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HomeMy WebLinkAboutROSEBUD HILLS BLK 2 LT 1I oscbud Hill Block Lot i #017-381-41 MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION ENVIRONIVIENTAL ENGINEERING DIVISION 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT qAME Absorption area Dwelling Material PHONE NO, OF BEDROOMS PERMIT NO. No. of compartments Dwelling Material Liquid capacity in gallons [~NEW [] UPGRADE "PERMIT NO. Nearest lot line /O '~' Trench width .~ ~ inches ¢~_.p inches PERMIT NO. Total effective absorption area MAILING ADDRESS ~o/ LEGAL DESCRIPTION LOT I /3cocf~ ?- LOCATION ~ Well O~ DISTANCE TO: ] NO-~ ~ ~ ~anufacturer ~ ~Liq capacity in gallons ~O~O F HOMEMADE: ~ ~ ~ DISTANCE TO: Well ~ Manufacturer Q I ~Well ~= I DI~TANCETO: I ~oT ~ [ ~ I No, of lines I Length of each line ~ ~ Top of the to B~is~ ~ade ~ ~ Foundation Total length of lines Material beneath tile Depth Crib depth Total effective absorption area Building foundation Nearest lot line PERMIT NO. Driller Distance to lot line PERMIT NO, Sewer line Septic tank Absorpt on area(s) OTHER PIPE MATERIALS SOiL TEST RATING iNSTALLER REMARKS APPROVED "__ / DATE LEGAL ~-.~UUNICIPALITY OF ANCHORAGE~ Department' ~ Health and Environmen~af '~rotection ~ ~' '~825 L Street, Anchorage, AK. ~'9501 '~ ' ~ ' 264-4720 * * * HANDWRITTEN PERMIT * * * Permit ~ ~3 © ~2~ WELL.AND/OR ON-SITE!SEWER PERMIT Applicant: /~/~ f~,~ ~/$d/~' Mailing Addre~s:~/~/~/~/~/~ Location: Z~F / ~ ~ ~Z'~ /'~'~'~'$ ~.Phone Numbe~: Legal Description: Type of Soil Absorption System Is: Trench: / Drainfield: Maximum Number of Bedrooms: ~ , Seepage Bed: Soil Rating Lot size: Holding Tank: sq.ft/br) 4~ ~$~'/ The Required Size of the Soil Absorption System Is:' DEPTH / ~ LENGTH ~ GRAVEL DEPTH ' WIDTH ~ The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the 0utfall ~ipe and t'he bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE =/OOO GALLONS * * Permit aPplicant has the responsibility to inform~this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department: will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 feet~ for a private well or 150 to 200 feet from a public well depending upon the type of public Well. Minimum distance from a private Well 'to a pri~ate sewer line is 25 feet and to a community sewer line is 75 feet. Well logs are required and must be returned to this department within 30 days of .the well completion. Other requirements may apply. SpeCifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 8 3 * * * I certify that: (1)I am familiar with the requirements for on-site sewers and wells as set forth by the Municipality of Anchorage. (2) I will install bhe system in accordance with codes. (3) I understand that the on-site sewer system may require enlargement if the residence is remodeled to include more th~. bedr?o~ ' Applicant Date: ?~/F~ SWP/024 (1/81) oepar.~ment of ~ealth and ~nvLronmen~ai 284-47~0 ~ ~ ) HANDWRI~EN PERMIT ~ ~ ~ ~ NELL AND/OR ON~SIT~ SEWE~ PERMIT ...... Address: ~/~/ ~ :.