HomeMy WebLinkAboutTANAINA VALLEY LT 13
MUNICIPALITY OF ANCHORAGE
DEPARTMENT Or HEALTH AND RUM^N SERWCES ~//-- ~.,~/-- .We
Environmental Health Division
,_..~
825 'L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Name
PI,one(s, pc~,~ ~ ,//i.~ NO O' Sedr~ms
LEGAL DESCRIPTION
Township, Range, Seclion
5ct T'/2.~ ~qvJ
TANKS
SEPTIC [] HOLDING
Malarial
_ 5-r'~'L
TYPE OF SYSTEM
[] TRENCH [~ BED [~ W. DRAIN [] OTHER
Depth to pipe bottom 1rom Total depth 1rom original grade
original grade
ill added above original grade
Gravellength
~7~ FT
0 FT
Number of lines Soil r aling~,./3
/ SQ FT
Gravel depth beneath pipe
ravel width
Pipe material
PV(L 3osq
WELLS
[] PRIVATE
Classification
DISTANCES
SEPTIC
TANK
WELL
LOT LINE
FOUNDATION ///
ABSORPTION
FIELD
t
WELL
p
/.00 +
AS-BUiLT DIAGRAM (Show location ol well, septic system, property lines, loundalion,
FT
[] OTHER (Identlfv)
Tolal Depth Cased to
Dale Ins[ailed: FT
RI-'MARKS:
InsRectio PeHormed by:
I ~1~ ~ ~ ~0 [~0 W ce,ily ihaI Ibis insoecllOll was pedonged according to all
72-013 (3/85)
Michael E. Anderson
438l -E
Name:
BF;:t H]IE
4000 WORIZNSOL
~:II',ICF~[)R AGIE ¢ AK 99~03
I .o'l'. I...ega 1: !!h.l[) d :i. v ~ ~i :i. c)l't: TANA INA VAI.I..EV l..clL ~ 1.:].";1] 11::~l:: k J~
Sec t :L on: 4 ol,4rl'~h :i.I): :L2N I::~an(l~,)',: *ll,,J
I..¢L S:i. ze 368~.1!::'i (sq,,(L,, of ac:pcs)
i',l,;).,~.: ~]16:~C]l'C](;])fl/'r~t~ Ih:i!:', Ir)p;'I'I'R:i.'f..~', *']' 'KC)tL.~'~]. [;apacit:.y: 4
Day
:iilEF'l'IC tAhtl.::: M:in:imum 'L
'J,Ed]J.;; IIlI,U;i't', J'l,blVIG) ,~:~.1'. ].ea!~lL 2 c:cJmpar'tfflertt:.!;~,,
Cal::lac::i. ty: ;L~250 ga].].c~r~s,, I:i!:a(::;h
Del:~th 'Lo top (::~f s=,ept:Lc tanl::(s) < 4,,0
I I',iS I'AL.L F:'IER IEN[:':) I I~.IEIEI~:S DIES ]; Gig ,, NOT I FY DHHS I:;:'R :[ []R TO EACH
I I',ISI:;:'ECT I lIN ,ElY ]HIE tii:l',l(.'¢ I Ixll!ii;lii:l::~ ,, TH I S I::"ERM I T I S I SSLIIED FOR
I::"I.ANI',Ili~.;D F:]::)LJF~ )~!IIEDI::IOOM S]:I~.IGI..IEFAMII...Y DWEL.L..I:I~.IG OI',ILY AND IEXPIRES
tIN 12/3 ;1./~i!19 ,,
:1: CIi!i:F,:T I I:: Y 'II"IA I:
eot'th by 1'_1"1(,~ Mur'l:ic:i. pal~.ty o~ ¢-:lnch~)r'age (IdOA) arid 'l:he State o{' Alaska,,
;::',,,;[ t.,,l:i. [I, [t ;i,r~iiF[,8],]. '~'.J"l~,.) ?~y~!~F(.G)fll :Lr] acc:opda~ice w:i.'Lh ail MOA
;]~;,,I t.~:i.]l ,adho;me 't:(::) a;L] MOA ~:~l'~l::l SL,'.~t(..¢ cH' Alaska i, equ:ip~.;~men'i'.s {'(:lr'. I..,lle s~t back
CJ:L~,~FL~I"IC:c;)S f'Pc]l¢l ar'Jy' ex:ist:i, ng we].]., t4asl:.~)wa'l'..~)r' d:i. sposal syst..em (:)~' F)ub]ic
].,. ]J t..tl]df(:.l'...Bt,'~fid It. hat th :i..~B pE;r i/~:['L ~z,~&] :i.d roi" a m,~..,, :[[RL..tTi
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN.SERViCES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:.
