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Home My WebLink AboutWENTWORTH BLK 1 LT 25 F'ERMtT NO. RPF'L I ]:RNT _Or':RT t ON _.~ ..~HL [:,ON HFINNRH E, Lk. ~L I.,JENTPJOR l H LT 25 ...... LOT SIZE :'1_000Ei .=, ~.!I.JH~..E FEET MINIMUM DI'STRNCE BETWEEN R WELL.. RND RN"r' ON-'SITE ~;EPJRGE DIE:POSRL S'¢%'TE.r'I !S :tEIE~ FEE]' FOR R PRt',,,'RTE WELL OR :t50 TO 2¢¢ FEET FROM R PUBLIC WELL DEPENDING UPON THE T'.r'F'E OF F'UBLIC WELL. MINIMUM DISTRNCE FROM R PRiVRTE WEL. L TO R PRI'¢RTE EXEI4ER LINE IS 25 FEET '1-0 R CO?IMUN!T'T' %EWER LINE ID; 7.'.-] FEET. ~4ELL LOG:E, FIRE RESU!RE:D FiND MUST BE RETURNED TO THE DEF'RRTMENT WITHIN 2:0 OF THE WELL COMF'LETION. OTHER REL~UIREMENTLE, t"1R'¢ RPPL'¢. SPECIFtCRTIONS RND CONSTRUCTION D!RGI:r.".RMS RRE R',,,'RILRBLE TO INL-nURE PROPER INE;TFILLRTION. t _.ERIIF~ THRT i: I Rf't F~MILIRR WITH THE REL.]UIREMENTS FOR ..N-z,~.E SEWERS RND t..EI.L: ..... E! FORTH E,~ THE: IlJN(.._E-MLI]. OF RNCH'/F?FIGF. 2: ! WILL INSTFtLL 'T'HE ;5'¢STEM iN RCCOR[:,FINC:E WITH THE CC, CE:B. RF'F'L l CRNT [:,ON HFINN¢!H 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 Parcel I.D. # _~/~ ~ - 0 ~ _ ~._ 1. GENERA~ INFORMATION Complete !egal description CERTIFICATE OF HEALTH AtJTHORITY APPROVAl_ FOR A SINGLE FAMILY DWELLING Location (site address or directions) .~ 3o [ ~ Z//~.~/. ,Z~.~,~ Property owner ,~..~c~-%, ~',*¥--! ~. ~-~, .DaYphone Mailing address '~/ ~ ¢1~~L , A~'~'~ Lending agency-'" ~ Ict/~,~ ~ ~,'~; I.['i' &-~l-~,~,-~-I Day phone Mailing address Address c~~p<2 Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: Day phone TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Fronl MOA #21 Engineer's signature STATEMENT OF INSPECTION BY ENGINEER ' As certified by my seal affixed hereto and es of the validation date shown be!ow, 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 regulati .ohs in effect on the date of this inspection. NameofFirm '-'~-1 --~u r-~.l~,~-~ ~,,-~ Phone Address ~0~ ~ /~ ~ ~c~ Date DHHS SIGNATURE /)( Approved for -~P bedrooms. Disapproved. Conditional approval for bedrooms, with the following stipulations: Additional Comments Date .The Municipality of AriChbrage 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 engi,n,~?registered in the State of Alaska. The D HHS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. Em ployees of DH HS do not conduci 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. 72~2§ (Rev, I/91) Back MOA#21 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental Se~ices Division a2s"u' street, aoom · nc.ora . .as a o so ' ( 07) a4a-47t Legal Description: A. WELL DATA Well type Health Authority Approval Checklist If A, B, or C, attach ADEC letter. ADEC water system number Log present (Y/N) y Date completed Total depth ~) ~/'1.