HomeMy WebLinkAboutT12N R3W SEC 35 S2NE4NW4NW4 PTN (2)Lo1"
(~.~ '~'J 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
MAI LInG AD~RE~S f/
LOCATION NO. OF BEDROOMS
'~ ~ Manufacture~[' / /¢¢) Mat e~_~ No. o~tment~
~ ~ Liq ~c~gallons IF HOMEMADE: Inside lengtb Width Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
O ~ ~ Manufacturer Material Liquid capacity in gallons
;~ DISTANCE TO: W~/OO ~ F°un~a~ ~ Nearest '?~ne,~
,~ ~ ¢C~ inchesinChes Total:f~n
,o. of linesI ke~h~ li~o Total I th o lin.s Trench idth
~ T°p°ftilet°fi~ishgrade~ Material beneath tile
Length Widt~ Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
¢ Class Depth Driller Distance to lot line PERMIT NO.
Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER ~
REMARKS ~ j ~
//
Box ~369, J~TAR JJOlu"i'E A ANCHORAGE, ,/lkLABKA J)9502
g/!n-_-??14
SIX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF
(~CU~)
PROPERTY oWNER __i~: ~/~
LOCATION OF WELL SIT
DRILLER
WELL LOG:
s~
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID .DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE ~UM OF ~
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRILLING WORKS
13t_J~ i, 1984
SERVICE CHARGE 0 F I~% P£R MONTH WILl.. BE A$$£$$ED ON PAST DUE ACCOUNT6.
......... OF - ....
':":'=i L .... I REEF., RNCHORRGE., RI.:::
F'EF~:!'] I T 1'-,IO: 3,::ha'L65
DaTE I ,::;'-":;I IF-F:,: Oq.,.' :L:I_,..
RPF'L I CRN'F:
FLr.',D R E:..:;~:
L-:ONTRCT F'FIONE:
ROE:ER'F ROSE;
120t t.4. 47"1'FI R'v'E
f::!Nl:: H O F(:FIG [::., RI.::: 9 '.'.-".~ 5 O ]~:
5G J..-27'rz]2
DEPTk! TO PIPE' E:OT-FOPi
GRAVEL. DEPTH ,::Fl''. :)
TOTRL DEF']"H ,::F'T..:)
GRFI',/EL. I.,.tiDTH '::F:'f'. ::'
GRFF,,,'E[.. L..ENC~TFI (I'-T. ::,
GRR'¢EL. YOLUHE (Ctj. [~.'[]l~;.
~;OiL. RFITIi",iG ,:::'E;gL f:T. /'E',R)
:+:* TlaNK f'rlI..I:::iT !'-IF!',/E Ft'T L. EF:IS;T THO C:L-II'"!PFiRTI'"IENT2;
CERTIFY 'I'HI::IT:
:t.. I RP'i FflHILIFIF~ HI'TH ]-HE: REQUIREHENT:~; FOR ON-SI'TE SEHERE; FIND HELLS RS SET
FORTH ['!:Y THE I,It...INICiPRL!T¥ OF FII'.,iC;HORlaGE (1"1OFt) FIND I'HE :STR'TE OF' flLflSKfl.
2. I HILL INSTRI...L. THE 2;Y~;TEM IN RE:'E:OF;:E:,RNCE !.4]:l"H RLL. MOB CODES aND REGULRTIONS.,
FIND IN COHF'LiRNE:FE HITH THE D,E~IGI'.,! CRtTERIFI OF THI'-:] F'ERHIT.
2. I HILL ADHERE TO F:ILL HOB AND STATE OF FILRSI.(R REg!UIREHENTL-L; FOR THE :E;ET BaCK
DIL-qTRNE:ES FROH FINY E,%I:E;I'ING HELL., HF!:E;TEk!F!TER DISPOSRL '-:;YSTEH O,:?. PUBLIC
E;EI.qERFiGE :~'-?STEP1 ON THiS OF:: RNY RDJRCENT OF: NERRBY LOT.
