HomeMy WebLinkAboutPETERS CREEK BLK 3 LT 18 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 MAll_lNG AD _~SS LOCATION DISTANCE TO: Manufacturer Liq. in gallons PHONE DISTANCE TO: Manufacturer Absorption area IF HOMEMADE: Well N~ DISTANCE TO: /~1.~ ~ No. of lines / Length of_~3~ Ij~e Top of tile to finish grade j Width Crib diameter Length Type of crib. Well DISTANCE TO: DISTANCE TO: Inside le ng~b_..___ Dwelling Dwelling Material,.~~ Width Foundation Total len~lir)es Material beneath tile Depth [] UPGRADE / ,~; 9¢/5-77 NO. OFBEDROOMS PERMIT NO. C'/~ No. of compartments Liquid depth PERMIT NO. Material Liquid capacity in gallons PERMIT NO. ~, Distance between lines Total effectives.absorption area ~3--O ~ "r PERMIT NO, Nearest lot linTo ~'~- Trench wid~o inches /---/E inches Crib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot line Septic tank PERMIT NO, Absorption area(s) Sewer line OTHER PIPE MATERIALS SOIL TEST RATING INSTALLER REMARKS APPI DATE 72-0'~ ~v. 3/~8) LEGAL © © © 0 MUNICIPALITY OF ANCHORAGE Department f Health and Environmenta' Protection 825 ,, Street, Anchorage, AK. J9501 / 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~ , ~ WELL AND/0R Mailing Address'~ Lo c a t i on: /~L/~ ~L//~,/ ,/~,//~.v Phone Numb er: Legal Description: ~/~'~,~/~~ f~ Lot Size: Type of Soil, Absorption System' ~s :' . Trench: X Drainfield: Seepage Bed. Holding Tank: Maximum Number of Bedrooms: ,~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is: 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 :--' "/~/~ GALLONS 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 departme will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 fe 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~ 1 9 8 3 * * * I certify that: (1) I am familiar with the requirements for on-site sewers and wells as set.f~rth by th~ Municipality of Anchorage. (2) I w/~_~ ~st~l~//he system in accordance with codes. (3) I/~n~tan~/x~hat the on-site sewer system may require enlargement if .~~~/~ ~ .. remodeled to include more t~~~ Signe~ :~/'~/_.~~/~ Issued by: ~/pplican~ ~ SOILS LOG MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION TEST 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST LEGAL DESCRIPTION: SLOPE SITE PLAN 10 11 12 13 14 15 16 17 18 19 2O WAS GROUND W^TER ENCOUNTERED? IF YES, AT WHAT DEPTH? 0 E Gross Net Depth to Net Reading Date Time Time Water Drop · PERCOLATION RATE (minutes/inch) COMMENTS PERFORMED BY: 72-008 (6/79) TEST RUN BETWEEN FT AND ~ FT 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Lot 18, Block 3, Peters Creek S/D Location (site address or directions) 22344 Glenn Court Property owner Diane Hiller Day phone 694-6688 Mailing address Lending agency Mailing address Agent Address 1RPQ7 Clear ~11~ Circle, Eagle River, AK 99577 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 3 N TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: xxx If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 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. S & S ENGINEERING _ Phone ~ ~ ''/ - ~- c) '7 ~ Name of Firm 17034 ¢.agle ~,,~i L r 0.,,4 Nh. Ea le River, Alaska 99577 Address ~ Engineer's signature ~ Date ~,,..-/f 3 / ct' ¢ DHHS SIGNATURE ~ Approved for bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments By: Date ~'-'- / ~'' ~ ¢ 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. 72.025(Rev, I/91) Back MOA#21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist ,~/-~ ,-~ ~;:)~Y-'~/~_~ ~/~ ~'~ Parcel I.D.: Legal Description: ~/OF /~ / A. WELL DATA Well type ,z~//~::>/__/.