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Home My WebLink AboutKNIK HEIGHTS BLK A LT 2Lo'l' 0/7 · ~ NAME~L~,~ '-~..l MUNICIPALITY OF ANCHORAGE .,j/ 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 PHONE ! 5--1& []UPG.ADE MAILING ADDRESS LEGAL DESCRIPTION LOCATION Well Absorpti DISTANCE TO: ~._ ~) r Manufacturer Liq. cap IF HOMEMADE Inside length Well ~ I Dwelling DISTANCE TO: No. of lines I Length ~, ~.~ch line Foundation Top of tile to finish grade Total length of Material beneath tile Length Width Depth __ rib depth DIST NO. OF BE~)OMS PERMIT NO. No. o~,~mpa r t me nts Width Liquid lot line ~idth Trench .t~-~inches PERMIT NO. ~¥quid capacit~in S~!!:nr PERMIT NO. Distance between Total effective4~i~'on areal~ 90 PERMIT NO. absorption area Nearest lot line Depth Driller Building foundation DISTANCE TO: Sewer line Distance to lot line PERMIT NO. Absorpt on area(s) tank OTHER PIPE MATERIALS SOIL TEST RATING I NSTA L(~i~'3__ . . ~ A. PPROV ED ~.,~ 72-'013~( v. 3/78) ~ DATE LEGAL .C'~ .~ ~ NICIPALITY OF ANCHORAGE Department o~/Health and Environmental ~0tection :. 825 L Street, Anchorage, AK. 99501 264-4720 ~ ~ ~ HANDWRITTEN PERMIT ~ ~ ~ WELL AND~ ON-SITE SEWER PERMIT Applicant: Fc ~< ~]~ -]~)A~ Mailing Address: ~-~ Location: A[n B ,OQ£ Number: 3Ll~- /~ negal Description: LOT A nlk Lot Size: Type of Soil ~sorption System Is: Trench: ~ Drainfield: Seepage Bed: Holding Tank: Maximum N~ber of Bedrooms: ..~ Soil Rating(sq.ft/br) ~OO The Required Size of the Soil ~sorption System Is: The length dimension is the lengtH~D feet) of the trench or drainfield. The depth of a trench or pit is the dist~e 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 minim~ depth of gravel between the outfall pipe and the bottom of the excavation(in feet). 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. ~ ~ ~ TW0(2) INSPECTIONS ARE REQUIRED Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Min~um distance between a well and any on-site sewage disposal system is 100 feet for a private well or 150 to 200 feet from a public well depending upon the type of public well. Minim~ distance from a private well to a private sewer line is 25 feet and to a co--unity 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. I certify that: (1) I ~ f~iliar 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 understand that the on-site sewer system may require enlargement if SWP/024(~/81) ..... ¥' ~'i~0N~CIPAL~TY OF ANC~-:ORAGE '"~ O£PARTMENT OF NEALT~; AF~D EN~;~ RONMENTAL PROTECTION Pouch ~-~;50, Anchor.%e, ~J~:ke 99502 ~76-222'~ SOILS LOC- - PERCOLATION TEST PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION:~ 5 10 11 12 13 14 15 16 17 18 19- 20~ COMMENTS ./4,~f,',~ -- ,~ Z~j/.~,,,~. PERFORMED BY: ~ WAS GROUND WATER ENCOUNTERED? iF YES, AT WHAT DEPTH? SLOPE SITE PLAN Gross Net Depth to Net Reading Date Time Time Water Drop ,, 7,'/o /o ¢" / ,, 7.'$o 30 ~Zz" z;,'~" PERCOLATION RATE ~.~ (minutes/inch) TEST RUN BETWEEN ~ , FT AND ? FT RETURN SOL Oivlslon of Oeologlcal and Ge $[cal Surveys (DOGS) STATE OF ALASRA 3001 Porcupine Drive (Te apl,_ ~J': 277-6615) ., ~/ DEPARTHENT OF NATURAL RESOURCES ~ Anchorage, Alaska ~950l WATER WELL RECORD Drilling Company Nan~ ~..,! ; ~ 'i ! i, , U.S.G.S. Local No. Drll)lng Permlt No. LOCATIOH OF WELLI Please complete either la, lb, or lc. A.D.L. No. ia. Borough Subdivision Lot Block lb. Fraction Section No. Township Range Meridian lc. Distance and Direction From Road Intersections 3. OWNER OF