4. I LINDE:R::;TRN[:, TF.IRT THiS PERP'IIT 1:5 'v'F~L_I[., FOR fl i',1RXIf,IUH OF ,4- BE[:,ROOI',IS laNE:,
RNY ENL. RRGE:HENI,' I,.IZL.L RE:QLfIRE FIN FJDE:,ZT]:ONRL PERi'flIT.
]:F R
THEN
HILL.
EL_ECTRiCRL HOF:'.K HLI'-3T E:E DONE E:Y R LICEN:SED EL.ECTI~:ILE:IFtN.
S'J:IDNEE:, ~ i DR'I'E:
R.,~:,- --:.v- !:~:O'E:E:F~:T F.?.OS~J; -
F, LIL. I~N r:
I-'rFT _.,l l-FIuJ,i 15 iN:E;TRLLED 'EH RH i::IF~:E:Fi ,._ ERE. E. E:Y f'lOR I:~UIL[r:'I['JI-"~ C_DE'--;.,
':::L:', FIN ELECTRIC:aL F,J..rI.i.T FfND INqF'ECTICIF4 I',iUST E:E ...E FPIIIEE. ,':--.", _, BL.IILT_
NOT E:E ]aF'F'RE¢,/ED 1.4ITFIOUT RN EL._.CI"RICFIL If-,I=,FE.,FIJN F..EFuRt., aND "~':, THE
J~ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVlRONIVlENTAL PROTECT'([~ A ~ ~[3~LATION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG -- PERCOLATION TEST -' 1 J ~ld'~
NOIJ~£OJd ~VJ. NiiIWNO~IIANg
V '
/
/
BLOPE zz, $~
7
8
9,
10
20-
COMMENTS
PERFORMED BY: (/~ ~ ~ e ~'t ·
WAS GROUND WATER /Vo t~
ENCOUNTERED? pO
E
IF YES, AT WHAT
DEPTH?
Reading Date Gross Net Depth to Net
Time Time Water Drop
~H~o I-I% I,'oo .---* I, ~'0 -~
I I,'10 - Io I,~ o,c:,~
~ I.'~o IO 1,7~ 0,03
,3 ,.'~ /O ~,,;~ ~,0~
,
,~,~ ~;~" ~0 1,77 ~,0(
~ ~ ~ (minutes/inch)
CERTIFIED BY:
72-008 (6/79)
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a)~cription (include 10t, block, subdivision, section, township, range)
Location
(b) Property owner /[/~ I ['/~-,~ .'['Ir:T,.':? ' Telephone: (home) .5~ - F64- Business
(c) Lending Institution ~,~//t Telephone
Mailing Address
(d) Rea[ Estate Company and Agent
Address ct J,/,q-
Telephone /kJ~ ~
(e) Mail the HAA to the following address: (or check here~[~,~ if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family: Number of bedrooms z.-/
3. WATER SUPPLY
Individual Well [~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site~ 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.
