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HomeMy WebLinkAboutSIEFKER TR 5 oGR ':R ANCHORAGE AREA BOp "IGH Department of Environmental Quality 3330 C Street Anchorage, Alaska 99503 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM LOCATION SEPTIC TANK: DISTANCE PROM WELL INSIDE LENGTH NUMBER OF PITS__ MANUFACTURER INSIDE WIDTH DIAMETER _ MATERIAL NUMBER OF COMPARTMENTS _LIQUID DEPTH____LIQUID CAPACITY GALLONS. OR WIDTH .~ L~NG-FH~'~, %'E~?~~-- -- LINING MATERIAL BUILDING FOUNDATION__ _ CRIB SIZE: DIAMETER NEAREST LOT LINE DEPTH DISTANCE FROM: WELL TOTAL EFFECTIVE ABSORPTION AREA (WALL AREA) SQ. FT, ADDITIONAL ABSORPTION 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: DIAGRAM OF SYSTEM G.A.A.B. SOIL TEST RESULTS GREA ~R ANCHORAGE AREA E~OF JGH :' {,~,~-~" / SEWAGE DISPOSAL. SYSTEM .-- APPI. ICATION AND PERMIT .... pI'"RMIT IS NOT VALII3 WI'FHOUT SOIL TEST COMPLETION DATE ANTICIPATED SEPtiC TANK - ~ / SEEPAGE Pit ~ / DRAIN FIELD [ CERTIFY THAT I AM FAMILIAR WITH THE REQUIREMENTS OF GREATER ANC RAGE AREA BOROUGH ORDINANCE NO, 28-68 AND THAT THE ABOVE DESCRI.~,D ~Y'TEM I~ [N ACCO:.~ANCE WIT~[ 'AI" COD~' R~Ay~'Y': GREATER ANCHORAGE AREA BOROUP' Jepartment of Environmental 3330 "C" Street Anchorage, Alaska 99503 ~SOILS I,OG PEROI,ATION TEST Performed for ~. ~fz2~&~2~_(~ Lega 1 Des c ri p~6-~-i -'~--Tt-~'-~e~- This form reports:--S~i'~s l og~'-' Depth Feet 1 3- Date Performed__ ~_~_~_~2~-~_'__~1- Percolation test 11 .- 12-. 13- Was ground water encountered? ?leo If yes, at what depth? Reading Date Gross Time Net 'rime Depth to Water Net Drop · Proposed ~nstallat]on: Seepa[le Pit Drain Field ',X:pth of Inlet . Deptii~}~"5~'~tO]~"~-])it or trench E~ 040 (6/74) G'"'"~TER ANCHORAGE AREA BORG' '~H HEALTH DEPARTMENT 327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511 INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM SEPTIC TANK: ADDRESS_ LEGAl. DESCR PT ON .--~)/Z~/~"Zz,( ~ PHONE-- DISTANCE FROM WELL___ LIQUID CAPACITY __MATERIAL__ ~J~ ~)f' ~ NUMBER OF COMPARTMENTS SEEPAGE SYSTEM: SEEPAGE PIT: NUMBER OF PITS__ / __OUTSIDE DIAMETER LINING MATERIAl ~'- ~/~ ~--/../~ NEAREST LOT LINE OR WIDTH ,~ ~'/ '*/ DISTANCE FROM WELL /,~-'~// / LENGT' _ /'/" , DEPTH_ · BUILDING FOUNDATION S ¢,, FT. TILE DRAIN FIELD: DIS1ANCE FROM WELL FOUNDATION_ , NEAREST LOT LINE TOTAL LENGTH , OF LINES NUMBER OF LINES DISTANCE BETWEEN LINES TRENCH WIDTH ABSORPTION AREA SQ. FT. LENGTH OF EACH LINE DEPTH: TOP OF TILE TO FINkSH GRADE .,~ I~ f%l~ THJ'OF FILTER MATERIAL BENEATH TILE WELL: TYPE ,/"~)/~/C~ ~.-/'~ DEPTH , BUILDING FOUNDATION SAMPLE LOTLINE /~;r /¢' NEAREST / * / SEPTIC ~r) / SEEPAGE /~/ / _, SEWER LINE__I~O . TANK / , SYSTEM , CESSPOOL IN. TOTAL EFFECTIVE / IN. ABOVE TILE NEAREST OTHER SOURCES DISTANCES: DIAGRAM OF SYSTEM DATE APPROVED GREATEi, 327 Eagle St. .aNCHORAGE AREA HEALTH DEPARTMENT Anchorage, Alaska 99501 )ROUGH 279-2511 SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT .'~'T/~-~- /Z'F /4 /-~/'/~;/-/- /.]-/4 NAME OF APPLICANT t") 0 ~//~[~L~ /'t, ]'/ RESIDENCE ADDRESS LEGAL DESCRIPTION ~) APPLICATION TO INSTALL: SEPTIC TANK_ ('/ TO SERVE THE FOLLOWING FACILITY. /dO/J/Z-P__ FINANCED THROUGH ]~' ~1 PERCOLATION TEST RESULTS MAILING ADDRESS LOCATION OF INSTALLATION_ SC'~O £07- o o ~1-o731 PHONE N .... S'T oFF I-Ib'FFWt/,g~ ~D ,SEEPAGE PIT b."' , DRAIN FIELD_ , OTHER_. Home TO BE INSTALLED BY ANTICIPATED DATE OF COMPLETION BELOW TO lie FILLED OUT BY NEAL'rH DEPARTMENT //~/Z. ~'/~Off~_ ., PERMIT TO INSTALL A ~/,O,(:7-&~C ~"/,~--~'~q AS DESCRIBED BELOW. SIZE OF UNIT TO BE SERVED )~ ~O~ ._.SEPTIC TANK SIZE. ,) 0 _TYPE tC9Ci&.SEEPAGE AREA ;-~= __TYPE DIAGRAM OF SYSTEM THIS IS 'ro SERVE AS DISTANCES: Health Authority I certify that 1 am familiar witk the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the above described system is in accordance with said code. AREATER ANCHORAGE AREA BOROUGH HEALTtt DEPARTMENT 327 EAGLE STREET ANCHORAGE, ALASKA 99501 CASE or , . Date Performed Legal Description: Lot~..~lock . busalvlslon_~%/C'~E .... This Form Reports a: Soils Loa.._..~.~.--.~2.Psreolation Test........_ Depth Feet Was Ground Water Encountered?_.~.___.~ if Yes, At ~hat Depth ...... Location Sketch Gross Net Drop Fime Net Time Depth To H20 "_______'z Prop~.,ed Installation: Seepage Plt~ Dra~n F~etd Dept.] .f Inlet .'R' ------- _Bepth To Bottom Of Pit Or lrench /D' Test Performed By: Pe,,e <' n Date.~! /~ WATER WELL DRILLERS LOG(I Well Owner .~' USGS Use of ~ell L~cation (address of; Township, Range, & Section, if known; or distance Size of C~s~ng ~ '~ _.Dept~ o~ ,~ole /.? feet. Oasea to Static water level ~ feet (above)(below) land surface. Finish one) Open end C>~J; Screen ( ); Perforated ( ). Describe screen 6r perforations Well pumpinEtest at ~0 gallons per (hour) (minute) for feet of ~rawdown from static lev@l. R~marks Depth in feet from sround surface hardness. MUNICIPALITY OF ANCHORAGE DEPT. ENVIRONMENTAL PROTECTIOI~ Give details of fore~tions penetrated, size and ?J to .~/~ to ~.~ to to to to /V 12 - 06/06~0, Q_ to to to to to __ to ~_~ · to __L& ~ :'S '~ ~pu~'~ o}~ ' oH ut ~u~% ol%d~s uolI~Z O~T %u~a~o ~ ~o uot~ITm%auI asdo~d uo~a~pu~ 'N '~a~O MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of L=nvironrnental Services On-Site Services Section P.O. Box '196650 Anchorage, Alaska 99519-6650 343-4744 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING r~¢;¢' J -- ~.. ')-- HAA# 1. GENERAL INFORMATION Compiete'legal description Location (site address or directions) Property owner Mailing address Lending agency Mailin. g address Agent ~ ~_~ Address [Day phone Day phone [)ay 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- lng 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. 72-025 (Rev. 1191) Front MOA #21 5. 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 -! DHHS SIGNATURE ~'~ Approved for Phone Date F° t..//~ bedrooms. __ Disapproved. __ Conditional approval for bedrooms, with the 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 DH HS does this as a courtesy to purchasers of homes and their lending institutions in order to satisfy certain federal and state requirements. 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 professional engineer's work. Municipality of Anchorage JUL 23 199c~ ~ DEPARTMENT OF HEALTH & FIUMAN SERVICF~N~C~e^uw or ^NC~ Environmental Services Division ~NViRONM~NT^L$1~P, ViCES I 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Health Authority Approval Checldist Legal Description: _'"~ J~ ~(..T- A. WELL DATA Well type ~-- Log present (Y/N) 7 Total depth __ 7 7 Cased to Sanitary seal (Y/N) y Date of test If A, B, or C, attach ADEC letter. ADEC water system number [)ate completed FROM WELL LOG _ ? 7 _ Casing height (above ground) Static water level Well production I O g.p.m. Wires properly protected (Y/N) _ AT INSPECTION g.p,m, WATER SAMPLE RESLJLTS: Coliform Date of sample: _ ~/"~ B. SEPTIC/HOLDING TANK DATA Date installed .,7//~/7u<... p~lO/z~'~O _ Tank size /~,~ ~ Number of Compartments V-N;¢,~leanouts (Y/N).___ Foundation cleanout (Y/N) _Iv1 5 J'¢~/;.~.._ Depression (Y/N) Date of Pumping_ I~/~,/~. Pumper ~¢~"' C. ABSORPTION FIELD DATA Date installed Length. ~,'?~,'1~) Width Effective absorption area Date of adequacy test _Soil rating (g~l~[~..orff~/bdrm) ~.~,~T~ Systemtype ?~4-4.~¢~..~' %~"~4 _ Gravel thickness below pipe ~:) ~l _ Total depth _ ~ _ Monitoring Tube present (y/N) y _ Depression over field (Y/N) ~ Results (Pass/Fail) _ ':~ For_ J'~ bedrooms Fluid depth irt absorption field before test (in.); ,.~ Immediately after~Ogal, water added (in.): Fluid depth_ 7 (ins)Minutes later: //~,5/¢-_:~ Absorption rate = ~ .~DY-~ g.p.d. Peroxide treatment (past 12 months) (Y/N) ~ O If yes, give date 72-026 (Rev. 3/96)* D. LIFT STATION Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES ~ns emVel at* "Pump off" level at* SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot "~,,~ Absorption field on lot /¢l Public sewer main ~//'~ On adjacent lots On adjacent lots Public sewer manhole/cleanout Lift station Sewer/septic service line SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation .~ Property line Water main/service line 7/.~ Sudace water/drainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line , ~-~ Building foundation Surface water Curtain drain Wells on adjacent lots Water main/service line Driveway, parking/vehicle storage area Wells on adjacent lots .~/~ ENGINEER'S CERTIFICATION I certify that I have determined thru field inspections and review of Municipal records that the above systems,are Engineer's Name 'T'4)/~ ~/.~ ~ ~ ti ~r ~?--I a ~4~7 Date ~/~ HAAFee $. ~ ~ ' /~-~) 72-026 (Rev, 3/96)* Waiver Fee $ Date of Payment Receipt Number JCiL..21-g9 16:$~ FD~¢CTE ENVIR0~MD;T^L Client Name [~roject Namet~ Ciien~ ~ampie Mamx 993421001 Tobben Spu,k!anfi Carl &~detsen Clien! PO/~ Priilted Date/Time Collext ed Date/Thne Reedved L>ate/Tim e Pre-Paid Coho/N©3 07/21/99 09:42 07114/99 ]6:30 07/15/99 l 1:45