HomeMy WebLinkAboutHUNDRED HILLS BLK 1 LT 3
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 ~IEW
LOCATION ~/O E¢¢ ~ ~/ /~' NO. OF "~ROOMS~
~ Manufacture~~ ~e / No. of compartments
~kiq, c~ac~ ~allons Inside length ~idth ~iquiO dopth
/~ bO ~"~: IF HOMEMADE: '~
~Z~ ~ DISTANCE TO: Well Dwellings_// j ~ PERMIT NO.
=_~O ~ ~ Manufacturer / ' '~ Material Liquid capacity in gallons
'~ We~ Foun~o~ / Neares~e E~IW~ ~--
, ~ DISTANCE TO: ~ ~l+s Trench ~D~ P
~!. NO. of lines // Lenot~h li~ Total l~inches i Distance
to fil~,~rad~ ii / / Material ~eneath tile . ~
Leng~ Widt~ V Depth PERMIT NO.
~ ~ T~pe of crib Crib diameter Cr Total effectivo absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
Driller Distance to lot line PERMIT NO.
~ Class~ ~D~
Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
REMARKS DEPT, O~ HI[AiTH
__~ ~' ~. ENVIRONMENTAL P~ OTE :TIOI 4'
,, .. ..:,,
A~.ROWU ~'&~E~8I~8I~ ~ E LE L
PERMIT NO:
DATE IG.~UED:
DEPARTMIEN]" OF t.-IEAi_]"H AND ENVIROI',IMENTAL PROTECTION,
8'25 L STREET, ANCHORAGE, AP:: 995C. I
264-472 )
iL-} INI ....... ~:]; ][ '3'" IE~ E.~ lEE.: II,,,¢ tiE'::: ,-F;.~ :~.,: II,,~ E L.i._ F I~:. F,. ~
84075
09 / () 5
APPL I CANT:
ADDRESS:
CON]"ACT F:'HONE:
LEGAL_ DESCF~IP:
LOT SIZE:
MAX BEDRGOMS:
ERIC S'T' I CEE
I:'~ 0. BOX 670637
CHUGIAI.:::, AK 99567
279'""66 :t. 1
SUBDIVISION: HIUNDRED HILL. S
SECT'ION: 10 TOWNSHIP: 13N
4A (SQ. FT., OFt ACRE:S)
4.
LOT: 5 BLOCK: 1
R AI',tGE: :I.W
Listed below are the c~ptions available t.o yOL~ $~] desiDning your' septic
system. Choose the option that best £its your' site.
DEF'TH 'T'O PIPE BOTTOM (F'T.) 4,,0 4.() 4.0
GRAVEL DEF'TH (FT.) 5.0 0.5 3.5
TOTAL DEPTH (FT.) 9,,0 4.5 7.5
GRAVEL WIDTH (FT.) 2.5 20.0 5.0
GRAVEL LENGTH (F:T.) 5~ 38.0 54.0
GRAVEL VOLUME (CU.YDS.) 25.5 28.2 40,,0
'TANK SIZE (GALS) 1~250.0 .~.~ 1,250.0 '~.~ 1~25().() '~'~'
SGII_ RATING (SQ.FT. /BR) 125 125 125
-~.-~ TANK MUST FIAVE AT I_EAST TWO COMPARTM~."NTS
I certi£y that:
1. I am ~'ami].iar with the require.,ments ~'of on-site '..sewer's and wells as set
Fo;-th by the MunicJpal:i. ty oF Anchor'age (MOA) and the State o{' Alaska..
2. I will install the system in accol-dance with all MOA c:odes and ~e~]ulations,
and in c:omp].iance with the des.~ign c~itet-ia o,~' this per'mit.
3. I will adhere to all MGA and State o~' Alast..:a requirements ~'or the set back
distances Fr'om any existirtg well, wastewater' d:i. sposal system of publ:i.c
sewer'age system on t-his or any adjac:ent or' near'by lot,,
4. I understand that this permit is valid For a max:imum oF 4 bedi"ooms and
any enlargement will requir'e an additional permit.
IF A L. IFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING []ODES,
THEN (1) AN ELECTRICAL F'ERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUIL. TS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTF~ICAL WORK MUST BE DGNE BY A L. ICENSED ELECTRICIAN.
1: SSUED B
MUNrCIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
3
SLOPE
SITE PLAN
10.
