HomeMy WebLinkAboutLOUDERMILK LT 1
NAME
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
LEGAL DESCRIPTION
LOCATION
~DISTANCE TO: Well Il t i
~ Manufacturer ~ ( ~ ~
~ ~ ~Liq. capac ty n ga OhS .......... E inside Width
~ O%~O IF nulvlclw~ : length
DISTANCE TO: We ~ Dwelling
Well
DISTANCE TO:
No. of lines line.
Top of tile to finish grade
Length Width
Type of crib Crib diameter
DISTANCE TO:
DISTANCE TO:
NO. OF BEDROOMS
PERMIT NO.
No. of co~rtment,
..Liquid depth
capacity in
j~DNEW
E~UPGRADE
Foundation/ et line PERMIT NO.
Total leno. th~.,~)~of lines~ ~/ inches Distanoi~e)~i.en lines
abso]
Material beneath tile ~ ~) ~ ~"inches
PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
Depth )istance to lot line PERMIT NO,
Driller
Sewer line
Building foundation
Septic tank
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
t...L'~UDER IF: ;ii
:i. ;I. 600 CANGE
A!',IC;HCiI::;'.AGtE ~ Al<
3.'.'.1. 5--' 7 0 0
t..i]i"i" ,:: T Z[ii;:
MAX BEDFd.]CIMS ~
L..OT ~
]'~.H,'J[:. c.; ..::,IAI
'X-'~i' , I ioir.. ~ l-i~.~: ¢~ AT t.,..!:::.?,..~ f TWO COMF'AF;'.'TMEN"I'S
· L :i..[' y t. h a'L ."
! am familiar v~:L-l:.l'~ the i"((.z, cjLt:i, pe0!~,r]'lxs~ {'ciP (:)n.l-..sit(~, ~a~et,,~%rs arid ~,~e].ls as set
for. th by the Mun:i. cipa].:i, ty oF Ar'il:hor.~'~.~E, (MOA) al"Id th~:.;, State of
I ~.~:i.!l :i. nsta!:l, the !i~')¢Ei'~',.(,Dlii :i.n ac:cc:mdar'v::;e wi'Lb a!l MOA c: c) d E:.:, ~ and
and :i.n c:c, mt:::,l:i, ance with the design cpit. e¢.ia c::,¢ '!:.h:is perm:i.t,,
]: &,',~;i.:l:! adhere to:, a].l MI]A and State o{ (:~lasl<a requ:i, reme~nts fc;,P the
ESC~V,)E.H"agiE, ~E. yEi'~.,E(,lil CiFi 'l.'.h:i.~iF, CiP ai"ly ;:'icJj~c:(.:;'Fi'I:.. C:)D l]~E'L~f'[:iy
]: i..U*iCJSI"S'~L¢¢.Fii:~ tha'L th:i.s permit :i.s vail. id fop a max:i, mum c::,f 3 l:)edr'c, on'is and
any eniargemerd:.. ¥~:i:!.l I"equ:Lr'e ar'l acldit~c,"~aZ
AF:'F'LI" ..... """ ' ~ ' "' ''¢"' "
/
×-
/ 1600 CAN~£ RD.
.~NCHORA~£ , AK.
SOILS LOG
[] PERCOLATION
TEST
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2O
COMMENTS
;LOPE
¢ 'v~' SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, Al' WHAT
DEPTH? ~'
Reading
Date
Gross
Time
Net
Time
Depth to Net
Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
FT AND
(minutes/inch)
FT
PERFORMED
3. OWNEi~ OF WELL:
WELL LOG
tG. WATER WELL CONTRACTOR'S CERTIFiCATiON:
Domestic
WATER WEi. L RECORD
STATE OF ALASKA
DEPARTMENT-OF NATORAL RESOURE;~
Division of Geologicol 3 Geophysical Survey~
¢;% ~:-7./.~ I~;o/./7t~x~.: ~.~ ...
.. ,... t /14
5. ~ATE OF COMPLETION - {` "
WELL DEPTH: (final} j ~ .. , , -- ~ . ~
~ Public Supply ~ edustt~ ,L
[] T~it Well [] Other:
~,o.._/~_,.. ,o 7o ir, D.p,h '~ig~, /7-
diem. in to ft. Depth Slloku
9. FINISH OF WELL;
irt.
I0. STATIC WATER LEVEL: ~7~'~ ..ft.
