HomeMy WebLinkAboutBRUIN PARK BLK 1 LT 1 LESS N25'
(~ 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
[] UPGRADE
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
o ,
Well -- I AbsorPtion area Dwelling PERMIT NO,
~ DISTANCE TO:
~ ~ Manufacturera~ No. of compartments
Liq. cap.irwin gallons Inside length Width Liquid depth
~ ~ ~O IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwellin9 PERMIT NO.
~--~OZ~ Manufacture~ Material Liquid capacity in gallons
~ Well Foundation 'Nearest lot line PERMIT NO.
~ DISTANCE TO:
~ ~ ~ No, of lines Length of each line Total lengt~of lines Trench width Distance between lines
~ Top of tile to finish grade Material beneath tile Total effective absorption area
Q ~ ~~ ~ ~ ~ inches
Length Width Depth PERMIT NO.
~ Type ofcri~.~ ~ Cribd[ameter Crib depth Total effectivo absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO,
~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
SOIL TEST RATING
iNSTALLER
72-013 3/78)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENI'AL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAI/lNG ADDRESS
LEGAL DESCRIPTION
LOCATION
UPGRADE
NO. OF BEDROOMS
I Well . I Absorption area I Dwellimj PERMIT NO
DISTANCE TO: ~, ' o - '
Manu tu r-- ~ [ Mater? ---';-- ........ N~: of~-~,nl~;r'tments
'Liq. capacitvingall°ns~ iFHOMEMADE I Insidelength ~ll ....
DISTANCE TO' /~ell /Dwelling
I Well FoDndat on ~--~'~ ~'~~
DISTANCE TO: I ~ / -- I~ ~ ~O I .... ~ ~' .
~lines '~lLengthofeaohlinez~_~. .... ]lT°tallength°f~es~ ¢-~widthj .... '~ inches Distanoebetweenline~
Top of tile to finish grade ~1 5~%t~ ~ ................... ~%"--~--'::- ~'~
~ O' . .o[al 8TTOCtlVR adsorption area
Length ~ Width Depth --- ~ ~R~~
.......... '
~~i~--) ~ ~b diameter Crib depth Total effective-;~;~];
. ~% Li~
~, DISTANCE TO W II Building foundation Nearest lot line
lCl~s Depth Driller Distance to lot line PE~MIT~
OTHER
PIPE MATERIALS
'To
SOIL TEST RATING
INSTALLER
REMARKS
DATE LEGAL
PERM I T I'-,I0.
~'-1 I_.! I'-,l :[ ~::: ]: F' F:I L_ :[ "T'
DEPRR.'T'MENT" HERLTH ~hlD ENVIRONMENTRL -:IOTEC]'I 0f'.,I
82:5 '" L. :-STREET., F~NC:HORRGE, Rk.::.
2'64-4?20
~..-£~ !"-,I .... "-_2=:; I T' E] ."_=-_1 E2 I-.-I E E: F' E] F.~.". I'"1 '[ T
( 8~.07'62": .':,
RF'F'L. I CRNT
L. OCFIT 1 ON
L..EGRL
C: & ..T EXCAVFtTING 8620 JFtDE STF.:EET 995E~2
FOREST
24000 :.];6!t..IFtRE FEET
'T"¢PE OF :-];(:]II_ RBSORPTION S'¢:.];TEM IS: TRENCPI
I"IFIXIMUM I",IUMBER OF E:EDROI3M'::; = 2
SOIl_ RFITING ('=;6! FT,,"BR)= :1.;:_:'5
]"HE REL::!LIIRED SIZE OF THE SOIL. RBSORPTIIDN S'¢S'¥EM IS:
D, E-: F" 'IF ~-~ == :t. ;;;L". L. E N ,::-~ T H =-: ;:-:~: 4 ,.3 F-: R '...." E: L. [:, [:_ F' -r t-~ == :D3;
THE L. ENGTH DIMENSION IS 'TPIE LENGTH (IN FEET) OF THE TRENCH OR [)RFIINFIELD.
]"NE DEPTH OF' R TRENE:H OR PI]' I'=; THE [:,ISTRNCE BETHEEN THE SURFRCE OF TPIE
GROI..IN[:, RN[:, THE E:OTTOM CIF' THE E',:-::CR',,,'FITION ,'.: IN FEET.':,.
