HomeMy WebLinkAboutHILLSIDE NORTH #5 BLK 3 LT 7
Municipality of Anchorage Page ! of
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: ~'~o~t2q PID Number: o~,/o-~'
Name: Wastewater System: [] New [] Upgrade
Address: ABSORPTION FIELD
Phone: No. of Be~ooms: ~ Deep Trench ~ Shallow Trench ~ Bed ~ Mound ~ Other
LEGAL DESCRIPTION soi, Rating: Total Depth from original grade:
, ~ GPD/Sq. Ft,
Lot: Block: Subdivision: Depth to pipe bottom from original grade: Gravel depth beneath pipe
Township: Range: Section: Fill ~dded Above original grade: Gravel length:
~ Et, ~O Ft.
Gravel width:
Number of lines:
Distance between lines:
~ELL: ~New ~ Upgrade
Classification (Private, A,B,C): Total Depth: Cased To: Total absorption area: Pipe material:
Dr~ler: Date Drilled: Static Water Level: Installer: Date installed:
YieI~:zO GPM IPu~p Set at:= ~ Ft. Casing Hei2Ab°ve Gr°und:FL TANK
SEPARATION DISTANCES ~ Septic d Holding d S,T.E.P.
TO Septic Absorption Lift Holding ~ublic/Private Manufacturer: Capacity in gallons:
From Tank Field Station Tank Sewer Lines ~0~¢ ~ ~
Material: Number of Compartments:
Surface ~LIFT STATION
Lot Size in gallons: Manuf~~
Foundation ~ ¢ ~ /~ I~ ~ ~ ~ "Pump on" level at: "Pump off" level a~er
alarm
Curtain Pump Make & Model Electrical Inspections performed by:
Drain ~¢/ f~ ~d ~
Remarks: BENCH MARK
Location and Description:
Assumed Elevation:
EN~J~SEAL
inspecbons .... penormea Dy
Department of Heal.nd ervices approval ~ ,'~, ,~..
Rewewed and approve Date: ~ /
72-013 (Rev 9/91) MOA 25
'Permit No. SW950224.
2 2
Page of
Municipality of Anchorage
DEPARTMENT OF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744
On-Site Wastewater Disposal System and/or Well Inspection Report
HILLSIDE NORTH #5, BLOCK .3, LOT 7 04105194
Legal Description: PID No.:
coz Co
4 BDR~.
HOUSE
mU-SOT~OM ==S~L 1~50 GAL. SEPTIC TANK
OF BAY WINDOW '
SOUTH SIDE OF
co
SCAI~ 1" = 40'
i A B
FCO 19,5 15,5
~01 24 19
C02 59 49.5
~03 111 100
MT1 110 99
~0.9
74.9' NO WATER FOUND ·
MT
CO5
C03
LOCATION OF WELL
BOROUGH $ DI~VIS O~ ~ LOT BLocK
STATE OF ALASKA
DEPARTMEN.T~OF NATURAL RESOURCES
DIVISION OF WATER
WATER WELL RECORD
SECTION TOW3~ISHIP RANGE MERIDIAN
DN I-]E
SECTION QYRS
LOCATION/SKETCH:
DEPTHS MEASURED FROM:l-lcasing top []ground surface
BOREHOLE DATA: ' Depth
Material Type and Color ' From To
WELL DEPTH: DATE OF COMPLETION
Depth o! hole: / ~:)~2- ft
Depth of casing: ,/-~! ft ~_~ / ~'~/ ~''~
DEPTH TO STATIC WATER LEVEL:
//~, ~-~ ft below [~-top of casing [] ground surface
METHOD OF DRILLING: ~'air rotary [] cable tool
[] other
USE OF WELL: [~domestic [] irrigation [] monitor
[] public supply [] other
CASING STICK-UP: ~ .~ ft, Diam: ~-P in. to/_~tt
Casing type: ~,~L'~ ~-~'~n~ to /
INTAKE OPENING TYPE: [] open end
[] perforated [~open hole
Depths of openings: __ to ft
[]screened
SCREEN TYPE: ~ Diam: in.
