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Home My WebLink AboutHILLSIDE NORTH #5 BLK 3 LT 4Hillsid North Block 3 Lot 4 #041-031-91 Municipality of Anchorage Page I ' DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL'SERVICES DIVISION P.O. Box 196650 · Anchorage, Alaska 99519-6650 · Telephone: 343-4744 On-Site Wastewater Disposal System and/or Well Inspection Report Permit Number: ,,~/ ~ ~ '?~ ~ PID Number: ~:3 I¥,/--O ,~ ~, - Cf ;~ Name: Address: Phone: F--t'-\bCLh:W/ ~ P-.,I~ ~, LEGA, DESCRiPTiON Lot: Block: Township: Range: WELL: ~Z New Classification (Private, A,8,C): Driller: Yield: Section: [] Upgrade Total Depth: Cased To: Date Drilled: I Static Water Level: From Well- Surface Water Lot Line Foundation Curtain Drain Pump Set at:, Casing Height Above Ground: SEPARATION DISTANCES 70 o Remarks: Inspections performed by: Wastewater System: [~New [] Upgrade ABSORPTION FIELD ?,~Deep Trench [] Shallow Trench [] Bed [] Mound [] Other Soil Rating; /r ~ GPD/Sq. Ft. ,Dep h o p pe bottom from original grade: Fill added above original, grade: Gravel width: Total absorption area: E;¢o SQ. Ft. Total Depth from original grade: Gravel depth beneath pipe '7' Ft, Ft, Gravel length: ¢~.~ Ft. Ft. Number of/lines: Distance bet.~ween lines:Ft. Pipe material; Date installed;/,0,/~ TANK ~¢..Septic [] Holding [] S.T.E.P. Manufacturer: A'-Nc TA.- Material: ~ ¢~..t¢.~/ Capacity ii ~'c~s:~.~ Number of Co,~.~rtments: 7e-013 (Rev 9/91) MOA 25 Department of Health and Human Services approval Reviewed and approved by: _~cc~c"t/~"c~,-- ¢~ Date' ~'1~-.¢~ Location and Description: Size in gallons; Manufacturer: "Pump on" leve~ at: "Pump off" level at; High water alarm at: Pump Make & Model Electrical Inspections performed by: BENCH MARK LIFT STATION SWINO TIES: AB 20 FT AC 55 BC 5,4 AD 67 £D 66 AE 84 BE 79 AF 72 BF 77 TTANDARD TRENCH OTAL DEPTH lOFT i~ , FFECT/VEROCK REPLACEMENT TRENCH ~)- WeI1 $0 75 SCALE: /" -- $0 FL 49~h I00 ]3BEN SPURKLAND No, CE-2225 125 1_50 I I / / / TOBBEN SPURKLAND P.E. 205 W 15TH. AVENUE ANCH. AK. 9950/ (907) 279-5916 ]HILLSIDE NORTH/rS, BK 8, MIDDLEROCK ROAD GRE$$ ENDSLEY LOT DATE: DEC, 15, ~997 SHEET; 2/3' '~: GRID: 2145 PER'MIT # SW970356 PI9 # 041-051-91 HSNO304i,?~6 PRIMARY TRENCH S tonctorcl ?reDches: 40' L on9 10' ~eep ZO' Sewer rock 3' Cover REPLACEWENF FRENCH SCALE Cleonouts 3' Cover 88.5:' 1£50 90{ Septic tank Foundotlon Cleon out 91i /E 84.7 77.5 7,0 Pt oF £ept/~ Woc~< 7Z5 IE 84. /E 85.90 TBBBEN SPURKLAN~ P,E, ~03 W15%h Ave Anchorage Ak 99501 NORTH/zS, BK 3, GRE$$ ENDSLEY LOT 4 SEPTIC SYSTEM",'~S .BUILT' D~T£: DEC.~$, 1997 PERMIT// SW970556 PARCEL ID // 041-051-91 HSNOJO45. DWG Fro~ : ALF'INE DRILL 9~,~ 345 02'~2 Dec. 15, 199'7 10:35 PH P01 STATE OF ALASKA D;EPARTMENT OF NATURAL RESOURCES DIVISION OF MINING & WATER MGMT WATER WELL RECORD WELL BOFIOUQH 6UBDWleION~..~k.,/~, , ~ LOT BLOCK 81EOYION QTflS 8ECTION TOWN~HIk~N [OCA~iON/SK~CH~ WELl_ OWNER: ' Mated~l T~pe and Color F~om CAS NG STIC~;U~ ~ft. Diem: ~{n. t~ft WELl. INTAKE opENING TYP~; I.: ......... ~ perforated ~'open hole Depths of openings; _ _ SCREEN TYPE: Dlam: ............ in. Slot/Mesh Size: Length: . GRAVEL PACK TYP~: Volume u~ed' __ Depth GROUT TYPE~, ~r" ....... Depth: from ft t~ ~, _ ft .... ....... ~ D~VELOPMENT M~HOD: PUMPIN~ LEVEL AND YI~LD= ' PUMP INTAKE DEPTH: , -- ft'~r~po~': PAGE 1 OF MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL AND WASTEWATER DISPOSAL SYSTEM PERMIT PERMIT NUMBER:SW970356 DESIGN ENGINEER:TOBBEN SPURKLAND, P.E. OWNER NAME:ENDSLEY GREGORY C OWNER ADDRESS:9620 BURNING BUSH DRIVE ANCHORAGE, AK 99507 DATE ISSUED:10/08/97 EXPIRATION DATE:10/08/98 PARCEL ID:04103191 LEGAL DESCRIPTION: HILLSIDE NORTH %5 BLK 3 LT 4 LOT SIZE: 100188 (SQ. FT.) NUMBER OF BEDROOMS: 4 THIS PERMIT: 4 THIS PERMIT IS FOR THE CONSTRUCTION OF: DISPOSAL FIELD /SEPTIC TANK / WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18kAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT) 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS: ~.~;LR~_T~RE~LOCATING THE DRAIN FIELD, CONTACT THIS WITH ADDITIONAL SOIL TEST RESULTS~ ISSUED BY: - \ DATE 203 W 15th. Avenue, Suite 203 ANCHORAGE, ALASKA 99501 (907) 279-3916 Fax (907)-276-6013 SEPTIC SYSTEM DESIGN HILLSIDE NORTH #5, BLOCK 3, LOT 4 GREGG ENDSLEY Municipality of Anchorage September 27, 1997 Department of Health and Social Services 820 1 Street Anchorage, Alaska 99501 We are submitting an application for the installation of a well and septic system for this lot. The submittal consists of three (3) drawings showing the present improvements on the lot and the adjoining properties, (sheet 1/3), the proposed improvements of the lot, of which only the well and septic system are subject to this permit application, (sheet 2/3), and a schematic of the septic system, (sheet 3/3). Soil logs and percolation tests of applicable testholes are also enclosed. The septic system design is based on the following: No Ground Water or Impervious Layer to 16 f. Use Standard Trench Soil Rating. < 1 min/in = 1.2 gal per sq.ft/day See Sieve analysis No. of Bedrooms 4 Required Areaper Bedroom: 150/1.2 = 125 sq.ft.. Total area required: 4 x 125 = 500 sq.ft Testhole depth 16 feet Bottom Rock At 10 feet Top Rock At 3 feet Rock Depth 7 feet Total Trench Length 500 / 14 = 35.7 ft SYSTEM CONFIGURATION STANDARD TRENCH TOTAL LENGTH 40 FT TOTAL WIDTH 2 FT TOTAL DEPTH 10 FT ROCK DEPTH 7 FT COVER 3 FT SEPTIC TANK 1250 GAL MUNICIPALITY OF ANCHORAGE ENVIRONI¢,ENTAL SERVICES DIVISION SEP 2 9 1997 RECEIVED The installation of this septic system will not prevent wells from being installed on the adjacent lots. There are no developed or natural surface / sub surface drainage courses on this or the adjacent lots. The proposed septic system will not change the general slope of the area. Ponding and/or concentration of surface runoff will not result from this installation. / / LL~? 3 i:!:!:!:!:!::: \ T(T~S < 25~ ~ LEVEL _. ~ -- ..::? N/ 50 0 50 100 150 PO0 850 300 SCALE; i" = I_00 VT, TOBBEN SPURKLAND P.E. 205 W 15TH. AVENUE ARCH. AK. 9950! (907) 279-$916 ]HILLSIDE NORTH//5, BK 3, LOT MIDDLE£OCK t~OAD GREGO ENDSLEY SEPtiC SYSTEM DESIGN DATE: SEPT. 26, 1997 SHEET: 1/5 GRID: 2145 PEEk/IT ii PID l! HSNO304Lgk/6 TOTAL ~E,T~ ,0 ~T X~ //~ // ~ /I 1 ~'~'~:'7" ... EFFECTIVE ,~0CI¢ Z FTn ~ ~ ~ II ~ // ~ /I I ~H<:':<.~:,:.