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Home My WebLink AboutCAMPBELL HEIGHTS BLK 1 LT 4C MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. ~ .WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geologicol 8, Geophy$icol Surveys Located ~tw~eh ~t 67th ~d E~t 68%h ~,d,,,,: 4029 E~st 68th Street Streets, ~ luch~. ~.ch~, ~ 99507 Feel Below 4. WEL~ D~PTH: (final) S. DATE OF COMPLETION S~d - Co~se %o fine - wzter ~e~g c=o~ ~3 ¢~ 8. CASING: ~ ThteQded "~ Wilde4 DE~. OF H~ ~ & sef between fl. and ~f. ~JRo~[N '*~ ~R~ ~ ,o..~T,~ .,,,, ~v~, 2~ .,,. ~2/8: 9b~"~ ".'""': (" "'"""""' "' ~'1~ · . ,,::..,: ~ ~o~c~ "" PERMIT NO: DATE ISSUED: APPLICANT: ADDRESS: CONTACT~ PHONE: MUNICIPAI--ITY OF ANCI-IORAGE DEPARTMENT OF HEALTH AND ENVIRONME.NTAL PROTECTION 8-'~5 L STREET~ ANCHORASE~ AK' 99501 264-4720 ON--S ITE I~,,JELL PERM I T 850059 02/21/85 WILLIAM A. BELENSKI 4029 E. 68TH ANCHORAGE, AK 99507 549-6245 LEGAL DESCRIP: SUBDIVISION:[H~L HTS.' "' LOT: 4C ' BLOCK:. 1 ' SECTION: 4 TOWNSHIP: 12N RANGE: 5W ' LOT SIZE: 14840 (SQ.FT. OR ACRES) I certify that: 1. I am ~amiliar with the requirements [or on-site ~ewers and wells 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 regulations, and in compliance with the design criteria o~ this permit. ~. I will adhere to ali MOA and State o~ Alaska requirements ~or the set ~ack distances ~rom any existing well, wastewater disposal system or public sewerage system on this or any adjacent or nearby.lot. SIGNED ~ __ APPLICANT: .... PERHIT NO. RPPL I CRHT LOCAT I ON LEGAL !"1UI'-,I I O I PAL I TY OF AI'46HORI=ICE DEPARTMENT .?'~'~HE8LTH AND ENVIRONMENTAL '!"~)TECTION 825 '"~' STREET., ANCHORAGE., AK. 9.9~..;2 264-4729 I-4ibb PERI"1 I T ( 830864 ) WILLIRH R BELENSKI 402.9 E 68TH ANCHORAGE 9.9507 SIHGLE FRHILY DHELLIHG ONLY ' L4C B~. CRHPBELL HEIGHTS 24~-4~30' LOT SIZE 999999 SQU8RE FEET MIHIHUH DISTANCE BETWEEN R HELL AND AHY ON-SITE SEHAGE DISPOSAL SYSTEN IS 'J. 00 FEET FOR 8 PRIVATE WELL OR 150 TO 2~0 FEET FROH R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WELL. HINII'IUH [*ISTRNCE FROH A PRIVATE WELL TO A PRIVATE SEHER LINE IS 25 FEET AND TO R 601'IHUHITY SEWER LINE IS 75 FEET. WELL LOGS ARE REQUIRED RND..HUST BE RETURNED TO THE ~EF'RRTHENT WITHIH ]0 DRYS OF THE WELL COHPLETIOH. OTHER REC~UIREHENTS 14AY APPLY, SPECIFICATIONS AND COHSTRUCTION DIRGRRHS ARE 8VRILABLE TO IHSURE PROPER INSTALLATION. PERI'I I T E×P 'r RES BEOEI'IBER ~'I., I CERTIFY THAT i: I RH FRMILIRR WITH THE REQUIREHENTS FOR ON-SITE SEWERS 8Nr~ WELLS RS SET FORTH BY THE, HUNICIPRLIT~ OF RNCHORRGE. 2: I HIL~Ti~L ~S~ IN.RCCORDRNCE WITH THE CODES. SIGNED: ~~-~- ' ~PLIS~I~ ~ BELENSKI ' >Z V4. 0 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Lot 4c~ Block I Campbel Heights Subdtv~$Op/ Ti2N R3W Section 3 Location (address or directions) 4010 E. 67th Avenue Anchorage (b) Applicant Nam(~m. Belinsk! Telephone: Home 349-626.'~ Business Applicant Address 4029 £. 