HomeMy WebLinkAboutMANN BLK 1 LT 1BarLn'
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. WATER WELL RECORD
STATE OF ALASKA -
DEPARTMENT OF NATURAL RESOURES
Division of Geological a Geophysical Surveys
I
Or,,,,., P..m,,
LOCATION OF WELL (Please complete either la, lb or I¢.) A D.L. No. - -
Ila.liBoroueh Subdivi,~on Lot Black ~J '/,,ir.. S.c,o. ,a.Town.hlP,E) Ron,. ED M.rldla.
F-J~u c h Mann 1B 1 --of_of_o, _ s E] wE]
'1~. J DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS S. OWNER
OF
WELL:
Mark
S.
Jones
. . . Addrese:
Street Address and Areo of Well Locution
2. WELL LOG Feot Below
~ Su(fac~ 4. WELL D~PTH: (final) ~. DAT~ OF COMPL~TION .
.gravely-lenses hard p~,boulSe~-O 25 ~. ~c.~,. ,.., ~.~,..~ ~.,..
hardoan 25 30 D Auger ~ Jetted ~ Bored ~Other: '
silty' clay, gravel seepage ...... ~30 32- '~:usz: ~ Dom,l,lc '~ Public Supply
brn till, d~p 32. 35 ~ ,,,i,o,,o. ~ ,.,,-~.
bedrock, gray-Ereen 35 85 ~ ~.,,w.,, ~ o,~.~:
brn rock-seep 85 110 ~. c~s,.s, ~ V~r.."., ~ W.,--,
110' heavy seepage gray rock 110 125 ,ta.. 6" i.. ,o 4~'". o.,,~ w.i,~t ,~,./,,.
g=~y rock, black stre~s H20 125 150 ,~a.. ~.. ,o. .n.o.,,~ sn,~u,. .-,,.
9. FINISH OF WELL:
~,.: open hole o,.~.,.,,
~ hr. 10 gpm s,o,/...~ s,..: ~..,,~:.
Set between ft. and ft.
Backfilling G~avll pack ,
..
~ ..... ~ Ahoy. or ~elo~ land surface D=te
F~O~c'Io~ II.PUMPING LEVEL below land outface and YIELD
-' 'A/V ~7 10o~ lOO' -. .~t., + h,,. ,.m.,.~ 10
'~ '' ft. offer hrs. pumping
1. ~ ~ ~ ' ' g.p.m.
Material: ~Neat Cement OOther:
I$. PUMP: (If available)
Length o~ Drop Pipe ~ft. capacity g.p.m.
; 0 Subm. 0 dst ~ Centri,lca, 0 Other
14.REMARKS:
16. WATER WELL CONTRACTOR'S CERTIFICATION:
15. Water Temperature . o ~ F ~ C
' 'ThJ~ well wes drilled under my jurisdiction and this report I~ true to the besl of my knowledge end belief;
Llaska Now-Well-Vern,s Drilling ~
~eg~sle~e~ Business Name Contract L~c~nse Number
,.-..: 1~ Ay, on St.
A~
~16
Form~i ........... ~ -- ....... ~ ~ ' ~ ~
Aut~Ortze~ Re~resen~live
~ OZ-WWR (11/81) Co~y DistriDutio~: WHITE-State DGGS, PiNK-Driller, CANARY-Customer
PERMIT NO:
DATE ISSUED:
APPLICANT:
ADDRESS:
LEGAL 'DESCRIP:
LO]' SIZE:
LOT LOCATION:
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PR[]TECTION
8~ L. STREET~ ANCHORAGE AK 99501
~ . 264-4720
O['-tI--S 3[ -F'E WELl__ PEB:~'"I I T
850186
05 / 13/85
MARK S JONES'
3609 CHECKMATE DRIVE
ANCHORAGE., A[~' 99508
SUBD'IVISION: :MANN
SECTION: 2 TOWNSHIP:
4.9503 .(SQ.. FT. OR ACRES)
LUNA STREET
I cer'ti£y that: ~ ~t~.~
LOT: lB
11N RANGE:
BLOCK: I
1. I am familiar with the ,requirements for oh-site sewers and wells as se.t
£orth by the~ Municipality of Anchorage (MOA) and the State ci£ Alaska.
