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Home My WebLink AboutT15N R1W SEC 8 LT 54 N2 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 wr-~LL INSPFCTION REPORT NAME PFION E /~ UP(,' RAD I; MAILING ADDRESS LEGAL DESCRIPTION LOCATION . NO, OF B DROOMS ~ Well - ~ A6~orption area bwelling ~ I~ PERMIT ~O ~ I anuacturer ~,~ ,~,~ IMaterial(.,,~, ~/ INo, of compartments DISTANCE TO: JDweiling PERMIT NO. Manufacturer Material Liquid capacity in gallons DISTANCE TO: ]Well / ~,~ ~.~ 17.~7 No. of lines ~/~/~ J [.~-ngth o~ ~ Trench widt Top of tile ,o finish grade :) ¢1'' //'5 Material bene~t~,e Length Depth Foundation/t/~' Nearest lot line PERMIT NO. Distance between lines tire absorptio~ area Type of crib Crib depth Building foundation Depth I~2 Building foundation Sewer line~O DISTANCE TO: Total effective absorption area Nearest lot line Distance to Septic tank Abso,p 2 / ;;~', OTHER PIPE MATERIALS SOIL TEST RATING INSTAELER REMARKS APPROVED (Rev. 3/78) DATE LEGAL . A & L DRILLING COMPANY ~OX 97, EAOLE RIVER, ALASICA ~S77 · TELL~4OPdE DEPTH OF WELL / ?C~ STATIC LEVEL OF WATER FT. DRAW DOWN F~. Ended ~:,~~ GALS. PER HR __ ~, P~RMn NUMBER 7~ ~ ~ O~ ~?~: r~.,~ r,.,. /r,.~ r~ - Ftc, ~ ~?:, .... F~ FI. lo Ft.__ FL Ft. ea.. F~ .., FL to. ,, FL .. From_ FI. lo Fl. _. F~.. FI, Io, Fl ..... FL ~ ~ Ft.- F~ Fl, to .... Fl. _ F~ _~ F~ .. Ft. F~.. FI. to Ft. ~-. FI. lo_, . Fl._ Frmw ~ Fl, to_._._:._ Ft ~ !/~;: ~ INFORMATION: DRILl PERMIT NO. DIEF'ARTMENT C HEAl. TH RND EN'¢IRONHISNTFIL ' 3'rEOTION ~/~r ~ ~ 825 "L STREET,264-4?a~RNCNORAGE" ElK.z....':,9' ~. ~( ~( RPPL I CaNT L.OCRT I ON LEGFIL STEVEN FLODIN CRAB'TREE LANE 2~:1.. MLILDOON i~SE;9 ~- 7-,.~-,4>- ,/('/ 4b,- LOT SIZE TYPE OF SOIL RBSORBTION ~' q .... IS : ?..]EM : TRENCH -~..~.?'"- ? ~0.9 54450 SQUARE FEET MR}¢IMUf't NLMBEI~' OF:' BEDROOMS = 4 :,uIL RATING ,,c .~ , -,._ "" ,_,Q F r,. BF..:,-. :tOO ]"HE REQUIRED SIZE'.' OF' THE SOIL FIBSORF'TION q"¢.- ' ~ T ~.TI:.M IS: THE LENGTH DIMENSION IS THE." LENGTH (IN FEET) OF' THE TRENCH OR DRRINFIELD. THE DEPTH OF FI TRENCH OR PIT IS THE DISTRNCE BETWEEN THIS SI..IRFFIE:E OF' THE GROUND I:IND THE BOTTOM OF' THE E,'<CRVFITION (IN FEET). THERE IS NO SET HIDTH FOR TRENCHES. THE GRR',/EL DEPTH IS THE i'IINIttLIM DEPTH OF ORRVEL. BETI.4EEN THE: OUTFRLL PIPE AND THE BOTTOM OF THE EXCRVR'rlON (IN FEET). PERI'tIT RFPLIuliNI HaS THE RESPCtNSIBILI'r~ TO INFORM 'f'FIIS DEF'RRTMENT D_RING THE INS IltLLI-TrlON INSPECTIONS OF RNY WELLS RD, HCENIT ..... TO THIS FF, C[-' ' ~EL]';' "'~ RND TNE NUMBER OF RESIDENCES I'HRT THE WELL WILL SERVE. BRCKFILI_ING OF' RN~' =,9~TIaM WITHOLIT FINRL IN..FECFION aND IqPF'ROVFIL 8~' THIS DEPARTMENT WIL. L BE SUBJECT TO PROzECL~ 'FION MINIMUM DI2;'rRNCE BETWEEN R NELL RND RNY ON-SITE SEWRGE DISPOSRL, SYSTEM IS .'LO0 FEE'F FOR R PRIVFITE WEL. L..t OR 250 TO 1~00 FEET FROM R PUBLIC HELL DEPENDING LIPON THE T"PPE OF PUBLIC HE]J... NELL LOOS FiRE REQUIRED FIND MUST BE RETURNED TO THE DEPARTMENT WITHIN Z-'O DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS NI=I'¢ FIPPL'~'. SPECIFICRTIONS 8ND CONSTRUCTION DIFIGRFIHS RRE RVBILFIBt. E ]'0 INSURE PROPER INSTRLLFITION. I ±: FORTtt B~¢ THE MUNICIPRLITY OF RNCHORROE. 