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HomeMy WebLinkAboutPATNODE BLK 1 LT 2 SCALE ROBERT A. SHAFER May 2, 1988 CIVIL ENGINEER 694-2979 HEALTH AUTHORITY APPROVALS SEWER & WATER MAiN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN MUNICIPALITY OF ANCHOR/~iE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION Mr. Dan Bolles Municipality of Anchorage Department of Health and Human Services 825 L Street Anchorage, Alaska 99501 MAY :3 t988 RECEIVED REFERENCE: Lot 2; Block I; Patnode Subdivision Well permit #880034 The existing well was extended from 201 feet to 500 feet. This effort did not produce any additional water. The well flow from this w~l continues to be approximately 5 gph. A second well was drilled as shown on the plot plan furnished with the referenced permit application. This w~ll was drilled to a depth of 300 feet and provides approx~mat~y 45 gph. The original well will r~main in service and is tied into the water service l~ne b~tween the n~wwe~l and the house. A key box and valve has been provided so that the well can be used to provide additional storage as w~ll as supplying it's minimal flow. Attached are copies of the n~w w~ll logs for both wells and a water analysis both coliform bacteria and nitrates from the n~ww~ll. A. SHAFER, P.E. SOIL TEST cc: Maureen Clayton PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 DOC Co. dba SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 )WNER OF LAND ADDRESS /~ LEGAL DESCRI~IONdO ~ DATE'- Started Ended PERMIT NUMBER I)EI'TIt Ot" WELL STATI(' LEVEL OF WATER F'F. DRA~,' I)OWN FT. GALS. PER HR _ ,,~'~ KIND OF CASING KIND OF FORMATION: From (~ Ft. toC~'~.~--Ft. 't~XJ.-l~'~t'''~Jcl F,.omO7 O $ Ft. t¢L~ S"'O .Ft../3 t~ eisa ¢. tC From~ Ft. to_,~_~,~Ft. /~e.?~ a¢.,/~ F,'o~Ft. to,a?_~"~_Ft. ,~Z~O ~'Oc,,'<' L4J~,.'_6_L_ _ From Ft. to .... F't. .(.Qfi~_ .~_ __ From Ft. to_ Ft. ~<~' From ~_ Ft. to_~ Ft. ~, ~_t;~'J ...... From _~__ FI. Io ___ Ft From~ FI. to~ Ft From .Ft, to__Ft._ From_ ~ ~ Et. to--Ft. ~&'O~ ~ _ ~-~ ~[~ From From .Ft. to~ Ft. ~/ to From __Ft. to___ Ft. From .Ft. to _.Ft. From-- Ft. to Ft. From Ft. to Ft. From .Ft. to_ Ft. From~Ft. to __ Ft. From__Ft. to _Ft, _ From .__Ft. to ...... Ft.._ From ,~- From ._ From ...... Ft. to Ft. Ft. lo __ Ft. Ft. to Ft. Ft. to__. Ft. Ft. to Ft. F t- m.~,,~.mm FANCHOR MUNICIPA1A ~ 's ~, DEPT. OF HEALTH From Eb~'/fR~J~4MF-NTAL ~Ro'r tGl'lOlq From ..... Ft. to~ Ft.~ From ....... Ft. to ........ Ft. From ..... Ft. t~C~i. _V~ From ...... Ft, to ...........Ft. From ..... Ft. to ..... Ft MISCL. INFORMATION: [DOC Co. ODa SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759 7)WNER OF LAND ADDRESS ./~g~'~? ? LEGAL DESCRIPTION DATE Started Ended PERMIT NUMBER I)EI'TH OF V;['~L.I. ___ ST&TI(' LEVEL OF' W.,VI'ER F'F. DRAW DOB'N FT. GALS. PER HR-- KInD 0~: C^S~NC KIND OF FORMATION: From ~e?) Ft. From '.__~_ _ Ft. From -~ Ft. From ] ~ Ft. Fro m ~ Ft. From !Tf Ft. From___~Ft. From I~{'" Ft. From ~_~ Ft. From .... Ft, From Ft. From~Ft. From Ft. From~_~Ft. From~Ft. From~Ft. From ..Ft. F t, ~_g~k~_~ ........... From_ to /D .Ft. ~/~T)~ ~~4~0 ~ 6 ~,'~,~,:',: e:, From .... Ft. to lTff Ft,~'~---~~'~9-. From ..... __0_¢~t7_ ~.,,0.,! From to~ Ft. ~ Zt~t~_~__~_~;_/~:. From Ft. to_~__Ft. _t~/_ t? O ~td~2~kfZZ?yL~ From _~Ft. From ...... Ft. to .... Ft. to____Ft to__~Ft. to __Ft. to ___ F t. From .... Ft. From ...... Ft. From .... Ft. From ....... Ft. VIISCL. INFORMATION: / 2' d. ~' T DRILLER'S NAME /~ 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 MAILING ADDRESS/ LEGAL DESOR,PT,O~ O, ~o ~ ?