LEGAL DESCRIPTION: ~. O T'
I
2
7'
11
12
13
14
15
16
17.
18-
19-
~,~ '~AFI^u-IA ~AlfeqT°wnship, Range,SeCtiOn: S L/ l'~.?.r.
I SLOPE SITE PLAN
WAS GROUND WATER
I;NCDUNTERED?
IF YES, ATWHAT
DEPTH?
Reading Date Gro[t Net D~}th to Net
Time Time Water
PERCOLATION RATE
__ {m~nutes,,inch) PERC HOLE DIAMETER
COMMENTS
72~8 (R~. ~1~)
TEST RUN BETWEEN , FT AND ~FT
S/~,:re,/ ct,~v ~:A,?,,?4o.~'- /~,~,bd, .~o,/s ~,,s,s~!,,~.f'-
IN
I
3'm
OI
~ O'l,l*eC
MUNICIPALITY OF ANCHORA(~E
DEPT, OF HEALTH &
ENVIRONMENTAl. PROTECTION
SEP ,f~ 1989
RECEIVED
ANCHORAGE/WESTERN DISTRICT OFFICE
3601 C STREET, SUITE 322
ANCHORAGE, ALASKA 99503
563-6775
DATE: Setp. 23, 1989
PWSID: 214706 --
According to the records on file in this office, the Qountrv
_~an~ Rstates water System is in compliance with
state of Alaska Drinking Water Regulations.
the
Sincerely,
Cindy Thomas
Environmental Engineer
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
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 lot. block, subdivision, section, township, range)
Location (address or directions)
¢l:,rn
(b) Property owner ¢¢~0CE. ,Z),4VID~¢z,/
Mailing Address ~-OOO bOOE E/,~,$c~/__ ])~-,
(c) Lending Institution ~,,"'~=",~/ <cc'x'//4' - S U ~"
Telephone: (home)
Business
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here E~,ii hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Number of bedrooms
Single-Family/~
3. WATER SUPPLY
Individual Well []
Community ~ Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4, SEWAGE DISPOSAL
On-site'¢, Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legality and status.
72-025 (Rev. T/88) Page 1 of 2
J J.O ~ @Sed
'~JON~ s,Jeau!~u@ leuojss@joJd eLl~. U]
SUO!S$!UJO JO SJo.ue Jo~ elq!suods@J ~,ou s! e~eJOqOU'¢ jo A]!led!ojunv~ @q/'penss! s! @]eo!jd~.JeO e eJojeq e~ep ez~leUe Jo
suogo@dsu! ]onpuoo ]ou op SHHQ Jo seeAold~3 's]ue~u@JjnbeJ eie~s pue leJepej u!elJeo,~js!]es ol JepJo u! suo!lnU~su!
8uJpuel J!eq] pue seuJoq jo sJeseqoJnd oi Ase~Jnoo e se s!q] seop SFIHQ eql 'eHSel¥ jo e~e1S eq] u! peJe~s!~eJ
~eeu!bue leUO!SSa,~oJd ~uepuedepu! ue Aq e^oqe S qdeJl~eJed u! ue^!6 suoRe~uesaJdaJ eq~ uodn ~lUO peseq
le^oJddv AuJoqinv q~,leeH senss! (SHHQ) seo!^Je$ u~nH pue q~leeH jo ]ueuulJedeQ eSeJoqou¥ ~o A)!led!o!un~
leAoJddv leUO!~!puoo ~o SLUJe..L
legs s,Jeeu!§u3
~.- ~)2'~' --~ ~-~ euoqdele/?c~l-[L;.-l.~fw!~c~ r~Oy-~7(~CV~/ LUJ!.-I Jo eLUeN
'uo!ioedsuj siq~ ,to elep eqi uo loejje u! suo!~elnDeJ pue 'seoueu!pJo 'sepoo e3e3S
pue ledio!un~ lie q~F~ eoUe!ld~uoo u! s! buels,~s lesods!p Jeiet~else~ Jo/pue Alddns ~e~eM eUs~uo eql 'uo!3oedsu!
