HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 1 LT 1ACampb
II Hts.
Block
Lot ;lA
#014-071-24
DAILY DRILLING LOG
PENN JERSEY DRILLING CO.
2833 Fmst 72nd Avenue
4128 £, 67th 99507
ADDRESS .............................................................................................
W~--SXT~ .............. E,a..s.E....6.Zr...h._.k..~.~,~ 0..r-~ -.g-a-.: .........................
DATF.,---STA wrED ....... .S..e.P.g..,e..m., .b.e...~....,2..6. !~ _.l. 9.-7-?-. ...................................
D ATE~L"~ £D .............. . .~. ~ ?.~ .e...~..~..e..~......2..6.. ~.....~...9...7..?. ........................................
Anchorage, Alaska 99502 . 341-2612
DEPTH OF 91 *
STATIC LEVEL OF WATER PT .................................................................
DRAW DOWN FT ..................................................................................
aALS. PER m~ ......................... !..2....~.~ ........................................................
rasp OF cA.q~c. ............. .6.~'~.~.~.!_~!~..l..~...~.s.!~ ........................
KIND OF FOILMATION:
FROM ................0.. ........ FT.
FROM ............. ..2...._...FT.
FROM ...............~.~.~...FT,
FROM ................'I'...5..,....PT.
FROM ................2...4.......pT.
FROM ................3...6.......pT.
FROM .......................... Fl',
FROM ............... .6...9.......FT.
FROM ..............1.7.. .-8- . .... . PT,
FROM .......................... PT,
FROM ............... .8...3..-.... FT,
FROM ............... .8...9.......FT,
bIISCL. INFORMATION:
TO ....... ..t..~ ......... FT~~..p....~..r..a..y...e~t.. .........
TO ......... ..2.~ ........... PT..?....ar?..p....~..a..n...d..y.....G..E..ay e 1
TO ......... .~.6_ ........ FT. ~..r..v....gr..?.y......c...t..a..L.'
TO ........ §?_ ......... PT.~.r.Z..§..r..gY......C.!.a.Y. ....
To ..................... .................
· o ......... ./..8_ ....... FT. p_~.p..._C..1...a..y....~...~..r..av e 1
TO ......... .8...3. .......... l~...3.....-.....G...P.~_...-.....S..~..1...t.y Sand
and Gravel
TO .......................... FT ........................................
TO .......... .8...9_ ......... PT....p.,..u..n...n. lr....~ .a...n. ,d y....~ ~ .a v e1
To ......... .Lt. ...........
FROM ........................ FT.
FROM ......................... FT.
FROM .......................... FT.
]~'IOM .........................
FROM ......................... PT,
FROM .......................... FT,
FROM .......................... PT,
FROM ......................... FT.
FROM .......................... FT,
FROS! .......................... FT,
FROM .......................... PT.
FROM .......................... FT,
Jul 05 1 9 03:02p Anchorage bNsll & Pun -p Ser :072430742 p.1
SVell 1)rzdlz g perrait Teeztalaer:
Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
7 F
4700 Elmore Street'
p t l
n73
P.O. Bax fi ' 9665_
hr,choraoe.,
� -
AK 49519-66,50
wv:w.ir.un orq/ars it
5
;��713a3-?904
Grp Installation Log
Parcel Identification Number: � ��_•�� 1.. a'�
Legal Descriptioxa filocl; Lor.
10.1 Y)�&U 1 I c 4C ,
Fnnzp Installation Hate:
Elate of Issue:
Pronert;. 0-w.r aj e c& Address:
—
�"'c�tlir,..�-r',-
Pun -'P Intake Depth Belaiv Top ofiVell Casing:
feel
Pui'313 ?'+'Iaoufacturer's Name_
Pump Model• �( S/
Pump size
Pilless :adapter Burial Depth:)� =°'_ fees
Pitless Adapter Maniefaeiurer's `iargc:
Pitless Adapter Installer:
Well Disinfected Upon coo letian? Yes T-, so
Method of Disinfeetion: a
._
Comments:
n
Pump Installer Name.
A
J
Company: ���
lr'Iallrng Address:
City:
Zip:
Rat e: —
Aftention: Tile p`Iup in.,naller shall p.ovidt a. P"rilp installation log 30 days of pump installati:)r�.
PERMIT NO.