68th Anchora_s~e (c) Applicant is (check one): Lending Institution I-I; Owner/builder []; Buyer I-I; Other I-I (explain); (d) Lending Institution Alaska Mutual Bank Address 1500 W Benson Blvd. Pouch 6-9003 (e) Real Estate Company and Agent N/A Address Telephone 338-7890 Telephone (f) Mailthe HAAtothefollowingaddress: Wm. Belinski 4029 E. 68th Anchora~e~ Alaska 99507 TYPE OF RESIDENCE Single-Familyt'~ Multi-Family D Other Number of Bedrooms (3) Three WATER SUPPLY Individual Well ~ Community I'-I Public r'l Note: If corn munity well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status, 4. SEWAGE DISPOSAL Onsite I"1 Public I~( Community I'1 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 ?;.025 o~,~ 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, 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 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 q.~l~-n F.n~'lne;,r'ln~: Tn~'_ Telephone (907~} 276-3770 Address /,01 East Fireweed Lane Date Engineer's Seal This office has receivedwritten confirmation from the engineer (quadra Engineering Inc.) that the conditions of Harch 11, 1985 Have been met. Therefore, this property meets H0A require~hts. DHEPAPPROVAL .,~J~.(~. .... ~ Approvedfor (3)Threebedr°°msby(~'~/w"~--'~)kJ~. Date June 12t 1985 Approved ~'x DiSapproved~J Condifiona~t-~/ Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) Issues Health Authority Approval certificates based ~olely 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 72-0~5 (11/84) 401 E. EIREWEED LANE ANCHORAGE, ALASKA 99503-2197 (907) 276-3770 ANCHORAGE · JUNEAU BETHEL June 11, i985 Municipality of Anchorage D.H.E.P. 825 L Street Anchorage, Alaska 99501 Subject: Lot 4'C, Block 1, Section 3, T12N, MUNICIPA~.IT't' ¢~, ,: .;. ,, DEPI. QF ' Campbell elghts E-C' EED R3W Inspection Addendum Gentlemen: Please refer to the D.H.E.P. inspection completed on this property dated March 5, 1985. This report illustrates the electrical and water lines from the well to be above ground in temporary locations. On June 11, 1985, we again inspected the well and found the wiring encased in conduit and below ground. Similarly, the waterline is now located below ground in an acceptable location. Sincerely, Michael E. Anderson, P.E. MEA/jb MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4720 Application Date Hatch 5. 1985 GENERAL INFORMATION (a) Legal Descr~ (include lot, block, subdivision, section, township, range) Lot 4~ Blk ! Campbell Heights Sec. 3 TWN 12N R3W Location (address or directions) 4010 E. 67th Avenue. Anchorage (b) Apphcant Name ..~~k i Telephone; Home .~.~ -.~rz~._~ Business . Apphcanl Address 4 O~S__J~68 ~i.~,~,/lC~tOF. D.g (I. (C) Applicant is (check one): Lending Institution r"l; Owner/builder'l~; Buyer I-I; Other D (explain); (d) Lending Inshtution ~,<'/~- /ql,-~,~:,q. · Address ,,j~ ¢!, ~ J~ E,'~£,,'/ (e) Real Estate Company and Agent Address Telephone (f) MailtheHAAtolhefollowingaddress: Wm. Belinski 4029 E. 68th Anchorage. Alaska 99507 TYPE OF RESIDENCE Single-Family[] Multi-Familyr-I Number of Bedrooms 3 WATER SUPPLY Individual Well ~] Community I~ Public [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. 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 I of 2 72-025(11 841 ENGINE[' tlltif'i fIRM PROVIDINLt ~'LCTIONS, TESTS, FILE SEARCH, DATf""~D INFORMATION · . .~,~ I. snal affixed hel~,h~ , As ce~mn'~''' Y ' · .,d a~ iq I1~o validation dalo shown below, I verify that myinvestigation of this Health . ~ /or wastowater disposal s~tem is safe, functional and adequate forthet~ ' I~l i tyof Anchor ~ , ' ' ' dhorein fu~herverfythatbasedonthe nformationobtained from the ~J~ll~ i -'-m :-: ~ ~lll ~ mid from my nveo nat On and insnect on the on-s te water su and/or wastewa * *' ' ~ '"'[ ~ ~ th al Munic pa and State codes, ordnances, and regu at ons in effect on the date t~f I1,1~ ilmpection. Name~tlH' QUAD~ ~tl~l[ttt~[,t,[tlq' ~nC, ~Telephone (907) 276-3770 $/b/~ - Date ~ ---, ,, -t~''~ -* ' I I,H,v,,, Date ,d'.,~------.