HomeMy WebLinkAboutELMORE #1 BLK 5 LT 7
GRE~.'~.R ANCHORAGE AREA BOR,.',.'.'"~.,.,.,GH
Department of Environmental Quality
3330 C Street
Anchorage, Alaska 99503
INSPECTION REPORT ON-SITE SEWAGE DISP~O,.,SAL SYSTEM
MA,L,NG ADD.ESSI a - P.O.E
SEPTIC TANK:
FROM WELL ~"'/"-~-~"] MANUFACTURER ATERIA[ COMPARTMENTS
INSIDE LENGTH /&) INSIDE WIDTH LIQUID DEPTH LIQUID CAPACITY] '~"~-'~::~GALLONS.
TILE DRAIN FIELD:
DISTANCE FROM WELL 7~I'~FOUNDATION
NUMBER OF LINES DISTANCE BETWEEN LINES
ABSORPTION AREA "~ ~ ~' ~
DEPTH: TOP OF TILE TO FINISH GRADE
/ TOTAL LENGTH ~.~ C) /
NEAREST LOT LINE 7 OF LINES
TRENCH WIDTH 3 /IN. TOTAL EFFECTIVE
SQ. FT. LENGTH OF EACH LINE
,,~ ! DEPTtt OF FILTER
MATERIAL BENEATH TILE
IN. ABOVE TILE
IN.
WELL:
TYPE CONSTRUCTION __DEPTH
BUILDING NEAREST NEAREST SEPTIC SEEPAGE
FOUNDATION__ LOT LINE.__, SEWER LINE , TANK , SYSTEM.
DISTANCE FROM:
CESSPOOL
. OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAl-:
LOT 5LOPE:
REMARKS:
Form EQ-O32
PERMIT NO.
APPL I CANT
LOCAT I ON
LEGAL
MUM I ¢ ]"'"'AL I TY OF. A~4CF/"'~RAGE
DEPARTMENT ~..,' HEALTH AND ENYIRONHENTAL
-, 25t~ E. TUDOR RD, · ANCHOR~GE~
L~ELL RND ON--SITE
JIM SCHEFERS
RIVERTON & TETON
L? B5 ELMORE #1
SRR BOX 325S
LOT SIZE
349-2427
35000 SOURRE F~E~
TYPE OF SOIL RBSORBTION SYSTEM IS: TRENCH
HR>,'IMUr.1 NUHBER OF BEDROOMS = 3 SOIL RATING <SO ET?DR)= 85
THE REQUIRED SIZE OF THE SOIL RESORPTION SY~T~I IS: ~/~
DEPTH= 7. 5 LEf46TH= ~ 6RR~/EL DEE'TH= ~
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE TRENCH OR DRRINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND RND THE BOTTOM OF THE E×CRVRTIOfi (IN FEET).
THERE IS NO SET WIDTH FOR TRENCHES.
THE GRRVEL DEPTH IS THE MINIMUH DEPTH OF GRRVEL BETWEEN THE OUTFRLL PIPE
RND THE BOTTOM OF THE E×CRYRTION (IN FEET).
REQU I RED SEPT I 0 TRf-IK Si:; I 7----E= ::L000 6RLLC'[4S
TI40 ( 2 ) I f,ISPECT I OHS ARE REnU I RED
BACK-.FILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
· ~_DEPRRTMENT WILL BE SUBJECT TO PROSECUTIO[I.
MINIMUM DISTANCE BETWEEN R WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR R PRIVATE WELL OR 200 FEET FOR R PUBLIC HELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DRYS
OF THE WELL COHPLETION.
SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE AVAILABLE TO INSURE PROPER
I NSTRLLRT I ON.
PERM I T VRL I D FOR Of 4E YERR FRO£'I I S_'5-UE
I CERTIFY THAT
1: I RH FRHILIRR WITH THE REOUIREMENTS FOR Of~-SITE SEWERS AND HELLS RS SET
FORTH BY THE MUfIICIPRLITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
3: I UNDERSTAND THAT THE Oil-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE I~ REHODELED TO INCLUDE MORE THAN ~ BEDR00rIS.
