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Home My WebLink AboutHIGHLAND HILLS #1 BLK 1 LT 9 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENI'AL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telenhone 264-472.0 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT LEGAL DESCRIPTION , i /-~'~CTI¢'L/tZ'~O I I Well I Absorption area _____DISTANCE TO: ] FN.~ ~)T'- I f~,J I ~:~ Manufacturer Liq. capacity in gallons I Inside length 70~)CJ ~ IF HOMEMADE: I ~ DISTANCE TO: IWell ~ I/I Dwelling ~nu,~c,a,~, //t Well DISTANCE TO: )NJ~?.i~ t ~ No. of lines / Lmmgth of2~,.~~ ,eacjl[ ne Dwelling Material~. J.Width Material Nearest lot line r] Trench wid$~ '::2L'~ iecbes Total le.~tb~.~f ~ines Top of tile to finish grade Material beneath tile /k~ I~9 ~.ches Length '~dth ath Crib diameter Type of crib Well DISTANCE TO: ]PHONE ,,~,,N E W OTHER DISTANCE TO: PIPE MATERIALS ?FY. ,. ~_~h ~uilding foundation SOIL TEST RATING, INSTALLER REMARKS NO. OF BEDROOMS PERMIT NO~ __ O,.SZ) / ~ No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons ib depth Total effective absorption area Building foundation Nearest lot line Driller Distance to lot bne I PERMIT NO, Sewer line Septic tank I A~sso~ area(s) I C[]I',F!'(tiC'T: ! I ~..~Nt:::. r, ziPPI.!:8 D :[ V :i: !i!~ ]: [)N ~: I.I :I: {,.] I.,!!....,q N :!i) !~ :1: i.. l,.~:ill :!$ SE:C'T' ]: !::)!'.1 ',', ,':./'.~iii T[)'?..tNS~I.I ]: F' i; :L 4N 87:5:5 :L (!!i~l:;! ,, F"T ,, JIF;..' P'~!:::l::~iiii:!!~ ) PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O COMMENTS PERFORMED BY: 72-008 (6/79) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST j~' SOILS LOG [J PERCOLATION TEST DATE PERFORMED: SLOPE SITE PLAN WAS GROUND WATER ~ O S ;NCOUNTER ED? L O P E ~.~ .~ ,:; Gross Net Depth to Net Reading Date Time 'rime Water Drop No. 14.57.~ P~'L 09~,.297,9 PERCOLATION RATE TEST RUN BETWEEN FT AND CERTI FI E D~_~ (minutes/inch) FT WAI'ER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of GeologicGI & Geophysicol Surveys LOCATION OF WEI_I. (Please complele either Io~ lb or lc,) __~/o-I Borough Subdivision. . Lo S ck _A~,r_ ~. __~?_ .-:' _ ;' Street Address one Arco of Well 2~ WELL LOG Mdieria Type Drilling Permll No. A.D.L. No. ck ~i/4qlrs. Section No. TownshiPN[~ Range E[~] Meridian · L__of__at of- SJ~ W[~] AD INTERSECTIONS 3. OWNER OF WELL: ' ' . ' Feet 8glow Surface 4. WELL OEPTH; (final) 5. DATE OF ~OMPLETION TOp BoHom % r ' fl' ' --" r ~'' .) ' ~ ' 7' USE: ~ Domeslic ~ Public Supply ~ Industry '.-'-' /';'" ' ~ Irrigation ~ Recharge ~ Commericel '" _~ ' ;~ ,' .-' 8. CASING: ~ Threaded ~ Welded Backfilling Gravel pock ~ Above or ~ Below lan6 surface Dote ---- Equipment used: '~ I1. PUMPING LEVEL below lend surface end YIELD ft after . hrs. pumping g.p.m. /~ / I~.GROUTING Well Grouted: ~ Ye~ ~ No 15. PUMP: (if available) HP Length of Orop Pipe ft. capacity g.p.m. ~ Subm. [] Jet ~ Cenlrifico, ~ Other I~. REMARKS: 15. Water Temperature ~.o ~ F ~ C Conirocl License Number 16. WATER WELL CONTRACTOR'S CERT MUNICIPALITY OF ANCHORAGE A Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF C)-N-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING HAA # ~-~ ~C3~C~('Y"~\ ~ ~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include 10t, block, subdivision, section township, range) Location (address or directions) (b) Property owner' .L, onh~r Mailing Address 15-85- ¢/¢ ¢¢v-o/"' Dr'..) (c) Lending Institution (d) (e) Telephone: (home) Z),~ 11~4 1"'-4 ~.,/ ~.,¢- e ~...c-- Telephone Business Mailing Address Real Estate Company and Agent /~¢,~ [ ~, Address ~¥~0 /¢~,"~¢ (! ~ Telephone ~ ~ ~ -O~ f ':' Mail the HAA to the following address: (or check here [~, if hold for pick upl) . .c .,;,.' · List contact person and day phone number below: : / 2. TYPE OF RESIDENCE Single-Family [] Number of bedrooms 3. WATER SUPPLY Individual Well [] Community [] Public [] ,,:, Note: If community .,..w.,ell system,must have wr tten conf rmat on from the State Department of Env ronmenta "Conservahon attesting to th legahty and status. ' .............................. 