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HomeMy WebLinkAboutMOUNTAINSIDE VILLAGE BLK 2 LT 4 MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEAt. TH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADORESS LEGAL DESCRIPTION N~). OF BEDROOMS --= ' PERMIT DISTANCE TO: Well /~ ~) -I- ~ Absorption area / ~ Dwelling ':10 ~ ~ d~ ~ ~/ ~ ~ No. of compartments ~Z Manufacturer ~ r~- Material ~ ~_~ ~, ~ Inside length Width Liquid depth Liq. capacit~ in gallons IF HOMEMADE: Well Dwelling PERMIT NO. ~ DISTANCE TO: ~ Z Material Liquid capacity in gallons ~ ~ ~ Manufacturer .... Foundatio,, .~ ~ Nearestlotline  DISTANCE TO: Well /0~)'F ~ ~ ~ Z No. of lines / Length of eagl~ Ib~ Total length of lines Trench width Distance between Ii n~s -- , ~ Total effective abso~tion area ~ ~ ~ Top of tile to finish grade ¢ Material b~'neath tile ~ inches -- Length Width Depth ~ ~ Type of crib Orib diameter Cr~b depth Total effective absorption area ~ Well ~ Building foundation Nearest lot line ~ DISTANCE ~O: ~ Class Dept~ Drill¥ Distance to I~t line -- PERmiT NO. ~ Building foundation Sewer line Septic tank Absorption area{si ~ DISTANOE TO: PIPE MATERIALS SOIL TEST RATING / APPROVED '" DATE LEGAL 72-013 (Rev. 3/78) WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geologicel a Geophysical Surveys LOCATION OF WELL (Please complete either ~o, lb or Drilling Permit Ne. A.D.L. No. Township N[] Range EE~ Meridian S [3 . WE} c~.] DISTANCE AND DIRECTION FROM ROAO INTERSECTIONS Mo un t a:L n .... Slreel Address Qn~ Area of WeH Loc~fion 2. WELL LOG Materiel Type gra~ely-w/cobble~ ~ haul. de:cs bedrock 5~p ~00~ 170 ' .~ ~pm 230 ~ ~ 50 ' - Top Bottom _JT} _ OWNER OF WELL: John Guthrr ~ Steve Bierlein 7. USE:~Domesflc ~ Public Supply [] Industry [] [trioorlon L~ Flechorge [] Commericol [~ Test Well E~ Other: -- 8. CASING: [] Threaded ~-Welded Jiam.~___[n. to ~,'~'_ ft. Depth Weight /'~_.lb$./f,. diam. in to .... ft. Depth Stickup__~ fi. 9. FINISH OF WELL: Size: - -- Slot/MeSh Length: Sot bolween ft. and ft. Backfilling _ Gravel pock I 0 m S'rATIC WATER LEVEL: ~.~?_ ~ ' m [~ Above or ~elow land surface II. PUMPING LEVEL below load surface and YIELD ft. Qfter_ hrs. pumping_ ']~- g.p.m. ft. after hrs. pumping _____g.p.m. I~.GROUTING Well Grouted: L~ yesX~] No Matorial: ~-] N~a~' Cement [] Other: IS. PUMP: (if ~vailoble) HP 14.REMARKS: 16. WATER WELL CONTRACTOR'S CERTIFICATION: 15. Water Tomperofure --- k~ AJ..aska ~1ow-.Vel.L-Varn' s )tilling E J,]nt A.A~27 better; Conlract License Number Authorized Rep~ntolJve MUNICIPALITY OF ANCHORAGE Department Health and Environmental rotection 825 - Street, Anchorage, AK. ~.J501 264-4720 * * * HANDWRITTEN PERMIT * * * Permit # ~$~C~q. WELL AND/~ON-SITE SEWER PERMIT _ ,. Location: Zor'_~ >~ .~ /¢¢;~ ~/'~../~Ll~'c-- Phone Number: .~.~$~ !~,]/? ,:L Legal Description: N:~:'CL //' '?-~HAJ ~"?~0 LOt Size: Type of Soil Aysorption System Is: Trench: ~ Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: ~ Soil Rating (sq.ft/br) /~ The Required Size of the Soil Absorption System Is: DEPTH ~ /~ LENGTH '~' . GRAVEL DEPTH ~ WIDTH The ].ength dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall Pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = 1~ GALLONS Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this departmen~ will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fee' for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minimum distance from a private well to a private sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31~ 1 9 ~ 3 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install the system in accordance with codes. (3) I un~r~tand t~at t~e on-site sewer system may require enlargement if the~den~s~e~d to include more t~/~: bed~~ SWP/024(1/81) [] SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST PERCOLATION TEST PERFORMEDEOR: LEGAL DESCRIPTION: Y~. '--'~\d-0,-.