HomeMy WebLinkAboutMADELINE LT 9A
MUNICIPAL ITY,OF' ANCHOi
L,~PARTMENT 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
I PHONE
.~.~.U PG RAD E
LOCATION
DISTANCE TO:
Manufactu?~r
IF HOMEMADE: Inside length
wa,, ..d / Dwa,,i.g
/
DISTANCE TO:
Manufacturer
Well
DISTANCE TO: ]Lengthofeach~/ /
No. of lines
Top of tile to finish grade /
Le ngt h/, ,~-~ /
Type.of crib
DISTANCE TO:
DISTANCE TO:
Width ~.* !
Crib diap)eter. /,
Well/',¢-.-~ / ~I"
Depth
,/ ,IL-'
Building foundation
Foundation
Dwelling.~ / .~
Mat~f~gl ~.
~/'~--K~ /
IWidth
P E R MJ.Y~,N O,...~
No, of compartments
Liquid depth
PERMIT NO,
Matarial
Neare'st lot line
Trench width
Liquid capacity in gallons
PERMIT NO,
T~3tal length of lines Distance between lines
inches
Material beneath tile Total effective absorption area
Depth ¢~/~-. /...
Crib depth / /
inches
Buildin. g fo~nda1:ion"
Driller
Sewer line
PER~kT NO. 5,
Total effective absorption area
Nearest lot lin~ ~ / .z:,
Distance to lot line
Septic tank
PERMIT NO,
Absorption area(s)
OTHER
PIPE MATERIALS
i) ./..
SOIL TEST RATING -'
/'/ . ) .,/ l: / ,
INSTAL LE~, /. / /'
REMARKS
DATE
/ ,;..--~,
LEGAL
72-013 (Rev. 3/78)
D MUNICIPALITY OF ANCH
epar . ~ Jf Health and'Environr~nta± Protection
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN,PERMIT * * *
Permit ~ ~"'L'~'--AND/OR ON-SITE SEWER PERMIT
Applicant: ~ ~~ _6~Z_~,/ Mailing Address: _pC3
Location: Phone Number:
Legal Description: ~ ?- ~ ~', ,.3,. ~ /--F~ gJ /~C/4P&~q~ot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: HolcLkF~ Ta.~k
Maximum Number of Bedrooms: ~ Soil Rating (sq.ft/br)
DEPTH
The Required Size of the Soil Absorption System Is:
LENGTH I 3 ~ [ % GRAVEL DEPTH .__~_' ccL~p WIDTH
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE = /O'F.~C) GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
* * * TWO(2) INSPECTIONS ARE REQUIRED * * *
Backfilling of any system without final inspection and approval by this departme~
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fe,
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper installation.
* * * PERMIT EXPIRES DECEMBER 1 9 8 3 * * *
I certify that:
(1) I am familiar with the requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage,
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
' ~ ' ' to include more that 3 b~drooms.
th,.~,,~es~dence is remodeled ~
Signe~ ~'~Applicant / ~/---- Issued by:
Date: </'~
SNP/024(1/81)
F'ERMIT NO.
[:,EPFIRTHENT C HEFILTH FIND ENVI[;..'OI'.,IMENTFtL ]I"ECTIOI'.,I
825 '[. STREET., fll',ICHORFIGE., FtK.
,:: 8~:E~5,1.]i: ::,
RPPL I C:FINT
LOCFITION
LEGFtL
E[.',GFIR [4 RBEF.:I"4RTH?
T:I. SNEii:I.4 S. ;:;"5
MR[:,ELINE LgR
SR .:..::t6~;{~ HILLE:REST 99567
LOT SIZE
'99999:i~ SC!URF.':E FEET
TYF'E OF '..=.,OIL RBSORF'TION 5"r'STEH IS: TRENCH
i'iRX'IICIH I'.,IUI,1BER OF BE[:,ROOM% = 2-::
:.::;OIL RBTING ,::$Q I:'I',,"E,'R>= :L~.3~Z.~
THE F.:FC!LIiF.:E[:, SIZE OF THE: SOIL FIB~ORF'TION S"r'$TEM I:"-.';:
]'fiE LENGTH DIMENSION 15 THE LENGTH '::IN FEET) OF THE TF:ENCH OF.: [::'RFIINFIEL[:,.