TPIERE ]::5 NO :.];ET IqIDTH FOR TRENCHES.
THE GRFIVEL DEF'TH IS THE MINIMUM DEPTH OF GRRVEL BETHEEN THE OU'FFRLL F'IPE
RND THE BOTTOM OF' THE: EXC:RVRTION ,.':IN FEET).
PERMIT FIPPL. IC:FtN'T f-IRS THE RESPONSIBILITY TI3 INFORM TH:['_--; DEF'RRTMENT DIJRING THE
INS'TRLLRTION INSPECTIONS OF RN'¢ HE:LL.S R[:,JRC:ENT TO THIS PROPERT"r' RND THE:
NUMBER OF: RESIE:'ENCES THFtT THE HELL HILL SERVE.
................. '"f"I..-41C~ ,( ;2 ::, ..'[ i'-,t::S;F"EC":T' I C,I"-.IL--~. FtF:-:E: F-:E:~;!!..J I
BF1CKFILLING OF FtN'T' S'¢SI"EM HITPIOt. IT FINRL INSPEC'TtON FIND FtPF'F.'.O',,,'FtI_ B"r' fi'HIS
E:'EPRRTMENT HILL BE SUBJECT TO PF.'.OSECUTION.
MINIMUM DISTF~NCE BETHEEN FI HELL RND RNY ON-SITE SEHRGE DISPOSAL SYS"F'E:M IS;
:1.0El FEET FL')R FI PR IVR'TE HELL OR :1.50 TO 200 FEET FROM R PLIBLIC: HELL DEF.'EN[:,tNG
LIF'ON ]'HE T'¢F'E OF F'LIBLIC P.IEI_L.
MINIMUM DISTFINCE FROM FI PRIVFtTE 1.4EL. L TO t:t F'RIVFI"FE '=;EHER LINE IS ;:::5 FEET
TO Fi COMMUNIT'¢ '.=;EHER LINE ID.; 7'5 FEET.
OTHER RE~].:It..IIREMENTS MR'T' FIPF'L.'¢. SPECIFICRTIONS .RND C:ONSTRUC'f'ION DIRGRRMS FIRE
RVFIIL. RBLE TO INSURE PROPER INSTRLL. RTION.
I CERT I F'.r' 'FHRT
:1.: I Fffl FRMIL. IFIR HITH THE REC!UIF.':EMENTS FOR ON-:5ITE SEHERS RND HELLS f:~S SET
FORTH B"r' THE MUNICIPF~LIT"r' OF' RNCHORRGE.
2: I HIL. L INSTRLL. THE S'¢STEM IN RCCORDRNCE HITH fi'HE C:ODES.
2:: I UNDERSfi'RND THFtT THE ON-SITE SEHER S'¢STEM MR'¢ RELT~UIRE ENL. BRGEMENT IF THE
RESSIDENCE I5; REMODELED TO INCLU[:,E MORE THRN fi: BEDROOMS.
S I GNE[:': ....................................................................................
RF'PL I C:RNT I.E'. & ..l E::.:,'CR'v'RT I NG
I '=;SUED
Applicant:
MUNICIPALITY OF ANCHORAGE
f Health and Environmenta. 9rotection
Department
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT * * *
WELL AND/OR ON-SITE SEWER PERMIT
~ J ~-~-~-~-~W~/ Mailing Address:
Phone Number:
Lot Size:
Location:
Legal Description: ~-~ ~ f ~C4,m7 P~
Type of Soil Absorption System Is:
Trench: ~-- Drainfield:
Maximum Number of Bedrooms: ~_~
Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br) /_l_g
The Required Size of the Soil Absorption System Is:
DEPTH / iL LENGTH ~--~ 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 pipe and
the bottom of the excavation(in feet).
* * REQUIRED SEPTIC(HOLDING) TANK SIZE TM /DO~ 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 1 * * *
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~ residence~..is remodeled to include more that~_.~;~.~ 3 b~drooms.
Signea: ~ ~. Issued by: ,~'~ ?
App 1 ic ant ~/:' /~ -
Date:
SWP/024(1/81)
r~ SOILS LOG
.~UNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENV[ RONN~ENTAL PROTECTION
Pouch 6-550, Anchorage, Alaska 99502 276-222~
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:~
LEGAL DESCRIPTION.'
