HomeMy WebLinkAboutT12N R4W SEC 10 LT 31 E2i
.~., MUNICIPALITY OF ANCHORAGE
DE 1TMENT OF HEALTH AND HUMAN SERif -=S
~ Environmental Health Division
~ 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
~ SEPTIC ABSORPTION
~r~ WELL
Phone(s)3ff~.. O30~ Permit8 d OZ~O~°' No. of a~ ...... WELL / o ~/¢~ ~. / o /
T
LEGAL DESCRiPTiON LOT LINE '~
Township. Range, Section
TANKS
~ SEPTIC ~ HOLDING
Manulacturer Capacity m gallo~s I
Material NO. of Compadments
TYPE OF SYSTEM
~TRENCH ~BED ~ W. DRAIN ~OTHER
ormginal grade ¢ ~Z FT~ ~ FT
WELLS
~ PRIVATE ~ OTHER fldenlilv)
Class,ficat,on (A B,C,__ T°tal Depth FI Cased t° FT 5' I~
RE~ARKS:-'~ - .... h
Inspections Pedormed by:
Heailh Depadment Approva~~~ Date: · / //
72-013 (3/85)
PERH I
DATE ISSUED
~)t,,~ A ,~hc.,IF HEAI..T'H AND ENVIRONMEN'I-AI :~O'TECTION
8;;~5 I.... STREET. ANCHORAGE[~ Ar. ....... I
26.q.-4'72C~ ~ ~
Ei6()28C)
08 / :t. 2
AF)PI..ICAI',I'T~ JOHN FR., DEARTH
ADDI::?,E]SS .-'. I~', 0. BOX 1 ]. 1463
ANCHORAGE, AK 995:1. 1
CON'i ACT PH[iNE r, :345-0302
L.EGAL :(>ESCR ! F':
L. OT SIZE:
MAX BEDROOMS;~
SUBDIVISION~ NA LOT= E 1/2'. 3~
SECTI[)N: 1() TOWNSHIP: :[2N RANGE: 4W
1 ,, 25A (SQ .. F"'l". OF';,' ACRES )
4.
BLOCK: NA
t....is'Led below ar'e) the opt:ions available 'Lo you in designing your sept:i.c:
syst:.('~n~,, Choose 'Lhe op'l:ion tha'L best f:i.'Ls
DEF:'TH ]0 F'IF)E BOTTOM (F:'T,,) 4,,0 4,,0 4,,()
GF::/~VEL DE]::'T't,[ (FT.) :LID. 0 (). 5 -3.5
]'OT'AI_~ :OE:I:::'] H (f:'l',) :!.4.0 4,, 5 7.5
GRAVEL WID'FH (FT.) 2;,5 20.0 5.0
GRAVEB.... I...EENGTH (FT.) 25.0 38.0 54,, 0
GRAVEL VOI_.UME (CU. YDS,, ) 24,, 4 28,,;2 40.0
I'ANK SIZE (GALS) :[,2.5().0 *.x- 1,250,,0 ~.* 1,250.0
SOIL I'kATING (SQ,,F']". /BR) 12.5 125 125
s.x. lANK MUS"F HAVE A'I" LEAST TWO CCtMPART'MENTS
(:::,:,~.r 'L :i. fy that:
1,, I am ~ami]iar' w:L'Lh 'Lhe requirements
for' orr.-.site ~,ewers and we]Lis as .set
£c;pth by Che Mun:i. cipality oF Anchorage (MOA) and the State oF Alaska.
I wi].! install the system in ac:cordance with ali MOA codes and regulations,
and in comp].iance with the design c::ritep:i.a of this pepmit.
I w:i.l:l adhepe to all MOA and State of Alaska pequiremen'Ls for the set back
d:i.s'Lances ~r'c)m any ex:istirlg well, wastewat, er d:i. sposal sys'Lem of public
I understand Chat this permJ.{ :L~s valid For' a maximum Of 4 I:)edr. ooms arid
any (erltar'gczmK~n'L t.,~J.].], reqt..tir'~ an additicina], permit.
