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Home My WebLink AboutTHE VILLAGES TR 13AThe Village #020-29! -30 Municipality of Anchorage Development Services Department Building Safety Division ~.~ On-Site Water and Wastewater Program, 4700 S. Bragaw St, P.O. Box 196650 Anchorage, AK 99519-6650 Page wvAv.d.anchorage.ak.us (907) 343-7904 ON-SITE WASTEWATER DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Permit Number: ..9c<,'o101~,( PID Number: Na,~e: G r~n Do [~r ~ Wastewater System: [] New [] Upgrade ~Y-t3 LEGAL DESCRIPTION Well: ~/~£/' [] New [] Upgrade n. Yield: GPM P~mpSetat:Ft, Cas~gHligh~Ab~veGmufld:EL TANK SEPARATION DISTANCES [] septic I-1 Holding ~ S,T.E.P. [] Other: T_~'-,-...~To Septic Absorption Lift Holding public/Private Tank Field Station Tank Sewer Line ~ ~_~30~'~5~ ~ ~ ~'¢ J ~ w~'~ Gal Lm L~ne ~'~' ~V Gal ~ou~m~ ~' / / . ~ /~ 'p~np~l'levekat: iA 'Pt~mp~r ,evela,: [n.IHighwater ale~ma`: ..~"."~: BENCH MARK Engineer's Stamp Inspections pe~ormedby: ~/~f~? ~r~ ~c Dates: 1't ~/l~/~o/ Development Se~ices DeDa~m~nt Approval Reviewed and approved by: Date: PERMIT NO: SW010101 PAGE 2 OF 2 PID NO: 020-291-30 NEW MON. TUBE~,, SWING TIES: FROM: COR. "A" COR. "B" COR "X" TO: C.O. "C" 15' S.T.C.O. "D" 13' 29' S.T.C.O. "E" 10.5' 33' DBL. C.O. "F" 11.5' 50' TR, M.T. "G" 29' 38.5' TR. C.O. "H" 30.5' 37' EXISTING SOIL ABS. TRENCH--~ DOUBLE C.O. NEW 1250-GALLON SEPTIC TANK TRACT 13A THE VILLAGES SID PLAN VIEW SCALE: 1" = 30' DBL. INV. 86,9' 4' SOIL COVER INV. 87.1' PROFILE VIEW SCALE: 1" = 5' TRACT 13A, THE VILLAGES SID SEPTIC TANK REPLACEMENT AS-BUILT INSPECTION REPORT FLATTOP TECHNICAL SERVICES 14530 ECHO STREET ANCHORAGE, ALASKA 99516 SCALE: AS NOTED DRAWN BY TFM MAY, 2001 MUNICIPAL/TY OF ANCHORAGE Development Services Department On-Site Water & Wa~teweter Program 4700 South Bragaw Street P.O. Box 196650, Anchorage, AK 99519-6650 (907) 343-7904 5". Io- l ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT Upgrade Date Issued: May 07, 2001 Expiration Date: May 07, 2002 Permit Number: SW010101 Legal Description: THE VILLAGES TR 13A Design Engineer: 0019 Flattop Technical Services Owner Name: BRIAN DOHARTY Owner Address: 19000 HILL ROAD ANCHORAGE , AK 99516-6211 Parcel ID: 020-291-30 Site Address: Lot Size: 50825 SQ. FT. Total Bedrooms: 4 Permit Bedrooms: 4 This permit is for the construction of: ~ Disposal Field [] Septic Tank [] Holding Tank [] Privy [] Private Well [] Water Storage 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 ( 18AAC72 ) and Drinking Water Regulations ( 18AAC80 ). 3. The engineer must notify DSD at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 ( 24 hours ). ( Not required for a Water Supply Permit only ). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must be either: A. Open and closed on the same day. B. Covered, sealed, and heated to prevent freezing. Received By: .,{a~'~ ~ Date: ~"-/~ ,/O ( Issued By:~ ~ ~ Date: ;~'"-- 7.- _/'~? / Parcel I.D. Municipality of Anchorage Development Services Department Building Safety Division On-Site Water and Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.us (907) 343-7904 ON-SITE SEWEPJWELL PERMIT APPLICATION FOR A SINGLE FAMILY DWELLING 0%0 -~I Property owner(s) 1~ r-, ~n Do A Mailing address (1) 19 ooo I-)-,11 Mailing address (2) /¢r,~ Legal description (Lot, Block & Sub'd.) Tr~ Legal description (Section, Township & Range) Lot Size ~'O: ~ ~.. 