HomeMy WebLinkAboutROCKHILL BLK 3 LT 3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONIVIEN'rAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
PHONI
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
Absorption area Dwelling
Ma
Inside length Width
Well
DISTANCE TO: I /~-)~ r
Manufacturer ~...
ILiq. caBacity ngallons IF HOMEMADE
DISTANCE TO: We I
Dwelling
Manufacturer
DISTANCE TO: Well l/~.~O I
/ Length of eac~li.~e
Top of tile to finish grade 7~'
Length Width
Type of crib ;rib diameter
DISTANCE TO:
Yell
DISTANCE TO:
Depth
Building foundation
Foundation
Total length of lines
~/-~
Material beneath tile
Depth
Crib depth
Building foundation
Driller
Sewer line
Material
~ Nearest lot line
Trench w~t~___~, inches
NO. OF BEDROOMS
~ERMIT NO. '~-I0
Liquid depth
PERMIT NO.
Liquid capacity in gallons
PERMIT NO,¢~./~.~ .~ ~__ ,
Distance bet wee,~/~//~
Total effective,.~so~)on area
PERMIT NO.
ITotal effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
APPROVED DATE LEGAL
'~'
PERMIT NO.
PIF F L I _.HNT
LOCRT I ON
R-
LE.~HL
L. HELE_,uN L.i:JN.-,TF..UL.T 101',I
MRIN TREE DRI',,,'E
L.~, TM B -~ RUCKHILL ~..,,."D
[:,EPRRTMENT O, HERLTH FiND ENVIRONMENTRL P~,{TECTION
9'25 'l_" .STREET, RNCHORRGE., RK. '9~"='0:t ~.~_~'~./~" 'fS~
264-4728 '
PO mFI .... ' " ~ ~95&~ ~ ' ~"' '"
LOT =,IZE ~c,o~= SQURRE FEEl'
TYPE OF SOIL RBSORF'TION =,'r_-,TEM IS: TRENCH
:,OIL. RRTING ("',Iq FT/BR)=
MR::..',IMLIM NUMBER OF BEDROOMS = 4
_,I~E OF THE SOIL RBqORPTION =~r_TEM :
'THE RE".;!UIRED c ~ _.. ~ ,c, IS
[:,EF'TH= '---~- [_ EI%~,STH = 4-----=: ,3 R R'-.-' E L [)EF'TH=
THE LENGTH DIMENSION IS THE LENG'rH (IN FEET) OF THE TRENCH OR DRRINFIEL[:,.--
THE DEPTH OF R TREN_,H OR PIT IS THE DISTRNCE E:ETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE EXCRVRTION (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF GRR',,,'EL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE E>(CRVRTION (IN FEET).
F:E,;~L~ I IqE[:. SEPT I
F'ERMIT RPPLICRNT HRS THE RESPONSIBILIT?~ TO INFORM THIS DEPRRTMENT DURING THE
INSTRLLRTION INSPECTIONS OF RN'¢ WELLS R[:,JRCENT TO THIS PROPERTY RND THE
· , ' ' '~ · I-' - '~
NUMBER. OF RE_,IDEN_.E_ THRT THE WELL WILL SERVE.
T I...~3 (=':' .') I [~SPE"]T I -
BRI_.KFILLIH~ OF RNY :~:TEH NITHOUT FINRL INSPECTION RND RF'PROVRL B'T' THIS
' '- ~ R PROSECUTION.
DEPRRTHENI' WILL BE :,UE, JE-.T TO
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SE[,.IRGE DISPOSRL :,~-,TEM
t0~ FEET F]E R PRI',,,'RTE WELL OR i50 TO 2F~F~ FEET FROM R PUBLIC NELL DEPENDING
' F:
UPON THE TN'PE OF FUBLI.. NELL.
MINIMUM DISTRNC:E FROM R PRIVRTE NELL TO R PRIVRTE SEWER LINE IS 25 FEET RN[:'
TO R COMMUNITY SENER LINE IS 75 FEET.
WELL LOrn:, 8RE REQUIRED FiND MUST BE RETURNED TO THE DEF'~RTMENT WITHIN
OF THE WELL UOMFLETIUH.
OTHER RE~UIRENENI-,": M~Y ~PPL'¢. '-:,FEC. IFIbHTIUN-,C ~ND' CONSTRUCTION DI~GRFtMS ~RE
~'¢~IL~BLE TO INSltRE FR_FER INST~LL~TION.
F'ERr'I I T E.--.P I RE--. [:,EC:F~-r-IBER ._--::L.. "-1- 3~c: :-IL
I CERTIF~¢ THRT ,- . . .,_,=. ,=.
J.: I RM FRMILIRR WITH THE REL.-~.LIIREMENTS FOR ON-SITE =,EWER=, RN[:, WELLS 8S _,ET
FORTH BY THE MUNIE:IPRLIT"r' OF RNCHORRGE.
2: I NILL INSTRLL THE --,'r_,TEfl IN RCCORDRNF-:E WITH THE CF~E:,E'-';.