1
2
3
5
6
7
8
9
/
SLOPE SITE PLAN
10
11
1.2
"13
14
15
16
17
18
19
2O
COMMENTS
WAS ROUNDWATE"
ENCOUNTERED? '
O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
% 224<'~-c '
PERCOLA'rlo N RATE'
TEST RUN I~I~TV~F..~
PERFORMEDBY: ~~,f~' ' '
CERT;FIED BY:
Imlnutaslinch|
FT AND ~ . FT
_ DATE :.~~
Sir /
WELL LOG
Date Drilled: ~F~
Static Water Level ~/-~x'~
Draw Down J-~ feet
feet
Gal 1 ons Per Mi nute
Total Feet of Casing
Type Material Drilled:
0 feet to ~/ ~-~/~}~
to y2~
to
RECEIVED
DEPARTMENT OF HEALTH & HUMAN SERVICES '~~rL=~='"S~i~l~l~q
Division of Environmental Services ' iI=LLI;~... ,--. A~'~ ] '~-~
On-Site Services Section ~, ~
PiO. Box 196650 AnchOrage, Alaska 99519-6650
:343-4744 RECEIVED
Parcel I.D. #
1, GENERAL INFORMATION
Complete legal description L-.c~-~'
:~.:;-:2F~Fr'.', F]C,.': TE C:,F HEAL'?H AUT; 'X-:dTY
APPROVAL FOR A SINGLE FAMILY DWELLING
Loc;:~tion (site address or directions) 1_O ~;O I P.--'~,~ c~,_~T "~-W ~ '
e
P,"':~;' - d7 c, wner
Mailing address
Lending agency
M;:~iiing address
Day phone ~z~q- 'Zo ~ '~.
Day phone
Address
Day phone 'P--~- qlq~'
Unless otherwise requested, HAA wiii be held for pickup.
NUMBER OF BEDROOMS: '--'~ ~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
X
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewe~'
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
NOTE: If community wastewater system, provide written confirmation from State ADEC
aftesting to the le';~lity ~nd status of system.
72-025 {Rev. 1/91) Front MOA #21
5. ,,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 bf 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 corn pliance with all Municipal and State codes,
~ ' ordinances, and regulations in effect on the date of this inspection.
Name of Firm ~"7-~:w~,~ ~-~'>~,,~,v,~c~-- i ~' ~-~ Phone
Address .~.~~ /~~;
Engineers signature -~ ~~ ~ Date
DHHS SIGNATURE
' X Approved for _~__~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the follOwing stipulations:
Additional Comments
Munic!pality of,Anchorage Department of Health and Human serViceS (DHHS)issueS Health AUthority
APProval Certific~atO~'basod Only upon the ropreSentations given in paragraPh 5 above bY an independent
professional engineer'registered in the stater of AlaSka~ The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to ~tisht certain federal andstate r~luirements. EmploYeSs of DHHs do nOt
:c°nduct inspecti°ns or analYze data: befOre a certificate is issued. :The MuniciPality of AnCh°rage is not
responsible for errors or omi~ions in the professional engin~r'S Work'. ' ,
72.-025(Rev. 1/91) Back MOA/C'dl
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 ° (907) 343-4744
Health Authority Approval Checklist
Legal Description:
A. WELL DATA
Well type ~'i'~d,~'-r--~.
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Coliform (~)
Parcel I.D.: ~l~ ~/C~! -1'7._
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed
Cased to /c~C~
FROM WELL LOG
g.p.m.
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
g.p.m.
Nitrate
Other bacteria
B#
Date of sample: ~'[7.o[ ~
SEPTIC/HOLDING TANK DATA
Date installed ~z_-~._ ~> ¢ Tank size
Foundation cleanout (Y/N)
Date of Pumping ~[ l':)-~ ~ ?
