HomeMy WebLinkAboutPETERS CREEK BLK 4 LT 1
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
Manufacturer
Li~~llons ~ IF HOMEMADE: Inside length Width Liquid depth
~v~
DiSTANCE TO: Well ~ l r~Dwelling 'PERMITNO.
Manufacturer Material Liquid capacity in gallons
DISTANCE TO: ~el~/~ / ~ F ou~ ~ ~ ~earest~ne ~
No. of lines / Length~ch li~¢ Total ~ of "X~ Trench~tb '¢ Distance
I
~ r inches
To~ o, ~i~,~s~de ~"~ ~ ~ / ~ inches
M eri ben h 'le / I Total effective 6bsorption area
Depth
/ /
Type of crib Crib d~t7 A Crib depth Total effect,ye a,sorption' erea
Well ~ Building foundation Nearest lot line
DISTANCE TO:
Class ~/~ ~~ ~ Driller Distance to lot line PERMITNO.
DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
KS
DATE LEGAL
Permit ~
Applicant
Location:
Legal Description: Z~3~ / ~/~
TYpe of Soil Absorption System Is:
Trench: Drainfield: ~
Maximum Number of Bedrooms: ~-
MUNICIPALITY OF ANCHORAGE
Department ,f Health and Environment~' Protection
825~ ~ Street, Anchorage, AK. ~.,9501
264-4720
* * * HANDWRITTEN PERMIT * * *
WELL AND/~, ON-SITE SEWER PERMIT
C~ ~, Mailing Address:
Phone Number: 3 37 ~3~
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br) ~
The Required Size of the Soil Absorption System Is:
DEPTH ~J
GRAVEL DEPTH 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(MOt-~) 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
ofl 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 8 3 * * *
I certify that:
(1) I am familiar 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
Signe~:
~'~'/~r4,~-~~-the .~esidence is remc~eled
~pPiican-~U~- - ~..,
tO include mo re th~ ~bed~oo~s~
Issued by:
Date: ~- ~ - ~] ~
SWP/024 (1/81)
//~ SOl LS LOG
PER~ORME,:, FOR:
· EGAL ~SCR,PT,Or,,:
MUNICIPALITY OF ANCHORAGE
[] PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
-
DATE PERFORMED: H It~/ ~5
SLOPE SITE~ PLAN
1
2
3
4
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7
8
9
10
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13
14
15
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19
2O
COMMENTS
:',D.
PERFORMED BY:
0L
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
CERTIFIED BY:
(minutes/inch)
~ATE: ¢---/,r--cq
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysicol Surveys
i e.llBorough ~_.ubdivilion ~ Block I'~].I I/dqtrs. Section No. TownshiP N[--] Ronge E[~ Merldion
'"JIDISTANCE 'N~ DIRECTION FROM ROAD'INTER'ECTIONS 5. OWNER ~, WELL: D''
Address:
~. WELL LOG : Feet Below 4.~L DEPTH/(finol) 5. E OF COMPLETION
M oterl~l Type Top Bottom ~ ' -- --
..~ ~ p // ~ dlom. G in. to /! 7 ft. Depth Weight__lbs./ft.
9. FINISH OF WELL:
Type: Diomefer:
Slol/Mish Size: Length:
Set between ff. and ft.
~ Backfilling Gravel pock
~ Above or ~ Below Iond lurfuce Dote
II. PUMPING LEVEL below lend surfece end YIELD
:" ~ft. offer ..hrs. pumping g.p.m.
. ~ ff. offer hrs. pumping ~g'p.m.
12.GROUTING Well Grouted: ~ Yes ~ No
Length of Drop Pipe ~ft. cupocity g.p.m.
Thl~ well w~drilled under my jurisdiction and this'rePort is lrue to the bast of my knowledge and belief;
~gist~red Busine~ N~me . - Conlroct LicenSe Number '
Drilling Permit No.
LOCATION OF WELL (Pleose complete either ID, lb or lc.) A.D.L. No.