_. ~ q LOCATION I I Dwelling PERM L* NO. ,., Abso~n DISTANCE TO: ~ m / Li?,~°Wsgall°ns IF HOMEMADE: Inside length Width Liquid depth 0 ;~ ~ Manufacturer Material Liquid capacity in gallons _~.,. D,STANCETO: /30 / -+' . - 6 ~_. ~ ! No. of lines / ken§th~ ~.ach ~n~ Total len~th~._._~ l~°f[[inesi~ Trenc?~. ~',inches Distance bet~ ~ I- Top of til~.t~.inish grade J~4/at,e, rial bene. ath tile -- ' ,if Total effective abso_r~p_~i7 are~ Length Width Depth PERMIT NO, E Type of crib Crib diamet Crib depth Total effective absorption area ~ Well Building foundation Nearest ~ot line ~ DISTANCE TO: C~ass Depth Driller Distance to lot line PERMIT ~ DISTANCE TO: Building foundation Sewer Hne Septic tank Absorption area(s) OTHER PIPE ~ATERIALS SOIL TESTRATING 7~~ '~ ' 7 . A R ED : , DATE LEGAL 72-013 (RI v. 3~78) PERMIT NO. t"lLIr4 I C: I F'RL_ I T"¢ mDF DEPARTMENT F'~ HEALTH AND ENVIRONMENTAL '--'OTECTION 825 '"~ STREET., ANCHORAGE, 264-472~t Or-.l--~ I TE SE~4EE: F"EE~bl I T' ( 80062~] ) RPPLICANT LOCATION LEGAL JOHN & MAUREEN CLAYTON ! PO BOX 249 E. R, SKYLINE DR & JAMIE 694-2663 65340 SQUARE FEET TYPE OF SOIL ABSORPTION SYSTEM IS: TRENCH M¢~XIMUM NUMBER OF BEDROOMS = 4 SOIL RATING <SQ FT/BR)= t50 THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS: [:,E F' T H--= 7 LEt4,]TH= E-;L-~ 13 F.: R '.,,.' E L DEPTH= 5 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 OUTFE.L PIPE AND THE BOTTOM OF THE EXCAVATION (IN FEET). F,:EG!LI I F-:E[:, SEF'T I C: TRt4K: S I ZE:= ~L25£~ PERMIT RPPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE INSTRLLRTION INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE NUMBER OF RESIDENCES THAT THE WELL WILL SER9E. TIL..I~D ( 2 ) I ~'-,ISPEC:T I or-.IS RI~;E REG:!L.! I BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL 8Y THIS DEPARTMENT NIL.[. 8E SUB..TECT TO PROSECUTION. MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS i00 FEET FOR A PRIVATE WELL OR t50 TO 200 FEET FROM 8 PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL MINIMUM DISTANCE FROM 8 PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND TO A COMMUNITY SEWER LINE IS 75 FEET. OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER INSTALLATION. P E F~: r.1 I T E .":---: F' I ~.' E S [:, E C: E r.1 E: E E: ~: :1 .. l. L-::~- :=: O I CERTIFY THAT ±: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPRL. ITY OF' ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. 3: I UNDERSTAND THAT 'THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS. SIGNED: ISSUED V4. 