2. I will install~ the system~in accordance with all 'MOA codes and regulations,
and in compliance with the design criteria o£ this permit.
3. I will adhere to all MOA and State' o~ Alaska requir(~ment-~ £or the ~.set. back
t~istances £rom any existing well., wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
APPLICANT: MARK o JONES
·
ISSUED BY __~_.
~' ' ~'~'~._ '~' "° ~" MUNICIPALITY OF ANCHORAGE ~"~'
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION '.
' 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE D'ISPOSAL sYsTEM AND/oR WELL INspECTION REPORT
NAME
I~'°~ 1
MAI LING ADDRESS ' : - - -
LEGAL DESCRIPTION ·
LOCATION ~ '~
EO ~ ~ ~T ~ ~T .o. o~ .~oo~
'
I __
DISTANCE TO: ~ Abs°rpti°~Ta Dwelling PERMIT NO.
~Z Manufacturer --- ~ =~ ~O I~--q~
~'~~. .. Materia'~T ~_~ N°' of compartments
Liq. capacity in gallons Inside length Width
~ ~ IF HOME.DE: Liquid depth
~ ~ DISTANCE TO: Well Dwelling PERMIT NO. -
O ~ ~ Manufacturer
~ -- ~ Material Liquid capacity in gallons
~ Well
~ No. oflines ~ Length of each line . Total length ofli~es Trench width ~ Distance bet~en lines
- ~f , .~ .. ~
~ ~ ~ Top of tile to finish grade Material beneath tile '
Total effective absorption area
~ ' / ' ' %6 inches
~ Length Width Depth PERMIT
( ~ Type of crib Crib diameter Crib depth Total effecti~ absorption area
~ ~ DISTANCE TO: Well Building foundation Nearest lot line
~ DISTANCE TO: : Building foundation Sewer line Septic tank ~ Absorption areais)
OTHER
PIPE
MATERIAL8
SOIL TEST RATING _
~H
REMARKS .... .. - -
-- ~ / : W~ 'lO~
;
.. ,...:,. ~-.~.::.'.. F~U~b~T::~ ~
..:~. ,, · .~;
APPROVED ~ DATE LEGAL '~1/~ ./ ~~ ~: >~ _~.~ ~ '.:~.." -- /~~.~~~
DEPARTMENT OF HEALTH~ AND ENVIRONMENTAL PROTECTION
825 L STREET, ANCHORAGE, AK i, 99501.
264-4720 : '
ON--SITE SEWER &.WELL PERMIT
PERMIT NO:
DATE ISSUED:
.APPLICANT:
ADDRESS:
CONTACT. PHONE:
LEGA~.DESCRIP:
LOT SIZE:
LOT LOCATION:
MAX BEDROOMS:
840575
07/16/84
C/O ACREAGE SYSTEMS MARK JONES
601E NORTHERN LIGHTS
ANCHORAGE, AK ~507'
276-6552
SUBDIVISION: MANN. LOT:
SECTION: /2 TOWNSHIP: 11N RANGE:
49505 (SO. FT. OR ACRES) ' i:~
LUNA STREET
4
BLOCK:.1.
TRENCH BED
5.0 5.~0
5.0 0.~5
8.0 5.~5
2.5 19.iO
74.0 55;'0
25.9 24.~ 6
1,250.0 ** .1,250.I0 **.
1lO ' ' 110
** TANK MUST HAVE AT LEAST TWO cOMP~RTMENTS
I 'certify that:
1. I am {amiliar with the'requirements {or on-site sewers .and welis as,set'
{orth by the Municipality o£ Anchorage (MOA) and the State o£ Alaska.
2.,'I will install,the system in accordance.with all MOA codes,and regulation~
" and in compliaffce with'the design criteria of this permit.
5. I will adhere to all MOA and State of Alaska'.re~ui'rements..for the-se~ bacl
distances {rom'any existing well, wastewater di'sposal system or public
sewerage system.on this.or any adjacent or nea~'~y lot.. '
4. I understand 'that this permit'is valid for a maximum of~ 4 bedrooms and
any enlargement wili' require an add.itional.per~it.