72~25 (Rev. 7/88) Page 1 of 2
5. 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 end 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 Fir~~''-'-'¢'/' ~ ~.~5~,'~;"-~ Telephone
Address
Date
Engineer's Seal
6. DHHS APPROVAL
Approved for ~ bedrooms by
/,~ ' Disapproved
Approved
Terms of Conditional Approval
Conditional
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval
cerificated 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 and state requirements. Employees of DHHS do not conduct inspections
or analyze data before a certificate is issued. The Mu nicipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
72-025 (Rev. 7/88) Back Page 2 of 2
A. WELL DATA ~
Well ClasSification // -'~/~',-'~
~ MUNICIPALITY OF ANCHORAGE (MOA)
l¥~u~li~;~o~ .~,x,~.,~.Health Authority Approval (HAA)
ENVt~.~'~J~ ....... ~I~'I~CKLIST - FEBRUARY 1984
.~ ~,~/~.cs D~V~ION 343-4744
: { ' I ~; ~m-~ Legal Description: /
t . If A, B, C, D.E,C. Approved (Y/N) ,X~/.~
we,,LogPresen )/ DateComp,eted /Y,e,d
Total Depth-~:~.~ Cased to/gF,~ _Depth of Grouting
Static Water Level ~"~" / .-~'~ /
Casing Height Above Gr0und
Electrical Wiring in Conduit (Y/N)
SEPARATION DISTANCES FROM WELL:
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (~) ~/o ~'~///~
/
To Septic/Holding Tank on Lot //~' ; On AdjOining Lots ~/g~'%~
To Nearest Edge of Absorption Field on Lot /~// ; On Adjoining Lots /'~'
To Nearest Public Sewer Line /t//.4 To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot '/'
Water Sample Collected by /~/~-'-)/ .,'~'/'"""¢J ;Date //'~
Water Sample Test Results
Comments
B. SEPTIC/HOLDING TANK DATA
Datelnstalled .~,/'/~/~/ Size ?,.~b N~.,~/~.,,?Ea~artments
Standpipe ) ¥-~ ~ Air-~.ghtCap~J~ .~-~, Foundat.onCle,anou, .~l),.1Z'~
Depression over Tank ('~ ."{'/,~ ~./ Date Last Pumped
Pumping/MaintenanceContactonFile(Y/N). ./V'/./'~.~ ;for
Holding Tank High-Water Alarm (Y/N) ./~///~ / Temporary Holding Tank Permit (Y/N) ~/'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
/
To Water-Supply Well //,Z
To Property Line /~
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
To Disposal Field
Comments
72-026 (Rev. 7/88) Front Page 1 of 2
C. ABSORPTION FIELD DATA ~ ~..fj
Soils Rating in Absorption Strata /.2¢'-5'/ J/~4~=~'~d Type of System Design
Date Installed __ /¢'- ~'~ ~ ,¢~?/~' Length of Field .~"~ /
Width of Field -~%'~'/ ~' Depth of Field
Gravel Bed Thickness -~
Square Feet of Absortion Area , $--.-~'~ ~-,~,,~ Statndpipes Present(~4)
Depression over Field (Y~ ~__~t4/.~- ~-Date-of_L4L~t Adequacy Test
Results of Last Adequac~'~'e t~ //~ ~(~_/~¢.,.-./..¢'~¢' ~ ~"~.,¢*..~
SEPARATION DISTANCE FROM ABSORPTION FIEL~z-'~'
To Water-Supply Well /~ ¢., i '
/
To Property Line
To Building Foundation ,Z? /
To Exisf;ing or Abandoned System on
Lot -'~,~'/~ ~-'~-¢-,¢~/,'¢7'-~, ; On Adjoining Lots -~/
To Water Main/Service Line
/
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area. or Vehicle Storage Area
Comments
/To Cutb~eresent) ..4/'..~
D. LIFT STATION
Date Installed
Size in Gallons _
"Pump On" Level at
High Water Alarm Level at
Tested for
Meets MOA Electrical Codes (Y/N~ ~~¢-
Comments ~
Dimensions
Manhole/Access (Y/N)
,, p u m p_O~f ~ Level at~a'~~'~-
r//Vent (Y/N)
Pumping Cycles during Adequacy 'Fest.
**Check Per?llted Bedroo('n/Rating Against HAA Request**
certify tha¢l,/i~ave, chec~ednverified, or conformed to all MOA and HAA
inspection/////~ ,~/~/~~ '~
Signed / ~.?~/~ ~' / ~~
Compan¢ ~;~(~~, /~,
Date /~} t ¢ (~
MOA No. ~¢ ¢~/%
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7~88) Back
effect on the date of this
Engineer's Seal
Receipt No. ~'~'~'~'~ ~'
Waiver Fee: $
Date of Payment
Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
FEDERAL TAX ID # 92-0040440
ANALYSIS REPORT BY SA~[PLE for Work Order $ 10677
Date Report Printed: DEC 5 88 @ 12:16
Client Sample ID:PARCEL 28, SEC. 25, T12N, RSW
PWSID :UA
Collected NOV 29 88 ~ 14:00 hrs.