~FERS
P~r fora. ed for
Leue,
1His form reports:
ffenth
Feet
3-
6-
Anchora~;e. Alaska
Soiis log _ ~/~"~ Perc~l~-~o'n test
7----
10
11
12
13
14
Uas'ground water encountered?
Reading Date GroSs Tin:e
Percolation rate
Proposed installation:
I
minute.
If yes, at what depth? ' //~- _
Depth to H20
~et Time
Net Drop
I Seepage Pit" Drain Field
~)c'pt~. of Inlet : . Depth to bottcm of pi~t. or t?e.nch .
]]OX 1~.~9, ST,%I~. I~.OUTi~ A .~NCIIORAGE~ ALASliA 99502
SiX INCH WATER WELL DRILLED AND CASED OUT TO THE DEPTH OF
DRILLED AT THE RATE OF $t8,00 PER FOOT.
PROPERTY OWNER
8~ feet
l~r. Ja~es E. $chefers SEA ~325-s Anch.
LOCATION OF WELL SITF Lt'-7 ]~'~' ~:~-~ ~-'~
Bernie ~,u~ of Rampart Drilling Works
DRILLER
WELL LOG:
0---22" ~ravel a~i ,~,11 b~,laers. 20% el~y.
~--83' ~avel,
83--85' Water bearin~ ~ravel. $~ew~at silty and sandy But should cl~_up ~.oD~
~p4~, ~!~!~ ~t to ~ f~t h~e~r ~ no~e wat~ to tha~ ,de~h~
~t~ at 8~ feet Ih~ 8G~ ~th a 1~ foot he~,
Cost of Dr'~ll'~,~ Paid in F~'I1 by l~r. Ja~es Schefersl ~t530,00
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF .........
THANK YOU VERY MUCH.
DATE
BERNIE CLAUS OF RAMPART DRILLING WORKS
SERVICE CHARGEOF I~% PER MONTH WILL BE ASSESSED ON PAST DUEACCOUNT~.
.... ~ 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
'- Parcell. D.# ~)\~,- I"t~ - --' HAA# ·
"i GENERAL INFORMATION " ' '" ....
::.~ .-..
Location (~lte address'or directions) ~1 ~ ~ "~U'PJ'I,~t~
i.:'. '. ' .: L.e..nd. ing.agency Day phone
· :.'. '~;. Unle~ otherwise roquest~, HAA wilt be ~etd for~.cku~. -. · .. : ...~ :.~...
· -- Individual
well
· ~ ...... ~.~..~; ........... Communitywel ........... _': .......... ~ .... . . ,~:..,
· .. ,.....- .... ............... . .... ................... ":',-.::~': ~ .
' :, .?:.'Publtc r'-' '
· --.- : --...., ......... .~.:; :; wate .................
.'-'.' - "NO '- I communi~ Well system, proidde written confirmation from State ADEC attest~ .
' '" ": ' :"'" in~ ~o tl~e legality and status of system.
individual On-site' - : ,,); ~ · . : ~-< ..
" '-; ! H ...... ' '
'': '"-.. _'~ :.~:': i~!~ oldin'gtank...' .:- ..-> :' ~.:..z..:-- ,,.,~_, .
.......... ',_. _Communit7 on-site i-- ...... ' '~""
· ... -.-~ . ......... . . ,,. ~.'.. . .... ? ~-'".' ?..... . "'."'-. .. ............ . ... _: '"'~-":--. . x,'~.',.',;,..~,,.,..,,,, .... ,.-~--< ?~,
'- · Public sewer ~ ·
:' ' *' :" '-' NOTE: ' :1~ community wastewater system, provide written confirmation from State ADEC" ' ':'""'-
''attesting 'to ~he legality and status of system. "-' .... ....