[] Above or ]~'Below I~nd ~urfoce
II. PUMPING LEVEL belo~ Ion~ sggfarx,a end YIELD '.'
¢t offer hrs. pumping g.p.m.
12.GROUTING Wall Groute(~:
~aot~rlal: [] Neat Cement [] Other:
I'~.PUMP= Jif avollable) HP
Length et Drop Pipe . ft. capacity __
E~ Sub~q. [] daf [] CentriJical [] O,her
PC) UGI~ 6-650
ANCIIORAGE, At ASi<A ~.~,~., , : ,.'~
(90~"i 764-,! I I 1
<Permit ~: 820745
.,January 31, 19~3
TO: Permit Applicant
Subject: Lot 1 Loudermilk Subdivision
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site s~wer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerel~
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
L. C C!:;! T Z 0
'T'P,E £:'EF'TH OF R ']",':.tEhl(;;:H OR P ZT Z'~; T,'-'.!E D Z:."];TRNE:E E',ETI4EE.!',! THE SUI:;i:FF:!E:E OF THE
GROUND F:!?.,!D THE F-'"~(}TTEii'd OF THE: E;:'::E:RVRTZOi'4 (;iN FEET.'."-.
THERE.' i% i",lO SE'?' H ii~i.')TH FEb':;;: 'Tf;i:ENC:HE"_:.::;.
THE .(3F:'.Fr?-'..?EL. D"EF'"i"I'..i Z~;5 THE ?tZNII'dLli'4 .(:,EPTH OF:' G.r...i:ffv'EL E~IETHEE?.,I TH,E: EJUTFFii....L. F'ZPE
FiND THE BOII'TOH OF THE E',:*(E:FiVFFFIE*i'.,i (:£N FEEl'?;:,.
UF-'ni''i THE '"] r,;i::"":',:.. CF F'I..iIEIL..'i,; r:u HEM ....
i',irq"i-,it.ii',1 D'i':~;'i"Ri'.,i(:;;i.Z -"-'"i;:,?,',. ?::I Pi:.--: ]; ',.,'!qTF' i ¢: ~ 'T'r' R F'?.]:',,,'I::!TE '.::7, EHEI:;?. : T~-~':' Z'.~:3; 2!'*; FEET
"i"(:) F! E:Ed"iHUi'.,!]:T'T' SEHER L. ZN!]!: '.}]S 7::':; F'~!:;ET.
!4EM... !....OC:iS FiRE ,'-]'i::'i':;iliT?¥'I;:T:, Fff.,,r., i-,'!!i~;T ~:~] ~.7.~:-.~- ~.., .......
.......... :_ .... ~., ,!.::.L. TO "rlqF', ....... [:,EI::'FiF;:Ti"!IEi'.,Fi" HT 'i'*14 1 i'.,i,: ;[:~:I2:.1 _..1"'~ '-"::', _
I~IF:' "l'Lli;' i.d~TM ~'-' -' "i i; , :"i - ,
t .......... "'" ~' '.~ ........ , ..-,,~. ;, , ..., ,,,,, . .......... :!i.:,,r':'E)L-: ][ F .i. C:F! T _T ']ih,F::; .... i:::q'-, , ....... "' f" i" ?.,?:;T,I;?! t" "1" Z "?' [) .~, ll...,l .., ,, L
. , ,,..,:...r...,. ....... "i"D '¢,..l,~lli:;,',::' P:,?":'F;..' 'Fi,..i,:::."rFl! F"rT'",i
[' ! SOILS LOG
. MUNICIPALITY OF ANCHORAGE
.,~-~.~: MENT OF HEALTH AND ENVIRONMENTAL PROTECTION [] PERCOLATION
~. i'~ /~ 825 L. Street, Anchorage, Alaska 99501 264-4720 = TEST
LEGAL DESCRIPTION:
5
6
7
8
9
10
11
12
13
19'-
SLOPE SITE PLAN
'Poo~~
YWASGRDUNDWATE.//,, _~ )s
ENCOUNTERED? ( ~O / L
IF YES, AT WHAT
DEPTH?
No. 2225-E
JUNE 25, 1971
!1¢4,~~o
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE
{minutes/inch)
TEST ~UN ,BETWEEN .-- __ FTAND FT
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
Parcel I.D. # ~ {~--~-~/-' ?~'~ HAA #
1. GENERAL INFORMATION
Complete legal description /_o'r- / d_ o (~'~,L,,~ / ~. ~..
