HomeMy WebLinkAboutT15N R2W SEC 25 LT 123
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
LEGAL DESCRIPTION
LOCATION
Well Absorption area
DISTANCE TO: I (~ ~
Manufacturer
Dwelling
Liq. capacit, length
IF HOMEMADE:
Width
DISTANCE TO:
Well Dwelling
Well
DISTANCE TO: ,~ ~,~ I~)
No. of lines Length of eagl~lij~Le (
Foundation
Nearest lot line
t-
Trench width
Top of tile to finish grade
Material beneath tile
~, ("~ inehes
Length Width Depth
PHONE
[] UPGRADE
PERMIT NO.
'7 ? o'+,-T--B'
No, of c.~artments
Liquid ~ tl~
PERMIT NO,
PERM,T7 e o ess'
;n lines
PERMIT NO,
Type of crib
Well
DISTANCE TO:
Crib depth
Depth Driller
Total
Nearest lot line
Distance to lot line PERMIT NO,
DISTANCE TO:
ng foundation Sewer line
Septic tank Absorption area(s)
O
OTHER
PIPE MATERIAL8
72-013 (R~, 3~78) /
DATE LEGAL
[:~I:~]':'F~F,~TI"i~'-Z'I"J'I" L., I-I`EI`-iLTH FIN[:, ENV I RONMEI",I'TFIL r ROTECT): CIN
:32.5 '"L'" 57I'REET., I':INCI-IOf~'.I::IGF., RK. DS~:SEk:!.
2"~:,:1. - 4 }:'2 ~:l
I'::lI'::' F:' L :t: C FIl"d T
LOCF:IT ~ 0 I",1
I..E(:~iRL
I;~:O Ei E F,;'. F'OR'I`'ER
S';EE:
GO',,,'T L:l. 23: S;:..:.':¢: T:I. 5N R2H Si"1
PO BOX ±62±
LCIT 'SIZE :'LEI82S~8
S(;!LIf:/RE F'I}]:::T
]'~./I::'E CLF SOIL f:lE~!gOf(:E:l'IOl".l S'¢S'TE:M l'S;: DI':~:RINFIEL.D
I','II::tXIHLIM i'4Ui'qBER OF' BE[:,F~:0Oi'IS :.= 4
SOIL RIqTIi'.,IG ,::.'S6~ F'F,..'BF..')= 85
TI.IE I:;;'.E.)]:~LIIRE£) SIZE OF:' THE SOIL I::IBSORP'f'ION S'-r'.S, TEM IS:
'f'Hl..-: L.I`.:.]'.,IGI'PI [:,II'tENS.'(.ON IS; THE I_.ENGTI`4 ,::IN FEET) OF THE TREN(::H OR DRFaINI:::ZEEL.D.
THE DIZPTH OF FI 'TRENCH OR PIT II.:]; THE DIS'FRNCE BE'I"HL:.'EIq I'HE SL.IRFFICE OF' FI`I`E
GI`,~'.CR.IND RND 'f]--IE BOTTOi't OF THf:': E;:..',CR',,,'RT I ON: < 'f r.,I FEET).
FI-.IE GRF¢,,,'EL IDEPTH IS I"HE i:,l:~¢;,{;[i','tMi',l F. iE"F,::'t'kl OF GF.'.RVEI... E, E II. IEEN THE OUTFFIL.I..
FINE:, THE E~O'f'TOM OF' THE E;:.::~?;¢$T:~ON ',:.'~¢II}.t~'.'FEEI':,
.z:. ~ ,,~:... ~:::., ..... 21- ,,.-:,. -_, ~:.l~
" ';'A"
F'F]:~:MIT -I' I L :l _. 141 FI~I TFIE "' .' c
t..E-,F L.N..IE IL! ~ T0 ];NFOF.'.M IIII- DEPFIRTMENT [', ~;'"N':i f'HE
]]',IS;TFILL. f:FI`'IOI"~ INSPEC:TION':'5 OF RN'¢ I.,.tELLS~; F~[:'JRCENT TO Tt"Ii[~ PF,:OF'ERT"r' FII",I[) 'THE
NLIME~ER OF RESIDEhtCES THRT THE HELL HILL 2;ER","E.
............ "If'" I!.,JI Cu ¢:." ;;;J.". ::, ]~ lI'-~ 2S; F> I.S:.-; C: 'T' :~; C) 1'-,~ ~S~; II::~ II~: E F~.'. EE (;:.~ L..~ ."IE IF4~: E; [;: ....................
DFICI`(FIL.I...ING OF FIN"r' 2;"r";'STEl'd P.IITHOU]" F~'NFIL ;[NSF'ECTLfON FINB, FIPPRO',,,'FIL B"/
I)Iii:PFII~:THI:~]",Ff .t,.I): L.l.. =': ':: :' - "" _ ";'""
L,E ...... I. JE,.. Et.. F 'i'F~ F f..t.c.E,k..) 1 ZL N.