~ - ~ // /i ~ ~ ~ u ~ Il ~~ ~ ~el] ? I //~ // ~/////~////~ ~ J ' // rR[~c~ mr ~E ~OW¢ CLOS~ rD ~ ~ / / I ~ ~ 49~h ~ ' .,~ ~.~..~ ............ .;-~. ....... ~$ TD~EN SPURKLAND ~?£AL£: ~ = ~0 FT. TOBBEN SPURKLAND P.E. 205 W 15TN. AVENUE ARCH. AK. 99501 (907) 279-$916 SEPTIC SYSTEM DES/ON DATE: SEPT. 26, 1997 SHEET: 2/3 GRID: 2143 PE£ivlfT # PfD fl HSNO3041,DIV5 PRIMARY TRENCH Monitor Cleon Out Cleon ZTu? £' W/de 40' L on9 15' Deep 7,0' Sewer rook ~' Covem ~4 ft REPLACEWENT TRENCH SCALE Monltom ~ -- Co vet ?oundotion Cleon out lL~50 901 Septic tank bauble C[eon ZTu?s Ex/st, 6round klm Cover To nk 7,0 £~ o£ Septic Rock Effective NO SCALE 1£50 goL septic tank BENCH MARK, TE]]~BEN SPURKLAN]~ P,E, ~03 WlSth Ave Anchor'age Ak 9950]. p79-3916 NORTH//5, BK 3, G£EGG ENDSLEY LOT SEPTIC SYSTEM DESIGN DATE~ SEPT. 26, ~997 SHEET~ GRID, ~9143 HSNOJO43. DWG PERFORMED FOR: LEGAL DESCRIPTION: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES 825 "L" Street, Anchorage, Alaska 99502-0650 SOILS LOG -- PERCOLATION TEST (ENGINEJ=R'S S E'~,L) DATE PERFORMED: 14 ILLgibi~ NO~'TH ~.~,'rownsh,p. ~n.e, Section: Lo'T ~, t'5~ ~ SLOPE S,TEP'AN WAS GROUND WATER · ~ ENCOUNTERED? l~'l O S L IF YES, AT WHAT O DEPTH? p i.E_. Oepth to Water Aller j J *' ~,~./~ ~ E Monitoring? ~ Date: Reading Date Gross Net Depth to Net Time Time Water Drop DISCLAIMFR: Groundwater Past and future presence from these OO~Vatlons. PERFORMED BY: PERCOLATION RATE ~ (minuzes/inch) PERC HOLE DIAMETER ~ ~j TEST RUN BETWEEN ~ FT AND ~ ~ FT conditions indicated are for the dates shown only. and/or depth of groundwater can not be predicted CERTIFY THAT THIS TEST WAS PERFORMED IN ~ ACCORDANCE WITR ALL STATE AND MUNiCiPAL GuiDELiNES iN EFFECT ON THiS DATE. DATE'. ~ .~% i~'~ 72-008 (Rev. 4/85) I~ER~T OF I~TAININO ' MuNIcIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Envlmnmental Se~ces On-Site Services Section P,O, Box 196650 Anchorage. ~Jaska 99519-6650 (907) 343-4744 CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILLY DWELLING Parcel I.D. # 041-031-91 ,. HAA# H/E)/ 1. GENERAL INFORMATION .Complete legal description H~L~SIDE NORTH SUBDM$;ON ';5'. ~OT 4. Bt_OCK 3.' Location (site address or directions) 10121 U~DOLEROCK ROAD ANCHORAC;. AK 99507 Property owner CREG FNDSI ~ Day phone (907) 384-7007 · 'Mailing address 10121 MIDDLFROCK ROAD ANCHORAGE. AK 99507 Lending ager~cy, Day phone Mailing address Agent RICHARD JORDAN w./ SUN PROPFRTIES Address. Dayphone (9o7'~ 248-0555 Unless otherwise requested, HAA will be held for pickup. · 2. NUMBER OF BEDROOMS: 4 3. 'TYPE OF WATER SUPPLY: Individual well xxx Community well Public water NOTE: If community well system, provide wdtten confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL= Individual on-site Holding Tank Community on-site Public sewer NOTE: XXX If community wastewater system, provide w~ftten confirmation from State ADEC lng to the legality and sfatus of system. 72-025 (Rev. 1/91) Front MOA #21 Computer Version Note;Alaska. Water. and Wa~teWate;' Consu. lta~ts,'ln.c. Shall be paid $1110 oo at, I" ' ' or prtor to, ctosing for the englneerin~g services prov;~Yed..'. .: .::: i ' ' '" · I'-: 5. STATEMENT OF INSPECTION BY ENGINEE..R.: .