IF A LIFT STATION IS INSTALLED IN.AN AREA COVERED~B~IMOA BUILD~'NG CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE~IOBTAINED; ,(2) AS~BUILTS.
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTIO~ REPORT; AND (5) THE
ELECTRICAL WORK MUST BE.DONE BY A. LICENSED ELECTRICIAN.
SIGNED , .. DATE:
APPLICANT:'C/O ACREAGE SYSTEMS MARK JONES'
ISSUED BY
W. DRAIN
5.0
5.0
8.0
5.0
52.0 .
55.7
1 ~ 250.0 **
110
DEPTH TO PIPE BOTTOM (FT.).
GRAVEL'DEPTH (FT.)
TOTAL DEPTH '(FT.)
GRAVEL WIDTH (FT.)
GRAVEL LENGTH. (FT.)
GRAVEL VOLUME, (CU. YDS.)
TANK SIZE (GALS)
SOIL RATING (SQ.FT./BR)
Listed b~low are the options available to you in designing your septic.
system.' Choose the option that best fits your site.
ALASKA ENVIRONI~"~NTAL
CONTROL SERVIC. /, INC.
1200 West 33rd Avenue, Suite B
ANCHORAGE, ALASKA 99503
(907) 561-5040
JOB.ZOT'/z~
SHEET NO.
CALCULATED BY
CHECKED BY.
SCALE
DATE
DATE,
i
I
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS I. OG
I-'] PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST
"ER,ORMED tO.: '~
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19.
2O
COMMENTS
DATE PERFORMED:
72-008 (6/79}
v,,,,,.,a¥ ,-,,--Id IooL-I'/.~
SLOPE
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
SITE PLAN
O
P
E
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
(minutes/inch)
~ TEST RUNBETWEEN FT AND F'E
2 "~ IX ,'.~ ~,,.~ .
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O, Box 196650 Anchorage, AK 99519-6650
www. ci.anchorage.ak.us
(907) 343-7904
Q- /-off
CERTIFICATE
FOR A
Parcel I.D. 020-041'-27
1. GENERAL INFORMATION
OF HEALTH AUTHORITY APPROVAL
SINGLE FAMILY DWELLING
Expiration Date:,
Complete legal description MANN
Location (site address or directions)
Current Property oWner(s)
Mailing address
· Lending agency
.. Mailing address
Real Estate Agent
Mailing address
SUBDIVISION; LOT lB, BLOCK 1
16040 LUNA STREET * ANCHORAGE, AK 99516
MARK JONES
16040 LUNASTREET
Day phone 345-7268
ANCHORAGE. 'AK 99516
'Day phone
Day phone
Unlessotherwise mqueste~ HAA willbeheldbyDSD~rpick~.
2. NUMBER OFBEDROOMS: 3
TYPE OF WATER SUPPLY: '
Individual Well
Individual Water Storage
Community class Well
Public Water System
TYPE OF WASTEWATER DISPOSAL:
Individual On-site I
Individual Holding tank F'~
community on-site D
Public Sewer D
The Municipality of Anchorage Development Services Depadment (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or
......... water supply system, DSD also issues HAAs upon request to homeowners. Certificates of Health Authority .......
Approval are valid for 90 days from the date of issue for propedies served by a private or Class C well and may
be reissued with new water samples. (Certificates may be reissued for a period of up to one year with valid
water samples.) 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,
Be
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 this application,
:shoWs that the on-site water supply and/or wastewater disposal system is(am) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I furlher 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(am) in compliance with ali applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of Firm GARNESS ENGINEERING GROUP, Ltd.
Address 3701 E. TUDOR .ROAD, . SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
-'In conducting this evaluation, GEG, Ltd. atiempted to provide a thorough,
conscientious engineering analysis of the system in ac~'ordance with ADEC and MOA
DSD Guidelines & Regulations. The reporled results described the performance of the
· system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the Io~al soils condition, groundwater levels that may
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are (~utside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there ara no hidden defects or encroachments. GEG, Ltd. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requiraments of the ADEC or MOA DSD. The content of this report is for ~
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorfzed, nor will it confer any legal right whatsoever.