-.:.::--._~..,DSPT8 ~ LENGTH~ ~g' GRAVEL DEPTH ~ ~' ~ WIDTH ~ , ~epth of a ~ranch or<pit [~ the ~%~ae between the surface o~ the the botto~ of the excavation(in ~eet). ~ere is nO set width ~Or th~ ~ttom o~ the eKcava~ion(in feet). ~ ~- REQG~ SE~IC(HO~iN~ TANK SIZE ~ ~0~ - -GALLONS *" ~e~it appiiaant ha~ Bhe reapo~lb~[ltY to i~fo~ ~his Ae~tmen~ d~ing th~ :"- tn~ta~atlo~ inspeakions of any well~ adjacent to this prope~Y ~-th~ ~f r~sidences that the we~i wi%~ * ~ ~ ~0(2) h~FcCTlON~"~'~ '- ' - ~ ARg. RE~~ "~ *~:'': ::--":"~or a ~rivate well oc ~0 to ~00 feet f~ a:.p~lz~ w~ll..u~-~::~: : . Other .ra~e~onts may apply. ~ification~ an~ conet~t-io~ 4'ia~r~- ara ~vailabl~ ~o insur~ prop~ inm~allakion. - -:--- -~-? ~ ~e~ti~y that: forth by the' M,~icipaIity ALASKA ~-~qgo~m~nTAL CONTgOL $~R"~g~S, I~C. ~.n~in~rin~ ~ ~nuJronmcntal Studk's ADDRESS ' PERCOLATION TEST DATA SHEET DATE ZIP CODE LEGAL LOCATION i, .~O.~-)L~ /.JFI~II~ ~-0-~- [ TOTAL DEPTH OF HOLE /0 ft. ZONE TESTED ~,(~ ft TO ~-', ~ TH # ,.~ TEST HOLE DIAMETER ft READING # CLOCK TIME MET TIME: DEPTH TO NET DROP RATE (min/in) DATUM FINAL PERCOLATION RATE PERFORMED BY MOA ST83-024 SQUARE FOOT/BEDROOM ~min/in) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION 825 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG - PERCOLATION TEST SOILS LOG PERCOLATION TEST I I ' - ' .... / SLOPE / OveFbur6en 2 ISO C-,~ F r/l~,oR~ 3 8 SITE PLAN 10 11 12 13 14 15 16 17 18 19 20.- COMMENTS ~-5/9 WAS GROUND WATER N~ I~ O ENCOUNTERED? P E IF YES, AT WHAT -- DEPTH? ! Gross Net Depth to Net Reading Date Time Time Water Drop z. ~:/6': so /0 ~z/~. .~ ~ 0'5 ~#~. 8jz/8~,..,~ = ~s-~ 0'3 PERCOLATION RATE TEST RUN BETWEEN PERFOR.ED.',: Oan P1OFI e-T'85 -OZfl- CERTIFIED B DATE: '~-~ WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geological 6 Geophysical Surveys Drilling Permit No, Please ~lste either lb lc.) A.D.L. No. la.lJaorough Subd,vie,on Lo, e,ook Ih. II I/4qtre. Section No. TownshlPNr-] Range EEl Meridian Ic.JlDISTANCE AND DIRECTION FROM ROAD INTERSECTIONS 5. OWNER OF WELL: Address: 1~ ~d~' Fief Below 4. WELL DEPTH: (final) 5. DATE OF COMPLETIQN M oterlal Type Top Bottom bT~ ~y ~[- ~ J~~ ~ Auger ~detted ~Bored ~Other: ~]T~ ~]]-~0' ~ ~ 7.'USE; ~ Domeatic ~ Public Supply ~ Indu,try b~'~ ~dy silt; ~ 70 101 ~ Irrigation ~'~ [~ ~V~]]~ ~.~L ~ ~ 8. CASING: ~ Threaded ~ Welded diam. In. lo ft. Depth Sflckup~ ff. 9. FINISH OF WELL: Type: Diameter: Backfilling GrOvel pock ~o.s~*~ ~;;. ~v~: 1~ .. / / Date ~ Above or ~ Below land lurface ~UNICIPALI~ OF ANCHO~ Equipment used: DEPT, OF HEALTH & II. PUMPING LEVEL below land surface and YIELD fl. after hr~. pumping g.p.m. Material: ~ Neat Cement ~ Other: I~.PUMP: (if available) HP Length of Drop Pipe ft. capacity --g'p'm' ~ Subm. ~ Jet ~ Centriflcal ~ Other 16. WATER WELL CONTRACTOR'S CERTIFICATION: ~ 15. W=t['[ T~eroiure e ~ F This well was drilled under my jurisdiction and this report Is true to the best of my knowledge o~bellef; Registered Bu~i~Name Contract LicenSe Number [ .... ~"'~ Aufho~~ ~epresentolJve Farm 02-WWR (11/81} COpy Dislribution: WHITE-Stats DGGS~ PINK-Driller~ CANARY-Customer .WATER WELL RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Division of Geolocjicol ~ Geophysicol Surveys Drilling Permit No. LOCATION OF WELL (Please com .lefe either la, lb or lc.) A.D.L. No. --,STl'la°r°ugh Subdlvis,o. Lot S,ock i~.I, '/4qtrs. SecHon No. Township N[~ Range EO Meridian Lc.J] DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS ~. OWNER OF WELL: "' ...... ' f' r"' ' ~ qi '' :;~ l ~;~; di,m. in. to ft. Bepth Weight lbs./ft. ~',:':' "( i~ ¢~' ~ ~:"~ ~ . ':>;:' ., _ ,, ..... diam. in. to ft. Depth Stickup ft. ;u~; ~ ?. (~'~f~; :. '~, ~ *.,¢) ;~:~'* ~?''