IF A LIFT STATION IS INSTALI._ED :[lq AN ARIEA COVERED BY MOA BUILDING CC)DESk,
]"HEN (:)) AN tE!...ECTRICAI... F:'E]::~MIT' AND ]:NSF:'E:C"FION PI!!ST BE: OB'TAINED~ (2) AS.-,BUII_.TS
b~iL.J.., tqCYf' BE. AF:'F:'F~OVED WITHOUT AIq IEL.ECTRICAI_. :[N~3FII~]C'I-~ON REPORT~ AND (3) THIE
PERFORMED FOR:
LEGAL DESCRIPTION:
~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES ~ ·
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
/--07'--L.~/ Township, Range, Section:
SLOPE SITE PLAN
WAsGRouNoWATEB
· f ENCOUNTERED?
9
10
11
12
13
14
16
17
18
19
20
IF YES, AT WHAT
DEPTH? pO
E
Depth to Waler~Jl
Gross Net Depth to Net
Reading Date Time Time Water Drop
P ~ ~J" " ~~ ~,2,5 l u fl""
3:03 .00 ' ~J
TEST RUN BETWEEN ~ ¥.," FT AND · ,~*~," FT
/ / ' /
. . I ~ CERTIFY THAT THIS TEST WAS PERFORMED
ACCORDANCE WI~H ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE· DATE:
72-008 (Rev. 4/85)
ALASKA ENVIRONmeNTAL
CONTROL SERVI(. ~, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
CALCULATED BY ~,~5~ ~'~ ~Z~
CHECKED BY--
OF
DATE
ALASKA ENVIRONMENTAL
CONTROL SERVICES, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JO. g~z ~Z-/4 ~.~ $ /
SHEET NO
CALCULATED BY
CHECKED BY
DATE
(~/} DEPARTMENT Of HEALTH & HUMAN SE~I*~49~?. %~
~ 825 L Street, Anchorage Aaska99502-~[~~eete~~~~___
LEGAL DESCRIPTION: 1--05~/ T°wnship~~g~ 9r~/O~
SLOPE 81TE PLAN
ENCOUNTERED?
t
2
3
4
.5
6
7
8,
9
10
11
12
13
14
17
18,
19
2O
IF YES, AT WHAT SL
DEPTH? pO
E
Moaitorinq? ,/z~, / t/~, /,,~' Date:
Gross Net Depth to Net
Reading Date Time Time Water Drop
t~ ~ "II,-~/~ a:l~ m~L-J .lox
r~0 ~:~3 I~' ~ '- .00
H~O $:o~ '~' ' .00
TES, RUNBETWEEN 0 '~'~"FT^ND ~0 FT
co.~.T~ ~~,,:1~ ~/, /~s~.~X~.,.~,. _ ,/> ~~, ~,~.
PERFORMED BY: h!a~'a~ I '~ CER, IFY ,HAT THIS TEST WAS ~ERFORMED IN
ACCORDANCE WITH ALL S~ATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev, 4/85)
~ WATER WELL RECORD STATE OF ALASKA
~DEPARTMENT OF NATURAL RESOURES
tDivision of Geologicol 8 GeophysicoiSurveys
Drilling Permit No.
A.D.L. No.