~/.j~.. I~, B, or C, attach ADEC letter. ADEC water system number ! Log present (Y/N) TOtal depth Sanitary seal (Y/N) Date completed Cased to ~ground) .~~"~ Wires properly protected (Y/N) FROM WE.L.L-~G AT INSPECTION g.p.m. Date of test ,< .CEIVku MAY 1 1999 ...... ~',DAI lTV hi: ANCHOP. AG ENVIRONMENTAL SERVICES DIVI,~ g.p.m. WATER SAMPLE RESULTS: Coliform Nitrate Other bacteria Date of sample: Collected by: B. SEPTIC/HOLDING TANK DATA Date installed ~') 7_J~/~:~'~ Tank size [ Foundat on cleanout/~N) Y~ Depression (Y/N) ~/r.~ , //~/'~'~ Pumper Date of pumping / . C. ABSORPTION FIELD DATA Length ~ ~ / Width ~ / Effective absorption area '~ ~ ~ Date of adequacy test ~/,/~ Fluid depth in absorption field before test (in.); o~y Fluid depth ~v//~- (ins) Minutes later: '~/,~ Peroxide treatment (past 12 months) ~ /~//0~ ~ /Number of Compa~ments High water alarm (Y/N) Soil rating (g.p.d./fF o~. // Cleanouts ~tN) System type / ,~-~-/',,'C~-/('~' Gravel thickness below pipe 4 ! Total depth ~ ' Monitoring Tube present~,l) ~//~4~ Depression over field (Y/~ /(/' ~ Results (Pass/Fail) ~ ~5; $ For ,~ bedrooms Immediately after~/77 gal. water added (in.): J)~, ~' Absorption rate = /-y .(-0 -/ .g.p.d. If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed /J Manhole/Access (Y/N) High water alarm level at* Cyc~ ~ SEPARATION DISTANCES Size in gallons "Pump on" level "Pump off" level at*. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ~_ ..... Absorption field on lot Public sewer main Se~ On ad'al~--- ~ On adjacent lots Public sewer manhole/cleanout , Lift station SEPARATION DISTANCES FROM sEPTIC/HOLDING TANK ON LOT TO: Foundation ~ / -/-- Property line / C:) / ~ Absorption field / ~'- Water main/service line //O / ~ Surface water/drainage ~/~:17/~'' Wells on adjacent lots SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /O/-/ Property line su ace water 700 / '/- Curtain drain ~,/0/",/ ~ Water main/service line Building foundation Driveway, parking/vehicle storage area /~'/~,/O ~ /".,/ Wells on adjacent lots ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal in conformance with MOA Hy~ gpideli~w in effect on this date. Signature ~ff / Engineer's Name Date /00 .4- HAA Fee $ '~ CrD ' ~'~ Date of Payment ~'"'-J/~/~' ? Receipt Number /-~'~--'~ F~' /7~) 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 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) LOT 18; BLOCK $; PETERS CREEK SUBDIVISION, Location (address or directions) NHN Glenn Lane (b) Property owner Mailing Address A.H.F.C.#104862 Telephone ' (home) 520 East 34th Avenue, Anchorage, Alaska 99503 Business (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent RE/,~Lk~. OF EAGLE RIVER ATT.~!." Doc Address 16600 Centerfield Drive. Suite 201 Eagle River, Ak. Telephone 694-4200 C~_ou8 e 99577 (e) Mail the HAA to the following address: (or check hereY~ if hold for pick up.) List contact person and day phone number below: $ & $ ENGINEERING 17034 Eaqle Ri~er Loop Read Eagle River, Alaska o TYPE OF RESIDENCE Number of bedrooms Single-Family ~ WATER SUPPLY Individual Well [] Community [] Public B[]X Note: If community well sYstem, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 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 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TES;rS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigatio~ of th is. 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 inspection. Name of Firm Address Date S & S ENGINEERING ..... ,~. 