· 5. STATEMENT OF INSPECTION BY ENGINEER · . * · ;.
As certified b~, my seal affixed hereto and as of the validation date shown belo~, 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 informabon obtmned from
the Municipality of Anchorage flies 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. ~[ ..... - _
Address '~O:~ I~' Icj ~ 1'/~7.~ .....
. ._ Enginee~"s signature "'~. ' ~~' Date Gj//~.../q ~-- ...... .
· · .
·. ..... .
'~ .... .-: ' '~'t: ~ '"'" ' ~.
": Disapproved.' -. :'. *: ·
· '.*' :. Conditional approval for
bedro~_..ms, with the following stipulations:
Additional Comments
Th~,MunicipalJty of,~,n.chorage Department of Health and Human Services (DHHS) issues Health Authority
A~pr(~'a!,'~C~...,,rtifi.c~..'es~ only upon the representations given in paragraph 5 above by an Independent
professi~n~'l 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 ~3r omissions in the professional engineer's work..
Legal Description: ~:~,~r~C/(~ "~)C~ ~J. [O'~'-'~
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Pamel I.D.
A. Wall Data
Well type ~
Log present (Y/N)
Total depth (~ ~
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter, ADEC water system number
Cased to ~ ~ ~'~
Casing height
Wires properly protected (Y/N)
o
; On adjacent lots >
; On adjacent lots ~
Public sewer manhole/cleano~
Petroleum tank ~ / ~
FROM WELL LOG
Da,e o, test /
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~l
Absorption field on lot il ~1 "~'
Public sewer main ~1///%
Sewer service line ~'
WATER SAMPLE RESULTS:
Coliform
Date of sample:
Nitrate
N ~ Other bacteria
Collected by: ~, ~'
B. SEPTIC/HOLDING TANK DATA
Date Installed i~/~--/7~
Cleanouts (Y/N)
Tank size I _..q_ ~O
Foundation cleanout (Y/N)
Compartments ,~
Depression (Y/N) t'~
High water alarm (Y/N)~.A ~.~/~ Alarm tested (Y/N)
Date of pumping ~ LI Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ) ~ 5 On adjacent lots
To property line ~/O Absorption lield J ~-- Water main/service line
Surface water/drainage
72-(~6 (3/93)' Fm~t CONTINUED ON BACK PAGE
Co UFT STATION ~ '"~/./~.
Date installed
Manufacturer
Size in gallons
Vent (Y/N) .'Pump on' level at
High water alarm level
Meets MOA electrical codes (Y/N)
Ma'nhole/Access (Y/N)
'Pump off" Level at
.Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length ~ Width
Soil rating (GPD/Ft~)
.Surface water
Gravel thickness
· Total absorption area -2~ ~ Cleanout present (Y/N) y
Date of adequacy test ~P//3/q ~ Results(pass/fail) "~
Water level in absorption field before test ~ Il/~
Peroxide treatment (past 12 months) (Y/N) ~ ~/
System type
Total depth
Depression over field (Y/N)
for ~.~
if yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot Ii~ "~' "
To building foundation ~ e
On adjacent lots 1 ~ (~ ~
Surface water ~t1'~
Curtain drain ~
On adjacent lots ~ /0-eP Property line
To existing or abandoned system on lot
Cutbank H ~ vi e. Water main/service line "~
Driveway, pa~ingN.ehicle storage area
E. ENGINEER'S CERTIRCATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspecb'on.
Signature
Date
HAA Fee $
Date of Payment
.eceipt.umber
Waiver Fee $
Date of Pavement
Receipt Number
CT&E Ref.~
Matrix
Client Sample ID
CT&E Environmental Services Inc.
laboratory Division ~'f~'sJ~'~'~w~'~'~'~'~'~'Jff~'s~'J~w~'~'f~,~'f~,ffffsfjsj~~
..~.~-1 Laboratory Analysis Repo~
Client Name TOBB~--~ SPUI~KI2~D, P.E. WOP. K Order 1S437
Ordered By TOBBEN SPURF~LA.%~ Printed DaCe 06/15/95 · 15114 hfs,
Project Name Collec=ed Da~e 06/13/9~ · 14100 hrs.
