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Home My WebLink AboutT15N R1W SEC 18 LT 188A ~-~1--~ MUNICIPALITY OF ANCHORAGE ~,~ O'-] DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION I ENVIRONIVIENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE [~] NEW LEGAL DESCRIPTION LOCATION NO. OF BEDROOMS ~ Manufacturer ~ . No. of compartments jLiq. capacity in 9allo~]s ' Inside length Width Liquid depth ~ ~-~D IF HOMEMADE: ,~* ~ ~ ~ DISTANCE TO: Well Dwel ng ~. PERMITNO. Well Foundation t ~ Nearestlotline~ iOt~ PERMITNO, ; DISTANCE TO: ~ Oo I ~ ~ .~: No, ofHnes ~ ,*' ~ ~' _~ t ~inches Distance between lines ~i~ ~ T~p~i tile to finish grade ~ I Material beneath the '. q~ 'riches Total effective absorptio PIPE MATERIALS OTHER ~ J~ ~ (~- INSTALLER ~( Oo, t q -¢, REMARKS ~ ~ '~ APPROVED ~ A ~ E~I~EERI~ LEGAL // 72 013 (Rev. 3/78) :1: I:': (~ I... ]: F::'T !iiN"f:Y'I" :1: (::)Iq :t: ':!i~ :t: N!iiN"(~l...I...l'Ji::O :1: N ~I',1 ~:'~I::~!E!:(~ CO'~/I!i!:I::RI!!!:D I?Y I'.'10¢'~ BI..I ]: L.D :[ N{3 CC))::)Ii!~ ~, THI!!i:N ( :[ ) (~1',f l!!i:l~..llii:C'H::~'. ]: C:(~L I:::'lii!:l::;:l"l :f: 'T' (~1',.I)::) :1: I',ISI:::'E!:C'T' :[ CIN f~ll,.l~ii~"l'' EIE!: C)l:::q"(:l ]: hl[i~:(:)ii (;?.) PlD'"'[i'!',L! :I: t..'T'[~ IA :t: L.I.. I'qC)'T' :~:!',E!: (,'q::'I:::'I::?.C]Vlii!:D ];J :1: 'l"l'"l[::Jl..!"l' [:~lxl lii!:l,,:li!!:{:::"l"l::~t ]: D(M... :t: Iq~BPI!EC71' ]: ()N FR[!!:I::'C)I::UF ii (~ND (:5) Ii!!:L. Iiii:CTF:R:I:C:(~I... NCHRI'::: I"IU!!iFI" BI!i!: :(:)DI",IIE: !'3Y (~1 I,,.. ]: C:IE:I',I!ii~E:D NAME 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 CCC" ViAl LIN ~ DRESS · ~ . LEG/V~ DESCRIPTION ~ t~ ' LOCATION NO. OF BEDROOMS~.~ Manufacturer ~,~ e/, IF HOMEMADE: Absorption~..~area / Dwelling ~ / ~ Inside le..gth __ ]WidthS:I'~-~' ( Liq,id depth [ D~elling PERMIT NO. y ' Material Liquid capacity in gallons Well DISTANCE TO: Manufacturer D,STANCETO: No. of tines / Lengt f c¥~ne of tile to finish grade Length inches Material beneath tile .z.. Uist"nc" b, eT> s Total eff~ ~._~.~ctive a.bj[o rr~' n ~-area Depth PERMIT NO. Type of crib Crib diameter Well DISTANCE TO: DISTANCE TO: foundation Total effective absorption area Nearest lot line OTHER PIPE MATERIALS REMARKS Driller Distance to lot line PERMIT NO. Sewer line Septic tank Absorption area(s) APPROVED PH, 694-2~79 7~-013 (Rev, 3/78) <:;~ . MUNICIPALITM OF ANCHORAGE % DEPARTM~,~]' OF HEALTH & ENVIRONMENTAL E,,OTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT NAME PHONE NEW MAILIN ' DRESS ~ M r~ ~ N~ of ~o~p~rtments~ LiTz~°n'I ,F ,O,~D.: Inside le,gth Width Uquid depth ~ ~ DISTANCE TO: ell g PERMIT NO. ; '~ Lengt_. f c~ne .... Total I~of,,~es T nh wi h inches Distance b~ey~s ~j~ Topof tile to finlsh graded~ , Material beneath tile ~, '' T0tolef~ctivea,,0~narea -- Length WJ Depth PERBIT NO. DISTANCE TO: Well Buil~J~datTo~-- Neares* lot line ~ ~S~/~ pth. ~ ~Z Driller Distance to lot I,ne PERMIT NO. ~ DISTANCE TO: ~ Buildi~ foundation Sewerline Septictank Absorption~rea(s) OTHER ' ~ / , SOl L TE~ RATI N 72-013 (Rev. 3/78) :[)EPARTM[.:.']q]" OF I'"IE!:~L..]]"'I AND E~NVIF~OI'~IME!iNTAL. F:"'F~'.OTE[]'I"IOI',I 264"-'472() F)IiERM I T NO ,", D ~ "l" E J. ,..