2.04 Eagle River, Alaska 995~ Telephone 6: DHHS APPROVAL.-, /.&~//~z~ ~J/ Approved for ~2 bedrooms by _ . . Ai~Proved /.~_' Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev. 7/88) Back Page 2 of 2 MUNICIPALITY OF ANCHORAGE (MOA) Health A[!thority Approval (HAA) ~ , CHEckLiST- FEBRUARY 1984 ............... 343-4744 Legal Description: A. WELL DATA Well Classification Well Log Present (Y/N) Date Completed If A, B, C, D.E.C. Approved (Y/N) Yield Total Depth Cased to Depth of Grouting Static Water Level Pump Set At Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Lot Water Sample Collected by ; Date Water Sample Test Results Comments [~//~, ~, ,~<~' B. SEPTIC/HOLDING TANK DATA Date InstalledL~,-~,-~"~ Size Standpipes ~N) Depression over Tank (Y~) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) /J~ To Property Line To Water Main/Service Line No. of Compartments Air-tight Caps,CF?N) Foundation Cleanout~N~ ) ~/ ~ /Date Last Pumped 14 /~ ;for '-"-"- Temporary Holding Tank Permit (Y/N) ~)/~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ,'?,~¢2¢ I Jr-- To Building Foundation ~ ~=.l.~ TO Disposal Field To Stream, Pond, Lake or Major Drainage Course ~ ~ I.~ Comments "~--'~ 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA \ Soils Rating in Absorption Strata _ Type of System Design ~ ~ ~ ~c~ _ I Date installed ~,~ .. ~::::~ ~ Length of Field _ Width of Field ~"~ _ Depth of Field _ ~EL) ~_ ~¢d ~:~-~/..,G ravel Bed T h i c kn ess Square Feet of A1osortion Area ~.~[~'~-~ ¢P' Statnd pipes Present~)'N) Depression over Field (Y~j~ - Date of Last Adequacy Test Results of Last Adequacy Test ~ "- "'~~ SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~ l'"~r~ To Property Line \ ! To Building Foundatio~,//-/~ ~"~'- To Exis. ting or Abandoned System on Lot ;O. Adjoining Lots '~/.-Jr' ~/.~3 To Water Main/Service Line / c~ [Jr' To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course \ ~ ~ To Driveway, P. arking Area, (~r Vehicle Storage Area Comments ~~ ~~"--~ "-'~"~"~~ ~x~.~ D. LIFT STATION ~'~/~ Dimensions Date Installed Size~ "Pump On" Level at High Water Alarm Level at Manhole/Access (Y/N) "Pump Off" Level at ~.~ _ Vent (Y/N) Tested for Meets MOA Electrical Codes (Y/N) Comments les 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 e inspection. Signed Company _ Date S & $ ~_Nc. iNF. ERING 17~34 Eagle River Loop Road No. 204 Eagle ,iver,...~iaska ~$~(:~ MOA No. Receipt No. Date of Payment Amount: $ 72-026 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 APPLI(. NT FILLS OUT UPPER HAl ONLY Property Owner ~_~/-~ ~/~)/_~ ~-')~.~) ,(..,/~,., / ~ /~'-~ ~ Phone MailingAddre~ ~ () ~ ~ ~-~d~ ~ ~/~ /~ ZipCode Address Zip Code Lendinglnstitution /~ ~ ~F/~ /F¢; / ~/~/'7 /~ Phone Address ~ ~ /~_ /, -- /2J [/¢' ~ - ;~J.' J~~pC°de Realty Co. & Agent /~ X' C ~"~ / 75* ~ /'~ ~ [-+~, J/~ I~ ~ ~ ~, Phone Address lD, ~ ~--¢~ ~, 7 ~ :~~ ,~ /: ZipCode Street Locati~ Ty~ ~esidence ~ngle Family :' Multiple Family No. of Bedrooms~~ ~ Other Water Supply ~ividual ATTACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well depth (attach log if available), ~ Public Utility Sewer Disposal ~dlvidual Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING ~N BE INITIATED. Inspector Inspector Inspector Inspector Field Notes: ~ .~,? .: ~"~,-~_~ '~? 0' ~, - JUL 1 81983 "~:~unic~p~l!tg of (~) APPROVED B~DROOMS ~ *CO.9~T~ONS OF A.PROV*L ( ) O~SAPmOVED ( ) CONDITIONAL AP~ROVAL~ ~ Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received ~ ~ g Well to Tank Septic T~k Size 72-023 (3182)