5" Acres/Sq. Ft. Day phone Zip Code Number of Bedrooms THIS APPLICATION IS FOR: Sewer Only Sewer and Well Sewer Upgrade THIS PROPERTY CONTAINS: Hot Tub Swimming Pool Therapy Pool [] Well Only [] [] Water Storage [] [] Jacuzzi [] [] Water Softening Unit [] I certify that the above information is correct. I further certify that this application is being made for a Single Family Dwelling and is in accordance with applicable Municipal Codes. (Signature of property owner or authorized agent) Permit Fees: Date of Payment: Receipt Number: (Rev. 12/00) Waiver Fees: Date of Payment: Receipt Number: TRACT 12 TRACT 13A THE VILLAGES S/D TRENCH MONITOR -- TUBE EXISTING SOIL ABS. TRENCH INSTALL DBL. C.O. INSTALL NEW 1250-GALLON -- SEPTIC TANK ABANDON EXISTING 1250-GALLON SEPTIC TANK :: ' CE - 3559 o 25' DRAINAGE EASEMENT R 100' INSTALL ', C.O. / / , TRAC~ 13B / (y~CANT) / LOT 3 PiNE RIDGE TRACT 13A, THE VILLAGES S/D SEPTIC TANK REPLACEMENT SITE PLAN FLATTOP TECHNICAL SERVICES 1 INCH = 50 FEET 14530 ECHO STREET DRAWN BY TFM ANCHORAGE, ALASKA 99516 MAY, 2001 NOTE: THiS IS NOT A SURVEYED PLAT. ALL LOCATIONS SHOWN ARE APPROXIMATE. MAILING AD RESS ib_o LEGAL DESCRIPTION I- ~ ~m]ufacturer DISTAN MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONMENTAL ENGINEERING DIVISION 825 L Street - Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAl. SYSTEM AND/OR WELL INSPECTION REPORT EDROOMS Absorption are~ Dwelling PERMIT NO. No. of co~artments Inside length Width ~ Liquid d~p~th PERMIT NO. DISTANCE TO: L.ength of ~,.~ne Top of tile to Enish grade Length Width DJ.~%~ CI~E TO: Well DISTANCE TO: Foundati / O ~ / 0 Total length o~.)~e~ Trench wldt Material beneath tile Depth Crib depth PE.M,T NO. ?¢0/'7 ¥ Total effective abs. pr~gon area PERMIT NO. Driller Distance to lot -~ / Building foundation Sewer line PERMIT NO, Absorption area(s) OTHER PIPE MATERIALS 72-613 (~ev. 3~78) DATE LEGAL :.Ix u:V hll::l::':::[h'lLIl'J i'.,ll..Ihl[:)EF~ (:il':. !!ff:l::,f;]:OOJ'"lri; ..... $ ::!;l::f ):l. t?.l=l't' :l: NCi ,:: :':i:[,:! F:'[,,"E:R :) .... 'Fl'l!]: I;i:!!f:QI.J:!:l:;i:l.g:l'::, %):;.i% ()F' Tllli: :i~;ECt:I.. I::II?,::ii;OFi:F:"T:EEd",I ::?'r'~!i;T[:J'"[ ]:?J;: TIlE [ l:i:N(:i'l'l'[ I::,.IZI'IE;I",I'."E;:I:CII",I :t::ii!; TI'if;i: I..li::l'-,l[:fi"lll 1lIE E:,E:F'I'H OF" f::l 'tR[':i",ICll 12)I;;: F':EI' I:~],~:OUI'.,I[::, I:::li'.,!E:, "Il'IF!: I:irI:?I"FOH or:' THE r!:'?0:Z:l::'l~,?F:l"l':Ecl['.,I THEI;i% ]:iii; NO :ii;EF I.,!:!:E:,Tt.I FOr;i: 1'I.II5: E!il:,?.f::lVli!:l 1::4:ii:l::"ll.I ;l:ri~; -I'HE I,I]:I.,!:IHI..II'4 E)~!!:F'TH Eft:: I::iI:;;H::IVE:I. [!i~li::'l'l,I[:_fii:!'.,l l'l.l~ii: EdI'I"F=I::II_I. r::' ]: F:'[ : I:::lt'.,ll:::, Till::!: Ii:O'i'TOH O1::' ['HFi: E:';.::E:I=¥,,4=rT/:OI'.,I F.'r!::F?.r,1]:T I=II:::'F:'I...]:C:I:::IN'I" t'IF:I:E; TILE!: tT::I!