HomeMy WebLinkAboutOUR MOUNTAIN BLK 1 LT 12 MAILING ADDRESS LEGAL DESCRIPTION z- 12 13 / Well ~: Z Manufacturer DISTANCE TO: 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 z/ ON.E IF HOMEMADE: Inside length Well /~ /,~Dwellieg Well Foundation DISTANCE TO: DwellT~-~ No, of lines Length of eacl 3 of tile to finish grade NO, OF BEDROOM~ PERMIT NO./~:=/~ No, of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons Nearest lot line PERMIT NO. Total length of lines Trench width Distance between lines inches Material beneath tile Total effective absorption area Type of crib Crib diameter i Total effective Well] ,,~ ,cra Nearest ,.~_ DISTANCE TO: /'~/ (,'.~ '~' ~ Driller Distance to lot line PERMIT NO, DISTANCE -FO: Buildin~ foundation Septic tank Absorpt on area{s) OTHER PIPE MATERIALS SOIL TEST RATI INSTALLE REMARKS Z9 Rub¢~rt A. ,Shafor ;' n 0 v O 0 0 0 O 0 O 0 0 0 0 0 : 0 Z Permit ~ Applicant: Location: Department 825 ~ 264-4720 ~ ~/~ * * * HANDWRITTEN PERMIT * * * · ''' WELL AND/OR ON-SITE SEWER PERMIT [~rv~ n~xC¢- '~/(t'~M~tu~Mailing Address: '~i~ C~ ~ £ I~ Phone Number: MUNICIPALITY OF ANCHORAGE ~ Health and Environmenta? ~rotection Street, /knchorage, AK. ~501 ~ Lot Size: _ Legal Description: ~(,1 ~ I Type of Soil ~sorption System Is: Trench: / Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: Soil Rating (sq. ft/br) V The Required Size of the Soil Absorption System Is: DEPTH / ~ LENGTH . ~ GRAVEL DEPTH ~7 WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance 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 minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = 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. * * * TWO(2) INSPECTIONS ARE REQUIRED Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum 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. Minimum distance from a private well to a private sewer line is 25 feet and to a community 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. * * * PERMIT EXPIRES DECEMBER 1 9 $ 3 * * * I certify that: (1) I ~ fs_miliar 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 the residence is remodeled to include more that 3 bedrooms. ~ Issued : Applicant Date: %~.-- Big, .t ,~CALE~ "[~ ',DEP',ARTMEN:i:~F,H~LTH,',&HUMANISER~ICES,~ '.. · ;.' ~':'~;~:D' ~' s 'b'ni'5{E6~ ~i;66mi~'nfal';S'~r~ice~:?,-; ~.'-" ..~.~: - ,:¢;,:L~.:.:¢ :,_ ;omSIte,,Se~icesSectibn:":',./,' ?': ~::. , ::-::. :-~ , , - ":. ~ P~O..Bo~.196650''A~Chorage, Alaska 99519-6650 , r" , . ,: ' - : ,: .,';343-47~4 ' : ~', : ': , ', CER'T~i CAT'E 'OF- h ~:L~: AUT~'oRITY' ' ;, APPROVALrFO~ A'SIhGLE FAMILY DWELLING "; ' I.D. ff051-111-44 'V ,: ¢~ . :::. , ,,... HAA~ - ' "": ::~ :,.;?~:?::;..,:;..1~, : LOc'ation (sitb a'dd,'b~'Sf:8i~dtion~)'-; ' ' ' ' ' 20'528,'~k C~CZe,' C~ugJ.ak ', . ' , Property owner .T~aS'~, S ;~O~rS. ~o=oe "' Day phone : "' ' Mai'ling address P;O~ ~x 671723, Chugiak, ~ , 99567 : r~ ;''Lending agenCY ~ ' , ' ' .. ' tewart:,Title/Nicki Clark Day phone 696-5122 ..Mailingaddress~6635 C~nt~f4eld gr~v~ Su4~ 103. Ea~l~ R4v~',:' A~ ~ .,~ ..; ent N/A : ' ' Day ph~¢.:' Unless otherwise requested, HAA will'be held,for pickup. , , ..... ., .., ,.. .._ NUMBER OF BEDROOMS: 4 ' ~ "-: ~. ::TYPE 0 F WATER. SUPPLY:. ~ ~ , Individual well ,x _ ~";--:~ ~';;~ ~'~. ~ ' . Public water ' ---,: ;~ '. · ' ~ : '" '~:~-~.~';~ ~ '.'...; ';:. NOTEIf community well system, Pr~Wde Written confirmation from State ADEC attest- :. :? :: · , ......... .~ '-~ ..~;' ~'. '., i~ to the:legalit~ and status~o'f..system. . ~ :"~:~?