HomeMy WebLinkAboutPENNINGTON PARK BLK 2 LT 1A
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 ,
NAME IPHONE
[] UPGRADE
MA, L,NGADDRESS £
LOCATION N~. OF BEDROOM~
IWell ~Abs°rPti°n~ / Dwelling , PERMITNO:7~¢¢~
DISTANCE TO: 5 ~
~ Ma,ufaoturer ~ ~atO~ ~0. Of co~.~rtm0nts~
~ ~ Liq. capaciW in ~allons ~ ' Inside length ~idth ~iquid depth
-- ~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~ - ~ Manufacturer Material Liquid capacity in gallons
~ Well Foundation Nearest lot tine PERMIT NO,
~--~ ~ No. of I,nes Length of7c~ine Total length ~es Trench w~ inches Distance b etwee~/~
~ ~ ~ Top of tile to finish grade / Material beneath tile / Total effective a~orption area
Length Width Depth PERMIT NO.
( ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
Class~l ~ ./ Depth Driller Distance to lot line PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPEMATERIA?~& ,
SOl L TEST RATING ~ ~.
REMARKS
lev. 3/78)
WELL
PERMIT NO.
APPLI CANT
LOCAT I ON
LEGAL
r. ILID~ ICI F ,tL I'T'T' OF RD-J£:HC _~RGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 ~'L~ STREET, ANCHORAGE, AK. 9950i
2~4-4720
ON--SITE SEPJER
SUN CONST.
SAR BOX 474E
LiP B2 PENNINGTON PARK
LOT SIZE 54450 S~I.IRRE: FEET
TYPE OF SOIL RBSORBTION SYSTEM IS' TRENCH
MR>~IMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT?BR>= 225
RE~!UIRED SIZE OF THE SOIL ABSORPTION ~.Y:.TEM IS
THE ' '
~-.EPTH: 10 LED~GTH= ?~ GRR%,'EL [:,EPTH= 6
THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DRAINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETWEEN THE SURFACE ElF 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 OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET>.
REC~4Lm I REC~. SEF"T I C TANK S I ZE= 1250 [)Al_L.k:mD-4~;
PERMIT APPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION INSPECTIONS OF 8NY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
TL. JmD 42> ID~SPEC:TION$ ARE RE~!LJIRE[:'
BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT WILL BE SUBSECT TO PROSECUTION.
MINIMUM DISTANCE BETWEEN R WELL AND RNV ON-SITE SEWAGE DISPOSAL SYSTEM
i00 FEET FOR R PRIVATE WELL~ OR
t50 TO 200 FEET FROM R PUBLIC HELL DEPENDING UPON THE TYPE OF PUBLIC HEEL.
HELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN ]0 DRYS
OF THE HELL COMPLETION.
DIRGRHM-. ARE
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS 8ND CONSTRUCTION ''
AVAILABLE TO INSURE PROPER INSTALLATION.
F"ER£~ IT EXPIRES DECEPIBE~ ~i~ 1979
I CERTIFY THAT
1: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS RS :SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2' I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES;.
~' I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 4 BEDROOMS.
V_?-.. '2
[] SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch 6-650, Anchorage, Alaska 99502 276-222f
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR: ~"~'tZA/ d'"d"P&/._%7-/?'/JE'7-'/(-.'.').AJ' ~'-,,"v'~-..
DATE PERFORMED: ~"~ - ~ ? -- ?~'~ ,
3
SLOPE
9
.... 10
11
12
13
16
17
18
19
20
COMMENTS
WASENCOUNTERED? GROUND WATER
....
P
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE ~J(,.= l , , : ''J ~ ~ 0 (minutes/inch)
TEST RUN BETWEEN - ~ FT AND "~ ,. FT
PERFORMED BY: ,/'~J,,'q',
72-008 (7/76)
19 ................ 22 rt. r'.'.':i
8~. ~o?
lo9-- 11~
111 121
121 1,%0 f~,,
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION
OCT :L g ~oo,:~
RECEIVED
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENq/IRONMENTAL HEALTH
DEPARTMENT OF HEALTH ANrD ENVIRONMENTAL PROTECTION
APPLICATION FOR t~iALTH AUTHORITY APPROVAL CERTIFICATE
i. Gene:'a! Information Application Da~e
(a) Legal Description (include lot, block~ subdivision, section, township, range)
- ,,,,~ ~...
' ' ' ' '~ i''
(b) Applicants Name /' !,,~,.,~i
Teleo._hone- Home Business ....
(c) Applicant is (check one) Lending Institution ~ ;~OWne~/builder~ ;
Buyer~ ; Other~ (explain); ~ ',.
Telephone
(d) Lending Institution
Address
(e) Real Estate Co. & Agent
Address
(f)
Telephone
Mail the h%kA to the following address:
2. Type of Residence
Single-Family~__~+..
Number of Fedrooms
Other (describe)
3. Water Suppl~
Individual Well ~ Community ,,~'---! Public ~
Note: If community well systam~ must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status.
4. ~ewage Disposal.
Onsite~ Public~ Community~ Holding Tank~
Note: If community well system, must have written confirmation from the State
Departmen~ of Environmental Conservation attesting to the legality and status.