2:: I UNDERSTRN[:' THRT THE ON-SITE --,EHER S"r'STEM MR"r' F.:EI,.UIF..E ENLRRGEMENT IF ]'HE
' '-- " -' I S
RE_I[.ENLE . REMODELED TO INCLUDE MORE THFtN 4 8E[:,ROOMS.
_, I _~HE[.:
RPF'L I CRNT C:RRLESON CQNSTRIJC:T I ON
I S'-]UED B'T' [ HTE
U~J~L
LOT
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
DATE PERFORM
LEGAL DESCRIPTION: ,L
1
2
4
5
7
9
SLOPE
(~SOI LS LOG
[] PERCOLATION
TEST
_AN
10
11
12
13
14
16
17
18-
19
2O
COMMENTS
NO. 1732-E
June 22, 1968
PERFORMED
WAS ~ROU"D WATER ~o ~
ENCOUNTERED? _ O
P
E
iF YES, AT WHAT
DEPTH?
Gross Net , , Depth to Net
Reading Date Time Time Water O Opr ,
PERCOLATION RATE minutes/inch)
TEST RUN BETWEEN , FT AND , FT
Z' u c
. Well Log
For ................ :. .................... ~ ....... . .,-'.'. ;., ..........................................................................
L o cation ..... ~ ~.~ ..... ~.~ ....... (~ ~. .... ~;~ ......... ~75::~ ~ ....... (fL(.:~..-. ..... ~ ~. ~. ?.. :'. .....................
Date completed.
......................................... : ............................ '~u~o~u~"~'~'o~ ·
Depth of well ................ : ..........................................................................................
.
Size of casing ...........................................................................................................
Distance to water.. .~u & ............. : ..........................
Dist~ce to water while pumping ........................................................ at rate
of ................ '.~ ............................. gallons per hour.
Formation
from to
'-~ / '7¥.'
Driller
DELTA DRILLING COMPANY
SRA BOX 394 B
ANCHOraGE. ALASKA 99507
Parcel I.D. #
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
~) \ Z'~ I~ ~ ,'~-(~\ HAA #
GENERAL INFORMATION
Complete legal description
Rockhill Lot 3,' Block 3
Location (site address or directions) 9600 Hain Tree Drive. Anchoraqe
Property owner
Mailing address
Lending agency
Mailing address
Wayne & Betty Brown
9600 Hai~
N/~
Anchorage: AK
Day phone 346-2746
Day phone
Agent Bonnie Maynor/Jack White
Address 3201 c K~r~, An~h~raq~, AK 99503
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 4 "4
TYPE OF WATER SUPPLY:
NOTE:
Day phone 762-3110
ndividual well x
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site x
Holding tank
Community on-site
Public sewer
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
s),uewwoo leUO!~!PPV
:suo!jelnd!ls §U!MOIIOJ eql ql!M 'SUUOOJpeq
JoJ leAoJdde leUO!lipuoo
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=IEIrI.L~fN~IS SHHO
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· uol3oedsu! slq3 jo e~ep eq~ uo 3oejje u! suo!~elnOe~ pue 'seoueu!pJo
'sepoo e~e~S pue led!olunlAI lie q~!t~ eoue!ldLUoo u! s! LUe3S~S lesOdS!p je~eMels~ Jo/pue/qddns
~ele~ e3!s-uo eq~, 'uol~oedsu! pue uo!~e§!~se^u! ~LU LUO~J pue sel!J e§e~oqouv jo ,~!led!oiunlAI eq~
LUO~J peu!m, qo UOI3eLUJOJU! eq~ uo peseq ~eq~ ~Jpe^ Jeqpnj I 'u!e~eq pe~eo!pu! e~n~on~s jo ed~ pue
SLUOO~peq ,tO jequJnu eq3 ~o~ e~enbepe pue leUO!~ounj 'e~es s! LUe~S~S leSOdS!p ~e~e~e~s~ Jo/pue
~lddns ~e3e~ ei!s-uo eq~ 3eq3 s~oqs uop, eo!ldde le^o~ddv ~poq3nv q~leeH s!q~ ~o
~LU ~,el.J:~/~JlJeA I 'MOleq UMOqS elep UOp, ep!leA eq~, ,to se pue o:~eJeq pex!jJe leas/~uJ Xq pe!J!lJeo s¥
'9
I:I=I=INION=1 Ag NOI.LO=IdSNI 40 .I.N=IIN=I.LVJ.S 'S
Legal Description:
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Parcel I.D.
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
,/'~-'-'/*',~'/-c If A, B, or C, attach ADEC letter.
21/ Date completed
ADEC water system number
Driller
Cased to ~d' /
Casing height
Wires properly protected (Y/N) ///
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG AT INSPECTION
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main ~'/.~
P~bl~c sewer service line
g.p.m.
; On adjacent lots //~° '
; On adjacent lots ~'/,~
Public sewer manhole/cleanout
Petroleum tank '"~'"~
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Collected by:
Other bacteria
B, SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts (Y/N)
water alarm (~..
