HomeMy WebLinkAboutCAMPBELL HEIGHTS BLK 4 LT 20B'\,
Lot ..2ORB
[#014 072-84
· Date Drille~
S~atic water Level
Draw Down
I
Ty~e ~aterial Drilled~
~O feet
feet
Gallons Per Minute
Total Feet of
0 fee% to
to
to
to
~o
Hefty Drilling
S.R.A. Dox 1553 H
A ~chora6e ,Alaska
DEPT. OF HEAI.DI &
Lq~*VI~OI~NI'A~. PROTECTION
RECEIVED
2E, 4-4720
HELL PERrq T T
PERHIT H0. (
APPLICRNT DANIEL G HODGE C~36 WINCHESTER ~507
LOCRT I OH
LEGRL 'L2~B B4 CRHPBELL HEIGHT5 LOT SIZE
HINIHUH DISTRNCE BETWEEH
~8~ FEET FOR R PRIVRTE WELL OR i5~ TO 2~ FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MIWIHUH DISTRNCE FRO~i~R PRIVRTE WELL TO R PRIVRTE ~EWER LINE I5 25 FEET RND
TO R COMMUNITY SEWER LINE I~ 75 FEET.
WELL LOGS RRE REQUIRED RND HU~T BE RETURWED TO THE DEPRRTHEHT WITHIN 3e DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS HRV RPPLV. 'SPECIFICRTIONS RND CONSTRUCTIOH DIRGRRHS RRE
RVRILRBLE TO INSURE PROPER IHSTRLLRTION.
,
PERI1 I m EX~ I RES DECErlBER 31~ 1983
I CERTIFY THRT
1: I RH FRMILIRR WITH ~THE REQUIREHENTS FOR ON-SITE ~EWERS RND WELLS RS SET
FORTH BY THE MUNICIPR~ITY OF RNCHORRGE.
2: I WILL INSTRLL THE[SYSTEM IN RCCORDRNCE WITH THE CODES.
~49-2538
99~99 SQURRE FEET
V4. 0
.for
t
~AN s t~lt3
~-~JUNICIPALITY OF ANCIIORAGE ..~
Hea~ ~, and Environmental Protec' ~n
Fourth Floor West
825 L Street
Anchorage, Alaska 99501
264-4720
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
LOCATiO,~j 3(,~:~'"? ~. &7-- LEOALDESCRIPTION__~-~7" ~ ~ /~ ~ ~ ~J~
SEPTIC TANK:
DISTANCE
FROM W~LL/~ MAe~UFACTUIIE R MATFRIAL
INSIDE LEr~GTH J__ INSIDE WIDTN LIQUID DEPTH
NUMBER OF
COMPARTMEt4TS
LIQUID CAPACITY.__ GALLONS.
TILE DRAIN FIELD:
DISTANCE i-ROM WELL .~._~-- FOU;JDATION NEAREST LOT LINE
· ~ of Lines / DISTANCE BETWEEN Lli*'JES
A SO,mIo:, ;.REA----3D,4 SQ. FT. LEITH OF EAC. ',NE
J DEPTII OF FILTER
DEPTll; TOP or T.,.L__~39 C~A~E M^TER,^L DENEATH TILE ~
OF LINE
TREHCll WIDTI~.~(~. IN. TOTAL EFFECTIVE
ABOVE TILE ~ IN.
SEEPAGE PIT:
Log Crib Rings
BUILDING FOUNDATION
DIAMETER OR WIDTtt LENGTH DEPTH
Crib Size: DIAMETER__L)EPDt DISTANCE FROM: WELL
TOTAL EFFECTIVE
NEAREST LOT LINE ABSORPTION AREA (WALL AREA)
SQ. FT.
Well
Class: Depth
Well Distance To: Lo~ Line
Bldg: Sewer Line:
Pipe Materials:
# of Bedrooms~!
Installer:
Remarks:
'i
! I
DATE~ '-"=~ - "'~ '"~\I"P R eVE O
'DEPARTM~.NT OF HEALTH AND ENYIRONHENTAL PROTECTI~,NiD'S'q-~'' '"~'/""~p,
8~5 'L' STREET, AI`ICHORRGE, PK. 9:~50:1l 279-25:L:L
OI",I--S T TE SE[dER PEEI"I T T
PERI'lIT NO. ( 7790~: )L
APPLICANT HERMAN HOKE~ 3657 E E;TTH E,6:g~ E HINCHESTER NONE
LEGAL L20 ~ ~ ~ ~ LOT SIZE :L8270 SQUARE FEET
TYPE OF SOIL ABSORBTION SYSTEM IS: TRENCH
MRXIMUH NUMBER OF BEDROOHS = ~ SOIL RATING (SQ FT?BR>= 90
THE REQUIRED SIZE OF ~THE SOIL ABSORPTION SYSTEM IS:
DEF'TH= 6 LENGTH= ...~4 GRR"-,,'EL DEPTH= 4
THE LENGTH DIHENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTANCE BETHEEN THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET WI~TH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRR'VEL BETHEEN THE OUTFRLL PIPE
AND THE BOTTOH OF iTHE EXCAVATION (IN FEET).
REQU I RED SEPT I C TRNK S I ZE= :l. eg~"~ GALLONS
pACI-<AGE PLANT OPT T 0 I'-.I
R PACKAGE PLANT MAY BE INSTALLED AT THE PERMITTEE"S OPTION SUB3ECT TO THE
FOLLOH I NG COND I T IONS:
4. EITHER A CLASS ! OR II NSF APPROVED PLANT MAY BE INSTALLED.
2. R CONTINUOUS M,RINTENRNCE AGREE~IENT IS REQUIRED. IF A I`IRINTENANCE
AGREEMENT IS NOT KEPT CURRENT YOU MAY BE REQUIRED TO ENLARGE THE SOIL
RESORPTION SYSTEM AND/OR YOU MAY BE SUBJECT TO PROSECUTION.
TI-,-i 0 ':: 2 ) 'r NSPEP~T T OI'-,IS PRE EEI;:;U T RED
SY~TEI'! WITHOUT FINAL INSPECTION Al'iD RPPROVRL BY THIS
BRCKFILLING
OF
ANY
DEPARTMENT HILL BE SUBJECT TO PROSECUTION.
I'IINII'IUI'I DISTRNCE BETHEEN R HELL AND ANY ON-SITE SEIqRGE DISPOSAL SYSTEM IS
't00 FEET FOR A PRIVRTE HELL OR 200 FEET FOR A PUBLIC HELL.
OTHER REQUIREMENTS I'IR¥ APPLY. SPECIFICATIONS RND CONSTRUCTION DIRGRRMS PRE
R'./AILRBLE TO INSURE PROPER INSTALLATION.
PEEl-'1 T T EXF-;'~ 'r RES DECEI-qBEE g-1, '1977
I CERTIFY THAT
1: I RM FRMILIAR HITH THE REQUIREMENTS FOR ON-SITE SEHERS RND HELLS RS SET
FORTH BY ]'HE MUNICIPALITY OF ANCHORRGE.
2: I HILL INSTRLL THE~SM$TEM IN RCCORDRNCE HITH THE CODES.