Z of 2]
! ee,-4mq P?. c~vi.d~tious ,__ Lests, File Searcha Data and
As -e~,-~":~; by my seal affixed hereto and as of the validation date sho~ below
w.,~,fy t~:~ my investigation of this Health Authority Approval shows ~hat the o~
water z~ppiy and/or wastewater disposal system is safe~ fmnction~ and ~eq~a~e fo
~he auz~ber of bedrooms and type of structure indicated herein.. I further verify
based on the info~ation obtain~ from the ~nicipality of ~chorage files and ~
investigation ~d inspection, the on-sit~ ~ter supply and/or ~stewater dis~sal
system is in compliance ~th ~1 ~nicipai and State codes, ordinances~ a~ ret
tions in effect on the date of this inspection.
Name of Fi ~~~ ~. ~
: Telephone () /~ ~C(~
Address /'";<~ F Q ~ : ' '/ ~ ~'
e
Approved fo~ ~: bedrooms
Approved __&/~_ Disapproved
Terms of Conditional Approvai
CAUTIOM
THE MUNICIPALITY OF ANCHORAGE DEP~ITMENT OF HEALTH AlqD ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CE - - ....
R~.IFACAZES BASFD SOI2LY UPON THE REPRESENT-
ATIONS GIVEN IN PARAG/hkPH 5 ABOVE BY ';2~ iNDEPENDENT PROFES~ w. ~
..~NGzAqEER 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 CER~a~IN FEDERAL AND STATE REQUIRE-
MENTS. ~PLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHOR3.GE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN THE PROFESSIONAL ENGINEEI~S WORK°
RR4/eJ/D18
[ga~e ~ of 2]
(DHEP SEAL)
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Le~3al De~scription: ~LOd~
Casing Height Above Ground
~fElectrical
Wiring in Conduit~_~.~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
Well Classification ~(:~, b" ts~'T-~----- If A, B, C, D.E.C.,Approved (Y/N) /'~ z/~ .
Well Log Preseny/~N) Date Completed ,~./' //~' Yield
Total Depth / ~/~) t
. Cased //'/~ /
Static Water Level '~[, ~ / ~) Depth of Grouting
Pump Set At ./.~Z~'~
O, ~ / Sanitary Seal on Casing
Depression Around Wellhead (Y~_~
[ ~)~/ "~ ~ ' On Adjoining Lots
To Nearest Edge of Absorption Field on Lot l ~*0/ '~' On Adjoining Lots
To Nearest Public Sewer Line ~ To Nearest Public Sewer
J
Cleanout/Manhole J~ - TO Nearest Sewer Service Line on
Water Sample Collected by ~~ r 'Date
Water Sample Test Results
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes
Depression over Tank (Y,~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
TO Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Comments
Size / ~.~ No. of Compartments
Air-tight CapON) Foundation Cleanout
Date Last Pumped
~'L/I~[- 'for
I~JtW Temporary Holding Tank Permit (Y/N)
To Building Foundation
TO Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
ALASKA i FIU ROFImI I1TAL COFITROL Si RUICI S, IFIC.
~nclinecrin§ ~, ~nuironrncnlal ,~tucJies
BILL PAUZAUSKIE
17201 MARY JANE LANE
ANCHORAGE ALASKA
99507
SELLER-SAME
JULY 24 1985
BILL PAUZAUSKIE
17201 MARY JANE LANE
ANCHORAGE ALASKA
99507
50325
LEGAL:PENNINGTON PARK BLOCK 2 LOT iA
ADEQUACY TEST FOR SEWER SYSTEM
ADEQUACY TEST DATE-JUNE 18 1985
THE TYPE OF ABSORPTION SYSTEM IS A TRENCH WITH AN AREA OF 912 SQFT.
THE SYSTEM IS CAPABLE OF ACCEPTING 450 GALLONS OF WATER PER DAY.
THE SURGE CAPACITY OF THE SYSTEM IS 500 GALLONS.
BASED UPON THE TEST DATA THE SYSTEM IS ACCEPTABLE FOR A
3 BEDROOM HOME.
SEPTIC TANK ADEQUACY
THE EXISTING SEPTIC TANK VOLUME OF 1250 IS ADEQUATE FOR
THIS 3 BEDROOM HOUSE.
THE SEPTIC TANK/PACKAGE PLANT WAS PUMPED ON 10/24/84 .
FLOW TEST ON WELL
WELL FLOW DATE-JUNE 18 1985
A FLOW TEST WAS PERFORMED ON THE WELL. 500 GALLONS OF WATER WAS
PUMPED AT A RATE OF 3.8 GPM OVER A DURATION OF 3 HOURS.
THE DRAWDOWN WAS 46 ' WITH A RECOVERY TIME OF 120 MINUTES
AND THE STATIC WATER LEVEL WAS 71 FEET.
THE WELL IS ADEQUATE FOR THIS 3 BEDROOM HOME.
1200 UJesl 33rd Aucnue, Suite J~,, Anchoraqe, Alaska 99503 ,(907) 561-5040
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
TO BE COMPLETED BY LABORATORY
WATER SYSTEM:
Water System Name
(*) See h on back
I.D. NO.
