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HomeMy WebLinkAboutTANAINA HILLS LT 15011 MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telepho]]e 264-4720 ON-SITE SEWAGE DISPOSAL. SYSTEM AND/OR WELL INSPECTION REPORT MAILING ADDER E_~ LEaL DESCRIPTION PHONE ~ El UPGRADE OF BEDROOMS DISTANCE TO: [~J"~ ~ O / . ,ft., /~ DweUing.~ / Manufacturer npartments Inside length Liquid depth I F HOMEMADE: Dwelling W dt ] DISTANCE TO: Well PERMIT NO. Manufacturer Material Liquid capacity in gallons No, of lines i Lengt 3 grade I Abs°rpt~_~] ~ea F o u n d~t i.~n ! Total~ ~.~.~1 ng~. of lines Material beneath tile Length Type of crib Crib diameter Depth Crib depth Building foundation DISTANCE TO: Class Driller Building foundation Sewer line DISTANCE TO: OTHER I Trencb ~ic~h [ Dista~7~e~n lines ' ~._~¢(~ ~t'inches /~O~( ~ Total ef e tiv ab .~on area.. PERM T NO, Nearest lot line ~sRo rMit~o~'rea (s) PIPE MATERIALS SOIL TEST RATING DATE 72-013 (Rev, 3~78) LEGAL u3 m, <~ 02_ 0 0 0 0 0 0 0 0 0 0 0 F'E]'RJ~I I T NO: DFIT(R IF;SUED: LEGF:IL..[:,IEiSCF;~'.IF:': SIJE:[:,IV]::~:I(]i",I; I']::II",IF:IINFI HIL. L!(i; LOT: :;I.5 BLOCI<: I",lF:l S~'.SE';I"I-ZI'.,I: ,4- IUl. ll,l=tllf : ::L2N I..OT '.~¢IZIE: 75000 (SQ. F"l". 0[?. F:ICP. E(S::, LOT LOCF'IT :[ ON: I< 1[ TI. I SR (::'R I 'v'E I'IF:IX IE',I~:[:, F4:1]lO H S: I.. I ::;TIZI::, IBE:;L.Olq FII;;~IE THE OF"T I OI",[Z [::1',,,'[:1 ]; LFI[~',[...E ]"O *.l)OI.J :[ I",1 DIES Z GI",I I NG "r'OLIl:?. SEPT Z C :;~"r%"I"EH. CHOO!;E THE: OF:'T1[ON 1[HFI'F E:E:ST I::;'Z'I".E; ~.r'l::ll...ll;~: S ZTE. F' ~;~ EEC P"4 CZ:: :+::+: GI:RRVIEL. L. EI",IGTH 3:' 75 I:;:'T. RE(;!I...IiiR[~::E; I'II_ILTIF'I..(:~; flU(BI:E; (blOT E',:-:;CEEDII",Im]i 75 FT. IEFICl-I) :+::4-: TFIbtl< I"ltJ?l" FIFl'v'E R'F I..EF:IST TI40 COMF'FIP.-FMEI'.,ITS CEE:T I F:'"r' 'I'FIFIT: J... I F'IM FF:IMIL. 1[I31:;~: 1.4]Y'FH THE f;~:IiD;!I._IIF]:EMEI",ITS FOR OI",I-SITE SEI.,.IE:I:;:S FII",IE:' I.,I[~.:LI._S FIS SET FOF;'.TH E',"r' THE MtJl",l I (::::[ F'Fll.. I'1%" O(:' FINCHOP. FIE!iE .'::1'"1(31::1) FIi",IE:, THE S'T'FITE OF:' F:ILI:'ISKFI. 2. I NIL..L. INSTR[.I. THE '/:;"r'STIEM I1",1 (:IC:COI:;:E:,FII'.tCIE I.,.IITFI FILL MOF:I CODES FII',ID F,'.E(C'iUI_FIT]:(.)N:E;., I"-Ii",f[) ]: N COMPL I FII",ICE f,I I 'I"H THE DES :[ GIq C:R l 'FEI~: l FI OFt TH I S F'EI;~'.I'I I T. Z:. I NIL. I.. FIDHEI4'.E TO F:ILI... HCIFt F::ll",l[:' S"I'F:ITE: OFr F:IL.FISI-:(FI RE(;!I..JIt~:EHEi",I-I'S'FOR THE !i;ET [:, 1' :E;'[:FINC:E'.E; F:(';tOH I::li",l'¢ (iX I ZT I I',~G I.,.IIEI...L., I-,.Ila:i~';TENFI"I"EI:.i: [:, 1[ :.-];F'O'.F.'iFIL 'Z'i'¢:'3TEM (1)Fi: F:'LIE:L I C SEI.,.I[EF;~F:IOE S't"ZTEI"[ ON THIS CFi: FIh,l'¢ FID..)'F:IC:ENT Ot;;'. h,lE;FIl',~:E:"r' LI]IT. 4.. :( LIt",tI:::,[i[I~:LE;"I"FIP,I[)' THFIT THZS F:'EI:~'.f'III" Zii; VI:rlL1[D I':'m.)lq: FI I"]FI',='=',ZHUM OF 5 E:EDB'.OOMLr':; FIi",ID F:ll",l"/ ENLFI[;;:GEIqEI",IT H I t..I.P. EQI.J :[ Fi:E: F:ll",l Fl[::'[:' 1[ T i ()I",tFIL F'E;[;~:I'I I T. :1: F R I.... I F:'T STFIT I ON 1[ E; :I;I'.,ISTFIL. I_EI::, I I',1 F:lbl FIl:;[:(:.::l::l I'_':O'v'EF;'.E[:, B"r' MOFI E:Ui1;I_D I bi6 COB'ES., THEN ,:::L) FIN [ii:[..E;CTF~'.ICFIL F'IZI:;;:MIT FH",tD ZhI:)~F'IEE:TION PI(.IST BE OE~TI'-:IIN(Z[:,; ,::;;i:) F:tE!;-'E~UII_"I'S I.,.I I I_L I",10'[' E',E f:lF'F'F4:O'v'EIi:, 141 THOt.I'T lan EI_.E:CTF;'. Z CFIL Z i",ISF'(::33T i[ 01",1 REPOP. T; FIND ,::;.!: ) "FHE IEI.