Received NOV 29 88 @ 15:00
Preserved with :4 DEG. C
Client Name : CORWIN & ASSOC
Client Acct: COEWINP
P.O.~ HOHE
Heq $
Ordered By
Analysis Completed :DEC I 88 Send Reports to:
Laboratory Supervisor :STEPHEN C. EDE / 1)CORWIN & ASSOC
Released By : ~ ~. ~_// 2)
Special
Instruct:
Chemlab Ref$: 3586 Lab Smpl ID: 1 Matrix: WATER
Allowable
Parameter Tested Result/Units ~ethod Limits
NITRATE-N ND(O,iO) ~/1 EPA 353.2 10
Sample ROUTINE SAMPLE
Remarks: SABLE COLLECTED BY W.N,
1 Tests Pez£ozmed See Special Instructions Above UA=Unavailable
ND= None Detected "See Sample Remarks Above
NA= Not Analyzed LT~Less Than, GT=Greater Than
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date ~/~/0/°°7
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner ~-'~..~-~-~.t.{ [....~_~ ~)Telephone: Home
Business ·
Mailing Address
(c) Lending Institution ~--~-'~-~': ~ Telephone
Mailing Address ~ ~t) ~/~/ ,.~-~
Address ~0t ~ ~lO~ ~?/~
Telephone ~ - 7~//
(e) Mail the HAA to the followina address: or: Check here ~ if hold for pick up.
List contact person and day phone number below. ~
/
TYPE OF RESIDENCE
Single-Family~
Number of Bedrooms
WATER SUPPLY
Well,[~ Community [] Public []
Individual
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
¢ Public [] Community [] Holding Tank []
Onsite
Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page I of 2 72 025 fRev 8/861 Front
~.~"
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 verity 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... /~l~
Name of Firm ~ Telephone
Address "~/-// /'~ ~
Date "~,-'A~_~ /iD ,, Z' ~
Engineer's Seal
DHHS APPROVAL
Approved for -~'~' '~" ~'~) b e d ro o m s by/x~ ''''~ '
Approved Disapproved
Terms of Conditional Approval .,'~.~,.~. ,.~
~.//~'~ Date
Conditional _
CAUTION
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 and 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.
Page 2 of 2 72-025 IRev 8/86) Back
i, AuNiCIpALI~ OF ANCHORAGE MUNICIPALITY OF ANCHORAGE (MOA)
iRoNMENTAL'SERvtCE ~EALTH AUTHORITY APPROVAL (HAA)
ENV S olVt$lO CHECKLIST - FEBRUARY 1984
RE£E V£O
WELL DATA
264-4720
Legal Description: '~-~'~ ~'~'
Well Classification
Well Log Present (Y/N)
Total Depth '-~,~-~-~'
Static Water Level
~' If A, B, C, ~,E.C. Approved (Y/N)
Y Date Completed ~'~'//'~' ~// Yield
Cased to /~ ~ Depth of Grouting ~e ~ ~
~ Pump Set At
~ ~l Sanitary Seal on Casing (Y/N)
~ Depression Around Wellhead (Y/N)
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ~ O ,k~ ~ To Nearest Public Sewer
Cleanout/Manhole J'~O bJ ~=:~ To Nearest Sewer Service Line on Lot
; Date
Water Sample Collected by '~, __c~ "~'~*' ~'~ F'~'/~'*~/ ~'/~,/~ '~
Water Sample Test Results
Comments ,~_ ~,l/~. ~.~ ,~4., C~,~.~ ~.. ~.V~
/
; On Adjoining Lots
l~ ~ ; On Adjoining Lots
B. SEPTIC/HOLDING TANK DATA
Date Installed Y~';~ \ Size /~-'*~o NO. of Compartments
Standpipes
(Y
/N)
Depression over Tar~-~N~ ~ Date Last Pumped ~'/'~///,~,
Pumping/Maintenance Contract on File (Y/N) ~'/'",~- ; for
Holding Tank High-Water Alarm (Y/N) t'~/~r Temporary Holding Tank Permit (Y/N)
Separati.?n Distances from Septic/Holding Tank:
To Water-Supply Well
To Property Line
To Water Main/Service Line
Course
Comments
To Building Foundation
To Disposal Field
IG
To Stream, Pond, Lake, or Major Drainage
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/N)
Results of Last Adequacy Test
Type of System Design
Length of Field ~'"~-
Depth of Field ~
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation
Lot N~
To Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments /'7/~, o~ ,~-
To Property Line ,~ /
To Existing or Abandoned System oil
; On Adjoining Lots
To Cutbank (if present)
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.
