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HomeMy WebLinkAboutSOUTHPARK #2 BLK 1 LT 20 O /~-%' 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 NAME , P:~ONE ~. NEW MAILING ADDRESS LEGAL DESCRIPTION ~ ~ Absorption area/ Dwelling~ / ~ Il PERMIT NO. / ~O I .......... Dc: Width Liquid depth ~ O ~ DISTANCE TO: WeU Dwelling PERMIT NO. O ~ ~ Manufacturer Materia) Liquid capacity in gallons ~ ~ Fou,dat)o~/C~ /, NeaFestlotJine/~, PERMITNO. Length Width Depth PERMIT NO. ~ Type of crib Crib diameter Crib depth Total effective absorption area ~ Well Building foundation Nearest lot llne m DISTANCE TO: a Class Depth Driller Distance to lot line PERMIT ~ DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s) PIPE MATERIALS SOIL TEST RATING / ~ REMARKS ~)H~ ~ ~( ~(:b~ ~ Permit Applicant: Location: Legal Description: ~P-O ~/ ~~na~ot Size: Type. of Soil Absorption System Is: Trench: ~rainf ield: ~MUNICIPALITY OF ANCHORAGE~ Department[-~ Health and Environmenta~ ~otection 825 ~ Street, Anchorage, AK. ~3501 264-4720 ~O~ * HANDWRITTEN PERMIT * * * W~/O~ ON-SITE SEWER PERMIT / ! Phone Nu er: Maximum Number of Bedrooms: ~ The Required Size of DEPTH c:~ LENGTH ~O / Seepage Bed~ Holding Tank: Soil Rating(sq.ft/br) ~ ~ the Soil Absorption System Is:' GRAVEL DEPTH ~ WIDTH Thelength 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(H~) TANK SIZE = /~ 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 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 r~quire enlargement if include more that~bedrooms~f)~ the residence~ ~o ~is remodeled to . ~/~~ S igne~: ~ ~,~~~ , Issued by. Applican~ <~ Date: ~/~?'~/z~'x/~ ~/ SWR/024(1/81) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 82B L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST J~ SOILS LOG [] PERCOLATION TEST 7- 8- 9- DATE PERFORMED: SLOPE ,'TI' SITE ELAN 10- 11 13- S WAS GROUND WATER /~/~ ~ ENCOUNTERED? P E IF YES, AT WHAT DEPTH? 14- 15 16 17 18 19 Reading Date Time Net Time Depth to Water Net Drop 2O PERCOLATION RATE (minutes/inch) PERFORMED BY: TEST RUN BETWEEN FT AND FT 72-008 (6/79) s & ENGINEERS, INC. 7125 OLD SEWARD H'WY. ANCHORAGE, ALASKA 99503 ,:349 - 6561 SOILS LOG .-- PERCOLATION TEST SLOPE SITE PLAN 3 10 11 COMMENTS' WAS GROUND WATER S - ENCO..~EREO~ ~JO ~ P E IF YES, AT WHAT {~/"///,5~ DEPTH~ Reading Date Time T_ime Wa(er Drop ~ '.%JOHN E. SWANSON.." ~... 183~E .. TEST'RUN BETWEEN 7 - FT AND (~ . FT PER, FORMEDBY: "~~ ,/ I( 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 Parcel I.D. # 1. GENERAL INFORMATION Complete legal description CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING -03-~ -- ~-O HAA# _ :?Location (site address or directions) / ~ 6' %0 Sc J ~ ' e · ' Property owner Mailing address '') ~-.G ~-c, Day phone 3 q' -?"- ~ '~ Lending agency Mailing address. ~,~,~'/<' O,~ /~,-~,r~4 Day phone ~,gent Address Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 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 invest, igation 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 S & S ENGINEERING 17034 Eagle River Leeft Read No. 204 Address Ea~le River, Ah~ska 99577 EngineeFs signature x-~'~¢' J Phone DHHS SIGNATURE '/" Approved for Disapproved. Conditional approval for bedrooms. V~..~, ~ ........ .,,-.y-'~ ~ ROIIERT C. COWAN ~,~ b~rooms, with the following stipulations: By: Additional Comments Date 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Em ployees 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. 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 LegalDescription: Lo~'r' >'~ .tg6~.ff. I .~0~,7#,~A~0~¢' ~ ParcelI.D.: 030 .