HomeMy WebLinkAboutTANAINA VALLEY LT 21
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Heallh Division
825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Address
TANKS
'~ SEPTIC [] HOLDING
DISTANCES
WELL
SEPTIC ABSORPTION
TANK FIELD
WELL
--LOT LINE ........
FOUNDATION .......
TYPE OF SYSTEM
~J 'tRENCH E] BED ~ W. DRAIN [] OTHER
/~O FT
lolal depth Irom original grade
~', % FT
~ FT
/0
WELLS
PRIVATE ~, OTHER (Idenlifv)
REMARKS:
I - ~1 ~¢A ~, ~ ~ ~ J~&'O~ ~ertily flint this igspeclJml was pedormed ~6~ordJng ~o all
Michcm) E.~ ~ndcrson
72 013 (3~85)
O N ..... ~iJ I 'T' E S Iii!: W E R P Iii: R M I T
F'ef'm:i'L NumberJ~ 8130~16
l)ate Issulm:.l: 07/07
Eng,.neet, Designed
Owner' Name~ I:)E~II:~I~S IN WI]OD
O~,~ner' Al::ldr'e!ss~ '7c)2:L DRIFT'WE)OD LANE
ANC]I-K)I~A[']E, Al< 995:1,8
Day
;:!;49 '"" JiJ ()
SI::P'f':[C', 'l'AIxlK.~ Min:lmum 'Le~tal sep'Lic tank (~apaci't.y: :1.,~.~5() ga:l. lcJr'Js.
tank mu~it J'l~sv(:? ~'il'J:. ].::h'i~:i'~.. ~:~ ~::c)fliJ;)L:P'~.fil(:~r'lt.~:. Dep'Lh 'Lo 'Lc:p oI' se:?pti~ tarll..'. (!~) < 4,,0
]:NI::I::)RM D,,H,,H,,S. F:'RJ:OR TO li~'T' & 2ND INSF:'E£:;TION,~3 BI:..'. ENGINEER!,
AF:]'I:!.:R OFF:'I[;Ei: I..IOLIRS, CAI....L ::4:3-468:1. AND I..EAVE A ME!38AGE,,
[',ONSTF~LICT F:'EF:/ I!:NI:~]:I',IEER!3 A'rTAI:.'Hlii:D APPRI:)VED
'T'H :l: ~iJ PI:~:F. IM I T E XI:::' I RE~3 :1. ,'2./:S 1/813
f'H ]:8 I:::'EFIM I'T VAL. I D FOR A S IlxlE)L.E FAM ]:L..Y RE81DEN[',IE ONLY.
CIEI:~"I' I FY T'HAT ~
:[ am t'am:L].iar, w:i.'Lh 'Lhe r'equir'enl(}~ntl:: fop c)n.-.si'Le sewer's and wells
~or'{h by l:l"t~.::, ~'JLu'l~lSipa],J,'Ly c:)(' ~rlcshlDpa:ge (MOA) arid 'Lhl.:, ~'Lal'..e of' A].asJ<a.
:1: wi].:l. :Li]sta].]. the system :i.n ac::ccmdar~ce wi'Ll"~ a:L1 MOA c:ode::: and
~3r'ic.J J.r'l cc)mj:i:J.J.~twic:(.:~ wi'Lb thJ.:e d(~.~J, gri {sPJ. ter':La or this pepmit,,
I Lu'ld~:~l'~'L,':~nd that 'Lh:i,s per'mi'L is w:~l~d {'Ol- a max:i, rm,.Ul/ oF 4 bedPc, e~ms,,
also und~'~tand that the c~:~::L'l',.y of the total sys't, em ~s 4 bedr, oonls and
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
LEGAL DESCRIPTION:
1
2
3
4
LT/.'/ / / /~
7
8
9-
10-
11
Township, Range, Section:
SITE PLAN
SLOPE
WAS GROUND WATER
ENCOUNTERED? ,d/~
13-
15-
16-
17-
18-
19-
20-
IF YES, AT WHAT
DEPTH?
0eplh 10 Waler ADer
Moniloring? fie ¢~/H~/~ Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
_ / ~,-ZT- ~8 0 o 17~,oo" o
_ f/ ,' ,'~'-', /o //, Z ,~-" .