Company MOA No.
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72 026 (11/84)
Engineer's Seal
"~' 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)'
Location (address or directions)
(b) Applicant Name ~&¢ 2 ~ ~ Telephone: Home ~¢' ~1~ Business
Applicant Address
(c) Applicant is (check one): Lending institU'tion []; owner/builde~; Buyer []; Other [] (explain);
(d) Lending Institution ~I~¢4'~'¢'~I I_ .L~J-~4¢.~'~4, Telephone
Address
(e) Real Estate Company and Agent - ~1~. ~
Telephone ~?~ - / ~ ~ ~
(f} Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single-Familyx Multi-Family
Number of Bedrooms ~
3. WATER SUPPLY
Other
Individual Weli~ Community[] Public [] ' . ' ' ,
Note: If community' well system, must have written confirmation from the State Department 0f/En/v~ro,nment,ali ~ ,i ~., C, onservation
attesting to the legality and status·
SEWAGE DISPOSAL
Onsite/~' Public [] Community [] Holding Tank []
/ -
Note¢lf community 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)
E,NGINEERING FIRM PROVIDII~INSPECTIONS, TESTS, FILE SEARCH, D~A AND INFORMATION ': r
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
t he date of this ,n.~.~...... ~ ~j f~.~.~
Nsme of Firm
Address ~ ~ ~0 ~ ~ ~--~
Date ~ ~. ~
ApProved for ,.~_/./,~(Z/~?bedrooms by .~.'~/~':/,~.~'//~J-'~ Date
Apwoved ,/~ Disapproved Conditional
Terms of Conditional Approval
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
Well classification
Well Log Present (Y/N)
Total Depth ~,~ ~"
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
MUNICIPALITY OF ANCHORAGE (MOA)
H~A,'L~H~ AUTHORITY APPROVAL (HAA)
'Q';{ &¢~.'bHE~KLIST- FEBRUARY 1984
Cased to /~ **/'
If A, B, C, D.E.C. Approved (Y/N)
Depth of Groutiog
Pump Set At
Sanitary Seal on Casing (Y/N) 'Y
Depression Around Wellhead (Y/N)
Separat on D stances from Well:
To Septic/Holding Tank on Lot ~/Oo / ; On Adjoining Lots //(~) /
To Nearest Edge of Absorption Fie d on Lot ~'~/0¢/ ; On Adjoining Lots
To Nearest Public Sewer Line, , /~//~ To Nearest Public Sewer
Cleanout/Manhole ,/~,'/~ To Nearest Sewer Service Line on Lot
Water Sampe Collected by ~'~ · ~_~,~? z!~M_~,¢~/ ;Date
Water Sample Test Results 1.~
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed ,~/~ Size
Standpipes(Y/N) y
Depression over Tank (Y/N)
Pu mping/Maintenance Contract on File (Y/N) ~/~ ;for
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well .~/O~ /
To Property Line
To Water Main/Service Line
Course
Comments
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/841
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ¢/,/~/~. ~4~-~ -¢,.~,_,
Width of Field ..~10r/
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Separation Distance from Absorption Field,:
To Water-Supply Well
To Building Foundation
To Water Main/Service Line ~"~
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
¢"'7"?/~/)/////~'-~ Type of System Design
Length of Field ~¢~
Depth of Field ~/
Gravel Bed Thickness ~/
Standpipes Present (Y/N)
Date of Last Adequacy Test
?