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SLOPE SOILS LOG PERCOLATION TEST SITE PLAN 10- 11 12 13 14 15 16 17 18 19 20 COMMENTS PERFORMED BY: 72-o08 (6/79) WAS GROUND WATER / I~ ENCOUNTERED? ~"~ O IF YES, AT WHAT // DEPTH? Robert A. $5~'~'r '~'. PERCOLATION RATE Gross Net Depth to Net Reading Date Time Time Water Drop (minutes/inch) TEST RUN BETWEEN FT AND ~ FT by A & L DRILLING COMPANY BOX 97, EAGLE RIVER, ALASKA 99577 · TELEPHONE 694-2588 OWNER OF LAND DATE - Started ............................. Ended PERMIT NUMBER I)EPTH OF WEI.,L STATIC LEVEL OF WATER FT: DRAW DOWN IrT. GALS. PER HR KIND OF CASING KIND OF FORMATION: From ........... Ft. to .......... F~ From ............... Ft. to From .................. Ft. to ............. Ft t. rom ................... Irt. to From ............... F't. to ................... F't om ............. FL {o From ........... Ft. to ................ Ft ........................................... From ......... Ft. to ...........Ft From ........... Ft. ~o ....... Ft. From ............ Ft. to~._ Ft, From ............ Ft. to ......... Ft ..... From ............ Ft. to From ........ Ft. to From .......... Ft. ~o From ............ Ft. to From .................... Ft. to From ..............Ft. to .......... Fl From ................. Ft. to ............ Ft _ . From ..............Ft. to ............ Ft From ............. Ft. to .......... Ft Erom ........... FI. to From ................ Ft. Io .............. Ft From ...................... Ft. to From ............ Ft. to From ....... Ft. to From ........... Ft. to From ....... Ft. to ...........Ft ..................................... From .... Ft. to ............. Ft Frmn ............ Ft. t () .......... Ft ................... .~ ............................ From ..... Ft. to ...........Ft From ...... Ft. to ......... Ft ...................................................... From .................. Ft. to From ............. Ft. to MISCL, INEORMATION: DRILLER'S NAM E MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 Parcel I.D. # CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Property owner ~"'~/~)~:;::~ ~ Telephone'(home) .Business Mailing Address [~f~c~c~ %,~~ ~'~' (c) Lending Institution Telephone Mailing Address (d) Real Estate Company and Agent ~-~-,'/~~ Address /1~.¢(~2~ /~,~r?-¢~-~-~. ~ ~~ .--- Telephone ~ ~ ~C' (e) Mail the HAA to the following address: (or check here~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING 17034 Eagle 'River Leep Road Eagle River, Alaska 2. TYPE OF RESIDENCE Single-Family," Number of bedrooms 3. WATER SUPPLY Individual Well~t~r' Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site~ 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. 72-025 (Rev, 7/88) Page 1 of 2 ')~JOM s,Jeeu!l~ue IBUO!SSejoJd eq~ u! 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X~ ~OJ¢ pue sell1 eS~Joqouv ~o ~l!led!o!unR eq~ ~oJt peumlqo uo!le~Jo~u! eql uo peseq l~q~ ~peA JeqlJn~ I 'u!eJeq peleo!pu! eJnlonJls to ed~l pue s~ooJpeq ~o Jeq~nu eql Jo~ elenbepe pue leUOROun¢ 'eCes s! ~els~s I~sods!p JeleMelSeM Jo/pue Xlddns JejeM eus-uo emi iBM1 SMOqS I~AOJddv Xl!Joq~nv qlleeH sjq~ ¢o uo!~e6!lSeAU~ ~ leq~ ~JpOA I 'MOleq UMOqS elep UO!leP!I~A eql ~o se pue o~eJeq pex!~ lees ~ ~q pe~;RJeo sV 'HOI~V~OdNI aNY v~va 'HOOVES ~lld 'S~S~Z 'SNOI~O~dSNI ONIQIAOSd ~MId ONI~tNION~ 'g MUNiCipALI~-Y OF ANCHORAC~'~ EN¥iRONMENI'RL SERVICES DiV~ ..J t,I L, 2 5 1989 R£C£1V£D MUNICIPALITY OF ANCHORAGE (MOA) ~ Health Authority Approval (HAA) CHECKLIST- FEBRUARY 1984 343-4744 Legal Description: ~[~=~r' '~--. A, WELL DATA Well Classification I ~"-~ ~ J~ ~,~0/~'~- . IfA, B, /~/~ C, D.E.C. Ap,p,.?O~.