~' i~, *[ * · As'ce~fi~l by my ~eal affixed hereto*and'a~)f't~ %;aiidat~on;data shown I~low. I verify that ~n~,' . Investigatioh of this Health Authori~ App .m..';;al application Sh(~ws that the on~slte water supply and/or*:~ Wastewater disposal system Is safe. functi0hel and ~Jde~a{~ fei. the nu'mbe~' of bedrooms and type of ~ structure Indicated hereln~,l further verify that ba,~KI Oh the informa.b.'on obtained fn~m"the Municipality of Anchorage files and from*my Invesfig~tio~ and In~pec~on~ the*0n-s~t6 water; supp,l~; and/o~wastewatar disposal system Is in COmplianCe ~th all Muhi~ipal ~,~1 State' Codes~ ordinances, and regulations In effect on the date ofthi~ln.specfion. .. ,.* ~' '~*~.~/c'I.. '~ .'. *',-* , .~ ~,~*, *~' ' ' *' ' .,'~'. penormanca of the system under the con~Yitions encountered at the time of the test, and separetio~ ~istan¢~ measured to rsadi~ identifiable features., Th~ opere~3~Ml life of'~ll wells alii septic systems'doped :,,~: · on the local soils condition, grot~nd water levels that may fluctu~ts d~drig the year, and the water usage of the fam~, be/ng =en~d ~y the ~/s~em.. rh~,e c~d~&~S ar~ outs/de the'co~tro; or - the evaluato;~ of the system. Satisfactory.test results do-not guarantee* future ~rlormance '-' Al/WI/C, 'lnc: can therefore .not P/~ide ;~ny ~;ab'~,~ future 'e~ffr~te'of I~v 'k~g 'the ~.* ". !-: The content of thls report ls for the sole beneflt of th~ owr~r'll~te~l ebove? Any ,: ' 'd'/.'// nor vvfll i~ cor~fer ant, legal ri~ht whatsoever~ . . .. 6. DHHS SIGNATURE " ' .... P'"' Approved for ~ . bedrooms, :.-. . . , .,.,.,..' '" '--'' ·., Disapproved " '"" Conditionalapprovalfor bedr°°ms'witht(ef(~ll°wings[i~:~.~"O'F'-A~'~.~... . .~,,~,x.x~.~-; . ... Additional C~mments ' '~ ~.. PROGRAM ~_~ '.... The Municipality of Anchorage Department of Health and Human Servlces (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 AJaska. 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 Municipality of Anchorage Is not responsible for errors or omissions In the professional engineer's work. 72-025 (Rev. 1/91) Ba~ MOA #21 Computer Version Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERVICES Environmental 8endces Divlelon 825 "L' $1~eet. Rm 502 Anchorage, Alaska 99501 (907) 343-4'/44 Health Authority Approval Checklist Legal Descrlplton: HILLSIDE NORTH S,/D 1~5; LOT 4, BLOCK 3, Parcel I.D.: A. I/V'EM. DATA Well Type PRNATE Log present (Y/N) Total depth San~aw ~ (Y/N) Date of test Stetlo water Imml Well prnductlon 041-051-91 ifA, B, or C, attach ADEC letter. ADEC water system number YES Date completed 12/1/1997 205' Cased to 111' Casing halght (above ground) YI~S Wires properly protected (Y/N) FROM WELL LOG AT INSPECTION 12/1/1997 1/2`3/Ol ~' 1 4.0 g.p.m. 5.0 +/- Date of sample: 1/2.3,/2001 Collected by: A.W.W.C. INC, B. SEPTIC/NOLDING TANK DATA Dateinstelled 10,/14-15/97 Tankalze 125o Number of Compartmente Foundal~on deanout (Y/N) YF.S Depression (Y/N) NO Date of Pumping 1/2`3/2001 Pumper C. ABSORPTION FIELD DATA Date Installed Effec~l~ al:~orptlon ama Date of adequacy test Ruld depth In abeoq)tlon I[eld before test (in.); Ruld deplh g' (Ins) Minutes later:. Peroxide treatment (past 12 months) (Y/N) 1 g.p.m. OLD MCDONALDS 2 Cleanoute (Y/N) High water abum (Y/N) N/A Soil ruling ~x)r fl2rrxlrm) 1 .