[:ZCTF;: I CI::IL b.IOFd<: I'll.J!!;T EIE DOblE E:~T' FI L i CEi",ISEL':, ELECTP:'. I C I Fll",l. S ;I; EiI",IE D FIF'F:'l... I CFINT: I :E;SUE:[:' B~'' MUNICIPALITY OF ANCHORAGE Department ? Health and Environmenta 825 ~ Street, Anchorage, AK. 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~ ~(}.q~_ WELL AND~O~ON-SITE SEWER PERMIT Applicant: I ~g~ ~LC ~ Mailing Address: Location: Phone Number: ~rotection ~9501 Legal Description: /~/,~' '~C:~% (2~ ~, Lot Size: Type of Soil Absorption System Is: Trench: 2~ Drainfield: Seepage Bed: Holding Tank: Maximum Number of Bedrooms: %~ Soil Rating(sq.ft/br) ~ The Required Size of the Soil Absorption System Is: DEPTH /c/ LENGTH ~(~ GRAVEL DEPTH ~P 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 ~ipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /©CP~ 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 will be subject to prosecution. inspection and approval by this department 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 require enlargement if tr ~gsidence is remodeled to include more ~hat 3 bedrooms. Signe~: Issued by: Applicant SWP/024(1/81) SOILS LOG, MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 b. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION 'rEST PE.EOR,.'ED EO.: D'/m./ /¢Z¢ / ,/ SLOPE 7 8 9 10 11 12 13 PERCOLATION TEST R'rcx,'eJ 15 16 17 18 19- 20- SITE PLAN ENCOUNTERED? P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop / +/qu o y.',¢3 ,5~ PERC~ATION RATE J¢;/~ ~[J /O (mmu es/,nc~ DATE: ..~ .~ ~ TEST RUN BETWEEN 72-008 (6/79) MJNICIPALI~£Y OF ANCItORAGE DIVISION OF ENVIRONMENTAL ItEALTH DEPAR2~IENT OF HEALTH AND ENVIRONMENTAL PROTECTION APPLICATION FOR I{EALTH AUTHORITY APPROVAL CERTIFICATE 1. General Information Application Date 2..~=_,~__C,1(:_~,~_~._~ (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Appl:[c~nts Nami _~/ ~-~g____~.~]:~hone - Home '~ Busiae~s Applicants Address ,~ (O fX~~ ~.~,,.,.~_~ ...... ~'7 (c) Applicant is (check one) Lending Institntion ~[ ; O~.,ner/builder ~ ; (d) Lending Institution Telephone Address (e) Real Estate Co. & Agent ......................................................... Address Telephone (f) Mail the NAA to the following address: 2. T e o~ R~sidence _'~!g~....=---' :-:-- Single-Family ~ Number oF_- Bedrooms Individual Well ~ Multi-Family ~ ) Other (describe) Note: If community well system, must have ~ritten confirmation from the Slate Department of Environmental Conservation attesting to the legality and status. 4. Sewage Dis~.o.j~]_~ Onsite ~--~ Public Li~--~ Community ~--[ Holding Tank ~I Note: If community well system~ mnst have wL'itten confirmation from the State Department of Environmental Conservation attesting to the legality and status. [Page 1 of 2] 5. _En_~_ineering Firm Providin~.I_n_s_~.ac__t_ion___s, T____ests___z, File Searcl]a Data 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 info~nnation obtained from the bR~nicipality of Anchorage files and from my investigation and inspection~ the on-site water snpply and/or wastewater disposal system is in compliance with all Mnnicipal and State codes, ordinances, and regula- [:ions in effect on the date of this inspection. DHEP Ap_p rov al Approved for "'~- bedrooms By .