{~:;F:'CII",~i;:I:E',i[L:I:T"r' '10 :(I-,ll::()F:h'i I'11:[::!; I}I!:I::'f:IF,::TI"II:~:I",IF :[H:!!;TI::'II..I..F:IT]ZOhl :l:hlr!E;F:'li:CTZ(l:3hl;:i!; OF' F:li",l*'r' NIETI.L.5!i I::IE:,..:II::IIZI:!i:I'-,IT '10 'I'll]::!; r:q:ROF:'ELI;i:Th~ (=iNE:* 'ri.Il: NI..II',II?.,'I[:]? OJ::: I:i%'~i;]:E:,li:NC:l}iZii; 'TIII'::I'I' TIIIE I,IEI.I_ I.,.I]:I..L :( C:)i~J;;:TJ:l='"r' 'f'l'lF:t'l' :1.: ] f:ll"l F'I':II'I)iI ]iFIl:;?. I'I]iTI'f I-I'l,~ill ~r'?.EI~:JI.Ji[I:'?.fi{f"IEiiJ",IT~:; I::'11)1:;?. CII",!'"'F:;)i'II~:i I=OI;?.11'1 E~¥ /'1111 I'"tf..IN]iIiZ:i[F:'I:::I[ ii'["r~ CIF' 2: ZIi I,I i[ I.I. i!i I",l:i!;'l'l::lt.,I. FIII!i '-::i;t?%'l'l:ild ]] I',I I:::I(]:E:(i~F!Ii:'I:iI~',ICIiil 1.4 i[ 'I"H 'l'lil::i ];¢: ]] I..tI",IE:dilI'~?.'.i;'FI=IND 'l'lql::ll' -I'Ht{ Oi",l"!!:;~('Fli!i '.:!;1:!!]'.1[~i1:;?. '.!i;"r'.:!;'l'hil"l I'1t':1¥ I;?.E'.ii;]:l;:,[i:l'.,ll:;:Ei: ]i::!; t:;?.li:H13[::,l:i!:t.~J:E:, J'O :!iJ'.,ll:i;[,I.,l[i;,~i:: h'tOI.;?.Ei: "1'111:::11'.,I 4 Prujocl Ifule No En]l'fleer$ -- Surve~/OrS Tolol Depth __ J .~. ~nchor~ge~ Field Purly Sumpl/ng T~ble Locuh~n Holes E Diugrom= esflmuled purl/cie size~ depths circulollDn lost, bils used, etc. Vegel~/ion! Un/ess otJ~rwise noted oil sumple~ ore token ~v./I.d"lO Stundard Ponelrah~n $ompler dri'~en wi/40 lb. hammer. 30" drop. /' D,illi.g Co. ¥Orll D ri Ilar Vernon ~L we~l o'~ner ',7oJo I~ELL CONSTRUCTID~ LOG Enterprises Type of rig cable-tool Wet[ location: (address & legal description) r£ract 3.~l'L~l ;'~ u.b. Nearest community. ,~ Anchorage The Vill?ges Lec~tio. sketch or remarka Depth of well 300 ft, Casing: de ptb 23 __ft. diam. 6 in. Static water level 28 ft. (~i:J'C~e;{ below)land surface. Finish of well: (G~b~]C.~:'L~C~':,':s~';(~C¢~,'~t~.oX~ZZfi~ open-hole, Giber) Describe intervals and size: Well yield tested by (~'~, haili,g,~at for hours with It, of dra.down ffo~ static level. gal/mi..bO-~led dovm~ recovery of '#ell ~000 ~pd DRILLER'S MATERIAL LOG Depth below land Dive descriplion of strata peaetrated surface in feet (size of material, color, hardness of drilling, and water content) '1 ,15 ~5 to 16'~' 1r~ 100 gravel,y brown ssmd & gravel broYm silty till bedrock ~ gray-brown~ mede hardness, fractures occurring seepage @ ~O' 1 gpm H20 @ 70' 2 3/t~ gpm @ 100' 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 DWELL:, " Parcel I.D. # ~"'~-~/~') _ ,.-~(:2~ \ .,.Z.~ HAA# ~ ~--,,c~ \ ~r~ ~')~L, 1. GENERAL INFORMATION (Must be completed prior to submittal) ' :%; , (a) Legal Description (include 10t, block, subdivision, section, township, range) Location (address or directions) (b) Property owner Mailing Address (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Address ."~ ~'¢' 'Telephone Telephone: (home)-~¥,.,C-8OSd' Business ~..,'[~-'--'~/'5'~ Telephone .,¢'d' ~ - (e) Mail the HAA to the following address: (or check here(~, if hold for pick up.) List contact person and day phone number below: J~ll '~orn?Co~ 2. TYPE OF RESIDENCE Number of bedrooms Single-Family ~ 3. WA'rER SUPPLY Individual Well Ei' Community [] Public [] Not, e".lf community we system must have, written confirmation from the State Department of Environmental Conservat on attesting to th ega ty and 'status. 4. SEWAGE DISPOSAL On-site ~] Public [] Community [] Flolding Tank [] Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev, 7/88) Page 1 of 2 5. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION As ce rtified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of th is Health Authority Approval, shows that the on-site water supply and/or wastewater disposal system is safe, functional end 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 w~ter 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 _ ~"/'~./-~o~ 7"'~-/~r~ ,; ¢o./ _~'~,-c~- Telephone ~ ~o'-- / ~,5-,-,c' Address Date Seal 6. DHHS APPROVAL Appr?,vedfor' /~ rbe~roomsby Approved ./X~ - Disapproved Terms of Conditional Approval 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 M unicipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 72-025 (Rev. 7/88)Back Page 2 of 2 A. WELL DATA MUNICIPALI'FY OF ANCHORAGE (MOA) Health Authority Approval (HAA} CHECKI. IST - FEBRUARY 1984 ~_~ ~A,',,,~', ~ 343-4744 Legal Description: ~'RAcT~ If A, B, C, D.~.G. Approvod (Y/~) Depth of Grouting t4/~ Pump Set At c~o Sanitary Seal on Casing (Y/N) ¥ Depression Around Wellhead (Y/N) Well Classification Well Log Present (Y/N) _~ Date Cgmpleted Total Depth Ioo Cased to .:2.-2' ~ Static Water Level ~ I ~ H/~,I/<II Casing Height Above Ground 22'" Electrical Wiring in Conduit (Y/N) __y SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot I~L+' To (' ,O. ; On Adjoining Lots To Nearest Edge of Absorption Field on Lot -I O I~ ; On Adjoining Lots To Nearest Public Sewer Line > /oo ' To Nearest Public Sewer Cleanout/Manhole f To Nearest Sewer Service Line on Lot K~ Water Sample Collected by FLATTOP TEeN '~v'(:5 ; Date Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Datelnstalled '7/12/7~ Size 2,$° No of Compartments Standpipes (Y/N) ~ Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SIEpARATION DISTANCES FROM SEPTIC/HOLDING TANK: To Water-Supply Well ~t H F~eN To Property Line ~O' Fg~\ C.O. To Water Main/Service Line Temporary Holding Tank Permit (Y/N) Foundation Cleanout (Y/N) Date Last Pumped ; for To Building Foundation ~$ F~oet C.O. To Disposal Field _ '25' F~'ob C.o, To Stream, Pond, Lake or Major Drainage Course ~,~/oo' Comments 72-026 (Rev. 7/88) Front Page 1 of 2 C. ABSORPTION FIELD D.,A,~TA Soils Rating in Abs, o'dJ~ion Strata Date I nsta~l-¢d'' ~/7~ ' Depressi~ver Field (Y/N) Results of Last Adequacy Test Type of System Design ~' EN cH Length of Field fi3~ PER ~NSP, ~,EP. Depth of Field 17 Gravel Bed Thickness '7 ' Statndpipes Present (Y/N) Date of Last Adequacy Test To Property Line To Existing or Abandoned System on SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well Io~ FgoN ¢.o, To Building Foundation 27 Lot ~/~ To Water Main/Service Line ~ ..gS" To Stream, Pond, Lake, or Major Drainage Course ~ To Driveway, Parking Area, or Vehicle Storage Area ; On Adjoining Lots '~A To Cutback (if present) NA Comments D. LIFT STATION N,/~, Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Cedes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~r"-~ Company Date MOA No. Receipt No, '=~-~' ~ ~ Date of Payment Amount; $ / 72-026 [Rev. 7/88) Back Receipt No. k~ ~ ~,o~ Waiver Fee: $ Date of Payment Engineer's Seal Page 2 of 2 _cnEM?__ZZ ~_ c, EoLo_____~cA_~ ?~_o_mroR~s o£ ~s~o; ~vc. ------~E-CEP~S~ -- -- ~E~ s-FF~t-7I-- ~ ' : Anchorage, Alaska 99,518 Drinking Wa'ter Analysis Report for Total Coliform' Bacteria TO BE COMPLETED BY WATER SUPPLIER [] PUBLIC WATER SYSTEM I,D.