HomeMy WebLinkAboutSOUTHFORK WEST BLK 5 LT 3
NAME
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION
'--~/ 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
FRONE . MEW
~{'3~._ ~/..~J ~1~ ~'~-~ ~ UPGRADE
NO. OFBEDROOMS
I Well [ Absorption area
DISTANCE TO: I
Manufacturer
Liq capacity in gallons ns de length
~ .~--~ F HOMEMADE: ~ '
DISTANCE TO: Wel] ~ ] Dwelling
I Manufecturer I
We Foundation
DISTANCE TO: I ~-~,~-~"~ % I,..~ I'~, ~::)'~- ~"'--~
No of lines I Length of J]ach Ible I Tota engtl~ of I ~es
' ~ I
Length Width ~ Depth
Type of crib Crib diameter I'~ / ~rib depth
Well ¢; Bui ding foundat on
DISTANCE TO:
Class Deoth .Drill er
DISTANCE TO Building foundation Sewer line
Dwelling
MateFia~
W dth
PERMIT NO,
No. of compartments
Liquid depth
PERMIT NO.
Material Liquid capacity in gallons
Nearest lot lilne
PERMIT NO.L_
Distance between lines
Trench w d~,~
-, '- inches
~ Total effective absorptic~ area
PERMIT NO.
Total effective absorption area
Nearest lot line
Distance to lot line
Septic tank
PERMIT NO.
Absorption area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
!NSTALLER
R EMAR KS
'//~/~ ~' ' DATE LEGAL
72-016¢ (Rev. 3/78)
6ertifieb Drillitt[l
., , DOC Co. dba
SULLIVAN WATER WELLS
P.O. BOX 670272, CHUGIAK, ALASKA 99567 * TELEPHONE688:2759
DATE- Started ~/~ ~ Ended
DILl'TH OF WELL ~O O' /, ~ ,
- STATI(' LEVEL OF WATER Fr. -]!
I)RAW DOWN FT.
GALS. PER HR
.. .... KIND OF CASING
KIND OF FOB'dATION: i-' , :'! i'! , ," -. '
From --~, · -
From_~ I .~'t.
From '?~ ~, :. Ft.
From_ Ft.
From- · Ft.
From___ Ft. to
From_ __Ft. to__
From_ Ft. to_
From Ffi to_ _
From .... Ft. to ....
Frmn-- _,_ F't.' to ....
From- ___Ft. to ---
Front ....... Ft. to_- --
From __Ft. to ...... Ft.
From__ _ Ft. to ..... Ft.
From __..Ft. to Ft.
Front Ft to ......... Ft.
._Ft
Ft.-
From
From .
From'
From__
From
Frmn__
From _
From ....
From ........ Ft. to--
From ......... Ft'
From ......... Ft
From .....
From ..... FI
MISCL INFORMATION:
Ft. to".-' .. ,Et."
Ft. to : Ft.
, Ft. to ' Ft..
F,.,,, :L 5;rt 5
Ft. to Ft
Fl to. __. FI
Ft. to - Ft.
FI to. Ft.
Fl
Ft.
/ /
DIEF'ARTMEI',~]" OF HEAI...TH AND ENVIRONMI:i'.NT(-~L F'ROTECTION
825 L STREET, ANCHORAGE~ AK 9950~
264-4.720
F'ERM I'T HO:
DATE IS~OED:
AF'PL I CAN']":
ADDRESS:
CON]"AC'T' F'HONE:
85(}446
07/26/85
C/O S & S ENG'G SOUTH FOR~i CONSTR
SRB 196X
EAGLE RIVER, AK 99577
694-P979
LEGAl_ DESCRIF':
LOT SIZE:
MAX BEDROGMS:
SUBDIVISION: SOUTH FORKrWEST
SEC'I'ION: 9 TOWNSHIP: 13N
7896]. (SQ.FT, OR ACRES)
3
LOT: .3
RANGE: 1W
BLOCK: 5
Listed bel(:w ape the options ava].lable to you :In designing youP septic
system. Ch~.)ose the option that best {'its you~* site.
DEPTH TO PIPE BOT'TOM (FT.)
GRAVEL DEt:"'I'I"t ~F'T. )
TOTAL DEPTH (FT.)
GRAVEL. WIDTFI (F-r'..)
GRAVEL LEI',IGTH (Fl'.)
GRAVEL VOLL!ME (CU. YDS.
TANK SIZE (GALS)
SOiL RATING (SQ.FT. /BR)
4.0 ff~ 4.0 4.0
10.0 ~ 4.5 7: 5
32.0 34.0 41.0
19.3 ~ 21.5 30.4
'000.-0 '~'~ 1~000.0 ~.~ 1,000.0 ~
:125 ~' 125 125
~--~ TANI< MUST HAVE A]" LEAST TWO COMPARTMENTS
I c.e~tify that: ~
].,, I am Cami].].ap with the pequzp~.ments £op on-site seweps and wells as set
. £oPth by the Municzpality o[ Anchopage (MOA) and the State o~' Alask. a.
2. I will install the system ~n acco~dance.with all MOA codes and pegulat, ions,
and in cc~pl:ance with the design cpite~'ia e[ this pepmit.
.3. I will adhere to all I~OA and State o£ Alaska pequipements fop the se{ back
distances £~om any existing well, wastewatep d:isposal system op pubIic
sewed'age systen~ on this o~ any adjacent, op nea~by lot..
4. I und~.r'stand that th~s pepmit ~s valid £o~ a ma;,'imum o£ 3 bedpooms and
any enIapgem~.nt wi] I ~'equ~.~e an additic~nal pem~it.