-. Cased to 5~ ¢~ Sanitary' seal (Y/N) / Date of test Static water level Well pmduction WATER SAMPLE RESULTS: FROM WELL LOG Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION Coliform ~2~ Nitrate N ~ Other bacteria ' ]x4_~ Date of sample: ~//q 7 Collected by: ~ -~ B. SEPT1CPrIOLDING TANK DATA e~'~]/~ 2./~-,~ ~ ~" ~/~-~':~ Date installed Tank size Number of Compartments __ Cleanouts (Y/N).__ Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION F~;LD DATA Date installed Depression (Y/N) Pumper Soil rating (g.p.d./ft~ or fl2flodrm) High water alarm (Y/N) System type Length Width Effective absorption area Date of adequacy test Fluid depth in absorption field before test (in.); Fluid depth (ins.) Minutes later: Peroxide treatment (past 12 months) (Y/N) Gravel thickness below pipe Monitoring Tube present(Y/N) Results (Pass/Fail) Immediately aller Absorption rate = Total depth Depression over field (Y/N) __ For bedrooms gal. water added (in.): g.p.d. If yes, give date D. LI~ STATION Date installed Size in gallous Mauhole/Acccss (Y/N) "Pump ou" level at* "Pump ofF' level at* High water alarm level at* *Datuul Cycles tested E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holdiug tauk ou lot Absorptiou field ou lot Public sewer maiu Sc;vet/septic service line ; On adjacent lots : Ou adjacent lots Public sewer maahole/cleaeout Lift station · ~ t~c_9 t '-I' SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO: Building foundatiou Property line Absorption field Water maitu'service line Surface water/draiuage Wells on adjaceut lots SEPARATION DISTANCE FROM ABSORPTION FiELD ON LOT TO: //\ Building fouudatiou Water maiiffservice line Surface xvater Driveway, parking/vehicle storage area Curtain drain Wells ou adjacent lots Property, liue Date A9 rd. [ / tT/: / ~? I ENGINEER'S CERTIFICATION I certiJj~ that i have determined thrufield inspections and review of Municipal records- ihat the -above, s~sJems are in conformance with MOA IIAA guidelines in effect on this date. ,' ' ': ' :~ . :, :i?.Enaiuee~iaa Seal Hera ~ '"'"- HAAFee $ 3¢' ~ Receipt Number ¢'2~5 [-~Oq/ Waiver Fee $ Date of Paymeat Receipt Number Rev. 8/95 eSS: haa.;vk.doc APR-15-199? 1~:29 CT~E ESI ANCHORAGE 90? 561 5~11 CT&E ReL# Client Name Project Name/# Client Sample tD Matrix Ordered By PWS[D 97173600 I Tobben Spurkland P. E, Lm 25. BK1, Wentworth Potable Drit~ing Water Client PO# Printed Date/Time 04/15/97 10:38 Collected Date/Time 04/11/97 10:00 Received Date/Time 04/11/97 14:00 Technical Director; Stephen C. Ede CT&E cemficatton status ts ptovmionkl as of Nitrate-N O.lO0 U O.!O0 mg/L $M18 4500-NO3F 10 max 04/14/97 JBL L'WNTRACT[NG t 212 E. INTE AIIIPORT ROAD 99502 October 2, 1981 Inspection Report Lot 25 Block 1 Wentworth Subd. We have inspected the well for Lot 25 Block 1 Wentworth Subdo and certify that it meets State and Municipal standards. We obtained and delivered the water sample from said well to the test lab on Oct. 1, 1981. We also verify that the sewer was inspected and meets the required standards. Ralph B. Jokela P.E. ~... , ,~ MUNICIFALIT'Y OF ANCHORAGE WATER 8~ SEWER UTILITIES 3000 ARCTIC BOULEVARD PHONE-277-762Z sEWeR