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Home My WebLink AboutROOS LT 20-~ 0oo MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES /~ C~Y..,I'4¢,~ ~i~Pc~ FROM-~ SEPTIC ABSORPTION WELL Address ZO"/~ fi, ~/~~ ~O~ TANK FIELD Phone(s)~ ~/~0 Permit~?No.~? ~ No of Bed~oms~ WELL I LEGAL DE, CRiPTiON LOT LINE J Subdiwsion Lot ~ ~'°ck ~ ~ U ~. FOUNDATION I Township. Range. Section ~ ~ AS-~UJLTDJAGRAM(Showlocat,onofweJl. septic system, p,opertyhnes.'oundat,on. ' . driveway, water bodies, etc.) TANKS i ~ SEPTIC ~ HOLDING I TYPE OF SYSTEM ~TRENCH ~ BED ~ w. DRAIN ~ OTHER Depth to p~pe bottom from Tota~ depth from original grade J °nginal gr~ , ~ FT ~ FT - Fill added above original grade Gravel depth beneath pipe Graveilength~ I ET 3ravel width~ ET ~:~, ~. Total absorption area ~ j Distance between lines ~ k ~ ~ I Number ol hnes Sod rmmg ~ hpe mmerim ~ Installer ~ ~--O~ --~ Date ~ WELLS ~PRIVATE ~ OTHER (Identify) Classnicatlon (A,B,C) 7oral Depth Cased to ~J ~J REMARKS: I Municipal ~nd Slate guidelines in ellecl on this dale: ~ t ~ j / ~ ~ ~ Mealth Bepa~em Approval: Date: GRE,.,ER ANCHORAGE AREA BOk..dGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION LEGAL DESCRIP U .... SEPTIC TANK: DISTANCE FROM WELL INSIDE LENGTH MANUFACTURER INSIDE WIDTH NUMBER OF COMPARTMENTS '~'-" LIQUID DEPTH · LIQUID CAPACITY /Z~) GALLONS. TiLE DRAIN FIELD: DISTANCE FROM WELL F. OUNDATION NUMBER OF LINES__ DISTANCE BETWEEN LINES ABSORPTION AREA ~/&~/"J SQ. FT. DEPTH: TOP OF TILE TO FINISN GRADE NEAREST LOT LINE TOTAL LENGTH OF LINES ~ / TRENCH WIDTH__ IN. LENGTH OF E~,CH LINE DEPTH OF FILTER TOTAL EFFECTIVE MATERIAL BENEATH TILE'-~ IN. ABOVE TILE IN. WELL: TYPE BUILDING FOUNDATION __ CESSPOOL APPROVED ___ CONSTRUCTION NEAREST NEAREST LOT LINE__, SEWER LINE____ OTHER SOURCES DISAPPROVED DEPTH _ SEPTIC SEEPAGE TANK __ SYSTEM __REMARKS DISTANCE FROM: DISTANCES: INSTALLED BY: SEWER LINE DEPTH: PIPE MATERIAL' LOT SLOPE: REMARKS: DIAGRAM OF SYSTEM D A T E -~'~__Z~__~.~_ APPROVED G.A.A.B. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES D,v,s, oN OF ENV, RONMENTAL SERV,CES CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~ ~ ~-- ~)c~ '~C~ OF ON-SITE SEWER AND WATER FACILITY 264-47'44 Application Date 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 Mailing Address (c) Lending Institution Mailing Address Telephone Business (d) Real Estate Company and Agent Address ' Telephone (e) Mail the HAA to the followina address: or; Check here ,[~if hold for pick up. List contact person and day phone number below. TYPE OF RESIDENCE Single-Family.~. Number of Bedrooms WATER SUPPLY Individual Well,~ Community [] Public [] Note: If corem unity well system, must have written confirmation from the State Department of Environ mental 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. Page 1 of 2 72-025 IRev 8/861 Fronl 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 inspection. Name of Firm '~'~'~ Address -~'"//~--~ Date ?/I'L~/ DHHS APPROVAL Approved for ,.,~ Approved /~ Disapproved Conditional Terms of Conditional Approval Engineer's Seal Date CAUTION 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 certifica(e 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 trey 8/861 8ack MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4744 Legal Description: MUNICIPALITY OF ANCHORAGE ENVIRONMENTAL SERVICES DIVISION J U L 1 1988 WELL DATA Well Classification Well Log Present (Y/N) Total Depth I 8'7 Static Water Level Casing Height Above Ground /~ ~'! ' Electrical Wiring in Conduit'(Y/N) Y'~'-~ Separation Distances from Well: To Septic/Holding Tank on Lot If A, B, C, D.E.C. Approved (Y/N) Date Completed Yield Depth of Grouting "~J~ Pump Set At /.~-'" Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) J r_~l.-~ ~ ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot J O~ ~ ; On Adjoining Lots To Nearest Public Sewer Linb ~/~ To Nearest Public Sewer Cleanout/Manhole To Nearest Sewer Service Line on Water Sample Collected by ~' ~ /-'~,~-,¢,1-~.~ ; Date Water Sample Test Results ~'~,~-o/--~t ". ~,~7'Y.5~ Comments '~,/~'~.~_ /~, ~ v ~',C~'Z2 /~ ,./ ,~ B. SEPTIC/bI~EDtl~G TANK DATA Date Installed Standpipes (Y/N) Depression over Tank (Y/N) ~.~o 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 ~"~""'¢'7'/~ ~'~'~" Size /Z:>~:)~./' No. of Compartments Air-tight Caps (Y/N) ~"'~ Foundation Cleanout (Y/N) Date Last Pumped ~'.