Parcel I.D
( MUNICIPALITY OF ANCRORAGE
DEPARTMENT OF HEALTH & HUMAN SERVlCES
'~ ~"~' ' DNisionof Envkonmental SerViCes
· ': ~.~ On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
- , 343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
LI~B4 Peters,,Creek
Location (site address or directions) ~ ~ 3/-¢ ,~' ~ ].~-'-,d/ ~'4;:)O ~T-
Property'owner ¢'%/~/4'4/'~'/~ "T"'~L.,/~/-~/2"[- .... ~'~'~ay phone '~ '7.~- .~/~
Mailing address
Lending agency ~'-"~l'~"f-¢/ ~"~-/~ ¢~"u'c-P'' 'Daypho~e.~'¢'/~'-("~?¢ /,'
Mailing address ////
Agent Day
Address
Un less otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: three x~
TYPE OF WATER SUPPLY:
NOTE:
TYPE OF WASTEWATERDISPOSAL:
NOTE:
Individual well
Community well
xx
Public water
If community well system, provide written confirmation from State ADEC attest.~
lng to the legality, and status of sYStem;':'"'!
Individual on-site "?,,:
Community on-site
Public sewer
If community wastewat'er syst¢~i~,'P~'8'Vlde Written confirmation from State ADEC ~ :
attesting to the legaliiy::arld st~'~d'~ ofs~/stem. ' ' '
72-025 (Rev. 1/91) Front MOA#21
STATEMENT OF INSPECTION BY ENGINEER
· "' '"' eal affixed hereto and as°~the validation date shown below, I verify that my
As certihed by my:. .S, ealtn" Aumorny-' .... ~ ~pp,uv;' ~::~l~'~[iCati'on~,~ shows that the on-site water supply
investigation of th~s H . ' ;-:~'.; '~ '_,:,_i'_, 'i..,~ o,~,,~,Uate for the number of bedrooms
and/Or wastewater disposal system.is.sate,::Tuncuuna~. ~.u~,,,.,,,~ .
and type of structure indicated herein. I fUrther.,verify that based on the information obtained from
the Municipality of Anchorage. files 'and from my. .investigati°n. .,. ~ and inspection, the on-site water
supply and/or wastewater disposal. :sYst'~m,, ,., is. in. compliance. . . with. all Municipal and State codes,
ordinances, and regulations in effect on the date' of this inspection.
376-6989
Erdman & Associates __ Phone
Name of Firm
191 g. Swanson Avei Was~lla, AK 99654
3/15/94
Date
Address
Engineer's signature
r DHHS SIGNATURE
~ bedrooms.
__~ Approved for _
__ Disapproved.
· Conditional approval for bedrooms, with the following stipulations:
Additional Comments
The Munici~3ality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval C6rtificates based only upon the representations given in paragraph 5 above by an independent
eol Alaska The DH HS does this asa courtesy to purchasers of homes
';,,~,,,-;,,innal enc~ine~er registered inthe Stat .....: ~. '. ----:---"=-,ments Employees of DHHS do not
?.'/~'~';'~,"~'[~e~(Jin~ i~Stit'utions in'o'rder to satisfy certal .n m_oe?! an .~.s~a~_.,=~unici~,alitv of Anchorage is not
: ?,,,--,,,.~-'/,- ,...--,* ,---' ~'--,~ ~'"~,',,"-' a'certificate is issueu. ~-= ,,, ~' ',
%!'?~'..'conduct 'i~s'PectiOns or ana~yzu ua,~',,~.~, .... sS~onaI ~ i.nee~s WOrk
resPOnSible for'er~orsoromissi°ns in the'profe ' ' '.gl, . , . '...'
Back MOA #21
Legal Description:
Served
A. WELL DATA
NA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
NA
Lot 1, Block 4, Peters Creek
Parcel I.D.
by Municipality of
If A, B, or C, attach ADEC letter.