~: I UNDERSTRND THRT ]'HE ON-SITE SEWER SYSTEP1 MRY REQUIRE ENLARGE~IENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THRN ~ BEDROOMS.
SIGNE
........
APPLICANT HE-,P~RN HOKE ~:E;57 E ~7TH
GAAS. HD.I
G~,TER ANCHORAGE AREA BORO~H
' HEALTH DEPARTMENT / ~
327 EAGLE ST. ANCHORAGE, ALASKA 99501 279-2511
INSPECTION REPORT ON-SITE SEWAGE DISPOSAL SYSTEM
NAME
LOCA110N
SEPTIC TANK:
DISTANCE FROM WELL
uou D CAPAC.Y
ADDRESS
LEGAL DESCRIPTION~
MATERIAl
GALLONS. INSIDE LENGTH
NUMBER OF /
COMPARTMENTS
INSIDE WIDTH -T¢ '-.-"' DEPIH '-,.-,~' ~
SEEPAGE SYSTEM:
NUMBER OF PITS
LINING MATERIAl
NEAREST LOT LINE
SEEPAGE PIT:
~ OUTSIDE DIAMEIER__OR WIDTH
DISTANCE FROM WELL
LENGTH /~ / /
. DEPTH ~
. BUiLDiNG FOUNDATION ~' /o
__ oo
TOTAL EFFECTIVE ABSORPTION AREA JWALL AREA) .SQ. FT.
TILE DRAIN FIELD:
DISTANCE FROM WELL
NUMBER OF LINES '
ABSORPIION AREA ~
DEPTH= TOP OF TILE TO FINISH GRADE
TOTAL LENGTH
, FOUNDATION. , NEAREST LOT LINE ., OF LINES
DISTANCE BETWEEN LINES TRENCH WIDTH
SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER MATERIAL BENEATH TILE
IN. TOTAL EFFECTIVE
IN. ABOVE TILE
WELL: TYPE ~ ~ , DEPTH ,~]) DISTANCE FROM / '7/ ' WATER
' , BUILDING FOUNDATION. ~'~' ~ SAMPLE ~ , NEAREST
LOT LINE , SEWER LINE , TANK , SYSTEM , CESSPOOL , SOURCES
DISTANCES:
GREATEI. ANCHORAGE AREA '._OROUGH C,~No.
· I IIEALTH DEPARTMENT
327 Eagle St. Anchorage, Alaska 99501 279-2511
SEWAGE DISPOSAL SYSTEM - APPLICATION & PERMIT
NAME OF APPLICANT ,'~'~ ~ ~J
RESIDENCE ADDRESS · ~
LEGAL DESCRIPTION
APPLICATION TO INSTALL: BEFTIC TANK
TO SERVE THE FOLLOWING FACILITY
-G I1~
I
LOCAt,ON OF ,NStAL t, DN
· SEEPAGE PiT , DRAIN FIELD , OTHER
MAILING ADDRESS ~ ~ W/'M~'5~PH~NE N0.~¢4-~0c'~
~E"C0~TION TEST "EsuLTs ~ ~/~//~C~ ANTICIPATED BATE OF COMPLETION
~ BELOWTO BE FILLED OUTBY HEALTH DEPARTMENT ~
AS DESCRIBED BELOW.
. SEPTIC TANK SIZE ~'"~('f~:, TYPE~ SEEPAGE AREA ~::~..~:~/TYPE
DIAGRAM OF SYSTEM
[0
II
11
I certify that I am familiar ith the requirements of Greater Anchorage Area Borough Ordinance No. 28-68 and that the
above described system is in accordance with said code.
t on t uatton .fat?
2204 Cleveland Anchorase, Alaska 99503
,rman Hoke Date Performed
Lot 2o Block 4
Performed For
Leflal ~escrtntton:
Thts Form Renorts Sotls Lo.
~eDth
Feet
Sandy Gravel
m
12--
14-- Bottom ~of Test Hole
16--
Ye~
Characteristics
9-9q-77
Campbell Heights
Percolation Test_
Was 6fourth Ware1
If Yes, At what
Encountered? Yes
iDepth? 10'
Readtnq Date Grnss Ttme Net Ttme Depth to HZ0 Net Dron
Percolattnn Rate ~ Utflute
Prn~osed Inst~ilatton: Seenaoe Pit Dratn Fteld
Oeoth of ~nlet Oepth To Bottom Of Pit Or Trench
C~MPEN?S: 90 Squ~re feet required per bg~rogm
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) 343-79O4
Mading address_
Lending agencY
Mailing addre s
Real Estate Age[t
Mailing Addr!ss
/
Un/ess otherwise tequesfed, HAA
I
2, NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
nd v due Water Storage
Community Class
Public Water System
The Municipality of ,~nchorage Development Servlces Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil
englneer registered iff the State of AJaska. Certifcates of Health Authoribj Approval are required for the transfer of
title (except beb, veenlspouses) for properties served by a slngle family on-site wastewater disposal and/or water
supply system. DSD ~lSO issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days fror~ 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
valid water samples.) Certificates are valid for one year for properties served by Class A or B weIis or a public
water system. The ~,,luniclpality of Anchora[;e is not responsible for errors or omissions in the professicnal
engineer's work.
"~,~t (~'~'A ~'~ e ,'- Day phone 7g/.,- 3~o
Day phone
~l~ ~c~ ~e~ Dayphone ~7d-~TUt
wi#be held by DSD for pickup.
~PE OF WASTEWATER DISPOSAL:
~ Individual On-site ~
~ Individual Holding tank ~
Well ~ Communi~ On-site ~
~ Public Sewer ~
...CERTIFICATE OF HEALTH AUTHORIT)', .APPROVAL
'" ;I FOR A SINGLE FAMILY DWELLING
Parcel I.D.'.Ofq- O'1.~-. r~q ' HA~,# , .
· ' J ' Expiration Date: ~-,~,. ~., - O I
1, GENERAL INFORMATION
Co.mplete legal descriptionLO
Loc~tioh' (site address or directions)' [&~ I-'~',,~e~'~5~'~-r'
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I vedfy 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 flies 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 instaItation.
Address ,,~.0,5 ~ /.~ F~ ~
Engineer's Printed Name
5. DSD SIGNATURE
~ Approved for ~ _
Disapproved.
Conditional approval for
Phone
Date
~ ~.~'.,*' ' E~GINEEP~:
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
X
Maintenance Agreements
Supplemental Engineer's Report
Other
/// /
Original Certificate Date: ¢.. ~ '~. -0 /
LOg~ Description:
A. WELL DATA
we" type ~.
Date completed I ~,
Total depth. ~, _~ ItI
Municipality of Anchorage
Oevelopment Services Department
Building ,Safety Division
On,Re Water & Wastawatar Program
4700 8ou~ Bmgaw St.
P.O. Box lg6650 An~omge, AK gg$19-6650
wvnv.ci.an~orage.ak.us
(~07) 343-79O4
HEALTH AUTHORITY APPROVAL CHECKLIST
If A, B, or C provide IWV~ID # %
we, Log (Y/N) ~.1
Wires pmpedy pmtacted (Y/N)
Casing height (above ground) I ;:2. in.