~,~* LJ L., D. 8 4 () 9 '7 8 1 ,'.'~ / 14 / 8 4 AI:::'PL I CANT I:OI'qTACT I" HC.NI I.,,EE]AL. DI,..,,.iC, I ~ J. I., I.,.. 0 T S I Z Ii!!:: MAX BEDF~OOMS: SUBD I V I S I ON: N/A LOT: 188A BI..,,CI[:',K :: ~ECTiON:: I8 ]"ONNSHIP: 15N RANGE: 1W z1'36()1, (~!!iQ,.I='I". OR AC',I::~IES) x/A L.J.!:i'Led J::)(~.)lc)~ ape the c)j::rLic:)rls avai].ab].(~ '(:.cJ ycn..~ :i.n (:le~[~i:i. gr'~:Lng yaur' sep'L:i.c: :~ys'Lem,. Chc:)ose 'Lhe c::)p'L:i.c)r'~ that best fits yc:)um" :a[~ite),. DI!!!:I:::"T]...I TC) I:::' ]: F)IE: BO'I"]"CIM (I:::'T.,) 4,, C) I/(.~ 4,, 0 4,, () Gl::d~ VIZI...: DIE:F:'TH (1::,,1., ,, ) ~,. ()~ ~ ~ ()., ,:.~:' :]: ,, 5 TOTAl.... DIE]='I"H (r='T.,) 1(). 0 ~~i~ ~ 4 ,, 5 7.5 GI::~AVEL WIDTH (F:'T,,) ~., 5 :1.4,, 0 5,, 0 GRAVEL.. LEIqC.i'T'H (F:"T'.) ~'~2:'. ,. 0 ~?.8 ,, 0 :28 ,, 0 GF;'.AVEL~ VOI,,,.UME (CU. YDS,. ) 13,. 3 14.6 20.8 TANK S I ZE (E)ALS) :L, OC)C)., 0 .,.-,. 1,0C)0 ,. () ,~.a. ~ :L, ()0C)., C) .x..~. SOIL F~A'I"ING (SQ,.F:'T. /BR) 85 85 85 .UL~ 'T'AlxlI< MUST HAVE AT I....1:::.~,::11"" I", .... 'T'WC] I]CIMPAR]"Mr.~IxlTS c::: e r' 'L :L f' y . I I a I ,, 1,, I am f'am:i, liar, ~:i,'LJ"l thee r'EeCJL,t:i.l"(.~.!fi'l(~!n'L!~ f'(::m{h by 'l:.he Munic:i. pal:i, ty c:)f Ancl'{c)r, agc~ (MOA) ar'id the S'Late c:~f A].asl.::a. I ~ill install the system in accept'dance ~itl"~ a].l M(]A c:c:n:~(;~s and r'egula'L:i,c:n"~s, ar'id J.l'] I:: c:}lilj:l ]. J, arl(:(~) wJ.'ll, J"} tJ'l(~) des:i, gn cP:i. ter':i.a c)f' 'Ellis per'mit,. :[ w:i,].], acJher, e 'Lo a].]. M[)~ ar'icl Sta'l:.e (::)f' A],aska r'(f:~qu:Lpements f(::H" the set I::)ac:k d:i. stal"tc::es f'Pc:Hi] ar'ly ex:Ls{:i, ng k~e].].~, ~as'Lewater, d:i. spc~sal sys't, em or' publ:i.c sf:~(~)Page ~P/~i~Fl:,~:f~ril ,:::)l"l 'Lh:i,s (:m any adjac::ervL any enlar, gement ~:i,].l r'equir'e an addi'L:LcJnal per'mi'L,, I I:::' A I,... I F:'T ,.:) I A 1 ]. ON 1 ,::~ I IqE~TAI....I....ED I N AN Al ~E.A C C)VI='I::~IE'D BY MOA bU 11...D 1N(:: I" ' r'~ :' 'I"I::?IEN(:~.) AN. E. ""R]~ ~ P ~::~' "" AxD ::x ~F:>E]""I :: x ~ ...~"." }~ E: ]ETA::B ~ED.' (2) A ] B I T' WIL..I....NOT BE: ~I:::'PI:~OME[ ~:['T'HC]UT AN, EL,.EC, TI::C[CAI,,.. IlxlSF:'EC;TION REF::'ORT AND C3) 'T'I'IE: EL.EC;TI~ I CAI.... WJ::il::~J~' MUS"I BE D~xlE BY A L I CENSI~ED IE]_IE:C]]]:;: I C I AN. .......... ..........................: ...................................................... .. ". .... AI::'PL,.IC;AIq]"~:~STF:~UCTIOIq % S~¢S IZNGINIE]ER];NG / // ,. ........................................... ................... / MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SLOPE