Slot/Mesh Size: Length: ft
GRAVEL PACK TYPE: ~,
Volume used: '~- DePth to top:
GROUT TYPE: . X~ Volume:
Depth: from ft to
ft
Duration: ·
PUMPING LEVEL AND YIELD:
,/ 7~) ft after ,~ hrs pumping ~,~(~ gpm
PUMP INTAKE DEPTH: ft Horsepower: __
WELL DISINFECTED UPON COMPLETION7 [~(ES [] NO
CONTRACTOR INFORMATION:
RegisteYed Business Name
Sigha'ture of Authorized RespreseGt~tive Date
REMARKS:
PLEASE MAIL WHITE COPY OF LOG TO:
DNR/DIVISION OF WATER
PO BOX 772116
'EAGLE RIVER AK 99577-2116
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
PAGE 1 OF
ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW930224
DESIGN ENGINEER:TOBBEN SPURKLAND, P.E.
OWNER NAME:CLARK STEPHEN E & DEBORAH M
OWNER ADDRESS:2440 E. TUDOR RD., SUITE 121
ANCHORAGE, AK 99507
DATE ISSUED: 7/16/93
EXPIRATION DATE: 7/16/94
PARCEL ID:04103194
LEGAL DESCRIPTION: HILLSIDE NORTH #5 BLK 3 LT
7 ~
LOT SIZE: 104108 (SQ. FT.)
NUMBER OF BEDROOMS: 4 THIS PERMIT: 4
THIS PERMIT IS FOR THE CONTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4329 OR 343-4681 AFTER BUSINESS HOURS
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED BY:
ISSUED BY:
LOT
205 ~ ~5~h, 6¥enue~ Suite 206
6NCHDR~SE~ ~L6SK~ 9~501
SEPTIC SYSTEM DESIGN
7 BLFJtCK :3 H · LLS [ DE I~It~R TH
STEVE CLARK
txlo Grcx.tnd Water c)r Imperv:i. ous L. ayer to ].6 .Ft,
U ~ e S t a n d a r d "F r e n ,:::: h
Soil Rat. lng. F'rom test June 2~ 1993
2,,5 mintin = gal/rain
15()/:t.. 2 .... ;~ 25 sq ,, f 'L'.. ,,
T e s t in o 1 e Tot a ;t. D e!::, t h
[., I,S' % ~iil 6 '}; E.? 6:.?
Less .4 Ciov,*::?~ ....
Rc~c I< Dep'Lh
1 ()90
109()
STANDARD TRENCH
TOTAL LENGTH
TOTAL WIDTH
TOTAL DEPTH
ROCK DEPTH
COVER
SEPTIC TANK
50 FT.
5 FT.
tO FT.
5 FT.
5 FT.
1250 GAL.
The :i. ns'l.:a :1. 1 ~,; I... :i. on o.¢ th :i. s ,,~el ]. ar'id ~-:.ep L :i. c: system w:i. 1 ]. not :i.
~:~ d j ,':'i :: (.), "i 'I2 ]. c,'t'.'. %. 'T' 1"1 (!i~' t4 (.)):, ]. 1 icI ii ~':i t :i. C)I'] i;;; {;:il"i '~: C) I' ill S t C) t h 6:, s=, :i. t :i. ri Cl (::~ 't: 'I] h E'
exJ, sting wells in the area,~ anti will, not p'-l,-ever'~t the adjacer'~t lc~t
c:)wners Yrom develc:,pi ng these 1 ors or repl ac::i, ng the ~):.).;<i s't::i, ng
,Fr"cm-~ be ins'~.al t ed on the adjac:ent ],(::~ts,,
c:(::x.u,"ses c:~n tl"ii~-; or" the adjac:er'lt lc)ts.
