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HomeMy WebLinkAboutKNIK HEIGHTS BLK A LT 15 NAME MAI LING ADDRESS LEGAL DESCa[PT[ON L._~. MUNICIPALITY OF ANCHORAGE L... 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 --2 ~ Y~_,) [] UPGRADE LOCATION NO. OF BEDROOMS ~N [Liq capacity in ga OhS ~ Inside length Width ~ Liquid depth ' /~OO F HOMEMADE: ~ ~ANCETO W.U ~ I~ni.~ _ ~ PERM~T~. O~ ~anufacturer .~ ~ /' I Materia/ ~pacity in gal~ O ~ IWell--~/ ~ Foundation~ / ]Nearestiotline~ PERMI~NO. '~ I.. DI~ANCETO: I W~/ ~ '~ ~0 ~ I / 0 L'~ ~ ] 0 ~ · ~ ~ No. of liras Length of~ach line Total lengthp, f~nes / . Trench wid~ Distan~ between lines ~ I ~p of tile to finish grade '. ' Material bone~~ ~/ Total effe~.iv~a~orption~ea I Length Wid~ Depth __ f ~ PERMIT NO. ~ ~ofcrib /~diameter/ Crib depth/ ,Totaleff~sorptionarea / ~' I DISTA~E TO: ~ ~ IClass ~ / ) ~ Depth Driller Distance to lot line PERMIT NO. ~ I ~iSTANCETO:m Building foundation Sewer line I Septic tank ] Absorption area(s) OTHER PIPE. MATERIA.LS ,¢4~~- ,J'C',D~ ~'¢i1¢//J"~'¢"~ SOIL TEST RATING REMARKS APPROVED DATE LEGAL 72-013 (Rev. 3/78) BEFHRi.1ENT OF HEALTH ~ND EN',,,'~RONMENT~L PF':TE3TZON .... PERMIT NCL ,:: 8t0423 ) LOCFtT t ON R I E: GE LEGRL L:t5 B R KNIK HTS S,.'[:, LOT Si~~'StDCIHRE FE~ r'laXZMUM NUMBER OF BEDRnnM':; = THE RELqUZRED S~ZE OF THE SOZL RB~ORPTZON SYSTEM ~S: E:.EF" T HI:: ;_t2 I__ E ~'--1C:~ T ~-~ = ~:~ :~: ~3RR%-'EL E:.EPTH== 7 THE LENGTH DIMEN'-]ION IS THE LENGTH (tN FEET) OF THE TRENCH OR DRBINFIELD. THE DEPTH OF ta TRENCH OR PIT IS THE DISTlaNCE BETWEEN THE SI..tRFtBCE OF THE GROUND RND THE BOTTOM OF THE EXCRVlaTION (IN FEE]'). ]'HERE IS NO SET WIDTH FOR TRENCHES. THE GRFt',,,'EL DEPTN IS ]"HE MINIMUM DEPTH OF GRla',,,'EL BETWEEN 'THE OUTFlaLL PIPE RND THE BOTTOM OF THE EXCf~YRTION (IN FEET). PERMIT RPPLICRNT HRS THE RESPONSIBILIT'T' TO INFORM THIS DEPRRTMEN"F DURING ]'HE INSTFILLRTION INSPECTIONS OF laN¥ WELLS laDJRCENT TO THIS PROPERT'¢ FIN[.', THE NUMBER OF RESIDENCES THlaT ]'HE WELL WILL SERVE. BRCKFILLING OF laNb' SgSTEM WITHOUT FINRL INSPECTION RND RPPROVRL B9 THIS DEPRRTMENT WILL BE SUBJECT TO PROSECUTION. MINIMUM DISTRNCE BETWEEN R WELL RND RNM ON-SITE SEWlaGE DISPOSlaL Sk'STEM IS ±00 FEET FOR R F'RIVRTE WELL OR ~.~,~ TO 200 FEET FRJM R PUBLIC 14ELL DEPENDING UPON THE T9PE OF PUBLIC WELL. MINIMUM DISTRNCE FROM la F'RIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET RND TO R COMMUNIT9 SEWER LINE IS 75 FEET. WELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT WITHIN 30 DBMS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRS" RPPLg. SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE laVRILlaBLE TO INSURE PROPER INSTRLLRTION. I CERTIF'¢ THRT 1: I BM FRMILIlaR HITH THE REQUIREMENTS FOR ON-SITE SEWERS RND 14ELLS RS SE]' FORTH B'¢ THE MUNICIPlaLIT'¢ OF RNCHORlaGE. 2: I WILL INSTFILL THE S'¢STEM IN RCCORDRNCE HITH THE CODES. 2:: I UNDERSTlaND THRT THE ON-SITE SEWER S'T'STEM MR'Y' REC!UIRE ENLRRGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE 'THRN ]: BEDROOMS. S I GNED: .................................................... RPPLICRNT R BflDLE"r' JOF.'[:'RN // V4. 0 PERFORMED FOR:. LEGAL DESCRIPTION: 3 ."11 1.2 · · "14- '16~ : ' 19 SOILS LOG- PERCOLATION TEST ' · ' '~ '; " /.."-'~ ~ ' DATE PERFORM~ :;~//~l/ .&/ ~ ~ ~,:~ ;~ = : SLOPE WAS GROUND WATER ENCOUNTERI~L~ ~ ~:" ;, P E IF YES, AT WHAT DEPTH? Date PER CO L.