Phone 337-6179
DSD SIGNATURE
~ Approved for ,Z~ bedrooms.
Disapproved.
'Conditional approval for ·
bedrooms, with the fllowing stipulations: . .,,[((([[(ffrr,- '
·
~ATER AND
Attachments:
HAA Checklist ,
Septic System Advisory
WelJFIow Advisory
(Rev. 12/01)
Manitenance Agreements
Supplemental Engineer's Reort
Other '
Lebai
~cription:
WELL~ D/~TA
We i PRNAIE
On-Site iWater & Wastewater Program
4700 South Bragaw St.
· ' ~ P.O. BOX 196650 Anchorage, AK 99519-'6650
www. c~.anchorage.ak.us
I(907) 343-7904
HEALTH.'AUTHORITY APPROVAL,.CHEc [
Mun c pal tyofAnchorage: ,i
.Development Services 'Department!i!
Building Safety Division !, [ ....
IST
MANN: SUBDIVISION; LOT 1Bp BLOCK '1
i. I'BEDROCK O 35'1
If A,. B, oi' c vide: wsIo# ..N/A
i Earcel ID:
'Weft .Log (Y/N)
Date )leted. 5/16/85 ,,,sanitarY s~al wN
.... ' FROM~WELL LOG' ' ' '
Cohform ~. ~ colonies/100 ml.~.. Nitrate O,.J~ rog.IL.
Arsenic; t,hN/A rog.IL. · ' ', Date bf sample: 5/20/2004
Tank s~ze~ 1250 gal. Number of Compartments
F0undeti6h Cleanout (Y/N) YES I .Depre~sl6~ 'o~,ei. t~nk (Y/N) NO
020-041-27
YES
;W~res prope,d,y protected (Y/N)
~asing height.(abOve groUnd)
AT INSPECTION
Othel-balcteria
Collected by:
Date instblled ' 7/31/84
CleanoutS ,(Y/N) YES
H~gh .water alarm (Y/N) N/A
YES
12+ in.
Date of pumping 9/18/03~
~umper, ' ·
. .. ~t.~, ~ .... ~ , ·
C. ABSORPTION FIELD DATA '~'/*BELOW,EXSTING GRADE L
::'.',I ' :' ' ' . , -I . ~ 2 i~ ;, . : .
Datems~a led '//~/~4 Sod rating (, .p.d./ft or~ 110 - Syst ;m type · SHALLOW TRENCH
,: . Ii ..... ! ~ , . , , ,, , .
Le, ngth :1t,,, 53 fl. "': Wldff~ ~: ~ r ;' '''~5':' 'ff. ' ' Gravel belowppe 3. fl.
Total depth ' 8.63 ' ff. iEff. absorption ~irb:~ ·457 .fl~ ~.~ Monitoring tube-YES [: Depression over field NO
Ddt9 of adequacy test 10/15/03 '~ ,~ ~lResults(Pass/Fail) PASS . . ~. ' . For 4 bedrooms
, ' · ~ ' ~it ~ ~ . : ,
,.,:, .,.1.,,. . ., I ~ : . r . . :
Fluid depth n absorpt on field before test ~ .~0]': in. ' , iWater added 630 ga ' ' New depth 7 in
~,~ . ~ : ~ ~ .-- : :. ·
l, ,, ' ' ' :' i '
Elapsed i'rime: 22 mln.: '. - Finalfluiddepth'! 0 in. . · . AbsorptiOn rate>= . 600+ ' .dod
Afi~:re~juV~'nation treatment (past 12 ms.) ~./N & t:~Pe) . :~ ' NONE KNOWN
· I~- ' i!i : ' 1:~ I' : t . t ; ·
..... ~ ,,,~ , , , , , , · , ,
__ colonies/100 mi.
GEGp Ltd.
D. LIFT STATION
Size in gallons~ "'
High water alarm level at
~ Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Date installed
"Pump on" level at ' . ·
100'+
Meets alarm & circuit requirements?