~::~y~N<}:..~ , Well Log Present ~5~;~N) ,.-/ Date Completed "~['/~ Yield ~...~_/"~ Total Depth~C> Cased to ¥"~ ~' Depth of Grouting "--'--- Static Water Level 1, ~,--t Pump Set At Casing Height Above Ground {'~-''~4'''~ Sanitary Seal on Casing{~9'N) '"/ Electrical Wiring in Conduit (~) ~r Depression Around Wellhead (Y/I~ SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot ~, ~ {Jr' ; On Adjoining Lots \~t'4'- ; On Adjoining Lots ToT° Nearest Edge of Absorption ~,d/~ LOtNearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot ~ Water Sample Collected by ~ 5 ~ ~r~,1 ; Date '7' "' I"~ -'~ Air-tight Caps Pumping/Maintenance Contact on File (Y/N)~/, Holding Tank High-Water Alarm (Y/N) No. of Compartments ~ Foundation Cleanout ¢E;~I) ~-~' //D~te Last Pumped ~, ---~ ~- ~ ~ · ; for ' ' Temporary Holding Tank Permit (Y/N) Water Sample Test Results Comments ~'~ ~~,~ SEPTIC/HOLDING TANK DATA Date Installed Standpipes(:i~N) Depression over Tank (Y/~J~. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: It> Jr To Disposal Field To Building Foundation To Water-Supply Welt To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course Comments 72-026 (Rev, 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field '~--,~ Type of System Design ~'~_~ Square Feet of Absortion Area Depression over Field (Y~;I~ Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: Length of Field I,.~x:::>~ Depth of Field ~ I ~., ~ Gravel Bed Thickness ¢~ ! ~ Statndpipes PresentatiON) Date of Last Adequacy Test To Water-Supply Well To Building Foundatiqn Lot ~/~ To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments .I To Property ,Line ~ ~ To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) "'"" ~ ! D. LIFT STATION j~/ Date Installed ,,Size~Gallons High Water Alar~ Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect inspection. Signed Company Date MOA No. S & S ENGINEERING 17034 Eagle River Loop Road No. 204 ~.agie ~,;,~mr, Ala;k,,~ Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 l:ei~ru,~I./ 6, 1989 RC~iiERT A. SHAFER CIVIL ENGINEER 694-2979 HEALTH AUTHORITY APPROVALS SEWER & WATER M/,JN EXTENSIONS SEWER & WATER INSPECTION ENGINEERING STUDIES AND REPORTS WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL 'rEST PERCOLATION TEST STRUCTURAL & MECHANICAL INSPECTIONS ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN ~aureen Cla~'ton 18639 Jamie Drive Eagle River, Alaska 99577 REFERENCE: Lot 2; Block. I; Putnc,.~,.~ SuI.~ivisi,~n Dear Mauree~, This letter is in response to yo~,~ dnq~iries of what the water system located on the referenc~d properly can dc, in ~erms of producing a 3 gpm equ~'.valent. You informed, us that only the new t.~!~.l is in use. F~.om the we~ log, this w~l is 300 feet deep w~I~ a static water ~ev~ at 15 feet and an estimated produ~o~ o~ 45 gph. If the well pump is set at 290 feet deep, then the useable w~,ter storage within the well casing would be approximately 400 g~llons. There are a~:so two air vented wa;(~e..