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Home My WebLink AboutBURLWOOD TERRACE BLK 23 LT 8007 GREATER ANChOrAGE HEALTh DISTRICT 217 E: STRE£T · P. O. BOX 9~1 ANCHORAGE. ALASKA Copy of Well log for well ~rilled for Mr. Elm Drilled to date 120' Approx. gallong per minute 5 Static H20 level~ 55' Draw Down 120' Diam. in inches 6" The produced 5 gpm at 120' Signed July 9, 1961 Bernard B Hopp Driller Anchorage Drilling Co. 0-18' 18'-30' 30'-60' 60'-88' 88'-94' 94'-120' 120'-126' Clay and Gravel Sufrace water - Sandy clay Sand and gravel Clay and Gravel Cemented Gravel Clay and Gravel Hard Pan Black water sand and gravel Copied 9/18/61 David L. Duncan Sanitarian I APPLV NTFILLSOUTUPPER ONLY Buyer Address //~/? ~ Zip Code Lending Institution /~/ /2'~ Phone Realty Co. & A~nt (~ F ~:~. /~. ~2., /~/' Phone Address Zip Code Ty~ ~esi~nce ~ingle Family ~ Multiple Family No. of Bedroo~ ~ Other Water ~ply ~dividual A~ACH WELL LOG. A w~l 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 vidual Year IndivMual Installed: lic ~ility When Connected to Public Utility: / ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED. Date Dat~i_./<c~_~._~~ ~ (/~,~_.~ ~ ~ /'" '/ Date ~ / Inspector Inspector~ Inspector ~ ~ Inspector /~ MUNICIPALITY OF ANCHORAGE ~ ~ ~,~ __ ~7,J.~~ ENVIRON,MENTAL PP, OTECTION ('- RECEIVED ( ) DISAPPROVED ( j,,,,~ONDITIONAL APPROVAL* Soils Rating Date Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size 72-023 (3182} MUNICIPALITY OF ANCHORAGE [ '-~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROT~eG~tON--~-~.'- -' 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL ENGINEERING DIVISION Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES !DI RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1. PROPE~,TYOWNER i PHONE MAI Lli~G ADDR ESS' PROPERTY RESIDENT (If different from'above) / . PHONE 2. BUYER PHONE MAILING ADDRESS 3. LENDING INSTITUTION I PHONE MAILING ADDRESS 4. REALTOR/AGENT ~ PHONE I MAI LING ADDRESS 5. LEGAL DESCRIPTION STREET LOCATION/ 6. TYPE OF RESIDENCE ' ' NUMBER OF BEDROOMS [] _One [] Four [~'/SINGLE FAMILY [~'~ Two [] Five [] MULTIPLE FAMILY [] Three [] Six [] Other 7. WATER SUP~_~;Y [~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY * ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach log if available.) 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** [~P~UB LIC UTI LITY **If individual/on-site, give installation date If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONL._- INSPECTION APPOINTMENTS TIME TIME DATE DATE DATE RECEIVED TIME DATE INSPECTOR INSPECTOR NSPECTOR DIRECTIONS: NUMBER OF BEDROOMS 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY [] ONE [] THREE [] FIVE [] TWO [] FOUR [] SlX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTI LITY Connection Verified []Septic Tank or [] Holding Tank Size: If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: Absorption Area to nearest Lot Line PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOILS RATING MANUFACTURER MATERIAL Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line 5. COMMENTS 4:~]~'AP P R O V E D FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED LEGAL DESCRIPTION 72-010 (Rev. 3/78) FHA FY ~ 2'573 ~..~-~..- ~ Form Approved Rev. JulyS958FEDERAL HOUSING ADMINISTRATION ~'~ Budget Bureau No. 63-R296.8 HEALTH AUTHORITY APPROVAL INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM Aaeborage, Alaalm MORTGAGOR OR SPONSOR PROPERTY ADDRESS ~ek ~. Can ~Je ~ other a~a be made into TOTAL NUMBER: BASEMENT New installation additional bedrooms? (ff Yes, how many~) ~WATER SUPPLY BY:~ ~ SYSTEM DESIGNED FOR ~ Public system ~ Comm~i~ system ~ Individual ,o. oF BDR~. GARBAGE DISPOSAL SEWAGE DISPOSAL ~ ~blic system ~ ~mmunity system ~ Individual ~ ~ Yes ~ No HEALTH DEPARTMENT ,NSPE~OR'S SKETCH I I ~ 1111 I III I I11 ~ ~ I I [ I ~ IIII IIII III I ~ J ' I I I I FI ~1 ~l J ~1 JJ ~ ' IIII ..... I I I I JJ JJ I JJ , IIII ll~ Ill ~ ! J I I I I . JJ I!1 I Jl i II II ~ JJ I!1 I il' J ' Ill Il Ill Ill ~ : , [ Il Il ~ Jl I!1 Ill I I II ' Jl Ill I I I I II_L'I , I I Iil ~1 I~1 i I I I ' I I III I I I I~ I~J~l I I I J I I I I1~ I1~ III I I I J It is the opinion of ~e ~ State ~ Coun~ ~ ~cal Department of Health that this individual water-supply system ~is ~ is not satisfactory as a domestic water supply for the subject properW. It is the opinion of the ~ State ~ County ~Local Department of Health that this individual sewage-disposal sys- tem with proper maintenance: Can be expected to function satisfactorily, and ~ Cannot be expected to function satisfactorily is not likely to cre~e an insanit~ condition E: The he~llh ~u~hority should corn s~o$emen* obove ~nd ~x'd~te, si~ture ~nd rifle in fhe spaces provided. Use of the above grid for Health ~epartment Inspect~ts sketch as ~el~ .,s u~e of the back of this form is at the option of the ~hea~ authority. TO T~ (HIEF I have reviewed ~e foregoing and the pe~inent FHA Compliance In.~e~,o~, Repo~, and recommend that 'the ~wage dis~sal ~ considered ~ Acceptable ~ ~ot Acceptable. DATE SIGNATURE ~ CHIEF ARCHITECT ~EPUTY FOR CHIEF ARCHITECT ! 1111 III I I11 IIII IIII III I I I I LI I-J, I I I "[ ' d .4 ,Ii I Illl _ .., I I I I I'l ~J b,,,, f ~1 Ii iiii ..... Jill Jill jjj I I I I Jl [J I J[ III] I I l~'q Ill I I I I JJ I!1 I Jl II II !i, JJ I!1 I Jl .... q~'Jq ! ! ] ; ' ~l Ill I Il -" Iq,,d I I I I I Il Ill [ Il I I I I Il Ill t JJ I I I I Jl I!1 I Jl I I II Jl Ill I Il I I I I II_L'I I Il I I I.I I LL/J'J 1 J[ I ILl I I I"/T-dJ J ! I IMJ. JMM ! I [.[ I I 1 NJl~'TJLd, Jl III I JJ WII Iw[ _.--4..JII I I I N litJ Il-J[ J'q' Il Ill 'q.'/.,,.., I Il " I lad, Il Ill 'q'.,.. [ i t [ l-Ill Il III 'q'~. I I I ~-t~,. m r I I III III III "~. II I.R r',~L" ~. I I Iii III Ill -~,._]iJ~k. j~ d I II IWl Jl II1 i 11 · · 1 J Idi, l I"' II III I k&l Id[~l I J Ill · nWJ[ ,,,t,' I'"'T-r,,I II III ~,,,. , f'lrl I I ill II Mir .N I g i I I Iii II Ill i Il I I ] Ill I1~ Ill I I I I I I III ~.[ Jq,,b ]1 I I I,dl[ Iq4_-t,..J I I I I I fll I Iql~] i I I I I Ill I 14,,,4' J I i INDIVIDUAL WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM R,v. July REPORT OF INSPECTION--INDIVIDUAL SEWAGE-DISPOSAL SY. STEM PRIMARY TREATMENT consists of ~Septic tank. [] Cesspool. ~i,,,,~ce f~om well t. M~:~ial c .... Number of compartments Total li~ , .v~+, ..... gallons. Capacity inlet compartment, gallons. Inside length, .feet. Inside width, feet. Liquid depth, feet. Distance from: Well, feet; foundation .... feet; ne~est~lot liree at [] front, [] side, [] rear, feet. Inside diameter, feet. Depth, feet. Liquid capacity, .gallons. Lining material' SE¢ONr)ARY TREA?MEN? consists of [] Tile disposal field. ~Se, epage pits. Other Distance from: Well, feet; foundation, feet; nearest lot line at [] front, [] side, [] rear, feet. Total length of tile lines, feet. Number of lines Dista~ce between lines, feet. Trench width inches. Total effective absorption area in bottom of trenches, square feet. Length of each line, feet. Depth, top of tile to finish grade,. .inches. Type of filter material: [] Gravel. [] Broken stone. Other Depth of filter material beneath tile,~ inches. Depth of filter material over tile, inches. Number of pits /. Outside cliamaae~r, ~ ,~ ~ feet. Depm,. ~'~" feet. Lining material Distance from: Well, /~e:~ feet; building foundation, ~-~ feet; nearest lot line at [] front, [] side, [~rear, f(,~ feet. Date of inspection / ~ .: ,"JK3' t.~,a}';.t'.'~ : 19__~ .... [nTt,) REPORT OF INSPECTION--INDIVIDUAL wATER-sUPPLY SYSTEM Distance to nearest public water main,~feet. Size of main, fifthlY- inches. Individual wells ~are [] are not customary in neighborhood. Give most recent record of failure of wells in immediate vicinity to furnish adequate supply of water Properties in n_eig~hborhood [~are [] are not being developed with both individual water-supply and sewage-~posal systems. Lot size:.