HomeMy WebLinkAboutROBINDALE LT 15
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF I-IEALTI-I & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE
Bi UPGRADE
MAILING A D D R E/~
LEGAL DESCR~TION
LOCATION
DISTANCE TO:
Manufactur
Liq IF HOMEMADE:/II/.¢~nsldelength
DISTANCE TO: Well [Dwelling
Manufacturer
/
DISTANCE TO:
No. of lines Length of~¢Tir~ Total le,~.~ lilies
Top of tile to fi de Material beneath die
Length Width Depth
Type of crib Crib diameter 'ih depth
Well Building foundation
DISTANCE TO:
Driller
Sewer line
DISTANCE TO:
OTHER
Material
I Trench_,~iC~h
inches
NO, OF BID OOMS
PER T -%' '"2 ~-
NO. of con~r~tments
Liquid depth
PERMIT NO.
Liquid capacity in gatlons
To iai ~f~e~,~o r p tie n a rea
P E R MTT NO.//
PA% s%) rMit~o~'rea (s)
Total effective absorption area
Nearest lot line
Distance to lot line
~e~-c tank
PIPE MATERIALS
d, E
SOIL TEST RATING ~.~,~ //~/~
~R,3 196X
BIV~' [:,
t:~H, ~¥)4 ?.970
72-013 (Rev. 3/78)
II'"'llll...jlll'~ql % I ,. % ~ [.-,11_..1t. "]F'"'~, ii;]}IF' ~...~dl ,,.II,:_,.II.'"'DE._]IIF'.~,.[h-~d.:::~,IE:::.. ;~
'--:~ ......~7~ ....
Dh.I AR I I IM II [)1::: I"IIEAI...'TH ~lxlD ENMIROIqI"IIEIq]"~I.. I:::'F/DTE[FI"IOIq
82'.t':i I; ,:~!1~,1 I;I, AI".CII(]FIAGI'Z, Al( . ~
26d'-4720
112111h,,ll -"' '.!]E~ ][ T' II'iiE ~!!!~; tEE IL,,,U I[!!i] I1:::,;',: ;I~.'..'~: Ipjl IE IL. I .... IP IE IF;i,", IP',~ ]1] T'
F:'ERMI T N £:L', ~i)4()858
DATE '.[ SSLIIED: '.1.0/()El/El4
AF)F:'I_ I CAIxlT:
A D D R E lil S ::
C;ON1'AC;T I>I"IOIxlE'.':
[iCC COIqST ,,
% ,c:!i&S IEIxlGIIqlEIEFH:IXlG
IE A (':U.JE I-'CI: VE f:l ~
694'"'2979
BI_.OI]I<: NA
ape 'M"Ha c][:rl:,ions ava:i, lab].e 'L(:~ yc:~u in designing youP septic
l]l'~ol:~se the opt ion tha'l'., best l';i. ts youp site.
"IF" II'q'.: II!E:: li"q{ Cf: ll""ll ]fiB: lEE: ][:'_) II.....tl ~.. :IE) I1::::i~. ,r:Z~jj ]t] II'.ql
DIEF:']'H. TO PIF:'E BOTTOM (F:'T.) 4.0 4,, 0 zt,, 0
TOTAl.,. DIEF:']"H (F'T'.) ~.(}. (:) /l',, f.~ '7 ,,
GFiAVIEL.. W I DTH (F~'T.) 2,, 5 25,. 0 5,, 0
([)RAVEL. I..EIqEiTH (FrT,.) 67,, () /I-B, 0 BT~ ()
GRAVEl.. VOI.,.I.JI'IE (CI.I. YDS.) 4(), 4 4/I, ,, 5 64 ,,
"I"ANI< S I ZIE (GALS) 1 ~ 250 ,, 0 '~"~' 1 ~ 2;0., 0 .~..)t. 1 ~ 250., ()
SC]II_ F(A'T':[NG (Si;L, F:']",, /BR) 200 :19'7 200
'~"~' (~)RAVIEI... LEI',II3'H'-I > 75 F:'I",, REI~U]:F~ES MI.,IL. TIPI,-E[ RUNS (NO'I' IEXCEI!!!])II',II3 75 F'"F. EACI't)
,)~.)1, TANI< MUST HAVE A'T L..IEAST "FI~JO COMP~R'H"IIENTS
c:: c.~ r' 'L :i. £ y t h a t:
Fora'th by the ~un:i,C~l:h:;x:l, ity c:)t' A)~chcmag~ (MO~) and 'l:.l'i[z: State c)F A].aska.