The pr"oposed septic system w:i. lt not change the gener"al
the ar-ca,, P(::~rx::i:i.n,~;~ and/ar cc:~ncen'~::r"at:i, or'~ ,~::~: surYace runc:~.F.f: w:i.].:l, not
r e s u i t .{: r o m t h :i. s :i. n s t a :1. 1 a t :i. (::~r'i ,,
LDT 7
LOT B
THERE ARE NO ~/ELL ~ -' /
~/ITH1N £00 FEETc
DF THE LDTLINES~'~
DF THIS LOt /
TDBBEN SPURKLAND P.E,
203 W 15TH. AVENUE
ANCH, AK, 99501
,5O 0 ,5O 100 1,50 PO0
SCALE; 'i' = 100 FT,
LOT 7 BLOCK 3 HILLSIDE NO£TH
SEC. 6 TI2N R2V
STEVE AND DEBBIE CLARK
850 300
REVISEDI JUL Y 7, 1993
SEPTIC SYSTEM DESIGN
DATD JUNE 9, 1993
SHEET~ 1/3 GRID, ,2043
-(~ WeU
SITE --
tEN
5eh Spurk!and
CE-2225
TQBBEN SPURKLAND P.E,
203 ~ JSTH, AVENUE
ANCH, AK. 9950!
/
/
~CALE; ]'
~ CiNTOUR
LOT 7 BLOCK 3 HILLSIDE NORTH
SEC. 6 T]2N
STEVE AND ]}EBBIE CLA£K
N[VISE~ JUL Y 7, 1993
SEPTIC SYSTEM DESIGN
D^TE~ JUNE 9, ]993
SHEET~ 2/3 'GRID~ 2043
~o~or
Cleon
Clean Out
3'W/de
50' Long ~ ,/~/,~_.
lO' Deep
5' Se.,er Rock
S, 5' Cover
NO SCALE
Exi$f. Ground
1250 SoL septic tank
TOBB£N SPURKLAND P.E,
803 ~lSth Ave
Anchorage Ak 99501
LOT 7 BLZTCK 3 HILLSIDE NORTH
SECTION 6, TI~N RRW
STEVE CLARK £440 E. TUDOR ROAD
SEPTIC SYSTEH DESIGN
~r£, JUNE 1LI993
SHEET, 3/3 ~[~, 2045
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION: k~~~ '7, ~ K %
1
6
?
9
~0
~5
~?
~9
Township, Range, Section: "r' i,,tN t
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
L
O
P
E
Oepth lo Water A~tn,¢/ ..... ~'~.,~?
Monitoring? //lc.~-'v~. Dale:
Gross Net Depth to Net
Reading Date Time Time Water Drop
COMMENTS
PERFORMED BY: '~ ~;-~'~ , 'TT"",-;~", CERTIFY .~. ~ ~H~IS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
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. # [~L~,~ - t'-')~\~c~L.I HAA# ~'~OIL'/(~L~
GENERAL INFORMATION
Complete legal description
HlllSid6 North ~5
Location (site address or directions) OZZn¢ Circle
Property owner
Mailing address
Lending agency
Mailing address
Agent
.Address
St6phen and D6borah Clark
3440 E, Tudor Road. Suite 121
Day phone
Anchorage.
Day phone
AK 99507
Day phone
Unless otherwise requested, HAA will be held for pickup.
./
NUMBER OF BEDROOMS:
4
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
./
XXX '
NOTE: 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:
XXX
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
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 m.~y~im~igation and inspection, the on-site water
and/or wastewater disposal syste~.isqi~n--c°r~-nce with all Municipal and State codes,
supply
ordinances, and regulations in effect qrrfJ;¢e date/o"f this inspection.
Name of Firm .,~.~_~--~ ~_ ~-~-Phone ~/'~:~/-7
Address S & S/rrfl,.CN~lN6// .
i/U;~4-Eagle River.,b/oop Road No, 204 /
Engineer's signature Eagle Rive~_.~a 99577 Date
DHHS SIGNATURE
~'k~_~ 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.