M I I',I I MUM [) I STRNCEE BETHEEi'.,I
;LE16:.~ FEET FOR R F'R):',/I::ITE HELI...~
J..L'i;E~ TO 2(.:lEi I::EET FRCd'I R PUBLIC HELL C, EPENDING UPON THE 'I"¥PE OF PUBLIC I, IEL.I ....
OTIIER I::;:E(;!t..IIF::EMENTS.] i'IR'¢ FIPF'L'.A SPECIFICR"I`'IONS RND CONSI"F:±JCTION [:,IRGRFIM'.5 IqRIE
F[VFIIL. FIE:I.E TO INSURE PROPER iN'.:];TRLL. F:ITION.
CERT): F".¢ Tl-lfrriT
i I::'[i'"l I::.'Fli't;~L):RR t4ITH 'fl-'lE REL;.!UIREMEN'F':S FOR ON--.SITE 5;EI.,.IERS FIN[) .t4EI._L.S RS
I
±:
FOR'I`'H [3'?' THE i'"ILINICIPFII..):T'.? OF FINCHORFIGE.
2: I HILl.. INSTRI..L THE S~r'STEM IN FICE:OR[:,RNCE !.,.I ;[ 'l'l-.I THE CODE':];.
2:: I UI'qDEF?.'Z,T.~:IN[:, THRT THE Of'~-..c;.,);TE ?.,EHEF.'. S'¢'.':';TEi"I 'i"lR~' F:'.E(;!UIF~L~: Ei",II...FIf;~:[~iEMENT Il':; THE
RESIDENCE I5; REMODELED TO INClJJE:,E MORE THRN 4 E:EE:,I`,:rOOM'.!i;.
2; :(GI'.,IEI): ........ ;.T,_ _'~/..~...".,.,.,.,~..% ..:;
F:IF F L):~-rl~t;rROGEI:;. F OKTER
//
SOILS LOG
Steven A. Johnson
P.O. Box 76
Chugiak, AK 99567
Phone: 907-688-3085
E] PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3-
5-
6-
7
8
9-
SLOPE
OAT. P,.FORMEO: o ~.To!
SITE PLAN
10~
11
13-
14-
15-
16-
17-
18-
19-
20-
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
P
Gross Net Depth to Net
Reading Data Time Time Water Drop
PERCOLATION RATE
{minutes/inch)
TEST RUN BETWEEN
COMMENTS J~t ~.~.~ ~ ~*~ ~,,~ ~-"~. ~)~'~ ~'('3 ~]~
72-008 (7/76)
P E RI'"I :ti T NO.
DEPFIRTMENT OF HEI=II_TH ¢:11'.,11) EN',/IR'OI'.~HEN't'RL
82!5 '"L¢ STREET, I=INCHORR(;iIE, F:II-.'.':.
279- 25::1.'.:1.
~.-~ lEE E._ L. FTM EE: II'~.'.. li".lI ].; "t"
77:'t. 88 )
i::IPF'L :[ C~tN"r i',l i E:HREL BLi3RE 89,:!-¢!. BLRCKBIERR"r' dl, 604
LOE:i=rf':[ON C:HUB:[FIK H..~S;.
I_.E{JRL. L~I. 2S~: SEC 25 T:I. SN R2.t,.l L. OT SLZE ~.0890EI SC.:!UI:4I;~tE I:'lEl.-':'r
i','i:~l'.,I.(I-,'lUf,1 DIS'T'RNCE BET!.,IEEN R !.4EI..L.. F'IN[> RN"r' Ol'.,I-..S :i; 'rE ~;E!.,.IRGE PI!.-'.;F'O$RL '.'.S,~¢;5'f'Ei','t
::LtZIO FEE'f' F'OR R I::'I;;:TVlUtTE 14EL. L OR 2E,(~l FE:E:'f' FOR FI PUE:L:£C I.,.IELL.
14EI._L LOBS I::iRE REL:.!U~:RED Rt'.4D f'lUS'f BE RE'¥1JI4'.NE[.'., TO THE I:;,EPI:IRTIdE:NI' I.,.tZ'I"H]:N :~:E1 L':,f:l¥S
01:' -f'HE: NELl.. COI','iPLE'f'~ON.
SF;'ECIF];CF:I'I":EONS f=II',ID CONSTRUCTION D]:RGRRfdS Rf;.'.E R',,,'RIL..RBI_.E TO II'.,ISUB'.E PROPER
hlS'f'RLLR'I" I ON.
