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Home My WebLink AboutT15N R1W SEC 18 LT 216 MUNICIPALITY OF ANCHORAGE DE ITMENT OF HEALTH AND HUMAN SER Environmental Health Division 825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Nam8 [ownship, Range, Section ' TAI~KS L~ HOLDING TYPE OF SYSTEM TRENCH ~ BED ~,,W. DRAIN [] OTHER o,IgJ[1.1 grade ~ , ~ I-T ~..~ FT /~--~) FT ~ FT WELL5 ,~PRIVATE [] OTHER (Idenlilv) DISTANCES WELL LOT LiNE SEPTIC TANI~ FOUNDATION .~---- ' ABSORPTION t FIELD WELL REMARKS: I j . 8RD ",JD8~ certily that thio inspection was pedormed aucording to all HealthDepadmentApprova/:,~¢~ ~' ~~ Date: 72 013 (3/85) DEPARTMEN'T [)F HEALTH AND ENVtR(]NI~II~i]NTAL PROTECTION 8.'~:~5 L. STREE'T, ANCHORAGE, AK 995() 1 264-472.0 'EiF:~M t1 'T' NC:): }A '1" E l ~, ,,~ U I,,,. D .. Id_IL, Al I1 . ~DI:)RESS ~ ;oN'r'ACT PI'"IONI?~: ],..~O6..~. E, NG I I II::.I:,IqED DES I GN J.C lC ..:. / 8.,, RICHARD HARBESON CIO S&S EIXlGIIxlEI~]]:~IIXlG EAGL. E RIVER, Al<: 99~'77 694-:?,979 .E..~AL. I)I.,,,,,~L,I&[F. SLJBDIVISION,". NA LOT: 216 SECTION: 18 ]"OWNBHIP': 15N RAN[~E: 1W ,O't" S; t Z E: zi, OC~O() (~c~[~. I:: l ,. (DR AI.,,F~E:.~:~' '. '"'r, ) E L,.DCK ." NA cer'tify that: 1. I am familiar, w:L'Lh i:,he I"equ:i.l'emen'Ls For, c)n-s:i.i:,e sewers arid we],].~.i~ as se-t. fcm'Lh by the Munic:ipali't,y oF Ar'~c:hor, age (MOA) and 't. he State oF Alaska. I w:i. ll insi'..all the sys'Lem :i.n ac:ccmdance with all MOA c:odes and regu].at:i.c)r'ls, and irt compliance wJ.'Lh i:,he design cr'i'Ler, ia o(' this per'm:i.t. I will adher, e 'Lo all MOA ancl SH:.at.e of Alaska r'equJ, rements f'or {he set bacl.:: (JJ.~J'J:,ar'lc:~H~i J'pom any ex:i. stil'lg we:l, lt~ wastewater disposal system of publ:Lc: F A LIF']" S'T'ATIOIq IS INSTALL,.ED tN AN AREA COVERED BY MOA BUILDINO [;ODES, HEN (1) AN ELECI"RICAL PERMI]" AND INSF~E[FI"ION MUST B~.:,': OBTAINED; (:?,) A~3-BUIL. TE1 ILl,... NOT BE AF'PROVED WITHOUT AN E:L, EC]"RIC::AL, INSF'ECTIDN I:~EF'OR]'; AND (3) TI-II,T:: L. Iii~CTI::¢ I CAI,,,. WOI:::~I< MU!3T BE DONE BY A L I CENSED ELEC'T'F~ I C I AN. i bl,ll::,D ~ I'd..,I.L, AI I1 . SSL~IED BY R ~IARD ]"IAFd3ESI]N ~t q of P.O. BOX 665O ANCHORAGE, ALASKA 99502-0650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES October 3, 1985 Robert A. Shafer, P.E. S & S Engineering SRB 196-X Eagle River, Alaska 99577 Subject: Waiver Request WR85-037, TI5N R1W Section 18 Lot 216 Dear Mr. Shafer, This department has reviewed your request for a waiver to 89 feet of the required 100 foot minimum horizontal separation distance between the well and septic tank on the subject property. Based on the information submitted this waiver request has been granted. This waiver is valid for the existing septic tank only. Sincerely, Stephen S. Morris Civil Engineer On-site Services SSM/lJw ROBERTA. SHAFER September 29, 1985 HEALTH AUTHORITY APPROVALS SEWER&WATER MAIN EXTENSIONS SEWER&WATER INSPECTION SYSTEM DESIGN WELL INSPECTION & FLOW TEST SITE PLANS ROAD DESIGN SOIL TEST PERCOLATION TEST