HomeMy WebLinkAboutKAROLASKA TR B2
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
/PHONE
MAILING ADDRESS
UOCATIO~ NO.
DISTANCE TO: )~ t(,~'-' C~''
~ Z Manufacture~' ~ ~ ~ Mat~ri~l, . , No. of mpCrtments
Li,. caT~_~ gallons IF HOMEMADE: Inside length Liclu,~
~ Well Dwelling PERMIT NO.
DISTANCE
TO:
~ ~ ~ Manufacturer Material Liquid capacity in gallons
~ Well. . ) Found~tcn, Nearest lot line PER~T.NO.
No. of ~ine~ Length o( e~ch line Total length of lines Trench widlJ~, Distance between lines
~ ~ Top of tile' to finish grade Material beneath tile Total effecq.e absorption area
Length Wi Depth - PER~iT ~0.
< ~ Type of crib Crib diameter Crib depth Total effective absorption area
uJ Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT N~
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPEMATERIALS~
SOIL TEST RATING
INSTALLER
REMARKS
APPROVED~ DATE . LEGAL
77-013~R~v 3t7g) ~
BOX ]3~9, ~TAR ROUTE .~k A~;cnor~Ac:~:, ALASKA 9950;~
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF ~23;00 PER FOOT.
PROPERTY OWNER ~ ~aZL.~,~orl,
LOCATION OF WELL SITE_~- ~,
DRILLER ~ ~ O~ ~ ~~ ~0~
WELL LOG:
0 .... 17' $,U.2..V.
17---38~ ~.
38--~P~~ B~
1/:2 gA~. 7~o~ 187 ,f~ 195 ~-,f., ~z ~ ,fqt. p¢ ,toe. k. ~ko~,b'w,. on.e.
210 ,fo 222 ~c.,
1.6 ~.ot.~n~ ~ .f_.f. ~ ,te.~e.'~e. Oue,v. 300 ~oI. Lor~. _ _
225 ~: $5~75,0o
MUNICIPALITY OF ANCHORAGE
DEPt. OF HEALTH &
ENVIRONMENTAL PROTECTION
tAN 1 6 Ig85
RECEIVED
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR'THE sum OF I15175.00
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRILLING WORKS
198/, ....
DATE '-- --~ ~. '-,..( ..... "~, ': ": .....
SERVICE CHAI~GEOF 1%°a =~'= ''ONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
I'"IFI::.::ZMLIH i'.,II_II','IEJE:Fi: CF E:EDF~:L-,L"H"I:5 =
'T'FIE F.:EI..-.!U l IRED '.:51 ZE I_-IF THE :E;O i L. FIE:E;13F:F'T t I:;lt'.,I 2';'r'?'FEH :1: 2";:
'THE I....Ei'.4diTH E:, :[ i"IEt",I~; I ON 1[ :5 THE [..EI",IGTH ,:: :[ lq FEET :) OF' THE 'TR[.::I',ICI"] Oi:;.: E:,RFI I l'.,ll:' :[ ELD.
THE DEF'TH OF FI TRENCH OF;.: F'ZT .T.S TFIE DIF:;TFINCE BETHEE?.,I THE :SUFtF'FICE OF THE
GF.:OUNE:, FINE:, THE E:OTTCd"I OF' THE E',:.:',CFI'v'FfT:I:C$1 ,::]:N FEET::,.
THEF::E :[:::T, 1",10 "2;ET I,.ItDTH FOR TRENCHE2;.
THE GF::FI'v'EL E:,[L:'F:'TH :[~5 "['PIE hlINtHUH E:,EF'TH OF' GFtRVEL BETHIZEN THE OUTFF:ILL. F:':[F'E
Rt'.,II) THE E:OTTOM OF THE: E::.::r':FI'v'RT ;1: FSI ,:: ]: I",1 FEET ::,.
I..IELL-_', FI[',.I'AI-:EI'.,IT "[' 3 'T'H 1:5 r" ,,._ r" c F.. 'r I:II",IE:' 'I"I~IE
i"t :1: I'.,I I I"tl..11"1 E:, ]: ~TFII'.,ICE BEZ'TI,.IEE[",I i9 I.,.IEL. L. FII'.,ID RN"r' ON-E; t -I"E '_"SEHI::IGE .r.:, .1.' ~;F'O~;FIL.. 2~,'~.'~.'q'T'EI'"I :[ :":;
:[.EIEI FLEET FOF.': FI F't~:]:',,,'Fft"E I.,.tE:L.L.. OB: :I..SE~ 'FO ;~:li.:.'t~l FEET F'F4:lZZIh'l FI F'LIE',L. IL~: I.,.IE:L.I_ E:,EF'[:.-'.I'.,IDINC~
UI::'CH',I T'HE T'¢F'E OF F:'UBL. tC I.,-![:.I...L.