Septic tank/lift station on lot
Absorption field On lot 100'+
Public sewer main N/A
sewer/septic service line 25'.1.
On adjacent lots ' 100'+ ': '
. On adjacent lots 100'+,.
Public sewer manhole/cleanout
Holding tank 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+ Property line 5'+ Absorption field ~5'.+
Water main N/A Water service line .10'+ Surface water' 100'+
Wells on adjacent lots
100'.1. ...... "
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: .
Property line' 10'+ - , Building foundation 10'+ Water main N/A
Water service line 10'+ Surface water 100'+ , Driveway. parking/vehicle sto'rage 10'+
Curtain drain NONE KNOWN Wells on adjacent lots'~,'100 .1.
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name JEFFREY A. CARNESS
Date ~'"/"Z,, ~,.-/C~,- ..
HAA Fee $
Date of Payment.
Receipt Number
(Rev, 12/01)
Waiver Fee $
Date of Payment.
Receipt Number
Parcel I.D. 'O20-041'27
1. GENERAL INFORMATION
Municipality o.f AnChorage
DeVelopment Services Department
Building safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650 ~
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAHILY DWELLING
Expiration Date:
Complete legal description MANN
.Location (site address or directions)
Current Property owner(s) MARK
.Mailing address 16040
Lending agency
Mailing address
Real Estate Agent
Mailin~ address
SUBDIVISION; LOT lB, BLOCK 1
16040 LUNA STREET * ANCHORAGE, AK 99516
JONES Day phone 345-7268'
LUNA STREET * ANCHORAGE~ AK 99516
Unless otherwise requested, HAA will be held by DSD for pickup.
NUMBER OF BEDROOMS: 5
Day phone
Day phone
-3.
TYPE OF WATER SUPPLY:
Individual Well []
Individual Water Storage I-"1
Community Class Well r'-I
Public Water System . · r'"l
TYPE OF WASTEWATER DISPOSAL:
Individual On-site []
Individual Holding tank I--I
COmmunity On-site. r-I
Public Sewer D
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representationSgiven in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Cedificates of Health Authority Approval are required for the transfer
of title (except between spouses) for properties served by a single-famity on-site wastewater disposal and/or
water supply system. DSD also' issues HAAs upon request to homeowners. Cedificates of Health Authority
Approval are valid for 90 days from the date of issue for propedies served by a private or Class C well and may
be reissued with new water samples. (Cedificates may be reissued for'a period of up to one year with valid
water samplbs.) ~edificates are valid for one year for properties served by Class A or B wells ora public water
system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's
work.
e
STATEMENT OF INSPECTION BY ENGINEER
As ce/lifted 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 this application,
shows that the on-site water supply and/or wastewater disposal system is(are) safe, functional and adequate
for the number of bedreoms 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(are) in compliance with all applicable Municipal
and State codes, ordinances, and regulations in effect at the time of installation.
Name of.Firm ALASKA WATER & WASTEWATER CONSULTANTS, INC.
, Address '3701
E. TUDOR ROAD, SUITE 101 * ANCHORAGE, AK 99507
Engineer's Printed Name JEFFREY A. GARNESS, P.E.
Engineer's Comments:
In conducting this'evaluation. AKWWc, Inc.-attemptdd tO provide a thorough,
Conscientious enginee#ng analysis of the system in accordance with ADEC and MOA
DSD Guidelines & Regulations. The reported results described the performance of the
system under the conditions encountered at the time of the test, and separation
distances measured to readily identifiable features. The operational life of all wells and
septic systems depend on the local soils condition, groundwater levels that may'
fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of the system. Satisfactory test
results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. AKWWC, Inc. can therefore not provide
any warranty or future estimate of how long the system will continue to meet the
operational requirements of the ADEC or MOA DSD. The content of this report is for
the sole benefit of the owner listed above. Any reliance upon or use of this report by any
other person or party is not authorized, nor will it confer any legal right whatsoever.
Phone.
Date
337-6179
DSD SIGNATURE
~ Approved for .~ bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the fllowing stipulations:
· . WASTEWATER:
Attachments:"
HAA Checklist "- '
Septic System Advisory
Well Flow Advisory
Ma'niienanCe Agre'emen's '-
Supplemental Engineer's Reort
Other
Original Certificate Date: i
(Rev, 12/01)
Lega,!