~:,:::~:".:::::4::::"T~PE OF'~AsT'EwATERJDisPOSAL:..' .. '. _: ',': :.:.~:'.?.-':."..~::..' .... Individual on~site~.: .:' "~, . ._.. Co m m~ nity:omsite' -~ ..... ' ' . ' : Pub lc'sewer'-'.,, ,.:, . . . . . if community wabteWater.'syste'm,. p~ovide, written confirma tion' fr~ attesting to,the legahty and status o~.'syst~. ~:" NOTE: :;!: :' ; :;; :IOU OPSHHQ jo seeXoldUJ:i ,siueUJej nbeJ e~ls pue eJep'~i ulelaoo/g%l~sOiJePJ° ui suo~lnl!lSul I~u~pue' ~ eq~ pUe :,:::: ;;:: %; ;: ":~eUJoq jo sJeseqgJnd ol XselJnoo ~S~ s~q~ seep sHHQ eqj.'~isei¥ ~0 e{e~S eqlu~ pej'als~6ej JeeL;i§u;; leU°;Ssejojd ; ' lugpu@depu! ug Xq e^oqB g qdeJSej~d u! ue^[6 suo!lelUeSeJdeJ eql uodn Xluo peseq seleoU!lJeO Ig^oJdd¥ /qHoqlnv qlleeH senss! (SHHQ) seoi~es ueLunH pue qlleeH jo 1u@uJ~Jed@Q eBeJoqou¥ jo Xl!ledp!unl~ eqJ. ~ eJnleuSis LL~66 ~ 'ZeAT~ elbe2. '~6EELL x~ "0'd sseJppv .. [6I~-~69 ouoqd SaDT~eS b~eaUTbUA ~eAy8 elbPAmJ!J to OmeN ' ?;'; U;h:. Jel~ 81 s-uo eql 'uo loedsu .pu~ u0 l~lso~u Xm. ~0Jl' p~¢'se t o6eJoqeuv lo A1 ed o unR eql '?? ":: w0jt P'o"~elqo uo l~wJotu~ eql uo Pes~q l*qi 4!)e~']oqunl I :~!oJeq Poi~o~Pu~ oJnlomls jo odXl pu~ .~}~}:-/? '(': ~'{' sm00Jpeq to Jeqmnu eql.Joi el*nbope pu~ le0O~ouni.'eles Si meiSAS ,sods~p Jel~Melse~ Jo/pu, ' ' ~}:';},~.~.,}';:"~ --,*.X ddns JeleM el~s-uo eql leql SMOqS UO!leO Iddel*AoJddv Xl Joqlnv ql ~OH sql 1o UOlleSIlSeAu! :" '::~'?~?'~;';':::"-:"' Xm :i~q~ XtUeA M0ieq uMoqs elep UOII~II~A eql 1° se Puu olejeq pexltte lees A~ Aq pe~ll~eo sv "~ ....... M]gNI~Ng AG NOIIO]dSNI dO INg~&VlS 'g Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: OU£ /'1~¢g~¢'/¢/,/I/ Parcel I.D. (~) S/-' ,/,/ A. Well Data Well type /P~/V,t¢"/'/~ If A, B, or C, attach ADEC letter. ADEC water system number Y~¢'-' .~ Date completed 0 ~/¢~'/¢¢~ Driller Log present (Y/N) Total depth ')~¢ 0 / Sanitary seal (Y/N) Y'~:~ Cased to ¢ ~ / Casing height Wires properly protected (Y/N) AT INSPECTION FROM WELL LOG Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO; Septic/ho~ tank on lot Absorption field on lot Public sewer main Sewer service line ; On adjacent lots /' /~'°/ ; On adjacent lots //¢':' / Public sewer manhole/cleanout /W///J' Petroleum tank /¢0/¥ ~. /r~/:)/O?']'~Ld/'-/7~ coO WATER SAMPLE RESULTS: Coliform -(~ Nitrate Date of sample: ~'~ / ~ Other bacteria Collected by: B. SEPTIC/H~EB;NG TANK DATA Date installed ~ '¢//Z//o~ Tank size Cleanouts (Y/N) Y,~-~ Foundation cleanout (Y/N) High water alarm (Y/N) Date of pumping ~ ¢ ~) Compartments )/~ ~ Depression (Y/N) Alarm tested (Y/N) Pumper '~¢ ~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot ~ /'~'-5 I On adjacent lots /-P/Of-) ~ /-~'/'~ Foundation To property line ~-~o ' Absorption field .? 5- '("/.'; ...... () WaterJ~n/service line Surface water/drainage v./o,, ' IU 72-026 (3/93)* Front CONTINUED ON BACK PAGE C. LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" ~e~el at r/ water alarm level ¢~'//'"~'\ High Meets MOA electrical codes (Y//~NN)/: SEPARATION DIST.~NC~'FROM LIFT STATION TO: Well on.J~t'//'~/ On adjacent lots D. ABSORPTION FIELD DATA Manufacturer ManBet/~ccess (Y/N) "Pump off" Level at Cycles tested Surface water Date installed Length 3~ Total absorption area Date of adequacy test Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) (~ ~///-//~ ~ Soil rating (GPD/Ft Width / ~ Gravel thickness ¢/¢ /-~ Cleanout present (Y/N) Resu,ts (pass/fai,/ System type ~ */(~,~(~l'otal depth Depression over field (Y/N) /2///,~ 5 for '~-'//' After test ~" If yes, give date Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 7~ / To building foundation On adjacent lots -k Surface water '/- ~" -¢ ' Curtain drain On adjacent lots '/-/g2~ / ~¢2~'~ Property line '~ ~ / To existing or abandoned system on lot Cutbank ~" ' Water me~/service line Driveway, parking/vehicle storage area + ¢~ ' E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to ali MOA and HAA guidelines in effect on the date of this inspection. Signature Engineer's Name ~¢::~/5 __/~M/~,/Z/~,. fo ~ Date HAA Fee $ ,.