` ,,? i, ~ 9. FINISH OF WELL: ~ Above or ~ Below land surface Date Equipment used;~ /::'~ ~"~ J : ';~,"'%."~-'~:~ (:~ :~" .'~?'~-~ ft: after ~' hrs. pumping ,"¢~ 1~.6ROUTING Well Grouted; ~ Yes ~ No Material: ~ Neat Cemsnt ~ Other: 0 Subm. 0 der ~ Centrific,I 0 Other 15. Weter Tempereture ~ F ~ C 5 . r,; ..- i ' ."~;-;, si~,~: >.,~ ...... **.-. 7'i :.~.~? :c <..:.* ""~: F:'ERM I T NO: DAT'E iSSUED: F z t" .~ 60 06/05/86 AF:'PL i []AN]': ADI)RESS: CONTACT PHONE I_EGAI.... DESCRIt::' I_E!T SI WAYNE/E]:L.E:EN FRISON 12090 BADGER LANIE ANCHOI:RAGIE, AK 99516 345-6994 I_OT: 1 BI_OCK: 2~ RANGE: 3W ]: c:: e v t i f y t. h a'l:.: 1. I am i'ami].iar' ~,~:i. tht. her, equ:i.r'ement:s ,rcm on-.site sewer's and wells as set ¢ctvt. h by t. he Municipality of Anchor'age (MOA) and the State of Alaska. ~;~,, ]: will. :install t. he system in accordance wit. h a!:f. MOA codes and regulations, and in co~llp].ialqce with the design cviter'ia of' this per'm~,t.. 3. I will adher'e t.o a].]. IflOA and Stat. e o{' Alaska requir'ement, s ¢(3p t. he siet back dist. ar]c:es i'pc, m any existing we].l~ uastewat, ei' disposal system of public sei-~evage syst, em on t.h:i.s or any ad.jal:::erd:, ch- near'by lot,, S I GNED , DATE :: API:~L ! CAN'T: . WAYNIZ/IZ I I.,EEN I:'R :1: SON PREPARED FOR -' .~'/,.~/'/E DES. BY: //~'.~.-~' CHK. ISH. NO. / OF / ~,~'~ , WAKON REDBIRD 8 ASSOCIATES CONSULTING ENGINEERS 600 WEST 53RD ANCHORAGE, ALASKA I hereby certify that an accurate survey of fbi following described property-- was made on_-~-/-7-//6s and that the improvements situated theron are within the property lines and do not overlap or encroach on the property lying adjacent thereto~ that no improvements on property lying adjacent there- to eneroach on the premises in gu. estJon and that there are no roadways, transmission lines or other visible easements on said property escept as indicated hereon. Dated at Anchorage, Alaska, thls._~.~day of -- '- Anchorage P.O. BL.. 196650 ANCHORAGE, ALASKA 99519-6650 (907) 264-4111 TONY KNOWLES, MA YOR DEPARTMENT OF HEALTH & HUMAN SERVICES June 23, 1986 Wayne/Eileen Frison 12090 Badger Lane Anchorage, Alaska 99516 Subject: Lot i Block 2 Rosebud Hills Subdivision On-site Well Permit #860106 - Issued June 5, 1986 On May 20, 1986, The Anchorage Assembly approved a new ordinance regulating on-site wastewater disposal systems (septic systems). Ail septic systems constructed after the effective date of this ordinance are subject to the provisions of this ordinance. Our records show that you currently hold a permit for the installation of a septic system. We strongly urge that you contact this office prior to constructing your system. Any changes in the code that could impact the construction requirements of your septic system will be identified and brought to your attention. Please contact the Environmental Services Division at 264-4720. Thank you for your cooperation. Sincerely, Susan E. Oswalt Program Manager On-site Services SEO/SSM/ljw 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 H F__ALTH AUTHORITY APPROVAL CERTIFICATE O,F' ..... · ' :'" ;" ' '" FOR fi,"S'I~(JLE FAMILY'DWELLING""'"' ' - . , . . ~., .,~, _.,..'