~._ Conditional ~ · ~...~.-.,-nal Approval · - CAUTION 'i'h¢ \'' '""~ '~' "" '~'"~':'"'~'~"~= f'~l""hl"ld ol Health end Environmental Protection (DHEP) issues HeaIth Authority -" :'"¢-="'='7 :e'~" VAil ~q.,h I1., I"presentation.~ ['t~,en in paragraph 5 above by an independent professional ''''' ' ' ' ~'~'~: ''f I11'';1'. I I'~ DHEP dOeS thl~ as a courtesy to purchasers of homes and their lending i,,~~ ' WELL DATA Well Classification Well Log Present (Y/N) Total Depth t'~ I,:;JN;CJPALITY OF DEPl'. OF MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (~) CHECKLIST - FEBRUARY 1~ I,~,'~R 0 ? ~85 L~,I ~ript,o.: ~O[ IVED c _ . A, 8, c, D.E:C'. A WN) ¥ DateComplele9 3/3/85~"'"~ ' Yield 8 ~;PM 5 8 ' ~ Depth of Grouting None~.------"'"~ 6 0 ' 271~Ca~ to Pump Set At 54 ' Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) Static Water Level Casing Height Above Ground ~ 4" ~ Electrical Wiring in Conduit (Y/N( ~ j~[ Si.trainer) Separation Distances from Well: ~ To Septic/Holding Tank on Lot N/A To Nearest Edge of Absorption Field on Lot N/A ; On Adjoining Lots City Sewer ; On Adjoining Lots City Sewer To Nearest Public Sewer Line 130 ' / To Nearest Public Sewer CIeanout/Manhole 100 ' ~ To Nearest Sewer Service Line on Lot Water Sample Collected by QUADRA - McFadden ; Date 3/4/85 Water Sample Test Results Passed. Comments Tem[3orar~/ water & electrical is above ground - should be buried this summer. B. SEPTIC/HOLDINGTANKDATA- Public Sewer System.~-'''~ Date Installed ~,".,.~,.~ Size No. of Compartments Standpipes (Y/N) ~'~".~ Air-tight Caps (Y/N) Foundation Cleanout (Y/N) Depression over Tank (Y/N~ Dale Last Pumped ~ ~ Pumping/Maintenance Contract on File~(~../~) ~ ; for Holding Tank High-Water Alarm (Y/N) ~ Temporary Holding Tank Permit (Y/N) Separation Distances from Septic/Holding Tank: ~ To Water-Supply Well __ To B13fl~jng Foundation ~ To Property Line .~. To Disp-osa'~~ To Water Main/Service Line To Sb,e~ Pond. Lake. or Major Drainage Course ~ Comments Page I of 2 72-026( I 1/84} C. ABSORPTION FIELD DATA N/A Soils Ratio~Absorption Strata Date Installed ~ Width of Field ~ Results of Lest Adequacy Test Separation Distance from Absorption Field; To Water-Supply Well To Building Foundation Lot To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Comments Type of System Design Lenglh of Fiel~l Depth of Field Gravel Bed Thickness Standpipes Present (Y/N) Date of Last Adequacy Test To~~y Line To Existing or Abandoned System on ; On Adjoining Lots "~ To Cutbank (if present) "~.._ LIFT STATION N/A Dimensions ,,S~ize ~in_ G~ali~ n s ~ Manhole/Access(Y/N) "Pump On" Level at '""-,.__ "Pump Off" Leve! at High Water Alarm Level at ~ Vent (Y/N) Tested for ~ Pumping Cycles during Adequacy Test. Meets MOA Electrical Codes (Y/N) ~ Comments ~ "Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verif)~d, or conformed to all MOA e~nd ~.IAA guidelines in effect on the date of this inspection. Company~*~ ~4/~J~ MOA No. Receipt No. % '~ ""~-) ~ :* --~ OF ' ;'~t- '" Date of Payment ~ '~ -~ 5 ~ ~ .~.~.~t "~ Amounts ~,~ ~*/4~ ~ ~';.~:~ .............. Engineer's Seal