11
12
13 ~
14-
15-
16
17.
18-
19-
20-
COMMENTS
PERFORMED BY:
WAS GROUND WATER N~0 I~
ENCOUNTERED?
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
P ERCOLAT,ON R ATE
TEST RUN BETWEENm ~,~/
(minutes/inch)
__ FT
~ I:~C Co dba
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKAIg9567 · TELEPHONE 688-2769
OWNER OF LAND
ADDRESS ~:}~' ' ~ ~7~ ~7 - ~0~ STATIC LEVEL OF WATER FT.
LEGAL DESCRI~ION Z ~ ~ ~c ~ ~ : ~O~O~; D . ~t~DRAW DOWN~ .ET'
PE~IT NUMBER
/'/7
GALS. PER HR
KIND OF CASING "~7~ "~
KIND OF FORMATION:
From ~ Ft. to
From ~ Ft. to /~I Ft. ~:t~,<O~/< From
From / .~; I Ft. to /~'f Ft. ~,,.z~..~.~ ~n,,c~ From
Ft. to Ft. ~/ ~ d~<~ From
From
F~m ]~ ~ Ft. to 1~ Ft. L~ ,;~7c~< From
FromlSP Ft. to 1'7:~ .Ft. /]~OgO,_~_ O~Z~~ From
From Ft. to Ft. / ,~' ~ ~t~7 From
From / ~,~ Ft. to. t'~'~O Ft. A~.~~--'~< ,.~..~L/~ From~
From Ft. to Ft. From
From Ft. to Ft.. From
From . Ft: to Ft. From
From ,.F~ to FL From
From , · Ft. to ' Fl; From
From Ft. to Ft From
From ....... Ft. tO' ~-~Fi:~.:'. ~ ' - From
From Ft. to Ft.
From Ft. to FL
From
Ft. to , Ft,
Ft. to ,.Ft.
Ft. to Ft.
Ft. to Ft,
Ft. to Ft
Ft. to Ft. lvO.~ 5
Ft. ,o Ft. ~
Ft. to Ft.
Ft. to Ft.
Ft. to ,Ft.
, Ft. to.__Ft.
I,AUNICJPALITY OF ANCHORA(D~.
g. DEPT.
Ft. to ~IRONM~NIAL
Ft. to. Ft.
JAN 2 8 ~98b
FL to
,. RECE!V D
Dr. to Ft.
Ft. to Ft.
MISCL. INFORMATION:
67 F 7 ToT,~-
' 9 MUNICIPALITY OF ANCHORAGg
DIVISION OF ENVIRONMENTAL HEALTH
'DEPARTMENT OF HEALTH AND ENVIRONMW. NTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information · Application Date
· ' ~wnsht~. range) '
(a) Legal .Description (include lot, block, subdivision, sectiin, township, aug ) '
Cc)
(d)
Location (address or directions)
Applicant, ame
Telephone - H,om,,~ Business~97g-&&//
Applicant is (check one) Lending Institution ~; 0Wner/builder~ ;
Buyer~ ; 0ther~_~ (explain); -- " -'
(e) Real Estate Co. & Agent
Address
(f)
Telephone
~ the HAA to the following address:
Single-Family~
Number of Bedrooms
Imdividual
Multi-Family
Other (describe)
Community ~ Public
Note: if community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. ~o~
No~e: If community well system, must have written confirmation from the State
Department of Enviroumen=al Conservation attesting ~o the legality and status.
[Page 1 of 2]
5- En~ineerin~ Firm Providin~ Ins ections Tests~ File Search ~.. .Data and Information
As certified by my seal affixed hereto and as of the validation date shown below,
verify that my investigation of. this Health Authority Approval shows that the
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 M~nicipality 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 regula-
tions in effect on the date of this inspection.
Name of Firm - Telephone
App=o .....
Approved ~ Disapproved ~ Co~ielon~ --
Te~s of Condition~ Approval
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HF2%LTH AUTHORIT~ APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS GIVEN IN PARAGR~H 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE. OF ALASKA. THE DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS° EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANAI~YZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEER'S WORK.