~',?ION RATE Z © TEST RUN BETWEEN 4¢/ FT AND .,4F FT ''" ~_ 'z.'a_o 5','-¢,. ,/"/,3/~-- ' 72,,008 (6/79) RETURN TO: Olvlslon of Geological and G~ ,slcal Surveys (DGGS) DEPARTHENT OF NATURAL RESOURCES 3001 Porcupine 0rlve ~ele~,, .,~: 277-6615) Anchorage, Alaska ~9501 WATER WELL RECORD ; ~ ~ . U,S,G.S. Local liD. Drilling Company Name Drilling Permit No. A.U.L. No. LOCATION OF WELL J Please complete either la, lb, or lC. ' .......... la. Borough Subdivision Lot Block lb. Fraction Section No, Township Range Meridian · ~ . / / / N/S E/W lc. Distance and Direction From Road Intersections 3, OWNER OF WELL: Address: Peet Below 4. WELL DEPTH: (completed} Surface Elevation Date of Z. WELL LOG Surface Completion Material Type Top Bottom ft. . . ~ $. ['~Cable tool E~]Rotary F~Driven -. [~ Auger [~] Jetted E~ Bored F-~ Other: 6. USE: []]Domestic r--~Public Supply []]Industry []]Test Well [~Other: · ! 7. CASING: [] Threaded l~Welded in. to ft. Depth Weight lbs/ft. ; in, to ft. Depth '' 8. FINISH OF WELL: Type: Oiameter: Slot/Mesh Size: Length: Set between ft. and . ft. Fittings: ~. STATIC WATER LEVEL: ft. E~AbOve E~aelow land surface Type of Measurement: JO. pUMPING LEVEL bel~ land surface - ft. after hrs. pumping g.p.m. ft. after . hrs. pumping g.p.m. 11. WELL HEAD COMPLETION: [] In Approved E~PItless inches above grade Adapter MUNICIPALITY OF ANCHORAGE 12, GROUTING: Well Grouted: [] Yes UEPT. OF HEALTH & rk ....... Material: [~]Neat Dement r"~Other: 13. PUHP: (If ava{lable) HP JUL 2 '7 i~6'i Length of Drop P~pe ft. c.~c,ty ~g.p.~ l-FFl\/Fh Type:r=-i D Submersible~ D Reciprocat lng ..... ' · I,= ~ L,J Jet k.jOther: 14. REMARKS: 15. WATER WELL CONTRACTOR'S CERTIFICATION: This well was drl)led under my jurisdiction and this report is true to the best of my knowledge and belief: Address: . ' ' ' ~ ~-' ~. Date: - , Au'thorized Re~resehtative -' " Form 02-WWR Copy. Distribution: WHITE - State DGGS, PINK - Driller, CAt~RY I Customer 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.# ("~t-~ ["~.'2,~ _?~_~ HAA# 1. GENERAL INFORMATION Complete legal description , ,, po,3 [:..'.,2 0 AHP Location (site address or directions) I~- Yql R,c__.,(dC.~c.,uo¢..~ /-foocX Property owner Mailing address Lending agency Mailing address AHr:C p,o. 13~ Day phone ,~-d'/- 19 co N. ~ Day phone Agent D~./~ Address '8 ~ 00 Un/ess 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. 1191) Front MOA It21 Name of Firm Address 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. _~¢r¢4c ~¢ Phone ~ Date DHHS SIGNATURE _ Approved for _~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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 DH HS 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. 72-025 (Rev. 1/01) Back MOA#21 Municipality of Anchorage ~.~ Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /--°1~ rs-., [~l/-r' ~,, /-c~tk HC'J Parcel I.D. A. WELL DATA Well type P ¢'~ Log present (Y/N) Total depth f $' ¢' ' Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. Date completed Cased to I 5- ~" Y FROM WELL LOG Date of test '7 / ~"/' 8 / Static water level I 3'~-, Well flow Pump level SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot ~ 130 ' Public sewer main hi./Jr, Sewer service line ADEC water system number 7 /,~ / Driller Casing height Wires properly protected (Y/N) AT INSPECTION ~//o g.p.m. '7. 7 + Fo sj I~" ; On adjacent lots > too ' ; On adjacent lots Public sewer manhole/¢leanout Petroleum tank WATER SAMPLE RESULTS: Coliform 0 co [ ¢/l~0 ~.'~ Date of sample: ~ / t'O / c)~,~ N it rate O. 5-~ m~/ t/-,~ Other bacteria ~ col Collected by: F/~/'/c~/¢ ~-e¢/o B. SEPTIC/HOLDING TANK DATA Date installed ~' / ¢--¢' / 8 ~ Tank size I000 ~,~/ Compartments ~" ~" Depression (Y/N) Cleanouts (Y/N) t Foundation cleanout (Y/N) High water alarm (Y/N) ~, ~, Alarm tested (Y/N) N ,~ Date of pumping '~ / 15- / <).