· ~~' ~ ~'/~ ¢ ~ 6. ~Coble tool. ORotery ~Driven ~Dug
t ~ Above or ~eelow lend ~co Dote
/ ~ IZ.GROUTING Well Grouled: 0 Ye,~ NO
..... 0 Subm. ~ Jet 0 Cenlriffcal ~ Other
. 14,RE ARKS:
WATER WELL CONTRACTOR'S CERTIFICATION: empe;elure ~ F ~ C
~ Registered Business Nom~ ' ~ a ConlrAct License Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL ~-~ ~'~ -
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date ~/'7/~7
1. GENERAL INFORMATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directio~
(b) Applicant Name ,~0¢~ ~, DEbR!~ Telephone: Home ~/~ Business
Applicant Address ~0 ~ ~4 ¢~ ~{J~ ~¢~'~ ~
(c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain);
(d) Lending Institution ~/
Address Te~/
(e) Real Estate Company and Agent
Address
Telephone /
Mail the HAA to e~'~'~ollowing address:
(f)
TYPE OF RESIDENCE
Single-Family[~ Multi-Family []
Number of Bedrooms ~
Other
WATER SUPPLY
Individual Well ~ Community [] Public []
Note: If corn m unity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite,~' Public [] Community [] Holding Tank []
Note: If corn m unity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 01184)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of this Health
Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe, functional and adequate
for the number of bedrooms and type of structure indicated herein, i further verify that based on the information obtained
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm
/
Address /~-O0
Date
Telephone ,,~--~'//~ '-~'"O ~/z'O
DHEP APPROVAL
Approved for ¢
Approved ~
Disapproved Conditional
Terms of Conditional Approval
CAUTION
The MuncJpality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP do not conduct inspections or
analyze data before a certificate is issued. The Municipality of Anchorage is not responsible for errors or omissions in the
professional engineer's work.
Page 2 of 2
72-025 (11/84)
ALASKA ENVIRONMENTAL
CONTROL SERVI¢'*-'~, INC.
1200 West 33rd Avenue, Suite B~
ANCHORAGE, ALASKA 99503
(907) 561-5040
Jo. L.31
DATE
Casing Height Above Ground
Electrical Wiring in Conduit ~)N)
Separation Distances from Well:
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
FEBRUARY 1984
MUNICIPALITY OF ANCHORA~:~JECKLJS2T6'4_4720
ENVIRONMENTAL PROTECTION Legal Description:
WELL DATA
Well Classification ~~D I(A, B, ~ D~;. ~pp ( )
Well Log Present eN), Date Completed I / /¢~r°ved Y/~ield
Total Depth ~ Cased to ~ Depth of Grouting
Static Water Level J ~ ~ / Pump Set At
' ~ ~ ~/ Sanitary Seal on Casing ~N)
Depression Around Wellhead (Y~
To Septic/Holding Tank on Lot 'l 0 J / ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot I 0/"/ / ; On Adjoining-Lots /
TO Nearest Public Sewer Line N/~ To Nearest Public Sewer
Cleanout/Manhole ~//~' To Nearest Sewer Service Line on Lot /~//~
Water Sample Collected by ~Z.~, '~ /~'J 7'C,~I' ~.~'~J~ Date J/~/.~ 7
Water Sample Test Results
Comments
B, SEPTIC/HOLDING TANK DATA
Size
Date Installed
Standpipes ~N) Air-tight Caps
Depression over Tank (Y~)~
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
TO Water-Supply Well
NO. of Compartments
Foundation Cleanout~N)
Date Last Pumped
./
Temporary Holding Tank Permit (Y/N)
To Building Foundation j ~ /
To Property Line
To Water Main/Service Line
Course / 0~) / ~
To Disposal Field /
To Stream, Pond, Lake, or Major Drainage
Comments
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field ,¢~-I /
Square Feet of Absorption Area
Depression over Field (Y6~
Results of Last Adequacy Test
12 S'
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation '/,..~' / '/-
Lot
/.
To Water Main/Service Line ~V'//~
To StreamlPond/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 O, ~--
Standpipes Present ~N)
Date of Last Adequacy Test
To Property Line //-//
To Existing or Abandoned System on
; On Adjoining Lots '-~--~) /'/~'-
To Cutbank (if present) /V//d~-
/Or..) ' '/--
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) .
Comments
Dimensions
Manhole/Access (Y/N) _/~'
"Pump Off" Level at ~
~ .-~:F~ping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav. e~:~e~ck~e,d, ~erifie¢, or conformed to all M, OA agd HAA, guidelines in effect on the date of this inspection.
Signed C'),/~-~'~-~.~-~ (¢ ~ ~_ _ Date //
1-1 ~ ' -~ ,
Date of Payment ~ '7 ~7
Page 2 of 2