HomeMy WebLinkAboutT15N R1W SEC 18 LT 122T15N, RtW,
Section :18
Lot 122
#051-172-39
MUNICIPALITY OF ANCHORAGE
DE ITMENT OF HEALTH AND HUMAN SERI
Environmental Health Division
825 "L' Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
,mine DISTANCES
~_--4'J ~/~¢~(-'~::~-- ~ SEPTIC ABSORPTION
~,ddr~m TANK FIELD WELL
Phone(s) Permit No No. o~ B~d¢oo~ WELL H~ ~1~
L~AU ~.SC.,.T,O. L0m LINE ~ I
I t
L°tt ~% Bl°c~ Sub~iv,mor~ FOUNDATION ,
~ SEPTIC/~I~ m HOLDING ~ ~ L
TYPE OF SYSTEM (~j ~,~ ~~ ~ ~ ~ i t ~ ~,~
Fill added above onglnal grade ~ Gravel doptb boneatn p,pe ~,~ p- ~
WELLS
~PRIVATE ~ OTHER (Identifvl ~ f
CIaSSIIICShOn(A,B,C} ,Tota, Depdl FT Cased:° ~[~ ~T~S~
~~ .... ~.,
I ~ ~ ~ [NGINEERING certify that Ihis inspecl~l w~s pedormed according Io all
leRI · k oadNo ~ ~ ~
Health Depadment Approval: ~ - Dme:~
72-013 (3/85)
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I:EA(?iI..E I::;: ]. VI.:!]F:(' ,! AK 99~;.'i'?'?
P H 0 N lie :t:i: 694 '"" 29 / 9
~:'~ 00 R E S ,S ::
I':'.0. BOX ??0398
I!!]AG[.IE RIVEI:;( Al.,:]
9957?
I I::'HE NC H BED W ,,
I::!]::t"l}:!]Z I .[VIE L)E]::' lid 8 0
l:;(iVI ]::,~ DEi]:::' IH 4 (I
t Of AI. Of!ii:::' TI'I ]. 2 () 0
I I:ii NI;I I I 8t5 () ()
I/,I f1J.)fid :,;:'. ,, 5 () 0
S(.q I:: I ,, 1 3 (:)() () (.~
('~I:"JEi;IAL C;ONDI fI()N(!~ i)l::,: iIqSI
lltI,% [ S AI',I tJl:::'t.)l:';~r'M,)E: I 0 I'I'tE EX I SI';I:N(.) SYSIE!]I,,
Municipality 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
9
9
12
13
14
16
17
19
2O
Township, Range, Section: ,~k~ SLOPE SITE PLAN
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Deplh to Water After
Mon&torlng? ~ , ate: '"~1 '"~"~-""~7
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN '~' ET AND ~ FT
S & S ENGINEERING
COMMENTS
72-008 (Rev. 4/8B)
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
DATE PERFORMED:
LEGAL DESCRIPTION:
1
2
3
4
7
8
10
~2
14
17
lO
2O
t
Township, Range, Section:
WASGROUNDWATER
ENCOUNTERED? ~,---~
SLOPE SITE PL,~N I
IF YES, AT WHAT
DEPTH?
Deptht0 Water ~er ,
Monil0rlng? I-~O I~/J~C~COale:
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION PATE ~ (minutes/inch) PEPC HOLE DIAMETEP ~;~
TEST RUN BETWEEN "~ FT AND ~ FT
COMMENTS
S &SENGINEERING . ,
17034 Eagle ~sv~ ~ ......... ~~/
PERFORMED BY: ~,..lvar: Alaska ~,577 ~ ~ CERTIFY TH~T~S TE~ WAS PERFORMED IN
ACCORDANC~ WITH ALL STATE AND MUNICIPAL GUIDE~ EFFECT ON THIS DATE, DATE
72-008 (Rev. 4/85)
QGRE'
ANCHORAGE AREA BQ ""GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATION~ ~(~ L~ dc)Od LEGAL DESCRIPTION /~d'/1222 ~.~ /~', RI L~
SEPTIC TANK:
DISTANCE
FROM WELL
~' MANUFACTURER
MATERIAL
NUMBER OF
COMPARTMENTS
INSIDE LENGTH
INSIDE WIDTH
LIQUID DEPTH
LIQUID CAPACITY / ~2g~g~) GALLONS.
