HomeMy WebLinkAboutMANN BLK 2 LT 3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 9950'1 Telepho.e 264-4720
ON-SITE SEWAGE DISPOSAl_ SYSTEM AND/OR WELL INSPECTION REPORT
NAME PION E I~NEW
Billy Mackey2~ 7-1826 []UPGRADE
MAILING ADDRESS
1210 Redwood Court Anchorage, AK 99504
LEGAL DESCRIPTION
Lot 3 Block 2 Mann Subdivision
LOCATION NO, OF BEDROOMS
Golden View Drive & 162nd --4
Well installed Absorptianarea Dwelling NoL ~;ult~ PERMITNO,
_or DISTANCE TO: Not 11' . ~tructed-to be 780321
-Z Manufacturer Materialabou~:- 15 ! No, of compartments
~ Greet ~°1 -- 2
hiq. capacity in gallons Inside length ~i~t'll ',- Liquid depth
1250 IF HOMEMADE:
I~ v DISTANCE TO: Well Dwelling PERMIT NO.
O :~ <~ Manufacturer Material-- Liquid capacity in gallons
I~ Well Foundation Nearest lot line PERMIT NO,
~ DISTANCE TO: Not installed To be about 0' 40' 780321
- _
No, of lines Length of each line Total length of lines Trench width Distance between linos
~-- 1 76 ' 76 ' 4 8 inches
~. Top tile to grade Material beneath tile Total effective absorption area
of
finish
m 3riglnal 4' backfllled to 5' 48 inches 304 S.F,_
Length Width Depth PERMIT NO.
~: I- Type of crib Crib diameter Crib depth Total effective abs(~rption area
~a Well Building foundation Nearest lot line-
~ DISTANCE TO:
~1 Class Depth Driller Distance to lot line PERMIT NO.
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
Cast to drain field rest P.V.C. ¢~,~ -~---~
SOIL TEST RATING --
INSTALLER
Argo Excavating
REMARKS
drain field to obtain 5' ~-
of cover -
AP~O~E,D~ / "' '" DATE LEGAL
72-013 (Rev, 3/78)
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(:!iF:Ed...Ih,E:, !:::!i",I[::, 'f'!'llE I!?,O'!'-IEIH OF' "I'I'IIE t!!:',:'::(:::FIVI:::FI":!:Ed",I '::):!",I
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:;L!:ii!;ill '!'I:i:1 ;;;i'.l;i:.ll;i:.l F::'I:!!:iE'T' !:::l:;;:Ellfl !:::! I::'UI::!:I..:I:E: t.,llii!:f.!. Dlii:l::'i;ii:i",!ii::,:l:i",l(:ii LIF'I:)i'.,! i'l"ll:ii: ' I" "," I:::' E: O1:::' I:::'UE',L. :!: E: HE:[.t ....
I.,.!L::!.L. ! OEi~ii; i:::II:;i:i~: !:;;:liii:l;!l.I):F,i:l~;[::, I::tHI:::' I"!lJ::ii;'t I:ii',!ii: !:;;'.!;i::'!'lJi:,i:h,!t.~:D TEl
OF::' 'IFil;i: !.,.tl!ii:l....l...
(:YT'F!!i!i;F;i: l:;;:!!!i)3Lf :!: I:;~:liii:l'fl!iil",F!':!i!; I'"ll:::l"l" I:::It:::'!:::'L "r'. ~;i::"!i!:l:::: :!: I::: :!: CI:::!"!" :!: O1",i~!; 1:::II"4E:'
F:]',,,'I:::1:1: ! .t:::!l:ii~!..IE TEl :1: I",!:!!;I..IFi:IE I:::'Fi:Eq::'Ei:F;i'. ): 1"4~!:i;'T'I:':II..t .I:::IT !: Ot",l.