~ System type TRENCH Width 2' Gravel thickness below pipe 7' Total deplh 11 560 SQ.FT, MonltoringTubepresent(y/N) Y~S Depresslenoverflald(y/N) NQ 1/23/2001 Results (Pass/Fa!l) pASSEO For 4- Bedrooms O' Immed~telyafter 764 gal, water added (In.): ~." 1,~ Absorption rate = 600+ NONE KNON If y~S, give date -- D. UFT STATION Date Installed Manhole/A~:'ess (Y/N) High water alarm level at* Size in gallons ofl" level *Datum E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot 100'+ Absorption tleld on lot lOO'+ Public eewer main N/A 6ewerlseptlc eendce line 25'+ SEPARATION DISTANCF..~ FROM SEPTIC/HOLDING TANK ON LOT TO: Foundation 5'+ Property llne 5'+ Water maln/seMce line 10'+ Surface water/drainage 100'+ SEPARATION DISTANCES FROM ABSORPTION FIELD ON LOTTO: Property line 10'+ Building foondatlon Surface water 100'+ Curtain drain NONE: KNOWN On adjacent lots 100'+ On adjacent lots. 100'+ Public tamer manhole/cleanout N/A U~ ~telJon N//A Absorptlon field .5% Wells on adjacent lots 100'+ 10'+ Water matn/sendce line 10'+ Driveway, perldng/vehlcle $lemge area 10'+ Wells on adjacent inte 100'+ Waiver Fee $, Dale of Payment Receipt Number HAAFee $ Date of Payment Receipt Number F. ENGINEER'~ CERTIFi,Cj~TIOJ~/~ of Municipal re~ord,~ tt~ th~ ~ve ~}y~ema ere in conformance wfth MOA HA/~ gu~e~t~/,~/O ~ct........°~ 'ls dale. ~glnee~s N?Ie~OARNESS 01-30-01 08:18 FRO~t-CTE ENVIIKWWNTXL ,d~l"~_' C'rAE Environmental Services Inc. 561§$01 T-493 P.02/03 F-720 CI'&£ ReL# Client Name Project Namem Client Sarape ID Matrix Orde~d By PWSID 1010425001 AK Water & Wastewater Consultants Inc. Hilbide North SE) Lot 4Bk3 D~%dcing Water 0 Sun'~lc Remarks: PQL Units Method Client pO~ Printed Date/Time Cnllected Dar e/Time Received Date/Time Technical Director Released By 01/2~2001 15:51 01/23/2001 13:45 01/24/2001 12:00 Stephen C. Ede Allowable Psep Analysis Limits Date Date Init W&~mrn De~ar~mmn~ Ni~-N 3.39 0.500 mg/L EPA 300.0 max 01/24/01 OCP Microbiology Labora=ory Total Coliform cot/100mL SMI8 9222D 01/24/01 SKW 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 Parcel I.D. # CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING GENERAL INFORMATION CompLete legal description Location (site address or directions) Property owner Mailing address Lending agency Mailing address Agent Address b Day phone Day phone Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: V TYPE OF WATER SUPPLY: Individual well Community well Public water NOTE: If community 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 Community on-site Public sewer NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 5. 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 'l ~ J~/~'~ ~O-'~o~'~'~[~t"-~-~ ~ ~ Phone ~-~i~ Address ~ ~ ~ 1~ ~ Engineers signature ~ ~~~ Date ~/3~/~ ~ Sm DHHS SIGNATURE ~'/ Approved for Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments 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 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. - M4JmCfPAUW OF APR O? 1998 Municipality of Anchorage DEPARTMENT OF HEALTH & HUMAN SERViCESD~oriiirr~..