Anchorage Public Water Utility
Eklutna Water Project
ADEC watersystem number
Date completed
Cased to
FROM WELL LOG
Driller
Casing height
Wires properly protected (Y/N)
g.p.m.
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANOES FROM WELL TO:
NA
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Nitrate
Date of sample:
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
10/26/83'
Date installed
YES
Cleanouts (Y/N)
1000 gal*
Tank size
Foundation cleanout (Y/N) YES
NA
two*
Compartments
Depression (Y/N) NO
NA
High water alarm (Y/N)
Date of pumping 3/4/94 ~ Pumper
*Information from MOA Files.
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot N^ .On adjacent lots
To property line 10+ Absorption field
lOOft+
Surface water/drainage
Alarm tested (Y/N)
7-It
NA
5ft*
Foundation
Water main/service line
45ft
45ft+
72-026 (Rev. 7/91) Front
CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed NA
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot NA
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
lO/26/8.3-
Date installed
Length 4Oft* Width 5ft*
Total absorption area 2.56
Depression over field (Y/N)
Results (pass/fail) PASS
NO
85
Soil rating
Gravel thickness 1.5ft*
Cleanouts present (Y/N)
Date of adequacy test
for Three
Peroxide treatment (past 12 months) (Y/N) NO
sqft/bedroosmy~tem type W~d,e Trench*
Total depth 6.5ft*
YES
3/11/94
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
NA
To building foundation
5Oft+
On adjacent lots
Surface water
Curtain drain
On adjacent lots N~i. Property line 10+
6Oft
To existing or abandoned system on lot NA
Cutbank lOOft+ 6Oft+
Water main/service line
lOOft+/'~//~' Driveway, parking/vehicle storage area 6Oft
none
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Engineer's Name I~,c_~,~_~_
Date
HAA Fee $ r-~
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA
Waiver Fee: $
Date of Payment
Receipt Number
ERDMAN & ASSOCIATES
Consulting Engineers
191 East Swanson Ave. Suite 201
~gasilla, Alaska 9Uf~4
Ph 907-3?6-6989 Il'ax 907-373-2157
SE?TlC SYSTElq ADEQUACY TEST
~umber of ~edrooms:
Septic ~ank Size: /D~ (gal.)
8oil tbsorption System: ~1~ ~~ 1'5 ~
labsorption)-
Time Vol.
(ga~.)
Change SAS Change
Tank Level SAS
(ft.) (ft.) (ft.)
Dat~
Inspector
~roJect #
~mments
RECOVERY
TEST RESIILTS
~/' Passed ~ Failed
it e viewed l~y :~'~~
~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
:[0/24/85
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Lot 1 Block 4 Peters Creek Subdivision T15N
R1W Sec. B
Location (address or directions)
North Peters Creek
(b) Applicant Name Joyce Denson Telephone:Home 688-2239 Business 688-2239
Applicant Address P.O.B. 966? Eagle River, AK 99577
(c) Applicant is (check one): ,Lending Institution []; Owner/builder ~]; Buyer []; Other [] (explain);
(d) Lending Institution
Address
N/A Telephone
(e) Real Estate Company and Agent
Address
_ N/A
Telephone
(f)
Mail the HAA to the following address:
pickup
t
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms ,~
Other
WATER SUPPLY
Individual Well [] Community [] Public []
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Ce nservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite [] Public [] Community [] Holding Tank []
Note: If community well system, must ha~e written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
72-025 (11/84)
Page 1 of 2
ENGINEERING FIRM PROVIDIN~ INSPECTIONS, TESTS, FILE SEARCH, DA..-~ 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 ail Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm EAGLE RIVER ENGINEERING SERVICES Telephone
EAGLE RIVER, AK 99577
Address P. 0.