~/,/'~ ~' .... ; for Temporary Holding Tank Permit (Y/N) To Building Foundation /'~:~ / To Disposal Field /'~)" ¢,o~cc~ ~,,~-' To Stream, Pond, Lake, or Major Drainage Page 1 of 2 72 026 (Rev 8/86~ Front ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed "4-/~./77 Width of Field ,-~'" Type of System Design Length of Field Depth of Field ~" Gravel Bed Thickness O,~ Standpipes Present (Y/N) Date of Last Adequacy Test To Property Line ~//--4"" ' To Existing or Abandoned System on ; On Adjoining Lots /,,2'"42 To Cutbank (if present) Square Feet of Absorption Area Depression over Field (Y/N) Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well f~ To Building Foundation Lot /¢~u'~ /CA..' To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ..,,~,~,~..~/ ~"~/.~,,~"~/,~ ~'~'~.C- LIFT STATION Date Installed ~/_/'///~ Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA ** Check Permitted Bedroom Rating Against HAA Request ** certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed Date Company MOA No. ReceiptNo. ~-- ~/ 7 Date of Payment Amount: $ Page 2 of 2 72 026 fRev 8/861 Back D. R. DAYTON, P.E., R.L.S. HC 78 Box 1026 Chugiak, Alaska 99567 (907) 688-2417 July 12 1988 ADEQUQCY TEST Legal Description: Lot 2, Roos Subdivision, NW-~, Sec. 8, T15N, R1W Date Performed: June 10, 1988 House Size: 3 Bedroom Septic Tank Sise: 1000 gallon, 2 compartment, steel tank.(MOA records) Absorption System: 5'x81', Shallow trench, 405 sq, ft. Soils Rating: 85 sq, ft. per bedroom Daily sewage flow: 3 BR x 150 gal. per BR = 450 gal. per day Average Flow: 450 Gal./1440 min = 0.313 gal per min Peak Flow: 0.313 x 1.5 =0.469 gal per min Test: Water was introduced into the system at a rate of 5 gal per min for 1 hour. ( 5 gal/hour is approximately 10 times the peak flow.) Results: The system accepted 5 gal/hour for 1 hour with no evidence of backup into the septic tank. Conclusion: Septic ayatem is currently functioning adequately. NI. uNIC1PALiTY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL pROTECTiON D. R. DAYTON, P.E., R.L.S. HC 78 Box 1026 Chugiak, Alaska 99567 July 12, 1988 WELL FLOW TEST Legal Description: Lot 2, Roos Subd. NW ~, Sec 8, T15N, R1W Date performed: June 10, 1988 Well Size: 6" Well Depth: 187' Casing Depth: 187' Pump Setting: 152' Driller: Unknown Date Drilled: About 1977 (907) 688-2417 Test: As the well is a low producing well, the test was conducted by manipulating the flow to the point where the flow equalled the recovery. At this equqlized flow, the well was pumped for a 4 hour period° Results: The well produced a sustained flow of 0.75 gallons per minute. CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. ~,~ L^BO,^,OR,~S '~ FEDERAL TAX ID # 92-0040440 ANALYSIS tEi'O~T BY SA~I,Z for Work Order $ 7!59 Date Report Printed: JUN 15 ~$ ~ 11:18 Client Samp].s ID:ROOS S/D, L2 PWSID :UA Collectsd JUN 8 $8 ~ 06:65 hrs. lecelwd 3UN 9 88 ~ 10:55 P~:e~ervsd with :NONE Client Name DAYTON, Client Acer DAYTDC Req ~ Ordered By Analysis Comp].ated :~UN 10 88 Send Repo~t~ to: Laboratory Sups~isqr :$TgPHEN C. ~DE i)DAYTON, D.R. ! Special In~gruct: Chemlab Ref $: 1343 Lab S~pl ID: I ~at~J.x: Allowable Pazamet e~ Tsst~d Result/Units Method Li~D.t.~ NiI'RATE-N I~D(O.IU) mg/i EPA 353.2 Sample Remarks Tests Pezfom~ed Ssa Special Instzuctlon~ Above UA~Unavailab].~ Nons Detected '~ Se~ Sample Remarks Above N~t Analyzed I,T~I, ess Th~n, GT~Gzea.er Than CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.: TELEPHONE (907) 562-2343 5633 B Street I Anchorage, Alaska 99518 Drinking water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I.D.# /~PRIVATE WATER SYSTEM Name ¢o. 60 . ¢7 Z4G' Mailing Address City State Mo. Day Year Phone No. Zip Code Z- SAMPLE TYPE: ~/~Routine Check Sample (for routine sample with lab ref. no. [] Special Purpose SAMPLE NO. LOCATION [] Treated Water J~Jntreated Water Time Collected Collected By TO BE COMPLETED BY LABORATORY SatiS shows this Water SAMPLE to be: isfactory [] 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 ~- ?-oC~ Time Received Analytical Method: Membrane Filter * No. of colonies/100 mi. Lab Ref. No. Analyst Result* READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter: Direct Count Verification: LTB. iFinal Membrane.~-I~sults~ RepOrted B~-~~~ ,z~--- TNTC = Too Numberous To·Count OB -- Other Bacteria BACTERIOLOGICAL WATER ANALYSIS RECORD BGB Coilformll00ml · ~ Coilformll00ml Anchorage Municipal Code Section 15.65.050 requires that "a septic tank must be pumped and cleaned at least or, ce every two years by a perxon homing a permit to perform that work... "This provision was enacted by 'the Municipal Assembly, and became effective, on May 20, 2P3,5. Municipal records indicate that you rrm. y have an on.-sim sc~Lic system. The