HomeMy WebLinkAboutBLUEBERRY HILL BLK 3 LT 4
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
IPH°NE I NEW
MAILING ADDRESS
LEGAL DESGRIPTION
LOCATION r NO. OF B~ROOMS
IWel' I Absorption area Dwe~ PERMIT NO.
U ~ DISTANCE TO: 2 5"O ~F ~ ~ YN~e~
~ M anufactu reI ~0~"~ 1 ~ M ateri a~T~ I .o. of co m part men ts
Liq~ggc~ rn gallons v IF HOMEMADE: Inside length Width Liquid depth
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ Manufacturer Material Liquid capacity in gallons
Well Foundation Nearest lot line PERMIT NO,
~= DISTANCE TO: ~ '~ /'7¢t ~ I¢¢ ~ +
~ ~ N°' °f lines~ Length °f each~ ¢ 'Crime Total len~f ~s Trench w~t~ inches Distance between lines
~ ~ Top of tile to finish grade,~ Material beneath tile Total effective absorption area
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
PIPE MATERIALS
Pvc
SOIL TEST RATING
REMARKS ~
· ~ .... . *~--
~ ~ e- e .~ ~
' -
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
I hereby cm'tify that ! have ~;urveyed lhe following
Anchorage Recording Precinct, Alaska, and that
ments s~tuated thereon are the
not overlap o~ encroach on
to, that no improvements on pro~rty lying adjac~t,
encroach on the premises in question and that ~h
roadways, transmission lines or other
said property excep~ as i~dicated her6~.
Dated at Eagle River. Alaska
~OBERT C. ~OHNSON
SCALE: Registered Land Su~eyor
1' -~ ~{,..: Box 456. EagleRiver, Alaska
Phone (907) 694-254~
MUNICIPALITY OF ANCHORAGE
~ Health and Environmenta3 '~rotection
Department
825 _ Street, Anchorage, AK. .3501
264-4720
d"~ * * * HANDWRITTEN PERMIT * * *
Permit ~~,~.
ON-SITE SEWER PERMIT
~ Mailing Address:
Applicant
:
Location:~'~/~ 6~7-- Phone Number:
Legal Description: ~7~ ~ ~ ~/~4~~ ~~-~/~ot Size:
Type of Soil Absorption System Is: ~
Trench: ~ Drainfield: Seepage Bed: Holding Tank:
Maximum Number of Bedrooms: . ,~---- Soil Rating(sq.ft/br) /.5~
The Required Size of the Soil Absorption System Is:
The length dimension is th~ength(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(HS'L-B'PNG-) TANK SIZE = /,~d'~ 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 ~ill serve.
· * * TW0(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 51, 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
the/~idence is rem~led to include more ~~r~~
Signe~: F _ ~ Issued by:
Date:
SWP/024 (1/81)
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR: ,,~<'/~0 ~lJ-/- 5~//~.~}~-~ DATE PERFORMED:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
2o
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
G ross Net ~ ~,1~, to Net
Reading Date Time Time~.'~,___ ~ ri ~ '~11,~ Drop
L
PERCOLATION RATE
(minutes/inch)
TEST RUN BETWEEN FT AND ~ FT
COMMENTS Z~I~,A[ /'-c)~,. i~'(~) ,~ /f~: /z~,~/~¢~,~. ~ /~l~o~. ~ oF T ~c'~C~ ~ ~ ~
PERFORMED BY: ~O~ '~ ~
~~C~/~/~ CERTIFIED BY: ~, ~ ~d~&T~ DATE:
72-008 (6/79)
INVOICE NO.
1448
/
Fig P~"/e/~'~'.EL V. ~ A ]~ I>, . g R ~ ~, .. F
7H 73~
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Ehvironmental 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
HAA# ~/~---~c~. \ (~%\0
GENERAL INFORMATION
Complete legal description
Lot 4; Block 3; Blueberry Hill Subdivision;
Location (site address or directions)
NHN Brownie, Drive,
Property owner
Mailing address
Lending agency
Mailing address
Barry Willis
1488 E~g~¢ Rive)~ Road.
Day phone 694-6261
Eagle. Riv~.J~, Ak. 99577
Day phone
L~i C~owd~r JACK WHITE COMPANY
Agent
Address 10829 Ea~le, River Road, Eagle, River, Ak.