WELL: :,]. ,' ~: . Address: [~ ! · ~ . Screet Address and Area of Well Location 2. WELL LOG Feet Below 4. WELL DEPTH: (completed) Surface Elevation Date of Surface Comp] et ion Hater iai Type Top Bottom '~.' ft. · : <. ,'i : ' ~;. r~lCab]e tool [--]Rotary ~')Oriven ~]Dug ~ 6. USE: I-~Oomestic ~-)Public Supply [~lndustry [---)Irrigation [~ Recharge [~ Cor~rci~l I-)Test Well [--']Other: 7. CASING: [] Thr~ded []Welded in. to ' ft. Depth Weight i lbs/ft. in. to ft. Depth 8. FINISH OF WELL: Type: 0 iameter: Slot/Nesh Size: Length: Set between ft. and ft. Fittings: 9. STATIC WATER LEVEL: ft. [] Above m-;1eelow land surface Type of Measure~nt: 10. PUMPING LEVEL below land surface i ft. after · hrs. pumping ' g.p.m. ~ ft. after -- hrs. pumping ~ g.p.m. 11. WELL HEAO COMPLETION: [~ In Approved PEt r-lPitless Adapter inches above grade 12. GROUTING: Well Grouted: [] Yes []Ho Material: []Neat Cement [] Other: 13. PUMP: (if available) HP Length of Drop Pipe -- Ft. capacity g.p.~ Type: []Submersible [~] Reclf~rocat lng [] Jet []Other: 14. REMARKS: 15. WATER WELL CONTRACTOR'S CERTIFICATION: This well was dril)ed under my jurisdiction and this report is true to the best of my knowledge and belief: Add res s: Authorized Representative Form O2-~A4R Copy-Distribution: WHITE - State DGGS, PINK - OriJler, CAMARY - Customer MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DiwsloN OF ENV, RONr .TAL "EALT. CERTIFICATE OF INSPECTION FOR HEALTH AUTHORI~'V'APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) (b) (c) (d) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) , : Applicant Name ~\f~L_ C~ V'V~-'¢-)~ Telephone: Homo Applicant Address ~',~¢lfv~ ~-T. '". Applicant is (check one): Lending Institution []; ow~er/bu!lder~[]q Buyer []; Other [] (explain); Lending Institution '/ Telephone Business Address (e) Real Estate Company and Agent Address (f) Telephone Mail the HAA to the following address: 2. TYPE OF RESIDENCE Single-Family,,~/ Mult~ily i~}~ Number of Bedroo~¢ ~-- :/~ 3. WATER SUPPLY Other Individual Well'~j/Community [] Public [] /- Note: If comrffunity well system, must have written confirmation from the State Department of'Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL Onsit~ Public [] Community [] Holding Tank Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (11/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION 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 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. J 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 .. (~',~j'j-j~-t,,~t~ --(~,,JC'C~, d~l'le~h~one ~-- _7~ Address ~ ~ ~k~ C~ ~b ) . ~ ~ Date ~ '~J ~/~ ~ ~~'~ ~ ~-~ Engineer's Seal Approved for /~.,~ ('-/-'/¢_,~ bedrooms by .¢' e Approved ~'~ Disapproved Conditional. Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 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 requirements. Employees of DHEP 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. Page 2 of 2 72-o25 (11/84) WELL DATA NW"O NT^, OT CT ON MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 :Legal Description: L~,~5-' ~" C E Well Classification ~ %_,~,~'~ Ii A, B, C, D.~.C. Approved (Y/N) Well Log Present (Y/N) ~:~DateCompleted ~'l~l~i Yield Total Depth ~' .~ i Cased to Static Water Level /-~"7 Casing Height Above Ground Electrical Wiring in Conduit (Y/N) ~.