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HomeMy WebLinkAboutUS SURVEY 3201 LT 15 T10N R1W SEC 9�� �r �;�; �� � � � �� , p, � � s x x ,7 � t �..m" �ac'�a`t. s, � � � � �� ,u �n �� � � �,, � i_ u, � � � y K }. X= U' m.{" � L � :. %' ^. s s � � � s �� �4 � ti :' �; � � � M �% t m n.� `� b .�... �� DEPARTMENT OF HEALTH AND HUMAN SERVICES "~' Environmental Health Division / 825 "L" Street, Anchorage, Alaska 99502, Telephone 2~-4720 / ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECT~ ~u~;~ ~ t 7 ~ '~ ~ {{s- ~ SEPTIC ASSORPTtON WELL Addre~ TANK FIELD Pho,e(s) Permd No. .o. o~ e~oo~, WELL ~ LEGAL DESCRIPTION Lot Subdivision ~H /~ ~,oc~ I~/o~l~T~, (USS ~3201) FOUNDATION ~ Township. Range, Section AS-BUILT DIAGRAM {Show location ol well. sep[ic system, pmpe~y lines. Ioundat*on, ~f~ ~ ~,,j ~ ? ~¢~ ~Oz/~Zy driveway, water bodies, etc.) SEPTIC HOLD . ,ateda, NO. of Compa..ents ~ ~ ~ TRENCH ~ BED ~ W. DRAIN ~ OTHER X X~ Depth to pipe bo.tom fro-- Total depth from original grade ~ odgina, grade I / FT /, 5-- FT ~~, ~,avel width Gravel length ~ FT ~' ~ FT ,umbe, of lines Pipe material ~ n~ r~'~ WELLS ~-~'~ - ~ ~ ~,9~D,~ ~ PRIVATE g OTHER (Identify) ~ f~.~ ~-~AAJ z'~ ' " " . emil~ Ihal thi~ [ns~e~ioa ~as ~derm~d ae~rdin~ to all Municipal and State guidelin, in ,lle~ o. this date: I~/~ 7/~ Z' Health Depadment Approval: Date' 72-013 (3/85) / ? / J / / / I / I I / / Municipality o! Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L' street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PEREORMED NOR: /~r¥~,~ Township, Range, Section: '7-x-o,~ SLOPE SITE PLAN (~) 1 0 ENCOUNTERED? S L IF YES, AT WHAT / O DEPTH? ~f' p Depth to Waler After 13 - MonitoriRD7 ~' g Date: 14- 15- 16~ 17- 18- 19- Gross Net I Depth to Net Reading Date Time Time Water Drop IoY? --/oJ~-) /0 ~.6 ~--~ .~6 PERCOLATION RATE ~ ' (minutes/inch) PERC HOLE DIAMETER ~ TEST RUN BETWEEN ~ .FTAND ~ FT COMMENTS /~1~ ~C /~-C)l::ll/~._ ~ ~/~/~ ~ ~"r~,~// i~ ~, ~ ~/o,~,.~ PERFORMED BY: ~' ~ ~ I CERTIFY THAT THIS TEsT WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: ~/~ ~/~ ~ 7~-oo8 (.e~. ~) ~-~ / ~ ~ ALASKA BNViRONi4ENTAL CONTROL SERVICES, INC. 1200 WEST S3RD &VENUE, SUITE B A-I~CHO~**,OE, aLASKA ~9~0~ (90"/)561-5040 SUPPLEMENTAL SOILS INFORMATION SUBDIVISION ~'/~,~ ~/~/' ~'~ LOT /Sm BLOCK 10 14. 16- 17- 19- 20- / / / / 6- 7- 8 18 19 20 MUNICIPALITY OF ANCHORAGE'- DEPARTMENT. OF HEALTH & HUMAN SERVICE. S Division of Environmental Services - · On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 ' - '; -? - 348.-4744 ' ..... CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING "':_~:.:'-:'.' Property owner-'~,'/'~, ;~:~/~r~'') ' ,~,'~./'./?-~ ' Day phone ' :-':' ' Mailing ad"~i;e~~'~ e_ ~ ' ~::~,L~ Lending agency, ~ -~ Day phone ~ '-. :-:~ -. A~en~ .................... Day phone.. ' · -- ~ .v;~:~_.;.-Address ............ - - :. ~;.~___~._.::.;~:.;./.. -C: 2, L..:_-.-CT=~_- . '_ : .. ._: .... ; .- ........ ; - . -- --'-t? ' .w " ? ': ~ ~-~:_::'-.~:-:~:-:-,~:;-?':~,CommUn ~ell · . - ',: .:.---:.:.-:: NOT~:.:~. If comm~m~ well s~,tom, prov de .~. ' -'-- '-: ~} ---. '-~;~¢ :,.~:: lng to the legali~ and status of system. '. - 4. ~PE OF WASTEWATER DISPOSAL: ' '" ' ._~?~ ;,;:. ~{~r .' :.' '~ -~:'lnd v dual on-site _ , ~:.'~;, · ?-? . ._L~/Z~ .2._'.~_/ '";'_.~Holding~ank -- . .-.... ., -"-~, ,, , ,. - -. ~- ' - -C~mmuniWon site ~ '--~ ':'--.~:--, '- ' ;Publicsewer~.;~ ,,~ "~ .............. NOTE: If ~o~m~'Waste~te~stem, p~ovide 'wri~n ~onfirma~i~ '~m State ADEC a~esting'to the legali~ and status of system. B¥~ ENGINEER ...... - .............. ~ · - AS certified, b~~y seal~affixed hereto and as of the vahdatlon date shown below, I venfy that my investigatio~o{ {his Health ~th0ri~-A~proval application shows that the on-site water supply and/or wastewater disP0sal'~ystem is'safe,_functional and adequate for the number of bedrooms and type of structure ih'dicated heroin. I furtherverify that based on the information obtained from the Municipality of Anchorage files and from my inves.ti_gation andinspection, the on-site water ....... ,':;: ;,;_~._.