HomeMy WebLinkAboutSCIMITAR #1 BLK 2 LT 14Block 2
Lot 14
#051-132-22
MUNICIPALITY OF ANCHORAGE
Development Services Department Phone: 907-343-7904
On-Site Water & Wastewater Section Fax: 907-343-7997
Pump Installation Log
Well Drilling Permit Number: _______________ Date of Issue: ____-____-____
Parcel Identification Number: ____-____-____
Legal Description Block Lot Property Owner Name & Address:
Pump Installation Date: _____-_____-_____
Pump Intake Depth Below Top of Well Casing: __________ feet
Pump Manufacturer’s Name: ___________________________ Pump
Model: _____________________________________
Pump Size: ____________hp
Pitless Adapter Burial Depth: _________ feet
Pitless Adapter Manufacturer’s Name: _________________________
Pitless Adapter Installer: ____________________________
Well Disinfected Upon Completion? XX Yes No
Method of Disinfection: _____________________________
Comments:
Pump Installer Name: __________________________________
Company: ___________________________________________
Mailing Address: ______________________________________
City: ___________________ State: __________Zip: _________
Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation.
�- Dzvelopment Services_ Deper-irnent
Builciny Safety Division
I( X 11 ?r-5(T2 �: a� i r 8, WasteNQter Progr-am
4'0:_' i3ragaw Street
9,705'0
Mark Segxh Anchorage,Ar' .99519-6650
Mayor .vmm.mun., arn: ensit
(407)343-7904
Pump Installation Log
Well Drilling Permit Number: SW Date of Issue:
Parcel Identification Number
Legal Description
-/-
Property Owner Name & Address:
A R eG.v 'RI4L.PH
R,
Cj c LDA
cNv6,r}lcf KIK �s6h
Pump Installation Date:
Pump Intake Depth Below Top of Well Casing: ,e!�-g feet
Pump Manufacturer's Name: �O --3,cyC i<C T
Pump Model: os Z J
Pump Size hp
Pitless Adapter Burial Depth: /d feet
Pitless Adapter Manufacturer's Name: lytQf�
Pitless Adapter Installer: rJ t`}
Well Disinfected Upon Completion? &Yes ❑ No
Method of Disinfection: C� Tt
Comments: A
ti
Anchorage Puna & weli Service
Pump Installer Name: 330 East 76th Avenue
Anchorage, Alaska 99513
Phone: 907-243-0740
Fax: 907-243-0742
Attention: The pump installer shall provide a pump installation log to the DSD within 30 days of pump installation.
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVlRONMENI'AL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telepl~one 2644720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
UPGRADE
MAILING ADDRESS
'~. c~, 't~_-.~-~,z- Lc~1.o/t-d-~- - ¢--vYO(% ~
LEGAL DESCRIPTION
LOCATION
~- [ ..... F~ll --- Absorpt'o a a
~ [ DISTANCE TO:_. I ~. I~ I.__ t~I
~ ~ IManufacturer
~ i~]q. capacit~in ga Io ~ ] ~n~ Inside length
I ~ ~ I F H ........... :
~ % I We}F Foundation
~ ~r. ~ ~~-- I Length or eac~ line Total length of lines
~tiletofi,l~shgrade ~ I Materialbeneathtile
.... rLength Width t Depth--
<~ ~'~f crib C,ib diameter t ~rib depth
~-- ~-- Wel~ ~u31ding foun~a~i%n
L DISTANCE TO:
~ I DISTANCE TO B~il~ing foundation Sewer line
Dwelling
Material
W dt~
Material
[Nero-est lot ~ine
/ T'en°h wi .c-> i,cl,e,
NO. OF BEDROOMS,.~ ./
PER,,M, ITN~).. , ~ . ,
No, of col~paitments ,~:~
Liquid dep~th~._ ..
PERMIT NO.
Liquid capacity in gallons
I PEBMIT NO, . ~
Distance bet ~ n/~es
Total effective absorp~on area
[PEBM T NO.
I~ ~"~ inches
Total effective absorption area
Nearest lot line
Distance to lot line PERMIT NO.
Septic tank
Absorption area (s)
OTHER
PIPE MATERIALS
SOIL TEST RAT, N~F
INSTALLER
REMARKS
[][)NTACT F:'I"H]iqI~Z:
DEI:::'AI::::'I'MI:NT OF HI!:Z~LT'H AND ENV I RONMENT~I... F1RO]'E!]]T ]; ON ~.2~-~-'~") ',
, I,= ..... L S"I"REi]:H', AI',IL,HOI ~AI.' [:., AK 99501
;~i~ 64.-' 472. ()
AI"II~:R I E',AI',I EXC.:AVAT I ON
% S& SEIxI['~ I NE'iEI::: ]: IxH'i~
L::AE';I..,E IR I VER, AK 99577
694-2979
SUBDIVISI[IN: SCIMITAR ~1~.1.
