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Home My WebLink AboutROSEWOOD PARK ESTATES BLK 2 LT 9 Municipality of Anchorage Community Development Department Can -Site Water & Wastewater Program 4700 Elmore St. a P.O. Box 196650 a Anchorage, AK 99507-6650 a www.muni_or onsite ■ (907) 343-7904 Well Decommissioning Log Legal Address: Z 3 40�r�ac�- Subdivision J_- ��s iay v � xcs Block Lot T R ______ Section Lot On-site Water & Wastewater Program certified contractor performing the well decommissioning: Name: �� cu~.�,�.i Signature Company:�'� Arc %,A <� Well decommissioning date: Method of decommissioning:AMC 15:55.0601-1 �° a. ❑ b. ❑ c. Location: Use the space below to provide a drawing of the property showing the following items; • North Arrow • Decommissioned well, • Other water wells on the property, • Two separate swing -tie distances for each well shown in the drawing, Note: The swing -tie distances shall be measured from either permanent structures of property corners, G~-~'ATER ANCHORAGE AREA BORC"~H u// GAAB-HD. J ~EPARTMENT OF ENVIRONMENTAL QUALIFY 3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM ~ TANK: DISTANCE FROM WELL LIQUID CAPACITY ~OC> GALLONS. MAILING 7'~30 ~_~ ~1."; L¥ L ADDRESS . LEGAL DESCRIPTION_g MATERIAL .~' ~ '~,~':' INSIDE LENGTH NUMBER OF COMPARTMENTS LIQUID INSIDE WIDTH DEPTH SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS LINING MA!/ NEAREST LOT LINE O~METER OR WIDTH ~-~ WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) , LENGTH ~ /, DEPTH SQ. FT. TILE DRAIN FIELD: DISTANCE FROM WELL. NUMBER OF LINES ~ ABSORPTION AR~A __ DEPTH: TOP OF TILE TO FINISH GRADE TOTAL LENGTH FOUNDATION . NEAREST LOT LINE , OF LINE~.~ DI~ LINES TRENCH WIDTH /IN. TOTAL EFFECTIVE DEPTH OF FILTER MATERIAL BENEATH TILE IN, ABOVE TILE__ WELL: F~ ,~, r,. TYPE ~-~L~,' I ~ G M , DEPTH LOT LINE , SEWER LINE. (~ ,~ DISTANCE FROM ,BUILDING FOUNDATION,_ SAMPLE J/k.~C'V~'~" , NEAREST SEPTIC ~ ~ SEEPAGE __ OTHER ., TANK , SYSTEM '~ , CESSPOOL. , SOURCES DISTANCES: DIAGRAM OF SYSTEM GREATE~'' ANCHORAGE AREA~OROUGH HEALTH DEPARTMENT 327 Eagle St. Anchorage, A~ 99501 279-2511 Case N o. -- SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT NAME OF APPLICANT/'/~ ~ia ~' RESIDENCE ADDRESS LEGAL DESCRIPTION APPLICATION TO INSTALL: SEPTIC TANK ~-e'~--'~ , SEEPAGE PlT~ - ~,-_~ . _ ~ TO SERVE THE FOLLOWING FACILITY ~ FINANCED THROUGH PERCOLATION TEST RESULTS MAILING ADDRESS~/~ PHONE NO. LOCATION OF INSTALLATION L~t-q , DRAIN FIELD , OTHER. TO BE INSTALLED BY. ANTICIPATED DATE OF COMPLETION BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT THIS IS TO SERVE AS ~/~ J~/ c/~'Z'"~t~-~- , PERMIT TO INSTALL A ~ '~--~'~-- AS DESCRIBED BELOW. SIZE~ ~0 BE SERVED SEPTIC TANK SIZE '~-"'~¢9 TYPE /,.e~ . SEEPAGE AREA '~-~ TYPE DISTANCES: ,, ,, I certify that I am familiar with the requirements of Greater Anchorage Area Boroug. h Ordinance No. 28-68 and that the above described system is in accordance with said code. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Gox 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Lending age~y Mailing addre?~ Agent N. ~. ( ~ ~ ~) Day phone Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~ TYPE OF WATER SUPPLY: Individual well Community weJl Public water NOTE: 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. Name of Firm )='(ct ~-/o? 7'~c~/~ ~'cc~f ~-~'~'c ~ Phone Address / Engineer's signature DHHS SIGNATURE Disapproved. Conditional approval for Date 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-o25(Rev. 1/91) Back MOAt421 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: J.-o{'~ ~//c~ f~oJe~c,¢.,¢.~' P/~'. Parcel I.D. O(z'['- /?3~Z- A, Well Data Well type Log present (Y/N) Total depth Sanitary seal (Y/N) N Y FROM WELL LOG If A, B, or O, attach ADEC letter. ADEC water system number Date completed 1~2 '7/ Driller Cased to ~'~' Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main~ Sewer service line g.p.m. N,A. (~C~,~.