HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 3 LT 15BCampbell Heights
Lot 15B
Block 3
#014-072-47
,~NATER WELL RECORD
,MUN;CIPALITY OF ANO"IOI~AGE STATE OF ALASKA
DF~T. CF H~,~.T't ,'~ --
E~I~:~r~,~,TA~ ~gO:ECrl~[PARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysical Surveys
JUL ~ 8 1982
LOCATtOH OF WELL (Pleaee complete either la, lb o, lc.) .- . A.D.L. NO.
.~ ~~L°~
of of of-- ~S~ ~ w~
OISTANC AND~IR[CT~ON FROM ROAD INTEfl~CTION~ 3. OWNER OF WELL:
~,~/o-
// ,.,,.,,.
BockflnlnQ Grovel pock
I0. STATIC WATER LEVE~ /~ ft.
PERMIT NO.
DEPARTMENT OF HEALTH FIND ENYIRONMENTAL PROTECTION
825 ~L~ STREET, ANCHORAGE,
264-4720
· HELL PEEf'I Z T
APPLICANT
LOCATION
LEGAL
C&E ENT. INC
LISB B3 CAMPBELL HTS.
PO BOX 10-991
LOT SIZE
8733 SQUARE FEET
MINIMUM DISTANCE BETHEEN A HELL AND ANY ON-SITE SEIqAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE HELL OR t50 TO 200 FEET FROM R PUBLIC HELL DEPENDING
UPON THE TYPE OF PUBLIC HELL
MINIMUM DISTANCE FROM A PRIVATE HELL TO R PRIVATE SEHER LINE IS 25 FEET AND
TO A COMMUNITY SEHER LINE IS 75 FEET.
HELL LOGS ARE REC,~UIRED AND MUST BE RETURNED TO THE DEPARTMENT NITHIN ~0 DAYS
OF THE HELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
PERM I T E×P I RES DECEt'IBER 3:L. 1982
I CERTIFY THAT
l: I AM FAMILIAR HITH THE REOUIREMENTS FOR ON-SITE SEHERS AND HELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I HILL INSTALL THE SYSTEM IN ACCORDANCE HITH THE CODES.
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Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 'L" Street Room 502
P,O, Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage,ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D.
Expiration Date:
GENERAL INFORMATION
Complete legal description L,O~ ~-~ -P~.."~
Location (site address or directions) ,~..~ '~.
Current Property owner(s)
Mailing address ~-~q L~_~
Lending agency r'&c~c,~,-E~r,~
Mailing address f~ ~O (,L) . .-~.~',~,~I,'~.
Real Estate Agent
Mailing Address
· Day phone
pti K
Day phone
Day phone
Unless otherwise requested, HAA will be held by DHHS for pickup, HAA picked up by:
2. NUMBER OF BEDROOMS: -.'~
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 []
[] Community On-site []
[] Public Sewer 'C~
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Certificates of
Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independem
professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are
required for the transfer of title (except between spouses) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
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
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.
72.025 ~Rev 01 001'
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 the Health Authority Approval
application show 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 applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installation.
Name of Firm ,~ ,.,. ~
Address ~ '~ C')~
Engineer's Printed Name ~ I'c--
Phone'
DHHS SIGNATURE
Approved for ~ bedrooms.
Disapproved.
Conditional approval for __
bedrooms, with the following stipulations.
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
Expiration Date: ~ - /~, '- O ~
Original Certificate Date: ~-~'-'- / ,~ - oo
Reissue Date:
75-025 (Rev. 01,001'
* "Municipality of Anchorage-- CEiVz E
Department of Health and Human Services
Division of Envimnme.,r~ta.I Services ~Y 1 2
On-Site Sewices Section 825 'L Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us ...... '~.N~At S~'~o ~-,, ,.
(907) 343-4744
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ]O~L /~' 6 ~1/~. S
A. WELL DATA
Well type ~;~'~e_ IfA, B, or C provide PWSID #
Date completed .5'-/,2~,~ Sanitary seal
Total depth
5';z.. . Casedto 5~ It
FROM WELL LOG
/2.'