]: CEI:;?/'I'iF'~.' THFI'f'
:t.: ;1:i~i1',1 I-::I::II'IILII:IR I,.IITH THE t4'.EQUIREMENTS FOI~;: ON~..SI'TE SEI.4ERS Ri'.4D 1.4EL. I...S F. iS SET
FORI'H E??' THE i',IUN]:C':(F'RL..;[T¥ OF
2: ;[ 1.4 :[ I....L }:I.,IS'I'RLL THE S'.r'STEI"I
~ ''*;,,. ¢ '- 2"
";;iF ' .....................................
J~N'OS'gg 11147
zTL
200 W, Po[~er Dr~ve
Drinking Water Analysis Report for Total Coliform Bacteria s 2-2 4 aG
READ INSTRUCTIONg 0/~ ~KE~E X/DE BEFO~ COLLECTING SaM~E ,~px: (9o71 661-53Ol
ML,ST B~'C'OM~LETED BY WATER S~;PPLiER TO I)E cOMPLEmF~O BY LABO~TORY
~3 PuflLIC WATER ~;YSTE~I I.D. ~
ff":~'RIVA'r ~ WATER SYS~M
Mo~th Day
tPLE TYPE:
Roullne ,
R~peat Sample (for_routine sample
wi~h lab ruf. no. )
Special Purpose
SAMPLE LOCATION
Year
~ Treated Water
[] Lluireated Water
Time Collec~ec~
Collected By
An~l~s~ sho~s this Water e. AMP[.£ to b~
Sa~lst'a¢10ry
Unsacisfactory
3ample over 30 hou~ old. r¢sulls may
be unrehuble
Fample xoo long in wa~l~lt; sample should
not be over 48 hours old a[ ~xamma~on
:o mdicam rehable resulls Plebe send
sew sample vi3 special dehve~ mail.
Time Recei,~d ./y ' ~
Analyds Bega~ ~ ~] ~ u
AnalYtical Method: .'lff-....Mcmbrane Ftlter
"m MMO-MIJO
Nur~ber of colonie~/100 mt.
Result*
,~ Fbks
AnalYs~
Juo []
iT.
CIlen[ no;ified at' unsatisl3.etory
Phoned Spoke
BACTERIOLOGICAL WATER ANALYSIS RECORD
MI~IO.-MUG R~ulc{ '[otal Coliform
Mcmnrane Filter: Dlr.~cl Count
Yemlicazton: LTB ~
Fecal Coht'orm Confimation
Final Membrane FiII,:' Results
geponea By ~ Dace
£. Coil
C,HoniestIOO mi
COLIFIRM ,. ,
. Coliform/lO§ mi
~~ MemUor at lbo SGS Group (So¢~etO Generala Je Survedlancel
BNVI[qONMENTAL FACILiTIE~ IN ALASKA, CALIFORNIA. FLORIOA. ILLINOIS, MARYLAND. MICHIGAN. MISgOIJ~ll. NEW JER!3EY. ODIO, WEST
JUN-08-~9 )l:4T FRO&(-CTE ENVIRONMENTAL
ztK C T&E Eh v iran men,a, ~erv,ces Inc.
T-$13 P.02/03 /:-717
CT&E Ref.#
Client NAme
Peoject Name///
Clicnl Sample
Matrix
Ordered By
PWSID
99242O001
Douglas Kealey P,E.
LoT 123 T15N R2.W Sec 25
Lo[ 123 TISN R2W Sec 25
Drinking Water
l¥inted Date/Time 06108199 10:32
Colk~:~ed Date/Time 06/01/99 19:45
R~eiv~ Date~ime 0~/02/99 14:25.
T~ Dir~tor: Stephen C, Ede
EPA
SM18
10 mex ObyO2/g9 Df~OX/g9 SCL
o TUE 12:20 FAX 1 907 696 3297 )IAIL BOXES ETC
by
SULLIVAN WATER WELLS
P.O, BOX 670272, CHUGIAK, ALASKA 99587 * TELEPHONE
OWNER OF LAND
ADDRESS.
LEGAL DESCRIPTION
DATE ·Startc, d
PERMIT NUMBER
Ended
i)l-:PrH OF WELL
sr.~T[(' LEVEL OF WATER Fr.
DRAW DOV,'N FT.
GALS. PER HR / c~ 0
KINI) OF CASING :~,
KIND OF FORMATION:
From~ Ft. to Ft. ~ ~ From
From - Ft. to ..... Ft ......... ] /~ ~ From._
Frmn .... FI. t, ....... FI,
Ft. to ..... Ft.'~
FI. {o___~ El,
Ft.
FI. to
Ft. lo
FI.
Ft, _. ~
Ft.__.
.... Fi, lo.__
_ Ft, to~ Ft._
From Ft. to Ft From Ft. t. --FI. ~.