To Property Line.,~/('~
To E:~isting or Abandoned System
; 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 Cedes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
yent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify t h a,.t I have checkecg v.,,erified/~r conformed to allJvlOA, and HAA guidelines in effect on the date of this inspection.
Signed '~- '~-/f.~'~/' Date
Company / MOA No,
Receipt No. '_(~)d) [' ~ /
,steofPeyment
Amount: $ ~O ~-' ~
Page 2 of 2
72-026 (11/84)
, CONSULTING ENGINEER TELEPHONE: (907) 279-3916
RESIDENTIAL WELL
INSPECTION
LEGAL:
PARCEL 28, SEC. 35, T12N. R3W
LOCATION:
14140 STOVER PLACE
OWNER: J&R ZECHER
TYPE OF WELL:
SINGLE FAMILY
WELL LOG AVAILABLE:
YES
INSTALLATION REQUIREMENTS MET: YES
WELL YIELD FROM WELL LOG:
2 GALLONS PER MINUTE
PUMP YIELD:
6 GALLONS PER MINUTE
DATE OF INSPECTION:
AUGUST 13, 1986
TEST PROCEDURE:
WELL WAS PUMPED AT A CONSTANT RATE OF 6
GALLONS PER MINUTE WHILE THE DRAWDOWN WAS
MONITORED WITH AN ACOUSTIC PROBE. STATIC
WATER LEVEL WAS FOUND AT 96 FEET BELOW TOP OF
CASING. AFTER PUMPING FOR 30 MINUTES AT 6 GPM
WATER LEVEL WAS AT 169. TOTAL WELL DEPTH IS
325 FEET WITH THE PUMP SET AT 305 FEET.
ACOUSTIC PROBE STUCK AT 169 FEET. PROBABLY
END OF CASING. ANOTHER 120 GALLONS OF WATER
WAS PUMPED WITHOUT THE ABILITY TO READ WATER
LEVEL.
TEST FOR COLIFORMS: WATER WAS TESTED FOR COLIFORM BACTERIA ON
AUGUST 14, 1986 TEST WAS NEGATIVE.
TEST RESULT:
THIS WELL MEETS THE REQUIREMENTS OF THE
MUNICIPALITY OF ANCHORAGE.
The Municipal requirement for well flow is
150 gallons of water per bedroom per 24
hours. This well surpasses this requirement.
The assessment of the condition of this well
applies only to the conditions as of this
date. The flow rate of the well may change
due to subsurface conditions that may not be
observed from the surface, and changes in
land use and other factors that may impact
the conditions of the aquifer feeding the
well.
~ ~ ~ ~ ~ ANCHORAGE, ALASKA 99501
· CONSULTING ENGINEER TELEPHONE: (907) 279-3916
SEPTIC SYSTEM ADEQUACY TEST
LEGAL:
LOCATION:
OWNER:
RESIDENCE:
WELL:
SEPTIC SYSTEM:
PARCEL 28, SEC 35 T12N, R3M --~_,~;~ O~./{'~%,
14140 STOVER PLACE ~'~.' ~ '~ '?~
...
PRIVATE, ON SITE '~ ..' '
FROM MUNICIPAL RECORDS:
TANK: ANCHORAGE TANK STEEL ~O COMP.
ABSORPTION SYSTEM: TRENCH
ABSORPTION AREA: 520 SQ. FT.
SOIL RATING: 125
INSTALLATION DATE: APRIL 1984
1250 GAL.
DATE OF PUMPING: AUGUST 14, 1986 ISAACS
DATE OF TEST:
AUGUST 13, 1986
TEST PROCEDURE: SYSTEM WAS INSPECTED AND MEASURED. TANK WAS FOUND
WITH 10 FEET OF COVER AND WITH 48 INCHES OF
LIQUID. THE NORTHERLY MONOTORING TUBE WAS 10 FEET DEEP WITH 4
FEET OF LIQUID THE SOUTHERLY MONITORING TUBE WAS 15 FET DEEP AND
WITH 13 INCHES OF LIQUID. 200 GALLONS OF WATER WAS ADDED TO THE
SYSTEM THROUGH THE SOUTHERLY STANDPIPE AT A RATE OF 6 GALLONS PER
MINUTE.THIS CAUSED THE WATER LEVEL IN THAT PIPE TO RISE 7 INCHES.