THE [:,EF'TH OF R TRENCH OR F'IT IS THE [:,ISI'FtNCE BET[qEEN THE SLIRFFICE OF TFIE
CiROLIN[:, FINE:, TNE BOTTC¢'I OF THE E'/,CRVFITION ,::I[',1 F'EET.':,.
THERF:!: I~ NO SET [,.I.T.[:,TH FOF.: TRENCHES.
TFIE GRFI',,,'EL [:,EF'TH IS THE HINIHUH DEPTH OF GRFI',,,'EL BET[,.IEEN THE OI...ITFRLL. F'IPE
FIND, THE BOTTOM OF '['PIE: E',,',;CI::I',,,'RTION ,::IN FEET::,.
F'ERHIT flPPLIC:RNT HFIL:; THE RESPONSIE:IL.I T'f TO :I:NFORM TFIIS D, EF'RF.:TMENT DI_IF...'INFi THE
'rI't:BTRLLFffZON INSPEE:TIOI'4S OF FIN¥ I.,.IELL$ R[:,..TRCENT TO "FHI::...; F'F..'CCERT¥ FIN.F;, THE
NUMBEF.: OF RD':;IDENF:E5 THFFF TI-IE I.,.IELL 14ILL SEF.'.',/E.
............... T' [4 C, ,::: ;2 :.':, Z f--~ :S; F' EE C: -F .'[ ,2, ~'-4 %:; ~-~ [;:.: FZ F-: [E [;:., L, Z tR E: C:
BFICKFILLIhlG OF tiNY S'-r'STEH [,~ITHOUT FINFtL. INSF'ECTION RI'-,I[:.', RF'F'ROVRL B"r'
E:,EF'FIF..'TMEI'4T [41 Lt.. BE SUE',..TECT TO PROSECUT I OIq.
HIt'-,IIHIJH [:,ISTFINI]E BE'FI.,.tEEN FI I.,ELL 'FIN[:, f~f'4"r' FN--qI'f'F_ ~ SEI.,.IFtGE [:'I'SF'OSflL..:,~:,~,~.'""'"'*cF'"' IS
:iE~C~ FEET FOF.': f::l PRI',,,'I::ITE I.,ELL 017 iStZ~ ]"0 ;.~.'C~E~ FEET FROM FI PUBLIC [,.IELI_ [:,EF'EI'.41)ING
UF'OI'.,I THE "I"'T'PE OF' PUBLIC I.,.IEL[ ....
I'IIhlIHUM C, IS'I'RNCE FROM R PRI',,,'fll"E [4ELL TO FI PF4:I',,,'RTE SEI.,IEF.: LINE I5 25 FEET FIND
TO FI C:OI"IMUNIT'f .'."-.',Et.,.IE[;:: LINE IS 75 FEET.
i.4ELL LOGS RRE REI.:.!UIRE[., laN[:, HUST E',E RETURNED TO THE [:,EPRRTMENI' I-,~ITI.-IZN
OF THE [,.IELL COMPLETION.
OTHER F.:EF...!UIREHENTS HFI¥ FIPF'LY. SPECIFIE:IaTIONS FII'.,ID CONSTI~:UC:TZON E:,ZRGF..:RI',15 FtF.:E
F.I',,,'FtIL. FIE~LE TO INSURE PROPER INSTFtLLRTI ON.
F" tEf;: ['"1 Z T' E >,: IF' I [F:~: lEE £¢ E:, Fi C: E:': Pi tEE," E [:4: 3: ::[ .... :L .'.9: E: 3::
i CEI:;.':I"iF¥ TFIfT'F
i: I tim F'FIM!LIFIF.: 1.4ITH THE F.'E ~ I'" - - - ,-
· ')l..T._ F4. EflENT::, FOF?. OI",I'"SITE SEI.,.IEF.:S FINE:' ['.IELL:, I:IS SET
FORTH B'T' THE MUNIL':IF'FtLIT'f OF FINC:FIOF.:Fll3E.
2: I [,.IILL. INST~aLL THE $'fSTEH IN FE:I_-:ORE:'flNCE [,.IITH THE C:IZIE:'ES.
.7-":: Z UNE:'EF-:STFII",IE:' THFIT TFIE CN'-SITE SEI.,.IEF.: S"/STEM I"lfl'T' REC!UIF.:E ENLtaF'::I.3EHENT IF' I'HE
RES I I.)ENCE' I S F.:EMO[:,ELE[:, TO INCL. UDE HOF..'E THRN :..i: BEE:,F..:OI.')MS.