~- ,~ ~ //, oo" , z ~'
~ $~ ~ ¥o. ?S'" ,
PERCOLATION RATE -~"~ (minutes/inch) PERC HOLE DIAMETER
TEST RUN BETWEEN ~' FT AND <~2 FT
COMMENTS
~ [95.00~
." 31~711
6
7
MichaeJ E, Andorson
4381 .E
14
13
MUNICIPALITY 0,:: ANCHORAGF
Deparh'nent of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHGRITY APPROVAL OF
ON-SITE SEWER AND WATER FACILII"Y FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
LoT' ~.1 TA/4,4/^IA t]ALL~ Sul~J, Sq TIZ~J ~J
Location (address or directions)
(b) Property owner
Mailing Address
Telephone: (home) ..
Business
(c) Lending Institution ALtlA~JdE:_
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here ,[~hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3. WATER SUPPLY
Individual Well []
Community ~ Public []
Nole: If community well System, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SE!WAGE 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. 7/88) Page 1 of 2
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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)
SEPARATION DISTANCES FROM WELL.:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
'Fo Nearest Sewer Service Line on Lot
WaterSample Collected by
WaterSample Test Results
Comments .5'~-_-E A'F'FAO~ICZ;Z
MUNIQ[~,~bli~¥~OF ANCHORAGE (MOA)
Cl~,~,t/~'I ~-~l~.~/~lfii~y Approval (HAA)
~¢,~- ~'~CKI. ST- FEBRUARY 1984
~}.'f~ ~. () ~ 343-4744
" Legal Description: ~d~ ~/
_ Date Completed
Depth of Grouting
Pump Set At
Sanitary Seal on Casin9 (Y/N)
Depression Around Wellhead (Y/N)
If Al B, C, D.E.C. Approved (Y/N)
Yield
Y
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Cleanout/Manhole
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed ¢-Z&-g~' Size
Standpipes (Y/N) y _Air-tight Caps (Y/N) ,I/
Depression over Tank (Y/N) _
Pumping/Maintenance Contact on File (Y/N)
No. of Compartments -~
Foundation Cleanout (Y/N)
Date Last Pumped MgW 42~/45T;,
; for ~¢-~v ~o/~:
Y
Holding Tank High-Water Alarm (Y/N) _
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well 12~00
To Property Line
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
To Disposal Field
Temporary Holding Tank Permit (Y/N)
Comments
7~-026 (Rev. 7/88) F¢ont Page 1 of 2
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field ,5' '
To Water-Supply Well
To Building Foundation
Lot &!o/4E oM LoT
To Water Main/Service Line
Square Feet of Absortion Area /ZoO
Depression over Field (Y/N)
Results of Last Adequacy Test 4/£¢/
SEPARATION DISTANCE FROM ABSORPTION FIELD:
; On Adjoining Lots
To Cutback (if present)
To Stream, Pond, Lake, or Major Drainage Course klo~IE /~ A~¢A
To Driveway, Parking Area, or Vehicle Storage Area ~f 5'
Comments Ar~5~pT-/~~ ~?srgt4 rs
Type of System Design
Length of Field /8~'
Depth of Field ~.
Gravel Bed Thickness ~' '
Statndpipes Present (Y/N) Y
Date of Last Adequacy Test W~-~'
To Property Line
To Existing or Abandoned System on
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA and HA'A guide_'~r~_'~s~i~ ~t~on the date of this
inspection. -- (~G~~ ,~,~ OF ~/~
Signed ~~
Company ~ a~ ,J ~. ~*~ ~aT~;Z~ ~
~. ¢~ ~ Michael E. Anderson ]
MOA No. ¢~ ~'% 438~ -~
Receipt No. ~0 ~ ~/ Receipt No,
Date of Payment ¢~¢~¢/~- Waiver Fee: $
Amount: $ / 7~.~ Date of Payment
7~ o~6 (n~. 7/8e) e.o~ Page 2 of 2
~NCHORA~E, ALASKA 99503
STEVE COWPER, GOVERNOR
563-~77S
To ~hom It May Concern:
accordinq to the records on File in this office, the _Co,.~,'5_~£~_ ......
~-~--,~ b~q-~5~ x_~,,v, ~A~tJater System is in compliance tJith the
'qtafe oF Alaska Orinkinq Water Requlations,
~SK:sa
Sincerely,
Environmental Field Officer