ABSORPTION FIELD DATA
Date installed ~-/'? / &P{~ Soil rating
Length .~ ~ i .Width
Effective absorption area ~
Date of adequacy test ~//l ~'~/
Fluid depth in absorption field before test (in.);
Fluid depth / I~" (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Collected by: r ~ ' ~ ~A~O~ ~
l '~..-~0
Depression (Y/N)
Pumper ~, c~ r~c-c>o
Number of Compartments '7__ Cleanouts (Y/N)
High water alarm (Y/N) ~
(g.p.d./fF or ft~/bdrm)
t
Gravel thickness below pipe
Monitoring Tube present (Y/N) 'l/
Results (Pass/Fail)
/ '~...~ ~ System type
~ ~ Total depth
Depression over field (Y/N)
For ~ bedrooms
Immediately after/4.~al, water added (in.): 3,5-"
Absorption rate = ~'T cl~c> g.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
High water alarm level at*
"Pump on" level
~ *Datum
"Pump off" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot /c~o~ ~ ~, ~¢~,~ ~)r~,Z-On adjacent lots
Absorption field on lot z c~ o ~''
On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer/septic service line
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation .5-1 ~ Property line ! cp ~' Absorption field
Water main/service line '~c~''~ Surface water/drainage Lpo '~- Wells on adjacent lots ! ~o 't-
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ! C~ "t Building foundation /c~''~
.f..
Water main/service line ~ o
Surface water t c~(p ~ Driveway. parking/vehicle storage area --~ '
Curtain drain / c~o~- Wells on adjacent lots / ~ c~ T
F.
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
in conformance with MOA HAA guidelines in effect on this date.
Signature~ ~
Engineer's Name .~Tc.~ ~--~,.-~ Fz~;~,~c~' c,~ ~,g,,
Date ~/~zo [ ~ 7-
Date of Payment J'? ?") (~"7
Receipt Number "~! (~. f "~ , ~-~~)
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment
Receipt Number
AS-BUILT
~/ASTEV/ATER ABSORPTION SYSTEM
LOT 1, BLOCK 1 BRUIN gUBD,
Exist, House
f
t
1
/
/
/
PANNONE ENG. SVC
P. B. BOX 148085
ANCHORAGE, ALASKA 99514
874-0308, 878-8818 Fmx
]]ATEm ,4-18-97,, I AS_BUZLT
SCALE, 1°:80'
APR-29-199? 11:51 CT&E ESI ANCHORAGE 907 561 5~01 P.04/06
CT&E Environmental Services
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
971892003
Pannone Eng Sty,
N/A
L1, BI, Bruin front hose bib
Drinking Water
Client PO#
Printed Date/Time 04/28/97 19:07
Collecled Date/Time 04/20/97 17:00
Received Date/Time 04/2)/97 10:40
Technical Director: Stephen C. Ede
Released By
~uarks:
Sample coil. cereal by: $,R,P.
CT&E Microbiology Ddnkir~ Water P~ogram certiiieation stares is provisional ~$ of 4/8/97.
NitrSteIN
Total Coliform
Results
PgL Units Me~hod
ALloweble
Limits
0.100 u 0,100 m(i/L $M18 4500-NO)F 10 max
0 col/100mL SM18 922~B
Prep AeaLysis
~ate Oate Init
04/~2197 JS~
04121/97
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 ,/
/ff ~/'12,,5
Complete legal description /_. I~ ]3 It
Location (site address or directions) JOSO~ '~ORR£-~'V DR
Property owner ~,~ubE
Mailing address 311~' WESToVE~ ~b. TCpEkA,
Lending agency ¢~ N~f'¢ ~N Day phone
Mailing address P.
Agent ~ o ~E TTA PET& ~ ~O~TUNE PRoPE~T/~ay phone
Address 3000
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: ~
3. TYPE OF WATER SUPPLY:
NOTE:
Day phone ct/3' 235--o/e/
c4,vs4 s
5'6 2 - 7(0 g3
Individual well
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4, TYPE OF WASTEWATER DISPOSAL:
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.
NOTE:
72~025 (Rev. 1/91) Front MOA #21
5. 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 FLATTOP
Address Jut 5'3o ECho ,~T'.
Engineer's signature
DHHS SIGNATURE
Approved for
Disapproved.
bedrooms.
Conditional approval for
bedrooms, with .the following stipulations:
Additional Comments
By: -.~oHl',.J ~%'f-"JlT-¢~ Date ~/~,~//c~/
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 DHHS 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 ~t21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL. CHECKL.IST
Legal Description: L
A. WELL DATA
Well type P~ti//iT~ If A, B, or C, attach ADEC letter.
Log present (Y/N) '}/ Date completed
Total depth /(,30 ' Cased to 100
Sanitary seal (Y/N)
Parcel I.D.