~~eet wi~te, /~O feet deep. Dwelling set back from front property line, ~ feet. Individual water supply from: ~ Drilled well. [] Driven well. [] Dug well. [] Bored well. Distance of well from: Building foundation, ~ O feet; nearest lot line at [] front, ~[~side, [] rear, 30 feet, cast iron sewer ~'~lrao feet; tile sewer, --<"~' feet; septic tank, ~"/_~ feet; disposal field, feet; seepage pit, '/t)~a~- feet; cesspool,, feet; other sources of possible pollution, feet. Weft construction: Diameter, (~ inches. Total depth, ~feet. Type of casing, 5~ ~, / Depth of casing, _L,.,.,.~__O~feet. Approximate depth to pumping level of water in well, &---~"' feet. Approximate yield, .gallons per minute. Sealed watertight to depth of /d,,O feet. Exterior space around casing sealed with: [] Cement grout. [] Puddled clay. ~[~Ordinaty backfill. Well cover: [] Concrete. [] Wood. ~i~,,Metal. Openings in well cover watertight: [~Yes. [] No. Pump~ [] Shallow well. 0t~Deep well. Length of drop pipe, ~5" feet. Pump capacity, Located in: [~ Basement. [] Pumproom off basement. [] Pumphouse above ground. [] Pump pit. Pumproom properly drained: [] Yes. [] No. Pump mounting watertight: [] Yes. [] No. Type of storage: [~Pressure. [] Gravity. Capacity, ~t,=.~/ gallons. Has bacteriological examination of water been made? ~Yes. [] No. If answer is "yes," give date 19~ Quality of water ~is [] is not satisfactory for human consumption. Installation {~kdoes [] does not comply w~th approved exh~Nts, if any. //'~' ~ Inspection made by: [] State. [] County. ~,~Local Health Authority. ( _t ,~ ,,- --~.. / / ,nspe~ , or- C-L ~ ~ , '7' ~'" / , I"~ Date of inspe~ion / ) .~,L' ~,~' ~ f '.~,.i.;.~"C'~ l~ (,; / ~i ~--.~"~D/%..~__~'~.'~ $ ~ (TITLE) gallons per minute. ~.~ U, S. GOVERNMENT PRINTING OFFICE: 1957 O-F--427038 GREATER ANCItORAGE t~ALTItDJ~KICT 217 E Street P, O~,k_ 968 Anchorage, Alaska BK 6'3351 Information required for FHA & VA Scale Drawings (To be submitted in triplicate on space provided on FItA Form 2573 or scale paper or plain paper - drawn to scale: 1 inch equals 20 feet.) 1. D~mension of Lot ~OX / FO 2. Dimension o~ .ouse fl'~',{ f ~ ' 3. Distance from house to 2 prope=ty lines (Side and Septic Tank: 1, Distance from sewer line outlet to corner of house 2, Distance from tank to house 3. Dimensions of septic tank (liquid depth minimum 30" width minimum 24") /0" - maximum 6' 4. Gallonage 7 ~O ~Pi~: ! 1. Distance from seepage pit tO house (minimum 20t) 76> 2. Distance from property line (minimum 10') 3. Distance from septic tank to seepage pit A~bs.o, r? tion Fie Id: 1. Distance from house (minimum 5') 2. 3. 70~ Recommended drop 6" in 100' /~" Trenches - Distance between trenches - minimum 6' Width - minimum 12" (Recommended 24") maximum 36" ~-9" Depth - 36" rec~aended Filled with coarse gravel 6" bottom and 2" on top of ~" washed gravel Pipe - 12" from bottom recommended / 18" from top recommended Covering (Backfill) - minimum depth 12" 1. 2. Distance to property line 10' (Give distance from side & front line) ~0~-~-0' Distance to house ?..0~ hea~- a ad ~a~ ~lal' ,'~~oe ~.po.aX .2.t4a .rea x. a<~equa~e rot ~e at, q~be' aim,re ]dmn~ oonP~ee 'vi. th the plot, plane and as-bu..~t, ~ . A~2-:_-tiSiC-P-Ft (e) i' This Form Mus~ Be Out Completely. Filled INDIVIDUAI WATER SUPPLY ALASKA DEPABTMENT OF uI~.~LTH Section of Sanitation and Engineering Please Look on Reverse o! Sheet for Sample Collection Request for Bacteriological Analysis Lab. l~o ...... : .................................... Water sample collected by ................. -~.-;~=~ ...... c_~..~.......~.