~ storage tanks in the crawl space. Each tank holds 160 gallons for a tota~ storage of 320 gallons. Together th~!. water sys'tem has a water storage capacity of approxima£~ly 720 gallons. Therefore, the system wou~.d be capable of producing 3 gpm for a period of four hours. This exclud~;s the pressure tank which holds approximately 20 gallons of storage and the actual producti~on of the we~ wl~ich would be 180 gallons over a four hour period. Therefore, the, entire system. should be capable of supplying 3 gpm for a period of five hours before the water storage within the casing and withi, n th~ crawl space has b~en depleted. please contact u.s. 17034 EAGLE RIVER LOOP, SUITE 204, EAGLE RIVER, ALASKA 99577 CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 I~'~TR--"~'~ ~~L--~'"~ 9"~"~ ~~(9--'~~ ~,.~'.~ FEDERAL TAX ID # 92-0040440 ANALYSIS REPORT BY SAMPLE for Work O~de~ ~ 14972 Date Report Printed: 3UL 20 89 @ 18:59 <Ilion* Sample ID:L2, B1 PATNODE S/D PW$ID :UA Collected JOg 17 89 ~ 15:20 hrs. ReceJYed JUL 15 89 ~ 15:25 hrs. Prese~¥ed with :AS REQUIRED Client Name : S ~ S ENGR P.O.~ NONE REC'D Req # Ordered ~y : Analysis Completed :JUL 19 89 Send Reports to: Laboratory Supervisor :STEPHEN C. EDE 1)S & S ENGR Special Instruct: Chemlab ~ef #: 6399 [,ab Smpl ID: 1 Matrix: WATER Allowable Paramete~ Tested ~esu]t/UnJts ~ethod Limits .......... .................................... 7 ........... ............... Sample ROUTINE SAMPLE Remarks: SAF~PLE COLLECTED BY RJS. 1 Tests Perfozmed ' See Special Instructi. ons Above Ul~Unavailab],e ND~ None Detected *~ See Sample Remarks Above NA~ Not Analyzed l,T-l, ess Than, GT-Grea~er Than MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal D.es~;iption (include lot, block, subdivision, section,~ Location (address or directions) (c) Applicant is (check one): Lending Institution [] · Owner/builder/[~; Buyer []; Other [] (explain); (d) Lending Institution ~D')~¢~.-.~-.-'~ ~~'~?--c7''-~e'--~z~,' Telephone Address ~,~.--¢/~ ~_..~?. c.6..tJ.¢ ~,.L~ . / (e) Real Estate Company and Agent Address . Telephone (f) ~the~ HAA to the following address: TYPE OF RESIDENCE Single-Family ~' Multi-Family Number of Bedrooms Other WATER SUPPLY Individual Well/l~ 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. 72-025 (11/84) Page 1 of 2 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. 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 inspesti~ns ENGINEERING ~' ~;~- ~-~'7~ Name of Firm .eR B ~°.~.~- Telephone Address r-~.i~_.l._l= ~!VE.DrAK 9q~77 Date _~.A¥ ! ! ICJ86 t DHEP APPROVAL Approved for~-'O¢~ bedrooms b Approved ~ Disapproved Condition~;~ 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 72-025 (11/84) MUNICIPALITY OF ANCHORAGE (MOAj HEALTH AUTHORITY APPROVAL (HAA) /glI~IIi~IPAI.1TY OF ANCHORAGE CHECKLIST - FEBRUARY 1984 DEPT. OF HEALTH & 264-4720 ENVIRONMENTAL PROTECTION Legal Description: MAY 1. 2 1986 WELL DATA RECEIVED Well Classification '~i~-~/~-'T~- If A, B, C, D.E.C. Approved (Y/N) Well Log Present t~)N'] Date Completed j ~ r'j ~ Yield Total Depth '~O I Cased to Static Water Level c..J o ~ Casing Height Above Ground Electrical Wiring in Conduit ~N-)--- Separation Distances from Well: Depth of Grouting - Pump Set At i,A I(,, Sanitary Seal on Casing ~IN~/' Depression Around Wellhead ¢¢~ To Septic/Holding Tank on Lot ~ ¢ ~ ~ +'' ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot |C:)¢> t~ ; On Adjoining Lots To Nearest Public Sewer Line ~J ~''~'''' To Nearest