· MuniCipality of Anchorage
, ~ ~: Development. Services Department.
· :~ Building safety Division
· ' ~ '" On'site Water' & Wastewater Program
. ' . ' ' :,4700 South BragaW St. 'r
' ~ '" }~;.~P.O. Box196650 Anchorage, AKO9519-6650
:' ' ~ , W'~/w.ci,ancho~age.ak.us
. · ' , :' ~(907) 343- 9
· HEALTH AUTHORITY APPROVAL CHECKEIST'
De§cdption:· · MANN SUBDIVISION; kOl ~B~ ~kOC~ 1 , ~
A. WELL DATA
. [*BEDROCK:@,!351
'4 Ii
,Well t. yp~
Date ~o~
· ,~
lleted 5/1'6/85', 'Sanitary sSal (Y/N) yEs
150 ft. cased{O' i.40 ift, · '
; ,: FROMWELEi'O~G ;::
_ : .i ~,:: :.
st' 5/16/85"; ~"
IfA, B, orCl~rOviSePWSiD#,N/A - ' WGI
" WireS prope
Casing hiig. i
AT INSPEC~
; 10/15
Static rr'level : :· 35
W~iI; pro~luct',o, .. 10
WATER SAMPLE RESULTS:
020-04-1-27
"- (Y/N)
~rotected {Y/Iq)
l-
(above ground}
g.p.m.
6;41
Other ria __
YES
YES
12+ in.
; ;Ii; I ~;L, c01oniesll00 mi.' .Uit~&te! O.'~O mg./L. ~, Colonies/100 mi.
Coliform
.; [ ,: .. l.: ~.t ' ! ' . .ilI~.~
Arse!lc: ~iN/A,mg./L. : Oateof~ample: 10/15/03~ Collectedl~y:. ' AKWWC,- INC.
' ' i :'F ' ~t~'
B. SEPTIC/HOLDING TANK DATA ~ r ' , ~, I
, ~,, ~,,~ ',,:, .: : , , . ,~:~, ~ ;,,. , , , ,~ F~, , ,
Tankl~ype/Materal ' STEEL,, ,~': ,.. ~ :., :; ~ ~ ' Date installed 7/31/84 .
Tank s ze I YES
1250 gal. , Number of Compadments ', 2 , ,Cleanouts (Y/N).
.;F ',t .... : ' ~:...: ~.,,~.~ : , ,, ,., r , NO '., 'l.~t~'r
Foundation cleanout (Y/N) YES ,, Depression'over tank (Y/N) H~gh water, alarm (Y/N) N/A
Date pf pumping 9/18/03 :,, PS~ )er . IS~CS
C. ABsORpTION FIELD DATA ; ~;' ~1 ' ~' ]'~'~ "'
Date nstalled ,' 7/31/84 Soil rat pg (g. ,d./fl or~ 110 .. : System type. S~LLO~ TRENC~
...... 53 , fl..: · Width, ~; ~ ', '_fl..' ~- Gravel belowp~pe 3 fl.
T°t~l 'deCth ~: 8.63 : _fl. Eft. absorption a¢ea, A57I, fi', Mbnitoring tube 'YES tt,. :Depression over field NO .
- , ;~ ' '. , · ., ; ' ~ ' ',* :~ · , , ~ . , ,~' ;,
:i =' '" ' ' ' " ' ' '
........... , ..... ,, ...... . ....
Date Cf adequacy test ' 10/15/03 ''r ~i ' ~: Results (Pass/Fail) PASS ,: ~. ~,,~ For 4 bedrooms
. . ~ ,: ,. ,. ~ i, . .
Fluid deCth ln'~bso~tion field before test ~O ;,in.. '~ :,:Wateradded 630gal. ~{, .: , 'Newdepth 7 in.