Project# Received Dace 06/13/95 · 14:4S hrs,
PWSID
Technical Direc=or STEPHEN C. £D£
Sample Remarkel SAMPLE COLLECTED BY= L~ SPU~.
QC Allowable Exc. Anal
See Special Insc~c=~ons Above UA . Unavailable
See Sample Remarks Above NA - NoC Analyzed
200 W. Potter Drive. Anchorage. AK 99518-1605 -- Tel: (907) 562-2343 Fax: (907) 561-5301
ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA. FLORIDA. ILLINOIS. MARYLAND. MICHIGAN. MISSOURI, NEW JERSEY, OHIO. WEST VIRGINIA
CT&E Environmental Services Inc.
Laboratory Division ~r.~J~r~'~'J~:~J~-J~-t~tj,~jjj~jt~j~jffjj~
Drinking.Water Analysis Report for Total Coliform Bacteria 2o0 w. Potter Drive
Anchorage, AK 99518-1605
READ LYSTRUCTIO. VS 0;; REI/ER~E SIDE BEFORE COLLECTING SAMPLE Tel: (907) 562.2343
Fax: {907) 661-5301
~FUST BE CONLPLETED BY WATER SUPPLIER
PUBLIC WATER SYSTEM I.D. # I lJJ[lJ
PRIVATE WATER SYSTEM
CI Send Resuta ~ Se~d l~volce
Send Results r'l Send
SAY, IPLE DATE:
blonth ' ~ Year
S.43.IPLE TYPE:
Routine 13 Treated Water
Repeat Sample (for routine sample O Untreated Water
with lab ref. no. )
Special Purpose
SAMPLE LOCATION
Time Collected
Collected By
TO BE CONLPLE'rED BY LABOR.&TORY
Analysis shows this Water SAMPLE to be:
~ ~atisfaetory
Unsatisfactory.
Sample over 30 hour~ old, results may
be unreliable
ra Sample too long in transit; sample should
not be over 46 hours old at examination
to indicate reliable results. Please send
new sample via special delivery mail.
Date Received ~:'/[ ~'
Time Received [/../t/~-'
Analysis Began _
Analytical Method:
~"~fembrane Filter
o MMO-MUG
· Number of colonies/100 mi.
Lab Ret'. No. Result*
Scm to A.D.E.C. (~ Fbks
Date: L'" - J~ Time:
Client notified ofunsatisfactoD' results:
Phoned Spoke with
~Date:' Time:
Faxed
[]
Fa~ed
BACTERIOLOGICAL WATER ANALYSIS RECORD
.MMO-.MUG Result: ToUt Coliform
,Membrane Filter: Direct C6unt
Verification: LTB
Fecal Coliform Confirmation
Final ,Membrane Filter Results
E. Col~ '
Colonies/lO0 rat
. BGB COLIFIRM
Coliform/100 mi
Vat, (o-I¢--~' Time /~'~ hr,
,"A~T ON-~ OF
~--~;S M.m-,' ¥'W'O TO FOLLOW
oe ot the SOS Grouo (Soci(~t(~ G(~n6rale de Surveillance)
ENVIRONMENTAL FACILITIES IN ALASKA. CALIFORNIA. FLORIDA, ILLINOIS. MARYLAND, MICHIGAN, MISSOURI, NEW JERSEY. OHIO, WEST VIRGINIA
WED
~' MUNICIPALITY OF ANCHORAGE "~ ';
DEPAR~E~ OF H~LTH& ENVIRONME~AL PROTECTION . . . ~
~ENVIRONMENTAL ENGINEERING DIVISION :
T.leph~ ~7~
,'
REQUE~ FOR ~PROVAL OF INDIVIDUAL WATER ~D SEWER FACILITIES
IAI LING ADDRESS
PROPERTY RESIDENT (If diff~reet from ~e) '
BUYER
MAII. IN(]
4. REALTORJAGENT
MAILING ADDRESS
PHONE
PHONE
PHONE
r-'] On~ [] Four
~'~;~ SINGLE FAMILY [] Two [] Five
[] MULTIPLE FAMILY ~]~ Three r-I Six
7. WATER SUPPLY
~ INDIVIDUAL* * ATTACH WELL LOG. A well log is required for all ,~mlls drilled
[] COMMUNITY since June 1975. For wells drilled prior to th~
[] PUBLIC UTILITY depth (attach log if available.)