Date of test
Static water level
Well production
FROM WELL LOG
g.p.m.
AT INSPECTION
'6/,,.
lto
/1~ g.p.m.
WATER SAMPLE RBSULTS:
colOnies/lO0 mL
Data of sample:
I
B. SEPTIC/HOLDING yANK DATA
/
Tank Type/Idatariel
Tank size __ ~1.
Foundation deanaut
Date of pumping /'
Nitrate H O mo./L
Collected by:
Number of Compartments __
Depression Over I
C~er bacteria ~) colonies/100 mi.
· ~rodrm)
lt.
~ Monitoring tube
Results (Pass/Fell)
Water added
Date installed
Cleanouts (Y/N)
H~gh water alarm (Y/N)
C. ABSORPTION FIELD DATA
Date installed I Soil rating
Length I lt.
Total depth ~ lt.
Date of adequacy te~t
Fluid depth in absorp[lon field before
I.
Elapsed Time: __
Any mjuvermflon trel~'nent (pest 12
System type
Gravel below pipe
__ Depression over field
Width
iff.
,.) (Y/N & We)
For bedrooms
New depth in.
g.p.d.
Absorption rate >=
If yes, give date
D. LIFT STATION
Date installed
'Pump on' leve~ at in.
Datum
E. SEPARATION DISTANCES
Size in gallons /
'Pump oft' leve/~af
Cycles ~
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
Absmption field on lot Iq/A'
Public sewer main
Sewer/septic sewlce line
SEPARATION DISTANCES FROM SEPTIC/HOLDIN~ANK
Building foundation Property line /
Water main Water sen, ice line
Manhole/Acce_ ~ _~s (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhoteJcJeanout
Holding tank t~4/
ON LOT TO:
Absorption field
Surface water
Wells on adjacent lots
SEPARATION DISTANCE FROM ABSORPTI0~, IELD
ProperS/line Building fouTation
Curtain drain . Wells onfadjacent lots
ON LOT TO:
Water main
Driveway, partY, lng/vehicle storage
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
rev/ew of Municipal records that the above systems am in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name "~4~t
Dat, t
HAA Fee S ~4)e '/''t
Date of Payment
Receipt Number
(R~. 1~)
Waiver Fee $
Date of Payment
Receipt Number
JiY,-20-OI 08'33 FROU-CT&E
CT&E Ref.~ 1013350(~3
Client Name Tobben Spurkhnd P.E.
.~a me/~ T.C. / NO3
Prolm
Client Sample lB L20B B4 Campbell
Matrix ~rmklng Waler
Ordered By
pWSID
Microbiology, Laboratory
R,:suhs PQL Umu Method
T-cog P.04/C~ F-854
Client PC),'~ Pre-Pa!d Coi/s.'NO3
Printed Date/Time 06119/2001 17:37
Collected Date,Time 06/13/200! 12:00
Received Date/Time 06~'14/2001 9:50
Technical Dirtctor Stephea C. Ede
AIh)v, able Prep
05C0 U 0.$00 mg/L EPA 300 0 (<10) 06/14,01
0 coI/100mL SMISg222B
f<l) 06/14.'01 ~KV.'
Parcel I.D.
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
GENERAL INFORMATION
Complete legal description
Location (site address or directions) ~'~'
Property owner Day phone
MailingaddressI /~g'"~, L~'l~'lC.~e~.; 5~
Lending agency, Day phone
Mailing address!
Address _/)./~'J~"-'; ~":'"'-"-~ ~"-t
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~-~
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
Day phone
NOTE: If com,munity well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OFWASTEWATER DISPOSAL:
Ind v dual on-site
H(~ d rig,tank " ..
Comm~Jnity on-site
Pub c sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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.
Name of Firm .T'~,/~]~.,, ~ c:~p u, ~'~ I A J '~J~ Phone
Address ~,-~ "5 bi~ I~--~/, ,hi ~_..~ _.~ ~'c~
Engineer's signature ~ ~~-'~ Date
/
DHHS SIGNATURE
Approved for ~-
Disapproved.
__ Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health ~d Human Services (DHHS) issues Health Authority
A~proval 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 orderto 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.
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 * Anchorage, Alaska 99501 * (907) 343-4744
Health Authority Approval Checklist
/
Legal Descdpfion: J[d~'*~,'~ ~.~/J~PJ~:-/../-. ~-'/~//l~.Pamel I.D.:
A. WELL DATA
Well type i1~ f
Log present (Y/N) ~
Total depth ~' 5 1'
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed I q/~ ~
Cased to ~,~ ~:~ I Casing height (above ground)
~m~ seal
Date of lest
Static water level
Well production
Y
WATER SAMPLE RESULTS:
Date of sample: ' ~'///~/*
Date installed
Foundation cleanout
Date of Pumping (
C. ABSORPTION FIELD DATA
FROM WELL LOG
Wires properly protected (Y/N) ~
AT INSPECTION
Nitrate
__ Tank size
g.p.m.
Collected by:
Number of
Depression (Y/N)
,~ g,p.m.
Other bacteria ~
c,e.~'~Y~ ~__~ ~
Date installed
(g.p.dJfF or fta/bdrm)
~icknass below pipe
Effecave absorption area
Date of adequacy test I Results
· Fluid depth in absorption field before test (in.)
Fluid del~h lin~) Mthut~ I~ter:,
Peraxide treatment (past 12 months) (Y/N)
72-026 (Rev. 3/96)*
present (y/N)__
(Y/N) __
For
If
after gal. water added
= g.p.d.
D. UFT STATION
Date installed
Size in gallons
Manhole/Access (Y/N)
'Pump on" level at*
"Pump off" level at*
High water alarm level at'
*Datum
Cycles tested
E, SEPARATION DISTANCES
R
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Uff station t"///A -t'
On adjacent lots
On adjacent lots
Public sewer main
Sewer/septic service line
SEPARATION DIST~,~CES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation Property line Absorption field
Water main/service line ~ SurFace water/dratnage Wells on adjacent lots
SEPARATION DISTANCE FROM ~S~ION FIELD ON LOTTO:
Property line Building fouh~on Water main/sewice line
;::::r, .', wD~Ol .o:aa~::i~l: storage area
ENGINEER'S CERTIFI CATION '?.
I certify ;hat I have determined thru field inspections end rm4ew of Municipal re;Ord.;hat the above ~ster~s am
in conformance with MOA HAA guide/Ines in~ffect on this date.
I
HAA Fee
Date of Payment
Receipt Number
Waiver Fee $
Date of Payment
Receipt Number
72-o26 (Rev.
CT&E Environmental Services Inc.
Laborator Division r.w~xff~-.w-~f~-ffff~jj~.-jf~~~~
200 W. Potter Drive
Anchorage, AK 99518-1605
Tel: (907) 562-2343
Fax: (907) 56t-5301
CT&E Ref.#
Client Name
Project Name/#
Client Sample ID
Matrix
Ordered By
PWSID
963538001
Tobben Spurkiand P.E.