-o$--,.9. A. WELL DATA Co,'.lr~¢ /v l r y Well type Log present (Y/N) IfA, B, or C, attach ADEC letter. ADEC water system number Date completed ~ Total depth Cased.~:~.~-~"~ Casing height (above ground) Sanitary se Wires properly protected (Y/N) Date of test Static ~vater level _ ~ WA~R S~LE ~s~Ts~ Coliform / Nitrate Other bacteria Da~ Collected by: SEPTIC/HOLDING TANK DATA Dateinstalled ]o/Iq ) $~.~ Tanksize Foundatlon. cl~anou{~/(q) Yd ~ Date of PUmping '~ A/'O 1~3'-0 Number of Compartments ~ Cleanouts(~q) 'f~) Depression (Y/~) r,/0 High water alarm (Y/N) A///A- Pumper t ~g &¢5 ABSORPTION FIELD DATA Date iustalled I~ / 16 /~' ? Soil rating (g.p.d./ft~ o~ ~ ~ System type T Le. ngth "7 ~ 7of&. V~idth ~ Gravel thickness below pipe '~ 0 Total depflt ~"- EffJ~ti~e, abs0rptionhrea 760 Cr~Ivlonitoring Tubepresent(~)/N) '7*3' Depression overfield (YFi~) Date of adequacy test ~ / ~/~ ~ Results (P~TFail))aa £fl For q bedrooms F~i~dept~i~abs~rpti~fie~dbef~ret~st~(in.?;~2~/q.~unnediate~ya~er~t).(~~. ~7~r gal. wateradded (in.): '~O %¢//: ~,,..,, Fluid depth 1 t~ ¢ Miuntes later: /% ~' /~ (in.) Absorption rate = ~ ~ t7 g.p.d. Peroxide treaUnent (past 12 months) (Yff~) ~ 0 ffyes, give date D. LII~ STATION Date installed S~ m ~0~~~~ Manhole/Access (Y/N) "Pu3xt[~'C~el at* "Pamp off' level at* High water alarm level at* ~ *Datum Cycles t~0~ E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/k~Mii-}g4ank on lot Absorption field on lot Public sewer ~nain Sewer/septic service line ; On adjacent lots ; On adjacent lots Public sewer mmflmle/cleanout Lift station SEPARATION DISTANCES FROM SEPTIC/H©LDINI3. TANK ON LOT TO: Fom~.dation &~ ! "P Property line q~o '-P' Absorption field Water main/service line ~ O ~ Surface water/drainage tv /~ Wells on adjacent lots SEPARATION DISTANCE FROM ABSORFIION FIELD ON LOT TO: Building foundation '~ O / % / Water mai~ffservice line / 0 Surface water t'4/A- Driveway, parking/vehicle storage area Curtain drain ~ o m ~ a: ,'~o a/,,¢ Wells on adjacent lots w' / F, ENGINEER'S CERTIFICATION I certify that I have determined thrufield inspections and review of Municipal recorcl~t~~~ are in conforlnancewithlg[OA,,A~gui~deliaesj~effectonthisdate. /. ~.~"~'- Signature ........................................................................................ ~ 22s_c~: ~ . HAA Fee $ ~' ~ Waiver Fee $ Date of Payment ~~ P/~fl~ Date of Payment Receipt Number ,//~ C~/~) Receipt Number Rev. 8/95 OSS: haa.wk.doc MUNICIPALITY OF ANa.. ~GE preStoN OF ~RO~mL H~LTH DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION ~OR HEALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date 4/~g'-/84 (a) Legal E~sc~iption (include lot, block, subdivision, section, town. ship, range) Location (add~ess or directions) ~4- ~<D~ ~ ~--. (b) Applicants Nam~ ~A/~y RIC~4 Telephone ~Lg_~% Applicants Add~ess ~A ~o)~ ~oo~-~ q~Oq (c) Applicant' is (check one) Lending Institution ~-~; O~%er/builder ~; Buyer ~; Othe~ ~--~ (explain); (d) ~nding Institution_ I~+ ~'~-[~I;E~-- Telephone Z~4-~ (e) Real Estate Co. & Agent Address . Telephone 2. _Type of Residenoe Single-Family Number of Bedrocx~ Multi-Family O~e~ (des~ihe 3. Wate~ Su~Dly Individual ~1~11 ~ Cc~, nity ~ Public ~ Note: If cc~Ntunity well system, must have %~itten confirmation frc~ the State Depa=tm~nt of Environm~=ntal Conservation attesting to the legality and status. Is the well adequate fo= the number of ~edrocms s~ecified in this ~AA (Y/N~ ~/ 4. Sewag~ Disposal Onsite ~ Public ~ Community ~--~ Holding Ta,~ ~ Is the wastewate~ disposal system adequate fc~ the number of k~drocms (Y/N) [Page 