IL EEWAGE DISPOSAL EYSTEM
· ' I f indivldual/on-site, give installation date ~ T /~7~
If system is over two (2) Veers old an adequacy test i; required
by this Department.
,~ INDIVIDUAL/ON-SITE**
I"-I PUBLIC UTILITY
Other
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
7~.,010(3/76)
.... THIS SIDE FOR OFFICIAL USE ONLY
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
DIRECTIONS:
1. TYPE 0~: RESIDENCE NUMBER OF BEDROOMS
~ SINGLE FAMILY r-i ONE J~I/THREE I--I FIVE I-'l OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
2. WATER SUPPLY PERMIT NUMBER
~"/INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
.~INOIVIDUAL/ON *SITE DATE INSTALLED
[]PUBLIC UTILITY ~ O
Connection Verified INSTALLER
[]Septic Tank or []Holding Tank
Size: /C~.~'7 If Tank is homemede SOILS RATING
give dimensions:
TYPE OF TANK ' , MANUFACTURER
TOTAL A~ORPTION AREA MATERIAL.~.___. ~
4. DISTANCES WELL TO: 'tic/H°ldin: Tank~'~ Ar' Is''"r u~' 1Nearer L°t une
5, COMMENTS
~APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
LEGAI~ DE$CR ~P'I'ION .~ ~ ~
72-O10 IRev. 3/78)
Cl '-~.~?,~J. G eEOLOClC.~&. L/~0?J'~TO~L~ 07/'.~l.~J~[~., l~:C.
P.O. BOX 4-1276 ANCHORAGE, ALASKA 92509 4649 BUSINESS PARK BLVD.
Drin~ing Water Analysis Report for Total Coliform Bacteria
TELEPHONE
(C07) 2794014
TO BE COMPLETED BY WATER SUPPLIER
PUBLIC WATER SYSTEM:
I.D. NO.
Public Water System Name
Mailing Addreae
Mo. Day
State Zip Code
Year
SAMPLE TYPE:
n Routine
[] Check Sample (for routine sample
with lab ref. no..
~Speclal Purpose
[] Treated Water
[~--Unt reared Water
SAMPLE
NO.
1 I
~ I
I
I
I
LOCATION
¢_- L,~ ,,r'/~,
Time Collected
Collected By
I ~,~ ~
I
TO BECOMPLETED BY LABORATORY
LABORATORY:
C_H_[M & GEO LABS CF ALASKA. ~NC.
NAME
4649 BUSINESS PARK BLVD.
ADDRESS
ANCHORAGE, ALASKA
CiTY
Date Received ¢'
Time Received ~,,~ :.~ Of ~.
Analytical Method:
[] Fermentation Tube
.~ Membrane Filter
Lab Ref. No. Result* Analyst
I ~s-7o-71 I-F) ~
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Form No. 18-310 (S-78)
O6-1220
Rev. ),978
BACTER IOLOG ICAL WATER ANALYSIS RECORD
Presumptive ]Omi ]Omi ),Omi ]0mi ),Omi l.Omt
total Tubes Positive/Total ),0mi PGrtlons
Coil form/] 00mi
BGB .
Collform~),OO~tt
o.t.
· ,,... I lr:~-~ ..
