HomeMy WebLinkAboutOLSON HEIGHTS BLK 2 LT 7
NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 2644720
ON-SITE SEWAGE DISPQSAL SYSTEM AND/OR WELL INSPECTION REPORT
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
]Well ---- ,~1 JAbsorptionarea~
Liq. capacit Inside length
IF HOMEMADE: .~
Well Dwellin9
DISTANCE TO:
Manufacturer
Dwelling
NO, OF BFDROOMS
Width
No. of co~artments
Liquid d e,~p t I,~
PERMIT NO.
gallons
Well Foundation
DISTANCE TO: ~
No, of lines eacf Total length of I
Top of tile to finish grade
Material beneath tile
Length Width Depth
Trench width
Total effective a~;~tioa area
PERMIT NO.
Type of cri
TO:
Building foun(
~rest lot line
DISTANCE TO:
Driller
Sewer line
Distance to lot line
Septic tall k
PERMITNO. ~>7 90~f¢''(~) ('
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
WATZ[~ WELL LOG
FOSS DRILLING ASSOCIATED
909 CHUGACH DR. #3?
ANCHORAGE, ALASKA 99503
WELL OWNER Frank O. Bethard
USE OF WELL
WELL LOCATION Lot 7~ Block 2 _Olson Heights Suhd±vision
Domestic
SIZE OF CASING 6" DEPTH OF HOLE ]66 FTo
STATIC WATER LEVEL 1LI. O FT. Go P. M. 1~
REMARKS
CASED TO
WITH
]66 FT.
22 FT. OF DRAWDOWN.
DATE COMPLETE~ ?/~/??
. PUMP TO BE SET AT 165~
0 to ]0 Alluviumi brown color~ medium hardness
jo to 6_..Z
.65 to_Zi
Z~_.aoZL~.
J ~.o toLS_q
.LE.q. to~ 6 ~
,.1 6.~ t. ol 66
to
Till~ grey color and hard
Alluvium~ gr~¥ cQlor, m~d~.~.h_ar_dn~~
Alluvium~ blue-grey colo~, medium~ardness
Alluvium; gre~ color~ medium hardness
Alluvium; light brow~_~olor~ med~ium hardness
Sand; grey color~ with water
to
to
to
to
to
to
to
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DEPT. OF HEALTtl &
ENV RONt,~ENTAI
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2
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-222l'
SOILS LOG- PERCOLATION TEST
LEGAL DESCRIPTION:
DATE PERFORMED:
[] PERCOLATION
TEST
SLOPE SITE PLAN
lO
11
12
13
14
15
17
18
19
2O
COMMENTS
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
.... ....
L
O
E
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
FT AND
(minutes/inch)
----. FT
72 008 (7/76)
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
OF ON-SITE SEWER AND NATER FACILITY
264-4744
GENERAL INFORMATION /MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision,'section, town~hip, range)
Location (address or directions)
(b) Property Owner '~ ~' ~1. [~)0::~-..Ul Telephone: Home
(c) Lending Institution Telephone
Mailing Address
(d) Real Estate Company and Agent ~~ ~,~ ~ ~
Address
Business
Telephone
(e)
Mail the HAA to the followine address: or: Check here ~ if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family ~[
Number of Bedrooms
WATER SUPPLY
Individual Wellj~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite/~' 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 77-o25 fRev 8/,86/ Fronl
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MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4744
Legal Descriptig.,n,: /-,,~2 ~ "7; ~.~ ~ ,x~.
WELL DATA
Well Classification
Well Log Present (Y/N)
Total Depth ./'
Static Water Level
Cased to / ~
/¢?
Casing Height Above Ground ~ /.¢' i
Electrical Wiring in Conduit (Y/N) ,'/v/
Separation Distances from Well:
To Septic/Holding Tank on Lot J O ~
To Nearest Edge of Absorption Field on Lot _/
To Nearest Public Sewer Line ~t/~ Id
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
If A, B, C, D.E.C. Approved (Y/N) _
Date Completed c///,~/.~? ~) Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
;On Adjoining Lots
To Nearest Public Sewer
A~/~l "f- To Nearest Sewer Service Line on Lot ~ ~' O
'~ "'~ ; Date Ii/j ~J ~ 7
B. SEPTIC/HOLDING TANK DATA
Date Installed '~//?~'~)
Standpipes (Y/N) CDI~/~.' Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N) __
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
Size ~ ~r¢--5'O No. of Compartments ~
y Foundation Cleanout (Y/N)
Date Cast Pumped "7/~.¢¢ /
Temporary Holding Tank Permit (Y/N)
To Water-Supply Well
To Property Line i~-~¢~ c) '~'
To Water Main/Service Line
Course
To Building Foundation ! ~2
To Disposal Field -~
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026 fray t~ 86! Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed '?/;/';7
Width of Field '~ ~'
Square Feet of Absorption Area
Type of System Design
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
i',,l O l,,l
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
;On Adjoining Lots
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify tha~_.av~.c.h.e~ kc ~ ,d~.ve.r:~:c°r c°nf°rmed t° ill ~,O/A,~.nd HAA guidelines in effect on the date of this inspection.
Signed #- ~' Date ~ 0 / , / 1~7
MOA NO.
Company
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
Engineer's Seal
72-026 (Bev 886) Back
DATE RECEIVED
INSPECTION APPOI NTM ENTS Ti M E~/~X)..,¢~
TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
llAUNIcIPALiTy OF ANCHoRAGij
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT, OF
825 L Street - Anchorage. Alaska 99501 E~VIJ~OIXIMENTA£
ENVIRONMENTAL SANITATION DIVISION ,JUL ~ 1980
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE".~i~I_~..~D
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed, Please allow ten (10} days for processing.
1, PROPERTY OWNER I PHONE
MAILING ADDRESS
PRQPERTY RESIDENT (If different from above) ' PHONE
2, BUYER PHONE
MAILING ADDRESS
;3, LENDING INSTITUTION PHONE --
MAILING ADDRESS
4. REALTOR/AGENT PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
-~ SINGLE FAMILY
[] MULTIPLI:- FAMILY
NUMBER OF.BEDROOMS
[] One [] Four
~ Two [] Five
L~ Three [] Six
[] Other
7, WATER SUPPLY
INDIVIDUAL~
[] COMMUNITY
[] PUBLIC UTI LI'FY
*ATTACH WELL LOG. Awell log is required for all wells dril ed
since June 1975, For wells drilled prior to that date, give well
depth (attach log if available.)
8, SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON'SITE~'~ YEAR ON-SITE SYSTEM WAS INSTALLED.
[] PUBLIC UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUI"ST BEFORE PROCESSING CAN BE INITIATED,
72-010 (Rev, 6/79)/I]"/,'~
THIS SIDE FOR OFFICIAL USE ONLY
1, TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection
Verified
LOG
RECEIVED
3, SEWAGE DISPOSAL SYSTEIVI PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified INSTALLER
[] Septic T.%rt[( or [] Holding Tank
Size: i~L_~ ~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCESwELL TO: Septic/Holding Tank 1Absorption Area Sewer Line [ Nearest Lot Line
Absorption Area to nearest Lot Line
5. COM[VIENTS
~//APPROVED FOR L.~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompan/~tificate)
[] DISAPPROVED
DATE BY