HomeMy WebLinkAboutTURPIN #1 BLK 6 LT 3
MUNICIPALITY OF ANCHORAGE
DEPARTMENT C F HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
· . . 343-4744 ~ ::.
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcei. ED.:#.~(~[f3-,(-"~O~(,,~-' ~.(~. (/~'~- ,_%") :.~"<~,:. XHAA,#,.~.~;~.(~\{~.'~'~C) .... ~ .-.~
1. GENERAL INFORMATION':..
Complet~ legal description
Location (site address or directions)
Property owne[
Lending agency
Mailing address ·
Agent L
Day phone 733-2q/5
Day phone
Day phone
Address
......... Unless otherwise requested, HAA will be held-for pickup.-'
2. NUMBER OF BEDROOMS: ,-)
3. TYPE OF WATER SUPPLY:
Community well ...........
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ~-" :
Holding tank
Community on-site
Public sewer
If community wastewater system, provide wriften confirmation from State ADEC
attesting to the legality and status of system.
72-025 rRev. 1/91) Front MOA #2f
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/,-I::I~NI~N~ AG NOI/O:Id~Nt .40 J.N=IIN=I.LVlS
(~ Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
~ ~ '~'iO,.~ (:) ~?~1.",[,{'0 '['t)~'~iA. Parcel I.D.
Legal Description: ~0~- I. , ~ ,
A. WELL DATA
Well type i/~,VJ~lJ~[
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
I
Date of test
Static water level
Well flow
if A, B, or C, attach ADEC letter.
ADEC water system number
Date completed p£~,- /~/J~ Driller [/~0v~''~,
Casingheight ILl/I ~lsob)'C,
Cased to ~'
FROM WELL LOG
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ,/~.~
Absorption field on lot
Wires properly protected (Y/N)
AT INSPECTION
g.p.m.
Public sewer main /0 ~)~
Sewer service line 7 ~_~
; On adjacent lots /:/V//~'
~O_q
>
zB
; On adjacent lots ~0,'2 ~r~
Public sewer manhole/cleanout ,~ //0 !
Petroleum tank ~ ~/~ ~-
WATER SAMPLE RESULTS:
Coliform ~r) Nitrate
Date of sample:
B, SEPTIC/HOLDING TANK DATA
Date installed /'[/O..d. ~ Tank size
/'h,~/.~ Other bacteria /] O/} C
Collected by: ~) o,,~ ~U'/~ ('i~ ,) ~
Compartments
Cleanouts (Y/N)
High water alarrn (Y/N)
Date of pumpin · Pumper
SEPARATION DISTANCES F, ROM SEPTIC/HOLDING TANK TO:
Well(s) on lot /(///~' ~ '" ~: ~ ~;: ~ ~)n adjacent lots
Foundation cleanout (Y/N) Depression (Y/N)
Alarm tested (Y/N)
Foundation
To propertyline
Absorption field
Water main/service line
Surface water/drainage
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Wellon lot
To building foundation
On adiacent lots
Surface water
Surface water
Curtain drain
Soil rating
Gravel thickness
Cleanouts present (Y/N)
Date of adequacy test
for
System type
Total depth
If yes, give date
bedrooms
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guideline&~_ (h~e date of this inspection.
Signature
Engineer's Name
HAA Fee $ ~ F~ Waiver Fee: $
, oe,p Nu b.r ,.oeiptN.mb.r
72-026 (Rev. 3/91) Back MOA
polarconsult alaska, inc.
ENGINEERS · SURVEYORS · ENERGY CONSULTANTS
Municipality of Anchorage
Department of Health and Human Services
P.O. Box 196650
Anchorage, AK 99519
August 19, 1991
Re:
Health Authority Approval Certification
for property at 6330 East 6th Avenue
To Whom It May Concern,
This report is intended to meet municipal requirements for issue of a Health Authority
Approval Certificate for the subject property.
1)
Separation Distances -- The well is located 108' from the community sewer line,
72' from the residence's private line, and over 110' to the
nearest manhole (see Attachment 1).
2) Casing Height --
The casing extends 14" above grade and the soil is graded
away from the case.
3) Well Cap --
The well cap is a sealed aluminum head with a rubber
gasket. Power is provided through a metal conduit
connected to the well cap, meeting current NEC codes.
4) Casing depth --
No well log is available. Inspection of the well
configuration and interviews with service professionals
verify that the well casing extends the entire depth of the
well, approximately 89 feet.
5) Flow Test --
A 1.5 hour flow test was recently conducted on the subject
well (see Attachment 2). The high rate of flow attained,
along with the quick recovery time, verifies that the well is
more than adequate for a three bedroom residence.
6) Lab Analysis --
Samples were collected and analyzed for total coliforms
mad nitrogen as nitrates. The results meet MOA criteria and
are included as Attachment 3.
The above results of Polarconsult's investigation indicate that the well meets or exceeds
all MOA requirements and we recommend that a HAA certificate be issued to owner
Gerald Berryman. Please call with any questions or comments.