_'~ g.p.m
Date of test
Static water level
Well production
WATER SAMPLE RESULTS:
Well Log~
Wires properly protected
Casing height (above ground)
AT INSPECTION
~'o lq g.p.m
Coliform < ~1" co~o~ie;;;i 0(~';n' .... Ni~aate-~.'~rng/I -- ~)th;; I~c';;,;~a '~ i-co,0nie-s/i'00 mi
Date of sample: ~'//,P//A. ooo Collected by: ~'J/~ /~ ~
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Date installed Tank size
C ....
leaj')O. Uts -. '. F.o ation cleanout
Date of 'pumping
C. ABSORPTION FIELD DATA
gal Number of Compartments
Depression over tank __ High water alarm __
Pumper
Date installed
Length
Total depth
Soil rating (g.p.d./it2 or ff2/bdrm)
__fi Width __ft Gravel below pipe __
It Effective absorption area fl~ Monitoring tube
Date of adequacy test __
Fluid depth in absorption field before test in
Elapsed Time: min Final fluid depth
Any rejuvenation treatment (past 12 mo.) (Y/N & type)
Results (Pass/Fail)
Water added"
in
System type
__ Depression over field
For bedrooms
__ gal. New depth
Absorption rate >=
.If yes. give date __
in.
g.p.d.
(Rev.
D. LIFT STATION
Date installed
"Pump on" level at in
Datum
E. SEPARATION DISTANCES
Size in gallons __
"Pump off" level at __
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Jn
Septic tank/lift station on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
Manhole/Access
High water alarm level at __ in
Meets alarm & circuit requirements
On adjacent lots
On adjacent lots
Public sewer manhole/cleanout
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Property line
Water service line
Wells on adjacent lots
Building foundation
Water main
Drainage
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line Building foundation Water main
Wa(e? Service line Surface wahe~
Curtain drain
COMMENTS
Wells on adjacent lots __
G. ENGINEER'S CERTIRCATION
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 9ffect on this dat~
Engineer's Printed Name Y~_ ,',F.~/~ ,--Y (~/Y~'~ v- ~'/
Date Z.~ c~
Absorption field
Surface water
Driveway, parking/vehicle storage
Waiver Fee $
Date of Payment
Receipt Number
72~26 (Rev.
NORTHERN TESTING LABORATORIES, INC.
3330 INDUSTRIAL AVENUE FAIRBANKS, ALASKA 99701 t907) 456.3116 · FAX 456-3125
8005 SCHOON STREET ANCHORAGE, ALASKA 99518 t907) 349-1000 · FAX 349.1016
POUCH 340043 PRUDHOE BAY. ALASKA 99734 (907) 659 2145 · FAX 659 2146
Gall M. Agen
3943 E. 67th Avenue
Anchorage, AK 99507
Attn: Gall Agen
Client ID:
Client Prqiect #:
Source:
NTL Lab#:
Sample Matrix:
Comment3:
IMethod Parameter
Kitchen Sink
AI66072
water
Report Date: 5/4/00
Date Arrived: 4/19/00
Sample Date: 4/18/00
Sample Time: 6:00
Collected By: Richard Oldford
** Legend **
MRL ~ Method Report Level
MCL - Max. Contaminant Level
B - Presen~ In bletl~xt Blank
E - Eslimated Value
M - Matrix Inlefference
H - Above MCL
D ~ Los~ To Dilution
Dale Date ]
Units Result MRL Prepared Analyzed
SM 4500 NO3 E
Nitrate-N
mg/L 0.70 0.10 5r2/00
Reported By: Wendy M. Mitchell
Anchorage Chemistry Supervisor
.,.~-' APPLIC'~NT FILLS OUT UPPER HAL'~"ONLY
Address Zip
Lending ,nstl~tton i~ ~ ~ ; ~; ~ g~ ~ ~ Phone
Address
~ Single Family
~ Other
~ndlvld~l A~ACH ~LL L~. A w~l I~ Is t~ulr~ for ail wells drll~ since June 1975.
NOTE: THE INSPECTION ~E MUST ACCOMPANY ~CH RE~EST BEFORE ~ES~ING CAN BE INITIATED.
Time Time Time Time
Inspector ~ ~ Insp~tor ~ Insp~to~ ~ % ; Insp~tor
' ( ~APPROVED mDROOMS ~ ~ ~*.~ Q~.CONDiTiONS OF~APPROVAL
( ) DISAP~OVED
( ) CONDIT~NAL APPROVAL'