~...~., P~'~eI".I D, ;" 0)"~;'--.'~ 8/ ¥/' -'-'~., , -',' '--~IAA#',' ,/;/',/¢0 / ID3z//'~'. . Expiration Date: lO -' ~/,~.. '" ~) I GENERAL INFORMATION Complete legal description Location (site address or directions) · Current ,Property ow,nor(s) Mailing address I ?-9 of, Lending agency Mailing address Real Estate Agent I~ on Day phone '~,,co -~ ~-c:,7 Day phone Mailing Address Unless otherwise requested, HAA will be held by DSD for pickup. 2. NUMBER OF BEDROOMS: ~ 3. TYPE OF WATER SUPPLY: Individual Well [] Individual Water Storage [] Community Class . Well [] Public Water System [] TYPE OF WASTEWATER DISPOSAL: Individual On-site [] Individual Holding tank' [] Community On-site [] Public Sewer [] The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority Approval (HAA) based only upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of title (except bob,yeah spouses) for propedies served by a single family on-site wastewater disposal and/or water supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with new water sample results less than 30 days old. (Certificates 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 wells or a public water system. The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work. 4. STATEMENT OF INSPECTION BY ENGINEER As certified by my seal afl,xed hereto and as of the validation date shown below, I verify that my Investigation, based on procedures outlined in the Health Authority Approval Guidelines for 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 files 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 o[ installation. NameofFirm /~'t,~F-A=,p 3-~¢~n,,'¢~/ ~"E."u,¢'~V- Phone., Address 1~3~ ~c~ ~ ~o~¢ ~ Engineer's Printed Name . ~A~o~ ~ ~o~ ~ Date 5.' DSDSIGNATURE '* °': " ','-"* Z,,~, Annrnwd fnr ". ~ bedrooms ~~. · . . . ~ . · .: . .. · . . , . ~ .. .. ,. ~ · D~sapproved. ,,;.~. % cE-35a~ ~..~ .. _ . .... Conditional approval for · bedrooms, w~th the follow~ng .. . ~ ,,. ~*. . ,-... ,..- , ~ - .. . . ~ Additional Comments PROGRAM · ... .... ... Attachments: HAA Checklist Septic System Advisory Well Flow Advisory X Maintenance Agreements Supplemental Engineer's Report Other Original Certificate Date:. "~ -/,~ - ID ! Municipality of Anchorage Development Services Department Building Safety Division On-Site Water & Wastewater Program 4700 South Bragaw St. P.O. Box 196650 Anchorage, AK 99519-6650 www.ci.anchorage.ak.ua (g0?) 34~Ze04 HEALTH AUTHORITY APPROVAL CHECKLIST A. WELL DATA Well type ' p~. f~,! s~' Date completed ~Sanltary seal (Y/N) }" la/' 2.,~,,4 IM' Total depth .