Phone No.
Mailing Address
City
SAMPLE DATE:
State
Day Year
Zip Code
SAMPLE TYPE:
/~::~Routine
D Check ~ample (for routine sample
with lab ref. ho.
I:] Special Purpose
Treated Water
Untreated Water
Analysis shows this Water SAMPLE to be:
~ Satisfactory
[] Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results. Please send new
sample via special delivery mail.
Date Received
Time Received
Analytical Method:
[] Fermentation Tube
Vlembrane Filter
SAMPLE
NO. LOCATION .,~
4 I I
Time Collected
C~, I I~ect ed By
Lab Ref. No. Result* Analyst
I I
I
I
*No. of colonies/lO0 mi, or No. of Positive portlo~ls.
06-1220 (b)
Rev. 1983
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
Membrane Filter. Direct Count
Verification: LTB
Final Membrane Filter Results
Reported By ~ - ~
BGB
Date
Time:
CoilformllOOml
Coilformll00ml
'/'-~ a.m.
COLLECTING SAMPLE TNTC = Too Numerous To Count
82~ L 6treet - An.horage, Alaska 99601
' · · AUG 2 9 1979
' ENVIRONMENTAL ENGINEERING DIVISION '
REOUEST FO~APPROVAL OFrlNDIVIDUAL WATER AND SEWER FACILITIES
DIRECTIONS: Complete all parts on page t. Incomplete ~qutl~ will not be proemed, Pleasa allow ten (10) days for processing.
I
J
~, PROPERTY OWNER / ' r ' PHONE
PHONE
~, LENDING INSTITUTION '
6." LI~I~I~ DESCRIPTION
STREET LOCATION
6. TYPE OF RESIDENCE
E~'--I~ING LE FAMILY
[] MULTIPLE'FAMILY'-'
7. WATER SUPPLY
~'[RDIVI DUAL*
[] COMMUNITY
[] PUBLIC UTILITY
' I~'. SEWAGE DISPOSAL SYSTEM ' '
E]~-"'TN-~iv I DUAL/ON-SITE**
[] PUBLIC UTILITY
[] One [] 'Four [] Other
[] Two [] Five
[~"'-rhre'e [] Six
* 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.)
**If individual/on-{ire, give installation date l' ¢ 7 c/ ,~, '.
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE:'THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED~
72-010(3/78)
C. ABSORPTION FIELD DATA
Soils Rating in Absorptio. n St~rata
Date Installed ::~/~l~'t~ / ~
Width of Field
~YSquare Feet of Absorption Area
Depression over Field (Y/I~I))
~"Results of Last Adequacy Test
(~5'~'~'~ Type of System Design ~',~
Length of Field
Depth of Field I ~/
Gravel Bed Thickness . ~/ d/
¢/Z ~'""~' Standpipes Present (~N) __
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well'"
To Building Foundation
Lot
To Water Main/Service Line ~ ~ ~/~'-
To Stream/Pond/Lake/or Major Drainage Course
!
To Property Line _.~0 ~-
To Existing or Abandoned System on
· On Adjoining Lots ~ ~)/
To Cutbank (if present) i~ I ~'
Comments
To Driveway, Parking Area, or Vehicle Storage Area
, \
D. LIFT STATION
Date Installed Dimensic ns ~
Size in Gallons | Manhole/Acd
Tested for ~.,.~-,.-,"~ \ Pumping Cycles during Adequacy Test. Meets MOA
Electrical Codes~ ......
~ Check Permitted Bedroom Rating Against HAA Request **
I certify that I h,~checke, cl, verified, or conformed to all MO~, anGHAA, guidelines in effect on the date of this inspection.
Signed ~h, ~ Date ~_ ~ ~ ~~/_~J~-
Company /~.C ~ ~ MOA No. ~T ~-- 0~'
Receipt No.
Date of Payment ~' ~-~5 .'~. ~e .~' ~I
Amount: $ ~ ~ ~.. ~ ...0~ ~,
' ~ ~ "" ~ ~9 ~b~ Engineer's Seal
Page 2of2 '~e,~.:, ,,. '¥ .'
72-026 (11/84) · 'M~ '~ ~v ~
TIME
DATE
INSPECTOR
DIRECTIONS:
THIS SIDE FOR OFFICIAL USE ONLY
INSPECTION APPOINTMENTS TIME
DATE "
INSPECTOR
DATE RECEIVED
TIME
DATE
INSPECTOR
r
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
'Connection Verified
NUMBER OF BEDROOMS
ONE
[] THREE [] FIVE
[] OTHER
TWO
[] FOUR [] SIX
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
'DATE INSTALLED
INSTALLER
SOILS RATING
[]Sep.tic,,T_~3l~, or []Holding Tank
Size: t"e/~-~~'~v If Tank is homemade
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
Septic/Holdin~ Tank
4~. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
IAbsorption Area ]Sawer Line
Nearest Lot Line
5. COMMENTS
3
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED I ~
DATE, I BY (Title)
LEGAL DESCRIPTION
72-010 (Rev. 3/78)