Public Sewer Cleanout/Manhole "-- To Nearest Sewer Service Line on Lot Water Sample Collected by Water Sample Test Results Comments B, SEPTIC/HOLDING TANK DATA Date Installed /O"~/-~2Size /Z~''-~ No. of Compartments Standpipes~,N-) Air-tight Caps ~ Foundation Cteanout~4~t~ Depression over Tank ¢¢~ Date Last Pumped Pumping/Maintenance Contract on File (Y/N) /~//-4--- ;for Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Mare/Service Line Course Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field To Stream, Pond, Lake, or Major Drainage Comments Page I of 2 72-026t11/84) C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed /~ "--~/'- ~ Width of Field -.~"/ Square Feet of Absorption Area Depression over Field (4 Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well z/4)~ ! To Building Foundation ~ ~' Lot '~"'//"~" To Water--Service Line -'~'~ / ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Depth of Field Gravel Bed Thickness Standpipes Present~N')' Date of Last Adequacy Test Type of System Design Length of Field To Property Line //z~ / w To Existing or Abandoned System on ; On Adjoining Lots To Cutbank (if present) /'"'/~-/ Comments D. LIFT STATION Date Installed Dimensions Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Manhole/Access (Y/N) "Pump Off" Level at '/~~ Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify th~jt~h~j~j;jf~~, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed CD D ,~zv Date MAY Ii J986 AV OOJ~"~"~ MOA No. Receipt NO. -~ ~ ~ ~ Date of Payment ~ - ~ ~- ~ Amount: $ Lc Page 2 of 2 72-026 (11/84) INSPECTION APPOINTMENTS TIME DATE INSPECTOR~ ~ TIME DATE \ DATE RECEIVED TIME MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIONDEPT' OF I'J.~ArLTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ?,;©TECTION ENVIRONMENTAL SANITATION DIVISION NOV ~[ $1980 Telephone 264-4720 r~ r-~,"~r,,,,i ,~ DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. .--. MAI LING ADDRESS [ PROPERTY RESIDENT (If different f~'o~n above) PHONE PHONE 2. BUYER MAILING ADDRESS ,v.r... 3. LENDING INSTITUTION MAI LI N'G ADDRESS ' 4. REALTOR/AGENT MAI LING ADDR ES,~, PHONE 5. LECa~L DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE ~ SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF,,BEDROOMS [] One ~ Four [] Two [] Five [] Three [] Six [] Other 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY 8. SEWAGE DISPOSAL SYSTEM INDIVIDUAL/ON-SITE** [] 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.) YEAR ON-SITE SYSTEM WAS INSTALLED. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified. 3. SEWAGE DISPOSAL SYSTEM [] INDIVI DUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or [] Holding Tank Size: I%~~ If Tank is ~omemade give dimensions: 'YPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line 5, COMMENTS THIS SIDE FOR OFFICIAL USE ONLY NUMBER OF BEDROOMS [] ONE ' [] THREE [] FIVE [] TWO [] FOUR [] SIX [] OTHER PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED ~ , ,, )ERMIT NUMBER DATE INSTALLED iNSTALLER SOILS RATING ISewer Line [ Nearest Lot Line MANUFACTURER MATERIAL Septic/Holding Tank IAbsorption Area DATE VED FOR [] DISAPPROVED <~ BEDROOMS CON DITIONAL APPROVAL (letter must accompany certificate) 72-010 (Rev. 6/79)