HomeMy WebLinkAboutLOMA ESTATES BLK 4 LT 1 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 NAME MAILING ADDRESS 5 ~11 fYox 402q - 0 ,4~ c,4vr~ LEGAL DESCRIPTION -~ --('~"(~Ocd¢6~ / / LOCATION V)'~'~ 0 DISTANCE TO: I'h Manufacturer G~ (~ ~ PHONE ~q ~'--3-~ l~- q.:o 7 / Dwelling .L , IAbs°rption area /¢ ~,~r ,,, Material~¢t~¢ j Inside length ~ [ Width ~ NO. OFBEDROOMS4 ~NEW [~UPGRADE PERM IT ~--~ d ~/~[//~ No. of compartments 2 Liquid depth Liq. IF HOMEMADE: Well Dwelling PERMIT NO. DISTANCE TO: Manufacturer Liquid capacity in gallons Material Nearest lot line Trench w~dth4~inches Foundati~Clf t'h Total length of line,)~_! / 08inches Well t No. of lines / Length of each I ne~, / Top of tile to finish grade 2, ~' ! Material beneath tile Distance between lines ~. Total effective absorption area 6?0/; ~ Length Width Depth Type of crib Crib diameter Crib depth Total effective absorption area Well Building foundation Nearest lot line DISTANCE TO: Class Depth Driller Distance to lot line Building foundation Sewer line Septic tank DISTANCE TO: PERMIT NO. PERMIT NO. Absorpt on area(s) OTHER PIPE MATERIALSp V~ SOIL TEST RATING 12: INSTALLEB/~ ~'d EJqt EX 8~ "00~~' REMARKS 01# h,? APPROVE~~ DATE LEGAL Lot I -~UNICIPALITY OF ANCHORAGE:-~ ? Department:' ~ Health and Environmenta~rotection · ~? ~ 825 ~ Street, Anchorage, AK. ~9501 264-4720 ~' * * * HANDWRITTEN PERMIT * * * Permit ~ ~ciqSJ WELL AND~R ON-SITE SEWER PERMIT Applicant Location: Phone Number: 3 ~ ~ Type of Soil Absorption System Is: Trench: Drainfield: Seepage Bed: ~ Holding Tank: Maximum Number of Bedrooms: .~ Soil Rating(sq.ft/br) The Required Size of the Soil Absorption System Is:' DEPTH LENGTH t-~7 GRAVEL DEPTH & · 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 ~ipe and the bottom of the excavation(in feet). · * REQUIRED SEPTIC(HOLDING) TANK SIZE : / ~'~ 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 department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet 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 31, 1 9 8 3 * * * I certify that: (!) I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of ~nchorage. (2) I will install the system in accordance' with codes. (3) I understand that the on-site sewer system may r9quire enlargement if the ~s~dence is remodelled to include more that?~3~bedrooms. . SWP/024 ....... :_L ......... Z ~ z ...... · ,~ ~ ~'-- WATER WELL RECORD STATE OF ALASKA ~ ~"' *~ DEPARTMENT OF NATURAL RESOURES Division of Geological ~ Geophysical Surveys Drilling Permit No. A.D.L, No. __o,--e,--o,--s []wO lc.I} DISTANCE AND DIREC~I~)N FROM ROAO INT, ERSECTIONS S. OWNER OF WELL:~'-i~t"'~!" -..~ ~ ~ .~ ~ // , ~ . , .. Street Address and Area of Well Location ~J/? Feet Below 4. WELL DEPTH: (final) 5.~O~T~__ O~ COMPLETION 2. WELL LO6 Surface .,~"~ fl. -- /t,,/ -- ~ ._.~ M oteri~l Type Top Boflom ~.~ ,=~ 8. CASING: J~ Ibs,/ft. diem. in. to.~ft. Depth SHckup <,.~ . ft. · ~.~ / / ,.,]~ ~ / Backfitling Gravel pack ..... lO. STATIC WATER LEVEL: ~¢' ~ Above or ~'Below land eurface [~.GROUTING Well Grouted; ~ Yes ~ No Material: ~ Neat Cement ~ Other; Length of Drop Pipe ft. capo~i~ g.p.m. Re~is~'ered Bus[ness Name // ~ ~' ] Number Authe~zed/Represe~toHve Parcel I.D. # 1.  