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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) Ii~i;i :I:F/ :01I!'I',!!~ F:'F;]:C]!::,'. lC) :l.~i~l' 8, ,2Ix!I:) :t:lxt~i!i!::'lilX::;i]i(:!lq[!~,, 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