STRUCTURAL& MECHANICAL INSPECTIONS Municipality of Anchorage Department of Health and Environmental Protection 825 L Street Anchorage, Alaska 99501 ATTENTION: Susan Oswalt REFERENCE: Lot 216; Section 18; T15N; R1W; SM Request you issue a permit to upgrade the on-site waste water disposal system in accordance with the application and soil log attached. Also request you issue a waiver which will allow the existing septic tank to be continued in use at a horizontal separation distance of 8~9feet from the private well located on this property. The existing septic tank was excavated to expose the top of the tank and the inlet and outlet collars. The tank is equipped with waker ti~t seals and appears to be in In accordance with risk analysis procedures it is almost sure that this source will not contribute contamination from household sewage and it is therefore our opinion that the horizontal separation distances prescribed by 18AAC72.021 are not required in this case. Attached for your review is a plot plan showing approximate location of all facilities, soil log and permit used to install the existing system in 1978 and a well log. As you can see from the well log, soils are highly silty with clay from the surface to a depth of 49 feet. If we need to be of further service, please contact us. ON SITE WASTE WATER DISPOSAL SYSTEM DESIGN SRB 196X EAGLE RIVER, ALASKA 99577 Municlpallty of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST PERFORMED FOR: DATE PERFORMED: LEGAL DESCRIPTION: ~.-~¢~'~ ~-~ ~- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Township, Range, Section: SITE PL~AN i ' SLOPE WAS GROUND WATER ENCOUNTERED? IF YES, AT WHAT DEPTH? Depth to Water Alter Monitoring? Date: Reading Date Gross Net Depth to Net Time Time Water Drop PERCOLATION RATE ~ (minutes/inch) PERC HOLE DIAMETER TEST RUN BETWEEN 5 FT AND ~ FT ' :C, ,'~1!~ RiVing, R~,~[~ '~'~ /VT~,-~ _ ~ CERTIFY THAT THI TEST WAS PERFORMED 72-008 (Rev. 4/S5) IN December 31, 1979 Jeffrey Blough 1001 Boniface Parkway Anchorage, Alaska 99504 Permit # 780665 - Renewed :for Calendar Year 1979 Subject: T15N R]W Section ].8 Parcel 11 Lot 2].6 A permit .issued by this department, for well and/or sewer system has expired. Pemnits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well lo~ should be sent to this department to document the installation date. If an engineeP has inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If there are any furtn__ questions, please contact this office at 264-4720. Sincerely, LNB/ljw enc: Copy of Permit December 29, 1978 9780665 Jeffrey Blough 1001 Boniface Parkway Anchorage, Alaska 99504 Subjectz T15N R1W Section 18 ParCel 11 Lot 216 A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz. R.S. Senior Environmental Specialist LNB/ljw enc: copy of permit DE:PFIR"I"f"IEI"4T I:)~*'IEFIL. TH AND EN',,,'IF~:ONHENTRL.. F" 'Cf'ECTION 825 '" L :~;TREET, FtNCI"IORFtGE:., FIK. E):':.a.5. ....... I1..,,,,11EE IL_. L, IF::l ~'-.il [:. "]]~ D".l -- ."E-~; ]J "[" E~Z :S:]; E bdt EJE IFE'.: F" EE P;:;,~ Ih'll ][ 'T' ( 78C1665 ) APPL ICRNT L..OCFYI"~ ON L..EGFIL · .IIEFF;REY BLOIJEiI.