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 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 agency Mailing address Agent Address Day phone Day phone Day phone · Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community wel Public water If community well system, provide written confirmation from State ADEC attest- NOTE: ", ingtothelegali~yandstatusofsystem. -. 4. T:y~EOFwASTEwATER'DIsPOSAL: .¢:?-~.'.'.:-~4-' .'' " ' - ~ ~'~' ' ..... '~ - -' ~ ' '- -:' ' "~" I '~ ) "~ ~,;~;~-'} .,-',;-?~C.;_,:-..;.::~-.~-. -._.. ,. ...., ;.' : · '... ~? - . , . . · .... _' . -;,. ~ ~ ~ , . ~ , ,- ,. . Holdmgtank ' . .... ',~ ',;-. ~ommumzy on-s [e - · . , :..-~ , ~. Pub c sewer ....... · .' ':'~":~-': ~'?~ ':N6gE:"::', if cbmmdnity wasteWate) systd~;:~vlde ~fitten confirmation from State :....,.?. . ~ . - attesting to the leoahtv and status of svstem -. ;:r' ' 72~25'(Rev.~/91~ Front MOA~I ' ', .t- . ' ' . ' ;..~ 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 flies 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. Address ("~r~(~ ~.~/-/g-'-/~'/"-/~°?'~'/'/?~//~---/.4 ~'~('~"'~ ~ ~/~ DHHS SIGNATURE ~.. Approved for 4 Disapproved. Conditional approval for bedrooms. F~ JamesF, Sizem~'re ~ bedrooms, with : Additional Comments · ~-'. , - , ~:'- ' ~: ........... - ~-'~ "uman Services/DHHS) ssues Health Authority -' '~THe M~ntc ~?ity of ,A~chorage uepar[mem u[ nu~,tu ~,-,~ ,, , ';:.,?~l~roval C~tif ca, t.e~.l~'As~d only upon the representations given in paragraph 5 above by an independent ' r~f' Ssjonal engi,~' r.e~'istered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes .P~d~l~'l~din~,i~titbtions in order to satisfy certain federal .an.d state requiremen, ts,. E,m, ployees o! DHHS .do no! ""' ';;~'; ~" anal ze data before a certificate is issued The Mumc pa ty of Ancnorage Is no~ conduc(' n'spect'i~ns or y " ' . professiona engineer's work. . .... . · responsible faf errors orr omissions in the . . . .. .,: 72-025 (Re~.1/91) Back MOAff21 Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST LegalDescription: J- ) /~'~"' ~/~ ~l~?/ ParcelI.D. A. Well Data t Well type Log present (Y/N) Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number. Date completed '-J~/'~' /4) ~-x~ Driller -/~ {~P ~:;~6~ -~/')~/'~' Cased to ~J ~ Casing height FROM WELL LOG 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 /k/'/A Sewer service line Wires properly protected (Y/N) g.p.m. AT INSPECTION / ; On adjacent lots ; On adjacent lots *~ Public sewer manhole/cleanout /~,/~ Petroleum tank ~¢/ O WATER SAMPLE RESULTS: Coliform ~ Nitrate Date of sample: ,'J~ (~ ~'~, I ') ~/~-~ Collected by: Other bacteria B. SEPTIC/HOLDING TANK DATA Date installed ~ ~/© - <0> '~ Tank size /"'-/-- c70 Compartments ~- Cleanouts (Y/N) "/ Foundation cleanout (Y/N) ~/ Depression (Y/N) High water alarm (Y/N) ;k,,/ / T'~ Alarm tested (Y/N) Date of pumping O C-"~ )/ )L~,~. Pumper ~;S~-d---! ~'P SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot / i ~ ( On adjacent lots To property line Absorption field C~ Water main/service line Sudace water/drainage 72-020 (3/93)° Front CONTINUED ON BACK PAGE C~ LIFT STATION Date installed Size in gallons Vent (Y/N) "Pump on" level at Manufacturer Manhole/Access (Y/N) "Pump 9_ff"_Level at High water alarm level ~ ~__--Gycle'~t~s~ Meets MOA electrical co~..