~] //C,~ ~')b("~i~'/'i~i~"~"~SLOPE ©L 2 3 4 5 6 7 8 9 10 11 12 13 14-' 15 16 17 19 2O SITE PLA~J ENCOUNTERED? O P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net /~/ Reading Date Time Time Water D r op'~:')~ PERCOLATION RATE ~ :~ . /._(minutes~i~l~- TEST RUN BETWEEN , (O . FT AND ' __-'--7'/'__ FT PERFORMED BY: ~.~ ~ 0~;~('~ CERTIFIED BY: ~~ 72-008 (6/79) -- 0 t~ r' 0 I o \ 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 HAA # ~/ g-'%,o~ / ('"//LI ~ Location (site address or directions) / '7 &'cO Ro_r ~_~o,~ t Dr~. Property owner ~--ohn ¢ A:~f4ryn ~c~¢'4ri.~ Day phone Mailing address ?. Lending agency ~-h-//~C Day phone Mailing address ~'5'o ~/. Agent {='c,r-/~.,~¢ /~n~?e~-F-t-~- - /,-/~,¢¢-et ~-o¢4~ Dayphone Address 30o0 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 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 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 Engineer's signature . 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 p' (¢c{'A:,lp T~c-,~ [~ ~/ .¢ ~¢-,,,~:.~.r Phone Address. /~5.~0 ,~:c4o ..¢~ /~,~O¢~o/'~-~'~' ,,z).~ DHHS SIGNATURE Approved for Disapproved. THEODO;~E F OOR~ bedrooms. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date-:~..z'~/'E~/~'/ The Municipality of Anchorage I:)epartment of Health and Human Services (DHHS) issues ,Health Authority Approval Certificates based only upon the representations given in paragraph 5 above b~:an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtes¢ 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 & Human Services HEALTH AUTHORITY APPROVAL CHECKLISTENWI~flI~i~i,< :,:: Legal Description: b~ ~ ~o¢rq"r~N~l~' ViL.~.46F. Parcel I.D. APR 30 199t A, WELL DATA Well type ~'R ~ I/A, Tg If A, B, or C, attach ADEC letter. Log present (Y/N) Total depth Sanitary seal (Y/N) y Date completed Cased to ~' 6£D~'o0~.. CasingheighL Wires properly protected (Y/N) RECEIVED ADEC water system number N,/~ · FROM WELL LOG Date of test Static water level Well flow ~ i/~ Pump level g.p.m. AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot I O~ Absorption field on lot I ~0 Public sewer main ~./~. Public sewer service line ~.~, ; On adjacent lots "2/oo ; On adjacent lots ~/o0 Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform Date of sample: Nitrate /, ~' m~¢'/"'~ Other bacteria Collected by: ~ ~-¢, B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Tank size I SOO G~ L Foundation cleanout (Y/N) y Alarm tested (Y/N) Date of pumping /¢ /2~' /gl ,~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot IO5 On adjacent lots. To propertyline ~2,0' Absorption field t Surface water/drainage ~'/oo Compartments 2 Depression (Y/N) N Foundation ~77 Water main/service line 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION N, /~. 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 Length ~J8 ' Width Total absorption area 7(.¢ 8 r)epression over field (Y/N) _ Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Soil rating I $2 l~'/l~C~£t4 System type Gravel thickness ~ Cleanouts present (Y/N) Date of adequacy test for ~ I-~o~4,,,0 If yes, give date Total depth bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Wellon lot lL~D' To building foundation On adjacent lots Surface water '>' 1oo On adjacent lots_ 7 ICc Propertyline To existing or abandoned system on lot Cutbank ~,/t Water main/service line_ Driveway, parking/vehicle storage area z'/5' Curtain drain _ 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 .~/"~~- Engineer's Name Date /¢/'8.~ /~)/ HAA Fee $ / Date of Payment Receipt Number _,~- ~.