-I ::I. 08~L BONIFFICE OFF:' BIRC:HHOOD I...F' L2::1..6 SiB 'T':LSN R:.'LW F'I=IRC:EL L. OT SIZE 0 SQI..II::IRE F=EET TYPE OF::' SI[)]:[_ FIBSORBTION SYSTEM IS: TRENC:H HI::[XIMIJM NUMBER OF BEDROOMS = 4 SOl[.. RBTING (Sg! FT.,'BR: .... t65 THE: RE6!UII:RED S';IZE OF TF'IE SOIL FIBSORPTION SYSTEM IS: E:::" EE F" -"Ir" IH :=:: (-B; L.... [+.'Z I"-.I ,Z~ T' ~..al .... :;..E: Z~: ILZ~ F;L" F:~ %." E: L .... [:::~ E.:.?, F:" 'T' F.-.II == .ql.. THE LENGTH DIMENSION IS TNE LENGTH (IN FEET) OF TNE TRE:NCN OR DRBtNF::'IEL,.[:,, THE [:'EPTH BF R TRENCH OR PIT IS THE D'ISTFINCE BETI.qEEN THE SURF'FICE OF:' THE GROUND fiND THE BOTTOM OF TNE EXCR'v'RTION (IN FEET). TNERE IS NO S';ET WIDTH FOR TRENCHES. THE GRFIVEL DEPTH IS TNE MINIMUM [:,EP]"H OF' GRF:F/IEL. BETWEEN THE OUTFRLL. F'IPE FIN[:' THE BOTTOM OF' THE EXCR',,,'ATION (IN FEET). I:::'Ei:l:;'.l"l]'."l" FIF'F'LIC:RNT HFIS "['I'4EE RESF~Oi'.,ISlBILITY TO INFORM THIS DEPRRTMEN]" I}URIN6 "I"HE INS:;TI=ILLFI]"ION INSPECTIONS OF FINk' WELLS FIDJFICENT TO TI'"IIS:; PRBPE:RTY FIND THE NUMBER OF: RESIDENCES; "I'FIFIT THE HELL I,.!ILL.. SER'Y'E. E:F:IC:I<F ILL I NG BF FINY SYSTFJEi'I L,.I I THOUT F I NFIL INSPECT I ON F:IN[:, FIF'PRO',,,'RL. B'.? TH I S DEF:'F;:IRTMENT WILL BE SUBJECT TO F'ROSECLITION. MINIMUM DISTFINCE bETWEEN B HELl. RND flN"l" ON'-SITE SEHRGE DISF:'OSRL ::L00 FEET FOR A PF.'.'I',,,'FITE HELL; OF:'.* J..51.3 TO 2~3(~I F::EET FROM R PLIBL..IC WELL. [:'EPENDING UF'ON THE TYPE OF PUBLIC HEL.L. HEL. L L.J.5 F:IRE REQUIRED RND MUST EE RETURNE[:, TO THE DEF'F:IR"f'MEHT WI"f'HZN :!.~: [ 4 = 01:::' TFIE WELL. COMPLETION. O'I"HER RE6!IjIRLI1EIq].:, MF"IY FIF'F:'LY. _,FL~.if IE. BrI..i',l: AND "':N'=T[' :']'ION DIF:I":i[;'I::: FIVFIIL. FIBL..E TO INSURE F'ROF'ER IN:!~iTRLLF:iTION. F" E F,;i;: lr."l :j[: ]"- EE ::'-::: ~:> 3[ F: EE 2:~ [::. E; C: EE i'.1 BEC F: ::.:/,~: :::JL i CERTIF'Y "f'HFIT t: I FIM F'FIMIL. II=tR I,.tI'FH THE REQUIREMENTS FOR ON-SI]"E SEW[Et: FORTH BY THE MUNICIPRLI]"Y OF RNCHORFIGE. 2: I WILL INSTFILL. TNE SYSTEM IN RCCOR[:,ANCE HITH THE: CO[:,ES. :Zc: I UNDERSTRND ]'HI=IT THE ON-SITE SEWER SYSTEM MRY REg!UIRE: EN RESIDENCE iS REMODELED "f'O INCLUDE MORE 'rNAN 4 BEDROOMS. .... [ ~ NL[.: F~PF'L I I]:I:~NT JEFFRE'¢ BL. BI.,IGH ' Z ..~... I..IE[., [:' ~'- ............ .- ................... DHq E HELL. S FE V3:. 2 0 8- E GEO Russell Ot(lter 694-2774 Soils Et Foundations 4 5 · ECHNICAL 8' DEVEL,./PMENT Box 90, Davis St., Eagle River, Alaska 99577 694-2774 or 688-2280 CO. Perfomed for= S0[~ LOG Name: /////~,, Hatltng Address: /~>/ Ear/EII/L~ · ~. ~8-22~0 ,, ,. Land Development Tel. No. Depth (feet) Sotl Charq¢~rlatlca 12, 16 Ground Nater Encountered: Yes__No .,, Propesed [nstallatton: Seepage Ptt Comments'. / If yes, what depth Drain Field Performed by: Date: KiN~tl': ¢~PANY PuMP SALES & SERVICE (9O'7), 94,11.7ee3 ,KEN JOHNSON /i,j3~L~ 2~1~..~,<)~~ ANCHORAGE. A~KA 3163 LI NDIL~N "~l~lV~ OOS02 ALASKA nuIROnMEnTAL CO[1TROL SEI UIC S, InC. ~.