CONNECT PERMIT ~L~,,O~/~]i-R ACT SUBDIVISION TAX CODE -'. BUILDING ADDRESS OWNER MAIL ADDRESS BLOCK sCHEDULED COMPLETION DATE /~/SIN G LE' FAMILY MULTI-DWELLING No. A~S ~ COMMERCIAL ~ INDUSTRIAL DRAWING No. "" ' PHONE CONTR AC TOR: (License 8~bend required) []ON PROPERTY ONLY F'IMAINTAP-TO FN:~DPERTY LINE ONLY 'r~T~IAINTAP--- &ON PROPERTY CONNECT f ASSESSMENTS [] Paid previously [] Main extension agreement .... []- Subdivision (~greement [] Extended connect agreement ~ Pending-AMOUNTS 6ONNECTION SIZE '.,:;: CHARGE 1NSPEDTION .FEE PERMIT FEE REIMBURSIBLE NUMBER· .DEPOSIT TOTAL PERMIT ISSUED BY: ,L ._ [] CASH ' MAIL PERMITTEE 'r [ (PLEASE PRINT) ' ,' ...p ADDR. ~ , ~*', PHONE: ..... ' I HAVE READ THE CONDIT ONS :AND REGUL]FIONS ON THE REVERSE ,SIDE OF THIS FJEF~MITAND.~GR~EE.?TO COMPLY WITHTHEM POST IN A CONSPICU~S PLACE ATTHE JOBSITE 80-02~ (4/80) 5 6 7 No sewer moh:, sewer co~lueotloo or sewer eXtellsiou rely be covered or b~okfilled ~nlil ins~eoted eud qpproved by qn (mlhorized representative of lhe sewer ufilily~ who shcdl bo notified ~t~ In ~dv~noe of when tho conslruotion or instqll~fion will be reqdy for inspeotion~ exoluslw of sqlurdqy, sund~y ~nd holidays, An ~pplio~lion for servioe must ~ oompleled to Inifiule monlhly billing All eommerc~e~ ~n~ industrial struolures require control menhole for monlloring ~nd s~mpling purposes, The developer, oweer, or colWrqctn,' shrill fees esfeblished py'~ny g~ernmenlQI unit Gsa condition for tho instelletlo~ of a sewer connection. Permit ssuence does not guarenfoe eveilel)ilify o~ sewer. Il shell be the develover's, owner's, or contractor's responsibility fo check elevetion~ of existing sewer -n~lns to Ir~sure grevify service is ~ssible. On site s)~wor system% cosspools~ septic touks~ must bo cdvod in end bdckfi]le~ pr~or ~o connection tofbe muuicipdlity's senltery sewer system. Fhis i)ormif expires ~)EQEM!)~B_AI~._ in the yo(~r issued. or (I ned buff iofile 2tM. copy -.yellow -.pul)lie works isl. copy pink -- ^WSU fin(d cqcy .-bu¢~ ndld ~tock-eLis~Olllor 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 Parcel I.D, # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING HAA# k~°l~ ~11 ~ 1. GENERAL INFORMATION Complete legal description Lot 25: Block 1; Wentworth Subdivision Location (site address or directions) 3301 East 41st Avenue Property owner Kevin Drake Mailing address Day phone Lending agency Mailing address NorWest / Lynn Pope Day phone. Agent Martelle Peppers/Coldwell Banker Address 4105 Tudor Center Drive, Anchorage 99508 Un/ess otherwise requested, HAA wiflbe he/d forpickup. Day phone 561-2488 NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well Public water X NOTE: If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025(Rev. 1/91) Front MOA#21 sluewwoo leUO!l!PpV :suo!~elndj, s 8UlMOllO~ eql H~!M 'SWOOJpaq JoJ le^oJdde leUO!~!puoo 'peAo~ddes!Q 'SLUOOCpaq .