~.~ Environmental Services Division 825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744 Legal Description: A. WELL DATA Well type Log present (Y/N) Total depth Sanitary seal (Y/N) Health Authority Approval Checklist Parcel I.D.: Date of test Static water level Well production Y Cased to FROM WELL LOG If A, B, or C, attach ADEC letter. ADEC water system number Date completed I~-/! / ~ -~ Ill F.-b Casing height (above ground) Wires properly protected (Y/N) AT INSPECTION WATER SAMPLE RESULTS: Coliform /~ Date of sample: ~///~l-'7 / Y g.p.m, g.p.m. B. SEPTIC/HOLDING TANK DATA Date installed / O/~///~/"7 Foundation cleanout (Y/N) Date of Pumping h//A- / Nitrate h '~- ~ 14.'[~/~. Other bacteria Collected by: '~'~"~ -~ Tank size i~- ~ 0 Number of Compartments ~ Cleanouts (Y/N) _ Depression (Y/N) ~ High water alarm (Y/N) ~ Pumper J'~/'h3c Soilrating (g.p.d./ft~e~f-~V~cl~-)- /,~ Systemtype r~- ~r'L-*- Gravel thickness below pipe 7 ~ Total depth c. A.SO.PT,O. P.E.D DATA Date installed I~/~ 5~/~ ~ Length qO ~"~ Width Effective absorption area b~{~ ~ ~-/~ Z Monitoring Tube present (Y/N) Date of adequacy test f'~//¥ Results (Pass/Fail) Fluid depth in absorption field before test (in.); L~ (ins) Minutes ater: b'/// Fluid depth _ Depression over field (Y/N) For Immediately after V/gal. water added (in.): cJ;p.d. ~/,Absorption rate = If yes, give date bedrooms Peroxide treatment (past 12 months) (Y/N) 72-026 (Rev. 3/96)* Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested Size in gallons "Pump on" level at* *Datum "Pump off" level at* E. SEPARATION DISTANCES F. SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/t'~,j~iia~tank on lot J L/Lo F Absorption field on lot I ~ ~ 'j' ~ Jo-- On adjacent lots On adjacent lots Public sewer main l'~/~ Sewer/septic service line ~ 10-69 Public sewer manhole/cleanout Lift station t'~//~ SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO: Foundation :~ J::::"t['' Property line ""]O ~--~ Absorption field ~1 ~) Water main/service line Ith9 j:::-[~ Surface water/drainage ~ IO Wells on adjacent lots '~'~ SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line bO ~..~L.- Building foundation 7~-~q~ Water main/service line Su~3ce water ~ ~ O Driveway, parking/vehicle storage area ~ Cur~.. ~ drain ~ Wells on adjacent lots ~ / ~ ~ ENGINEER'S CERTIFICATION ~'~ ~ I ce~ify that I have determined thru field inspections and review of Municipal mc~rds that the~above in conformance with MOA HAA guidelines in effect on this date. J .'- ~ ' :: ~: Signature ~~ ~:~;~ 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number l~t~l~ CTS~E Environmental ServiCeS AHCHORAGE 3[3 ._,61~,..~31 P. 04,/E14 CT&E Reg.# Ciieot Name Project Name/# Client Sample ID Matrix Ordered By PWSID Sampie Remarks: Parer~ter 981364001 Tobben Spurkland P.E. Lot 3 Bk 4 Hillside North Lot 3 Bk 4 Hillside North Drinking Water 0 Client PO# Printed Date/Time 04/07/98 02:11 Collected Date/Time 03/27/98 15:00 Received Date/Time 03/27/98 15:30 Technical Director: Stephen C. Erie Units pQL Method Limits Date__ Date Init o 3.25 coL/lOOmL SM18 922~ 0.100: m~/L EPA 300.0 10 max 04/06/98 RMV