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Home My WebLink AboutWOODED HOLLOW LT 3AL()"I'" MUNICIPALITY OF ANCFIORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-472.0 ON-SlI'E SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT PHO~ [] UPGRADE NAME MAILING ADDRESS LEGAL DESCRIPTION LOCATION DISTANCE TO: .L L~'~:~-) ~ in §ailons IF~ DISTANCE TO: I~bsorption area~- Dwelling i ~ ~ Material Well Dwelling Manufacturer Material lWell I Nearest e~c DISTANCE TO: \ ~'%~ ~j~.l~ No. of lines/ Length o f~)~ll~n, f ilines Length Widtil Depth Type of crib Crib diameter Well DISTANCE TO: NO. OF BEDROOMS _~ PERMIT NO. No. of compartments Liquid depth PERMIT NO. Liquid capacity in gallons PERMI~ NO. Distance between lines ~ lA Total effectiveabsor tionarea PERMIT NO. Total effective absorption area Nearest lot line Driller Distance to lot line PERMIT NO, DISTANCE TO: foundation Sewer line Septic tank Absorption area(s) OTHER PIPE MATERIALS SOIL TEST RATING INS FALl_ER REMARKS 72 013 (Rev. 3/78) DATE LEGAL ON [ ~(.,] I:::'1101xlEI: f'(::H"'l.h by 't..lt,~:.) I"h..u"iic:l. pa].:i.t¥ (:){' Ar]c:l'il::)f'a(i].,::! (MOA) ][ ~4:i.].]. :i.i'Hi[d:.a].]. 'I:.I'iE: !~yEit(~-.'m :J.l:] ,:a.(::ccH-daitc:(::t .v..qi.'E.h ,:'.tl]. I v,!:i.].l aq!hePc.) t,:::l all ["tC)A and S~'.a'/:.e i::l{' A].a!il::a SOILS LOG" MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L. Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST [] PERCOLATION TEST PER.ORMED FOR: 1 2 C-\ ~" ~w-//~'/~-~ D IF~'~--~' DATE PERFORMED: SLOPE SiTE PLAN 10 11 12 13 14 15 16 17 18 19- 20- COMMENTS ¥\~)b~.lF YES, AT WHAT DEPTH? WAS G ROU N D WAT ER ~%..$~ L~ ~ ENCOUNTERED? O P E Gross Net Depth to Net Reading Date Time 'rime Water Drop PERFORMED BY:.~, ~.. ~.~l=?. _~.~11~1~ ~'~ 72-008 (6/79) PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) FT DATE:j~~/ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division o! Geologicol e~ GeophysieoI Surveys grilling Permit No, LOCATION OF WELL (Please complete either la. lb or lc.) A.D.L, NO, Borough Subd vlslon Lot Block ~ I/4qtrs, Seclion No. Township N[~] Street Address and Areo of Well Location ..,~ , ~ "~,, ~'~ [ ~, [~ ' 7. USE: Domestic ~ Public Suppty ~ I,dustry ~ [~0~0~ ~ Above or ~ Below lend surface Date ~0~b ~ '~ ~ II. PUMPING LEVEL below lend surfoce end YIELD g~ ~ Subm. ~ dot ~ Contrif[col ~ Other 15. Wofor Temperature ~o ~ F ~ C MUNICIPALITY OF ANCHORAGE DEPAR'rlViENT 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 r~a,e ~/-~/~// GFNERAL INFORMATION (a) Legal Description (include lot, block, subdivision, sectioe, township, range) Location (addre?s or directions) (b) Applicant Name Telephone: Home ~ ,~,~%~ ~ Business Applicant Address ~f'~..~ '~'¢¢ 7~ '~¢~--~ -~'¢':)~ _¢c~ .._,~' ~_ ~ (c) Applicant is (check one): Lending Institution []; Owner/builder/~; Buyer []; Other [] (explain); Address (e) Real Estate Company and Agent Address (f) Telephone Mail!:.t~i~e HAA to the following address: TYPE OF RESIDENCE Single-Family ~' Multi-Family [] Number of Bedrooms Other WATER SUPPLY Individual Well,~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation altesting to the legality and status. 4. SEWAGE DISPOSAL Onsite.~ Public [] Community [] Flolding Tank [] Note: If community well system, must have written confirmation from the State Department of Enviromnental Conservation attesting to the legality and status. Page 1 of 2 ENGINEERING FIRM PROVtDIN,. ,',ISPEC'I"IONS, TESTS, FILE SEARCH, DA, AND INFORMATION AS certified by my seal affixed hereto and es 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 Municipelity of Anchorage files and from my investigation end inspection, tbe on-site water supply and/or wastewater disposal system is in compliance with ail Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm'~ ~ Address ..:, ,;~[~ __ Telephone DHEP APPROVAL ~. ,~y~.~ Approved for -~'~.~c~..z.~''' bedrooms by Approved ___,~ Disapproved Terms of Conditional Approval _ Conditional CAUTION The Muncipality of Anchorage Departmenl 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 DI-IEP 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 (I 1/84) WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHI:[CKLIST- FEBRUARY 1984 MUNICIPALITy DF ANCHOR/ DEPT. OF HEALTI & ENVIRONMENTAL PROTFCT o~,~ 1985 264-4720 Legal Description Well Classification Log Presenf(Y)N). Well Total Depth /~;t'>d_ ,O /~)ed to Static Water Level Casing Height Above Ground Electrical Wiring in Conduit (~/N) Separation Distances from Well: To Septic/l:k;4di~cj 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 Comments If A. 13. C. D.E.C Approved (Y/N) _ Date Corn ;.leted _,.~/~//~:%--%-- Yield //- Depth of Grouting Pump Set At Sanitary Seal on Casing [.~N) Denressioa Around Wellhead (Y/~ : Oh Adjoining LOtS __ On Adjoining Lots ~L/o ~c¢~- To Nearest Public Sewer /¢'0/~,.~-- To Nearest Sewer Service Line on Lot ' ~:;0 B, SEPTIC/HOLDING TANK DATA Dale Installed Standpipes (~/N) ' Air-tight Caes (~/N) Depression over Tank (Y/~ Pumping/Maintenance Contract on File (Y/~ Holding Tank High-.Water Alarm (Y/N) Separation Distances from Septic/Holding Tank To Water-Supply Well /d~4¢2 To Property Line ,..~-~'" /"'' To Water Main/Service Line _ Course /~ r/. / ¢,Y~'". Size /¢oo%~- No. of Compartments Foundation Cleanout .~/N) Date Last PurnDed ~ ; for '--' Temporary Holdiag Tank Permit (Y/N) To Building Foundation 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 Square Feet of Absorption Area Depression over Field (Y,~ Results of Last Adequacy Test Separation Distance from Absorption Field: To Water-Supply Well To Building Foundation -"~'~, Lot ~//~, Type of System Design Length of Field '"~/~' Depth of Field ~ Gravel Bed Thickness ~//~¢' Standpipes Present f~/N) Date of Last Adequacy Test To Water Main/Service Line 'j~ ~2 -A- To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area To Property Line 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 Oft" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Bequest ** I certify that I have checked, verified, or conforr~ed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~ &' ~' ~NfGINEI~RIN¢~ Date Com¢~fl~l,~ }~}VER, A~SK.~ '~957~' MOA No. Receipt No. '' Date of Payment /~ 'D (-~ Amount: $ Page 2 of 2 72 026 ¢1/84)