~oJ. pa^oJddv /~ ::IMn.LVN~DIS SHHa euoqd sseJppv LUJ!:I ~o eUJeN '9 'G (~ Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: ~-~{/'(J/2_~/./"-~,. /-.O7~! /~'[ Parcel,.D. A. WELL DATA Well type ~uR-TP_ Log present ~IN) Total depth r_~'-~, ,~' Sanitary seal,N) If A, B, or C, attach ADEC letter. Date completed Cased to FROM WELL LOG Date of test '-~-2 [- ~ ( t Static water level Well flow Pump level ~r~ ADEC water system number '/0/A ~'J~-'~L~- ~ ( Driller ~'~ ~'~, ,'~' Casing height Wires properly protected~l) 7 AT INSPECTION ~~'~~~ g.p.m. .~'~/~ g~. SEPARATION DISTANCES FROM WELL TO: - ~c.-¢-j. zc ~.~v~ Septic/holding tank on lot ,'~[/-r / Absorption field on lot . ~///)r Public sewer main - / Sewer service line '~-~ ~ 'IF WATER SAMPLE RESULTS: Coliform C) Nitrate Date of sample: /0-1 ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank Collected by: ~..~:~.t -Jr Other bacteria ~ & $ ENGINEERING B. SEPTIC/HOLDING TANK DATA /'//,/~- ~'~.~- ~ Eagle Rive., Alaska ~.~ Date installed ~/~-_ Tank size _ Co:partments ~ Cleanouts (YIN) ~eanout (Y/N) _ __ epr~s~ :' Date of pumping . ~~ SEPARATION DISTANCES ~,~D: NG TANK TO: ~ Well(s) ~ I~~ ~ un adjacen~ IO~S ~ rounaaupf~~ TO pro--ne Absorption field Water main/service line %% Surface water/drainage 72-026 (Rev. 7/91) Front . CONTINUED ON BACK PAGE C. LIFT STATION Date installed ~//~ ~ Manufacturer Size in gallons Manhole/Acce/~f'~N) Vent(Y/N) "PM m p ~'~: ""~'~ ~o f f" level at High water alarm level / / '""--..~es tested __ __ __ Meets MOA electricS__ SEPARAT~_...~ANCE FROM LIFT STATION TO: Well on lot On adjacent lots Surface water D, ABSORPTION FIELD DATA '~...t.d.. Date installed ~/,//~ '~ Soil rating System type Length Width_ Gravel thickness Total absorption area Depression over field (Y/N) ~ Date o~ Results (pass/fail) ~ for Peroxide treatment (past 12 months) (Y/N) If yes, give date SEPARAT¢/~ DISTANCE FROM ABSORPTION FIELD TO: Well on Io~'J//~ To building foundation Surface water ~ehicle storage area Curtain dra n E, ENGINE:ER S.CERTIFICATION bedrooms I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & $ ENGINEERING 17034 Eagle River Loop Road NO, 204 Signature Engineer's Name Date [ 6>~'~."~p -'~'2---- No. [ HAA Fee $ Date of Payment _,/~) Receipt Number 72-028 (Rev. 3/91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS RESULTS for INVOICE $ 59741 Chemlab Rof.# 92,5804 Sample ~ 1 Matrix: FAX: (907) 561-5301 Client Sample ID PW$ID Collected Received Preserved with L25 S1 UR OCT 16 92 ~ 12:00 hrs. OCT 16 92 AS REQUIEED Client Name :S & S ENGINEERING Client Acct :SNSENOP EPO~ Req~ : Ordered By :R. POS :NONE RECEIVED Analysis Completed : OCT 19 92 Send Reports to: lis & 5 ENGINEERING 2) Paramotel Rasults Units Method Allowable Liralts NITRATE-N ND(0.10) ~g/1 EPA 353,2/300.0 10 Sample ROUTINE SAMPLE COLLECTED El: J.W. Remrks: I Tests Performsd See Special Instructions Above UA-Unavailable ND- Mono Detected *' See Sample Relaark8 Above NA- Not Analyznd LT-Loss Than, OT-Greate~ Than ~S~ Member of the SGS Group (SociSt8 G~nSrale de Surveillance)