2:: I HILL INSTRLL THE SWSTEM IN RCCORDRNCE HITH THE CODES. ~: I UNDERSTRND THRT THE ON-SITE SEWER SYSTEM MRY RE6~UIRE RESIDENCE IS REMODELEED TO INCLUDE MORE THFtN 4 BEDROOMS. ................. RPPL~CRNT STEVEN FLODIN ... ::, CERT I F"r' THRT I RM FRHILIRR WITH THE REQUIREMENF_, FOR. ON-SITE SEWEF'S .... RND HELl .... M=,"'" ..,ET ENL. ARGEMEN]" IF THE '%, PERMIT NO. DEPR~TMENTi,~HERLTH AND ENVIRONMENTALi ~t'FECTICN 82.. ~.~ "~TREET~ ANCHORAGE, AK. D.llEEL_L_ PI~ERI't ]ET A20 ~ FIPPL I OFINT LOCFtT 'r ON LEIJFIL STEVE FI.El)IN CRRB TREE LFINE N:'L,.'2 L54. S!FC8 T::LSN R:IH SM ,~21 MULDOON LOT SIZE 54-450 SL;!LIFIRE; FEET MINIMUM DISTFINCE BETHEEN FI HELL AND RN¥ ON-SITE SEHAGE DISPOSAL SYSTEM IS 100 FEEl' FOR Ft PRIVRTE HELL~ OR 150 TO 200 FEEl' FROM R PUBLIC HELL DEPENDING UPON THE TYPE OF PL.IBLIC HELL. HELL LOGS RRE REQUIRED RND MUST BE RETURNED TO THE DEPRRTMENT HITHIN 30 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MRY FiPPL¥. SPECIFICSTIONS 8ND CONSTRUCTION DIRGRRMS RRE RVRILRBL. E TO INSURE PROPER INSTRLLRTION. I t: FORTH BY THE MUNICIPRLITY OF RNCHIDRRGE. 2: I HILL INSTALL THE SYSTEM IN 8COORDFINCE WITH TME CODE:S. ~,~,,..-,~:_~~~_:~~ ..................... RPPL~OHNT STEVE FLED[N .... ....... ........... _ .......... CERTIFV THAT ! RM FRMILIRR 14ITFI THE REQUIREr4EI'-~TS FOR ON-SITE _LHER_, RND HELl__, RS SET MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF E;NVlRONMENTAL HI-'ALTH OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date ~'/'~7-- GENERAL INFOBMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~'7"~o,G,~Z, ~f'~'/oGq_ Telephone: Home ~¢~'~ 257'30 Business Applicant Address ,~/~ / ~,~'K, ~--7~ r ~/~'~ ~ ~ ~ (c) Applicant is (check one): Lending Institution []; Owner/builder,J~; Buyer []; Other [] (explain); (d) Lending Institution -L~'f~'/~/~' ~'~"/-'/~7~z~. ~,,%AZ,/,~ Telephone Address _ (e)AddressReal Estate C°mpany and Agent Telephone (f) Mail the HAA to the following address: TYPE OF RFSIDENCE Single-Family ~ Multi-Family [] Other Number of Bedrooms WATER SUPPLY Individual Well ~, Community Public Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ~ ', ~ .' 4, SEWAGE DISPOSAL Onsite~ 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. Page 1 of 2 72.025{11/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SI=ARCH, DA'IA AND INFORMATION As certified by my sea[ affixed hereto and as of the validation date shown below, I verify that my nvestigetion 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 turther 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 ~' '~ 7~/~, Telephone _ ~-' ~ Address ~' ~ ~ ~/~ C//~I/~/~ ~/~ ~--~ 7 Date ~' ~7, Engineer's Seal Approved for -r/~]~./~edr~ms b~~~~ ~- ~_~-~ Date Approved ~- ~ Disappro~- Conditional Terms of Conditional Approval \ CAUTION The Muncipality of Anchorage Department of Health end Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representatior~s given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DNEP does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHFP 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 {11/84) i~U~,iiCip.