~. ................................................................................................. (Name of person collecting sample) (Date) (Time) Water sample collected from [~ Kitchen tap; [] Bathroom tap; [] Basement tap; [] Other (list) ............................... : ......... .......~.........~...~ .....'"'"'"""':'"'"'""":'"'"c'":'""' .... Address premise where source is located .......... ~ A _ ~,, · .~ ~.~./. J.D..~.._.~.. ....... ~ ?:~~//~/~ ........................ ~....~'~ c~ ~ ~'~6 d~' v~ ~-~ ........ i ........... (Mr.) repe t to ................................................................. street address) (Name) Please place an "X" in the box before items which best describe your water supply: SOURCE: Well ~ [] Dug, [] Driven, ~ Drilled, [] Bored [] Spring, [] Cistern, [] Other (list) ............................................................................................................... [] Creek, [] River, [] Lake, [] Pond .................................................................................................................. DUO WELL OR CISTERN CONSTRUCTION: Walls ~ [] Wood, [] Concrete, [] Metal, [] Tile, [] Brick or Concrete Block Top ~ [] Wood, [] Concrete, [] Metal, [] Open Top LOCATION: [] In basement, [] Basement offset, [] Under house, [] In yard Other ..................................................................................................................................................................................... DISTANCE TO: Building sewer or other drainage pipe .............. feet, Septic tank ....~.~..feet, Tile field .............. feet, Seepage pit ~.L...(~.....feet,~ ~ ..]/.o ..... feet, Privy ..............feet. Other possible sources of contamination (list):....'.~.~..' ................................................................................................................................. MATERIAL: Building sewer ~ [] Cast iron, [] Wood, [] Tile, [] Fibre pipe, [] Asbestos cement Joint material ~ Type ....................................................................................................................................................... GENERAL INFORMATION: Does water become muddy or discolored? [] yes, [] no When? ............................... .~.;; .................................................................................................................. Diameter of well ............. .o... ..................................... depth ........................ L~...~.. ......................... feet ............... Well easing material ...... ..~..~ ................. diameter ...... .~. .......... depth ......... /. ..... ..0.. .............. Length of drop pipe ......................................... , ..................................................................................... f Water depth from bottom ...... . ....... ~ ........... .~..~.. .......................................................................... feet Pump location: [] In well, [] Offset in basement, [] In basement [] In utility room, [] On top of well [] Other (list) ........................................................................................................ PURPOSE OF EXAMINATION: Illness suspected? [] yes, [] no New source of supply? [] yes, [] no Repairs to existing system? [] yes, ,~ no Remarks: .......... ~.~ ...... :~ .............................................................................................................................................................. PLEASE DRAW A SKETCH IN THE SPACE BELOW. THIS SKETCH SHOULD SHOW LOCATION OF HOUSE, WATER SUPPLY SOURCE, SEPTIC TANK, SEWER, DRAIN LINES OR OTHER SOURCES OF POLLUTION AND DISTANCES BETWEEN WATER SUPPLY SOURCE AND ANY OF ABOVE FACILITIES, SAMPLES MUST BE S~IBMITTED IN CoNTAINERs PR'OVIDED BY THE ALASKA DEPARTMENT OF HEALTH