pue uo!leeRse^u! ALU ~uoJj pue sellj e§eJoqouv Jo A1ued!o!un~ eq~ uJoJ¢ peu!e3qo uoj3euJ~oju! eq3 uo peseq
3eq~ ,~pe^ Jeq~Jnj I 'ujeJeq peleo!pu! eJn3on~s Jo edA~ pue sLuoo~peq jo JequJnu eq3 ~o,t e3enbepe pue' leuo!3oun,t
'e,[es 9! t.uelsAs lesods!p Je~eMeise~ Jo/pu~ Alddns ~e3e~ e3!s-uo eq3 ~eq3 st~oqs le^oJdd¥ A~Moqlnv qljeeH
s!q~ Jo uo!3ee!3se^u! Au~ 3eq~ AMJe^ I '/~oleq u/~oqs e3ep uo!3epue^ eq3 jo se pue oleJeq pex!jJe legs ALU Aq Pe!J!lJeo sV
NOI.L¥1NIdO=INI aNY ¥.LV(3 'HOI=IV~$ ~llJ 'S.LStJ. 'SNOI.LO~dSNI 9NIOl^Oad INI=II=I 9NII:BI;aNIISN=~ 'g
MUNICIPALITY OF~oE!
DEPT. OF Hll~-~l~
ENVIRONMENTAL
RECEIVED
MUNICIPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
A. WELL DATA
Well Classification
Well Log Present (Y/N) __
Total Depth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Date Completed
Depth of Grouting
If A, B, C, D.E.C. Approved (Y/N)
Yield
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service Line on Lot
Water Sample Collected by
Water Sample Test Results
Comments _~ F_- ~::
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ~,/-~//~ Size
Standpipes (Y/N) y _Air-tight Caps (Y/N) _
Depression over Tank (Y/N)
Pumping/Maintenance Contact on File (Y/N) kJ
Holding Tank High-Water Alarm (Y/N) /4//)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
No. of Compartments
y Foundation Cleanout (Y/N) _~/
Date Last Pumped ~J~J
:for
Temporary Holding Tank Permit (Y/N)
To Building Foundation //
'fo Disposal Field
To Water-Supply Well
To Property Line _ ~'S'
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Com merits ~f-~ T ! c:
72-026 (Rev. 7/88)From Page 1 of 2
ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~h/,h?
Width of Field -.~ /
Square Feet of Absortion Area ,b"4, O
Depression over Field (Y/N)
Results of Last Adequacy Test /c,~&~
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well
To Building Foundation z_/~.,
Lot tOOdE 0.~ LoT
To Water Main/Service Line 2__ ~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Type of System Design
Length of Field ~' ~'"
Depth of Field ~:¢ /
Gravel Bed Thickness , ~ /
Statndpipes Present (Y/N)
Date of Last Adequacy Test
ual, 844/,u
Y
To Property Line ¢(~ '
To Existing or Abandoned System on
; On Adjoining Lots /.5'¢ /
To Cutback (if present) ,/t/o/u'~' .,z~,~'~'.~-~/-~
~TION
Date I n s t a I I e d'~/'/'/'/'/'/'/~ . Dimensions
Size in Gallons
- Manhole/Access (Y/N)
"Pump On" Level at ~~ "Pump Off" Level at
High Water Alarm Level at '~ Vent (Y/N) _
Tested for '~"~...~Pumping Cycles during Adequacy Test,
Meets MOA Electrical Codes (Y/N)
Comments
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to ail MOA and HAA ~Lkd~lCh~.~i~,.effect on
inspection.
Company ~ ~O~
Date
MOA No ....
~ . Neoelpt NO. '
Amount: $ ./~¢-~O Date of Payment
Engineer's Seal