Si Gi'.,IE[:,:
FIF'F'L. l CFtNT E[:'GFtF?. I.'.1 FIBERNFITH"r'
",.'4.
LOf ~IZE
TREHOH
TH( LENOTH O[I'IEN$[ON IS THE t.~NOTH ': [Pi FEEt) ,DF YHE TRENCH OR
)-HERE {~ NO SEt H[OTH FOR FRENCHE'5, :-,
THE O~nV'~L OEPTH [~ FHE HIN~HUN DEPfH OF O~V~L 8EfH~EN FHE OUD~RLL
~HO THE 80FROM OF fils EXCaVatION (IN
,P~RHI/ RPPL[CRNT H~t'S file RESPONSISIL[T"¢ TO [NFORDI TH['& DEP)~RTPI~NF OJRINB TH~ :;
': [ .:~RFIF'¢ THRT
: . . ~ *-'-:¢. :, / ~ o, ~:- 4:,//-, .',,
PERFORMED FOR:
1
2
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage. Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
10
SLOPE
11
12
WAS GROUND WATER .~ ]..~ S
ENCOUNTERED? f ~/i~.' L
O
P
E
IF YES, AT WHAT
DEPTH?
SOILS LOG
[] PERCOLATION
TEST
14, /~0 L/?
15
16
17
18
19
20
COMMENTS
PERFORMED BY:
72-008 (6/79)
SITE PLAN
Reading Date Gross Net Depth to Net
Time -rime Water Drop
PERCOLATION RATE
TEST RUN BETWEEN FT AND /~FT
(minutes/inch)
by
P,O, BOX272, CHUGIAK, ALASKA 99567 * TELEPHONE 688-2759
OWNER OF LAND ./.?/J,¢.,~. r.;,47,'~ ~
ADDRESS
LEGAL DESCRI~ION '~'
'
DATE. Started ~'~-//
PE~IT NUMBER
DEPTH OF WELL
STATIC LEVEL OF WATER FT. b -)
DRAW DOWN FI'.
GALS. PER HR
KIND OF CASING
KIND OF FORMATION:
From 'D. Ft. to ;'''') _Ft
From_L'~ Ft. to f ; Ft..
Fromd_d .Ft. to ,2 -~ Ft.
From.. Ft. to Ft.
From-~-%'" Ft. to (, / Ft.
From Ft. to.__. Ft.
From Ft. to Ft.
From Ft. to__Ft.
From Ft. to Ft.
From Ft. to__Ft.
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft.
From __Ft. to__ Ft.
From Ft. to_ Ft.
From Ft. to Ft
__Ft. to Ft.
__ Ft. to Ft.
Ft. to , Ft
From Ft. to. Ft
From____Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
From__Ft. to Ft.
From____Ft. to Ft.
From Ft. to Ft
From Ft. to Ft
From_ Ft. to Ft
From Ft. to Ft
From__Ft. to Ft.
From__Ft. to__Ft._
From Ft. to Ft
From
From
MISCL. INFORMATION:
DRILLER'S NAME
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
GENERAL INFORMATION
Complete legal description
T15NR2W
~i~deline Subdivison Lot 9A, N.E. 1/4 Section 25
18126 1~illcrest, C"nugiak, AK
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
Harold and Nannette Belk
Day phone 694-9629
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
3 '~
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
NOTE:
Public water
If community well system, provide written confirmation from State AD£C attest-
in9 to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
NOTE:
Individual on-site
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
5. STATEMENT OF INSPECTION BY ENGINEER
o
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 dat. c-of~this inspection.
Na · EnvironmeT~al Managemen~,-//- ~n¢
me of F~rm ..... · Phone
// u k, /
Address 206 East: Federated ~'., Cf 20%/
Engineer's signatur.~? Date
272-9336
DHHS 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 (Rev, 1/91) Beck MOA~21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Pri.,v. ate
Well type
Log present (Y/N) Yes
Madeline Subdivision Lot 9A Parcel I.D.
N.E. 1/4 Sect. 25,T 15 N, R2W
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 04/12/83 Driller
Cased to 40 ft. + Casing height
60.5 ft.
Total depth
Sanitary seal (Y/N) Yes
Date of test
Static water level
Well flow
Pump level1
Wires properly protected (Y/N) "fe8
FROM WELL LOG AT INSPECTION
04/12/83 06/20/94
35 ft. 35 ft.