NO RISE WAS OBSERVED IN THE TANK OR IN THE OTHER STANDPIPE. AN
ADDITIONAL 120 GALLONS WERE ADDED AT A RATE OF 1.5 GALLONS PEWR
MINUTE. THIS CAUSED THE WATER LEVEL TO RISE IN THE FILL PIPE 3
MORE INCHES. AGAIN NO RISE WAS NOTED IN THE TANK OR IN THE
NORTHELY STANDPIPE. THE WATER LEVEL IN THE STANDPIP[E WAS
OBSERVED FOR 30 MINUTES. IT DROPPED 2 INCHES DURING THIS TIME. NO
CHANGE IN TANK OR NORTHERLY PIPE.
TEST RESULT:
THIS SYSTEM MEETS THE CODE REQUIREMENTS OF
THE MUNICIPALITY OF ANCHORAGE.
The operational life of all septic systems depends on the local
soil conditions, groundwater levels that may fluctuate during the
year, and the water usage of the family being served by the
system. These conditions are outside the control of the evaluator
of this septic system. We can therefore not give any estimate of
how long the system will continue to meet the operational requi-
rements of the Municipality and State.
1o General Information
MONICIPALITY OF ANCHORAGg
DIVISION OF ENVIRONMENTAL HEALTH
DEPAR~ OF HEALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR RE~ZLTH ADTHOR%TY APPROVAL CERTIFICATE
Application Date
(a) Legal Description (include lot, block, subdivisign, section,
Location (address or directions) ,/ , , ' ~
(b) Appllcan~s Nam~fo~ goSS ...... ~e~e - Home
Applicants Address ~ ~ ~4'~ Joe ~c~ z~C
(d)
Applicant is (check one) Lending Institution
Buyer~_,; Other~ (explain)~
Lending Institution
to~mship~ range)
Business
3 e _l e_3 ho n e
Address
(e) Real Estate Coo & Agent
Address
Telephone
(f) Mail ~he FJJ~ to the following address~
2o ~of Residence
Single~Family~
Number of Bedrooms
Individual Well~
Other (describe)
Community ~ Public
Note: If community well system~ must have ~itten confirmation from the Stage
Department of Environmental Conservation attesting to the le~ali~.y and status°
Sewe.~ Di__sposa~
0nsite~ Pnblic_:~~ Community L~--~ ~olding ~ank~
Note: If community well system, must have written co~fiz~ation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
3o En~g~ Firm Providlnj~ Ins~pections, Test~ File S~ata and Information
As certified by my seal affixed hereto and as of the validation date shown below, I
verify tha~ my investigation of this Health Aut~rity Approval shews that the on~slte
water supply and/or wastewa~er disposal system is safe, function~ and ~equats for
the number of bedrooms and ~pe of structure indicat~ herein°- I farther verify tha~
based om the informat~n obtain~ from theN~nicipali~y of Anchorage files and from my
investigation and inspecgion~ the on-site water supply and/or w~stswater disposal
system is in compliance wi~h all Municipal and State codes~ o~iaances, and rsgula~
tions i~ effect on the date of ~his inspsc~iono
Name of Firm~z~.~ ~.~f~( ~~ ..... Telephone~~
Address
DHEP
Approved for~/~bedrooms
Approved _~.~ Disapproved
Terms of Conditionml Approval
(ENGINEER SEAL)
Conditionsl
c. Reld,
No. 225'~-5
CA~TION
TEE MUNICIPALITY OF ANCHORAGE DEPAR~MEN~f OF ~IF~ALTH AND ENVIRONHENTAL PROTECTION
(DEEP) ISSb~S MEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT~
ATIONS GIVEN IN P~JlAGRAPH 5 ABOVE BY AN INDEPENDENT PROFESSIONAL ENGINq~ER REGISTERED
IN THE STATE OF ALASKA. THE DMEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES A~ND
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED° TIlE ~,fUNICIPALITY OF ANCHORAGE IS NOT RESFONSIBLE FOR ERRORS
OR OMISSIONS LN T~E PROFESSIONAL ENGINEER'S WORK.