~ £~-'~-~} ;Onadjacentlots N,//-. ~ S'~' Public sewer manhole/cleanout~ ~> ,5-0 ' ~. ~-5-' Petroleum tank WATER SAMPLE RESULTS: Nitrate I0/~ /~J Collected by: Tank size Foundation cleanout (Y/N) Compartments Depression (Y/N) Alarm tested (Y/N) Pumper Coliform 0 Date of sample: to~lb-/~-~ B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot To property line Surface wateddrainage On adjacent lots Absorption field Foundation Water main/service line CONTINUED ON BACK PAGE 72-026 (3/93)* Front C. LIFT STATION N, ~. Date installed Size in gallons Vent (Y/N) High water alarm level Meets MOA electrical codes (Y/N) "Pump on" level at SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot D. ABSORPTION FIELD DATA Width Date installed Length Total absorption area Date of adequacy test Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested On adjacent lots Soil rating (GPD/FF) Gravel thickness Cleanout present (Y/N) Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot To building foundation On adjacent lots Surface water System type Total depth .Depression over field (Y/N) for After test If yes, give date On adjacent lots Property line To existing or abandoned system on lot Cutbank Water main/service line Bedrooms Surface water Curtain drain E, ENGINEER'S CERTIFICATION Driveway, parking/vehicle storage area I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect Signature %~ ~ ~ ¢ ¢¢,"d,.',, CE- 3589 HAA Fee $ ~_~> Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number COMMERCIAL TESTING & ENGINEERING CO. AK DIV CHEMICAL & GEOLOGICAL LABORATORY TELEPHONE (907) 562-2343 5633 B Street Anchorage, Alaska 99518. Drinking Water Analysis Report for Total Coliform Bacteda TO BE COMPLETED BY WATER SUPPLIER PRIVATE WATER SYSTEM F:/~c-/~,. 79ch,~ Name Mailing Addr~s SAMPLE DATE: ~-~ ~ Mo. Day SAMPLE TYPE: ~] Routine [] Check Sample (for routine sample with lab ref. no. [] Special Purpose Phone No, State Year Z~p Code ) [] Treated Water [~ Untreated Water SAMPLE No. LOCATION I Time Collected Collected By TO BE COMPLETED BY LABORATORY 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 T,me Uece,ved Analytical Method: Membrane Filter * No. of colonies/100 mi. Result* 310098 ' ~ I A~t READ INSTRUCTIONS BACTERIOLOGICAL WATER ANALYSIS RECORD Membrane Filter: Direct Count (~ Coliform/100 mi BEFORE COLLECTING SAMPLE TNTC = Too Numerous To Count OB = Other Bacteria Verification: LSB BGB Fecal Coliform Confirmation Final Membrane Filter,~esul? } Reported By /."~ Coliform/100 mi Time: /'"~0-~ a.m. Member of the SGS Group (SociSt~ G~n~rale de Surveillance) OMMERCIAL TESTING & ENGINEERING CO. $,NCE,.O~ RE-ORA of ANALYSIS chemlab Ref.~ :93.5276-.1 Cl.~ent Sample ID :L9 B2 ROSE~IOOD PK ESTATES 7~40 BASEL ~,~at r ix ~ WATER 5633 B STREET ANCHORAGE. AK 99518 TEL: (907) 562-2343 FAX: (907) 561-5301 Client Name :F£.ATTOP TECHNICAL SRV Ordered By :T.F~ MOORE Project Name Project% PWSID Sample Remarks: ROUTINE ,c. AMPLE COLLECTED BY: ToP. MOORE, WORK Order' : 71783 Report Completed : ~ 0/08/93 Collected :10/05/93 @ 12:30 his. Received :10/05/93 @ 14:00 hrs. Technical Director: STf,PHL;',N Qc Allowable E×t, Anal Parameter Results Qua J, Uni'ts Method Limits }Date Date Init Nitra/e-~N 0,].0 U mg/L EPA 353,2/300,0 I0 10/06 LLH See Special Instructions Above UA = unavailable See Sample Remarks Above NA ~ Not An~:d.~zed Undetected, Reported vaiue is 'the practica], quantification limit. LT =: Less Tha~"~ Secondary di].u't~ion, (~T =: Greate'~:' Th;:m ~SGS Member of the SGS Group (Soci~t~ G6n6rale de Surveillance) ............................................ ~,~ ~,,,a ll^n~/i ^kin t~l~C,T %11D~'~--I1%11~% klEt~I IEI:3Q~V 9rlllT$4 f":ARt~H