Unknown 47 ft.
SEPARATION DISTANCES FROM WELL TO:
150 + ft.
150 + ft.
N/A
N/A
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
,; On adjacent lots 115 ft.
; On adjacent lots 120 ft.
Public sewer manhole/cleanout N/A
Sullivan Water W~lls
31 inches
Petroleum tank N/A
WATER SAMPLE RESULTS:
0
Coliform
Date of sample: 06/09/94
Nitrate 2.1 rog/1 Other bacteria
Collected by: Chad Helgeson
B. SEPTIC/HOLDING TANK DATA
Date installed 4-28-83 Tank size 1000 Compartments
Oleanouts (Y/N) Yes Foundation cleanout (Y/N) Yes Depression (Y/N)
High water alarm (Y/N) No Alarm tested (Y/N)
Bate of pumping 06/18/94 Pumper JR' s Pumping
No
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot 150 + ft. On adjacent lots
To property line 25 + ft, Absorption field
None Observed
Sudace water/drainage
150 + ft. Foundation 10 ft.
19 ft. Water main/service line N/A
72-026 (3/93)' Front CONTINUED ON BACK PAGE
C. LIFT STATION N/A
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
Meets MOA electrica~ 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 /,-?R-R3 Soil rating (GPD/FF) 100 System type Crib
Length i5 ft, Width 15 :ft, Gravelthickness 5.4 ft, Totaldepth 10.4 ft.
Total absorption area 360sq, ft. Cleanout present (Y/N) Yes Depression over field (Y/N)
Date of adequacy test 06/20/94 .R, esults (pass/fail) P~ss for
,,.,. /.?..../...,/o .....
Water level in aosorpdon f'i'eJd'befd~e test t.~' y' z ~:t.. ) ' / After test .." 'g i 1 ft.
Peroxide treatment (past 12 months) (Y/N) No If yes, give date
No
Bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot 15o + ft,
To building foundation 35 ft.
Onadjacent lots 150 + £t.
Sudace water None Observed
Curtain drain Hone Observed
On adjacent lots 140 ft. Property line 15 ft.
To existing or abandoned system on lot 19 ft.
Cutbank N/A Water main/service line N/A
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I ce~'fy that I have checked, verified, or ¢~formed to all MOA and HAA guidelines in effect on the date of this inspect/on.
Signature .
H~ Fee $ ~¢o. ,, ¢. Waiver Fee $
Date 0f Paymem ~.-- ~ ~ "-~/~ Dato o~ ~aymont
Receipt Numar F/ ~ ~'~;~ Receipt Numar
72-026 (3/93)' Back
0E,."14/94 EI9:14 CT~:E EI.I'..JIF:I-INHEI.ITi:iL LAB !E;EF.'~.II,]:E!E; * 90?2?24159 1.10. i;~? I~F_12
Commercial Testing & Engineering Co.
Environmental Laboratory Services ~~-,ar~-~-~'j,,,~',~;~,~r~.~',ar,~-,~-~
LABORATORY ANALYSIS REPORT
C'I',~ }". l~.el:# 94.2837- I
Client Sample ID I.IA.'I'ItI~.()(.IM FAUCET
MaD'ix WA'I~'_.R
Clicnt Name ENVI ?,oNMENTAL MGMT INC (EMI) WORK Order '79327
Ordcrcd By SIMON Prinlcd Date 1'16/14/94 (/~! 06:39 l~_rs.
Prt'ti¢ct Num. e Collected Date 06/09/94 (~! 1,1:30 hrs.
Projcc(# RcccJ v cd I)at ¢ 116/09/911 tX? 15:10 llr,s.
PWSID UA
Tcchnical l-hrccl~a r
F__DF.
S ~lt~p. e Re~ ~ru'ks SAMPLE COLLECTED BY: CHAD l 1ELGL'iSON
(.).C'. ^llmvable Ext. .,,'uml
l-'r~rameter B.¢s~dt$ Dual units Mclh~.~d ~ ts Dale D.'..~ [ c hd!