~_~-2 ,; ~ ~ ¢~-- ~2-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE DIVISION OF ~VIRONMENTAL HEALTH DEPAIY£?4ENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATICN [,Y)R HEALTH ~DjTHORITY APPROVAL CE~IFICATE 1. Ger~ral Information Application ]Date (aD Legal Desc~4ption (includ~ lot, block, subdivision, s~ction, to~ship~ range) Lormt ion (addre ss or direct ions) (b) Applicants Na~ ~ Applicants Address ~3~-~ (cD Applicant is (chec~ o~) ~nding Institution (d) Lending Institution Te lephor~ Adctress (eD R~al Estate Co. & Agent Address Te le phone 2. TV_~_~. of Fesidence Single°'Family Number of Eedrc~rs Other (descri~ya) 3. Water Su~ Individual ~%11, ~?'I ' 't' Note: If ~2nity v~ll system, must ha~ ~itten ~nfim~tion fr~ the State ~pak,~nt of ~viro~mntal Conservation attesting to tI-~ legality ~'~d status~ ~ // Is tJ~e ~11 adequate fo~ the n~r of lm~'~ s~cified in this ~A J~[)__/</.~ Onsite t-r~, ~blic ~,'~-'-1 Co~nity ~-"1 Holding '¥aD]~ ~l1 the wastewat:e~ dispsal system adequate ~oe ~e n~mr of t~clr~ (Y~) / [PaDe 1 of 2] 2-15-84 5..En_q~r~ering_Firm Providinq_~nspections, Tests, l~nta and Information I ¢~rtify that I have checked, verified, or conforn~d to all MOA [~AA Guidelinss in effect on the date of ti]is inspection° Date Te lepholm Sigr~d by .~ ( ENGINEER SEAL) The Municipality of Anchorage Depa~h~~-nt of Health and Environ~ntal ~otection does not ~uarantee the continued satisfactory psrformance of the water supply and/or the wastewate~ disposal system. %his approval indicates that~ as of the v~alidation (late sho~n above, ba~,~d on the data and information fuz, nished by an e~jir~eer registered in the State of Alaska, the water supply and wastewater disposal system is safe and func~ tional fo~t t3~e number of bedrozx~s and type of st~uctu~fe indicated° (DHEP Mail the ~iAA to tl~e fol].¢7~ing adck'ess: S /dS/s [Paue 2 of 2] 2-15-84 DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Well Classification t.~ ~./~/ Well Lcg P~esent (Y/N) C~CKL[~ - F~RU~Y 1984 Legal Descriptioq: Total Depth j~ ,.~3TM Static Water Level '~ .3~ ~--& ~ Pump Set At Casing Height ~Rx~ve Ground Electrical Wiring in Conduit (Y/N). · Separation Distances f~om Well: To Septic/Holding Tank on Lot /'~3~ /' To Nearest ~k]ge of Absorption Field on Lot../.'~ To Nearest Public Se~ Line ... Cleanout/Manhole /J//~ To Nearest Sewer Se=vice Line on Lot Wate~ Sample Collected By .,~.3~/~-+..~/---. ; Date Wate~ Sample Test P~sults ~_ 7~--/~ ; On Adjoining Lots ~5 /~ ; On Adjoining Lots ~ /~ ~ To Nearest Public Sewe~ .SEPTIC/HOLDING TANK DATA Date Installed ~/..'~/~3 Size /~<~ o Standpipes (Y/N) ,/~3' Ai~-tight Caps (Y/N) Depression over.~ Tank (Y/N) /~ Date Last Pumped /~ ~7~/~ .,~ Pumping/Maintenanoe Contract on File (Y/N) /~/7 ; for /t/~ Holding Tank Hi~h-Wate~ Alarm (Y/N) /~z~ Temporary Holding Tank Permit (Y/N) Separation Distances f~om Septic/Holding Tank: No. of Co~a~tments JP- , ./~ Foundation Cleanout (Y/N),/~_2 To Water-Supply Well /~ To P~operty Line ,~ /o To Water Main/Service Line Course To Building Foundation ~P j~7~ To Disposal Field /~ w To Stream, Pond, L~¢e, or Major D~ainage [Page 1 of 2] 2-15-84 ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed. ~. Width of Field ~ ~ Square Feet of Absorption A~ea D~p~ession over Field (Y/N) Length of Field __~ ~'~ Depth of Field_ ~ ~ Gravel Bed Thickness ~ zz~ Standpipes P~esent Date of Last Adequacy Test Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well > /~ ~ To P~operty Line To Building Foundation ~ ~Z- To Existing or Abandoned System cn Lot /~/~ ; On Adjoinin~ Lots -~/'" ~ o" TO Water Main/Service Line ~ ~/¢~. To Cutbank(.if present) / TO Stream/Pond/Lake/c~z Major Drainage Course To D~iveway, Parking A~ea, o~ Vehicle Storage A~ea ,~ ~TZ~f~ ~z~/~. Cor~rents ~ ~ f>/~z~P :/z~ LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Ele ct~ical Codes (Y/N) Dimensions Manhole/Access .(Y/N) "Pump Off" Level at Vent {Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Co~nents ** Check Permitted Becl~oom Rating Against HAA Request ** ,~ ~/~z/~,¢~3 I certify that I have checked, verified, o~ confor~d to all MOA HAA Guidelines in effect on the date of this inspection. Company C'"%~".'~.~-..,-~ KB1/d5/s [Page 2 of 2] Date MOA No. ENGINEERS 2-15-84