Frmn__ Ft. to Ft From
From ..~ Ft. to Fl. __ From___
From Ft, to... Fib __ From___
From__. Ft. to .... F t,. From .....
From .... Ft. to Ft. ., From
MISCL. INFORMATION:
7-0 7-~
Ft. {o
Ft. to. ,. Ft
_Ft. to .... Ft.
Ft. m .... Ft. '
JUN l? 1999
Muniopahly ol Anollorage
Dept. Health & 14uman Services
MUNICIPALITY OF ANCHORAGE
{~."~1 . DEPARTMENT OF HEALTH & HUMAN SERVICES
~--~,/ Division of Environmental Services
~. On-Site Services Section
P.O. Box196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
1. GENERAL INFORMATION
Complete'legal description
Property owner
Mailing address
Lending agency
Mailin. g address
Agent
Address
Day phone
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~/
TYPE OF WATER SUPPLY:
Individual well ~
Community well
Public water
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-(YZS(Rev. 1/91) Front MOA~21
STATEMENT OF INSPECTION BY ENGINEER
As certified by my. seal affixed heretoand as of the validation date showr~ below, I verify tl3at 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 flies and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is ~n corn pliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of th~s inspection.
Name of Firm
Address ¢¢~¢
EngineeCs signature
DHHS SIGNATURE
J// Approved for
__ Disapproved.
bedrooms.
Phone
__ Conditional approval for
bedrooms, with tffe following stipulations:
Additional Comments
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.
RECEIVED
Municipality of Anchorage ' JUN 16 1999
DEPARTMENT OF HEALTH & HUMAN.'SE~uT¥ OF^NCHOP~
Environmental Services Division ~NVlRON~4EN'~AkS~RWCE$
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checklist
Parcel I.D.:
Legal Description:
A. WELL DATA
Well type
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B. or C, attach ADEC letter. ADEC water system number
Date completed
Cased to x/~ '//'
Y
FROM WELL LOG
,.~,~/
Casing height (above ground)
Wires properly protected (Y/N)
AT INSPECTION
Date of test
static water level
Well production
WATER SAMPLE RESULTS:
Cbliform ~;c
Date of sample: ~',~7"~ ?
Nitrate
B. SEPTIC/HOLDING TANK DATA
Date installed
Foundation cleanout (Y/N)
Date of Pumping
C. ABSORPTION FIELD DATA
Date installed
Length ~R~ Width
g.p.m. '~ -/" / g.p.m.
~" ~' ~ ~ Other bacteria
Collected by:
Number of Compartments ,~ Cleanouts (Y/N). Y
Depression (Y/N) ~U High water alarm (Y/N) ~'/'~
Pumper '~'/~,/"~ J
Soil rating (g.p.d./fF or fF~/bdrrp) ~' System type w~'~Z~¥-'
---~,'~-/. Gravel thickness below pipe ,,~+/' ' Total depth '~/~"~'-~'
Effective absorption area J+"~ ,~/~MonitoringTube present (Y/N). Y Depression over field (Y/N) '~/
Date of adequacy test ~//~'~'~//~ ? Results (Pass/Fail) ,~,,~.,,-.r' For ~ bedrooms
Fluid depth in absorption field before test (in.); ~//'/ Immediately after~?'~ gal. water added (in.): //~/ o
Fluid depth 2'//'~ (ins) Minutes later:
Peroxide treatment (past 12 months) (Y/N)
Absorption rate = -,~/~'-"~ ~'~ q.p.d.
If yes, give date
72-026 (Rev. 3/96)*
D. LIFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N).
High water alarm level at*
Cyele sl'e~T~
"Pump on" level at*
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDINGTANK ON LOTTO:
Foundation ~--,~ ,~.~z Property line / ~ "~,~",~, Absorption field
Water main/service line ,~---,,~;z Sudacewater/drainage /~'~/~/ Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line / ~- ~' -'~ Building foundation ~' ~---~'~ Water main/service line -"~'~ ~'~'
Sudace water -' ¢~ ~ '~-~'- 7z' Driveway, parking/vehicle storage area
Curtain drain ~.O~-',,~.,LJ~,,~ ~L~ ~,¢~,~,-'~ Wells on adjacent lots /z~
ENGINEER'S CERTIFICATION ~ ~.~.%~,_~
I certify that I have determined thru field inspections and review of Municipal rec~t't~e,
in conforma~e with MOA HAA guidelines in effect on th/~ date. ~;'
S~gnature' ~:~:~ ~
Engineer's Name ~,~,~/, ~~ ~,~ DO~ ~Ey~
Date -- ~ ' IJ {~.~ ..... A.~
are
HAA Fee $
Receipt Number /'~"~
72-026 (Rev. 3/96)*
Waiver Fee'S
Date of Payment
Receipt Number