1991
RECEIVED
ADEC water system number
CJ/¥/~,1 Driller H£FTY
Casing height 2
Wires properly protected (Y/N) Y'
Date of test
Static water level
Well flow
Pump level
FROM WELL LOG
g.p.m.
AT INSPECTION
57
g.p.m.
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot jo3 To ¢.o.
Absorption field on lot J Icj
Public sewer main > Io0 r
Public sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
!
~'/oo
DB~EI~.I/E b
Petroleum tank
WATER SAMPLE RESULTS:
Coliform O
Date of sample: ~/'vz-/9 (
Nitrate
Other bacteria
Collected by: ~/~/z/~.~, T~c,~
B. SEPTIC/HOLDING TANK DATA
Date installed 7/"1/~1
Cleanouts (Y/N) "/
High water alarm (Y/N) N,~'
Date of pumping ~/'///~/O
Tank size J '~.$o G/IL Compartments ;2.
Foundation cleanout (Y/N) "// Depression (Y/N).
Alarm teSted (Y/N) lq.A,
iSAA c$
N
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot IO3 F'~'0~ C.o. Onadjacentlots '71oo Foundation ,52 F,~otd C.o,
To propertyline ~ $5' Absorption field ,5' Water main/service line ~ 7~
Surface water/drainage ~ lot>
72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA eleCtrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed 7/7/~1
Length 2, 5' ~ Width
Total absorption area ~OO
Depression over field (Y/N)
Results (pass/fail)
N
Peroxide treatment (past 12 months) (Y/N) ~
Soil rating J 2, E
Gravel thickness
Cleanouts present (Y/N)
System type
Total depth
Y
Date of adequacy test
for :R
bedrooms
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot J Icj On adjacent lots
To building foundation
On adjacent lots '75'
Surface water ;;,/oo
'~/00 Propertyline
Driveway, parking/vehicle storage area
Curtain drain NoNE
Cutbank
To existing or abandoned system on lot
N ,,~, Water main/service line
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date ,,T~n ~._
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
/70 oO
~,'~-~¥..,.. -...:~,o~ ..,
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING &'ENGINEERING
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALYSIS REPORT BY SAMPLE for WORKoxder~ 34900
Date Report Printed: 3UN 7 91 @ 12:46
FAX: (907) 561-5301
Client Sample ID:L1 B1 BRUIN PAEI FRONT HOSE BIB Client Name ;FLATTOP TECHNICAL SRV
PWSID :UA Client Acer :FLATTOT
Collected JUN 5 91 @ 12:00 hrs. BPO ~ PO ~ NONE RECEIVED
Received JUN $ 9t @ 12:20 hrs. Req %
F~eserv.d with :AS REQUIRED Ordered By :TED MOORE
Analysis Completed :JUN v 91 Send Reports to:
Laboratory ~upe~¥~soz :STEPHEN C. EDE 1)FLATTOP TECHNICAL SRV
Released By ~. ~.. ~___~ 2)
Chemlab Re£ ~: 912476 Lab Smpl ID: 1 Matrix: WATER
Allowable
Pa~amete~ Tested Result Units Method Limits
NITRATE-N ND(O.iO) mg/1 EPA 353.2 10
5ample ROUTINE SAMPLE COLLECTED BY: CHRIS.
Remarks.
I Iests Performed See Special Instructions:Above UA-Unavallable
ND- None Detected "' See Sample Remarks kbeve
NA- Not Analyzed LT~Less Than, ,ST-Greater Than
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
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 /~zd¢
Mailing Address ~
(c) Lending Institution
Telephone (home)~--/fJ])2.~-.¢ '
· . . Business
Telephone
Mailing Address
(d) Real Estate Company and Agent ~e/-fcC
Address '~00 ~'"C~ ~'4:~'o c,'~ .~'/~,
Telephone
(e) Mail the HAA to the following address: (or check here r~, if hold for pick up.)
List contact person and day phone number below:
TYPE OF RESIDENCE
Number of bedrooms
Single-Family []
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 system, 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
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A. WELL DATA
~11 ~l~ifi~tio~ ~ ~
Total ~e~t~ ~0 ' ~ased [o
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST- FEBRUARY 1984
343-4744
Legal Description: /.,,o{'
If A, B, C, D.E.C. Approved (Y/N)
Date Completed c) ! q/8 ! Yield ~. 75' ~,~,~
IOo' Depth of Grouting N,~-.