SEEPAGE PIT:
NUMBER OF PITS I DIAMETER g~'~' ' /~/,'
OR WIDTH // , LENGTH DEPTH /~'9'
LINING MATERIAL (~'0}?£t~-~L CRIB SIZE: DIAMETER ~/~ DEPTH ~' DISTANCE FROM:
(~' TOTAL EFFECTIVE
BUILDING FOUNDATION , NEAREST LOT LINE
WELL
ABSORPTION AREA (WALL AREA)
ADDITIONAL ABSORPTION
SQ. FT.
WELL:
BUILDING
FOUNDATION
CESSPOOL
APPROVED
CONSTRUCTION
NEAREST
LOT LINE
OTHER SOURCES
DISAPPROVED
NEAREST
SEWER LINE
REMARKS
DEPTH DISTANCE FROM:
SEPTIC SEEPAGE ,
TANK ¢~' //~
SYSTEM
DISTANCES:
INSTALLED BY:
PIPE MATERIAL:
LOT SLOPE:
REMARKS:
Form No. EQ-031
DIAGRAM Of SYSTEM
DATE t'¢/L :',' APPROV :G.A.A.B.
Boa
EesXe RAve~o Alaska
90677
System Set. viu~ heidenee
The ({.'eate~ An~he~ge Az,es BoL',ou~h Health
Uepa~ment inepeoted and approved the
at ~he sub,eat iooatian.
DAVID R,, L. DUHCAH. M. D.
~odi,mal Dlr'eetoz,
RRS/m~T
BYt
Sanitarian
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www. ci.anohorage, ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.~'~_) / / 7--~ ._~c/
1.
GENERAL INFORMATION
Complete legal description Lot
Location (site address or directions)
Current Property owner(s)
Mailing address //c;~2~
Lending agency
,/~/./
HAA# ~-/"¢(.~'.~(/,_) ~
Expiration Date:
122, Section 18, T15N, R1W
18768 Birchwood Loop Road
Barker
Brook/Remax
Dayphone 694-4200
Day phone
Mailing address
Real Estate Agent Remax/Brooke Stiltner Day phone 694-4200
MailingAddress16600 Centerfield Dr.,Ste 201, Eagle River,AK 99577
Unless otherwise requested, HAA will be held by DHHS for pickup. HAA picked up by:
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site
[] Individual Holding Tank
[] Community On-site
[] Public Sewer
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of
Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent
professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are
required for the transfer of title (except between spouses) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by
a private or Class C well and may be reissued with new water sample results less than 30 days old. Cedificates
are valid for one year for properties served by Class A or B wells or a public water system. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
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
based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval
application show 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 applicable Municipal and State codes, ordinances, and regulations in effect at the time of installation.
S & S ENGINEERING
Name of Firm 17034 Eagle River Loop Road No. 204 Phone (6 ¢) ~ - ~ ¢~ '~'~:~
Eagie ~,Jver~ Aiaaka 9y577
Address
Engineer's Printed Name Robe]st: C. Co~,~an
DHHS SIGNATURE
],.-'"/ Approved for ~ bedrooms.
Disapproved.
Conditional approval for
Date ;o ,/
/~',.,~j~ .,' ENGINEER~'7 .7~_
~ ¢ ~ EOSE~? £. ¢OWAN ¢'~-'J~
r¢ c~,,., C,_-8~01 ,.:.~..~,
bedrooms, with the following stipulations.
