HomeMy WebLinkAboutT15N R1W SEC 18 LT 182
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Gl ~TER ANCHORAGE AREA BOROL H
DEPARTMENT OF ENVIRONMENTAL QUALITY
3500 TUDOR ROAD ANCHORAGE, ALASKA 99507 279-8686
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
SEPTIC TANK:
PHONE_('
DISTANCE FROM WELl J',3o'~ ,,g T/ ('~ ;'dL~:~
LIQUID CAPACITY_ /(.~'C(.~ GALLONS·
NUMBER OF
MATERIAL (._ C'~ k)(.'t'c E; ~ c~ COMPARTMENTS
LIQUID
iNSIDE LENGTH INSIDE WIDTH DEPTH
SEEPAGE SYSTEM: SEEPAGE PIT:
NUMBER OF PITS__ / OUTSIDE DIAMETER
LINING MATERIAL (- Ol°Oid f' ~l-- ~ / /PI,~,.~..~
NEAREST LOT LINE-/!~' ' ''~ ~/c.2
OR WIDTH / ~' / LENGTH / ~> DEPTH
· DISTANCE FROM WELI'~h'~//O~, ./~"! /;~'J'~"
· -.~.~, BUILDING FOUNDATION
TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) ~ ~'C~" '! .SQ. FT.
TILE DRAIN FIELD:
DISTANCE FR~ -~
NUMBER O?'LI N ES
ABSORPTION AREA___
FOUNDATION__
SQ. FT. LENGTH O~'["~
TOTAL LENGTH
· NEAREST LOT LINE_ , OF LINES
TRENCH WlDIH IN.
TOT~/J/~FF ECTIVE
DEPTH: TOP OF TILE TO FINISH GRADE_
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. ABOVE TILE
WELL: TYPE~J'C°'t' ~'~..) ~ , DEPTH.
NEAREST
LOT LINE ~ , SEWER LINE
DISTANCES:
}.g c:t b.
DISTANCE FROM - WATER
., BUILDING FOUNDATION .... SAMPLE_
SEPTIC,__ . ~ SEEPAGE
, SYSTEM~~0 CESSPOOL
TANK b~ /C'Ez (~
DIAGRAM OF SYSTEM
. NEAREST
OTHER
· SOURCES
DATE'"'/ V '
GReATEr ANCHOrAGe Area BorOuGh
SEWAGE DISPOSAL SYSTEM -- APPLICATION AND P,I~tRMIT
FINANCED THROU6H ~ ¢~ TO BE IN StaLLED BY ~ ~~ ~%~%
SEPTIC TANK SIZE
· DRAIN FIELD
SEEPAGE PIT
ALSO CONSIDEr AREA WELLS.
SEEPAGe PIT
., DRAIN FIELD
DIAGRAM OF SYBTE:M
[CERT[FY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANCHORAGE AREA BOROUGH ORDINANCE NO. 28-68 AND THAT THE ABOVE
DESCRIBED SYSTEM IS IN ACCORDANCE With SAID CODE.~/ ~ ~/~j~/~
.. YfONICIPALITY OF ANCHORAGE
DIVISION OF E557IRO~ENTAL HEALTH
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR [~ALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information Application Date
(a) Legal Description (include lot,, block, ~sub~i~v. isian, section, township, range)
Loc~tton (address or.d%ractions) ~3 1~. ~i
(b) Applicants Name ~ g ~r-"7 Telephoue - Home Business
Applicants Address
(c) Applicant is (check one) Lending Institution
Buyer ~--~ ; Other ~--~ (explain);
(d) Lending Institution
~--~ ; Owner/builder ~ ;
Telephone
Address
Address
Telephone
(f) Mail the }~kA to the following address:
2. Type of Residence
Single-Family.~
Number of Bedrooms
3. Water Supply
. Multi-Family ~--~
Other (describe)
Individual Well ~ Community ~-~ Public
Note: If community well system, must have written confirmation from the State
Department of Environmental Conservation attesting to the legality and status,
Sewage Disposa__l
Onsite~ 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.
[Page I of 2]
~nBineering Firm Providin~_In__~spections, Tests~ File Search~ Data and Information
As certified by my seal a~ixed 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 wad.{%water 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 regula-
tions in effect on the date of this inspection.