~ Separation Distances from Well: Depth of Grouting Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot TO Nearest Public Sewer Line Cleanout/Manhole Water Sample Collected by '"---~%~'~ Water Sample Test Results ~ CE;).' "~-- ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on ~, ~"~ ;Date Comments B. SEPTIC/HOLDING TANK DATA Date Installed 5/'~¢-~ /~/' Size I '~-J~"~~7.D ~"/No. of Compartments ~-~ Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~"~ Foundation Cleanout (Y/N) %¢~ Depression over Tank (Y/N) ~ Date Last Pumpe~ ~, ~ ~' ~6 Pumping/Maintenance Contract on File (Y/N) ~/~ ; for ~ /~ Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well ~ ~ ~'-* To Property Line J To Water Main/Service Line Course j ~.~-~ Temporary Holding Tank Permit (Y/N) To Building Foundation J ~.~ I ~,_~_. To Disposal Field ~ C~ To Stream, Pond, Lake, or Major Drainage Comments Page 1 of 2 72-026(11/84) ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date installed ',~-~/-~ Width of Field '?> ~" Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: t To Water-Supply Well ~, ~ '"f'"'- To Building Foundation ~.'~_'_~ Lot '~.O i Type of System Design Length Of Field Depth of Field i I ~ Gravel Bed Thickness ""7 Standpipes Present (Y/N) Date of Last Adequacy Test / To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Water Main/Service Line t*~ ! ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments To Cutbank (if present) i D. LIFT STATION Date Installed -. f')imensions ~ . Size in Gallons anho e/Access (Y/N) "Pump On" Level at ~ "Pu)np Off" Level at ~ High Water Alarm Level at ~ Vent (Y/N) ~ Tested for // Pumping Cycles durin..g,.A~equacy Test. Meets MOA Electrical Codes (.~/ ~ Comments ~. ** Check Permitted Bedroo,,~m~"~T'~-,&-~'ainst HAA Request ** I certify that l have c~b/ke~verified, o c~2med to all MOA an¢ HAA guidelines in effect Company ~, -.~.'i~'lj:Lc'v~,~'177i~_ Receipt No. H' Date of Payment Amount: $ Page 2 of 2 72-026 (11/84) on the date of this inspection. Engineer's Seal ,.. DATE RECEIVED INSPECTION ~ APPOINTMENT,~ TIME !' TIME ~ ~,.~ j~ TIME DATE DATE INSPECTOR INSPECTOR DEPT. OF I~S~LTH MUNICIPALITY OF ANCHORAGE ~NVIRONMENTAL I ;~OTECTION DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL SANITATION DIVISION Telephone 264-4720 R REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS: Complete all parts ou page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPERTY OWNER PHON~ MAILING ADDRESS PROPERTY RESIDENT (If different from abo~e) PHONE PHONE 2. BUYER MAILING ADDRESS 3. LENDING INSTITUTION ~ PHONE MAILING ADDRESS 4. ~E~TO~I~NT PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION TREET LOCATION 6. TYPE OF RESIDENCE [~NG LE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [~'~ou r [] Two [] Five [] Three [] Six [] Other 7. WATER SUPPLY [~'~'iN DIVI DUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.} 8. SEWAGE DISP~OSAL SYSTEM ~ INDIVIDUAL/ON-SITE** [] PUBLIC UTILITY / ~;~ <~/' YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] 'SINGLE FAMILY [~ ONE ~] THREE [~ FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] ?OUR: [] SIX PERMIT NUMBER ? 2, WATER SUPPLY ;' ~ .... [] INDIVIDUAL DEPTH OF WELL , . [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~INDIVIDUAL/ON -SITE DATE INSTALLED E~]PUBLIC UTILITY ~-'"-- (~ { Connection Verified ....... INSTALLER ,,. ,, r. ,. []Septic Tank or [] Holding Tank Size: /,,~'~-~) If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER ~,,A.,<..~,,_~~ 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 APPROV,&,L (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79)