Location (site address or directions)
PrOperty Owner
Mailing address
,~ending agency
Mailing add~ess,
Agen~ ~
Add~ess
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 well
Public water
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing 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.
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 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 ~E)~o~ ~L~ ~. ~'./4_ Phone
Address %~-o.~o~.-/~-~ s ~ot, l- ~(¢_ ~_~/~
Engineer's s gnature ~ · -- Date
DHHS SIGNATURE
~' Approved for 2
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
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 DH HS 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) Back MOA ¢Y21
Legal Description:
A. WELL DATA
Well type ~;:~t,J
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
MUNICIPALITY OF ANCHOP, AGE
I~NVIRONMENTAL SERVICE~ION
Municipality of Anchorage JUL .... Z
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division I;) ~.¢' E !
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4~44~ L
Health Authority Approval Checklist
Lo~,'-~b~--,"Z/~t ~ L.K.. Parcel I.D.: (:~ I.~; ~/'c~:~ -
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to "~c>
FROM WELL LOG
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform ~ (:~ ~
Date of sample: ~/&~
B. SEPTIC/HOLDING TANK DATA
Date installed z[/l~/~, ~, Tank size
Foundation cleanout (Y/N)
Date of Pumping "¢(/~ ,/'?
C, ABSORPTION FIELD DATA
Date installed ~/~/~,
Length ~,~'~ Width .,~ '
Effective absorption area
Date of adequacy test ~//~,/?
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
g.p.m. ~" (-~ g.p.m.
Nitrate ~, ~ J Other bacteria~
/-?-/zo/~,~-- Collected by:
/mc>c> Number of Compartments ~_ Cleanouts (Y/N) ~
Depression (Y/N) High water alarm (Y/N) ~
Pumper ,~-b'
Soil rating (g.p.d./ff~ or ft2/bdrm)
Gravel thickness below pipe
Monitoring Tube present (Y/N)
Results (Pass/Fail) ~/3
Fluid depth jn absorption field before test (in.); /~:~
Fluid depth /~'" (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
System type ~ "F'
.~- ¢ Total depth ~ (
Depression over field (Y/N) ~
For , ? bedrooms
Immediately after z/.g2 gal. water added (in.):
Absorption rate = ¢,.-t- ~,,To g.p.d.
If yes, give date ~
D. LIFT STATION
Date installed Size in gallons . ~
Manhole/Access (Y/N) ~~'Pump off" level at*
High water alarm level__at* .~-~-~ / 7~atum
IF.. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation /t'C~ ¢ Property line /o ' Absorption field
Water main/service line ,5"~ ' Surface water/drainage ,~¢c~"r' Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line /¢' f Building foundation
Water main/service line ~-o ·
Surface water ~'0,¢ .t- Driveway, parking/vehicle storage area /O ¢
Curtain drain ¢¢o 4- Wells on adjacent lots
ENGINEER'S CERTIFICATION ....
I certify that l have determined thru field inspections and review of Municipal record~_e~._~,~,~.e, ms are
in conformance with MOA HAA guidelines in effect on this date.
Signature_ _
Engineer's Name ~¢~ ~h~No~,~.~
HAA Fee $ '~/~--0[ ~)
Date of Payment "7 ,/'2~, ~/~'7
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
~t~ CT&E Environmental Services Inc.
CT&E Ref.# 973611001
Client Name Parmone Eng Srv.
Project Name/# West Hose
Client Sample ID West Hose
Matrix Drinking Water
Ordered By
PWSID
Sample Remarks:
Client PO#
Printed Date/Time 07/10/97 11:45
Collected Date/Time 07/06/97 12:00
Received Date/Time 07/07/97 11:30
Technical Director: Stephen C. Ede
Released By ~ .~f~~
Parameter
Nitrate-N
Total Coliform
Results POL Units
2.31 0.200 mg/L
TNTC OB COL/lO0 ML.
Method
Allowable Prep Analysis
Limits Date Date Init
SM18 4500-NO3F 10 max
SM18 9222B
07/08/97 JRJ
07/07/97 TMW
·
· - CT&E EnvironmentatServices Inc.
Laboratory Division
Drinkin~ Water ,~nalysis Repor~ for Total Coliform Bacteria ~oo ,,v.