~ Pumper ~ t- SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I ~0 ~ To property line 5-0 ' Surface water/drainage On adjacent lots Absorption field ~ IOO ° Foundation 5' ° Water main/service line '7¢' 72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) High water alarm level "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MQA electr ca codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D. ABSORPTION FIELD DATA Date installed Length /'/',¢ ' Width Total absorption area ¢" 7 Depression over field (Y/N) N Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) Jqo,~ e Soil rating '8 20 ~//~¢"~ System type Gravel thickness '7 ' Total depth Cleanouts present (Y/N) Date of adequacy test for ~ocu~ o.~' If yes, give date bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~ /.30 To building foundation On adjacent lots '~..,~o Surface water ~ Curtain drain /~lo~ ~ On adjacent lots ~ ~oo' Propertyline To existing or abandoned system on lot /'4. ,~.. Cutbank ),4, A~. Water main/service line Driveway, parking/vehicle storage area 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. HAAFee$ /70 ,~ Date of Payment ~ '~ ~./~ ~ ~'.~ Receipt Number 72-026 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE [907) 562-2343 FAX: (907) 561-5301 Chemlab Ref. $ : 93.0545-1 Client Sample ID :L15 5 A KNIK HTS. PRESSURE TANK HOSE ' },~at r ix : ~'~ATER REPORT o£ ANALYSIS Client Name :FLATTOP TECHNICAL SRV Ordexed By :TED PtoJ ect~ PWSID :UA CollectsR :02/10/93 Received :02/10/93 WORK Order :63078 Report Completed :02/11/93 Technical Director :STEPHE, N C. EDE Sample ROUTINE SA},iPLE COLLECTED BY: T.F.}L ' 8lB Remarks: QC Allowable Extract tnaly~s Parame*or ~esu].te Qual. Urn. ts Method Limits Date Date Init NITRATE-N 0.59 m~/1 EPA 353 2/300.0 10 02/11/93 02/11/93 LLH '- See Special Instructions Above UA -Unavailabla "' See Sample Remarke ~bove NA ~ }lot Analyzed U - Undetected, Reported value is tho practical quantification limit. LT - Less Than D - Secondary dilution. GT - Greater Than ~ S~"~S Member o! the SGS Group (Soc,61~ G~rale de Surveil,a~ce) I -, - DATE RECEIVED ' · INSPECTION APPOINTMENTS IME TIME TIME DEPT. OF H~A~TH & MUNICIPALITY OF ANCHO~A6[ ~N~I~ONMENT ~L P :'OTECTION D[P~TM~NT O~ H~ALTH  ~S*,~-~.~o,~.~a~O~ Simp 8 1981 ~VI~ONMENTAL S~NITATIO~ DIVISlO~ Telephone 264-4720 RECEIVED REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DI REOTIONS: Complete all parts on page 1. Incomplete requests will not b~ processed. Please allow ten (10) days for processing. 1. P~OPE~Y OWNER ,~ PHONE MAILING ADDRESS PROPERTY RESIDENT (If different from above) PHONE '2. 'BUYER PHONE 3. LENDINGINSTITUTIONi [ PHONE M~ILI~G ADDB[SS 4. REALTOR/AGENT PHONE MAILI~ 5.Z~ ~z~ /~'~LEGALDESCRIPTION s~E~ ~OCAT,ON 6. TYPEGIF RES DENCE [~'~SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF~BEDROOMS [] One [] Four [] Two [] Five [~'"'~h ree [] Six [] Other 7, WATER SUPPLY ~ INDIVIDUAL* ED 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.) [~'"'INDIVIDUAL/ON-SITE** .//.,~'7/ YEAR ON-SITE SYSTEM WAS INSTALLED. . x? x:. : 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 [] .~S~I~GLE FAMILY [] ONE E~'~TH REE [] FIVE F'~ OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY ~ INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED iSNWAGE DISPOSAL SYSTEM PERMIT NUMBER DIVIDUAL/ON -SITE DATE INSTALLED [~ PUBLIC UTILITY Connection Verified INSTALLER [~eptic Tank or []Holding Tank Size: 4' ~ PO IfTank is homemade SOILS RATING give dimensions: -~,~ TYPE OF TANK MANUFACTURER-- ~ TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line 1 WELL TO: Absorption Area to nearest Eot Line 5, COMMENTS ' APP.OVEOFOR .EDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev, 6/79}