HomeMy WebLinkAboutUS SURVEY 3200 LT 13C
) 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 WELL INSPECTION REPORT
NAME PHONE I [~NEW
MAILING ADDRESS
LEGAL DESORIPTION
:~ ~ I IAbs°r~ti°n ar"a Dwelling PERMIT NO.
Manufacturer~ ~ ~ ~ate ri.~ ~}~.~L ~o.
~ ~ ~ NO. of lines Length of each line Total length of lines Trench width Distance between lines
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
m DISTANCE TO:
~ Class, ~ Depth Driller Distance to I t line PER IT NO
OTHER
PIPE MATERIALS
D3o3¢
SOIL TEST RATING
INSTALLER
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
MUNICIPALITY Of ANCHORAGE
.-'':' Departmen~-'!.f Health and EnvironmentallY, Protection
825 ~ Street, Anchorage, AK. ~9501
" 264-4720
HANDWRITTEN PERMIT '~~
Permit
- . ' -~R ON-SITE SEWER PERMIT
Location: ~ ~ ~~Phone Number: ~'-- V~-~
Legal Description: L;~ ~ ~d3 Lot Size:
Type of Soil Absorption System Is:
Trench: Drainfield: Seepage Bed: __ Holding Tank:
Maximum Number of Bedrooms: Soil Rating(sq.ft/br)
The Required Size of the Soil Absorption System Is:'
DEPTH LENGTH GRAVEL DEPTH 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 pipe and
the bottom of the excavatioD~n feet).
* * REQUIRED SEPTIC~C~HOLDIN~G~G TANK SIZE =(~)(~D% GALLONS * *
Permit applicant has the respons~bility-~--~<' '~ 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 inspection and approval by ~his departmen~
will be subject to prosecution.
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
the residence is remodeled to include more that 3 b~rooms.
Signe~: ~ A~ ~]A Issued by: ~
kppl~nt \ Date: ~ ~-- ~
SWP/024(1/81)
~ SOILS LOG
MUNICIPALITY OF ANCHORAGE
[] PERCOLATION
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
TEST
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
DATE PERFORMED:
r~o~ ~T~ oz~L
SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Gross Net Depth to Net
Reading Date Time Time Water Drop
Reading
PERCOLATION RATE (minutes/inch)
TEST RUN BETWEEN FT AND FT
COMMENTS
PERFORMED BY: ~'~¢~'/ CERTIFIED BY: DATE:
72-008 (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological 6 Seophysicol Surveys
icj D STANCE AND D RECT ON FROM ROAD INTERSECT ON$ 'r~': ~-- : ,?' ' '.? \ ,5. OWNER OF ~E[I~ !::i!::~ ; :; '~.P~'a~:
2. WELL LOS Surfoc. - 160 .. -. ' 9 -
Gravel and'~boulders ' 0 · - .30 - ' . e...~co~l, too,..~Ro'~,~ ~o~i.,. - ~.~;
Soft shale · .. : 50 .' 50.:. :~ ~A~er-'-:~' ~defted' ~Bored ~Other
Shale I)3 : - 14~' '~-.~:"~f/(::~?;'~W, .b':~.Olher:' -" "'
, '. '' ~"Subm. ~ dst ~ Centrificel ~ Other
" 14. ~EaRR~S: ~00
- · Bail teated at
~,,.,: P.O. Box 50~ ~gXe River, · ' ..... ....
· ... . ' ,..,/-~-.( ' ,../.:~?:;. , - .
F%RM~ T NO.
DE:F'FiRTMENT O,~'-- 1-41:(I-:iLTH .,':':!I"~D Ei'.,iVII:;~:ONI'dEhFrRL PROTECTION
8251 ." L. '" .?,T?.EET, FI!'.,KSHOtS~RGE.,
F:IF'PL. _f
LOE:FI'? I O?'.!
LEI;3RL.
..;r l::li'.,!E L L .E ~ilS TI...L!N D
];N~r::,;t.' FIN ..';--".:D/HtJL-!'T CIRCLE;
L:!.i:C USS 1i:2OO
i I",!I].', I I;~1 N I::!K
LEFf' SIZE
,::l,,::l-OOEi S~;!UFiF.'.'E FEET
I"iiN:[!"iUi"I DISTFIi',!L':L:: E~E'T'~qEE:i"~ R HELL RN[:' RN'¢ ON-SITE SEHFIC:iE
:.LOO FEET FOR R F'Fi:Z","RTE HELL OR ::LSE:! TO 2'(.'~lE~ FEET F'?.OM Fi P"UBLZC I.,.iEL..L DEPEI",ID]i?-,!G
I..iF'Ohi T!-IE 'T'?'F'E OF F'!_!E=L. ZC klL:;I.,.L..
i"IZi",!ZFIUt'! [:'?Z';TRNE:E FROM R F'i?.:I.'VRTE 14ELL TO FI Pi::~i?',,'RTE SEk!ER L~NE ZS 2El F'.~SE:'i' FiND
TO F! COFiMLIt'4ZT',t SEkiEF.: L. ZNE IS 75 FEET.
