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HomeMy WebLinkAboutSKYWAY PARK ESTATES TR A O000OO000OO00.OO000p~ I^iO~O~AI 10~ WATER WEhL RECORD OF BOROUGH DIRECTIONS WaLL BLOCK SECTION QTR$ TOWNSHIP RANGE MERIDIAN WELL surface DA~A: ~YP~ top of casing other: .... ~ ............... · Oopth R~MARK$: WELL DEPT~: Depgh of h)l~: ? z .... ft Depth of casing~m~'i,~?,~ ft DATM OF CO14~LMTION: ?/ STATIC WAT~R LEVEL:~?~ .... ft, Date L©'.,, METHOD O~ DRIbLING: ~air rotary ~cal)le tool ~other: ~. USE OF WELL: ~dome~tio ~irrigation ~monitor ~publi~ supply ~other: CA$:~NG: St ickyup. '2,,:' ..... ft. Diem: ~ __in WEhL INTAKE: [] open end ~oreened [] perfoz'ated ~opea hole Depths of oponings:____ to ft GRAVML PACI'~ Diam; ~ in __Length: ~! ft oepth ~o top: GROUT TypE.I.w, Volum~ I P~PIN~ LM~L AND YIELD: f~ a~ger__ hfs pumping~C INTAKE DEPTH:...... ft Horsepower: Date Pul%p Installed . - WATER CHEMIS~(RY S~PLE TAKEN? Mell afeotod letion? PLEASE MAIL WHITE COPY OF LOG WITHIN 45 DAY$ TOt OGG$ PO BOX 77-2116 IAGLE RI'VER, AK, 99577 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW910380 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:KNIGHT ERIC J OWNER ADDRESS:3441 W. 88TH, NO. 11 ANCHORAGE AK 99514 DATE ISSUED:12/24/91 EXPIRATION DATE:12/24/92 PARCEL ID:01906117 LEGAL DESCRIPTION: SKYWAY PARK ESTATES TR A LOT SIZE: 26500 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: 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 (iSAAC80). 3. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS RECEIVED BY: _/~'5;~'t/~-~ ISSUED BY: DATE: [2-/'~/~ ~ 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 1. GENERAL INFORMATION Complete legal description -F P-.A-cT ~ Location (site address or directions) Property owner ~¢~-~- ~,~4,~- Day phone ,~t~_ qt]~ Mailing address ~1~5 ~ ~ ~ Lending agency ~C ~ Day phone Mailing address Agent Day phone Address 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Unless otherwise requested, HAA will be held for pickup. NOTE: Individual well '/ Community well Public water 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: Individual on-site Holding tank Community on-site Public sewer ~ If community wasfewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-O25 (Rev, 1/91) Front MOA ~21 5. 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 "~o b/¢ ~-/,'/ ~/P U ~"~'/~ ~¢¢ ~-- Phone Address ;¢,-~ ~ ]~,'~/--¢r Engineer's signature DHHS SIGNATURE Approved for Disapproved. bedrooms. Conditional approval for 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 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 #21 Legal Description: A. WELL DATA Well type ~ ....... Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) Total depth Y Date completed /~, '~t~ ~(~ ( Driller _Cased to ~.~ ¢'~ Casing height Sanitary seal (Y/N) FROM WELl.. LOG Date of test /~' Static water level Well flow Pump level Wires properly protected (Y/N) g.p,m, ? AT INSPECTIOI~uNi¢IpALt~Y OF ANCHO.AGE JU',_ '- 8 SFPARATION 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: ~ ~ / ~¢ 2_ B. SF. PTIC/HOLDING TANK DATA Date installed Other bacteria __ Collected by: '%~;~- ,--¢ NONE- Tank size Compartments Cleanouts (Y/N) Foundation cleanout (Y/N) Depression (Y/N) High water alarm (Y/N) Alarm tested (Y/N) Date of pumping Pumper SF_PARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface water/drainage On adjacent lots Absorption field Foundation Water main/service line 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" lever at · Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Date installed Length Width Total absorption area Depression over field (Y/N) Results (pass/fsil) Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water Curtain drain On adjacent lots Soil rating Gravel thickness Cleanouts present (Y/N) Surface water ·. System type Total depth Date of adequacy test for If yes, give date bedrooms On adjacent lots Property line To existing or abandoned system on lot Cutbank 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, oq ·the,,c/ate,.o,f this inspection· Signature ~ ~ Engineer'sName ~ ~u¢~L~ ~ HAA Fee $ /,~7~ Date of Payment Receipt Number ~ ~Z~ _ 72-026 (Rev. 3/91) 8ack 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) 552-2343 FAX: (907) 551-5301 Chm,,iab R~.(; 92.3~33 Sa]~p]e ~ 1 t~at~x: I1A)~E~, TkAC!t ~ SKYWAY UA JUL ~ 92 ~ 16:00 Jl)L 2 92 O 1.6:]0 ~,S R](QUI RY, I> )TOP, E)J $I?URSi, AIt)), 1',71. ?.) 1[[ [[1 J g , P,D(O,iO) :rqf/k F, Ph 35% 2 Member of the SGS Group (Soci~t~ G(}n~rale de Surveillance)