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.--. MUNICIPALITY OF ANCHORAGE - -
DE 51TMENT OF HEALTH AND HUMAN SER, .Es
· Environmental Health Division
~ ,, ~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name DISTANCES
~ ~ J'P~ ~ ~¢' ¢--" YP~ ~ ~ ~ SEPTIC ABSORPTION
Address ~ TANK FIELD WELL
Lot ~ 1 BI~ Subdivision
~O~E Pa L ~ FOUNDATION
T .... hip. Range, Section
'Ti~ ~ i ~ ~ g ~C ! ~ dr,veway,AS'BUlLT DIAGRAM [Show Iocat,on of weft, septic system, property hnes, ,oungat,On,water bodies, etc.)
Manufactuaer Cap~c,ty ~n gallons
Material NO. Of Compadments
TYPE OF SYSTEM
TRENCH ~ BED ~ W. DRAIN ~ OTHER
Depth to p~pe bottom Irom Total depth from original grade
orlginalgrade ~ ~FT ¢ FT
Number oI hnes Soil rabng
Date Install d
,pstaller
WELLS /
PRIVATE ~ OTHER (Identify)
CJassdicahon (A,B,C) Total Depth
Cased to
REMARKS:
' 'JLJ~ Scale: 4 E~.~N. EER'8~EAL
Health Depa.ment Approval: .. ' , ~d~...~ Z~. Date:~,~¢~
ate ~._'x'XCU
f_ dtqb,. !
}}EPARTNEI',i]" H, EAL. TH AN]9 ENV I RQIxIMENTAL RO'T'!EC]":I:[]N
20:3 W. :1.5 TH
ANCHC.,'RAGL-'il, AK 9950
2. 79 -39 :l. 6
SUBD I V I S I O1",1: LODGEPOLE
.SIEC'I' ]: [:]hl ~ :L 4 TOWNSH I P: :/2N
4
L. OT: 6
Fd..SNGE: 3N
bl....L]C~... ~ N/A
.... ].~ . ':~ ..J 17)~9]..])L.,.,I ~:'~r"E.? ~.~ J~...... op ..... )!]=:~ ,2~.Ya:L ].~::u. ] a~ '[..,.':) 'y(Z)L.L il"~ da:,sJ, gn :i.r'~(.~l yC;LU~
~:z. .......... },'~:::. L.~::!,[i~ ..... . ~.,,C'I .......... il l~. k:~ .~;' J.'. ¢]E~ c)p']~. :J. C)FJ t h ~I'~. [] ~):'~E.'['. f i 'L. ?.-!. ~/c:)u.p.
'T' F:i:: E:.E: !t'",,~t C:]: .~-~ ]F]?a EE'.
DEF'TH TCI F:' :!: [::'!i'5: BOTTE~M (I::'T~)
GRAV,r'5].... DEPTH (F'T,
TOTAL.. DI.Ei:::"TH (F'T'~)
GRAVE].... WIDTH (F:"I"~
GRAVEL.. L..ENGTH (F:]'~)
GFd:~VEI... VOLU!qE (CLJ,, YDS,
TANK SIZE (GALS)
4 ,, 0 0 ,, 5 3 ,, 5
Ii'}. 0 5.5 7 ,, 5
2. U ::-?.0 ,, 0 5 ,, 0
65. O ~ :39,, 0 56.0 ~
27 ,, J. 28.9 4. 1.5
250.0 -~..~- i, 250 ,, 0 .~..~. 1,250.0 ce.x-
:[ 3 0
...... (. ~...L ~ 7 ,.} : ;.
....'~ ]: al[It '} ¢':~1irJ ]. ], :Li:':1P V,l :i_-i.:.h '[,~.f ........ [ 6,.? t,? l., L, .L' I t::. [ ..= ! ri !:~ ~' C) P c}n,.,..~i :i. t (.~ EiE.?V{{T[P iii; iill"}c} Ni.:a :Ii :[ (~i a ~
and_..5 ~.-~ cc, rap1 :J. artce with 'l:.hes:, des:i, gn ............ ... J...=.. · :i.a c,f th:L~=.., per'm:i.'L,,
3. I t..,~:L'i ]. ,:~J~:,!.~.....:, '~'.(::) a'l 1 MC)A and (:'~ ~,-', ..............
....... ,.. ,::. _ ,-= c) ~. A ]. a s }.:: a::l p .5>) ci. t J. r' a.: i ,.= 1 . :::, f c) p 'l:. J'] E, s (?:-)'~.. D a (]
dj- .... .: ..... ,. ' ' . . _ . .
~-., .:. ~,( t-.,,... [ r' om ;:,p~/ ex ]. s'L ing ws~ :! ]., wastewater', cl :~, %pi:]sal ] ~E.y!~'iLi-FHii EiP pt.,ti:] ]. 'J. E;
sei,~aH, ai:j,:~ sys':.e ~ (:)r'i th :i. s c)r' anv. aclj ,:: L (,,.z~-~ t.. (::H" near' '~.., ..... ~..- 1 c)t ~
ZF:' A L:.,':F'T S"FATI',::)N ]:!:':] :[NS't"AL.LED ]:hl AN AF;.tEA ,C:OVERED BY MOA BUIL. D:[NG CODES,
'THE::h! ( ! ) AN ELEC]"R I CAL.. F:'EI::i'.M ]: T AND :[ N.':':~P!~:9:]T ]: [::]iq MUS]" EIE OBTA :I: NEI) .~ (2?.) AS-.BU I L]'S
W ]: L..L NC}T Eqi!:: AF'F'RC)VED W I ]'IqOU]' AN ELEi)]TF?. t CAL. I NSF'!5:C"I" I ON REf::'OF::,T.~ AND (::~:) TH,rE
I;::~ ~::c'f'l::;']F"~:I i.d/:]jRl.:' 5-!Uc,~E,'Ei: !}OiXI[E f:lV A t...'r'"" "['-I :h::''] [::'I !::'i"'"J'J:~"fC'r/"\~
.... ~ .............. DA'T'E ~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
/~ SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
DEPTH
(FEET)
1
2
4
8
13
14
15-
COMMENTS
DATE PERFORMED: .~/,~///~
' S'L~)PE / SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
/~0 ~D~/~ IF YES ATWHAT
~ O E PTH'.7
/¥ !