DEPARTMENT O~ HEALTH AND ENYIRONMENTAL~OTECTION
825 t' ~ STREET, ANCHORAGE, AK. 91
,264-4720
[WELL PERMIT
IPPLICANT
50CATION
LEGAL
ALBERT J. KILLIAN 412BE 67TH. AVE.
LOT iA BLK I CAMPBELL HETS SUB LOT SIZE
444440 SQUARE FEET
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
i00 FEET .FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPEHDING
UPON THE TYPE OF PUBLIC WELL.
iMINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS ~5 FEET AND
:TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
I CERTIFY THAT
l: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
~: I WILL INSTAL~ THE SYSTEM IN ACCORDANCE WITH THE CODES.
S I GIqED: _.
APP~i.~T ALBERT J. KIL~IRN
V4. 0
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and 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 FAMILY DWELLING
ParcelI.D. O t '1' - ~ 7 /
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Expiration Date:.
Current Property owner(s) ~,,=~-,~
Mailing address
Lending agency
Day phone
Day phone
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: :3
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding tank D
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Development Services Depadment (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except bet',Yeah spouses) for propedies 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 properties served by a private or Class C well and may be reissued with
new water sample results less than 30 days old. (Certificates may be reissued for a period of up to one year with
vaIid water samples.) Certificates ere valid for one year fcr properties served by Class A or B wells or a public
water system. The Municipality of Anchorage is not responsible for errors er omissions in the professional
engineer's work.
4. 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(are) 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(are} in compliance with all applicable Municipal and State codes, ordinances.
and regulations in effect at the time of installation.
NameofFirm f= (,~ cz j~,p 7-,,c~,,, ,'¢-,! ~ ,-"o '~ *'J Phone
Address
Engineer's Printed Name 'T/~'o~-,D--'"d /~. /-/oo,-¢ Date
5. DSD SIGNATURE '.h: ,-~'-/ ~-, ~
t,~ Approved for ~ bedrooms. ~ · . .,~
, ~ ~, ~ ~0~ F. ~00~ ~
Conditional approval for _ bedrooms, with the
Additional Comments
PROGRAM ..'
-. .... .- .
"Z, ZO)))))H~H
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
Original Certificate Date: ~ - ~ '7- ~/
(Rev, 12;C)
Legal Description:
A. WELL DATA
Mnnicipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box196650 Anchorage, AK 99519-6650
w~v.ci.anchorage.ak.us
(907) 343-7g04
HEALTH AUTHORITY APPROVAL CHECKLIST
~t~91. ttt N~ -~/t> ParcellD: Ot~'-O7t-~-tt'
Well type ~'t~,o
Date completed ~/
Total depth ?1 lt.
Date of test
Static water level
Well production 12.
WATER SAMPLE RESULTS:
Coliform (~ colonies/100 mi.
': Date of sample: ~'/'/.,//,;::~/
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal.
Foundation cieanout (Y/N)
Date of pumping
If A, B, o~ C provide PWSID #
. Sanitoryseal(Y/N) ~'
Cased to (// lt.
FROM WELL LOG
912.~'/"/?
lt.
g.p.m.
Well Log (Y/N) 'r'
W'~s properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
~;z' lt.
~. 7 g.p.m.
in.
Nitrate ~,~'.~' mgJI. Other bacteria _
Callec~ed by: /~/~,/- Ac?
Number of Compartments __
Depression over tank (Y/N)
Pumper
~ colonies/100 mi.
Date installed
Cleanouts (Y/N)
High water alarm (Y/N)
Co
ABSORPTION FIELD DATA M.A. ~. /'9' t~' t<'' /-< tt~k/;t$"~"~'"'"J
Data installed Soil rating (g.p.d./ft2 or ft2/bdrm)
Length lt. W~dth ft.
Total depth __ fl. Eft. absorption area ft= Monitoring tube
Date of adequacy test Results (Pass/Fail)
Fluid depth In absorption field before test in.
Elapsed Time: min. Final fluid depth
Any rejuvenation treatment (past 12 me.) (Y/N & type)
System type
Gravel below pipe
Depression over field __
Water added gal.
in. Absorption rate >=
If yes, give date.
For bedrooms
New depth in.
g.p.d.
D. UFT STATION
Date insteiled
"Pump on" level at in.