(DHEP SEAL)
P. R4/ej/DlS
[Page 2 of 2]
7-19-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAAi
CHECKLIST - FEBRUARY 1984
Legal Description:
MUNICiPALiTY OF ANCHORAG~
DEPT, OF HSALTH &
ENVIRONMENTAL P~O] ~CHON
JAN 1 '~ 1985
RECEIVED
'T /~ ,q,,
Well Classification
Well Log P~esent ~"~). ,
Total Depth -~ Cased to
/
Static Water Level
If A, ~, ,~ c, ~.~.c. ~p~oved(Y/N)
Date C~%~leted ,~-[~- ~ ~ Yield
/~& f ~p~ of ~outing
G~nd 'i~
Casing ~ight ~m Sanit~ ~al on ~sing
Elec~i~l Wi~ing in ~ndu ~essi~ ~ound ~l~ead (Y~
~p~ation Dis~n~s ~ ~1~ --
To ~ptic~oldinG Ta~ ~ ~t ~ ; ~ ~joining ~ts
To ~a~st ~ge of ~s~tion Field on ~t · ~ ; ~ Adjoining ~ts
To Newest ~blic ~ Line ~ To ~est ~blic
Clean~t~ole '~ ~ ~ To ~est ~ ~rvi~ Li~ on ~t
Wate~ S~le Colle~ed By' ~ ~ ; ~te ~ ~--~ '
Wate= S~le Test ~sults
B. SEPTIC/HOLDING TANK DATA
Date Installed ~-~ ~'/-/ Size /~--O No. of CQt%~a~tments
Standpipes ~) Ai~-tight Caps ~) Foundation Cleanout
Dep=ession ove~ Tank (Y~ Date Last Pumped
Pumping/Maintenance Cont=act on File (Y/N) ~ ;. for .4/~_
Holding Tank High-Water Alarm ~ Temporary Holding Tank Permit (Y/N) ~/4
Separation Distances f~cm sePtic/Holding Tank:
To Wate~-SupDly Well ~ To Building Foundation
,
TO P~operty Line ~;4' To Disposal Field
To Water Main/Service Line ~ To Stream, Pond, Lake, c~ Major Drainage
..~/A ~
aO
Receipt #
Date Paid:
Amount:
[~ge 1 of 2]
2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption A~ea
Depression over Field (Y~
Results of Last Adequacy Test
(~ Length of Field 5-~
~ Depth of Field
Gravel Bed Thickness
!
(?? Standpipes P~esent~)
Date of Last Adequacy Test //A
Separation Distance frcm Absorption Field:
To Water-Supply Well
To Building Foundation
Lot /~/~
TO Water Main/Service Line
To Stream/Pond/Lake/c~ Major D~ainage Ccurse ~/~
To D~iveway, Parkin~ Area, o~ Vehicle Storage A~ea
?
~7 To Existing or' Abandoned System on
; ~ ~joinin~ ~ts ~
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Weter Alarm Level at
Tested for
Elect2ical Codes(Y/N)
Comments /
Dimensions J
Manhole/Accel)
"Pu~/Q~' Level at
~--~Vent (Y/N)
Cycles du~ing Adequacy Test.
Meets MOA
** Check Permitted Bedroom Rating AGainst HAA Request
I certify that I have checked, verified, o~ confornmd to all MOA HAA Guidelines in effect
on the date of this inspection.
oate
KB1/d5/s
[Page 2 of 23
2-15-84