~9_~__fl. ~ Cased to t ~.? ft. t If A, B, or C provide PWSID # __ FROM WELL LOG ft. g.p.m. Date of test' ' to Static water level I Well production WATER SAMPLE RESULTS: ColifOrm O colonies/100 mi. Data of sample: ~' / t9 / O I wal~ Log (Y/N) · Wires properly protected (Y/N) Casing height (above ground) AT INSPECTION 13~' . I~ ft. O. o~ O. 5'.t-- g.p.m. Nitreta4~,$$¥ mg3. COllected by: F4o'/'~o_/7 In. Other bacteria (~, colonies/100 mi. Bo SEPTIC/HOLDING TANK DATA TankType/Material ~',~"~'~'*"¢ / Tank size 1000 gal. Number of COmpartments Foundation ctaanoot (Y/N) Y Date of pumping '7~'/O I C. ABSORPTION FIELD DATA Data installed Cleanoute (y/N) ~ Depression over tank (y/N) ~ High water alarm (Y/N) Length '7 Z 'Totaldepth fO ft. Date of adequacy test Date installed ~ ! 2.6'/~,.,~ Soil rating (g.p.d./ft2 or ~/bdrm) Y ~///6"O~System type ft. Width .~ ft. Eft. absorption ama J t~'~-~ Monitoring tube __ ~ /19101 Results(Pass/Fail) Fluid depth in absorption field before test ~ 7 In. Water added ~..~ gal. Elapsed Time:~/~ min. Final fluid depth:~y in. Absorption rate >= Any rejuvenation treatment (past 12 mo.) (Y/N & type) /'~ ~'~¢ ~','~,,. ~-~ '/",~n c~ Gravel below pipe ~r ft. Depression over field ~ For -~ bedrooms New depth ~1'~. 2'in. q $'O g.p.d. If yes, give data J~/. ~', LIFT STATION N. ~. Date installed 'Pump on" level at in. Datum Size in gallons 'Pump off' level at Cycles tested Manhole/A_ _cces_ s (Y/N) in. High water alarm level at in. Meets alarm & cixcuit requirements? E. SEPARATION DISTANCES SEPARATION DISTANCES FROM WELL ON LOT TO: ~ ~ "Sel~tic*tanldllff station on lot , / O-/'~ ~',' , .... ,OJ~ adja. cent. lots '~, t o¢, Absorption field on lot I 2"~' On adjacent lots Public sewer rna n I~, &. Public sewer manholeJcleanout Sewer/septic sen, ice line '~ 'Z S' ' Holding tank N." SEPA. R~I1ON DISTANCES FROM SEFrrlGt[JOLi~,ING. . T .t~IK , ON LOT TO: ' ': Building foundation ~ '~'O ' Proper'o/line Watermain . ~' ~'$" ,. .. Water sewice line Wells on adjacent lots ~ '~ ! ~'~' '-, ' ' . , ' ', SEPARATION DIS'~ FROM ABSORPTION FIELD ON LOT.TO: ,. Pmpertyline ~ ~,~" ~ Bulldingfoundatlon Water Service line ~, ~.,5' ' Surface water Curtain'drain I~ '.~'~,/'t Wells on.edJaCept lots ~, loc ,.. , .. -.. F. COMMENTS ,~ ~-~'. 0. ENGINEER'S CERTIFICATION I certify that I have determined through f/ell inspec~ons and review of Municipal receMs that the above systems are/n conformance wf/J~ MOA HAA guidelines in effect on this date. Engineer's Pdnted Name HAA Fee $ .~~ Date of Payment Receipt Number (Rev. 1?.JO0) Waiver Fee $ Date of Payment ~ .~. Receipt Number MUNICIPALITY OF ANCHORAGE MEMORANDUM WATER WELL ADVISOR~ HEALTH AUTHORITY APPROVAL NO. O /O ~ During a recent Health Authority Approval on-site inspection and test of the potable water supply well,on Lot Block ~ _ of~(~u~ H///$ Subdivision, the well's productivity was ~etermined to be O,~ gallons per minute. The minimum well productivity required by this Department '(AMC 15.55) for a ~ . bedroom residence is ~,~/gallons per minute. Although the subject well currently exceeds this minimum requirement, all parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns and gardens may be required. This advisory mu~t be attached to all copies bf the subject Health Authority Approval. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services On-Site Services Section P.O. Box 196650 Anchorage, Alaska 99519-6650 343-474~, CERTIFICATE OF HEALTH AUTHORITY APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D. # L¢~\'-'~ -- a.~,~\ - L\ \ NAA # ~F~°~%(~_,\9'~_~-? GENERAL INFORMATION Complete legal description Location (site address or directions) I e~2c~¢2 /3'¢~_~ er /.¢,~ C Property owner Mailing address Lending agency Mailing address Agent /~o~ ¢._ Address Day phone 7 ~/5-- 7o.7 ;~ Day phone Unless otherwise requested, HAA will be held for pickup. NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well~- Community well NOTE: Public water If community well system, provide written confirmation from State ADEC attest- lng to the legality and status of system. TYPE OF WASTEWATER DISPOSAL: Individual on-site Holding tank Community on-site NOTE: Public sewer If community wastewater system, provide written confirmation from State ADEC attesting to the legality and status of system. 72-025 (Rev. 1/91) Front MOA #21 5. STATEMENT OF INSPECTION BY ENGINEER As certified by myseal affixed hereto and as of tile validation date shown below, I verify that my investigation of this Health Authority Approval application shows that the on-site water supply and/orwastewater disposal system is safe, functional and adequate for the number of bedrooms and typeofstructureindicated herein. I furtherverifythat 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 Address /*/~.~O Engineer's signature Phone 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. 72-025 (Rev. 1/91) Back MOA~Y21 RECEIVED Municipality of Anchorage JUN 0 2 1998 DEPARTMENT OF HEALTH & HUMAN SER~I,,,,,,,,,,,,,,,,,,~LiTy o~ ^NCHORA~ Environmental Services Division I~NVlRONMENTALSERVICE$ D1¥151 825 L Street, Room 502 · Anchorage, Alaska g9501 · (907) 343-4744 Legal Description: A. WELL DATA Well type ?ri ~,';~ Log present (WN) Total depth ~ c) Sanitary seal (Y/N) Health Authority Approval Checklist ~/¢,c~ ~ F¢o..c¢ ~<c,¢ /-}~/~ Parcel I.D.: IfA, B, or C, attach ADEC letter. A_DEC water system number Date completed F,r~F I ~ Cased to I ~ I ~ Casing height (above ground) I Wires properly protected (Y/N) FROM WELL LOG Date of test Static water level / Well production ~/~' WATER SAMPLE RESULTS: Coliform 0 ~'o( AT INSPECTION Nitrate I g.p.m, o, I/q ' O, ~ g.p.m. Other bacteria No^~ Date of sample: ~ / B. SEPTIC/HOLDING TANK DATA Date installed ~/' E~'/'~ Tanksize Foundation cleanout (Y/N) Date of Pumping C. ABSORPTION FIELD DATA Date installed ~/Ed'/ Length "7 ~ ' Width Effective absorption area I I ~- ~' /~" Date of adequacy test Collected by: /~h~/~ '7-~c4 ~Cc, c Depression (Y/N) Pumper A{o~, Number of Compartments __ High water alarm (Y/N) Soil rating (g.p.d./ft2 or fF/bdrm) ~t3Z~/5'0 Gravel thickness below pipe Monitoring Tube present (Y/N) Y' Results (Pass/Fail) />oAr ?- Cleanouts (Y/N) IV.,4, System type '7'/'¢~ ~ ' Total depth ~-/~71~ __ Depression over field (Y/N) For 13 bedrooms Fluid depth in absorption field before test (in.); fi/I 3/?, Immediately after~73 gal. water added (in.): Fluid depth ~/5' 'x/o~ (ins) Minutes later: ~ .,3 Absorption rate = ~ /-/',,4'<:::2 g.p.d. Peroxide treatment (past 12 months) (Y/N) /V~n~ ~',~o~.