~,UTy OF ANCHOk,.~"= MUNICIPALITY OF ANCHORAGE (MOA) DE~', O~ HEALTH & ENVi~ON~NTAL pROT~CTtON HEAL'tH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 ~OV 6 ~ 264-4720 CEW A. WMLt. DATA Well Log Pre~enl (Y/N) ~ Dale Compleled ~/~/~ Y~eld Static Water Level ~7 ~ ~; ~/¢~ Pump Set At Casing Height Above Ground /~ ~ Sanitary Seal on Casing (Y/N) Electrical Wiring in Conduil (Y/N) __ ~ Depression Around Wellhead Separation Distances from Well: t ~ To Septic/Holding Tank on LOt /~ ¢ On Adjo,nmg Lots To Nearest Edge of Absorption Field on Lot ~ '~/~ : On Adjoining Lots To Naarest Public Sewer L ne /~ ~ To Nearest Public Sewer Cleanout/Manhole ~ ~- To Nearest Sewer Service Line on Lot Water Sample Test Results Comrnents B. SEPTIC/~Jaft~K- DATA Date Installed _ Standpipes (Y/N) Depression over Tank (Y/N) Size (~"~ ~ No. of Corn 3artments Air-tight Caps (Y/N) ~' _ Foundation Cleanout (Y/N) _ /V Date Last Pumped _ ~ : for Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) ~rk~ Separation Distances from Septic/Holding 'rank: To Water-SL pp~y Well / ~4~ ~ .-/- To Property Lin(; To Water Main/oervice Line Course /'~, Comments Temporary Holding Tank Permit [Y/N) 3'0 Building Foundation To Disposal Field ~"~-- · /V To Stream, Pond, Lake, or Major Drainage Page 1 of 2 ABSORPTION FIELD DATA Soils Rating in Absorption Strata /'~d23 ~TI~ of System Design Date Installed ~/~/7 ~" .- L"'~ength of Field ~''7/ Width of Field ~ / ~'~ Depth of Field /~.p r ~ Gravel Bed Thickness ~ ~ Square Feet of Absorption Area /.///.//L// ~/,c~ Standpipes Present (Y/N) Y Depression over Field (Y/N) /%'/ Date of Last Adequacy Test Results of Last Adequacy Test /¢¢¢.~¢'-¢~ ,/~,~¢~' /~'~/~- .~../~' Separation Distance from Absorption Field: To Water-Supply Well /,~) ~ Y'' To Property Line ~-'~ / To Building Foundation ~,.~L~ To Existing or Abandoned System on Lot N,J~ ;On Adjoining Lots ~ -/~:~ ! TO Water Main/Service Line ~d~ ! ~ To Cutbank (if present) To Stream/Pond/Lake/or Major Drainage Course ~t ~. To Driveway, Parking Area, or Vehicle Storage Area ~"'~ ''-~--~ Comments LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request , certify t bat~ve ~h_ecked, verifi..~.~or ~on, formed to all Signed ~/~,i~1.671.4.¢0 ~ ~ate Company ~ ~ ~ /~' MOA No. Receipt No, /~O/ OO/~ Amount: $ 6L¢ ¢~ Page 2 of 2 72-026 (11/84} MOA and HAA g uiddines in effect on the date of this inspection. Engineer's Seal IVIUNICIPALITY OF ANCItORAGE DEPARTIVIENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-47:~.0 ........ Application Date .... :.~.___¢~' ..... GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, soction, township, range) Locatioe (address or directions) (b) Applicant Name .~L~.¢_~-~,~.~___~/"~:~;Telephono: Florae '~'":"¢¢' ") '~ ;'~' '~ Applicant Address . __,~_L?~___~¢~__~.fj~/'?~,) ¢;//~..¢.¢;t/¢I~' .