L20B B4 Campbell Heights
L20B B4 Campbell Heights
Drinking Water
0
Sample Remarks:
Client PO//
PHnted Date/Time 08/08196 08:09
Collected Date/Time 08/06~96 12:00
Received Date/Time 08/06/96 12:45
Technical Director
Nitrate-#
Totat Cotiform
ALtouabte Prep Analysts
Results PQL Units Hethod Limits Date Date Init
0.100U 0.100 mg/L EPA 353.2 08/06/96 ERB
~ 9 OB ~/0 COLI S~18 9222B 08/06/96 TAV
,~~ Member of the SGS Group (Soci6t~ G6n6rale de Surveillance)
ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA. FLORIDA. ILLINOIS. MARYLAND. MICHIGAN, MISSOURI. NEVi/JERSEY. OHIO, WEST VIRGINIA
Laboratory Division
Drinking Water Analysis Report for Total Coliform Bacteria 2o0 w. Potter 0r~ve
' ' Anchorage, AK 99518-1605
RF_~D INSTRUCTIO.%'S 0.%' REVER~E,7IDE BEFORE COLLECTI, YG SAMP£E Tel: (907) 562-2343
MUST BE COMPLEfED BY WATER. SUPPLIEK
PUmCW^TSRSYS'rm m# IIIIII ]
~"PmVAT£ WAX£d SYS~Z~t
n
0
.-=
Send Invoice
[J Send Results
SAMPLE DATE:
,Month Day Year
SAMPLE TYPE:
Roatlne
Repeat Sample (for routine sample
with lab ret. no. )
Treated Water
?~//Untreated Water
0 Special Purpose
Time Collected
SAMPLE LOCATION I Collected
k , J riel, se hint
Fax: (907) 561-5301
TO BE cOMPLETED BY LABORATORY
Analysis shows this Water SA.MPL£ to be:
~;~ Satisfactory
o Unsatisfactory
o Sample over 30 hours old, results may
be unreliable
Sample too long in transit; sample should
not be over 43 hours old at examination
to indicate reliable results. Please send
n?v sample via special delivery mail.
Date Received
Time Received
Analysis Began
Analytical ?,letbod: ,~'~Membrane Filter
0 MMO-MUG
* Number or'colonies/lO0 mi.
, ~,k n,,r. No. Result* Analyst
Sent lo A.O.£.C. Anch Fbl~ Jun
Date: Time:
Client notified of unsatisfactory results:
Phoned Spoke with
Date: Time:
BACTERIOLOGICAL WATER ANALYSIS RECORD
.M.MO-.MUG Result: Total Coliform E.
Membrnne Filter: Direct Count Colonies/100 mi
Verification: LTB -- .BGB '"-" COLIFIRM
Feca Coliform Confirmation
Time
~ Coliform/I O0 mi
/A ~ hfs
Final ,Membrane Filter Res,pits
L
t' "~ ' ~' r~.~LUW
[]
Fased
Faxed
ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA. FLORIDA. ILLINOIS. MARYLAND, MICHIGAN. MISSOURI. NEW JERSEY. OHIO. WEST VIRGINIA
IE~3/14/9G
09:45 CTSE ESI AHCHORAGE -, 90?5451355 H0.669
ZT~_- C T&E Environmental Se ~ices Inc.
~borat~ Division
' :~' " ' ~C ~ 2~ W Potte~ Orfve
D:~ng~atc~ ~a]ys]s R~poA ~o~.Tot~l Coliform ~ t
~D I~T~U~IONS O~ ~rE~E ~DE ~EFO~ ~O~LE~IN~ ~A.~/PL~ Tel: [907J 5~2.2343
I Fax: (~ 561-5301
M'dST BE COM?LETED BY WATER SUPPLIER
o PuDuc W^T~R sYn'~.,~ ,.O., I tl"llll
~ ~VATE WATER SYS~M
TO DE COMPLETED BY LABOR~TORY
Analysis shows t~is Wate~ SAMPLE to b~:
~ Sadsfacto~
O Unsatisfacto~
5ampl~ over 30 hou~ Ol~ ~sul~ may
be unreliable
Sam;lc t~ long in ~it; ~mple should
not ~ over 48 hou~ o1~ g ¢xamin~ion
to indlca~e ~liable r~sul~. ~lcu~ send
new ~ample via s~cial dcllve~ mail.
Date Received
T~me Receive*!
Analysis Began
AaatTti¢3! ~,tetbod: ~ Membrane Filter
O HMO-MUG
· Humber ofcolonicS/lO0 mi.
Lab Ret'. ~o. Result* Analyst
SAMPLE DATE:
I~Iontl~ Day
SAMPLE TYPE:
Treated Water
Routine
~epent Sample (for rc ati~e simple 0 ~Unt~ate~
with Inb rtl. no. )
O Speci,, Purpo,. / Ti~X Cold,ed X Oient ~otified of u~,2tisf, cto~ results:
SAMPLE L~ATION / / CoUcct~ J ~ By ~ .
BA~OLOGICAL WATER ~YSIS ~CO~
, I
MMO-MUG Retail:. Total Coliform £. Coil
Membrane F tier: DirettCount ~" O~ ~'//~ ~ ~' Colonial00 mi
Verification; LTD ' ' 8Ge ,,, COLI~RM
F~nl Coliform Con~atlon
{ ~ Collform/10g mi
Final Membrane Filter Re~ul~
0
Parcel I,D. #
1.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT (~F HEALTH & HUMAN SERVICES
Division of Envlronmental Services
On-Site Services Section
P,O, Box 196650 Anchorage, Alaska 99519-6650
343-4744
oIq' C
GENERAL INFORMATION
Complete legal descr pbon
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Location (s,teaddressord,rect,ons) ~(~.~:~' I~,~1~,~_~,~" ~--.~
Property owner
Mailing address
Lending agency
Mailing address
Agent
Address
~D~ne o~LTI- ~'-c~q2..
Day phone
Day phone
e
e
Unless otherwtse requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well
Commumty we
Public water
NOTE:
If comm, unity 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
Commumty 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 th~s Hea th Authority Approval application shows that the on-site water supply
and/or wastewater d;sposa system ;s safe, funct,onal and adequate for the number of bedrooms
and type of structure indicated here~n. I further verify that based on the information obtained from
the Municipality of ~,nchorage files and from my investigation and inspection, the on-site water
supp y and/or wastewater disposal system s in comphance with all Municipal and State codes,
ordinances, and re(~ulations in effect on the date of this inspection.
Phone ~-7~ "~/~
Approvedi,for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates b~sed 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 sat sfy 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'omissioits in the professional engineer's work.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: J~/~3~; ~,~4.~ Pamel I.D.
Well type "~ . If A, B, or C, attach ADEC letter. ADEC water system number
Date completed I ~~Driller
Cased to ~.-.-~ Casing height
Wires properly protected (Y/N) "/
FROM WELL LOG
Log present (Y/N) r,,~
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ ~'/,~
Absorption field on lot i /"//'~r--
Public sewer main ~ ~ ~.