...................................NJtr.,'~te.-N -2-.~ .......... ;~/~-.- ...... l~i';~-\' 553.2/7_~¢¢2~- ...... ~ ~ ............................... 06/10/9,1 DJ8
* See Special I~l$tr~mt[ons Above., UA = Unuvmlable
** See Staple Rclnat'ks Abovc ~ = Not Analyzed
U = [.ln&t~ted, Rc~orted vel m ia the practical qmndfiuation limit. Ut'= ~ss ~an
..., D = Sccmt~try ~ lution. GT= ~euter'lhan
5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fez: (907) 561-5301
r-NViRONM[NTAL FACILITIES IN ALASKA, COLORADO, FLORIDA, ILLINOIS, MARYLANO. N~W JERSEY, OHIO, UTAH. W~ST VIRGINIA
I~IUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SiTE SEWER AND WATER FACILITY
264-4720
/
GENERAL INFORMATION
(a)
(b) Business
Legal Description (include lot, bl¢ck, subdivision, section, township, range)
Location (address or directions) .- '
Applicant Name ~- ( ~--~~ , Telephone: Home
Applicant Address
is (check one): Lending tnstitution~; Owner/builde,f.,J~; Buyer []; Other Lq (explain);
(c)
Applicant
(d) Lending Institution Telephone
(e)
Address ~.~.; :-.~:> ,/ //~¢, . .Z'/. /,
Real Estate Company and Agent .... - - .
Address L:~ :'~.'/ ¥ ,' f-.-. ,
Telephone
(f) Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family)-7'~._ Multi-Family [~]
Number of Bedrooms
Other
WATER SUPPLY
Individual Wel~]... Community ~ Public
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsit Public [] Community [] Holding Tank []
Note: If community well system, must I~ave written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84}
ENGINEERING FIRM PROVIDIN,~ INSPECTIONS, TESTS, FILE SEARCH, DA~A AND INFORMATION ~ * ~
As certified by my seal affixed hereto and as of the validation (late 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 ot structure indicated herein, [ 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 regula,!ions in effect on
the date of this inspection.
Name of Firm
Address --
[)ate
___Telephone
Approved for '~'~/~-~¢~..~ bedrooms by/~_~c~
;:~'m°sV:t (~o n c~ al A pprova~`sapp''°v/~d
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes ano their lending
institutions in order to satisfy certain federat and state requirements. Employees of DI--iEP 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.
Page 2 of 2
72-025 (11/84)
WELL DATA
Well Classification
Well Log Present ~N)
Total Depth Lei
Static Water Level
MUNICIPALITY OF ANCHORAGE (MOA) MUNICIPAl. IfC OF ^NCHO~AG~
HEALTH AUTHORITY APPROVAL (HAA) E~IRONMENTAL PROTECTtON
CHECKLIST- FEBRUARY 1984
264-4720 ~ ~ ~ ~ ~g~.,
Legal Description' ~- ~
If A, B, C, D.E.C. Approved (Y/N)
Date Completed z:~- ~'~_....-- ~I~-¢ Yield
Depth of Grouting
Pump Set At ~t
~c.;-~ Sanitary Seal on Casing
Depression Around Wellhead
Cased to ~1~
Casing Height Above Ground
Electrical Wiring in Conduitd~5'N)
Separation Distances from Well:
To Septic/l~ Tank on Lot
\~ ~ ~,.~-' ; On Adjoining Lots
To Nearest Edge of Absorption Field (in Lot \~"~ ~'~ ; On Adjoining Lots
~"~Cleanout/Manhole
To Nearest Public Sewer Line %/¢~ To Nearest Public Sewer
Water Sample Collected by
Water Sample Test Results
Comments
B. SEPTIC/HOL~:};;',;~ TANK DATA
Date Installed ~¢~-~'~ ' ~F Size ~ ~)6:~¢-'~~ No. of Compartments
Standpipesd~l'N) Air-tight Capsd~N) Foundation Cleanout~/N)
Depression over Tank (Y/,~i~
Pumping/Maintenance Contract on File (Y/N)i,
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Ne~ding -Tank:
To Water-Supply Well
To Property Line ~. ~ t..~
To Water Main/Service Lin, e1
Course '~'~/
Date Last PumPed ~. ~ ~ ~ ~
t,.%/~ ;for ' --
Temporary Holding Tank Permit (Y/N) ~,,,5/~/
To Building Foundation.
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Cornments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/4~J~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I ~ t ,.~
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field ~ ~ ~
Depth of Field '¢~
Gravel Bed Thickness L~
Standpipes Present ~N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ¢-~
To Cutb~nk (if present)
Comments
D. 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 **
I certify t hat .t. hav, e~he, cked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed SI~B 19~,x Date
Company Eagle ,~iver, AJasl~a 99577 MOA NO.
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