P
E
Reading Date Gross Net Depth to Net
Time Time Water Drop
TEST RUN BETWEEN FT AND -- FT
PERFORMED
CERTIFIED BY:
72-008 (6/79)
MUNICIPALITY 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
Application Date ~ ~..~
GENERAL INFORMATION
(a)
(b)
(c)
Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Name ?.r~-~/ ~p~-t' "~: '" ~7 Business
Applicant Address ,~ O~ C f'~ ~ ~ ~
Applicant is (check one): Lending Institution ~; Owner/~r ~'; Buyer ~; Other ~ (explain);
Telephone: Home
.'¢~f 7~/~
(d) Lending Institution
Address
(e) Real Estate Company and Agent
Address
Telephone
Telephone
(f) Mail the HAA to.the following address: ~ '
TYPE OF RESIDENCE
Single-Family/~, Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual We I~,' 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 have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
5. ENGINEERING FIRM PROVIDh..., INSPECTIONS, TESTS, FILE SEARCH, D~,A AND INFORMATION
' As certified by my seal affixed hereto and as of the validation date shown b~low, I verify that my investigatio~ of this. ~lealth
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 /' E2/-'~/L~i~ ~(~'~J -.~'~x-[~..4~ Telephone
Address ~...C] ~ ~b
Seal
.6.
Approved for ~:~c¢/7.~ bedrooms by
Approved , ~//' ' ' Disapproved Conditional
Terms of Conditional Approval
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 and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: LdT
Well Classification '~
Well Log Present (Y/N)
Total Depth ~ 0 Cased to
Static Water Level ~-'
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/M,tdd=,m2 Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
If A, B, C, D.E.C. Approved (Y/N)
Date Completed '~"-~ '/¢/7,.~ Yield
Depth of Grouting ~O
Pump Set At BO
]/~' ~ Sanitary Seal on Casing (Y/N) '~"
Depression Around Wellhead (Y/N)
fv'o
Comments
D
; On Adjoining Lots
/,,'~ ~- ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
Date
Standpipes (Y/N) 7't2//L~
Depression over Tank (Y/N)
Size I~,~O No. of Compartments
Air-tight Caps (Y/N) '~/" Foundation Cleanout (Y/N)
Date Last Pumped
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well t
To Property Line
To Water Main/Service Line
Course
; for
Temporary Holding Tank Permit (Y/N)
t-///,..,.. __
To Building Foundation
To Disposal Field ~'
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELI') DATA
Soils Rating in Absorption Strata
Date Installed ///¢'/,/'¢ -~¢
Width of Field ~¢~0
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
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
Comments
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~;~ /~---~-'~
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, oJ;conformed to all rvl, OA and HAA guidelines in effect on the date of this inspection.
Signed ~ %,¢,¢-.,~'~ Date ,
Company /~ ~. '~ ~/,.,4,~_ ~'"' MOA No,
/
Receipt No. \,o,,:,
Date Payment %1 / '1',g
Amount: $ '~_~;~ 0'b'~ Engineer's Seal
Page 2 of 2
72-026 (11/84)
, CONSULTING ENGINEER
'"-~,203 W. 15th AVE "C" SUITE 203
ANCHORAGE, ALASKA 99501
TELEPHONE: (907) 279-3916
RESIDENTIAL WELL INSPECTION
LEGAL:
LOCATION:
OWNER:
TYPE OF WELL:
WELL LOG AVAILABLE:
LOT 6, LODGEPOLE SUBDIVISION
5900 OLYMPIA CIRCLE
JERRY CYPHER
SINGLE FAMILY
NO
INSTALLATION REQUIREMENTS MET: YES
WELL YIELD FROM WELL LOG: NOT AVAILABLE
PUMP YIELD:
WELL RECOVERY RATE:
DATE OF INSPECTION:
TEST PROCEDURE:
7 GALLONS PER MINUTE
5 GALLONS PER MINUTE
AUGUST 18, 1986
WELL WAS PUMPED AT A CONSTANT RATE OF 6
GALLONS PER' MINUTE WHILE THE DRAWDOWN WAS
MONITORED WITH AN ACOUSTIC PROBE. THE WELL
WAS PUMPED TILL THE DRAWDOWN STABILIZED.
STATIC WATER LEVEL WAS FOUND AT 64 FEET BELOW
TOP OF CASING. AFTER 30 MINUTES OF PUMPING
THE WATER LEVEL HAD STABILIZED AT 80 FEET.
TOTAL WELL DEPTH IS 90 FEET.
TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM BACTERIA
AUGUST 19, 1986. TEST WAS NEGATIVE.
TEST RESULT..
ON
THIS WELL MEETS THE REQUIREMENTS OF THE
MUNICIPALITY OF ANCHORAGE.
The Municipal requirement for well flow is
150 gallons of water per bedroom per 24
hours.This well surpasses this requirement.
The assessment of the condition of this well
applies only to the conditions as of this
date. The flow rate of the well may change
due to subsurface conditions that may not be
observed from the surface, and changes in
land use and other factors that may impact
the conditions of the aquifer feeding the
well.