~l ~,,stem s in comn lance with all Municipal and State codes Supply aha/or was~e~a~L.u,~,~P~, o~" , -. · : a"d r' iA{i; A ;;re of. this inspection.'=.::,'-,: --:::?~:-' ;:':")~:-'iL':r:~:''' '" ordinances. .eg . : .,:. . ~ ~ _~ . ..>,,.::.:,~ ,=..,;..>:f.::;~; ,. . . ~ ~...,.-;.;d~:}:.,~::,:?f;.i~-~%~::.k.~;' -.~ ,;:,,-,-..-:,-~. : , ~- ~;~. -, .:~. '.~ : - - -, ..... phone. ..... Name of Firm~2~/7~ -* ~, - ~, · ~,,-,-:.- ~.. Engine,s' si~r6'-: Date ".'~ ". ,,~ "::: ~, ~:'~ ~ :' "':': * DHHS issues Health Autho ty ~ The Muific pslity~0t ~,nchorage DePa~ment Of Health and Human Services ( ) ...... , :: ::., ~ i i: Approval Certificates based only Upon the. representations given in Paragraph~5 abOVe by an ndependent ::, :: :'-:~ i© ': : profeSSi0~l~gi~;~isteredinth~state~fAlaSka. TheDHHSdoesthisasac~urtesytOp~:chasersofh0mes~-',.! andtheirl.end ng ~Stitutior~ norde~t~sat sfy~ertain federala~dstaterequireme~ts'Emp °yees0f DHHSd°n0t: i. conduct ns .~o~S ~:.anayze-data beforea Cart fcate s~issued. The Municipality of A~ch~ge'is not:' .,:. ' respon~iblefPo~-~n.,~0r.:~3m~!~'Si'n't~.pi~fassi0nalengineer'swork. ': ,! . Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~- J~ ~-/~/~/' ~,. I '~ ~ ~-----(~- ? Parcel I.D. A. Well Data we, jpe Log present (Y/N) /' Total depth Sanitary seal (Y/N) If A, B, or C, attach ADEC letter. ADEC water system number Date completed Driller Cased to Casing height y Wires properly protected (Y/N) ~" FROM WELL LOG AT INSPECTION ~_ [ o ,--~ g.p.m. -~ ~' ~'~ g.p.m. [ ~ ~ l : On adiacont lots ~ /~ x ~ t ; On adjacent lots ~ /~ ? ~ ~ Public sewer manhole/cleanout .~ ~ [ Petroleum tank ~ O ' ~,~ Other bacteria / Date of test Static water level Well flow Pump level1 SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main Sewer service line WATER SAMPLE RESULTS: Coliform O Nitrate Date of sample: ~ ~ '~-<~'--~2 B. SEPTIC/HOLDING TANK DATA Date installed ~0--~/~.. ~'~ Tank size / ('~ Compartments "~ Cleanouts (Y/N) Y Foundation cleanout (Y/N) .~ Depression (Y/N) High water alarm (Y/N) ~f/~ Alarm tested (Y/N) /~//~ Date of pumping ~'~ "~ ~ ?~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: / Well(s) on lot ~ {~ '~ On adjacent lots ~ "~)~, Foundation To property line > j~[ Absorption field ~J'~ Water main/se~ice line Sudacewater/drainag~ ~'d~ ~~)~ ~ }~ 72-026 (3~3)° Fro~t CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer .~ Size in gallons ManholelA~c~ess'(YIN) Vent (Y/N) level ,~J~ "Pump off" Level at High water alarm level Cycles tested Meets MOA electrical codes (¥/N)~ ~ SEPARATION~DISTAN~CE- RF~OOM LIFT STATION TO~ Well on lot .. ~ On adjacent lots "-'-Sudace water D. ABSORPTION FIELD DATA Date installed / (-~ "- )~-~ Length ~ (d Width Total absorption area ~,. ~-,.//_ b' Cleanout present (Y/N) Date of adequacy test --./(-'J ~(~ ~2--c~' ) ~? Results (pass/fail) Water level in absorption field before test Peroxide treatment (past 12 months) (Y/N) /Soil rating (GPD/Ft2) System type ~ (':~ ~2I ~ Gravel thickness t ~ ~ Total depth \/ Depression over field (Y/N) /~ -~-~ ~,~ for 3 Bedr~ms After test ~ .If yes. give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot / ~-~0f On adjacent lots ~ 1 P~.2(0( Property line To building foundation ~ ~,~ I To existing or abandon~ system on lot On adjace~ lots J~ [~[~( Cutbank ~ Water mai~se~ice line Sudace water ~ ~ ~ ~ Driveway, pa~in~veh~cle storage area ~ 0 Cu~aindrain ~ ~ ~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. # ]517 ~ HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)' Back Waiver Fee $. Date of Payment Receipt Number