2. I w:i.],], :i, ri~'La].], the sy!~si'L~]m in a(::cc)r"danc:~ b~J.'Lh a],l MO~ cod(.:~s arid
arid il) coi)U~].:i, an(::;e ~/diCll the desiun (::Pite:;,r'~a (:)F this
3,, I will adht:]r'e:? 'L(::i a:l,]. MOA and State (:d' Alasl.::a r'e:~qu:iPlz.!m[:~rfl, s FCH" 'Ll:le !~iet I:~acl<
ar')y (.:)n].ar'cJemerrL ~J.].l requi[-c~ an adc:l:i..ti(~m"~a~ per, m:i.t.
Il:::' A I..,IF:'T STATIOIq :t:S INSTAI,.I..IED IN AN AREA COVIERI~D BY MOA BUIL. DING CODIES,
THE[Iq (1) AN IEL, EI]TF/]:I]AI.., I:'IERIII]' AhlD ]:NSF'ECTICIN MIJS]~' BE I]B]"A:I]qED; (2)
W I I.,.L IxlC)]" BE AF:'F:'FIOVED W I 'H"IOUT AN IEI_E[i"FFi'. I CAL I NSF:'EC]" ]: ON REF'i]R'I]; AND (3) 'H-'lIE
I~i]_,.IEI]TF~ICAI.. WORK MLIST BE DONE BY A I.:]:CIEI',ISED
S
I
GNIED
AI'"FI...[CAN] ~ I.:{..:C []l~l . ,
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, AncBorago, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] SOILS LOG
PERCOLA']ION
TEST
PERFORMED FOR:
LEGAL· DESCR IPTION,~.~
SLOPE
D^TE PE.EORMED: LF-
SITE PLAN
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
.20
No,
COMMENTS
PERFORMED BY'
Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(~inutes/inch)
by
Doc Co. elba
SULLIVAN WATER WELLS
P.O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND
ADDRESS
LEGAL
DESCRIPTION
DATE-Started ////~ 5'~ Ended
PERMIT NUMBER
DEPTIt OF WELL c~O / -]--~-~ ('~
STATIC LEVEL OF WATER FT. / 7~
DRAW DOWN FT.
GALS. PER HR
KIND OF FORMATION:
From 0 Ft. to ~ Ft,
[''rom G~ Ft. to~ ~ Ft.
From Ft. to__ Ft,
From ~.'.~ Ft, to. ~ ,~'- Ft.
From__ Ft. to Ft.
From_&5__Ft. to %,.
[''rom /6,~_~Ft. to /~g Fi,
Vro,n_,Jt~ 2- Ft. to o~-O / Ft.__
From Ft. to~ Ft.
From Ft. to Ft.
From Ft. to~ Ft.
From Ft. to~ Ft
From_ Ft. to.~Ft
From Ft. to__ Ft
From Ft. to Ft.
From __ Ft. to Ft.
From_ Ft. to__Ft.
From
From
From
From
M1SCL. INFORMATION:
Ft. to Ft
.Ft to____.Ft
Ft. to__ Ft.
Ft. to__Ft
Ft. to Ft
Ft. to____F
Ft. to Ft
· Ft. to Ft.
From Ft. to__Ft
From .Ft. to__Ft. ____
From Ft. to Ft
From_ Ft. to Ft
From Ft. to__Ft
From_ Ft. to__.Ft
From Ft. to__Ft ____
From Ft. to__ E.t.
From_ Ft. to Ft.
RECEIVED
AUG 18 1%7
Municipality of Anchorage
Dept. Health & Human Services
DRILLER'S NAME
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Se~¥ices Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I,D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY r)WELLING
051-0~3-17
GENERAL INFORMATION
Corn plete legal description .