DATE PERFORMED: SOILS LOG [] PERCOLATION TEST SITE PLAN 10 11 12 13 14 15- 16 17 18- 19- 20- E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time 'rime Water Drop PERCOLATION RATE (minutes/inch} COMMENTS TEST RUN BETWEEN FT AND FT PERFORMED BY: , ~""~-']LE ~IV~J~K~"~'~'~,~,. ~, 72-008 (6/79) {ger' fiei ¥, Drilling by SULLIVAN, WATER WELLS P O,'BO~ 272, CHUGIAK, ALASKA 99967 · TELEPHONE 688-2769 )WNER OF LAND ._.~J~L.(~/<' '~70 ~,a ~(~ ~ ; .... DEPTH OF WELL ~DDRESS ~;/ ,3 . /~oA . *$~ ~ _~ ~_ STATIC LEVEL OF WATER ~T. ~- 'ERMIT NUMBER _ ,LIND OF FORMATION: trot __ :rom. ~t. to _F troT , .Fi, *~rom _ Ft. to' Ft. ·,' ~rom , , Ft. to , Ft. ~ . , From, , Ft; 7rom From Ft. to Ft. From _Ft. to, Ft. From _Ft, to___~Ft.. Froni ...... Ft. to From _Ft. to___ From Ft, to r ErOfi From. __ From Ft. to , _Ft. From_ Ft. to Ft ...... From .Ft. to · Ft.~ .... From Ft. to_ ~Ft. ...... From Ft. to Ft,__~_. ...... Crom Ft. to _Ft. . From Ft. to - _~Ft. , ', ,,~' VllSCL. INFORMATION: From Ft. 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 GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision., section, township, range) Locabon baddress or directions) ' (b) Applicant Name ~- ,/~~ Telephone: Home ~A~'o~-'-~DT_-~ Business ApplicanLAddress (?/~ K'~ (c) Applicant is [ch~eck.., one):. Lending Institution [] ,' Owner/builder/l~; Buyer []; Other [] (explain); (d) Lending institution Address (e) Real Estate Company and Agent Telephone Address {f) Telephone 'l~l the HAA to the following address: TYPE OF RESIDENCE Single-Family,~ Multi-Family [] Number of Bedrooms '~ Other WATER SUPPLY Individual Well/[~' Community [] Public [] Note: If corn munity 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 community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. ENGINEERING FIRM PROVIDIN~ ~NSPECTIONS, TESTS, FILE SEARCH, DA...~ 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 e~sposal 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 Date ' Telephone Approved for /~/~bedrooms - ~ ~,~ Date Approvecl ,,~ Disappr v d Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DNEP) 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) A. WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Description: ~ MUNICIPALITY OF ANCHORAGE DEPT. OF HEALTH & ENVIRONMENTAL PROTECTION 1985 Well Classificauon ~t,~ If A. B C D.E.C. Approvea (Y/N) Well Log Present ~;~'N) Date Completed J~--" ~'/3L Yield Total Depth t~ Cased to ~O' b ~ Depth of Grouting Static Water Level '~/~" Pump Set At Casing Height Above Grour a ~ ~ Sanitary Seal on Casing i~'N) Electrical Wiring m Conduit (d~N) Depression Around Wellhead (Y/~ Separation Distances from Well: To Septic/,'Ic,=dh'~g Tank on Lot [,.