RR4/eJ/D18
[Page 2 of 2]
(DHEP SEAL)
7-19-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (BAA)
CHECKLIST - FEBRUARY 1984
WE. LL DATA
Well Classificat'
Well Log P~esent/(Y_/~
Total Depth /~dQ ! Cased to
Static water Level /
Casing Height Above Ground /
Electrical Wiring in Conduitd~
Separation Distanoes f~cm Well:
MUNICIPALITY OF ANCHORA~
DEFL OF HEA[:i'Jl ~
JAN 2 8 1985
TO Septic~Tank on Lot /~t(3 ~',-f
_ ; ~ ~joining Lots
To ~a~st ~ of ~s~ption Field on ~t/~ ~/ ; ~ Adjoining ~ts
To Newest ~blic ~ Line ~//~ To ~est ~blic
Clean~t~a~ole ~'/~~ To ~est ~ ~rv%~ Li~ on ~t
+
Wate= S~le Colle~ed By ~. ~ ~{~ m/ , ~te //~
. , ~/~ ~ -- --
Wate~ S~le Test ~sults 3~--~ ~L~'~
SEPTIC/HOLDING TANK DATA
Date Instal]~d ?//~'~/ Size /~--~ No. of C~a~tments . _
- Foundation Cleanou~Y_~)
Standpipe sd~~ '/ ' Air-tight C~P (~)
Dap~ession ove~ Tank ~ Date Last Pumped ' ,,~' ~:~ ~ ~
Pumping/Maintenance Contract on File (Y/N~~ ; for --
Holding Tank High-Wate~ Alarm (Y~9~///~ ~ Temporary Holding Tank Permit (Y/~/~
Separation Distances f~c~ Septic/~ Tank: ~
To Water-Supply Well //~ ~ - To Building Foundation ~ ~
To P~operty Line /~
To Water Ma{n/Service Line
Course
To Disposal Field ~ ~
To Stream, Pond, Lake, c~ Major D~ainage
Receipt 9
Date Paid:
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date .Installed 9>~/~/~ 4/
Width of Field ~'~ O ~*
~//~ Type of Syst ~n ~/~ ~
Depth of Field ~ / /
Squa=e Feet of Absorption Amea ~0 ~ Gravel Bed Thickness
Standpipes P=esent
Depression over Field ?f& Date of Last Adsquacy Test
Results of Last A~equacy Test
Separation Distance f~cm Absc=ption Field:
To Water-Supply Wall /~ ' ~ To P=operty Line
To Building Foundation ~ ' To Existing or Abandoned System cn
Drainage Course
To Stream/Pond/Lake/c= Major / /3 / /~
To Driveway, Pa~king Area, c~ Vehicle Stc~age A=ea
D. LIFT STATION
Date Installed
Size in Gallons
"Pu~p O~" Level at
High Water Alarm Level at
Tested for
Dimensions
Ma o / ss
, ~' - {~ /~nt (Y/N)
Pumping Cycles du=ing Adequacy ~st.
Meets MOA
Electrical Codes(Y/N)
Cc~ments
** Check Pe=mitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, c= conformed to all MOA HAA ~es in effect
on the date of this inspection.
~._~anvf.=}~:~ ~KA {0~ MOA ~o. ' /
[Page 2 of 2]
2-15-84
HEMICAL & GLOLOGICAL LABORATORIES F ALASKA, INC.
/~~ TELEPHONE(907) 562-2343 A NCHORAG e INDUSTRIAL CENTER5633 S Street
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM: -- (*) See h on back
Water ~m~ /~}' Phone No.
Mailing
Ci~ State Zip C~
Mo. Day Year
SAMPLE TYPE:
'~Routlne
· /[-I 'Check Sample (for routine sample
with lab ret. no.
[] Special Purpose
.Treated Water
/./.~.~nt reared Water
SAMPLE
NO. LOCATION -- /
3 I I
Time Collected
Collected /~J
/4
TO BE COMPLETED BY LABORATORY
·. Analysis shows this Water SAMPLE to be;
Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results, Please send new
sample via special delivery mail.
Date Received /- 2 ~ ,'- 0~'.-~
Time Received / ~ ~)
Analytical Method:
[] Fermentation Tube
~3~Membrane Filter
Lab Ret. No. Result* Analyst
*No of colonies/100 mi or NO of Pos~hve potl~onl
06.1220 (b)
Rev. 1983
BACTERIOLOGICAl WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
Membrane Filler:. Direct Count
Verification: LTB
Final Membrane Filter Results
BGB
Date
Time:
Coilformll00ml
Coilform/100ml
a.m.
COLLECTING SAMPLE TNTC= Too Numerous To Count