# )~ PRIVAI'E WATER SYSTEM FL/tTTo~ T. ~. t~S3o ECl-tv 3 q,5'- t~ 3-.s' Phone NO. Mailing Address City State SAMPLE DATE: [-~F~ F~'-I:'-I I--~-[7-1 Mo. Day Year Zip Code SAMPLE TYPE: ~' Routine Check Sample (for routine sample with lab ref. no. _) [] Special Purpose [] Treated Water 1~ Untreated Water SAMPLE NO. LOCATION 2 I TR,~CT 3 I 41 5 I Time Collected Collected ay TO BE COMPLETED BY LABORATORY s YatiS shows this Water SAMPLE to be: isfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results, Please sond new sample via special delivery mail. Date Received , F-~- 7/~', i//~- 'rime Received ? Analytical Method: Membrane Filter No. of colonies/lO0 mi, Lab Ref. No. Result* ~I, i O~'~'u,/ ~ J Analyst BACTERIOLOGICAL WATER ANALYSIS RECORD READ INSTRUCTIONS Membrane Filter. Direct Count Coliform/100 mi BEFORE COLLECTING SAMPLE Verification: LTB BGB Final Membrane Filter Results Coliform/100 mi Time: ~.,%"~7~ a.m. TNTC = Too Numerous To Count OB = Other Bacteria PART ONE JIF TWO REHAINDER TO FOLLOW CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 FAX: (907) 561-5301 :fl,ATTOf IVi[JNICIPALITY OF ANCHORAGE DEPARTiVIENT OF HEAL.TH AND ENVIRONMENTAl- PROTECTION DIVISION OF ENVIRONMENTAL HEALTH CEWIIFICATE OF INSPECTION For{ HEALTH AUTFIORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY 264-4'/20 Application Date .... _7/,~ 5/~'~ 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions) (b) Applicant Name ~, ~Ho~P~A .... Telephone;Horne ~4~-~O3~ Business Applicant Address Iq O~___~1~ ~, ~C~ ~ (c) Applicant is (check one): Lending Institution ~; Owner/builder ~; Buyer ~; Other ~ (explain); ........... (d) Lending Institution .~¢tl~t~ ~v~t~4'~-'tG~G¢-.. Telephone (e) Real Estate Company and Agent _ ~ Address Telephone (f) Mail the HAA lo the following address: TYPE OF RESIDENCE Single-Family ~ Multi-Family [] Number of Bedrooms__ ~¢ Other WATER SUPPLY Individaal Well~ Community ~ Public ~ Note: If commenity well system, must have writtan confirmation from the State Department of Environmental Conservation attesting to the legality and status. 4. SEWAGE[ DISPOSAL Onsite [] Public [] Community [] Holding Tank El Note: If community well system, must have written cordirrnation from the State Department of Environmental Conservation attesting to the legality and status. Page 1 of 2 72-025 (~1/84) ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SF-ARCH, 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 ~~__~._~O~/ ~ Telephone ~t'~ /0~ Address /~ ~OO ~ Engineer's Seal DI-IEP APPROVAL 'Approved for /-~,~'?l_~/~/ bedrooms by Approved Disapproved Conditional Terms of Conditional Approval CAUTION The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority Approval certificates based solely upon the representations given in paragraph 5 above by an independent professional engineer registered in the State of Alaska. The DHFP 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 72-025 {11/84) MUNIglPA~J'rY OF ANCHORAG g~l~¥, OF HEAUH & i~NVI~,ONM~NTAk I~Ro'r[¢TION 't L 2,5 t!