1 of 2] 2-15-84 · 5. En~ir~ering Firm Providi~_~ Insp~.ct. ions, Tests ~ rata and Informatio~ I certify that I ha~ Checked~ verified, or conformed to all MOA HAA Guidelines ir effect on the d~e of this inspection. Signed by Date (ENGINEER SEAL) 6. DHEP Approval_ Apl~ eve d for__~ bedrooms Approved ~ Disapp~o~d ~ Conditional~ Terms of Conditional Approval__ Tne MuniciPality of Anchorage Eepa~tmmnt of Health and Environmental Protection d( not guarantee the continued satisfactory t~erfo~ance of tb~ water supply ara/or ti wastev~te~ disposal system. This approval indicates that, as of tho validation ~ shown abo~, based on the data and information furnished by an engineer ~egistere~ the State of Alaska, the water supply and wastewater disposal system is safe and J tional fo~ the r~r of bedrOOms and type of structure indicated. ( (DHEP SEAl,) 7. Mail the HAA to the folloNing address: KB2/d5/s [Page 2 of 2] 2-15-84 A® MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY OF ANCHOP, AGE DEPT. OF HEALTH ENVIRONMENTAL PROTECTIOI~ APR IgP : Well Classification ~ Well Log Present (Y/N) Total Depth Cased to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (Y/N) Separation Distances f~om Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Se%~ Line C leanout/Manhole Water Sampte Collected By Water Sample Test Results Cc~wents ~)~Ag~ I%'%/ All D DJAI-~ Li ~J ~ RECEIVED If A, B~ o~ C, D.E.C. Approved(Y/N) y Date C~pleted Yield Depth of Grouting. Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot ; Date B. SEPTIC/HOLDING TANK DATA Date Installed I(,%-- ~ Size J~O No. of C~,~artments Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N) Depression ove~ Tank (Y/N) N Date Last Pumped ~u3 Pumping/Maintenance Contract on File (Y/N) ~I/A ; for N//~ Holding Tank High-Water Alamn (Y/N) ~/A Te]~ora~y Holding Tank Permit (Y/N) ~/A, Separation' Distances f-~cm Se~ic/Holding Ta,~n~.: To Water-Supply Well ~'~f~ ~ To Building Foundation To Property Line ~ To Disposal Field To Water Main/Service Line JOI .{- TO Stream, Pond, Lake, c~ Major Drainage co se oN r-I D Co,~ments [Page 1 of 2] 2-15-84 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed %O-- ~ Width of Field ~[ZE~C~ Square Feet of Absorption A~ea Depression over Field (Y/N) Results of Last Adequacy Test ~,~/~ Type of System Design 'I-~E~QCH Length of Field ~l Depth of Field ~'~ Gravel Bed Thickness ~(D" Standpipes Present (Y/N) )/ N ~to Date of Last Adequacy Test Separation Distance f~om Absorption Field: · 9.7q' To Water-Supply Well ~o~Ud ~ ~T~. To ~o~ty Li~ IoI To Building Foundation ~%~ To Existin~ or ~ndo~d System Lot ~/~ ; ~ Adjoining ~ts N /~ To Wate~ Main/~vi~ Li~e ~ ~ To ~t~(if pre~nt) To St~e~ond~ke/~ Ma3o~ ~aina~ C~se ~o~ ~ To ~iveway, Pa~king ~ea, ~ Vehicle Stora~ ~ea ~ I + D. LIFT STATION N/~ Date Installed Size in Gallons "Pump Oa" Level at High Water Alarm Level at Tested fo~, Electrical Codes(Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles du~ing Adequacy Test. Meets MOA Co~:~nts ** Check Permitted Bed~ocm Rating Against HAA Request certify that I have checked, verified, oF conformed to all MOA HAA C~]idelines in effect on the date/~f/this inspe~. DEPT. OF ENVIRONMENTAL CONSERVATION BILL SHEFFIELD, GOVERNOR Telephone: (907) 274-2533 Address: 437 E. Street Suite 200 Anchorage, AK 99501 April 4, 1984 To Whom It May Concern: According to records on file in this office South Park, Addition #2, Water System is in compliance with the State Drinking Water Regulations. Sincerely, Anchorage/Western District Supervisor JCA/msm cc: Gary Rich SRA Box 4005-H Anchorage, AK 99507