cycles tested S~udace water Date installed ] 1 / R r/ R g Soil rating (GPD/Ft2) ] R n s Length 20 '~ [~'! 0 A ) Width ] 4 ' ( H 0 A ) Gravel thickness Total absorption ama 408 s f Cleanout present (Y/N) Y Date of adequacy test ] 1 / 2 / 94 Results (pass/fail) P a Water level in absorption field before test 33" Peroxide treatment (past 12 months) (Y/N) System type SRep~ge 6'(MOA/ Totaldepth 9,5' probed .Depression over field (Y/N) .N for 3 Bedrooms After test 33" N o If yes, give date Well on lot ] ] 5 ' To building foundation On adjacent lots_ ] 00 "+ Sudacewater ] 00 ' + Curtain drain ] 00 ' + SEPARATION DISTANCE FROM ABSORPTION FIELD TO: On adjacent lots 1 00 ' + Properly line 20 ' + .50 ' + To existing or abandoned system on lot N / A Cutbank ? 0 ' Water main/service line 25 ' + Driveway, parking/vehicle storage area 50 ' + E, ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer'sNameKND EngiY:~erin9 Kenneth H. Duffus Date ll/14/g4 HAA Fee $ ,~d) Date of Payment ////,~//~z/ Receipt Number 72-026 (3/93)' Back Waiver Fee $ Date of Payment Receipt Number NORTHERN TESTING LABORATORIES, INC. ALASKA'S WATER QUALITY PROFESSIONALS 2505 FAIRBANKS STREET, ANCHORAGE, ALASKA 99503 (907) 277-8378 SOLD BY CASH I coo. I CHARGE ON ACCT. MOSE, RET'D PAID OUT QTY,~'~[~) / [~ . D~C~ PRICE AMOUNT I 4115 All claims and returned goods 3330 INDUSTRIAL AVENUE 2505 FAIRBANKS STREET TESTIN6 LABORATORIES, INC. FAIRBANKS, ALASKA 99701 (907) 456-3116 · FAX 456-3125 ANCHQRAGE, ALASKA 99503 (907) 277-8378 · }-AX 274-9645 KND Engineering 20441 Ptarmigan Pl. Eagle River Ak 99577 Report Date: Date Arrived: Da~e Sampled: Ti~e Sampled: Collected By: Zl/11/94 Zl/O3/94 ll/02/94 Attn: Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Lab Number Method A135259 22469 Deer Park Water Parameter * Definitions * B = Below Regulatory Min. H = Above Regulatory Max. E = Estimated Value M = Matrix Interference D = Lost to Dilution MDL = Method Detection Limit Units Result * MDL Date Date Prepared Analyze¢[ A135259 EPA 353.3 Nitrate-N mg/1 0.88 0.20 11/10/94 vR~cP:~s ,b~~hns°n NOV ].4. '94 03:$0PM HTL AHCHORACE P.1/1 NORTHERN TESTING LABORATORIES, INC. .. Drinking Water Ana,!,ysis Report for Total Coliform Bacteria . =- "' TO BE COMPLETED BY L480RATO.RY~ TO BE COMPLETED BY CLIENT Next Sample Due ~ailing Ad~a~ Ol~, ~te, ~p CoMe ~ ~-~u I ,,. ~AM.~AT~~ F~ ~o, Oay Ye~ Ro~ ~ T~d W~r Spec~ Pu~ose ~ Un~eated W~ter Check S~mpls (for origin¢ cont~in~ted sample with I~ reference no. ~OD OF ANALYSIS; D ~me Collemed Labotato~ o[le~ad by Ref. No. SATLqF~rORY ~ UNSATISFACTORY U RES~X4~ R OTHER aAC3ER~ OB TOO N,UMEROUSTO COUNT 'rNTC CON~ GClOWI'H CG ~EAVY 8~DNENTMAS~JNG ~esult~ may not be reliable HSM SAMPLE AGE >48 HRS OLD For L~omtor~ Use Only Prep='d TransmiHal FaX Holm MOV ~1 ~ 0~:~0~M NTL ~MCW©R~E P~1×1 NORTHERN TESTING LABORATORIES, INC. 3330 INDusTRIAL AVENU~ FAIRBANKS, ALASKA 99701 (~07) 45S-3116'. ;A~ 456-3125 2505 FA~RBANK~ STREET ANCHORAGE, ALASK~ ~9503 (907) 277-8~78. FAX 274-~645 'DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BA'~ERIA '' KND Engineering 20441 Ptarmigan Blvd Eagle River, AK 99577-8736 Public Water System I.D.# Date Received: Date Analyzed: Date Reported: Next Sample Due: 11/11/94 Time Received: 11/11/94 Time Analyzed: 14:00 11/15/94 Time Reported: 13:$g Collected by: KND Sample Type: Routine Method of Analysis: Membrane Filtration Comments: U POS ND TNTC CG HSM SA -- Old ~ Comments: R NT 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 Resample Required No Test * # Colonies/t00 ml ** # Colonies/mi Sample Sample Total* Fecal* Other* HPC** Location Date Time Lab# Coliform Coliform Bacteria Result Comments Hose Bib Outside 11/10/94 15;lg AB5883 0 ND ND NT S 22469 Deer Park Julle Schaefer Environmental Analyst