$1 RECEIVED WELL DATA MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 264-4720 Legal Descript,on: Well Classification ~/,~/¢//¢/~",/~_,¢- If A, B, C D.E.C. Approved (Y/N) _ ~,~ Well Log Present (Y/Nj Y Date Completed 7' /jT/7 ~ Yield Total Depth /CO Cased to J'2~,¢¢~//* ~-~ ~)D~epth of Grouting /'J//~?' Static Water Level 23'" Casing Height Above Ground /~" Electrical Wiring in Conduit (Y/N) _ _~' Separation Distances from Well: To Septic/Holding Tank on Lot To Nearest Edge ol Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole ~/~'~ Water Sample Collected Dy Water Sample Test Results Cdmments _ ',~ Standpipes (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Con~ Holding Tank High~Water A Separation Distances from To Water-Supply Well __ To Property Line To Water Main/Service Line Course Comments Pump Set At ~'4P Sanitary Seal on Casing (Y/N) ~t' Depression Around Wellhead [Y/N) /~ : On Adjoining Lots On Adjoining LOtS To Nearest Public Sewer To Nearest Sewer Serwce Ltne on SEPTIC/HOLDING TANK I: ¢ ,,.'~ Scol9,{1' 7664 "Post,it" Routing. Request Pads Date Installed R'O¢ ING - REQUEST ~ READ / To L and ~ RETURN , or Major Drainage Page 1 of 2 72-026(11/84) C. ABSORPTION FIELD DATA To Water-Supply Well To Building Foundation Lot /~¢/~F To Water Main/Service Line To Stream/Pond/Lake/or Major Drainage Course To Driveway, Parking Area, or Vehicle Storage Area Soils Rating in Absorption Strata /:~-~.~ Type of System Design Date Installed ~//.,'A/~' /¢/7"~ Length of Field _,~"~' Width of Field ¢¢'- f)~_~CSd-~t~', I 0]~' Depth of Field // .,~ Gravel Bed Thickness 7 Square Feet of Absorption Area ~:~ ~-' Standpipes Present (Y/N) Y Depression over Field (Y/N) /V Date of Last Adequacy Test Results of Last Adequacy Test ,~*¢"~c:~,4,¢ ,~/~-~c~ U ,,,¢-- F"t~ f-~,,'/~ ~/~ Separation Distance from Absorption Field: /O~.~ To Property Line /'~ To Existing or Abandoned System on ; On Adjoining Lots "t,///~ ~'/~.2~ To Cutbank (if present) Comments D. LIFT STATION Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Electrical Codes (Y/N) Dimensions ~ Manhole/Access (Y/N) ~ "Pump Off" Level at ~ Vent (Y/N) " ~ Pumping Cycles during Adequacy Test. Meets MOA Comments ** Check Permitted Bedroom Rating Against HAA Request ** I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed ~'~¢,¢~'~ --¢-~- = - Date Company ~/~-¢¢~/ ~¢ MOA No. Receipt No. Date of Payment Amount: $ ~ ~O Engineer's Seal Page 2 of 2 72 026 (H/841 .... -~'A-~ ~-R ECE VED ' A4UNICIPALITY OF' AN£ MUNICIPALITY OF ANCHORAGE DEPT. OF JHALTH & DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECT~J~ONMEt{],LL 825 L Street - Anchorage, Alaska 99501 980 SA TAT ON mWS O I) Telephone 264-4720 ~ E C E J V E D REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES DIRECTIONS= Complete all parts on page 1. IncompJete requests will not be processed. Please allow ten (10) days for p~ocessing. 1. PROPERTY OWNER TPHONE MAI EING ADDRESS PROPERTY RESIDENT (If different from above) PHONE ~ BUYER PHONE MAILING ADDRESS ~ REALTOR/AGENT "HONE ~'. LEGAL DESCRIPTION STREET LOCATION 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS ~ One ~ Four ~ Other.~_ ~ ~ Two Five SINGLE FAMILY ~ Three ~] Six MULTIPLE FAMILY 7. WATER SUPPLY INDIVIDUAL* * ATTACH WELL LOG. A well Icg is required for all wells drilled COMMUNITY since June 1975. For wells drilled prior to that date, give well [] PUBLIC UTILITY depth (attach Icg if ~vailable.) 