4. SEWAGE DISPOSAL : Note:'lf com.?unity we system must have wr tten confirmat on from the State ..D, epart~ent of En¥ ron,m,,e,n;!.a' 72'4)25 (Rev. 7/88] Page 1 of 2 ')pOM s,Jeeu!eue iBuo!ssejoJd eq), u! SUO!SS!LUO Jo sJoJJe JoJ elq!SuodseJ lou s! ebBJoqouv ~o ~!led!o!u ntAI eqj. 'penss! s! e~BoljRJeo B eJojeq re, Bp ez/qBue Jo suoRoedsu! ~onpuoo ~ou op SHHQ jo see/~oldLU~] 's~ueLue~!nbe~ e~s pub le~epe~ u!B],¢eo ,~lsp, Bs o~ ~ep~o u! suoRn~Rsu! 8u!puel Jieq~, pub s@uuoq jo sJesBqo~nd o~, ,~se~noo B sB s!q~ seop SHHQ eq.l. 'misel¥ ~o e~m,S eq~, u] pe~e),s!ee~ ~eeu~6ue iBuo!ssejo~d ~,uepuedepu! u~/~q e^oqB g qde~eB~ed u! ue^!8 suoR~uese~deJ eq~, uodn ,~lUO peseq le^o~'ddv,~,poq~,n¥ q~lBeH senss! (SHHQ) seo!^~eS uB~unH pub q~lBeH ~o ~UeLU~JBdeQ eeB~OqOUV ~O ,~),!lBdio!unlAl eq.L A. WELL DATA Well Classification _ MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) UN;C p^,, .'C,~IrE/,C..,KLIST ' FEBRUARY 1984 ENVIRONMENTAL $I-'RVIC~S D!VISION Legal Description: R 'CEIVEI) Well Log Present (Y/N) ~¢S _Date Completed Total Depth_2~o Cased to. IG Depth of Grouting Static Water Level Casing Height Above Ground_ 2G¢ Electrical Wiring Jn Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot I 3~ ' To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot ~ 8~ ~ Water Sample Collected by FL~T~P ~¢~. Water Sample Test Results ~&Lf ~c~e~ - ~ ~oh~ Comments If A, B, C, D.E.C. Approved (Y/N) Yield '7 GPPI Pump Set At :~, Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots I ff~' ' ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole ;Date B. SEP'HC/HOLDING TANK DATA Datelnstalled 5/u/~5 Size IooO G No. of Oompartments Standpipes (Y/N) "/e'$ _Air-tight Caps (Y/N) _ Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) kI.A . Holding Tank High-Water Alarm (Y/N) l~,/~ , SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well I 3 z( To Property Line '7 ~'~ ' / To Water Main/Service Line To Stream, Pond, Lake or Major' Drainage Course '~ ,, o e ' Foundation Cleanout (Y/N) Date Last Pumped S'/~',¢/? 0 ;for ~,~ ' Temporary Holding Tank Perrnit (Y/N) To Building Foundation ~'~ To Disposal Field ~.~ ¢,o. ~ro C.c. Comments 72-026 (Rev, 7/88) Fronl Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field 15o 5oo Square Feet of Absortion Area Depression over Field (Y/N) NO Results of Last Adequacy Test /) SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well I~$ / To Building Foundation Lot N,/4r - ~//~ ~1~ Type of System Design Length of Field 25' Depth of Field ~' Gravel Bed Thickness Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on ; On Adjoining Lots To Cutback (if present) To Water Main/Service Line cJ'Z ' To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments ~ y.¢ ~em c~c..,J"~,¢,¢~ D. LIFT STATION Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HA~jCd~..~. ~o effect on the date of this inspection. ~ _~,?.~ O~ /'~,~ Signed ~~ .¢ Company F(~/ ~c~c~l ~e~c'~ ~/._ _/.. ~ ~ .... ¢ Engineer's Seal MOA No. 2 ¢ - Of~ Receipt No. ¢2/~ /~¢[8"2 Receipt No. Date of Payment ~< ~ l/- ~ ~ Waiver Fee: $ Amount: $ ,/~), ~'~ Date of Payment 72-026 (Rev 7/88) Back Page 2 of 2 A CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. #92-0040440 e IVIUNICIPAL~TY OF ANCHORAGE DEPART¢clEN'r OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTI--IORITY APPROVAL OF ON-SITE SEWER AND WA~ ER FACILITY 264-4720 Application Date 1. GENERAL INFORtVlATION (a) Legal Descrip[ion (include lot, block, subdivision, section, toycnship, range) _/.,~. ~.._ ~_. __..l??:_ /____./.-_: ,:~ /, / ~ ...... : /,~' / z'' '~' / Location (address or directions) (b) Applicant Name ._._~.