HELL LOGS Ri,lrE RE6!LiZRED RND P!UST BE ¢;~:ETURNED TO THE DEF'RF.','Ti"IEI",IT P.!ZTI'"II!",I ~:O Di::I"¢'.S
OF THE P.!EL.L COMF'LETZON.
OTHEi;': RE,'.';!UZRE,~"iE?¥TS !'dRY F!F'F'L¥. SPEC::.(F'LrC,¢:ITZCtNS FI,ND COI",.tSTRI._tCTZOi'-~ I.')II::~CiR:i::IPI:i~ F:IRE
Fi',,,'I:::IZLRBLE;-i"O ~i",!SURE P,q:OPER
I CE;RTiF'~' I'HFF!"
"_!.: :r. Rf'l Fi:IH!!.._.'.rF~IR I,.!iTH "I"HE RE6!U!REMEN'f'S FOR ON-SITE SI_::;!.,.IERS RND I.,.!ELL. S F:!S SET
FORTH B'-? T,:--IE 1,1!...INIC};P!::ILtT? OF Fff.,IC:!-~iOI'4~FIGE.
;2: Z !,l!i_J... iNSTfiI.L. THE SVSI"E!t IN RE:CO!:E'.DRNC:E ,.'-!'_rTH THE CO[:,ES.
¥4.. 0
ApPL[~:"'~NT FILLS OUT UPPER H,~'i c,: ONLY
Buyer
Phone
R~alfy 0o. & Agent Phone
~j//'> Zip Code
Address
Legal Description' ,~T15~ ¢ O. <g. ¢-¢dF._d G--F ~ SzO0 -
Street Locati~ ~, 30~- (1 ,I f~ (~ ¢
Type of Residence
Single Family
'~u[tiple Family No. of Bedrooms J-k I(.)1: ¢
[] Other
Water Supply
lndividual ATTACH WELL LOG. A well Icg is required for all wells drilled since June 1975.
Community For wells drilled prior to that date, give well depth (attach Icg if available).
~ Public Utility
[] Individual Year Individua, I installed: t
[] Public Utility When Connected to Public Utility: .
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Date Date Date Date
Inspector Inspector Inspector Inspector
Field Notes:
('~.~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ) DISAPPROVED
CO D ~-ION APPROVAL*
DATE
BY: / /
/
Soils Rating Date ,~wer Installed Well TO Absorption Area Well Log Received
Well to Tank Septic Tank Size
CHEMICAL & GI~. LOGICAL LABORATORIES ~- ' ALASKA, INC.
AI~CHORAGE INDUSTRIAL CENTER
5633 B Street
~"TELEPHONE (907) 562-2343
Drinking Water Ana ys s Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER.
.~. I.D. NO.
Water System Name .~ ' Phone No.
Mailing Address '~ '
City State ~ ,' ~ ~
A PLE DATE
S M : ,'-"~'~ '""
MO. Day Year
SAMPLE TYPE: ~~
[]'~Routlne ~." ~' ~
[] Check Sample (for i'outlne Sample
with lab ref. no, ! [] Treatea Water
[] Special Purpose [] Untreated Water
SAMPLE Time .-~(, Collected
NO, LOCATION ,~-, Collactsd By
2 r1't 3~d ~B5~o~ ~
TO SE COMPLETED BY LABORATORY
Analvs~s snows th~s,Water SAMPLE to De:
~atisfactor~
[] Unsatisfactory
[] Sample too long n transit; sample should
not be over 48 hours ola at examination
to indicat(~eliable results. Please send
new sam ~le.
Time Rece ved
Analytical Method:
[] Fern~entatlon Tube
~Membrane Filter
Lab Ref. No. Result* Analyst
I
I , i-i--1
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220 (D)
Rev. 1978
BACI~RIoLOGICAL WATER ANALYSIS RECORD
BGB
PLEASE REPLY TO ~.
DATE SIGNED
Redi~prm ®
S~N~ PA~TS ~ AN~ ~ W~m CAR~ON ~NTACr.
45 469 PART 3 WILL 8E~ETURNED WITH REPLY.