2204 Cleveland Anchorage, Alaska 99503
Performed For Glacier Excavation ,~at~ Performed_5-~-7~
Leaal ~escrtDtton: Lot 3 ~lOCk 2 Subdivision
This ;orm Renorts Soils Lon Yes Percolation Test
TEST HOLE #2
~e~th
~eet
Sot1 Characteristics
1' Fea~ & Black Organics
Dark Grey Slightly Silty Sandy
Gravel
10--
14~
18--
Water ,Entering @ 2 GPM
Bottom of Test Hole
20--
Was Ground Water Encountered?
I~ Yes, At what Depth? 12'
Yes
Readtnq Date Grnss Time Net TJme Depth to HgO Net O,.on
PercolatJon Rate Minute
Prn~osed InstallatJon: 'Seenaae Pit Draln Field
Deeth of Znlet . .Dept-~ To Bottom Of Pit Or Trench
¢~t~.NTS: 150 s~. ~to ..dr~aina~e area required
Test Performed By Neal ~a~sam
~ata 'Certified Bk:._ ,CTL __
WELL CONSTRUCTION LOG
OrillerVe-cn~ L, l~/co~v_.[I ,~pe cf ,i~ ¢cO~t~
Well location: (address & legal descr ion)
Oepth ot well l~ ft. Cas,,,: deptb~ It. dia$. (¢ ill.
Static water I.vel~ _ft. (~, below) land surface.
Finis~ of well: (open-end, screen, perforatad,~ other)
Describe Intervals and size:
,oil yield tested by (pumping,C~_..._~ air)at I0
for I hours with 51 _ft. of drawdown from static level.
USGS no..--
Nearest community_
Location sketch or remarks
I/mi n.
ORILLER'S MATERIAL LOG
Oepth below land dive description of strata penetrated
surface in feet (size of material, color, hardness of drilling, and water content)
0
t c
~0 fo
to
__to
____t o
__~to
-- to
____to
____t o
____,to
__~to
te
----to
to
to
~to
roc .- brouaq
0 ,J
50~
qo'
00'
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. # O ~.~) ~O,~t-I -
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner "~.i~ ~; ~-"~_t~..- ~,~-~ Dayphone ~
Mailing address ~¢~*-'~-- ~ /:~'O~/~-~
Day phone t,,.)/.~
Lending agency
Mailing address_
Agent
Ad dress
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: zCr ''~
TYPE OF WA'rER 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 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
Name o f Fi rm. (~.A~ ~..~- ~,.~/~--~--~-- ~¢
EngJn~¢s signature
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
ate of this inspection.
~ ~-,zS.-w',~ Phone
bedrooms, with the following stipulations:
Additional Comments
Date
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.
Legal Dcscriptioo:
Municipality of Anchorage~um:~p^urt
DEPARTMENT OF HEAL'FH &
Environmental Services Divisi~'W '
RECEIVED
Health Authority Approval Checklist
Parcel I.D.: O~,,0 -- 04.-I-7-,4--'
A, WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
~2~'4et"'"" If A, B, or C, attach ADEC letter. ADEC water system uambcr
x,,~ ~___~ Date completed
t
Cased to 2{o g..~f~'~-c'J~Casiug height (above grouud) ~ ( 7_, tt
Wires properly protected (Y/N) 'x,l ~_~
Date of test
FROM WELL LOG
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform (~3
Date of sample: /b/g'<~/~
Nitrate
AT INSPECTION
/.3!
. g.p.m. ~' ¢~ + g.p.m.
~ - q ~ ~ Other bacteria
Collected by: ~~
I~. SEPTICatOLD1NG TANK DATA C~ ~ ~,t,~x~ Ot.O
r atei, stalled /' o Za,msi e Number of Coulpartments __ Cleanouts(Y*) ~~_.