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
Day phone 694-4200
$ N
99577
NOTE:
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER 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
'~{JO~ S,JE)eU!6U9 leUO!SSejoJd ~q~, u! suo!ss!uJo Jo sJoJJa Joj @lq!suodsaJ
3ou s! ebeJoqou¥ jo ~Hled!o!un~ aql 'p~nss! s! a:jl~o!j!:iJeo ~ aJoj~q e~ep @ZXleUe Jo suo!3oedsu! ]onpuoo
3ou op SHHQ jo s99~OldUJ3 's~ueLuej!nbeJ ~3e3s pue leJepej UmlJeO/g,s!~s o~ JepJo u! suop, nu~,su! l~u!pu@l J!eq~ puc
SeLuoq JO sJeseqoJnd o~ ~selJ noo e se s!q3 seop SNHQ 9ql 'e>isel¥ jo m, e3S @q] u! peJe]s!l~eJ J~@u!l~u9 leUO!SS@jOJd
]uepuad~pu! ue ~q a^oq~ cj qdeJSeJed u! ua^!6 suop, e]uaseJdeJ eq~ uodn ~lUO pas~q sm, eo!j!~JeO le^oJdd¥
,q!Joq~n¥ q~,leaH s~nss! (SHHQ) S~O!AJeS uewnH pue q]le~H jo ~,uauJlJedaQ al~eJoqouv jo XUled!o!unlAI ~qJ.
s~uewwoo leUO!Upp¥
:suo!~elnd!~s ~U!MOIIOJ eq], qj]M 'SLUOOJpeq
JOJ leAoJdde leUO!Upuoo
/g-h z.'Z
'SLUOO~peq
euoqd
'peAoJddes!a
Joj peAoJddv ~-~
31~nJ.~INelS
· uo!~oedsu{ s{4i Jo ejep eq{ uo loejje u} suo{leln6eJ pue 's@oueu!pJo
'sepoo e~,elS pue led!o!uniAI lie LIUM eoUe!ldLUoO u! s! LUe~SXS lesods!p Jm, eMelS~M JO/pUe Alddns
Je~eM eUs-uo eq~, 'uop, oedsu! pue uop, el~p, seAu! XLU LUOJ,~ pUe Selg[ el~eJoqou¥ Jo ,q!led!o!unlAI
LuoJj peu!elqo UO!leLUJOJU! eql uo peseq ~eql XJ!JeA JeqlJnJ I 'u!eJeq pe~eo!pu! eJnlonJ~,s jo edam, pue
SLUOOJpeq JO jeqLunu eq~, Joj e~,enbepe pue leUO!lounj 'ejes s! Lure, SAS lesods!p Je}eMm, SeM Jo/pue
Alddns Jm, eM m,!S-UO eql leq~, SMOqS uop, eo!ldde leAoJddv XuJoqlnv q~,teeH s!q~, jo uo!~elS!~SeAU!
ALU ],eq~, AJ!JeA I 'MOleq UMOqS eJep UO!~ep!leA eq~, jo se pue o~eJeq pex!jje leas XLU Aq pe!j!lJeO sV
'9
,. EI:r:INI!DN=1 AEI NOIJ. O:IdSNI dO .LN=IIN::I.LV/S '9
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. WELL DATA
Well type ~"~-t~ ~
Log present i~/N)
~-~ ~ ~t~-'~ ~o~. ~,~.-~/ Parcel I.D.
If A, B, or C, attach ADEC letter.
Date completed ~".. ~,~ _ ~.-z~
Total depth
Sanitary seal [~N)
Cased to
FROM WELL LOG
ADEC water system number .
Date of te~t ~"~'
Static water level ~Z..