§in¢~rinq 8- ~uironmcntal Studies MUNICIPALITY OF ANCHORAGE DEPT. OF I[ ALiH & ENVIRON~vlEN I Al Jeffrey T. Blough 1703 Twining Anchorage, Ak. 99504 November 21, 1980 NOV 2 1 1980 RECEIVED Dear Mr. Blough: On November 21, 1980 we performed an~adequacy test on the new on-site system on pareel 11, lot 216~ See 18, T15N, R1W, S.M. The test consisted of introducing water into the existing system to determine if the system could accept at least 600 gallons of water per day. The existiil~ septic tank was approximately half full of water. We added water until the septic tank ~as full (appmoxlmately 600 gallons) and then d~nped another 1400 gallons into the system without any evidence of overflowing or the system backing up. As this was over 2x the daily flow needed ~ can assume the system to be adequate for a 4 bedroom home. The seepage system is over 150 ft. from the neighbor's well to the north. The well located on your lot is 89 feet from the septic t~k and in excess of 100 ft. from the seepage system. The tank is 1200 gallons, 2 compartment from Greet. See attached receipt. 1220 LUcst 25th Aucnu¢ */~nchore§¢, Al~sb 99503 ,. (907) 276-1361 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERALINFORMATION Completelegaldescription Rema±nder o£ BLH Lot 216, SE 1/4, Section 18, T15N, R1W Location (site address or directions) 19535 Spruce Crest Drive, Chugiak Property owner Tom Brown Dayphone_msq 694-9125 Mailing address P.O. Box 1134, Del Valle, TX 78617 Lending agency _~/A Mailing address Day phone Agent 2. NUMBER OF BEDROOMS: 3. TYPE OF WATER SUPPLY: Lee Scanlin/Great Land Realty Dayphone 694-9125 Address 11411 Old Glenn Hwy., Eagle River, AK 99577 Unless otherwise requested, HAA will be held for pickup. 3 ~ Individual well x Community well Public water If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. NOTE: 4. TYPE OF WASTEWATER DISPOSAL: x Individual on-site Holding tank Community on-site Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. NOTE: 72-025 (Rev 1/91) Front MOA~21 STATEMENT OF INSPECTION BY ENGINEER 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 application 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. NameofFirm Eagle River Engineering Rvcs Phone 694-519~5 Address P.O. Box 773294, Eagle River, AK 99577 Engineer's signature Date ///'-3' ~,//¢,~ DHHS SIGNATURE Approved for Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates based only upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal end state requirements. Employees of DHHS 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. 72~25 (Rev1/91) B~ck MOA#21 Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: /~-~/Y////Vp~ ().~ ~£~ ~)F ~/b/ Parcel I.D. SE. ¢% 5£~/v I~, 775~,/, I~11~ A. WELL DATA Well type ,P/~/ V~ T~ 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 Casedto B3 ~ I0" Casing height wires properly protected (Y/N) ~/ FROM WELL LOG Date of test Static water level Well flow Pump level g.p.m. AT INSPECTION //D-? / ? ~ MUNICIPALITY OF ANCHORAGE ! ENVIRONMENTAL $I-RVICES DIVISION ~o.