-~'~ ~' : On Adjoining LOtS To Nearest Eage of Absorption Field on Lot I ¢='~;:' 4- : On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole I'j Je,. To Nearest Sewer Service Line on Lot Water San- p~e Collected by ~ ~ ~ /~"'""~" ~,~'-~;..~.--1..u,,..3~-. Date Water Sarr pie Test Results Comments B, SEPTICPHeEi~k~N~ TANK DATA Standpipes {33/N) Air-tight Caps Depression over Tank [Y~ Pumping/Maintenance Contract on File (Y/N) Holding Tank High-Water Alarm (Y/N) I~/,~ Separation Distances from Septic/H%!dh,~ Tank: Size ['~-~"~=> No. of Compartments Foundation Cleanout ~N) ,Date Last Pumpea : for Temporary Holding Tank Permit IY/N) To Water-Supply Well To Property Line To Water Main/Service Line Course To Building Foundat on ~ ~ To Stream. Pond. Lake. or Major Drainage Comments Page 1 of 2 72 026(11/84) MICAL & GEc,~OGICAL LABORATORIES. oF ALASKA, INC. TELEPHONE (g07) 562.2343 ANCHORAGE INDUSTRIAL CENTER 5633 B Street Drinking Water Analysis Report for Total Coliform Bacteria TO BE COMPLETED BY WATER SUPPLIER WATER SYSTEM: I.D. NO. Water System Name (*) See h on beck ~-~ - z~ ? ~ Phone No. Mailing Address City State MO.' Day Year Z;p Code SAMPLE 'WPE: ~-r.1 Routine Check Sample (for routine sample with lab ref. no. ) D Special Purpose [] Treated Water ~ Untreated Water SAMPLE NO. LOCATION 4 I 5 I Time Collected Collected /i.,/o/ TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: J~Satisfactory [] 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 mail. Date Received ~'-/~ - ~_c Time Received ,) ~ Analytical Method: [] Fermentation Tube :~embrane Filter Lab Ref. No. Result' f CF-] Anelyet 06-1220 (b) Rev, t983 BACTER IO LOG ICAL WATER ANALYSIS RECORD READ INSTRUC'J'IONS BEFORE COLLECTING SAMPLE Membrane FIItec Direct Count Verification: LTB BCe Final Membrane Filter ~eeul~. Repoded By "~ Time: TNTC = Too Numerous To Count Collformll00ml CollformllOOml C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Suuare Feet of Absorpuon Area Depression over Field (Y/~). Results of Last Adequacy Test Separauon Distance from Absorption Field: To Water-Supply We To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area. or Vehicle Storage Area t~'~--=PIr~L~ Type of System Design Length of Field /'~ '~' I Depth of Fielc Gravel Bed Thickness ~ ~ '=p~'2..'~ Standpipes Present ~N) Date of L/~st Adequacy Test To Property Line I C:::'~'~ To Exis, ting or Abandoned System on On Adjoining Lots ~ ~ To Cut~ank (if present) ~ /4 Comments D LIFT STATION Date Installed Size in Gallons "Puree On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level au Vent IY/N) Pumping Cycles during Adequacy Test. Meets MOA Check Permitted Bedroom Rating Against HAA Request ** I certify that nave cnecl<ecl, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection Signed ~,,e ~ ~*,~er~,~l:lttkt~ Date Receiot No, ~ ~ ~ ~ ~ ~ Date of Pay mem ~*/~ - ~b~ Amount: $ ~¢~ Page 2 of 2 72-026 11/841 d: J'-o o .E,