"~1~', ~' :~,' --: '. '_ ::.~ ,I,~[~;.~'.,,~; .',:,~: :' ' ".,~ ,[:~t;:!'.., 600+
ElaCs'edTime~ zz min. ~inal~luig oepm u in; ; ; .. :'~osorpdon rate >=____ _g.p.o,
, i ,; · , ' , · ,2 · · : ,: ' i '
' ' ! i , ~ ",. ' ; , ~ ;I ~': I '~, : :, ~ t I ,
Any, r ~juVenation treatment (past 12 m0,) (YIN &type) .j ~ ~NE ~Nq~ ~ !f Yes, give date -
: - : ~,.t ;.. ..
I. ~ . -I I: , , ,
D. LIFT STATION
Date installed
"Pump on" level at
Eo
Size in gallons
in. "Pump o~~.' .
Cycles tested
SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septictank/lift station on lot ' 100'+
Absorption field on lot 100'+
Public sewer main N/A
sewer/se ptic service line 25'+
Manh~
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots 100'+
On adjacent lots 100'+
Public sewer manhole/cleanout
Holding tank 100'+
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 5'+- Property line '~ 5'+
Water main · N,/A : Water service line 10'+
Wells on adjacent lots ' 100'+
5'+
Absorption field
Surface water.
100'+
· F. COMMENTS
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Building foundation 10'+
Surface water 100'+
Wells on adjacent lots 100'+
in.
Water main N,/A
Driveway. parking/vehicle storage 10'+
Properly line 10'+ -
Water service line 10'+
Curtain drain NONE KNOWN
G. ENGINEER'S CERTIFICATION
I certify that ! have determined through field inspections and
. review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Nam~ JEFFREY A. GARNESS
Date of Payment
Receipt Number
Waiver Fee $'
Date of Payment
Receipt Number
CAPTAIH COOK TRAVEL 90?2?93406
! /%
· JOB NO.:
ZONED
FIELD 80OK;
CLIENT : .~.~;.'~=
I
SCALE.
F. &. $. EiZNG Z NEERS,
E. 76v' STREET
ZNC.
: HE..A:_BY rj.:....-'~lIFY THAT [ HAVE S:.:'RYEI'ED THE FOLLOW!ND DESF.~iB,c-D P~DPERTY.
LOT ~,:' . P.t.K. t , I- :*'"'., :l .. ,; P' ,' ' .
?I",.HC.";-'~E ~C~.Jl.Ht~ 3ISI.~'~C'T, AK., it'D THAT THE ~,F,=RDVEEEN'TS SI'TUAIED THENEON ARE
~I'~HIN THE ,~F,~P'-:~TY L:N[$ AND "dO NDI F_flCAOACH EN 'IHE FR.~PERTY LYING ADJACF_NT
T'.,4.:qE~C: T~A7 :JO [HP;iOVE~ENTS DN ~'.~GPERTY LYING ~,DJACENT 7HERElO ENCROACH DN THE
1H-.' .-'.F,E.~4~':FE$ i'~ ~'.;E-3TIO,q AN: 'T, FiAI ':HE.~E ARE ';0 .~O~DWAY$, TRA!GM~SS]ON L.~NE5 DR
~.7,~'~[.q Vi.".-:~,:.E E.~-'"E'~E';T$ Oh~ SAID PXOFERTY E.(CEPI AS INDICATED HEREON.
.... ~'," '~-'= PfilOR TO C.3t;ST~UC'TiD.% TO VE.A:FY
~ MUNICIPALITY OF ANCHORAGE ~
DEPARTME~ i' OF HEALTH AND ENVIRONMENTAL PRU i'ECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date i-~-~'~'~
Legal Description (include lot, block, subdivision, section, township, range)
,: ,: ·
Location (address or dir&ctions)
GENERAL INFORMATION
(a)
(b) A.p~lica~t Narn'e~,/~'..~,..'~'." ~/-'~' Telephone: Home .~'z/'/5'''''' ~'~' ~' Business ~'~"
(c) Apl~ii~'ant is, (~:hecl~ one):: Le~n.di~{l' Institution []; Owner/builder~; Buyer []; Other [] (explain);
(d) Lending inStitUti6~"... .... ~'' ,.~.; '- '' ;' ~'' r . Telep~'n'~'
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) Mail the. HAA to the following address:
AsAF
TYPE OF RESIDENCE
Single-Family~ Multi-Family []
Number of Bedrooms ,~
Other
o
WATER SUPPLY
Individual WelltJ~ Community[] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~, Public [] 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.