~{_._ ~"-: ">C 11 Telephone: Home ~I~"~-'~ Business ~'? ¢¢ '- ~ ?~-~ Applicant Address -~',.1~" ~ .7? ~- ~r' &7 ~ / ,Yr~ ~ /'~J~_ ~ ~3- ~D .~ (c) Applicantis(chockone):Lendinglnstitution~;Owner/builder~;Buyer~;Other~ (explain); (d) Lending Institution --~:~'-r~ Telephone Address .................................................................... (e) Real Estate Company and Agent f/~ ................................... Address (t) -I-elephone /.~ z_ -~v~a~l'th~ ,-~AA to the following address: TYPE OF RESIDENCE Single-Family ~¢ Multi-Family I~J Number of Dedroorns '~ Other WATEFt SUPPLY Individual Well ~1 Community FJ Public ~ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to tile legality and status. 4. SEWAGE DISPOSAL Onsite ~']" Public E] Community [~] Holding Tank [~ Note: If cornmunity well system, must have written confirmation from the State Department of Environmental Conservation attesting to tile legality and status. Page -I of 2 72-025 (11184) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFOt:;MATION As certified by my seal affi×ed hereto and as of the validation date shown below, I verify that my mvestigatior 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 investi!:~atio ~ 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 Telephone [)HEP APPROVAL Approved for _ :"-%% ~'~-, bedrooms by Approved ~ Disapproved Terrns of Conditional Approval ~ ',._., - ~ . ~- ,:.~.~.,'- ~_, .t; Date Conditional CAUTION The Muncipality of Anchorage Department of Flealth and Envir~)nmental Protection (DHEP) issues Health Authority Approval certificates baaed 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 72~025 (11/84) MUNICIPALITY OF ANcHC ;E DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION - MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORYrY APPROVAL (HAA) . UL 2, 2 lg85' RE6EIVED CHECKLIST ~ FEBRUARY 1984 264'4720 Legal Descript~_on: _~c~J~ WELL DATA Well Classification Well Log Present Total Depth ¢2~-~¢'~ ~ f Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduib~'~'.~N) '"' Separation Distances from Well: To Septic/J4etC~g Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole If A, B, C, D,E.C. Approved (Y/N) Date Completed ~:~- - ',~'~ ' ~.; Yield 'L(,~_/ ~ Depth of Grouting Pump Set At __ ~.) Sanitary Seal on Casing Depression Around Wellhead I 1 ~.~Z.~- ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer TO Nearest Sewer Service Line on Lot ~ C~ (''~ Water Sample Collected by ~----~" ~-~ ~1¢2..,. ~L:,~C...x,/'I,-"~--~ ; Date .~ Water Sample Test Results Comments ~ ~-~ ~ ~ ~. B. SEPTIC/hI,t~,E.BH',~'G TANK DATA Date Installed ~-' \ \ - ~?'~' Size \ ,:~¢-~",f.-- No. of Compartments '*Z- . Standpipes~N) '* Air-tight Caps ~'~N) ~' Foundation Cleanou~b'N) ''~ Depression over Tank (Y/.~ -' Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) Separation Distances from Septic/Holding Tank: To Water-Supply Well To Property Line To Water Main/Service Line Course Date Last Pumped .; for _ Temporary Holding Tank Permit (Y/N) 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 Date Installed ~ - t \ Width of Field ~ Type of System Design Square Feet of Absorption Area '~--~ Depression over Field (Y,~'~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ¢ /t~ To Water Main/Service Line Length of Field Depth of Field Gravel Bed Thickness Standpipes Present Date of Last Adequacy Test To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line To Existing or Abandoned System on ; On Adjoining Lots '"'~'~-~-~ To Cutbank (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 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ ~ -~ ~*~,~,~,~'" ..... Date ~/2 ~.-/c~. Comp~ay2!-~ ~l~m~?, ~ ~¢~ ...... MOA No. Receipt No. ' ......... Date of Payment ri Amount: $ ~ ,0~ Page 2 of 2 72-026 (11184)