~¢'~,~:¢ ~¢~'%%~ (c) Applicant is (check ono): I_ending Institution F~; Ownel/buikJer ~;:-~: Buyer 3; Other [3 (explain); re)AddressReal Estate Company and Agent ............. Telepbone J ~,1 ~ ' ' .............................. (f) blail the HAA to the following address: TYPE OF RESIDENCE Single-Fan'lily ~ Multi-Family [~] Other Number of Bedrooms .... _¢--------__ WATER SUPPLY Individual Well~( Community E] Public E] Note: If commenity well system, must have written confirmation from th( Stat(. Department of Environmental Conserv,~tion attesting to the legality and status. SEWAGE DISPOSAL OnsiteJ~ Public ['-] Community L'.] Holding T~nk b~ Note: If corn munity well system, must have written confirmation from the Stat(; Departmeat of Environmental Conselvatiol~ attesting to the legality and status. ENGINEERING FIRM PROVIDING INSPECTIONS, 'rESTS, FILE S[:;ARCI-I, DATA AND INFORMATION As eer tilled by my seal affixed hereto and as of the validation date shown belov/, I verdy that my mvest~gat~or~ of th;s Health Authority Approval shows that the on-site water supply and/or wastewater disposal sys!em 'rS safe functional and aOequate for the nLl~bOI O~ bedrooms and type of structure indicated herein. I further verity that base0 On tt~e mformabon obtained from the Mumcipality of Anchorage files and from my investigation and inspection, tl~e on-sale water supph/ under wastewaler disposal system is in compliance with all Municipal and State codes, ordinances, and regolahons ~n effect on the date of this inspection. Name of Firm _~,~¢"~. ............. Telephone ~',~ ~ DHEP APPROVAt. Ap~ re _ r->~:b~.'~ ~ .................. Date )ved for/¢~' , '~ bedrooms by / ........... t- ~,-t*~-¢--~-( ,~"_ Approved ____ ~. ...... Disapproved ............. Conditional .............................. Terms of Conditional Approval ................................................. CAUTION The Muncipality o! 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 coudesy to purchasers of homes and their lendir~g institutions in order to s~tisf¥ certain federal and state requirements. Employees of DHEP do not conduct inspections or analyze data before a certificate is issued. The Menicipality of Anchorage is not responsible for errore or omissions in the professional engineer's work. Page 2 of 2 72.025 {11/84) MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL [HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: WELL DATA Well Classification P~'~,,~ ~,~t~,~ ~"~f Well Log Present (Y/N) ~ ~' bate Com'~leted ~"/~/? ~" Yield I #" ¢1~ ~"~¢'~'/Deoth of Grouting Total Depth ~/~"'~-~ Cased to Static Water Leve __ /~,"J~ ~,~15 ~.,¢~ ?,/f~/~'~"~ PumeSetAt __,~'~""~' Casing Height Abow) Ground _/-~' ~'~ Sanitary Seal on Casing (Y/N) A. B, C, :).E,G. Approvea (Y/N) /'~'~ · ~' "-/ -/ ' ' Electrical Wiring ~n Conduit (Y/N) Separation Distance.,; from Well: To Septic/Holdi.ng Tank on Lei ./~- To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Jne ___,~V Clearlout~ Manhole __,~- ~- Water Sam cie Collected ey Water Sarr cie Test Results Depression Around Wellhead (Y/N) /t~;) : On Adjoining LOtS I ~¢¢"'t~ On Adjoining Lots To Nearest Public Sewer ~,4~ To Nearest Sewer Service Line or] Date "~'~ ~"~'~' ~"' Comments B. SEPTIC/FI4~,~h~RM~K DATA Date Installed. ~/~-~1'~ ~'~Size/! No of Compartments Standpipes (Y/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) ,,4,~ ,~- Seearatlon Distance.'