Lot 15:
Rob~nda]o Subdivision
Location (site address or directions) 24015 Sunnyside Drive
Property owner
Mailing address 2401 5 Sunnys±c]_e
Lending agency
Mailin. g address.
gh~rry Wq]l~m~ Day pp0ne
Drive Chugiakt AK 99567
Day Chone
Agent
Address
Day phone
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
Four 4 )
NOTE:
Individual well ×××
Comrnunity well
Public water
If community well system, provide written
lng to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
XXX
NOTE:
confirmation from State ADEC attest-
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
STATEMENT OF INSPECTION BY ENGINEER
As certified by my sea[ affixed hereto and as of the validation date shown below, I verify that 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 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 Firm Ander'son Engineering Phone 522-7773
Address P.O. Box 240773 Anchorage, AK 99524
Engineer's signature
Date 9/21 /99
DHHS SIGNATURE
__ A.p. proved for~ /d ~//~,. bedrooms.
Disapproved.
__ Conditional approval for bedrooms, with tile following stipulations:
Note: The well for this property meets existing State and Municipal Codes.
There are nitrates present. It is sum~ested that oeriodic testing be
: performed to insure the wells continued suitability. Current nitrate
.... entr_~ti~ 4_= 5_3/~ ~g/~. ~p~ _~,v~ .......... ~n in !0_0 mg/!.
'More information on nitrates is available from the On-site Services Program,
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 rsgisterad in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
and their lending institutipns.i ,n order to satisfy certain federal and state raquirements. Em ployees 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 profess!onal engineer% work.
Municipality of Anchorage I1~ E (~ 1!1 V [~ D/~,
DEPAF{TMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division SF.Iu 2 1 1999
825 L Street, Room 502 · Anchorage, Alaska !)9501 · (90~ -47~.4
u~ahty of Anchorage
Dept. He.~lth & Human Services
Health Authority Approval Checklist
Legal Description: _ Lot 1 5 ¢
A. WELL DATA
Well type Private
Log present (WN)
Total depth 2 01 '
Sanitary seal (Y/N)
Robinda].e SubdivisionParcelI.D.: 051 -053-17
. If A, B, or C, attach ADEC letter. ADEC water system number
Y Date completed
Cased to 2 01 '
Y
Date of test
Static water level
Weft production Unknown
WATER SAMPLE RESULTS:
Coliform 0 . Nitrate
Date of sample: 9/13/99
B, SEPTIC/HOLDING TANK DA'rA
Date installed 1 0 / 8 4 Tank size 1 , 2 5 0
Foundation cieanout (Y/N) Y
Date of Pumping 9 / 21 / 99
C. ABSORPTION FIELD DATA
Date installed 10 / 84
Length 6 7 ' Width
Effective absorption area 804 SF
Date of adequacy test 9 / 1 3 / 9 9
Fluid depth in absorption field before test (in.); 0
Fluid depth 0 (ins) Minutes hater:. 0
Peroxide treatment (past 12 months) (Y/N) _ N
72-026 (Rev. 3/96)*
FROM WELL LOG
11/84
172'
g.p.m.
11 ,/84
_ Casing height (above ground) > 1 8"
Wires properly protected (Y/N) Y
AT INSPECTION
9/18/99
184.8'
5.3
g.p.m.
5.34 mg/L Other bacteria
Collected by: A. Harala
Depression (Y/N) N
Pumper JR's Pumping
Number of Compartments 2 _ Cleanouts O'/N) Y
High water alarm (Y/N) N / A
Soil rating (g,p.d./fl~orfF/bdrm) 200 SF System type _ Deep Trench
2.5 ' Gravel thickness bslow pipe ~.~6_' _ Total depth 10.5 '
Monitoring Tube present (y/N). ¥ . Depression over field (Y/N) ___.
_Results (Pass/Fail) Pass For Four
Immediately after_ 9 2 q2al. water added (in.):
Absorption rate = > 6 0 0 _g.p.d.