Sewer sen/ice line
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~ i
Date of sample: to/il q'~
B, SEPTIC/HOLDING TANK DATA
Date Installed
Cleanouts (Y/N)
High water alarm (Y/N)
Nitrate ~ ~,~ Other bacteria ~'
Collected by: ~ /
.Tank size
Foundation cleanout (Y/N)
Date of pumping
Compartments
Depression (Y/N)
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
To property line
Sudace water/drainage
72-~6 (3/93)' Fn~t
On adjacent lots
Absorption field
Foundation
.Water main/sen/ice line
CONTINUED ON BACK PAGE
C. UFT STATION
Date Installed
Size in gallons
Vent (Y/N)
'Pump on' level at
Well on lot
D. ABSORPTION FIELD DATA
Date installed
.Length Width
Total absorption ama
Date of adequ~cv test
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
On adjacent lots
.Manufacturer
.Manhole/Access (Y/N)
.'Pump off' Level at r
Cycles tested
.Soil rating (GPD/FF)
.Gravel thickness
.Cleanout present (Y/N)
Results (pass/fail)
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots
Surface water~
.System type
.Total depth
Depression over field (Y/N)
.for
After test
yes, give date
Proper~ line
.To existing or abandoned system on lot
.Cuthank. .Water main/son/ice line.
Driveway, parking/vehicle storage ama '
HAA Fee $
Date of Payment
Receipt Number
72-026 (3193)° Back
Waiver Fee $
Date of Payment
Receipt Number.
Bedrooms
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in eff~t'ort the date of, this inspection.
Engineers Name
COMMERCIAL TESTING & ENGINEERING CO.
ENVIRONMENTAL LABORATORY SERVICES
· ,~c, ,.. I REPORT of ANALYSIS
Chemlab Ref.~ '.93.5222-I
Client Sample ID --L20B B4 CAMPB~ff. ~EIGHTS
Matrix
Client Name =TOBBEN SPURKLAND, P.E.
Ordered By -.TOBBEN SPURKLAND
Project Name ..
ProJect~ .'
PWSID .'UA
5633 B STREET
ANCHORAGE, AK 99518
TEL: (907) 5~2-2343
FAX: (907) 56;-5301
WORK Order ~71638
Report Completed :10/05/93
Collected ~10/01/93 @ 12:26 hrs.
Received t10/01/93 @ 17=30 hrs.
Technical Director:STEPHEN~. EDE
Released By ,
Sample Remarks: ROUTINE SAMPLE corx~ul*~u BY: STUART.
Parameter
Nltrate-N
! Results Q~i Units
/
Allowable Ext. Anal
Method Limits Date Date Init
0.10 U mg/L PA 353.2/300.0 10 10/04 LLH
* See Special Instructions Above UA = Unavailable
** See Sample Remarks Above NA = Not Analyzed
U = UndeteCted, Reported value is the practical quantification limit. LT = Less Than
D = Secondary dilution. GT= Greater Than
ENVIRONMENTAL SERVICES IN ALASKA, COLORADO, UTAH. ILLINOIS. OHIO. MARYLAND. WEST VIRGINIA. NEW JERSEY, SOUTH CAROLINA
MUNICIPALITY OF ANCHORAGE
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. # Z~/~ 0 7i~ ~(/Z- HAA # ~
1. GENERAL INFORMATION {Must be completed prior to submittal)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Property owner j/'~(~/~') /' '~,'o~'~ ! Telephone : (home)
(b) ., - L, ...,/.~_~ ~
Mailing Address ~'~"~ /..L./ ."~ .~u/ ~ t/
(c) Lending Institution ! ~./2~' ' Telephone
Mailing Address
(d) Real Estate Company and Agent /
A~dress
Telephone ~ /~
{e) Mail the H~ to the ~ollowin~ ~ddres~: ~or check here ~i~ hold ~or pick
U~t contact per,on ~nd day phono number below:
/3//
2. TYPE OF RESIDENCE
72-025 (Re~, 7/B8)
Single-Family ~" Number of bedrooms
WATER SUPPLY
Individual Well (~ Commun ty D Public~3
Note: If community wel! system, must have Written confirmation from the State Department of Environmental
Conservation attesting to th legality and status: ' '
SEWAGE DISPOSAL
On-site I-I Public [~j Community [] Holding Tank []
Note: If community wel system, must have written confirmation from the State Department of Environmental
Conservati.o.n attesting to the legality and status.
Page I 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, 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.
,,z}.s.soc. Telephone 2. - / 3 / /
Name of Firm
Address ~DO~) ~'. /_~/'13.7~/30I /...~ / ~, o/. ~'Z.~..,,' ~ 2 ~:::)..G" -
6. DHHS APPROVAL
Approved for
Approve~ : ~"~'"" Disapproved
Terms of Co~ditional Approval
bedrooms by j~~ ~' ~ Date
Conditional
The Municipality of Anchorage 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 Mu nicipality of Anchorage is not responsible for errors or omissions
in the professional engineer's work.
Page 2 of 2
A. WELL DATA
'~ MUNICIPALITY OF ANCHORAGE (MOA)
A[ITY OF ~.~l~l~thorlty Approval (HAA)
ENTN. SER~- FEBRUARY 1984
~' . ~/~3.4744
AUG - 7 1989
RECEIVED
Legal Description:
Ac,/- .2o z3 /'31,oc/<
Well Classification
Well Log Present (Y/N) I ~ Date Completed /.~./") ~
· , I ' ~' ~ ~ Depth of Grouting
Total Depth .-,' J~",~Cased to
Static Water Level I '~O ' Pump Set At C{.../'1//~ Y') O
Casing Height Above Ground '~-- Sanitary Seal on Casing (Y/N)
E ectr ca W r ng in Conduit (Y/N) ' Y Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL: ,, ·
To Septic/Holding TankIon Lot t3//'~_. ; On AdjOining Lots '
To Nearest Edge of Absorption Field on Lot ; On Adjoining Lots
To Nearest Public Sewer Line c~ ~:~ 'Y~ To Nearest Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot ~ '
,
Water Sample Collected by /[~'. /-. I',~ ~.~ ~ ; Date
Water Sample Test Results
If A, B, C, D.E.C. Approved (Y/N) Yield ,~"'..,~
Datelnstalled ~,~ " ·Size ND. of Compartments
Standpipes (Y/N) ~ Air-tight Caps (Y/N) Foundation Cleanout (Y/N)
Depression over Tank (~Y/ _ Date Last Pumped ·
· 'P'umping(MaintenanceiC°ntact/on Fi'~l~ ~. ; for'
Holding'Tank High-Water Alarm (y/N) ~ Temporary'Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOL
To Water-Supply Well
To Property LIn~ - To Disp
To Water Main/Service Line
To Stream, Pond, Lake or Major Drainage Course
Comments
Page I of 2
C. ABSORPTION FIELD DATA
Soils ~ng in Absorption Strata
Date Install'e(
Width of Field~'~
Square'Feet of Abso~
Depression over Field (Y/N)
.Type of System Design
, Length of Field
Depth of Field
· Gravel Bed Thickness
Statndpipes Present (Y/N)
Date of Last Adequacy Test
To Water Main/Service Line
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Results of Last Adequacy Test
SEPARATION DISTANCE FROM A~'SoRPTIoN~ '
To Water-Supply Well _ To..P~perty- Line
To Building Foundation '~ ~ To Existing or Abandoned System on
Lot r . ; On Adjoining Lots""~
To Cutback (if pre'es r~
Date Installe~ Dimensions
Size in Gallons ~ Manhole/Access (Y/N)
"'Pump On" Levelat ~ ' ' '
'"Pump Off" Level at
High Water Alarm Level at ~
Tested for
Meets MOA Electrical Codes (Y/N)
Comments
Vent (Y/N)
~"~-~....~umping Cycles during Adequacy Test.