~ Anchorage, AK 9951 8-1~05
~ L~TTRUCTZO:VS ON ~E~ SZDE BEFO~ COLLECTZVG SAHPLE Tel: (~07) 5~2-2343
Fax: (~07) 55i-5301
Nfl/ST BE COMPLETED BY WATER SUPPLIER
P~VATE ~'ATER b~bTE: I
J]
Send ResMt~' ,~ Send Invoice
Send Res.M.rs O Send Invoice
S .&MT LE DATE:
>.--U IPL= TYPE:
s.~x,n~ [oc^'no~-
Routine
Repeat Sample (for routine sample
wi'th lab ref. no. )
Special Purpose ~0~
3[on~h Da)' Year
Held~ Fo~zC~ f~6~9 t io ~
Untreated Wazer
Time Collected
Collected By
Date Received
Time Received
Analysis Began
Analytical bIethod:
TO BE COMPLETED BY LABOR-ATORY
.-hnai?'sis shows this V,'azer S.-k3,LPLE to be:
~ Sadst~cDrv
Unsafisfactoo' ~
O>amv[e over 30 Eo:5 old resuk~ay
be unreliable
o Sample too lonz ia ;~asit: sample shouM
not be over 48 hours o[d at examination
to indicate reliable results. Please send
new sample via speciM delive~ mail.
)lBO
7(v tU', 3o
~Membrane Fi[ret
~ MMO-MUG
Number ofco[onies.;[O0 mi.
Lab Ref. No. Result* Analyst
Sent to A.D.E.C. Anch gbka .Jun U
Faxed
Date: Time:
Client notified of unsadsfactor}' results:
Faxed
BACTERIOLOGIC.&L WATER A_N.XLYSIS RECORD
%1~IO-~.-'G Result: Total Coliform
Membrane Filter: Oirec't Count
Verification: LTB '"' BGB
Fecal Coliform Confirmation
E. Col~
Colonies/100 mi
COLIFIRM
~'- *JUL-22-199? i5:i8 CT&E ESi ANCHORAGE 9075~i530i P.02/02
CT&E Environmental Services Inc.
Drinking Water Analysis Report for Total Coliform Bacteria 200 w.
And-homage, AK 99~ 18. ! ~0~
~40 /~TRUC~IO~.~ ON RE~E~E $I~E ~EFORE COgL~L. vG ~,~[P~E Tel: (907)
MUST BF. COMPLET~J~-BY ~VATER SUPPLIER
PUBLIC WATER S¥ST£~!
PRIYATI~ WATER SYST£M
~.,, ~,~i. ......
~;T,- ' '.,
....
SAMPLE ~PE: '
~ Repeal S;mplJ (for routine *=mplJ
L' with lab roe. no. )
SAMPLE LOCATION
Year
Teeoted Water
Untreated Water
Collected
By
Fax: 1907)
TO B~ COMPLETI~D I~Y LABOR. ATORY
Analysis ;ho~ ~his Water SAMPLE to be~
Satisf=;tory
0 U~atisf~ccoD'
S~ple over ]0 hours old. r~ut~ may
be unreliable
S~ple too Ion! in transit: sample should
not be ove~ 48 hours o1~ at e~amination
to indi~e reliable result. FlaMe send
,ow sample via special delivew mail,
...
Dote Received
Time Received
Analyst
Analytical Method: '~Membranc Filter
M,%IO-MUO
~ NUlTIJ~Ir of¢olonie~'lO0 mi.
~ ..... Result*
Client notified of unsntlsfnctory results:
BACTER/OLOGICAL WATER A:.N'.,LLYSiS RECORD
Commcnu:
Fe~nl Coliform ConfirmaUen: ....
Filtol Memb~p. Rr~tet R~..uI~ .O C..llro~'m!!00 m!
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D.#
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Lot I; Loud~rmilk Subdivision
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
Location (address or directidhS):-
10541 Loudermilk "Anchorage,·''Alaska
(b) Property owner H.U.D.' #037370 :
Mailing Address'
(c) Lending Institution -
Mailing Address
Telephone:(home)
60~-W~st 4th-AVenue. Anchorage. Ak.
"=": ' Telephone
Business
(d) Real Estate Company and Agent ASSOCIATED BROKER_~ ATTN.'
(e) Mail the HAA to the following address: (or check here ~if hold for pick up.)