Earle Ausman, PE ~/~¢,~ '
1503 WEST 33RD AVENUE · SUITE 310 · ANCHORAGE, ALASKA 99503
PHONE (907) 258-2420 · TELEFAX (907) 258-2419
WOOD
IOl
I
I0't
15' TEME
;0
WIRE
EDWARD ST.
~ERM. ESMT.
' TEMP ESMT.
30 30
0
ATTACHMENT
WATERWELL . TEST PUMP REPORT
Cond-otedby..~ Ano_h.o,.r. age well & PumD 8er..v.j. ce
Owner_J.ame s'" ,A J Ri~a~
AdUre~, 6901 g~m~%na Drive, A~gh°ragg., ~'~'~ ....
Well Loeallon 6330 E. 6~ht Anchora~9, Alask~
Well Inf0lmltmoh; TII, Depth , 95~ Olplh of Oamlng Sam~_acreen [=rom-._ To
~aSl~9 ~Ize $~en Diam --
Remarkl, "
Pump Informatlgm Inltlke Depth 89 ! Pump Size .... Air Line Depth --
ltatlo wa!er LeYe! = 6 ~, ~ Ay. Dl=eharga GPM, Max, Drewd0wn
~ump Om. Time 1 = O0,. ~ Dale 7"30-9~ump Off:
TIME WATER P~O, FLOW WATER PIEZO- FLOW
LEVEL ~UEE GPM R~MARK~ TIMI LEVEL TUBE GPM REMARK~
Meber Rea~in~
~0:0( ~5 ,0134150
3:0( 73 8.3 .0134175
10~0( 7~ ~.1 0134231
~Df 7.8 8.0 01~431Q
~t0C 7Q 8.1 0134391
~0~0~ 78 7,7 0134460
50=0C 78 7,5 0134~43
50=0~ 78 7~7 0134620
7.8 ~ average
~CO~ ~ry C
61~00 7~.. ..
~2=00 72 ....
~4: 00, 70
~65 ~0~ 69
66~( 69 ..........
67:0C ~8
68=0~ 68
69:0Q 67
71~00 67
)2x00 67
~ 00 ~7
L4~O0 G7
~7:0c 67 ~~
~8~0C 67 ' ''
~ 67 .,
~0 67 ...... ' ....
~2~00 67 '
~l~&~~= ' ......... , ....
~_~7 .............. ,.,
~:0~ 6~ ,,
7:00 6~ '" ,~.
I --' .....
FtUG 19 '91 14:18 MTL-~HCHORAGE 90? 274-9645
NORTHERN TESTING LABORATORIES, INC.
C,,stome~ Rame Lab # Cus~ome~ 'ID ~hod ~aramet'er Units Kesul~s
Polar'Consul[. Aii3296 E6-01 BPA 300.0 NO3-N ~g/1 1.0
/
~.0 ~
I h~eby ce~ that I have s~e~ the ~oHo~g
~. ~ .~"~. =chorage Re~ ~ec~ct. ~ka. =d that ~he
~provemen~ si~a~ thereon ~e ~t~ the prop~y
~ ~ do ~ot overlap o~ e~o~c~ o~ the
~ ly~g a~t thereto e~cgoaeb on the p:e~e~
t *~ ~ NO: ~!' ~ question and that there are no roadwa,s, ~=~ion
~es or oth~ visible e~men~ on said pro~y except
THOSE SHOWN ON THE R~OR~EO ~V. ~O~S~Y ~ ASS~CIA~S
PLAT, ARE NOT SHOWN HEREON. ~e~ist~ State L~d S~veyo~ ~
~ INDIVIDUAL SEWAGE A~CILITIE~/k~~
person reques%ing approv~
Numbe~:.o~.~rooms in house
5. Matem, Analy~is:
6, Well data:
2. Septic tank /;~.~t . ~ ~ ~~~~
3. Seepage Area . // ~
5. Property Line .
6. Other sources of possible contamlnation~ i.e.~ creeks~ lakes~
houses~ barn~ dralna~e ditch, etc.
Sewage disposal system.
b.
Co
Age of system .
Septic tank capacity in gallons,
Name of septic tank manufacturer
1.
If "home made" show diagram on reverse side of this form.
d.' Disposal field or seepag% pit size and type.,. ,~U~'-.~'~_
,
1. Distance to property line to house foundation
Percolati~ Test ~esults
f. Percolation Test performed by ....
Use the reverse.side of this form to show diagram. Diagram should include
'~<he foilowing information: ~operty lines~.well location, house location,
~utic tank location, disposal area location, location of percolation test,
an~ direction of ground slope.
9. The tn-for~tion on this form is true and correc~ to the best of my knowledge.
Signature of Applicant ..... Date Sigh'ed
\
!? BE FILLED OUT BY HEALTH DEPART~.~ENT PERSONNEL
~T~e above described sanitary facilities are hereby approved, subject to the
.......... ~61!owing conditions: ' '
The above descPibed sanitaPyfacllxt~es' ' ' ape disappPoved fop the following
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