Well flow ~',
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Public sewer service line
Driller
'Z..~>~ ~, [Z.. Casing height
Wires properly protected ~N)
AT INSPECTION
g.p.m. '7, .'1
~11~
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: 7'-/~'~ I
Nitrate
-- /
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed b~3., --~'~
Cleanouts~N) ~
High water alarm (Y~
Date of pumping '7-. J'7--~ I
Other bacteria ,/~o~---
S & S ENGINEERING
i 7~,~4 t:agie River Loop R~ad No. 204
Eagle River, Alaska 99577
Tank size t. ~C>~ Compartments
Foundation cleanout(~N) ~/ Depression (Y~
Alarm .tested (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well (s) on lot J c~ ' ~'~ On adjacent lots ~ Cx-~ t -r"
TO property line lC) ~ +' Absorption field ~' '
Surface water/drainage 1~3~3 ~ +'-
Foundation
Water main/service line
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electriC,
~E~TANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Manhole/Access (Y/N)
.,-~'~'b"~'p off" level at
Cycles tested
Surface water
D. ABSORPTION FIELD DATA
· Date installed [~'- ~ - ~
Length ~ Width
'Total absorption area 5"D~:~
Depression over field (Y/~
Results4~Xfail)
Peroxide treatment (past 12 months) (Y~
Soil rating
System type '~-'~--~/--'~
Total depth
¥
Gravel thickness 1~~
Cleanouts present ~)/N)
Date of adequacy test
for ~/~h~.~__ ~-5_)
If yes, give date
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
On adjacent lots
Well on lot loc> ~'~
To building foundation
On adjacent lots '~1~'~ ~'~
Surface water I
Curtain drain ~ 1~~,-
E. ENG~EER;s CERTIFiCATIoN
Property line
Cutbank
To existing or abandoned system on lot
~t ~' Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff_e~t
e~Lf~.e~.(;~t{ date of this inspection.
S & S ENGINEERING
Signature
. Eagle River, Alaska ~5~
Engineer's Name
Date
HAAFee$ //~- ~/
Date of Payment y'".,~ ¢~'/"
Receipt Number .~,~,2_. )/~/ .~/L// )
Waiver Fee:$ ·
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
CHEMICAL & GEOLOGICAL LABORATORY.
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
Date l~eport Printed: JUL 18 91 ! 16:52
FAX: (907) 561-5301
Client Sample ID:L4 SI BL~BERa! HILL S/D Client hM :$ & $ ENGINISItIJI~
P~ID :UA Client Aeet :SHSEN~P
Colloetod ~ 8 91 ~ 17:45 ~s. BPO t PO J H0~ ~ICII~D
Chemlab Ret l: 913276 Lab Smpl ID: 13 Matgix: MATE~
Allowable
Paxamotez Tatted ~etult U~tt, Mtthod Limits
NITRATE-# 0.32 ag/1 EPA 353,2 XO
~emple ltOUTI~ SAMPLE COLLECTSD BT: PAT.
lteMrks:
1Temtm PerforMd ' See Special Imtzuctior~ Above UA-Urdvailable
~D- None Defeated '* See Sample Ser,~zkt Above
NA- Not ir~lyzed LT-Leso ?ham GT-Greater Than
Member o' the SGS Group (Soclete G6.erale de Surveillance)
~ on ~ pre~ m ques~on n~ that ~ ~ no
APPLIC !T FILLS OUT UPPER HAL" ONLY
Property Owner ^LAMelY e~t~t L~:/''p- % Phone
Buyer i~:'~. 2..~ c~ ~ /._.~ ~ ~
Address ~&:~C~Z:l& ~*L.,~?)~'-/,, ~-~0~; ~i~/q:/2 /~.~:,~:-A ZlpCode '~Q~:~ 7~
Lending Institution f:~.Lo/w? i::~:~2~ (:.. ,2~.~:2 I (' ~;~i ~%x.j Phone
Address & o~ ~g C ,',,'t ~x~ ~.q Zip Code ~&~ -> 7~
Realty Co. & A~nt {'~) F,: .~',.-~ (':- *~ ~-.- ;'ff ,~LY} ~ "/~ ,~:O ~_ ~' Phone
Address.?, O, ¢.'.~O ~ '~l / / ~,:/~ ~:,/. :' /~.~ z ,.2{ ~ /i/. ,3 -. ~,/A Zip Code 'i ', ~:~ 7 -7
Legal Descript~n~ ~ ~ /~L~d/~/PM ///~c.'% ~
Street Ldcati~ ~//~ /~z.~/~ i)~/q~
Type of Rest~nce
~ Single Family
~ Multiple Family No. of Bedroo~ ~
~ Other
Water Supply
~ Individual A~ACH WELL LOG. A wall log Is required for all wells drilled since June 1975.
~ Community For wells drilled prior to that date, give well depth (attach log if available).
~ Public Utility
Sewer Disposal
~ Individual Year Indiv~ual Installed: i ~)(;~
~ Public ~llity When Connected to Public Utility:
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Insp~tor Insp~tor Insp~tor Insp~tor
; * '.
AUG 2 9 I983
( ) DISAPPROVED ff
Soils Rating Well To Absorption Area Well Log Received
/~.~ Well to Tank Septic T~k Size
72-023 (3182)