72~25 (Rev, 1/91} Back MOA ti21
Legal Description:
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
h ADEC letter ADEC water s stem numb
If A, B, or C, attac . Y ,~/~.
/~:_% Date completed ~L~ -¢~'-~- ~? Driller /~/~//V~_~
A. Well Data
Well type
Log present (Y/N)
Total depth
Sanitary seal CN)
Cased to
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level1
g.p.m.
/ -Z~// Casing height
Wires properly protected ~_~N)
AT I/NSPECTION
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lOt
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform (-~ Nitrate
Date of sample: ] '" ~ "1 ~
B. SEPTIC/HOLDING TANK DATA
Date installed (~ ~c~-fl-~ Tank size
Cleanouts CN) .~'
High water alarm (Y/N)
Date of pumping /V//~ -
Collected by:
Foundation cleanout ({~IN)
Other bacteria
Compartments ¢,~
Depression (Y/{~)
Alarm tested (Y/{~)~ /U~
Pumper ~%)//~
SEPARATION DISTANCES FROM SEPTIC/~ TANK TO:
Well(s) on lot 100 ~4- On adjacent lots
To property line ~ 0'+ Absorption field
Surface water/drainage / 00' k
Foundation
Water main/service line
72-026 (3/93)* Front CONTINUED ON BACK PAGE
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTAI~'"0M LIFT STATION TO:
Well on Io~/ On adjacent lots
D. ABSORPTION FIELD DATA
Date installed ~>vC~ ~ ~.~
Length ,~ (~! ~Width
Total absorption area ~ 0
Date of adequacy test/~/~ - /~Vd ~[,'x,Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Manufacturer
Manhole/Acc~)
"Pu~' level at ~ "Pump off" Level at
~~ Cycles tested
Surface ~v~te r
Soil rating (GPD/Ft2) /, ~
?2 / / Gravel thickness
Cleanout present ~.)N) ~Y
After test
If yes, give date
System type
Total depth / (~
Depression over field (Y/N)
for L~
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on tot l O0 'J~ '
On adjacent lots I 0 0 '~ Property line
To building foundation ~ ~ ' ~ To existing or abandoned system on lot
On adjacent lots ~.~ ~ Cutbank /~)/~ Water main/service line
Surface water
Curtain drain
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified,
Signature
, S & S ENGINEE~
Engineer s Nal~r~)34 ~..,;,, AN'~r L~,m/~oad
Date Eagle River, Alas~9~577
HAA Fee $
Date of Payment
Receipt Number
72-026 ~3/93~ Back
Waiver Fee $
Date of Payment
Receipt Number
Chemlab Ref.$ :94.0356-1
Client Sample ID :HILLSIDE NORTH
Matri× :WATE~
~O. 478 G
Commercial Testing & Engineering Co,
Environmental Laboratory Services ~a~a~erm~f~,-~3~,~.~,~,~~~~~
REPORT of ANALYSIS 5633 B Street
L7 B3 Anchorage, Al( 99518-1600
Tel: (907} 562-2343
Fax: (907) 561-5301
Client Name :S & S ENGINEERING
Ordered By IR.
Pro~ect Name :
Pro~ect#
PWSID :UA
---SamPle Remarks: ROUTIN"~ SAMPLE COLLECTED BY: J,W.
WORK Order :75198
Report Completed :01/25/94
Collected :01/20/94 @ 12:45 hr
Received :01/21/94 @ 16:00 hr~
Technical Di~ector:S7%'PMEN. C. EDE
Released By ~ .~~
C
Parameter ~,.._~+,. ^.Q. ........... Allowable Ext. Anal
~u,~o ~ua~ un,lis ~e~oo Limits Date Date Ini~
* See S;ecial Instructions A~ove
** See Sample Remarks Above UA = Unavailable
NA ~ No~ Analyzed
,~ U = Undetected, Reported value is the practical quantification limit, ET ~ Less Than
137D = Secondary
", GT = Greater Than
__l~ ~'~B Member of the S~ Group (Soci~,, G~n~,le de Surveil,a~ce~
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