List contact person and day phone number below:
S & $ ENGINEERING
17034 Eagle Ri,cer Loop Road No
Eagle River, Alaska ~577
2. TYPE OF RESIDENCE
Single-Family [~ Number of bedrooms
WATER SUPPLY
Individual Well,~] Community [] Public []
Note: If communitY, Well system~ must have written confirmation from the State Department of Environmental
Conservation attesting to' th legality and status.
SEWAGE DISPOSAL
On-site [~ Public [] Community [] Holding Tank []
Note: If community well systemj must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 {Rev. 7/88) Page 1 of 2
~ ~.o ~ e6~d
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., NOI.LVlNldO.-INI aNY YJ.¥a 'HOld~$ ~l'114 '$.L$iilJ. '$NOIJ. C)~IdSNI ~DNlalAOUd
A: WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
,~y oH,_e, althAu,!~0rity Approval (HAA)
~'~'~'~.~r'. ,.CI:jCTC~I~Li~'i'--~,FEBRUARY 1984
~,~,~ .... ~' ........ '" ~-4744
'~'~. *: ?F~.~ Legal Description: ~
Well Clas§ification I ~ ~J ~ ~/~"'L~ If A, B, C, D.E.C. Approved (Y/N)
Well Log Present(~N) '"( Date Completed
Total Depth "'~ Cased to '"'~ Depth of Grouting
I
Static Water Level
Casing Height Above Ground ~.'Z..~ .Jr"
Electrical Wiring in Conduit(~)'N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on/Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Co,ected by '.
Water Sample Test Results
Comments
Yield [~,"~.. ~_.~-~"1 ~
:. d, ,,~ .... Z..,~' -- '~,~ '".'.)
Pump Set At t).~
Sanitary Seal on Casing(~N) ~
Depression Around Wellhead (Y~ ~'
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
B. SEPTIC/HOLDING TANK DATA
Date Installed ~ O -~.~ t~6ize
StandPipes ~(.~N) V
Depression over Tank (Y~
Pumping/Maintenance Contact on File (Y/N)~,~/~
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well-
No. of Compartments ~'-
Foundation Cleanout (~N)
! Date Last Pumped
Temporary Holding Tank Permit (Y/N)
Air-tight Caps ~;~/N)
To Building Foundation
To Disposal Field
To Property Line
To water Main/Service Line
To Stream, POnd, Lake or Major Drainage Course
Co mentsA -
72-026 (Rev. 7/88) Front Page 1 of 2
C, ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Type of System Design ""~..~
Length of Field
Depth of Field
Gravel Bed Thickness ~. I
Square Feet of Absortion Area t,¢ ~-~:,"~ Statndpipes Present~)N)
Depression over Field (Y~' Date of Last Adequacy Test
Results of Last Adequacy Test ,~¢~./-~ ~
SI=PARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation ,/
Lot ICi
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
; On Adjoining Lots
~, o* ~ To Cutback (if present)
To Property Line
To Existing or Abandoned System on
Comments
Date .lO, stall ed
Size in ~
"Pump On" Level
Dimensions
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
. P..~umping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HAA g
inspection.
Signed $ & $ ENGINEERING
17034 Eagle Rl~er Logp Rg~d No, 1~0~
MOA No. ~ ¢ / ¢~¢ ¢~
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
u de n~,Ci-~~.~e of this
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SAMPLE for Work Order $ 17682
Date Report P~inted: OCT 24 89 @ 12:18
Client Sample ID:L1 LOUDERMILK
PWSID :UA
Collected OCT 20 89 @ 13:00 hzs.
Received OCT 20 89 @ 13:00 hrs.
Preserved with :AS REQUIRED
Client Name : S & S ENGR
Client Acct : SNSENGP
P.O.$ NONE RECEIVED
Req $
O~dered By : R.P.
Analysis Completed :OCT 20 89 Send Reports to:
Laboratory Supervisor :STEPHEN C. EDE 1)S & S ENGR
Special
Instruct:
Chemlab Rei ~: 8155 Lab Smpl ID: 3 Matrix: WATER
Allowable
Paramete~ Tested Result/Units Method Limits
NITRATE-N 1.2 mg/1 EPA 353.2
Sample ROUTINE SAMPLE.