I"IINIMIJt'"t I)i'STFtt',IC:E FF.:OH FI F'I~:rZ',,,'FiTE: I,.IEL. L TO I:"'1 F'F.:Z'v'F:f'I'E~: :.F.qEH[.::R LINE I::-:; 2.5 F-"EET FIIqD
TO R CC$il'ql_liqIT'¢ :51EHER L. tNE Z[::-., ?'5 I::'IEET.
OTHEI;i: F..:E(P.I_I Z F..'EI'IENT'-:~; J'"IFq'¢ FIF'F'L'T'. E;F'EC I F' I E:FfT Z Oi'.,l:i'~; FIND E:EII'.~'.':~;TRUC:T Z CIN [.':, I F:IGFi:FtH:L:, FIR[.::
Fl'v'l::l :[ t._FtBL.£:: TO Z F,Ir~.:,Uf;.".E PF'.OF'EF.: :[ N~TFILI....FIT I O1'.,I.
]: C:ER'T' ,T, I":"T' THF:fT
t.: I i::11-,'1 I':'I::II',tIL.]:FII:~'. H I'I'T-I "FHE F::E~:.qLilREHENT~; FOR OI'.4--'.:.';ITE: :SEiI.,.tE~F:::ii; FIND t.,IELI._L'.5 I:t'.:..; SE']"'
FORTH E:'T' THE f"ll..li"41 E: ]: F'FIL :[ T"r' OF' IaI",IC:HOF:'.FIGE.
2: Z I.,.I :[ I_1_ I 1",t:STFILL THE E;"r'E;TL:;H ]: N FICCORDRNCE !-,.I I TH THE E:CE:'Erii;.
2: ]: IJI",tl)EF,~:STFtI",I[::' THFIT THE OI",I-".:.:;]:"I'E E;EI,JER S"r'STEH I'IFI'T' REg!UIP:'.E L::NLJ:::IF;:GEHENT IF THIE
I:;.'E::5 :[ E:'ENCE Z '."5 F:EHODELED TFJ :[. NCL. UDE i"lOl~:E 't"HRN q. E:EDF.'.OOHS.
' / ' ' '' / : ' ' : " V4. ~i
:[ I:~ '-'"'!; I..I "E' [:' E." .... 'r ......... ~ ...... ' ............. , .............................. .- ................................... [-' P'I-'"] E" ................................................. '
MUNICIPALITY OF ANCHO' SE
DE~,,RTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
, [] PERCOLATION
'~EST
PERFORMED FOR:
LEGAL DESCRIPTION:
6
7
8
10
11
12
13
14
15
16
17
18
19.
20-
DATE PERFORMEDt
SLOPE
ENCOUNTERED? ~ I~
P
IF YES, AT WHAT E
DEPTH?
SITE PLAN
Reading Date Gross Net Depth to Net
Time Tlma Water Drop
PERCOLATION RATE
(mlnutel/InchJ
COMMENTS
TEST RUN BETWEEN , , FT AND ~ FT
CERTIFIED BY:
PERFORMED FOR:
LEGAL DESCRIPTION:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Streel, Anchorage, Alaska 99501 264-4720
PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST
DATE PEREORMED: /O -/~' .- 92-
1
2
3
5
6
7
8
lO
11
12
13
14
15
16
17
18
19
2O
COMMENTS
PERFORMED BY:
SLOPE
SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH? // ~
Reading
PERCOLATION RATE
TEST RUN BE-rWEEN
CERTIFIED
OrOS$
Time
Net
Time
Depth
Wate~
Net
Drop
72-008 (6/79)
MUNICIPALITY OF ~NCHORAGE
DIVISION OF ENVIRONMENTAL t~ALTH
DEPARTMENT OF kiEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AI~HORITY APPROVAL CERTIFICA%q~
1o Genera], Information
Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or direc~:ior~s)
(b) Applicants Nam%_~g~_.~g~50~~ Telephone ~ ~ ness
Applicants BJdress ~X~ )~ q--%Z~ ~Skqo~~~
(c) Appllcan~ is (check one) Lending %nsti~ution ~ ; O~er/bui'..der ~;
(d) Lending Institution
Telephone
Address
(e) Real Estate Coo & Agent
Address
(f)
Telephone
Mail the tL~A to the follm-;ing address:,
2o ~T_xp_e of Residence
S ingle~Family
Number of Bedrooms
3, Water
Xndividu~.l Well
Other (describe)
Community ~X Public
Note: If community well system~ must have %r~itten corLfir~atiou from the Stage
Department of Environmental Conservation attesting to the legality and status°
Note:
~ community well system, must have written confirmation from the State
Department of Enviropmen~al Conservation attesting to the legality and status°
[Tge 1 of 2]
E_~n~ineerin~Fi~.vm ~'_o_y.~.i..d.i~n~g Ins. pec~i~o~ns,~T_est_ s~p~_File SearffJ!~D~ata and Information
As certified by my seal affixed hereto and as of the validation date sho~,m below, I
verify that my investigation of this Health Authority Approval sho~ tha~ the on-si~e
water supply and/or ~sgewater disposal system is safe, functionsl and adequate for
the number of bedrooms and ~ype of structure indicated herein°. ~ f~rther verify that~