~-J ' - --. SEPARATION DI~"~CE FROM LIFT STATION TO: ' Well on lot On adjacent lots Sudace water ABSORPTION FIELD DATA Date installed ~2~ -- iC/ ""~ ~-~ '~ Soil rating (GPD/FF) / :,~-., Length ~ ~ Wi~h ~-// Gravel thickness ~I~ System type ~-~-~'¢'*--~T~3.'~(: Total depth Total absorption area ~> ';??~ Cleanout present (Y/N) ~ Date of adequacy test /~,' li ~2 Results(pass/fail) /~'~> for Water level in absorption field before test ~'~ ' Peroxide treatment (past 12 months) (Y/N) /~v) (~ After test If yes, give date Depression over field (Y/N) ./'~// Bedrooms SEPARATION DISTANCE FROM ABSORPTION FIELD TO: we, on lot On adjacent lots Property line To building foundation On adjacent lots i~J~t ,2. Cutbank /~V~ ~Y/,~ Water main/service line Sudace water /') 0/}6: Curtain drain O~(?i:'~?' ~<' Driveway, parking/vehicle storage area fi!, ENGINEER'S CERTIFICATION I ce~'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on th.~.E~!.e of this inspection, Signatur Date ell I..IAA Fee $ Date of Payment Receipt Number Waiver Fee $ Date of Payment Receipt Number Commercial Testing & Engineering Co. Environmental Laboratory Services CT&E Ref.~ 94.5593-1 Client Sample ID L1 BLK4 LOM3t S/D Matrix WATER LABORATORY ANALYSIS REPORT Client Name JAMES SIZEMORE & ASSOCIATES WOR/< Order 10541 Ordered By JIM SIZEMORE Printed Date 11/03/94 Project Name Collected Date 11/01/94 Project~ Received Date 11/01/94 PWSID UA 11:17 hrs. 10:20 hrs. 16:00 hrs. Technical Director STEPHEN C. EDE Sample Remarks: ROUTINE S~34PLE COLLECTED BY: J. SIZEMORE. QC Allowable Ext. ~nal Parameter Results Qual Units Method Limits Date Date Init Nitrate-N 1.02 m~/L EPA 353.2/300.0 10 11/02/94 CMR ==================~===========~============================================================================ * See Special Instructions Above UA = Unavailable ~** See Sample Remarks Above NA = Not Analyzed ~ = Undetected, Reported value is the practical quantification limit. LT = Less Than ~D = Secondary dilution. GT = Greater Than 5633 B Street, Anchorage, AK 99518-1600 -- Tel: (907) 562-2343 Fax: (907) 561-5301 .. .' ~,' APPLI¢ ~',NT FILLS OUT UPPER HAl' ~ ONLY .... ~v,' ./::/',.-:,~-: ~ Phone ~ailin~ Addre~ Buyer .., Address ~ - /' - / r Zip~ode Lending InstiluIion ~/:.. _: ,/ :' ~-' z -? ~ .... :-. : '- ~ ' : . Address (?:' "? z ~-~'~: _- . :. , Zip Code Realty Co. & Agent ~:: .- ::~ / ~5:A:~',:~: ~ /~-/:./ ¢ ~ Phone Address Street Locati~ Type of Residence .~Single Family ' D Multiple Family No. of Bedrooms ~ Other W~ Supply ~lndividual ~, ~ A~ACH WELL LOG. A w~l Icg is required for all wells drilled since June 1975. ~ ~ Community ~-~ ~ ~(~ ~ For wells drilled prior to that date. give well depth {attach Icg if available). ~ Public Utility Sewer Disposal ndividual Year Individual Installed: ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time i~ MU q~C',PAL',TY CF ' RECEIVED ( ~ APPROVED BEDROOMS 'OONDITION8 OF APPROVAL ( ) DISAPPROVED ( ) OONDITIONAL APPROVAL' 8oil8 Rating Date ~wer Inslalled Well To Absorplion Area Well Log Received