IF' A [_IF']' STATION IS INSTAl_LED IN AN AREA COVERED BY MOA BUII_DING CODES,
THEN (1) AN ELECTRICAL ~'ERMIT AND INSPECTION MUST BE OBTAINED; (~.) AS-BLIILTS
WIL. L NO]' BE APPROVED W'ITHGUT AN ELECTRICAL INSF'EC]"ION REPORT; AND (3) ]"HE
ELEOTRICAL WOPI< MUST BE DONE BY A L. ICENSED ELECTRICIAN.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
,~ SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR: ,
LEGAL DESCRIPTION:
I
2
3
4
5
SLOPE
SITE PLAN
10-
11
12
13
14
15-
16
17
18
19
2O
No. 14~7.E
COMMENTS
y SRB 196~ -
PERFORMED B .: ' ~ ~ ~'~,~ ~ ~,~ -~-
72-008 (6/79)
WAS GROUND WATER ~ ~
ENCOUNTERED? O
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ /,~ (minutes/inch)
! -
PERCOLATION RATE
TEST RUN BETWEEN FT AND ~ FT
//
~-tMUN CIPALITY OF ANCHORAGE
DEPARTMENT OF FIEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
SLOPE
DATE PERFORMED:
SITE PLAN
10
11
12
13
14
15
16
17
18
19
20
WAS GROUND WATER
ENCOUNTERED?
P
E
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date
Time Time Water Drop
PERCOLATION RATE (minutes/inch)
TEST RUN BETW'EEN FT AND -- FT '
/L., f '
72-008 (6/79)
S 6 2 7 7 J u~ - 2
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
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
L.._9 6,~. _goo'l~ Fo.,-~ tcd~+
Location (address or directions)
Applicant Name ~_.~ ~-i ~,~--+~. Il Telephone: Home ~.9q57-~7 Business
Applicant Address
(b)
(c) Ap.plicant is (check one): Lending Institution []; Owner/builder,S]; Buyer []; Other [] (explain);
(d) Len din g I nstit utio n '~'O7¢45~0 'T'-~ ~ ¢ ~'¢1
Address
Telephone
(e)
(f)
Real Estate Company and Agent
Address
Telephone
Mail the HAA to the following address:
TYPE OF RESIDENCE
Single-Family [~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well'~ Community [] Public r"l
Note: If community well system, must have written confirmation from the State Department of'Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite'~' Public [] Community [] Holding Tank ['"1
Note: If community well system, must have written confirmation from the State DePartment of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
¸5.
EN,GINEERING FIRM PROVIDIN~iNSPECTIONS, TESTS, FILE.SEARCH, D 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.
Telephone
Name of Firm o.,,~,J¢~ ~-~¼~,~ ,r',a'~ .,,~.;
Address .~OJ ~b~/~ ~ ~)(~ ~¢ ~,~
Date J ~- ~ 5 ~
DHEP APPROVAL
App,oved for ,~,~C~) bedrooms by ~ ~' ~~
APproved ~ Disapproved Gonditional
Date 12.. - / ~
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) 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.
Page 2 of 2
72-025 (1 ~/84)
WELL DATA
Well Classification
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
MUNICIPALITY OF ANCII~IST- FEBRUARY 1984
DEPT. OF HEALTH & 264-4720
Ei'qVIRONMENTAL PROTECTION
Legal Description: L
'OEO ! 5 1986 uoC T
Well Log Present (Y/N)
Total Depth (o
Static Water Level
RECEIVED
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
If A, B, C, D.E.C. Approved (Y/N)
fY' Date Completed 4:~- ~',~ Yield
Cased to ~ 0 ~ /k~/ ~
Depth of Grouting
Pump Set At ;~- ~" ~
"~' ~ Sanitary Seal on Casing (Y/N) Y
Y Depression Around Wellhead (Y/N)
; On Adjoining Lots 'Jc / O O
; On Adjoining Lots "J- I OO ~
To Nearest Public Sewer Line ~' I ~ O ~ To Nearest Public Sewer
Cleanout/Manhole '~' I OC') ~ To Nearest Sewer Service Line on Lot "~' [ O O t
Water Sample Collected by ~--~'~'"~'~/u~'"~'~ ~%..% t',~(' ;Date ~'2"11~~
Water Sample Test Results '~/~'tl~ F-~,<:-%¢~'
Comments
B. SEPTIC/HOLDING TANK DATA
Size
Date Installed
Standpipes (Y/N) N// Air-tight Caps (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~ '/~::2 ~
To Property Line "'J- /--~ /
To Water Main/Service Line .-.¢1- (~'0
Course -/- / O (..0 /
No. of Compartments
Foundation Cleanout (Y/N) y
Date Last Pumped ~ F___fc,.P ~
; 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
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Type of System Design
Length of Field ~ '?-" ¢
Depth of Field ? /
Gravel Bed Thickness ~' '
Standpipes Present (Y/N)
Depression over Field (Y/N) Date of Last Adequacy Test
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well ~ /
To Building Foundation
Lot /t-~ ~2/'-)~'-
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments o~' ~--'~--~'/~ ~
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
LIFT STATION /J O ~" O %
~ Dimensions
__ Manhole/Access (Y/N)
"Pump On" Level at ~~ "Pump Off" Level at s.---,~'~'- __
High Water Alarm Level at
Tested for ~ ~ during Adequacy Test. Meets MOA
Electrical Codes (Y/N)~
** Check Permitted Bedroom Rating Against HAA Request **
I certify that~t~ a)~. h/e/c~k/eeo'/a h e. Cwerified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ';~J/~¢¢///'U/~/'~"k--~ Date
Date of Payment /~( % '~ "
72-026 (11/84) ~E)¥~oHDNV :10