Pump Set At 9 ,.T ·
Sanitary Seal on Casing (Y/N) ¥
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot JO$' '~,
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line '~. (~oO '
To Nearest Sewer Service Line on Lot
Water Sample Collected by ~'1~'/'/~/') '/-~//~
Water Sample Test Results
Comments
To Nearest Public Sewer Cleanout/Manhole
I
~ ~,tj' ; Date
;'On Adjoining Lots
; On Adjoining Lots
B. SEPTIC/HOLDING TANK DATA
Date Installed 71'?/~t Size
Standpipes (Y/N) Y'
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Air-tight Caps (Y/N)
N
No. of Compartments
'r' Foundation Cleanout (Y/N)
Date Last Pumped ~'{ ?/~0 ~y .-~.~c_r
N,/), ;for /~,,~,
/V, 8, Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well I O.T' ~-~o~ ¢.
To Property Line ~ '~5'~
To Water Main/Service Line ~ 7,¢,~ '
TO Stream, Pond, Lake or Major Drainage Course
Comments
TO Building Foundation ~" ~.-o/,, c.o,
To Disposal Field .5' '
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 7 / 7 (~'/
Width of Field ¥8 ~
Type of System Design
Length of Field ~' '
Depth of Field 19 ~
Square Feet of Absortion Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Gravel Bed Thickness 8 J
Statndpipes Present (Y/N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well (17'
To Building Foundation 0"8 '
Lot
To Water Main/Service Line
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots '75' '
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
D. LIFT STATION /~/,/~.
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
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~~:r~ .~effect on the date of this
inspection.
Signed ~~
Company F [~t ~
MOA No.
Receipt No.
Date of Payment ~~ ~ Waiver Fee: $
Amount: $ / ~ ~. 0 ~ Dateof Payment
z2-o2~ (Rev. v8s) a.c~ Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET · ANCHORAGE, ALASKA 99518 · TELEPHONE (907) 562-2343
FEDERAL TAX I.D. #92-0040440
ANALYSIS REPORT BY SA}dPLE fox Work 0rde~ ~ 25519 Date RepoRt P~inted: 3un 23 90 ~ 17:56
Client Sample ID:L1 B1 BRUIN PARK, FRONT WEST HOSE BIB
?WSiD ~OA
Collected JUL 18 90 ~ 11:40 hrs,
P~ese~ved with :A3 REQUIRED
Clie*~ Name : FLATTOP TECHNICAL SRV
Client Acct; FLATTOT
P.O.~ NONE RECEIVED
geq #
Ordered By : TED MOORE
Analysis Completed :JUL 18 90 Send Repozts to:
Labozato~y Supezv~so~ :STEPHEN C, EDE 1)FLATTOP TECHNICAL
Special
In~truct:
Che~ab Re£ %: 902504 Lab Smpl iD: 1 Matrix: WATER
Allowable
Pazamete~ Tested Result Umt~ ~ethod Limits
NITRATZ-N ND[O.IO) ~-~/1 EP~ 35~.2
Sample ROUTINE SA)iPLE, SABLE COLLECTED BY CHRIS.
Remarks;
Testa Pe]:fomued See Special Instzuetions Above UA-Unavailable
None Oe~ected "See Sample 5emark~ Above
Not Analyzed LT-Les~ Than, GT-G~eate~ Than
APPLI¢ NT FILLS OUT UPPER HAl ONLY
Buyer Zi~ Co~e
Realty Co. & Agent Phone
Street Location " F' ~ k'~ %.T- [~ ~ ,' V~L~
Type of Residence .
[][] OtherMU't'p'e ~am,,y ,o. o,
Water Suppl~
~Jndivldual ATTACH WELL LOG. 'A well 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
~i'ndlvidual Year Individual Installed: ~ /
~Publlc Utility When Connected to Public Utility:
__ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
~')~, 7-'''~ ~-'-/ Date Date Date , ,
Inspector Inspector Inspector Inspector
(.~) APPROVED B~DROOMS 'COND,T,O.S OF APPROVAL
( I D,SAPPROVED
Soils Rating Date ~wer Installed Well To Absorption Area Well Log Received
~ ~ [ Well to Tank Septic T~k Size
72.023 (3182)