based on the information obtained from the M~nicipality of Anchorage files and from my
investigation and inspection, the on~site ~mter supply and/or ~stewa~er disposal
syscem is in compliance ~th eli Municipal and S~a~e codes~ ordinances, and regula~
tions in effec~ on the da~e of this inspection°
Data
(ENGINEER 8F~L)
Approved for ~/~'.~bedrooms
Approved~ Disapproved
Terms of Conditional Approval
Telephone
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF H~TH AND ENVIRONMENTAL PROTECTION
(DttEP) ISSUES REALTH AUTHORITY APPROVA~ CERTIFICATES BASED SOLELY UPON T}~ R~PRESE~f~
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER REGISTERED
IN THE STATE OF ALASKA° TH~ DHEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDEP~AL AND STATE REQUIRE-
ME.NTS. EMPLOYEES OF ~{EP DO NOT CONDUCT INSPECTIONS OR ~MALYZE DATA BEFORE A
CERTIFICATE IS ISSUED° ~{E M-0NICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN T}IE I~.OFESSION&L ENGINEER'S WORK°
(DHEP SEAL)
RR4/eJ/D18
[Page 2 of 2]
7~]. 9~84
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
Well Classification
Well Log P~esent
Total Depth r,~2,~S-"- / ~d to
Static Water ~1
Casing ~ight ~ Gr~nd
Elec~ical Wiring in ~nduit ~)
~p~ation Distan~s ~ ~11:
Cleanout/Manhole
Water Sample Collected By
Water Sample Test Results
If A, B, c~ C, D.E.C. Approved(Y/N) ~J//4 _
Date Completed ~%--/~/~-~/ Yield ~/,~o~-~ ,
~/ ~pth of ~outing ~ ~%~ ~ 9
/.,~ ~ C~ Sanit~y ~a~ on Casing
~ession ~ound ~l~ead (Y~
To Septic/Holding Tank on Lot /pq "" ~/-~ ; C~ Adjoining Lots /'g)O
TO Near-est Edge of Absorption Field on Lot //,7 /C~_~; On Adjoining Lots..
To Nearest Public Sewer Line /u/'/4 To Nearest Public Se~r
To Nearest Se~r Service Line on Lot
pete
/ C/ /
B. SEPTIC/HOLDING TANK ~ATA
Date Installed (e/2%~/~_~ Size /~_j~ No. of C~artm~nts
Standpipes ~) Air-tight Caps ~) Foundation Cleanout~/N)
Depression over Tank (Y~ Date Last Pumped
Pumping/Maintenance Cont=act on File (Y/N)~C]//~ ; for
Holding Tank High-Wate~ Alarm (Y/N) '%]//~Tempo~a~%; Holding Tank Permit
SeDaration Distances f~cm Septic/Holding Tank:
To Water-Supply Well ,/0
To Property Line ,/O/'+
TO Water Main/Service Lir~
Course ~/(~0 x
To Building Foundation
To Disposal Field ~' /
TO Stream, Pond, Lake, c~ Major D~ainage
F'~ [Page 1 of 2]
Receipt ~
Date Paid:
Amount:
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date .Installed ~f2_c~/~.~%
Width of Field ~ /
./(~)(~ ~.~ Type of System Design
Length of Field
~p~ of Field
Gravel Bed Thickness 6
~ Standpipes Present
Square Feet of Absorption A~ea
Depression over Field (Y~ Date of Last Adequacy Test
Results of Last Adequacy Test ~J[~'
Separation Distanc~ f~om Absorption Field:
To Water-Supply Well ~ ~/ ~ To Property Line /0/+
To Building Foundation ~ / ~/~ To Existing or' Abandoned System cn
Lot k)//% ; On Adjoining Lots ~ 3 o / ~
To Water Main/Service Line ku/~4~ To Cutbank(if present) ~/~
To Stream/Pond/Lake/or Major D~ainage Course 4-/69 o
To D~iveway, Parking Area, or Vehicle Storage Area o?.5 +
Comu~nts
D. LIFT STATION
Date Installed
Size in Gallons
"P~¥~ On" Level at__
High Water Alarm Level at
Tested for ¥t3/~
Electrical Codes(Y/N) a3)/v-
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles du~ing Adequacy Test.
Meets MOA
Con~¥ents
** Check Permitted Bedroom Rating Against HAA Request **
i certify that I hav~checked, verified, or conformed to all MOA ~~%~ln eff.ct
on the date.mf.J~ff'Lg'inspection. ~-'~ t]~ ~:~..? ...~
Coi,Qany ----~%'C~ MOA No. ~-0%~ . [Z~¢~" ~'~
[Pa~ 2 o~ 2~
2-15-84