~, JAN 3 0 1~)92 g.p.m. RECEIVED SEPARATION DISTANCES FROI~ELLTO: , / ~¢~ / Soptic/~ tank on lot .( ~ ..-"/' ~]/~IV£D /o/3/IrF; On adjacent lots Absorption field on lot 10 ? ~ ' ~ ; On adjacent lots Public sewer main PtYofl~ sewer service line WATER SAMPLE RESULTS: Coliform '-~" Public sewer manhole/cleanout Petroleum tank /JDM£ Nitrate ~ O, I I'~//- Other bacteria Data of sample: 0//O~/¢ ~- a. SEPTIC/IVb~;i;~ TANK DATA , .~ ~,,,/~ · - Date installed ~2/-~/~L~ Tank size Cleanouts (Y/N) ~ High water alarm (Y/N) ~/~ Date of pumping ~///.~/9~ Collected by: Foundation cleanout (Y/N) Compartments Depression (Y/N) Alarm tested (Y/N) SEPARATION DI/STANCE$ FROM SEPTIC/~G TANK TO: Well(s) on lot ~ ~ To properfy linde~ ~/0 Surface water/drainage FoundatIon ~ / Water4:rk~A~/service line ¢/¢ ' 72-028 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed Manufacturer Size in gallons ,, ' Manhole/Access (Y/~N~~ Vent (Y/N). Pump on" level at ~ ,--"~"Pump off" level at. H,gh water alarm level,} J~- ,/ Cycles tested ~ Meets MOA electrical codes (Y/N) Y ' SEPARATION ~T STATION TO: · D. ABSORPTION FIELD DATA Date installed /,')/~(,~/,,~'~ Length /P-o/ ~ _Width. Total absorption area. Depression over field (Y/N) /V- Results (pass/fail) /~'/~ Peroxide treatment (past 12 months) Soil rating ~ ,:zS- Gravel thickness System type ~/. ~,~ .Total depth ~,.5 · Cleanouts present (Y/N) .. ,Y Date of adequacy test ~//~.~/~"Z-~ .~' for On adjacent lots -r/~ ~," SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ... /~ 7 To building foundation On adjacent lots Surface water ~///~ Curtain drain If yes, give date ..~ ~bedrooms Property line To existing or abandoned system on lot Cutbank /'V./~ Water m~Jn/service line Driveway, parking/vehicle storage area 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. Signature Engineer's Name Date ,/,/~ "'//.~ -..~. HAA Fee $ Date of Payment Receipt Number 72-028 (Rev. 3/91} BacX MOA 21 Waiver Fee: $ Date of Payment Receipt Number Eagle River Engineering P.O. Box 773294 Eagle River AK 99577 - NOII"I'IIEllN ]'!~S'I',NG ~A~ I]OIIATOIIIES, . Report Date: 01/10/92 Attn: Louis Butera Date Arrived: 01/07/92 Date Sampled: 01/06/92 Time Sampled: 1555 Collected By: ~B/LM Our Lab #: Location/Project: Your Sample ID: Sample Matrix: Comments: Al15923 Lot 216 T15NR1WS18 Water Definitions MDL = Method Detection Limit B = Below Regulatory"Min. H = Above Regulatory Max. E = Below Detection Limit Estimated Value Date Method Parameter Units Result Flag MDL Analyzed EPA 353.3 Nitrate-N mg/1 <MDL 0.1 Reported By: William E. Buchan Anchorage Operations Manager 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 Dat~.. _~?~ GENERAL INFORMATION (a) (b) (c) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) Applicant Name ~ t('~w.~/' Telephone: Home I _ Applicant is (check one): Lending Institution (d) Lending Institution "~-4'~,~/.~/.~,~-.