o ~'Foundation clcanout (Y/N) ~0 Depression ~m) ~ High water alam (Y~ ~ ~
m'~ DateofPumping ~/~ Pumper ~~O-fgO~'
.~C.. ABSOR~ION F~LD DATA ~
~/ Length ~3,~' __~Width ~ ~ Gravel thic~ess below pipe ~ . Total depth ~ ~ Xo~
Effective absorption area ~ O 9 Monitoring Tube prcscnt(Y~)~U~Dcpression over fic]d (Y~ ~
Date ofadequacy test [,/2~)~ Results(Pass.ail)~ _For~ bedrooms
Fluid depth in abso~tion field before test (iu.); ~ Immediately ~er g~ water added (iu.): ~
Fluid depth ~ (ins.) Minutes later: ~ Absorptiou rate = ~ ~OO .g.p.d. ~
Peroxide treatment (past 12 lllouths) (Y~) ~o~1~ If yes, give date ~ {&
Manhole/AccesS (Y/~) ~~tmp off level at*
High ~t~~ *~ ~ MUNICIPALITY OF A~HO~E
C ested ~¢NVIRONME~AL $ERVICES DIVISION
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
I
Septic/holding tank on lot
Absorption field ou lot
Public sewer main
Sewer/septic service line
1996
, RECEiVE D
~ J ~ ; On adjacent lots ~' IO O
I
~ I00
; On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~O r~' Property line ~.-O' ~ s'u°-"~bsorption field J
t
Water main/service line "~ I O Surface water/drainage '~ I o O / Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation
Surface water
Cu~ain drain
ENG~ER'S CERTIFICATION
.......
I cert~v that I have det~'i~ined~u ~dd inspections and review ofMunic,pal reco~[~t$~ ab~'
m con ormanc
Date
Date of Payment
Receipt Number c'O"'(D 2~ (7 ~f')
/
Rev. 8/95 OSS: haa.wk.doc
Waiver Fee $
Date of Payment
Receipt Number
CT&E Environmental Services Inc.
Laboratory Analysis Report
CT&E Ref.#
Client Sample 1D
Matrix
962645.962645001
5801 East 162nd Ave. Hose Bib
Drifting Water
Collected Date 06/28/96
Technical Director: Stephen C. Ede
Released By~_%~_~,~_.o,~.._.~ ~.~,~.~.~_~
Smnple Remarks:
Nitrate-N
Nitrite-N
Total Coliform
Results QC
Qual
PQL
Units
Method Allowable Prep Analysis Init
Limits Date Date
1.92 0.100 mg/L EPA 353.2
0.100 U 0.100 mg/L EPA 353.2
0 0 co[/lOOmL SM18 9222B
06/29/96 ENB
07/02/96 ESC
06/29/96 TAV
U - Undetected
LT - Less than
GT - Greater than
D - Secondary Dilution
J - Below the calibration range
200 W. Potter Drive, Anchorage, AK 99518-1605 --Teh (907) 562-2343 Fax: (907) 561-5301
3180 Peger Road, Fairbanks, AK 99709-5471 -- Tel: (907) 474-8656 Fax: (907) 474-9685
ENVIRONMENTAL FACILITIES IN ALASKA, CALIFORNIA, FLORIDA, ILLINOIS, MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY, OHIO, WEST VIRGINIA
CT&E Environmental SerVices Inc.
L a b o r a t o ry D i v i s i o n ~.,~.~-~.,¢-~ .~-~.¢~.~.~-.~.~.~-.~.~-.~.~'~.~'j.~.~-j~,
Drinking Water Analysis Report for Total Coliform Bacteria 200 w. PotTer Or~ve
Anchorage, AK 99518-1605
READ INSTRUCTIO,.YS 0.¥ REVERSE SIDE BEFOR~ COLLECTIWG SA~I~IPL.~ Tel: (907) 562-2343
Fax: (907) 561.5301
O
PRIVATE WA,TER SYSTEM
Alaska Water &
8471 Brcokridge Dr
ts 0 Send Invoice
SAMPLE DATE:
i'Vlonth
SAMPLE TYPE:
P, outine
(21 Repeal Sample (for routine sample
with htb ref. no. )
O Special Purpose
SAMPLE LOCATION
Day Year
Treated Water
Untreated Water
Time Collected
Collected By
Please Pdat
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
Satisfactory
Unsatisfactory
n Sample over 30 hours old, results may
be unreliable
Sample too long in transit; sample should
not be over 48 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
ate Recei,,e
Time Received
Analysis Began
Analytical Method: ,J2~Membrane Filter
m MMO-MUG
* Number of colonies/100 mi.