If yes, give date N/A
N
.bedrooms
0
D. LIFT STATION - None on Lot
Date installed
Manhole/Access (WN)
High water alarm level at*
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot > 1 0 0 '
Absorption field on lot > 1 0 0 '
Public sewer main N/A
Sewer/septic service line > 2 5 ~
F.
Size in gallons
"Pump on" level at*
*Datum
On adjacent lots > 10 (~ '
On adjacent lots ~ 100 '
Public sewer manhole/cleanout
Lift station N/A
"Pump off" level at*
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation > 5 ' Property line > 5 '
Water main/service line > 10 ' Surface wateddrainage > 100 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line > 1 (~ ' Building foundation ;~ 10 '
N/A
Absorption field. > 5 '
Wells on adjacent lots > 1 0 0 '
Water main/service line
Surface water > 100
Curtain drain N~n~ Oh~,~-v~, ~n T,n~ Wells on adjacent lots >100'
ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections
in conformance with MOA HAA guideli~s in effect on this date.
Signature
Engineer's Name Michael E, Anderson, P.E.
Date 9/21/99
Driveway, parking/vehicle storage area
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/96)*
Waiver Fee $
Date of Payment.
Receipt Number
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519~6650
343-4744 ,~ ~-.~ ~-~ ¢~
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # ~.L.;~ / ~ ('-')~.'~ \'~ NAA # ~ \~'~ ('~ C~.z~ ~,~
1. GENERAl. INFORMATION
Complete legal description Lot ].5~ Robindale Subdivision
Location (site address or directions)
'Property owner
Mailing address
Finis Shelden
P.O. Box 671087
24015 Sunnyside
Chuqiak, AK
Chugiak,
Day phone _
AK 99567
244-67'75
Lending agency
Mailing address
Agent
Address
Day phone
Day phone
2. NUMBER OF I:~EDROOMS:
3. TYPE OF WA'rER SUPPLY:
Un/ess otherwise requested, HAA will be held for pickup.
4
NOTE:
Individual well
Community well
Public water
xxx
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4, TYPE OFWASTEWATER DISPOSAL:
NOTE:
Individual on-site x×x
Holding tank
Community on-site
Public sewer
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72~25 (Rev ~/91) Front MOA #21
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 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 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 Firm
Address
Engineer's signature
$ & $ ENGINEEEING
]7C,~4 Eagle Eiver Loop Eoad No. 204
Eagle ElYe~, Alaska
Phone Gq~/ -g--e '~
Date ? /'~ ~'/¢/ 7
DHHS SIGNATURE
~Approved for ~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
By: ~,:,~ ~,~t~ J~ Date
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.
72~)25 (Rev 1191) Back MOA #21
MUNICIPALITY OF ANCHORAGE
I:NVIRONM[NTAL SERVICES DIVISIOt*J
Municipality of Anchorage JUL 2 9 1997 ~
DEPARTMENT OF HEALTH & HUMAN SERVICE,~
Environmental Services Division 1~ [! C J~ i V E D
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
Health Authority Approval Checldist
Legal Description:_U J~'~ ~'~i~t4~,~-"~.~_ ~"~/1~ _ Parcel I.D.'.
A, WELL DATA
Well type ~'~¢-.-['4/~-~'¢~.---~ If A, B, or O attach ADEC letter. ADEC water system number
Log presemt~) I [)ate completed
Total depth _ ,~;J o / / Cased to '=~ ~ /
Sanitary seal ~1) \J
FROM WELL LOG
_ Casing height (above ground) ')
Wires property protected (Y'~) _ ~
AT INSPECTION
Date of test
Static water level
Well production
g.p.m.
WATER SAMPLE RESULTS:
Coliform f-~
Date of sample: 7- f~'""' ~ 7
Nitrate~) f ~ Other bacteria ~
Co,,eoted by:_
B, SEPTIC/HOLDINGTANK DATA
Date installed /'~-~'¢_Tanksize~/~,5'-'~ Number of Compartrnents ,~_ Cleanouts~)_~./__
Foundation cleanout~ .~ )_ y____Depression (Y~J~ ~.) . High water alarm (Y/N) '~'"~4~'
DateofPur~i;i~':"~//~r,'ii~,'~l~ .1~¢''~c> ,4.'¢'"/'~/~'¢ Z~..~.?"7"~-_.~_
C. ABSOR~T ON FIEED DATA
Date installed /0 ,"D' ¢ _
Fluid depth in absorption field before test (in.):
Fluid depth (ins) Minutes later:.