Check Perm Bedro g Against HAA Request . ~"'"'~
I certify that Ijl~f~v~xC~eck~e~', v.efified, or confo, rmed to all MOA and HAA
inspection. ///////~// ..,., .
Signed I ~I~ ~"
Date [ ~2~ /'
MOA NO. ~¢~~ ' '
date of this
iEngineer's Seal
Receipt No.
Date of Payment ~- 7-2~
Amount: $
I~fect 0r~';he
OF ,
Receipt No.
Waiver Fee: $
Date of Payment
Page 2 of 2
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
FEDERAL TAX ID it 9243040440
Client ~ample ID:CAMPII[E HTS
Collected AU$ 2 89 i 08:10
Eecetved A~ 2 09 I 09:15
I
Analysis Completed :AUC 2 89,1
Special
Instruct:
Che~ab lei l: 6737 Lab ~mpl ID: I
~ate lepers Pztnted: AUG 3 09 ! 23:18
Client Hame : COEMIR & ASSOC
Client Aces : COE~I~P
P.O.I IDlE REC'D
Req !
Osdezea Ey :
Semi lepotts to:
I)CO[~IR & ASSOC
2)
Allocable
~esult/Units Limits
Pazametez Tested Method
RITEATI-R RD(O.iO) ~/1 EPA 353.2 10
~mple SAMPLE COLLECTED BI ~L.
I Tests Pezfozmed · See Special Instzuctions Above UA-Unavailable
ID* Rome Detected "See Sample ~eme~ks Above
RI* Not Analyzed ET-Less Than, GT-G~eatez ?~n
II~II¢IPALITY OF A~CHOP. AG~
DIVISION OF BN~IROI~I"-NTAL H~LTH
DEP~ OF ~TH ~ E~IRO~ ~O~CTION
' 1. ~neral Info~atio~ Application Date
(a) Lesal Description (i~lude ~oC, block, ~ubdivision, sec~ion,~o~ship,~e)
Location (~dress or dlrec~o~)
(b) Applican~s Name ~ Telephone - Home
Applican~s Mdress
Buyer ~; O~her ~ (=plain),
(d) Lendin~ InstitUtion ~ Telephone
Address
Address
Telephone .
~il the ~ ~o the following ~dress:
2. TTpe of Residence
Single-Family~
Number of Bedrooms
3. Water Supp17'
Individual ~ell~
'Note: If co.unity
Hulti-Pamily~
Other (describe)
~ Communitlr["-") Public~
well system, must have written con~ir~ation from the State
Department of Environmental Conservation.attesting to the legality and status.
Business---------
4. Sewage Disposal
Note: If co~unity well system, must have written con~lrmation from the State
Department of Environmental Conservation attesting to the legality and status.
[Page 1 of 2]
£n~ineer{n~ Firm Providin~ Inspectionst Tests~ File Search~ Data and Information
As certified by my seal affixed hereto and as of the validation ~e sho~ below,
verify ~ha~ ~ tnveg~iga~ion of ~his He~h ~hori~y Approval sho~ ~ ~he o~si~e
water supply aM/or i~stewa~er disposal sys~ea is safe, f~cCiou~ a~ ~eq~e.for
the n~ber of bedro~s a~ ~pe of structure i~lcat~ herein. I further verify
based on ~he t~o~ion ob~ain~ froa ~he ~nicipali~y of ~chorage files aM fro~
investigation ad i~peccion, ~he o~sl~e ~er supply a~/or ~s~e~a~er
system is in coapli~nce ~h ~1 ~nicipal and S~a~e codes, ordinances, a~ reg~a-
~ious in ~fec~ ou [he dace of ~his inspection.
Na2e of Fi~ /~. Telephone
DHEP Approval
Approved for
Approved~r~
Terms of Conditional
bedrooas
Disapproved
CondltionT'
Approval
CAUTION
THE ~I/NICIPALITY OF ANCHOP&GE DEPARTMENT OF f~kLTH AND ENVIROL%~NTAL P~0TECT10N
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-!
ATIONS GIVEN IN PARAGRAPH 5 ABOVE BY AN INDEPENDENT PEOFESSIONAL ENGINEER REGISTERED'
IN THE STATE OF ALASKA. THE DflEP DOES THIS AS A COURTESY TO PURCHASERS OF HOMES AND
TI~IR LENDING LNSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
HENTS. DIFLOTEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCHORAGE IS NOT RESPONSIBLE FOE ERRORS
OR 0HISSIONS IN THE ]PROFESSIONAL ENGINEER'S WORK.
q
(DHEP SEAL)
RR4/e~/D18
[Page 2 of 2]
7-19-84
Ao
MUNICIPALITY (F ANCHORAGE (~1~)
HEALTH ~n~O~Y APP~0VAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANC~IOP, AG,~
DEPT. OF HEALTH &
ENVIRONMENTAL PROTECTIOIq
I,I^¥ 0 7 BS~'
Well C!~-sificatfc~ >ZII/~7-~" If A, B, C~ C, D.E.C. A~OV~d(Y/N)
Well Lo~ P=eSent ~ Date C~leted
Static Water fe~l Pump Set At
Casi.~ H~ight Ab~ U=amd /.
Sepa=atic~ Distanc~sl . f~m Well: ~//~
To Segtic/Holding Tank c~ Lot
Sanita=y Se&l on CasinG~N)
Dap=essic~ A=cund Wellhead (Y~
; On ~dJoining Lots
Stand~~ Ai~-tiGht Caps
Dap=ession ~=~Y/N) Date ~*-~t
Pumping/Maintenan~ c~ File
Sepa=ation Distances
To Water-Supply Well
To
To Water Main/~vi~ Lira
[Pa~ 1 of 2]
No. cf C~a~b~nts
Foundation Cleancut (Y/N)
Tank ~ermit (Y/N)
Foundation
c~ Major D=aina~
2-15-84
Width
Betin~ in A~tion St=ats
Squa~s Feet of A~ea
Pep=ession ~ Field
Results of Last ~g Test
Separation Distar~s fl-cra
To ~ate=-Supply Well
To Building Foundation
; On
To Water Main/Se=vies r-ine
Type of Sys.te~ Design
I~ngth of Field
Depth of Field
Bed Thickness
Standpipes P=esent
Last Ad~quac~ Test
Line
c~ Abandor~d System
Lots
To Cutbank ( if ~nt)
To S~zeam/Pond/Lake/c= ~ajc~ ~ain~ Course
To D=iveway, Parking A=ea, c~ Vehicle St(xa~e
C~=nts.
D. LIFT ST~TION
Size in Gall~~ ]Mar~ole/A~cess (Y/N)
'Pu~p On" --1 at ~~_J ~/~f' Lavei at
High ~ate~ Alarm I~vel at ~ ~nt (Y/N)
Electzical Codes(Y/N) _
Ccx~nts . ' ~ ~
** Check Pemmitted Bedroom Rating ;~ainst HAA Bequest ** ~
I certify t~at I have d~ed~ed, verified, c~ co~fe,~=d to ~1 in effe~
on ~ ~te pf ~is i~i~. -- -.