Page 1 of 2 72-025111/84)
'5. ENGINEERING FIRM PROVIDIh/~NsPECTIONS, TESTS, FILE SEARCH, DA/~AND INi=ORMATi0N
'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 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 inspe..ction, 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. "".5~' ~
'"" .' Name of Firm /~'~ ~' -'~ /
Telephone.
"~ddress /~ ~/ ,~f ~ ~., ~ : "'~~ ':'
Date /'~- ~ ":
.. ~ ~ ~ ~. '.
'
Approved for~ .~4~,u/...u~ bedrooms b~"
Approved /~' DisapproveVd'
Terms of Conditional Approval
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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.
Page 2 of 2
72-025 (11/84)
Ac
Bo
WELL DATA :'"
Well Classification "'~'
Well Log Presen N)
Total Depth ./~.~ ,,
cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in
Separation Distances from Well:
MUNICIPALITY OF ANCHORAGE (MOA). MUNICIPALITY OF ANCHORAGF.
HEALTH AUTHORITY APPROVAL (HAA) DEPT. OF HEALTH &
CHECKLIST- FEBRUARY 1984 ENVIP. ONMENTAL PROTECTION
264-4720
Water Sample Collected by
Water Sample Test Results
Comments
If A, B, C, D.E.C. Approved. (Y/N)
Date Completed :~'-/b ' ~'~ ', Yield
Depth of Grouting '
Pump Set At
Sanitary Seal on Caiing~)
Depression Around Wellhead (
:; ,, /.?,z/'
To Septic/Holding Tank on Lot i! ~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot __; On Adjoining Lot~
:! To Nearest Public Sewerl
To Nearest Public Sewer Line :
CleanouVManhole ' To Nearest Sewer Service Line on Lot
,:
i i'Air.tight Caps N)
i ,
No. of Compartments
Foundation Clean~i~N)
Date Last pumpedO
Temporary Holding Tank Permit (Y/N)
To' Building FoundatiOn
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
SEPTIC/HOLDING TANK DATA:,
Date Installed 7-..$ ]-~/ '
Standpipes
Depression over Tank
Pumping/Maintenance Contract on File {Y/N)
Holding .Tank' High-Water Alarm {Y/N)
Separation Distances from Septic/Holding Tank:
TO Water-Supply Well
To Property Line
TO Wate; Maih/Service Line
Course ' · '
· .
comments (~ :t$~rr~,
-. ~ ~' :
72-026(11/84)
ABSORPTION FIELD DATA
Soils Rating in Absorl~tion Strata
Date Insta ed
idtho F'ed ~ ~
Square Feet of AbsorPtion Ar~a
Field;
Depression over (Y,~N)) .'
Res~Jlts of Last Adeqdacy Test
Separation Distance f'rom Abs~)rption Field:
i', ' 147'
Water-Supply Well
To Building Foundation
!:~Lot
T(~ ~/ater Main/Servide Une /-//~
To Stream/Pond/Lak~/or Major Drainage Course
T° Driveway, Parking Area, or Vehicle Sto~'age Area
'Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness -~
Standpipes Pre!en~N)
Date of Last AdeqUacY Test
To Property Line ',~ /
; To Existing or Abandoned System on
present) /</'//~
; On Adjoining Lots
To Cutbank (if
LIF~ STATION '
Date Installed~"~
SI iZ;:in Gallons
",Pump On" Level at
High Water Alarm Le~e[ at
Tested for
I'
E ectrica Codes (Y/Ni
Cor~ments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
A
i* Check Permitted Bedroom Rating Against HAA Request **
I certify that I hav_e/~hec~lfed, ve/ified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
I [ .
Signeo _ ~-"-"~; . D e /' ·
Ii,
company
Rece pt No. %-70q~C:3
Date of Payment ~:'~"i-~lp,
iage 2 of 2
72-026 (11/84)