. Soil rating (g.p.d./ft~ or f¢/bdrm) ~2¢ ~, ?u_~ystem type. ""T-~.¢-,,,J~ ~
Length ~ ~ I Width ~ ,0~ / Gravel thickness below pipe ~- ~ ~ ~ i
_ Total depth
Eflective absorption are& ~5 ¢ / Monitoring Tube present~)~ Depression over field (Y~_~
J~~) For bedrooms
~ _ Immediately after _ gal. water add~~
__~~on rate =, g.p.d.
If yes, give date
72-026 (Rev. 3/96)'
D. LIFT STATION
Date installed Size in gallons
Manhole/Access (Y/N) "Pump on" level at* "Pu~
High water alarm level at* '~¢¢¢n~'~~'---
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/HOLDING TANK ON LOT TO:
Foundation ,,,¢" Property line / ~) Absorpt!on field
Water main/service line /¢, I 4- Surface water/drainage /¢,o I~-
Wells on adjacent lots
/06 I+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line ! ;~ / Building foundation ! ~ / 'P Water main/service line
Surface water ID o t '{'- Driveway, parking/vehicle storage area ..~ o I
Curtain drair~ ' : /d/~ Wells on adjapent lots
F, ENGINEER'S CERTIFICATION
I corti~/that I have determined thru field inspections and review of MUnicipal recor~~ams are
conformance with MOA HAA guidelines In effect on this date.
Engineer's Name ~ I~¢4 ~' C .
Date 7{~ ~( ~7 i~' 6E-8801 ,~
HAA Fee $ 5
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-026 (Rev, 3/96)*
JULY 11,1997
p],EA2F BE ADVTSED THAT I, VERNON BROWN, HAVE BEEN THE OWNER OF LOT 15,
RO~iNDALE SUBDIVISION AT CHUGIAK,AK. CONTINUOUSLY SINCE BEFORE 1984. I
[~AD SULLiVAn[ WgTER WELL COMPANY DRILL A WELL ON THE ABOVE PROPERTY AND-:
ARtTi~) FIR~P iNSTALLED A' WATER PUMP IN THE WELL. I ALSO HAD CHUCK MOWRER
])Oi[~G BUSINESS AS CCC CONSTRUCTION COMPANY EXCAVATE AND INSTALL A 24 X ~0
FOOTING FOUNDATION AND SLAB FOR A NEW HOME'WHICH HAS NEVER BEEN BUILT. CCC
CONSTRUCTION COMPANY ALSO INSTALLED AN MUNICIPALITY OF ANCHORAGE APPROVED
A BEDROOM SEPTICE SYSTEM FOR THE PROPERTY. IT HAS NOT BEEN USED EITHER
SINCE INSTALLATION IN 1954o I DO NOT WARRANT THEIR CONDITION BUT BELEIVE
THEM TO BE IN SAT~,SFACTORY AND USABLE CONBITI~N. '
JUL-~J-1997 10:14 CT&E ESI ANCHORAGE 90?5615301 P.06×11
~t~_- CT&E Environmental
Services
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
lrvVSID
973g01005
$ & S Eugiuccriug
Lot 15 Robindale
Drinking Water
Sample Remarks:
Client PO#
Printed Date/Time 07/23/97 09:19
Colle~tedDate/Time 07115197 11:30
Received Date/Time 07116/97 16:00
Technical Director: Stephen C. ]gde
g)trate~N
Totat CoEiform
PaL
Units
Atlowabte Prep Analysis
Method Limits Oate Oate Init
0;500 U 0.500 mg/L $M18 4500-N0)F 10 m~x 07/18/97 J~J
0 cot/lOOmL $M18 9222B 07/16/97 TMU