KB1/dS/s
[Pa~ 2 of 2]
2-15-84
ALASKA
KAREN HODGE
6636 WINCHESTER
ANCHORAGE ALASKA
nuII OIIlll FITAL COI1TI OL S I UICI S, IilC.
~n(lin¢¢rin0 G (~n~ironmcnl(d $1u(li¢~
SELLER-KAREN HODGE
s/7/ss
PICKED UP FROM OUR OFFICE
50183
LEGAL:CAMPBELL HEIGHTS BLOCK 4 LOT 20B
FLOW TEST ON WELL
WELL FLOW DATE-5/3/85
A FLOW TEST WAS PERFORMED ON THE WELL. 310
PUMPED AT A RATE OF 3 GPM OVER A DURATION OF
THE DRAWDOWN WAS 4.9 ' WITH A RECOVERY TIME OF
AND THE STATIC WATER LEVEL WAS 39 FEET.
THE WELL IS ADE(UATE FOR THIS 2 BEDROOM HOME.
~-~... ~ ...~.~
GALLONS OF WATER WAS
2 HOURS.
20 MINUTES
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEALTH &
ENVIRONMENTAl. PROTECTIOI'I
RECEIVED
,1200 UJcsl 33r0 Aucnut. Suil( I~ * Anc~oroqt. Alosko 99503-{907) 561-5040
F · ~ 0A ~ ~EC'EIVEO
- i NSPECTION -APl~)l NTME NTS
TIME ] TIME TIME
)AT~
DATE
~NICIPAU~ OF
[ MUNICIPALITY OF ANCHORAGE DEPT. CF H~AL%d &
[ DE~ARTME~ OF H~LTH & ENVIRONMENTAL PROTEC~ONMENTAL
ENVIRONMENTAL SANITATION reViSeD" AUG 1 3 1981
REQUEST FOR ~PROVAL OF INDIVIDUAL WATER ~D SEWER FACILITIES
i~ LE~ING I~TIT~ION
MAI LING ADDRE~
t S. LEGAL DESCRIPTION
~ TYPE OF R~IDENCE
~ StNGLE FAMILY
~ MULTIPLE FAMILY
7. WAT~LY
INDIVIDUAL'
~ COMMUNiTy
~ PUBLIC UTILITY
I-3 Other
NUMBER OF BEDROOMS
r--I One I-'1 Four'
~ Two r-I Five
D Three [] Six
· 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.)
.YEAR ON-SITE SYSTEM WAS INSTALLED.
8. SLqVAGE DIS _I~,~L SYSTEM
i-'l INDIVIDUAL/ON-SITE"*
UBLIC UT LITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72.O10 (R~. ~/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
I'--I SINGLE FAMILY [] ONE [] THREE i-'l FIVE [] OTHER
[] MULTIPLE FAMILY I"'1 TWO [] FOUR [] SiX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[:::] COMMUNITY
DATE DRILLED
I--] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[]INDIVIDUAL/ON -SITE DATE INSTALLED
I--'1PU BLIC UTI LITY
Connection Verified
- INSTALLER
[] Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
Absorption Area to nearest Lot Line
5. COMMENTS
[ ^PPROVED FOR 't.---- BEDROOMS
[] CONOITIONAL APPROVAL (letter must,,~company certificate)
[] DIS^PPROVED //
72.010 (Rev. 6/79)
F"~IUNICIPALITY OF ANCHORAGE?'~
DEPARTMEN'. OF HEALTH AND ENVIRONMENTA. PROTECTION
825 L Street, Ancboraa~. Al&ska 99501
Date
264-4720
Date Received: September 2F 1977
Time ~3: Time
Date Date
Insp Insp
REQUEST FOR APPROVAL OF INDIVIDUAL SEWER AND WATER FACILITIES
Lending Institution Request: Alaska Mutual Savings Bank
Mailing AddressI: Post Office Box 1120 99510 Phone: 274-3561/244
Property Owner:
Mailing Address
Herman Hoke
· 6636 Winchester Street
3. Legal Description:
4: Single Family Residence: (
!
Multiple Famil~ Residence:
5. Well System:
Permit ~
Construction
Sewage Disposal
Permit ~
Phone:
Lot 20 Block 4 Campbell Heights Subdivision
Individual well
System:
Septic Tank Si~e
Absorption Area
Distances: Well to
Number of Bedrooms: ?
Number of Bedrooms:
( ~ Community/Public System ( )
to Sewer Line
to Nearest Lot Line
Depth of Well Well Log on File ( )
Bacterial Analysis
On-site System ( ) ?? Public Utility
Installed Installer
Manufacturer
Soils Rate Material
( )
Septic Tank to Absorption Area
Nearest Lot line Absorption Area
D~partment of Health and Environmental Protection
Request forl Approval of Individual Sewer and Water Facilities
Legal Description:\ Lot 20 Block 4 Campbell Heights
Subdivision
Comments:
Affadavit Attachedl
Approved: ~_ ~,~t ~ I
Disapproved:
Letter Attached: ( )
Date:
Date:
Department Worksheet.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
2510 East Tudor Road, Anchorage, Alaska 99504 276-2221
REQUEST FOR APPROVAL OF
INDIVIDUAL SEWER and WATER FACILITIES
J'"'~t/~jNtCtPAtrf? OF AN
DEFT. OF HEALIH &
ENV[ROHMr..NTAL PRoIECT[ON
SEP 2
Type of Inspecti.on: , CMRO ' VA FHA
Mailing Address! ~_~ ~/~/P ~/~/~ ~ Day Phone:
3. Name of Buyer-' ~/~ ~ ¢ ~/ Z. ~~
Mailing Address~Z .~7~--
4. Name of Lending Institution: ~~ ~/~/~ ~J~~
5. Name of Realtor or A~nt:
Mailing Address:, Phone:
Location: ~ ~/~~~
o
Type of Facility to I- ~ Inspected:
Water Supply
No. Bdrms.
Individual .,,~
Type of Supply:
If Individual, ri!tuber
If Individual, ddpth of well
Sewage Disposal System
Type of System: Public Utility
If Ind vidua, date of installation
Public Utility.
of dwellings presently served
Individual (on-site)
72-003(3/76)
INDIVIDUAL
FEDERAL HOUSING ADMINISTRATION .~ ~dg~t ~u,eau No. 63-1t296.11
HEALTH AUTHORITY APPROVAL
INSURING OFFICE
~c~oz'a£e ~ Alaska
MORTGAGOR OR SPONSOR
WATER SUPPLY AND SEWAGE DISPOSAL SYSTEM
PART I.--TO BE COMPLETED BY FHA
MORTGAGEE
John B. Tallay
SERIAL NO.