~ D~::) ' ¢.%L} Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number CT&E lb:L# Clit~al 8ample Il) Ordered tJy Ptqject lqonle Project8 PWSID Commercial T'ostin9 IA Engineering Co. Environmental Laboratory Services . ~'~a~-~ . LABORATORY ANALYSIS REPORT 94.1536 I OUR MOUNI'Adlq 12/I WATER EAGLE R1TER ENGINEERllqG WORK OrrD~ 77302 Prit~ted Date 04tl 1/9,! ~16:37 Collected.Date 04/07/~ ~ 15:I5 ~, ~cdv~l~ta 0~7/~ ~ 16;55 3.~01,d ~l Director S~ O. DE SedtlpJ.e l~emm'ks: ROIrllNE SAMPLE COLLECTED BY; C.IL QC Allowahlt: Ext. Atlnl l'arameler [~,~ull~ (,311al I Jnj.tq Method LJ~oiila Da~ Date kilt Nibate-N 0,13 mg/J. EPA 353.2/300.0 10 {.N/08/94 CMK UA= (lsmvn[le~hle NA'-' Not Analyzed UI'= (he~t et Th tm ~33 15 Street, Anchorage, AK 99518-1 gO0 -- Tel: 1007) §f12-Td]43 Fox: (907} 561-5301 ENXtlRONMENTAL FACILITIES tN ~LASK.~, C. OLORA~O, FLORIDA. ILLINOIg. MARYI..~ND, NEW J~RSEY. OHIO, UTAH. WEST VlflGINtA APPLIO IT FILLS OUT UPPER HAL; ONLY Property Owner Emmmt F. And Corinne lteidemann MamogAddress P.O. BOX 770061 Eagle River,AAk Phone Zip Code 99577 Buyer Same Address Zip Code Lending Institution Home SaYings & Loan Phone Address 535 D. St. Anchorage, Ak. 99501 z~p Code Realty Co. & Agent Phone Address Zip Code Legal Descriplion Lot 12 Bloc~ 1 Our Mt, Bubd. Street kocatio,~ NHH Mark Cr. Type of Residence Single Family F~] Multiple Family No. of Bedrooms 4 [] Other Water Supply XX Individual ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975. [] Community For wells drilled prior to that date, give well depth (attach Icg if available). [] Public Utility Sewer Disposal  I ndividual Public Utility [] Holding Tank Year Individual Installed: When Connected to Public Utility: NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Time Time Date Date Date Date Inspeclor h~spector Inspector Inspector Field Notes: ( ~. ) APPROVED BEDROOMS ) DISAPPROVED ) CONDITIONAL APPROVAL* DATE BY: *CONDITIONS OF APPROVAL Soils Rating Date Sewer Installed 72.023 Well To Absorption Area Well to Tank _ Well Log Received Septic Tank Size APPLI( FILLS OUT UPPER HA. ONLY Property Ovner Mailing Address Buyer Address Zip Code Phone Lending Institulion //~/i/~/r~/~,,'i: Address , ./,"' i: z--',~ ~) Realty Co. & Agent Zip Code ~"..~- .~, ~;~'/ Zip Code Phone Phone Street Location /',/ Type of Residence ¢.~ Single Family [~ Multiple Family No. of Bedrooms ~ Other Water Supply  Individual ATTACH wEEL LOG. A well Icg is required for all wells drilled since June 1975. '" Community For wells drilled prior to that date, give well depth (attach Icg if aveilable) ~ Public Utility Sewer Disposal - /© Public Utility When Connected to Public Utility: .;~/' ,.,j [] Holding Tank NOTE: TI4E INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. Time Time Date Date h'~spector Inspector Field Notes: ( ) APPROVED BEDROOMS ( [!) r)ISAPPROVED ( ) CONDITIONAL APPROVAL* DATE ( ( - [ i ,-,5 Soils Rating Cate Sewer Installed Date Date Inspector Insp~tor DEPT. OF ENVIRO?N,',dE~q]'AL 'CONDITIONS OF APPROVAL Well TO Absorption Area Well to Tank Well Log Received i Septic TaJ~k Size 72.023 (3/82)