~ from Septic/~ To Water-Supply Well ~ ~' ~"¢- To Property Line ~It To Water Main/Service Line ~ Course _ /~/. '~' for '-' ' Temporary Holding Tank Permit (Y/N) ~'~';~ To Building Foundation __ ~'¢¢~ To Disposa Field _ .~. t 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 Depression over Field (Y/N) Results of Last Adequacy Test "'~'~"'~"~: Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation Lot ~/.. ,~- To Water Main/Service Line (~ ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Type of System Design Length of Field ~ 7 Depth of Field Gravel Bed Thickness ~--~ ~'~, "~ Standpipes Present (Y/N) Y &',-~ Date of Last Adequacy Test To Properly Line To Existing or Abandoned System on ; On Adjoining Lots ~' /¢:~ TO Cutbank (if present) Comments D. LIFT STATION Date installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify t h,a,t~J;ta~e checked, vgrified/~r conformed to all J,,4OA ant' HAA guidelines in effect on the date of this inspection. Signed Company ~~ MOA No. ~ I ~' 0 // / Receipt No. ~ -, ' (-- ', - '~gmeer s Seal Amount: Page 2 of 2 '~ TIME TIME DATE DATE' DATE INSPECTOR INSPECTOR k..jv MUNICIPALITY OF ANCHORAGE DEPI. OF ~-~ DEPARTMENT825 OF' L REAl. TH & ENVIstreet - Anchorage,RONMENTAL Alaska 99501PROTECTIo~NVIR© blM~ N L"'L-' (~-41 ,~rr~ ENVIRONMENTAL SANITATION DIVISION REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SFWER FACILITIES PROPERTY OWNER PHONE PROPERTY RESIDENT (If different from above) PHONE 2. BUYER PHONE MAILING ADDRESS MAILING ADDNESS 4. REALTOR/AGENT J MAILING ADDRESS 5. LEGAL DESCRIPTION Z~ N Z 5'g P 776'/,/ /az' STRI-=ET LOCATION 6, TYPE OF RESIDENCE NUMBER OF~BEDROOMS [] One ~,,. Four [] Other '~ [] Two [] Five SINGLE FAMILY E~ MULTIPLE FAMILY [] Three [] Six 7, WATER SUPPLY ~ INDIVIDUAL' *ATTACHWELL LOG. AweIIIog sreouired for all wellsdri ed [] COMMUNITY smce June 1975. For wells drilled prior to tibet date, give well I-D PUBLIC UTi LITY de~th (attach log if available.) 8, SEWAGE DISPOSAL SYSTEN1 ~ INDIVIDUAL/ON-SITE*' [ ?'7~"/ .YEAR ON-SITE SYSTEM WAS INSTALLED [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING (;AN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2. WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED ' 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] INDIVIDUAL/ON -SITE DATE INSTALLED []PUBLIC UTILITY ~:~ ~'~ ~Y Connection Verified INSTALLER [~]Septic Tank or [] Holding Tank ~ Size: I ~,~-O If Tank is homemade SOILS RATING give dimensions: I ~O TYPE OF TANK MANUFACTURER . ,~,_~_~j..~~ TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS PPROVED FOR BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) - [] DISAPPROVED DATE BY 72-010 (Rev, 6/79)