Campbell HeiF, hts Subdivision
Add~ 15
WATER SUP~Ly BYs
D Public system
SEWAGE DISPOSAL BYz
-~ Public system
[] Y~s [] No
[] New installation
8LOCK ~O. LOT NO.~0
Can ~ttlc o~ ether are be mad~ Into
(If Yes, hay, martyr)
E~] Yes ~No
[] Communi~/system [] Individual
]Community system
[] Individual
PART II.~TO BE COMPLETED BY HEALTH DEPARTMENT
SYSTEM DESIGNED FOR
'4E~LTH DEPART/V~NT INSPECTOR'S SKETCH
It is the opinion of the [] Sta~e [] Coun~ [] local Department of Health that this individual water-supply system
[] is [] is not satisfactory!asa domestic water supply for the subject proper~y.
It is the opinion of the
rem with proper maintenance:
~ Can be expected to function'satisfactorily, and
is not likely to create an insanitary c, onditlon
}__ , . TITLE
[] Sta~te [] County [] Local Department of Health that this individual sewage-disposal sys-
[] Cannot be expected to function satisfactorily
NOTS: The health'authOrity should complete the appropriate opinion statement above and offlx date, signature and title In tho
Inside diameter, feet. Depth feet. Liquid capacity,
S~CONDARY TREATMENT consists of i--I Tile disposal field. [] Seepage pits. Oth~
Tile Disposal field:
Distance from: Well.
Total length of tile lines.
Trench width,
Length of each line,
gallons. Lining material
feet; foundation, feet; nearest lot line at [] front, [] side, [] rezr
feet. Number of lines. Distance between lines,
inches. Total effective absorption area in bottom of trenches,
fort. Depth, top of tile to finish grade,
Type of filter material: [] Gravel. [] Baok~ stone. Other.
Depth of filter material beneath tile,, .inches.
Number of pits , Outside diameter., feet. Depth,
Distance from: Well, __ feet; building foundation,
Inspection made bln [] Scare. [] County. [] Lcx~ Health Authority.
Inspa~ted by
Date of inspection 19
.feet.
square feet.
inches.
Depth of filter material over tile
feet. Lining material
feet; nearest lot line at [] front, [] side, [] rear,.__
inches.
feet.
REPORT OF INSPECTION--INDIVIDUAL WATER-SUPPLY SYSTEM
Distance to nearest public water main,, feet. Size of main, inches.
Individual wells lq are [] axe not o:sroma~ in neighborhood.
Give most i'~ent r~ord of failure of wells in immediate vicinity to fumith adequate supply of water
Properties in nelghbothood [] axe [] ate not being developed with both individual water-supply and sewage.dislx~al systems.
Lot size: feet wide feet deep. Dwelling set back from front property line feet.
Individual water supply ftom: [] Drilled well. [] Driven well. [] Dug well. [] Bored well.
I)~ltance of well froms
Building foundation,
cast iron scwc~, feet; tile sewer,
seepage pit, feet; cesspool,
Diameter, inches. Total depth,
Approximate depth to pumping level of wate~ in well.
Sealed watertight to depth of feet.
feet; nearest loc line at [] front, [] side. [] rear,
feet; septic tank, feet; disposal field
fo:t; other sources of possible pollution, feet.
fe~. Type of casing,.
feet. Approximate yield,.
Depth of casing,
gallons per minute.
Extetioc space around casing sealed with: [] Cement grout. [] Puddled clay. [] Ordinary backfill.
Well covet: [] Concrete. [] Wood. [] Metal. Openings in well covet watertight: [] Yes. VI No.
Pumpz [] Shallow well. [] Deep well. Length of drop pipe,, feet. Pump capacity,.
Located in: [] Basement. [] Pumproom off basement. [] Pumphouze above g~ound. [] Pump pit.
Pumptoom ptopetly drained: [] Yea. [] No. Pump mounting watertight: [] Yes. [] No.
Type of stocage: [] Pressure. [] Gravity. Capacity, gallons.
Has bactetiologkel examination of water been made? [] Yea. [] No. If answe~ is "yea," give date
Quality of water [] is [] is not satisfactory for human consumption.
Installation [] does [] does not comply with approved exhibits, if an),.
Inspaction made by: [] State. [] County. [] Local Health Authority.
Inspaeted by
Date of inspection , 19
gallons pet minute.
.19
feet;
· TO THE CHIEF UNDERWRITER~c
I have reviewed the for,
q PART III..---~I~)R USE O~F'-iHA OFFICE
oin I and th:
illll
Individual water-supply system be considered [] Acceptable [] Not Acceptable
D Not Acceptable.
disposal be considered [-] Acceptable
I ,,
'/v'iunicipMitYo
AnclXorage __.
825 "L' STREET
ANCHORAGE, ALASKA 99501
(907) 264-4111
GEORGE M, SULLIVAN,
DEPARTMENT OK HEALTH AND ENVIRONME'NrAL I'IIOTECTION
August 14, 1981
David P. Baggett
6636 Winchester
Anchorage, Alaska 99507
Subject: Lot 20 Block 4 Campbell }{eights Subdivision
Approval fo~ the individual sewer and water facilities
cannot be g~anted until the following items have been
completed:
(1)fk/The wate~ analysis report needs to be submitted to
~'/~his o~lce from the Chem Lab, 5633 B Street, for
~v~-our revzew. .
(2) The top one(l) foot of the well casing ]%as been cut
away from the remaining casing. This will need to be
welded back on.
(3) The well seal needs to be tightened so that it is
water ~iqht.
September 1E, 1977
Herman Hoke;
6636 Winchester Street
Anchorage, Alaska 99504
Subjects Lot 20 ~lock 4 Cam. pbell Heights Subdivision
For the following reason this department cannot give approval
for the sewer ana water facilities serving the subject property.
(1} The well is eighty-four(84) feet from the ~easpool,
State law requires one-hundred(100) feet separation.
(2) The well is in a pit and the casing is below ground
level.I
The sewer s~stem will need to be relocated so that the seepa~
syste~ is one-hundred(100) feet away 'from any well. Before
you relocate, you will nee~ to obtain a soils test so that
we can issue a permit, wh&~h is required before any
construction begins.
~e well needs to be extended twelve(12} inches above ground
level and the pit filled with imperv~bus soils.
If there are any further questions,
at 264-4720.;
Sincerely,
Robert C. Pratt,
Sanitarian
cc~ Alaska~.llutual Savings Bank
Post Office Box 1120 99510
please contact this office
ALASKA GEOLOGICAL CONSULTANTS
Ma, 8, 1969
2227 SPENARD ROAD
ANCHORAGE. ALASKA 99503
Mr. John Talley
6636 Winchester
Ancl4orage, Alaska
Re: Percolation Test, Lot 20, Block 4, Campbell Heights #2
De~ Mr. Talley:
This[ letter is to certify that a percolation test has been conducted
on tl~e above-mentioned property. The test was performed in a
twel{,e-inch diameter, twelve-inch deep test pit in the bottom of
the l~roposed absorption field. Location of the test pit, the log of
the test pit and percolation data are shown on the attached sheet.
This! test was made in -~ccordance with the Greater Anchorage Area
BoroUgh Healtk Det:~r;me:.: specifications as prescribed in Appendix
B of the Na:ional piumbir.~ Code, 1962 Revision.
BGP
Very truly yours,
ALASKA GEOLOGICAL CONSULTANTS
Bruce G. Purcell ·
Attach.
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