-, -~. ~ ' Telephone - ~ (e) Real Estate Company and Agent ~. ~ ~~a¢ TYPE OF RESIDENCE Single-Family/~ Multi-Family~ [] Number of Bedrooms Other / ~ I WATER SUPPLY 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 DISPOSAL Onsite ~]. Public [] Community [] Holding Tank [] Note: If corn munity 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 (11/84) 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 '. 'SRB lg6~ Address __~ Date Telephone DHEP APPROVAL Approved for Approved Terms of Conditional APproval bedrooms by ~'"~"' '/~' ',~ Disal~,~d Condi~a, Date CAUTION The Muncipality 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) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 MUNICIPALITY O,F ,ANO'iORAG~ DEPT. OF HEAI.'IJ'I & ENVIRONMENT/g~, I~ROTECTION o n-r 0 7 1985 264'4720 Legal Description: Z Z/~, ' .~/~,ECEIVED Well Classification Well Log Present. N) Total Depth ~L.~.~. Static Water Level Casing Height Above Ground Electrical Wiring in ConduitS/N) If A, B, C, D,E.C. Approved (Y/N) Date Completed O¢...'~."~.~ . ~7~ Yield ......~ ~ ,..b Cased to ~ Depth of Grouting "' Pump Set At ~&/~-~ Sanitary Seal on Casing((~) Depression Around Wellhead (Y/~D ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Seearation Distances from Well: To Septic/~Id:,ng Tank on Lot To Nearest Edge of Absorption Field on ,Lot To Nearest Public Sewer Line ~ /~ Cleanout/Manhole Water Sample Collected by Water Sample Test Results Corr ments ~ ~::~-.~-- ~ ~ To Nearest Sewer Service Line on Lot ~ I ~ "--'~ ~--~ I~:;~'~C'-~t~1~=~'ft-4~'''''''''''''''''~ ;Date ~,--Z.~f--j~(~' B SEPTIC/HQL-~4['4G TANK DATA Date Instalh Stanompes (~N) Air-tight Caps Deeression over Tank ('~j~ Pumping/Maintenance Contract on File (Y/N) ¢ Holding Tank High-Water Alarm (Y/N) No. Of Compartments ("' '~. Foundation Cleanout Date Last Pumped ~.¢'~- ~ ~ ~:~ / ~/~ ; for Temporary Holding Tank Permit (Y/N) Separation Distances from SeptieCJ-4eh:ffrrg Tank: To Water-Supply Well ~ ! ~"~ ~"~To Building Foundation To Property Line ~.~==,' ~'~ ~ To Disposal Field To Water Main/Service Lin% t ~ ~ '~ ,& To Stream, Pond, Lake, or Major Drainage Course Comments J~r') ~::~ f2--~ d~, t/,,,5 ,~t.. t ~,~-~,_~_.~z_~ ~ ~,,,. 'x, ~ Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata "Z-~..--~ ~ I t~-~A-.--' Type of System Design Date Installed ~ ~ ~ ~¢-f~,~" Length of Field ['''2--¢~ Width of Field ~ / Depth of Field ~ ~ Square Feet of Absorption Area Depression over Field (Y~i~. Results of Last Adequacy Test Gravel Bed Thickness I I Standpipes Present (~N) Date of Last Adequacy Test Separation Distance from Absorption Field: \ C:~ "'/~ To Water-Supply Well To Building Foundation Lot ~ ~ To Water Main/Service Line ~, ~ ~ 4.-- ~ To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line ""7...~ ~. To Existing or Abandoned System on ; On Adjoining Lots ~ ~ ~ ""-' To Cutbank (if present) Comments D, LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked;' verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Comp~,~ alu~. ReceiPt No. of Amount: $ Page 2 of 2 72-026 (11/84)