8. SEWAGE DISPOSAL SYSTEM ,.~ INDIVIDUAL/ON-SITE** [I~ YEAR ON-SITE SYSTEM WAS INSTALLED. [] PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED. THIS SIDE FOR OFFICIAL USE ONLY 1. TYPE OF RESIDENCE NUMBER OF BEDROOMS [] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER [] MULTIPLE FAMILY [] TWO [] FOUR [] SIX PERMIT NUMBER 2, WATER SUPPLY [] INDIVIDUAL DEPTH OF WELL [] COMMUNITY DATE DRILLED [] PUBLIC UTILITY Connection Verified LOG RECEIVED 3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER [~] INDIVIDUAL/ON -SITE DATE INSTALLED Connection Verified INSTALLER []Septic Tank or [] Holding Tank Size: ]<:~.~-~3 If Tank is homemade SOILS RATING give dimensions: TYPE OF TANK MANUFACTURER TOTAL ABSORPTIQN AREA MATERIAL 4. DISTANCES WELL TO: Septic/Holding Tank Absorption Area Sewer Line Nearest Lot Line Absorption Area to nearest Lot Line 5, COMMENTS (~].~'APPROVED FOR /~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED (Rev. 6/79) 563 ~ ~- ~ IJf,~'u .4? (~l~,n. kir~l Water Analysis Repo~ for Total Coliform Bacteria ~ ~ ~O BE COMPLIED BY WATER SUPPLIER TO BE COMPLIED BY ~BORATORY I.D. NO. Phone No. cay SAMPLE DATE: ~ MO, Day Year SAMPLE TYPE: ~, Routine ~~? '~"'~. ' r'] Check S~'~pte~for murine with lab ref. no.. [3 Special Purpoae Zip Code rn Treated Water [] Untreated Water SAMPLE NO. LOCA~ON 3 [ 4 [ Time Collected Collected By ~1~. Satisfactory [] Unsatisfactory' [] Sample too long in transit; sample should not be over 30 hours old at examination to indicate reliable results. Please send new sample via special delivery mail. Date Received 7 ~-~3 ~ 3~- Time Received /"2 0//?. Analytical Method: [] Fermentation Tube ,~ombrane Filter Lab Ref, No. Result* Analyst I-1-] I-i-1 r-F'] r-l"] 06-1220 (b) Rev. 1983 BACTER IOLOG ICAL WATER ANALYSIS RECORD READ INSTRUCTIONS BEFORE COLLECTING SAMPLE Membrane Filter:. Direct Count Collformll00ml Verification: LTB. Final Membrane ,~r R~S~S .~1 ~ Reporled By_.-~' /~'W,_~'~-- .BGB Colllormll00ml Time: /Xc~ ~') a.m. TNTC = Toe Numerous To Count CHEMICAL & GL...LOGICAI, LABORATORIES ~./ ALASKA, INC. '~.E~~014 ANCHORAGE INDUSTRIAL CENTER 274-3364 5633 B Street i Report for Total Coliform Bacteria TO BE COMPLETED ElY WATER SUPPLIER WATER SYSTEM: Mailing Address I.D. NO. ~' Phone No. City State Zip Code Mo, Day Year SAMPLE TYPE: [] Routine [] Check Sample (for routine sample with IBb ref, no. [] Special Purpose [] Treated Water [] Untreated Water SAMPLE NO. 1 2 3 LOCATION 4 I L Time Collected Collected By TO BE COMPLETED BY LABORATORY Analysis shows this Water SAMPLE to be: ,~ Satisfactory [] Unsatisfactory [] Sample too long in transit; sample should not be over 48 hours old at examination to indicate reliable results. Please send new sample. Date Received Time Received Analytical Method: [] Fermentation Tube [] Membrane Filter Lab Ref. No. I Result* Analyst *No o[ colonies/' 100 mi. or No. ol Positive pOrlions READ INSTRUCTIONS BEFORE COLLECTING SAMPLE 06-]220 (b) Rev, 1978 BACTERIOLOGICAL WATER ANALYSIS RECORD Date Collected Source veal Time Received p,m. Lab. No, 4.~..~8 H ou r.,_..~[___ EMB Multiple Tube Report: Membrane FIIter~ Direct count VerlRcatlon= I.T8 Final Membrane Filter Resultl