The URL can be used to link to this page

Home My WebLink AboutKWIK LOG BLK 3 LT 5 PAGE 1 OF 1 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW930371 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:BRADLEY GREGG OWNER ADDRESS:738 E 72ND AVE ANCHORAGE, ALASKA 99518 DATE ISSUED: 9/16/93 EXPIRATION DATE: 9/16/94 PARCEL ID:01304346 LEGAL DESCRIPTION: KWIK LOG BLK 3 LT 5 LOT SIZE: 11135 (SQ. FT.) NUMBER OF BEDROOMS: 3 THIS PERMIT: 3 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: REGULATIONS (18AAC72) AND DRINK~I, NG NATER REGULATIONS THE ~/~GINEE~/MUST ~DTIFY DHH~ A~ LEAST ~/HOURS / PRI~R TO E/~CH INSPECTION. /PROVIDE NOTiFICATION/BY C~LING ~43-4744/ OR 343-~4681 AFTER ~USINESS /HOURS /~ROM OCTOBER 15/TO APRIL/15 A SUBSURFACE SOI~/ ~ ABSOR~P~ION SYSTEM UNDER/CONSTRUCTION DURING/FREEZING WEA~4ER MUST/BE EITHER~'~ ~' A./OPENED ~ND CLOSED QN THE SAME ~Ay / B. COVERE.~, SEALED A~D HEATED TO/PREVENT/FREEZING 5. THE FOLLOWING SPEC~/AL PROVISIONS. ~ THE ATTACHED APPROVED DESIGN. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL (18AACS0). RECEIVED BY: / ~ '~' ~ DATE: ISSUED BY: ~_~_~ e.~_~t~-~ DATE: ILO/ i%.0~. 0 MUNICIPALITY OF ANCHORAGE ~ DEPARTMENT OF HEALT~I & 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 1. GENERAL INFORMATION Complete legal description Location (site address or directions) Property owner Mailing address Day phone. Day phone Lending agency Mailing address_/'" Agent ~P~/vlPc¢' Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: ~'~ ~' TYPE OF WATER SUPPLY: Individual well ~ ~' Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng 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. 1191) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal affixed hereto and as of the validation date shown below, I ver.ify that my investigation of this Health Authority Approval application shows that the on-site water supply and/orwastewaterdisposalsystem is safe, functional and adequate for the number of bedrooms and type of structure indicated herein, lfurtherverifythat 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 Phone Address Engineer's signature Date Alaska Water & Wa~t~yater 6. D~ SIGNATURE / Approved for ~ ~ bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments 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 (Rs,'. 1/91) ~3ck MOA i¢21 KELI'IVEU Municipality of Anchorage I~4AY 0 3 3998 DEPARTMENT OF HEALTH & HUMAN SERV~I~p^u~y OF ^NCHO~AG~ Environmental Services Division ENVIEONMENrALSI3~VICES 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checklist Legal Description: J,.~-r ~'~, ~31.~ %.~, ~..k)~, L.¢6 ~/¢ Parcel I.D.: A. WELL DATA Well type Log present ~,N) Total depth Sanitary seal (~N) Date of test Static water level ~)~'{ IV,N'I'E- If A, B, or C, attach ADEC letter. ADEC water system number k/ES, Date completed ~O '- ~ -~'-& I I I j G Cased to t ~ ~ Casing height (above ground) Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION iq ~ Well production /~) g,p.m. ~, j g.p.m. WATER SAMPLE RESULTS: Coliform j2~' /'] J'.~ Nitrate Date of sample: £i/4~'/'¢l;~' B. SEPTIC/HOLDING TANK DATA Collected by: C. ABSORPTION FIELD DATA Date installed Foundation cleanout (Y/N) _ .-,-~~Tssiem(.YJ.N~ High water alarm (Y/N) Dat~ff'P"~ pi n g Pumper Soil rating (g.p.d,/fF or ft2/bdrm) System type Length-~'"'"~.. Width Gravel thickness below pipe Total depth_ Effective absorption area ~~ng Tube present (Y/N) Depres¢i5n over field (Y/N) Date of adequacy test ____ Resu~E-aiJ).~ ....... For __ __ :bedrooms Fluid depth in absorption field before ~.¢st.-(iri;)'i ...... Immed~.g~water added (in,):_ __ Fluid depth .¢¢~'(ins) Minutes later: Absorpbon rate =_ ,.Ber. o3k'T~e treatment (pest 12 months) (Y/N) If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/A~. "Pump on" I.ev.~el at* High water alarm level at* E. SEPARATION DISTANCES Size in gallons ~--~ Pump off level at SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/h01ding tank on lot ~//N. Absorption field on lot ~//N On adjacent lots On adjacent lots Public sewer main Sewer/septic service line Public sewer manhole/cleanout IOo I,¢. Lift station ~//~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: ~d¢~ci ~- ~¢~4., Foundatfen,, -P-r. eper~yJjg.~ ~~~_ti_o~.field~__ : Wa.~ter~r.~m.~i~/.ser~icetitl~' Surface water/drainage Wells on~J'ace~tq~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: PrOperty4 ne~ ~,_, Surface water ENGINEER'S CERTIFICATION////~ I certify that/h.,¢~ do~'~i~e¢~tru fi¥/d inspections and review of Municipa/recorg's'th~'the,abb' Signature ~ lillY, Engineer's Name Date ¢) (~ ': ': ~Bui~lding foundation Water main/_,S.e~JceqiRe Wells on adjacent lots are NAA Fee $ Date of Payment Receipt Number 5///¢2 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number ALASKA WATER & WASTEWATER NUMBER OF BEDROOMS j-~------J F.H.A.- FOUR ~O(~FLOW TEST: YES WELL DEPTH (PER WELl- LOG): I CASING DEPTH (PER WELL LOG): CASING HEIGHT (ABOVE GROUND): -- DEPRESSION AROUND WELL: (~)/ NO --- .~-~HT O~-~'P,~-'-~si,A SAN~T^RY SEAL= C9~/ NO WIRES IN CONDUIT: ~/ NO ~ L~o'T~'~,~ Z~' WATER SAMPLES TAKEN:~Y~E-~/ NO IF YES, DATE: FLOWRATE WATER LEVEL TIME METER READING (G.P.M.) (BELOW TOP OF CASING) j~lo j~5'5~ ¢ B.q STATIC = WELL PRODUCTION MEASURED ~ ~'J - /~/;W~ CT&E Environmental Services Inc. ChemLab Ref. #: Client Name: Project Name: Client Sample ID: Matrix: Ordered By: PWSID 98.1908 Alaska Water & Wastewater Svc. L5 B3 Kwik Log s/d L5 B3 Kwik t_og s/d Drinking Water JM n/a Sample Remarks: Client PO#: Printed Date/Time: Collected Date/Time: Received Date/Time: Technical Director: n/a 4/30/98 09:00 4/28/98 13:00 4/28/98 13:45 Stephen Ede Released Parameter Results PQL Units Allowable Prep Analysis Method Limits Date Date Init Total Coliform (MF) Nitrate 0 col/100 mi 0.1U 0.1 mg/L SM9222B 4/28/98 TMW EPA 300 10.0 4/28/98 RMV