Remarks: COLLECTED BY
i Tests Performed ' See Special Instructions Above UA=Unavailable
ND= None Detected '* See Sample Remarks Above
NA= Not Analyzed tT=Less Than, GT=Greatez Than
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
;ENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
(b)
(c)
Location (address or directions)
Applicant Name~'""~w\ ,~"~Ct. -,fj,~L- Telephone: Home -~ "-7~--'t--'7 Bus ness
Applicant Address ~ f~-,4.¢:;~ C,-,~-~- ,-----------------~.~- , ,~I~F~A~,~
Applicant is (check one): Lending Institution []; OWner/builder []; Buyer~; Other [] (explain);
(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~ U ~ti-Famii~ [] .~ ~Other ',
Number of Bedrod~ns
WATER SUPPLY
Individual Wel~ Community
Note: If community--well system, must have written confirmation from the State Department Ol Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite'"~'~ 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.
72-025 (11/84)
Page 1 of 2
5.,
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION ~
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 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.
Nameof Firm ~,~'~'~t'V['~:~z,~ ~-~'"-~-~5~- Telephone ~'~_~" --~7 ~
Address ~ ~'~ ~ [" ~7~ ~ ~~-- ~ ~ ~'~ t
Date ~ ~-~(~
DHEP APPROVAL
Approved for YZ- 'L - edrooms by
Approved ~.~..~. Disapproved
Terms of Conditional Approval
Engineer's Seal
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEPi 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.
P~n~ 9 r~f 9
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal Description: ~
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTION.
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
Well Classification '['"~'FI'~J~ If A, B, C, D~.E.C. Approved (Y/N)
Well Log Present (Y/N). k¢~;~ Date Completed 7/~/~ :~ Yield
· 'no '
Total Depth ~71~ Cased to Depth of Grouting
Static Water Level 4-~' /~,,//,¢./~ ~ Pump Set At (--,~ C~ /
~ // ", Sanitary Seal on Casing (Y/N)
"r'~ Depression Around Wellhead (Y/N)
To Septic/Holding Tank on Lot ~ ~ ~ / ~ ; On Adjoining Lots I ~ ;
To Nearest Edge of Absorption Field on Lot iZf7 ~ ; On Adjoining Lots
To Nearest Public Sewer Line ~/ICr To Nearest Public Sewer
Cleanout/Manhole~ I',~ / ict', _ To Nearest Sewer Service Li n(~o? j ,,¢_/~,,,,,,,,,,,,,,,,,~ _C~_Lot
Water Sample Collected by' ~'~.~*'~ .-~-., ~'~ ,~¢-Jcf~--%~--- ;Date ., .
Water Sample Test Results
Comments
SEPTIC/HOLDING TANK DATA -
Date Installed 4 77'%--':i: .... No. of Compartments '~?-
Standpipes (Y/N) "i'~- Air-tight Caps (Y/N) '1'~-~ Foundation Cleanout (Y/N) ~'~-~
Depression over Tank (Y/N) ~q.~O Date Last Pumped ~'/~,~'./~'~ ~
Pumping/Maintenance Contract on File (Y/N) 74~/~ ; for
Holding Tank High-Water Alarm (Y/N) ~/i,~' Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well '~ I ~ ~
To Property Line i ,~
To Water Main/Service Line i ~
Course i ~-¢"~ ~,h~ '
To Building Foundation
To Disposal Field '
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Square Feet of Absorption Area
Depression over Field (Y/N) ~'-,~ ~;~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I ~ "7 /
To Building Foundation I ~,O ~.--~-
Lot ~k~J ~
Type of System Design
Length of Field '~:~"'"
Depth of Field_ ~'/
~:~"'""~ ~[_a_vel Be d Th ic k n ess
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
TO Property Line 15 /'-Jr--
To Existing or Abandoned System on
; On Adjoining Lots -~(~ t.~_._
To Cutbank (if present)
JO/ .~ ..
Comments
D. LIFT STATION
Dimensions
sDi~teeilnnS~llll~Son" Level at
"PumP __ / "Pump Off" Level at
THiegsledW~r Alarm Leve,,~
Code~ tvZ Adequacy Test.
Electrical
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I P za. ve checke~f, verifiel~. '0r,,conformed to all MOA and HAA guidelines in effect on the date of this
inspection.
Signed '"~'~'"~' ~', ~~-- Date ~ ' J~/"~/~-~(~/'~-'
Company ¥-¢4xT~¢rrl_~ /~ MOA No.
Receipt No.
Date of Payment
~,.. _ ~ ..~ Engineer's Seal
Amount:
$
'3,.~
Page 2 of 2