Name of Firm
Address
Date
DHEP Ap_proval
Approved for ...-%~ bedrooms
Approve~. Disapproved __
Terms of Conditional Approval
(ENGINEER SEAL)
Conditional
Telephone
CAUTION
THE MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIROb~NTAL PROTECTIONi
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE~ REPRESENT-I
ATIONS GIVEN IN PARAGRAPH 5 ABO~E BY ~AN INDEPENDENT PROFESSIONAL ENGINEER REGISTEREDI
IN Tim STATE OF ALASKA. THE DHEP.DOES~ THIS AS A. .COURTESY TO PURCHASERS~0F I~OME$ AND
THEIR LENDING INSTITUTIONS IN ORDER %0 SATISFY CERTAIN PEI)ERAL AND STAIE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ~INALYZE DATA BEFORE A
CERTIFICATE IS ISSUED° THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN TI~ PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
RR4/ej/D18
[Page 2 of 2]
7-19-84
ae
MUNiCiPALITY OF ^NC'HORAQ~
DEI:q:, rO'~ I~IEALTI.I &
E~¥~)NMENT,~L PROT ECTIQit,,
MUNICIPALITY OFANCHORAGE (MOA)
HEALTH AUTHORITYAPPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
RECEIVED
Well Classification~
Well Log P~esent
Total Depth /~-~' Cased to
Static Water Level ~O !
Casing Height~A~ove Ground ~
Electrical Wiring in Conduit~
Separation Distances from Well:
To Septic/K~ Tank on Lot /FCC
If A, B, c~ C, D.E.C. Approved(Y/N)------~
Date Completed ~A~=- /~7 / ~ Yield~'~-~'w~
~ ~t At ~ ~
'' Sani%ary ~al on Casing
. ~ess~on ~ound ~l~ead
7/- ; On Adjoining Lots
Cleanout/Manhol~ ''~- l _~- To Nearest Sewer Service Li~e on Lot 2~9 ~
Water Sample Collected B~-~(~c~/~d'~-~//&¢/ Date /~/~//~/~
Water Sample Test Besults ~/'~/9 '~/-~/;}~--
Comments
Be
SEPTIC/HOLDING TANK DATA
Date Instal~d ~/~/7/ Size
Standpipes. //N~' / '~. Air-tight -Caps.. ~(~' ) _ Foun tic Cleanout (~)'
Da.e ss lon~ve/r Tank (.~)) Date Last .P~ped
. 't/ .
Pumping/Maintenance Contract on Fzle (Y/N)--/,
Separation Distan~s f~c~ Septic/Holding Tank:
To water-suppl
TO l~_*operty Line /O
To Water ~ai~v'Service Line
Course
Comments
To Disposal Field w/~~ /
To Stream, Pond, Lake, c~ Major D~ainage
Receipt
Date Paid:
Amount:
2-15-84
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHOi~IE (907) 562-2343 ANCHORAGE INDUSTRIAL CEN'~ER ~
~ 5633 B Street
Drinking Water Analysis Report for Total Coliform, Bacteria
TO BE COMPLETED BY LABORATORY
TO BE COMPLETED BY WATER SUPPLIER
WATER SYSTEM:
~ I. NO.
(*) See h on back
M~iling Addr®ss~
Z~ Code
Collected
By
Mo. D~y year
SAMPLE TYPE:
c:=~loutlne
[] Check Sample (for routine s~mple ! [] Treated Water
[] Special Purpose
SAMPLE // Time
NO. LOC&IIO~ Coll~oted
Analysis shows this Water SAMPLE to be:
st[s{sctory
[_1 Unsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination to
indicate reliable results, Please send new
sample via special delivery mall.
Date Received
Time Received
Analy,ical Method:
Fermentation Tube
~,.Membrane Filter
Lab Ref. No. Reeult' Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAM PLE
Membrane Filter:., Direct Count
Verification: LTB
Final Membrane Filter Results
BGB
CollformllOOml
Time:
Collformll0Oml
TNTC = Too Numerous To Count
ABSORPTION FIELD DATA
Soils Rating in Absorpt?og/St~ata
Date Installed
Width of Field
Length of Field /'~7../'
Depth of Field ~
Gravel Bed Thickness
Squa=e Feet of abscrption,~wea ~--0~ ~- Standpipes ~esent ~)., .-
~ession ove= Field (~ ~ ~te of ~st A~a~ ~st
Results of ~st Adequa~ ~ st ~ ~/~ ~c ~ ( ' ' '
Separation Distan~ fr~ ~sorption Field:
To Water-Supply ~11 /~ ~- To ~o~rty Li~
To Building Fogndgtion ~ / To Existing or ~ndo~d System
Lot /~ ~ ; ~ Adjoining ~ts /~ O
To Wate~ Main/~vi~. Line ~J3 ~ To Cut. S(if ~esent}
TO ~tre~ond~e/~ Major ~ainage Co. se ~
To ~iveway, Parking ~ea, ~ Vehicle Stora~ ~ea
C~nt~_
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes(Y/N)
Commsnts
~lee ts MOA
** Check Permitted Bedroom Rating /~ainst HAA R~quest
I certify that I have checked, verified, o~ conformed to all MOA HA~
on the dat~
~ .?~ 8RB 190X
Si~ned I~a[~ I:IIVER,~I.~.~I~ '~/' Date
Company, ~--~;~,~ i MOA No.
//
KB1/dS/s ! [
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2-15-84