Datum
Size in gallons
'Pump off' level at
Cyctes tested.
in*
Manhole/A,_ _e~_~__ ss (Y/N)
High water alarm level et
Meets alarm & circuit requirements?
in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/llfl station on lot /v. ,4. ~,,.,~v~x £,r,,r~ adjacent lots /V.~-.
Absorption field on lot /d, ,,/. On adjacent lots /~, ~,
Publlcsewermatn ~' ~'Z:' ~'~e /,o/'e~v' Publlcsewermanhole/cleanout
Sewer/septic service line '~ ?-.f" Holding tank /v. ~.
SEPARATION DISTANCES FROM sEPTIc/HOLDING TANK ON LOT TO: .~, ,4. (' ,A-,,....
Building foundation Property line Absorption field
Water main Water service line Surface water
Property line
Water Service line
Curtain drain
F. COMMENTS D
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: /~.
Building foundation Water main
Surface water D~veway. partdng/vehicle storage
Wefts on adjacent lots
&
I certify that I have determined through field ir=pectlona and /.,,..: ~......... ~f ,, ~,
,, ..*..
'., e.
review of Municipal records that the above systems am in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name ')"/'~ #~,,,~'"o/'~' ~ /"' ~,o ,.~
Date ~'¢4,~_ ~- Z. '~.,'0 1
~: ~:.'. CE-3589
HAA Fee $ '~
Date of Payment
R~ipt Number
(R~. 1 ~)
Waiver Fee $
Date of Payment
Receipt Number
9075615301 T-066 P,O~/03 F-gZT
Nit~ate-N 0.500 U
PQL t~s Ideda~d T ~..~. ~ I~le I~it
0.500 mF/L EPA 300.0 ¢<10) 06/13/01 SCL
~Lc~obiology L~:~oz',,l~r,/
To~l Coliform 0
0 ~ol/lOOmL SMI89222B
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. # ..
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Day phone
Day phone
Unless othe~ise requestS, H~ will be held for pickup.
NUMBER OF BEDROOMS: ~ ~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If ~ommunity well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAI-
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.
Se
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.
NameofFirm ~fvlJo~, '/-,~;,~ol ,C~r~,'c~J Phone ~'~--/.~.~-.r'
Address I ¥ ~'.~ ~
Engineer's signature .~~
DHHS SIGNATURE
~ Approved for _'T/t'~j~--c'~' bedrooms.
Disapproved.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
Date ~-,~/- c:~c~
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 requirement. 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.
i<ECEIVEb
Municipality of Anchorage JUL
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 .~~744
Health Authority Approval Checklist
LegalDescfipflon: ~.~o/- 1,4~ l~lPcl; ~4~,p/,~ll /-~/'~' PamelI.D.:
A. WELL DATA
Welltype J'r',u'~,/~ IfA, B, orC, attach ADEC letter. ADEC water system number
Log present (Y/N) y~J Date completed
Total depth ~/' Cased to ? ~'
Sanitmy seaJ (Y/N) Y
Date of test
Static water level
Well pmducfion
FROM WELL LOG
? / ~. ~/-7,e
Casing height (above ground)
Wires properly protected (Y/N)
"AT INSPECTION
-~ 19 /99
SAMPLE RESULTS:
5'¥ /
1 2 g.p.m. 5': E + g.p.m.
Tank ~ze Number of Comperlmante __
Depression (Y/N)
Pumper
Soil ra~lng (g.p.d./t'ff or ft't/tx:lrm)
Gravel thic~ne~s below pipe
Monitoring Tube pmsem (Y/N)
Resu~ (Pa..~/~a~)
Immedlately aRer
Other bectefla N~,,,/ ~-¢/~ o /' ,/-,, .,~
C~eancx..te (Y /N) __
· High water alewn (Y/N)
System type
Total dep~
Dep _re_~__!un over field (Y/N) __
For
gal. water added (In.):
.bedrooms
g.p.d.
D. UFTSTATION N.,4-.
Date installed
Size in gallons.
fi/N)
'Pump on" level at'
'Pump off' level at*
Sewer/septic sewice line ~, ?..~' Lift station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: /~. ~..