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Expiration Date: l- ~- ~7L - O /
Original Certificate Date:
Reissue Date:
~ Municipality of AnchorageL'-J
Department of Health and Human Services _ ~
Division of Environmental Services ~ E C E I V
On-Site Services Section 825 "L" Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us OCT ~, 3 2000
(907) 343-4744
MUNICIPALITY OF ANCHORAGE
HEALTH AUTHORITY APPROVAL CHECKLI~VIRONMENTAL SEP, VICES DIVIS~ION
Legal Description: /-oi- I ~ ~., 5'~c-7~/~),,J / ~' / T J~"-"'J ~ ~ ~ ~ Parcel I.D.: __
A. WELL DATA
Well type p/~,-v/P/'~,
Date completed .'~) ~/2 ~1
Total depth ¢! ~: ft
IfA, B, or C provide pWSID
Sanitary seal
Cased to ~¢~) -t ft
FROM WELL LOG
Date of test
Sta~[!c water level 1J}~~' ft
Well production J g.p.m
WATER SAMPLE RESULTS:
Coliform O colonies/100 mi Nitrate ~).-5- mg/I
Date of sample: 10 / I ;~ / o o Collected by:
B, SEPTIC/HOLDING TANK DATA
Tank Type/Material
Dateinstalledl'~ ~-/o/~'? Tanksize
Cleanouts Y~--~ FoundatiOn cleanout /~'
Date of pumping
C. ABSORPTION FIELD DATA
Well Log ~v ~)
Wires properly protected ¥4~$
Casing height (above ground) ~- + in.
AT INSPECTION
/o/ o / o
~/,0 g.p.m
Other bacteria ~ colonies/100 mi
S & S ENGINEERING
17034 Eagle River Loop Road No. 204
Eagle River, Alasl(a 99577
gal Number of Compartments 3
Depression over tank ,v o High water alarm
Pumper ~ ,,8 ~
Date installed /0 / '~ 7 Soil rating (g.p.d.fit2 or/ff2/bdr~,~ '~' 5- System type
Length ~'~c ft Width ;~. ~' ft Gravel below pipe ~ ft
Total depth II ft Effective absorption areaI~'~ fF Monitoring tube ¥~/ Depression over field ~' 0
Date of adequacy test Io//o'/oo Results (Pass/Fail) . 'p''f xJ For (o bedrooms
Fluid depth in absorption field before test. O in Water added /e ~ ~ gal. New depth-~ in.
Elapsed Time: (~0 rain Final fluid depth I q in Absorption rate >= ~) oo g.p.d.
· Any rejuvenation treatment (past 12 mo.) (Y/N & type). ~ ~,' ~- ~ ~ ~ ~' ~' .If yes, give date
72~026 (Rev. 01/0D)*
LIFT STATION
Date installed /o / ~ 7
"Pump on" level at I)J ~ ' in
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot ~,F'~ '+/'/ob t~
Absorption field on lot /o o ' -~
Public sewer main ~ /,4-
Sewer/septic service line · '~5"- Q/-
Size in gallons /
"Pump off" level at/
Cycles tested
in
Manhole/Access 'y/c.)'
High water alarm level at ')~" ~ in
Meets alarm & circuit requirements
On adjacent lots
On adjacent lots ! o ~
Public sewer manhole/cleanout
Holding tank /v/'4
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Building foundation "¢'-/''~ Property line
Water main ~ J ~ Water service line Jo
Drainage ~' [ ,~ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line lo 4-
Water Service line
Curtain drain ~,.,4.
F. COMMENTS
Absorption field
Surface water
Building foundation /o d- Water main ,~'///
Surface water / o ~ ~ 4~ Driveway, parking/vehicle storage
Wells on adjacent lots ) o~ '¢-
G. ENGINEER'S CERTIFICATION .,,¢~/"...-"
I ce~ify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance w~th MOA HAA guidelines in effect on this date.
Engineer's PrintedName ~6~ C. ~0~4~ --
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number __
72~026 (Rev, 01/00)*
IO-l§q]§ ~§:00 FROM~C~E ENVIRONMENIAL
~l~m~ CT&I~ Environmental ServiCes Inc.
5615~01
T-GSO
P.03/05 F*G9~
CT&E Re J'.# 1006408002
Client Name S & S Engineering
Project Name/# N/A
Client S~imple ID LI22 Bi~chwood LP
Matrix Dri~g Wate~
Ordered By
PWSID 0
Client PO#
Printed Date£rinte
Collected Date/Time
Received Date£1'lme
Technical Director
10/18/2000 12:18
10/12/2000 15:10
10/13/2000 9:30
Stephen C. Ede
Released
Sampl~ Remarks:
Allowable l'~p Analysis
Palameier lle.sul'~ PQL Units Method Limi~a Date Dale fail
ixlitrate-N 0.500 U 0.500 mg/L EPA 300.0 10 max
I0/13/00 SCL
biioroSiolog~ ~aborato~r
Total Coliform 0
col/100mL SM18 9222B
10/13/00 JDT