Lab Ret. No. Result* Analyst
Sent to A.D,E.C. ~ ["b B Jun
Client notified of unsatisfactory results:
Phoned Spoke with
Date: Time:
[]
Faxed
Faxed
BACTERIOLOGICAL WATER ANALYSIS RECORD
M.MO-MUG Result: Total Coliform
Membrane Filter: Direct Count
E. Coli
Colonies/lO0 mi
Verification: LTB BGB COLIFIRM
Time
Coliform/100 mi
hfs
\g
DEPT. C,'l:' '~: ; &
MUNICIPALITY OF ANCHORAGE ENVIRONMEN[AL i,,, :~;:!CTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
825 L Street-Anchorage, Alaska 99501 --
k AY
ENVIRONMENTAL ENGINEERING DIVISION
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS; Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10) days for processing.
1. PROPERTY OWNER PHONE
MAILING A~D~ESS ~
PROPER~Y RESIDENT (If different from above) J ' J PHONE
2, BUYER PHONE
MAILING ADDRESS
3. '~ENDINGINSTITUTION - ' I 'PHONE
I o¢ I
MAILING ADDRESS
4. REALTOR/AGENT I PHONE
I
MAI LING ADDRESS
6, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] One ~_I'-'-'-F our
[:];P'~SI NG LE FAMILY [] Two [::::1 Five
[] MULTIPLF FAMILY :::] Three [] Six
[] Other
7, WATER SUPPLY
~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all wells drilled
[] COMMUNITY since June 1975. For wells drilled prior to that date, give well
[] PUBLIC UTI LITY depth (attach log if available.)
S. SEWAGE DISPOSAL SYSTEM
[~" I NDIVI DUAL/ON-SITE** *~ If individual/on-site, give installation date
If system is over two {2) years old an adeauacy test is required
[] PUBLIC UTI LITY by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010(3/78)
1
THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TiME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVI DUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVEDI
3, SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
I~1 INDIVI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY (.~- ~'~
Connection Verified . INSTALLER
[]Septic Tank or []Holding Tank
Size: l~'~ If Tank is homemade: SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER I~.. o ~
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
I
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
~ APPROVED FOR -~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certific~te)
[] DISAPPROVED
DATE BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
e OLOalC4L LAaO ATO J OF A .A KA,
P.O. BOX 4-1276 a,~49 BU$tNE,~ PARK BLVD.
ANCHORAGE, ALASKA 99509
Drinkin§ Water Analysis Repo~t for Total Coliform Bacteria
TELEPHONE
(907) 279-4014
TO BE COMPLETED BY WATER SUPPLIER
Public Water System Name.~_
Mailing A' rase · ~ ' ~ ~ ?
City State
Mo. Day Year
Zip Code
SAMPLE TYPE:
[] Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
[] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
Time Collected
Collected By
TO BE COMPLETED BY LABORATORY
LABORATORy:
NAME
ADDRESS
CITY
Date Received
Analytical Method:
[] Fermentation Tube
./~..Mem brahe Filter
Lab Ref, No. Result* Analyst
,
J
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310(3-78)
06-1220 (b) BACTERIOLOGICAL WATER ANALYSIS RECORD
Rev. 1978
Date Collected Source
Date Received Time Received p,m. Lab. No.
Presumptive 10mi 10mi 10mi 10mi 10mi 1,Om1 0.1mi
24 Hours ,
48 Hours ,~ /
Confirmatory
24 Hours
48 Hours
EMB_ Broth 24 hours: __Broth 48 hours:
Multiple Tube Report: 1Omi Tubes Positive/Total 1Omi Portions
Membrane Flitert Direct Count Collform/lOOml
Verification= LTB _~ BGB
Final Membrane F~.~ , Coliform I mi