Date / ~.//:;;:z .~-/~ 5- 694-5195
Engineer's Seal
6. DHEP APPRO~ "~"J'l'Pe'~'" '~
Approved for,.~~-bedr~.~
Approved ; ~ ,' Disapprovea'~
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: ANCHORAQ~
DEPT. OF HEALTH &
IRONMENTAL PRGTECTIOt
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) ; - r*, ~ ~J985
CHECKLIST - FEBRUARY 1984
Legal Description:
WELL DATA
Well Classification /<::;>~' I ~2~ 7- ~_~ '-~ If A. B, C. D.E.C. Approved (Y/N)
Well Log Present (Y/N) /V Date Completed /~,:f'~ ~J' / ~ ' Yield ';~"
!
Total Depth ! ~ '~ Cased to //7 / ~/4
Depth of Grouting
Static Water Level ,~5-' /'~-~/¢'~ d~ ~,:.j ~,.~ Pump Set At
Casing Height Above Ground ! ~'~- x Sanitary Seal on Casing (Y/N) ,~'
Electrical Wiring in Conduit (Y/N) ,)x Depression Around Wellhead (Y/N)
Separation Distances from Well: *. -'
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot //~ ' ' On Adjoining Lots /~, v-
To Nearest Public Sewer Line '/~g~"~ To Nearest Public Sewer
Cleanout/Manhole /z./,,.,-.~ To Nearest Sewer Service Line on Lot
· On Adjoining Lots /'~ ~-
Water Sample Collected by
Water Sample Test Results
; Date
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N)
Size
Air-tight Caps (Y/N)
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 /¢
/~,~ ¢ ~"/'""No. of Compartments "~
Foundation Cleanout (Y/N)
Date Last Pumped /"./g5
· for
Temporary Holding Tank Permit (Y/N) ~/'~
To Building Foundation ;~ s-
To Disposal Field ~ '
To Stream, Pond, Lake, or Major Drainage
Course
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed / °//'z 4//~' ~
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ?~'~
To Building Foundation ~
Lot ,,~./~r..-~
To Water Main/Service Line /~--P ''~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments '~'&"' ~' ~"'- '~ ~'~
Type of System Design
Length of Field ~'/~ /
Depth of Field
Gravel Bed Thickness /,
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Property Line /¢
To Existing or Abandoned System on
' On Adjoining Lots -~"~ ¢
To Cutbank (if present) ,--z~
LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Dimensions
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 that I have checked, verified, or conformed to ali MOA and HAA guidelines in effeCt on the date of this inspection.
Signed ~""~'~ Date
Company ,~'~'"/~ r~'J" MOA No. ._C' ~- ~ ..~"J*'-
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
December 20, 1985
Municipality of Anchorage
Anchorage, Alaska
To Whom it may concern:
This is to certify that the septics, system installed
on Lot 1, Block 4 Peters Creek Subdivision was in-
stalled prior to the building of the dwelling on that
lot. The dwelling was constructed in the winter,
sp~ng and summer of 1984. It has not been occupied
and the septic in use for more tham fourteen months.
The system was installed for a 3 bedroom house.
Denso~ & Denson Contracting
State of Alaska
Third Judicial District
This is to certify that on this 20th day of December
1985, before me, the undersigned, a Notary Public in and
for the State of Alaska, duly commissioned and sworn as
such, personally appeared ~Q~ ~. ~6~N~<P~ , President
of Denson and Denson Contr~c't ' , Inc., an Alaskan'Corporatio~
known to me and to me known to be the person authorized to
sign for the corporation and he acknowledged to me that he
executed the foregoing document and attests to same for
the intents and purposes therein contained.
WITNESS my hand and seal the day and year in this certifi-
cate first written.
NOT~Y PUBLIC in and for ALASKA
My ~ommission expires: 7-/~-f7 ,.
J"~=,J~,. 4S 472 SEND PARTS 1 AND 3 INTACT-
.................. PART 3 WILL BE RETURNED WITH REPLY. carbanlegs POLY PAK (50 SETS1 4P472
DETACH AND FILE FOR FOLLOW-UP
:,~.',.; ,~ : ,':. , .........