~!i,~ ~f Approved x Disapproved .... Conditionol .... Terms of Conditional Approval CAUTION TtH'] MUNICIPALITY OF ANCI1OKAGE DEPAR'I}IENT OP HEALTH AND ENVIRONY~NTAL PROTECTION (DHEP) ISSUF, S iIEALTtl AUTHORITY APPROVAl, CERTIFICATES BASF. D SOLELY UPON THE REPRESENT- ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINEER PoEGISTERED IN THE STATE OF ALASKA. THE DHEP DOES Tills AS A COURTESY TO PURCHASERS OF itOME$ A~D THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY' CERTAIN FEDERAL AND STATE REQUIRE- MENTS~ EblPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEI"ORE A CERTIFICATE IS ISSUED. T'}IE MUNICIPALIT'~f OF ANCIIORAGE IS NO%"' RESPONSIBLE I.'OR ERRORS LOR OMISSIONS IN ~HE PROFESSIONAL ENGINEER S WORK. (DHEP SEAL) RR4/ej/D18 [Page 2 of 2] 7-19-84 MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) WELL DATA Well Classification CHECKLIST - FEBRUARY 1984 Legal Description. ~l~-- ~ /_ If A, B, c~ C, D.E.C. Approved(Y/N) Well Log P~esent (Y/N) Total Depth~ ' Cased to static water Level _ ~' / Casing He l.ght Above G~cund 2~ ~D~ ' Electrical Wi~ing in Conduit (Y/N) Separation Distan~s f~cm~ Well: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on ~t To Nearest Public Sewe~ Line ~/~ Date Completed Pump Set At Ill/ ~ --~-~4 Yield Depth of G~outing Sanit~y ~al on Casing (Y~)~ ~ession ~ound ~l~ead (Y~) ; ~ ~joining Lots ~ IOO ; ~ Adjoining ~ts ~OO To ~est l~blic Cleancut/Manhole /9./4 To Nearest S~we~ Service Line on Lot Water Sample Collected By /~ ; Date Wate~ Sample Test Results B. SEPTIC/HOLDING TANK DATA Date Installed __~/~/~z[ __ Size ,,I 5-00 ~-~-C NO. of C~,9a~tm~nts Z~ Standpipes (Y/N) V~ Ai~-tight Caps ~Y/N) ~c~Foundation Cleanout (Y~)~¢~. ~p~ession o~ Ta~ (Y~) ~_~ ~te ~st P~d ~./~ ~;~ ~ P~ing~intenan~ ~n~a~ ~ File (Y/N) ~./~_; fo~ '~ Holding Ta~ High-Wate~ ala~ (~)~/A- ~a~y Holdi~ Tank ~t (Y/N)~ ~ ~p~ation Distan~s ~ ~Ptic~olding Tank: To Water-Supply W~ll } O~P ' TO P~ope~ty Line ,~> / ~) ' TO Wate~ Main/Servic~ Line j~,/~ course ,S /A Con, ants To Building Foundation ~1 To Disposal Field ~/ To Stream, Pond, Lake, c~z Majo~ D~ainage [Page 1 of 2] 2-15-84 Ce ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed ~-~-~ ~ Width of Field ~ i Square Feet of Absorption A~ea / /Length of Field ~3' Depth of Field [~-,5 ~ Gravel Bed Thickness ~0,~ Standpipes P~esent (Y/N) ~5 Depression over Field (Y/N) ~0 Date of Last Adequacy Test /~./;%- Results of Last Adequacy Test /~/~ Separation Distanc~ f~om Absorption Field: To Water-Supply Well ~ [ [ ~ / To P~operty Line ~O/ To Building Foundation ~_~2~ To Existing or Abandoned System ca Lot ~./A ; on Adjoining Lots To Water Main/Se=vice Line A3/~ To Cutbank(if present) To Stream/Pond/Lake/o~ Major D~ainage Course To D~iveway, Parking A~ea, Or Vehicle Storage A~ea [O! Cor~nts LI T STATION /O0'U Date Installed Size in Gallons "Pump On" 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 Counts ** Check Permitted Bedroom Rating AgaiF~t HAA Request ** I certify that I have checked, verified, oF conformed to all MOA HAA Guidelines in effect on the date of this inspection. Company' ~ ~A/G//t/t--67~q MOA No. S7'-~-00V KB1/d5/s [Page 2 of 23 2-15-84