High
Date of pumping
Tank size /,o~.-~ Compartments ~
Foundation cleanout (Y/N) .// Depression (Y/N)
Alarm tested ('(~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /'~' 5'/
To property line ~"~
Surface water/drainage
On adjacent lots 2'~/'~ / Foundation -'~' /
Absorption field /e-' Water main/service line ~-/o
72-026 (Rev. 3/91 Front MOA21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N)
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length .~ /
Total absorption area
Width
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months)
Soil rating ,=~5- System type
Gravelthickness_ z~,' _Total depth ~"
Cleanouts present (Y/N)
Date of adequacy test ~/"~.,/~
for
'""',/,,¢- If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
Onadjacentlots ~'~ /
Surface water
Curtain drain
On adjacent lots ?'"~'~ ' Property line ?/
5-~" To existing or abandoned system on lot
Cutbank -"//~ Water main/service line
Driveway, parking/vehicle storage area
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.
Signature
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
A
Eagle River Engineering Services
11940 Business Blvd. Suite #205
P.O. Box 775294
Eagle River, Ak. 99577
694-5195
Fax 694-5297
J Legah /ff,~o/~/n~t, LOT' TS., ~ae~ $
Owner: k,',4/,~ ~' 8'~:~'~'~' -7~ ~-,,~./ Date:
JType of test:
/l~Well Flow Test [] Septic Test Only [] Well & Septic Test [] Other:
Meter Monitor Well Tank GPM PSI Remarks
Time Reading Level Level Level
/,y ; 2zt In, 5 ~2, '2 /" 55
CHEMICAL & GEOLOGICAL LABORATORY
Cllont
Client
bm !
Oral.od
~0 ! NOJi {ICIIVSD
2)
Allowable
....... ~ ..................................... 2.4 WI I~l 3S3.Z lO
Ml~Tl-N
Above UA.~rdveihble
APPLI ' '\NT FILLS OUT UPPER HA ONLY
P~gP~grtyC~vner .~'~>L4- C'~. 7'
Phone
~-' ~ ~ ~ Zip Code
Buyer /..~ /~}',/~-i ,~., Z,p._20 64,3 H
/~ ,~/~- ~/lrt ~- Zip Code .
Lendinglnstitution /~'r/~:~7~ ~/~'t~2. ~r'~ /'?f'~'b''4-~l~ ,none
Address /L. '7///~ ~..i~ //~/~/'Tb
Street Location O0 +~1~ I ~'-
Type of Residence
Single Family
Multiple Family No. of Bedrooms
[] Other
Water Supply
,~ Individual ATTACH WELL LOG. A well 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
~ Indi¥idual Year IndMdual Installed: f / -'" !
[] PuBlic Utility When Connected to Public Utility:
[] Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
JV1 JNICIPALITY OF ANCHORAGE
Field Notes: DF~T C
ENVIR D; ~;, :r,:,'~ ..... O, ~-'.~[ION
RECEIVED
{ ) DmAPPROVED
( ) CONDITIONAL APPROVAL*
Soils Rating Date Sewer installed Well To Absorption Area Well Log Received
Well to Tank Septic Tank Size
ALASKA " ,IUIROFIIlleFITAL COFITROL SE!I dlC S, IF1C.
~nqineeHn§ $ I~nuironmentul Studies
February 10, 1983
Municipality of Anchorage
Department of Health & Environmental Protection
825 L. Street
Anchorage, Ak. 99501
Re: Health Authority
On February 9, 1983 our company collected a water sample from the house
located on Lot 3 Block 3 Rock Hill Subdivision. The property owner is
Bowman. The water analysis was satisfactory.
The well has a seal and the casing stands approximately 1 feet above the
ground. The electrial wires are completely enclosed in conduit. Ail
standpipes are capped.
A copy of the report is attached.
Sincerely,
1200 LUest 33rcJ Auenu¢, Suite J~ · Anchoreq¢, Alaska 99503 · [907) 276-1361
,,, DATE RECEIVED
" INSPECTION APPOINTMENTS
'rIME TIME __ A~-~ TIME
DATE DATE DATE (~ --
INSPECTOR
INSPECTOR
INSPECTO .~
R~
MUNICIPALITY OF ANCHORAGU
MUNICIPALITY OF ANCHORAGE DEPT. OF 1ff2/,.LTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAL PRO~ENTAL [:,[~OTECTION
825 L Street - Anchorage, Alaska 99501
ENVIRONMENTAL SANITATION DIVISION O:P~
Telephone 264-4720 R E C E I V E D
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
)IRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
PHONE
MAILING ADDRESS
PROPERTY RESIDENT {If different from above)- PHONE
MAILiN~ADDRESS
4. REALTOR/AGENT ] PHONE
MAILING ADDRESS
5. LEGAL DESCRIPTION
6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS~=
~ One ~ Four
~ SINGLE ~ Two ~ Five
FAMILY
~ MULTIPLE FAMILY ~ Three ~ Six
[] Other
7. WATER SUPPLY
~.~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
* 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.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE** /¢5/
[~] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79} )~,/ ]
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
I'~ ONE [] THREE [] FIVE [] OTHER
SINGLE
FAMILY
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2, WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIViDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or []Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES Sept[c/Holding Tank Absorption Area Sewer Line I Nearest Lot Line
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
[~'~'APPROV ED FOR z~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY