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HomeMy WebLinkAboutGRAHAM LT 14 i~llJN "i' m.7- T t:~:~lL I TY OF DEPARTMENT OF HEALTH AND E~VIRONMENTRL PROTECTION 825 "L" STREET., ANCHORAGE, AK. 9D50't 264-4720 1.4ELL PEF'~I'I [ T' PERMIT NO. < ?8089? > ALASKA BLDG. CONTR. W?4TH · BRRNCHE L 14 GRAHAM S?D APPLICANT iLOCATION iLEGRL SRR BOX ~?6-R LOT SIZE 20000 SQUARE FEET iMINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE BI.PO-AL SYSTE[4 IS 100 FEET FOR A PRIVRTE WELL~ OR i50 TO ~00 FEET FROM A PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. t~LL LOGS 8RE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN _~0 DRYS OF THE WELL COMPLETION. OTHER REQUIREMENTS MAY RPPL~. SPECIFICRTIONS AND CONSTRUCTION DIAGRAMS 8RE AVAILABLE TO INSURE PROPER INSTALLATION. PFRtI [ T EXP I RE~ DEC:EMBER ~..1 ~, 1978 I CERTIFY THAT l: I RM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE. 2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES. SIGNED:. APPLICANT ALF, tSKA. BLDG. CONTR. ISSUED BY __DATE- V...-. 2 December 29, 1978 #780897 Alaska Building Contractors Star Route A Box 376-A Anchorage, Alaska 99507 Subjects Lot 14 Graham Subdivision A permit issued by this department for well and/or sewer system has expired. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If there are any further questions, please contact this office at 264-4720. Sincerely, Les N. Buchholz. R.S. Senior Environmental Specialist ~B/ljw enc: copy of permit 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 HAA # GENERAL INFORMATION Complete legal description ' Lot Graham Sub vZsZ°n; Location (site address or directions) 7336 Branch¢, Anchorage, Alaska Property'owner A.H.F.Co #110275 Mailing address Day phone Lending agency Mailing address Day phone Agent Linda Smith VISTA REALTY 3og0 C ~, Anch~g~_~ A£z~s~a 99501 Address Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: 4 TYPE OF WATER SUPPLY: individual well XX Community well Public water Day phone 562-6464 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 ' Publicsewe¢ XX -. .' NOTE: If comm~nify:WaSteWafer System, Provide Written confirmation from State ADEG' attesting to the legalitY and status of system. 72-025 (Rev. 1/91) Front MOA#21 · ~po~ s~eeu!Sue leUO!SSe;o~d eq~. u! SUO!SS!LUO JO S~OU@ JOJ elq!suodse~ ),ou s! e59]oqou¥ ,to /q!lgd!o!UnlAI eqL 'penss! s! e),eoU!lJeo ~ eJojeq ~I~P eZ~l~U~ Jo suo!~oedsu! ~onpuoo ),ou op SHHQ jo seeXoldLu~ 's3ueLueJ!nbeJ e~m,s pu~ i~Jepej u!e~Je~ ~s!),es m, JepJo u! suo!),m,p, su! 6u!puel J!eq~, pue SeLUOq Jo s~essqoJnd o~, ~sela no9 ~ s~ s!q~ seop SH H Q eqJ. '~tS~l¥ jo e~m,S eq~, u! pe~e~s!6eJ ~e@u!l~ue leUO!SSejo~d ),uepuedepu! u~ Xq e^oq~ 9 qd~6eJ~d u! ue^!l~ suo!393ueseJdeJ eq), uodn ,quo peseq sm,~o!J!lJeO I~^o~ddv ~),!Joq~,n¥ q~,l~eH senss! 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OgdSNI .dO ..LN31AIg.L~.LS 'g Legal Description: /-~'~ A, WElL DATA Well type ,~J~:~ If A, B, or C, attach ADEC letter. Log present (Y/N) ~ Date completed Total depth Sanitary seal (Y/N) Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST ADEC water system numbe~ t/~'~ (.J~ Driller Casedto 40 / iL Casing height Wires properly protected (Y/N) Date of test Static water level Well flow Pump level FROM WELL LOG g.p.m. AT INSPECTION g.p.m. SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot Absorption field on lot Public sewer main ~"~ ~ ' -/' Public sewer service line -~- On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum tank WATER SAMPLE RESULTS: Coliform ~ ¢~ ~ 5t-~c '/L~ tH, Nitrate ~.~RtLS~C.tO ¢ ~ Date of sample: ~ ~ I ~ -- ff I r Collected B. SEPTIC/HOLDING TANK DATA Date installed Cleanouts (Y/N) High water alarm (Y/N) Date of pumping Tank size Compartments Foundation cleanout (Y/N) Depression (Y/N) Alarm tested (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot I,,) I lin To property line ~/~ Surface water/d rainage On adjacent lots ~-I/ k Foundation ~/~ Absorption field hJ/'//~r Water main/service line 72-076 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed e~'~ ~ Ven,.t,~:~;Y?N) . %~ ¢_ 'Pump o~level at ~ ig h w ale~ ~ Meets M~rical codes (Y/N) X~ ,,,T T.T.O. TO: Manufacturer Manhole/Access (Y/N) "Pump off" level at Cycles tested Well on lot On adjacent lots Surface water Length Total absorption area Depression over field (Y/N) Results (pass/fail) Peroxide treatment (past 12 months) (Y/N) ~. D. ABSORPTION FIELD DATA Date installedWidth"~ Soil rating Gravel thickness Cleanouts present (Y/N) Date of adequacy test for System type Total depth bedrooms If yes, give date SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot ~On adjacent lots Property line To building foundation ~, To existing or abandoned system on lot On adjacent lots Cu~t~%~ Water main/service line Surface water Drive'w,,ay, parking/vehicle storage area _ Curtain drain ~ pL) ~::~ / t' C.~ E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspec, tion. Signature River Loop Road No. 204 Engineer's Name Date HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3t91) Back MOA 21 Waiver Fee: $ Date of Payment Receipt Number MUNICIPALITY OF ANCHORAGE ~r~ Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D.#-¢'~)t~-~ - ~-~--- '-'-'-'-'-'-'-'-'-'~ HAA# ~'¢~°lf'~f'/?'~?b~ 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 14; Graham Subdivision (b) Location (address or directions) 7-q36 R~anche, Anchorage, Alaska Property owner AF]~'C.. ~] ] 0275 Telephone:(home) Business Mailing Address WA ~75760 (c) Lending Institution Mailing Address Telephone (d) Real Estate Company and Agent 3000 C Street, Address VISTA REALTY/Linda Anchorage, Alaska 99501 562-6464 Telephone (e) Mail the HAA to the following address: (or check here E~, if hold for pick up.) List contact person and day phone number below: S & S ENGINEERING/694-2979 -_17034 Eagle R4v~r f,o~? Road, ~h~ PO~ Eagl~ R~V~r¢ Ala~km 99577 2. TYPE OF RESIDENCE Single-Family [~ Number of bedrooms 3. WATER SUPPLY Individual Well ~ Community [] Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site [] Public~i~ Community [] Holding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 72-025 (Rev. 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As certified by my seal affixed hereto and as of the validation date shown below, lverifythat my investigation of this Health Authority Approval 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 Date Telephone S & S ENGINEERING 17034 Eagle River Loop Road No. 204 Eagle River, Al-ska 99577 6. DHHS APPROVAL Approved for _~/' bedrooms by Approved ,~'",,.._ Disapproved Terms of Conditional Approval - -- - - v Date Conditional -- l'/::~li i [0] ~ l"l F The MunicipalityofAnchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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. 72-025 (Rev 7/88) Back Page 2 of 2 A. WELL DATA Well Classification Well Log Present (Y/N) MUNICIPALITY OF ANCHORAGE (MOA) Health Authority Approval (HAA) CHECKLIST - FEBRUARY 1984 343-4744 Legal Description: L~.TL//-C.i~'f~.~. Date Completed Pump Set At Sanitary Seal on Casing (Y/N) Total Depth (J(~ Cased to zed '~ Depth of Grouting / Static Water Level ~/0 Casing Height Above Ground Electrical Wiring in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line To Nearest Sewer Service Line on Lot If A, B, C, D.E.C, Approved (Y/N) ~ Yield ~.~'. ¢/D/tA Depression Around Wellhead (Y/N) ; On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer Cleanout/Manhole Water Sample Collected by ,~ ~_~ /~-A)~/'/de¢£~'~.~ ;Date Water Sample Test Results ,~ ~1 ~/~ -~?¢) C."~o/-c~ -- /~ ~o?~¢'/'tPt Comments ~'O ~ / I'c ~ .~ ~. v.~ f B. SEPTIC/HOLDING TANK DATA Date Installed %ze No. of Compartments Standpipes (Y/N) %. Air-tight Caps (Y/N) __ Foundation CleanoUt (Y/N) Depression over Tank (Y/N) ~. Date Last Pumped _ Pumping/Maintenance Contact on Fi.le"~/N) /'~ ; for Holding TankHigh-WaterAlarm~l~) ~1 Temporary Holding Tank Permit (Y/N) SEPARATION DISTANCES FROM SEPTIC/HObD_~G TANK: To Water-SupPly Well '% To Building Foundation To Propert~Line ~ ~ TO Water Main~Service Line To Stream, Pond, Lake or Major Drainage Course Comments '/~0~/f~ ~,~ ~'~m ¢' "~sposal Field 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed Width of Field Square Feet of Absortion Area__ Depression over Field (Y/N) __ Results of Last Adequacy Test SEPARATION DISTANCE FROM To Water-Supply Well To Building Foundation Lot Type of System Design Length of Field Depth of Field Gravel Bed Thickness Statndpipes Present (Y/N) __ Date of Last Adequacy Test IELD: ; On Ad To Water Main/Service Line To Stream, Pond, Lake, or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments I~L~ ~[f~ ~ ~ C ¢' TO Property Line To Existing or Abandoned System on Lots To ~ack (if present) D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) ~% ~/'X, "Pump Off" Level at ~ '~\ Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. $ & $ ENGINEEI~ING Signed ]?034 ~;agie i~i,~ei' Lc, c,p ,~c,~ No. 20~ Company ~anie River, Alaska ~577 Receipt No. D,_~' Date of Payment Amount: $ 72-028 (Rev. 7/88) Back Receipt No. Waiver Fee: $ Date of Payment Page 2 of 2 APPLIC ~ NT FILLS OUT UPPER HAl - ONLY Address Zip Code Phone Lending Institution Address Zip Code Phone Realty Co. & Agent Address Zip Code Legal Description ~-~ Type of Residence -'~ ~ngle Family ~ Multiple Family No. of Bedroo~ ~ Other Water Supply A~ACH WELL LOG. A w~l log is required for all wells drilled since June 1975. ,~ndividual ,. ~ Community For wells drilled prior to that date, give well depth (attach log if available). ?~ ~ Public Utility Sewer Disposal ~ Individual Year Individual Installed:_ ~Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Time Time Time Time Inspector Inspector Inspector Inspector Field Notes: Jl I~UNICIPALITY OF ANCHORAGE ENVIRONMENTAL PROTECTION AUG I. 1983 RECEIVED ( k,~) APPROVED BEDROOMS 'CONDITIONS OF APPROVAL ( ) DISAPPROVED ( ) CONDITIONAL APPROVAL* DATE Soils Rating Dale Sewer Installed Well To Absorption Area Well Log Received Well to Tank Septic Tank Size MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE  DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION DEPT. OF HEALTH & 825 L Street - Anchorage, Alaska 99501 ENVIRONMENTAL P~,©TECTION ENVIRONMENTAL ENGINEERING DIVISION NOV 1 1978 Telephone 264-4720 REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWEI~6 ~fl~Sj~ D DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. 1, PROPERTY OWNER PHONE MA~ El N G A E)D~R-ESS PROPERTY RESIDENT (If different from above) / PHONE 2. BUYER PHONE MAILING ADDRESS MAI LII~G ADDRESS 0 4. REALTOR/AGENT J PHONE MAILING ADDRESS 5. LEGAL DESCRIPTION ;TR LET LOCATION' 6. TYPE OF RESIDENCE [~'~SINGLE FAM]LY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] One [~'~ou r [] Two [] Five [] Three [] Six [] Other 7. WATER SUPPLY ~ INDIVIDUAL* [] COMMUNITY [] PUBLIC UTILITY *ATTACH WELL LOG. A well log is required for all wells drilled since June 1975. For wells drilLed prior to that date, give well depth (attach log if available.) Y"~ ~ ~ 8. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON-SITE** [~-'~ PUB LI C UTILITY **If individual/on-site, give installation date .,/k.,/,./~ If system is over two (2) years old an adequacy test is required by this Department. NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. 72-010(3/78) THIS SIDE FOR OFFICIAL USE ONLY : DATE RECEIVED INSPECTION APPOINTMENTS TIME T~ME TIME DATE DATE DATE INSPECTOR INSPECTOR iNSPECTOR DIRECTIONS: 1, TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTI L~TY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [] I NDIVI DUAL/ON -SITE DATE INSTALLED [~ PUBLIC UTILITY Connection Verified IN8TALLER []Septic Tankor [] Holding Tank Size: If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER 'TOTAL ABSORPTION AREA MATERIAL 4. DISTANCES Septic/Holding Tank Absorption Area Sewer Line I Nearest Lot Line WELL TO: Absorption Area to nearest Lot Line 5. COMMENTS PPROVEO FOR BEDROOMS [] CONDITIONAL APP/OVAL (letter must accompa.~tificate) • DISAPPROVED / / DATE .- / BY (Title)_ LEGAL DESCRIPTION 72-010 (Rev. 3/78)