~ If yes, give date h./. 72-026 (Revl 3/96)* D. LIFT STATION N/./4. Date installed Manhole/Access (Y/N) High water alarm level at* Cycles tested E. SEPARATION DISTANCES Size in gallons "Pump on" level at* *Datum SEPARATION DISTANCES FROM WELL ON LOT TO: Septic/holding tank on lot ! d) 7 ' Absorption field on lot ! ~2' Public sewer main ~. ,~. Sewer/septic service line '~ ~' SEPARATION DISTANCES FROM SEPTIC/HOLDiNG TANK ON LOTTO: Foundation ~ 30' Property line ~ Water main/service line '~ lo' Surface wateddrainage SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO: Property line ~ d'£' Building foundation Surface water _-~ too' Curtain drain /~oN~' ENGINEER'S CERTIFICATION On adjacent lots '~ t c,¢, ' On adjacent lots ".> Ic,o ' Public sewer manhole/cleanout Lift station /V. ,,~. "Pump off" level at* Absorption field . '7 / Wells on adjacent lots ".> ~oo, Water main/service line Driveway, parking/vehicle storage area "~ 5"~" Wells on adjacent lots '~ t¢o ' I certify that I have determined thru field inspections and review of Municipal records tlt~t the at)of/e systbms are L'_ in conformance with MOA HAA guidelines in effect on this date. Signature ~-~ Engineer's Name Date d--~ ~ ¢ I,, HAA Fee $ Date of Payment Receipt Number 72-026 (Rev. 3/96)* Waiver Fee $ Date of Payment Receipt Number MUNiCiPALITY OF ANCHOP~IGE MEMORANDUM WATER WELL ADVISORY HEALTH AUTHORITY APPROVAL NO. ~A ~0 /~r-' During a recent Health Authority Approval eh-site inspection and test of the potable water supply well on Lot ~ Block ~ of ~0~UP ~/~ Subdivision, the well's productivity was determined to be 0,~ gallons per minute. The minimum well productivity required by this Department (~4C 15.55) for a ~ bedroom residence is ~o ~ gallons per minute. Although the subject well currently exceeds this minimum requirement, al! parties concerned are advised that the production capacity of the well may fluctuate. Restriction of non-critical water uses such as washing cars and watering lawns ani gardens may be required. This advisory must be attached to all copies hf the subject Health Authority Approval. APPLIC"--'~IT FILLS OUT UPPER HAL:~3NLY Owner i ~. )~ ~' ' :i ~' /~ -'~ ~ , I,'":- :~ /~' ~'- f / .... < ~ P~6~eity Phone ,, .......... ~ .... . .~ ~-... ~6 A~dr~ Zip · ~ ~ ~-. --,_, "i - ~ :~: .-~p , Type af Resi~nce D Multiple Family No. of Bedrooms n/_~ ~ Other Water Supply ~4~dividual A~ACH WELL LOG. A well Icg is required for all wells drilled since June 1975. ~ Community For wells drilled prior to that date, give well deplh (attach Icg if available). ~ Public Utility Sewer Disposal I~:~ ,-': -. ~ Individual Year Individual Installed: i ~ ;~ ~'' ~ Public Utility When Connected to Public Utility: ~ Holding Tank NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED. Date Date Date Date Inspector Inspector Inspector Inspec~r Field Notes: ( ) APPROVED BEDROOMS ~ / ~ . , ~ *CONDITIONS OF APPROVAk . ~ soils .~.n~ ~t. ~, ~n~,.~ W., ~o ~*o,~.o. ~ W., ~o~ .ec~i~ q 3 2 ~' ~--t .~ Well to Tank Septic T~k Size