Foundation Property line Absoq3tton field
Water main/service line Sudace water/draJnege Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO.' N. ,4. (/~ ~, ~-,c~ ~
Property line
Surtace water
Building foundation Water main/sewine line
D~aay, partdngNehic~e storage area
Curtain drain
Wells on adjacent lots
F. ENGINEER'S CERTIFICATION
HAA Fee $ 7~o~-~
Waiver Fee $
Date of Payment
Receipt Number
High water alarm level at* *Datem __
Cycles tested ~* p,e'.c.'.- 9/?/'7,~ I¢/¥*e~. ('*4F/.,<./,,,,V,) ~/,/~,-c,,./,*,/~
SEPARATION DISTANCES FROM WELL ON LOT TO: oF ~¢ f'~¢/~ r~,,;,-e,~'
Absorption field on lot ~.~. (,,l~,~,c~ ~'~,~.,~,'~ Onadjacentlots
'~Publlc sewer main ~ ¥~' ('.~ ~,/'~ Publlcsewermanhole/clsenout -/3' ,~ ¢. ~,,
CT&£ RefJ
Client Nm
ProJe~ Name/~
Client Sample ID
Mstrtx
O~dered By
PWSID
993208001
Fl~op ?ech~¢~3 Sr~.
Lot lA Blk ] C.tmpbe11 H~ S/D
~ IA Blk 1 Campbell H~s $/D
Drlnt(tn~ Wa:er
Client PO~ prc. P~id Coh~NO3
Primed D~erl'ime 0'//08,~9 15:30
Collet~ed Date, Tune 0'//06/~'9 15:00
Re~elved Da~t/Tlme 0-//0~/99 16:2~
Ttchnlcal ~-ec~or: C
Sample Rcm,vks:
EP300 Nhr'a~: Labonmry Control S,~T. lc was omslde accurate criteria (111%); $;tmplc MS ~ 96% retorts. All
ot~cr C~ n~ c~tccia, no ~ur~cr action t~kcn.
&tto~abte Prep
Total Cotito~ 0 co~ll~ ~la
kltrlte-~ 0.813 0.5~
.... ,Septetbar ?,~10 0 ..... .
s
t appxzc ion i
~rovtdes minimally, acceptable protection for the nearby
if' · functional and I
"'-;',private water veil.
· ~-~ Please forward a copy of the contract cha~fe order showing the
'.', .adjustment to the contract price when it is available.
. , ,. ;,Sen ior :Administrative Officer
;i: 2, ~, ~ .Anchorefe ,Water and'Sewer, Utllltte,s.
,,'.~;~..~.i,i3000;Arcttc' Blvd. :~' i;.,',-..~-~,'.~: '
!'..,,... ;,... ' ;Anch0rege ;' Alaska '. 0OS03'· : ~ ':'"
!~'}:!: .,~SU~IECT:. '-'578-17-7130: ' ' : '
,. . :. ',. ' . LID 91 Caspboll flellhts South
, '- .... : (Your letter g-?-79) 'f
,~.. %, ,Dear John:
~:1'. :: .The design plans you subni{ted for the addition of 216 linea{'
" '" - ifeet of 8-inch DIP sawer and tva clean-outs onto tho subject pro, oct
":'"~ !are approved for the teens ,concern to this Department. Althoush
~. ,.i ~lt is an unusual )ltcat )f a clean-out, the application is
Sincerely,
tOO
NOTE
190
31J1_-15-1c~9'~ ~8:5'2 FLRTTOP TECH. SUCS. 9BT-J4SI~JS P.I~2
............. "" '" I'*P~ NO.
· .'* . ~..j ..
.... *r~.or
· it
TOTAL P. 02
· APPLIC-'NT FILLS OUT UPPER HAL~'ONLY
Property. Owner
Buyer
Address Zip ~e
Address Zip ~e
Strut L~ati~ /~/~ .~ ~ ~ 7 ~
Type of Real.rice
~ Single Family
~ Other
~ ~mm~ity For wells ~ill~ prior lo that date. gfve well depth (attach I~ If available). ·
~ Public Utility
~olding Tan~ .
NOTE: THE INSPE~ION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Date Date Date Date
Inspector Inspector Inspector Inspector
Field
Notes:
BECE! ED
{ ~) APPROVED SEDROOMS ~ *CONDITIONS OF APPROVAL
( ) DISAP~OVED
( ) CO.mT~.ALAPPROVAL'
~ATE ~~ -./~ ~.
Soils Rating Date ~wer Install~ Well To ~sorptlon Area Well L~ R~elv~
Well to Tank Septic T~k Size