SIEI]T I ON: 10 'TOWIxlSH I F': 15N
4535C) (SQ. I:::'T, OR ACRIE:S)
L,O"I' ~ 14.
BLOCF; ~'.~
L..z.:~,Lc..d I::)elow ape t. he op'Lions avaiZI, able t.o you in dt:a~i:i,C.I]ilr'l(:~ yOUl' sept.:i.c:
sys'Lern. Choose t,I"IE,~ opt, J,C)l] tha'i:, best F:i,t.s youp sit. e,,
.... ::, ':'"'H TO F' :t: I::: IE: BOTTOII (F"l".) 4,. (")
GI:;iAVEI,,., DEF:'TH (F:'T.)
TOTAl_ DEI:::'T'H (I::'T,,)
[.{iRAVEL.. WIDT'H (F"['.)
GRAVI~:I_ ME:IqG'T'I.I (F"l',)
GRAVI:I.,. VOI..UI"IE (CI.I,, YDS. )
TAIxlI,::: SIZE: (GAl_S)
SOIl,,,. IRATIIqG (131:;I.FT,, /BR)
'~.~'~ TANI< MUST HAVE AT I_[::,A,~t 'TW[I I::;[IMI:::'ARI"ItEI1"I"S
:1: c:er't. :i. t'y. that,:
1. I am l'amil:i, ai' wi'l:.h t.h~:~: pequipemer'rLs For, on-s:i,'Le sewer's and wells as set.
l'or't,h by the MLu'~:i. cipal:i.'l:.y oF hnchclpage (PI[)A) and 't'..he St, ate of Alasl<a.
2. I will inst. all 'Lhe ~!~ysit. em in ac:copdanl:::e wit. h all MOA (:::c)des and I'egu].at:i, ons,
and ir'l compliance wit. Ii t.I-H,:.'~, desigrl <:P:i. ter'ia of t.h:i.s i:)ePm:i.t.
3,, I ~,~il]. ~t(:JhBgr'c.~ 'Ecl ali. M[IA and Sta'l:.e cji' Alaska I"E.H:IIJiI"E~Illi.~i~'L~i I'll:Il" '[',.h(i{? Eii.:~YL bacl<
d :J. st. ances Ir'oil1 any ex ist, ing we:J. 1, was't',ewater, d:i. spc~ial system or, publ ic
s(:.~b~ePag~':,~ syst. c{~m on 'Ll'~:i,s oP any
]: t,ll]i:h:H":;t.i:lr'ld ti'tat '[.hi~i pl:.l"r~:i.t, is valid felt, a maximum oF 3 bedr'oc)ms and
any enllar'gem[~l"rL ~i],l peql,.lir'e an adcli'Lional per'mit..
Il:::' A I...]:F]" S"['ATIOIq IS INST'AI.,,,I..,,E0 IN AN AFi~I_::A I]OVERIZD BY MOA BI,JII_DIIqI~; CI31.)1;:..:~,"' ' ':"~"
't'HEIxt (1) AN .......... :LI=L,' ......... I[~I(..,AL F:'E:RMIT Alxm0 iNSI;::'IECT']:EIN HU,.:~" c' I BE I]B"t"AIIxlED~ "~
(,~=:.) AS.,..,Btl I L'I"S
WII,,,L NOT BE AI::'F:'ROVED WI]HOLtT AI',I I::L.E:.CI[~.[CAI., Ilqc~l,lsl..ll0N I::it:F'ORT~ AND (3) THE
EI_.I~iCTI:;II[:iAI_ WORK MUST BE DONE BY A L. ICEIxlSED I:::.I.]:.L. II'~.I.' .......... .,,tAN.'
x x' / ' ~/":~' ~ ~ , () ..... PAT'[ ........ '
SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION: L~_.~-
1
2
3
6
7
8
9
10
11
12
1 6
17
18
19,
20-
COMMENTS
PERFORMED BY:
72-008 (6/79)
SLOPE SITE PLAN
WAS GROUND WATER & ~ S
ENCOUNTERED7 ~N._J ~ L
-O
P
tF YES, ATWHAT ~
DEPTR?
Reading Date Gross Net Depth to Net
Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN FT AND
(minutes/inch)
Municipality of Anchorage
Department of Health and Human Services
Division of Environmental Services
On-Site Services Section 825 "L' Street Room 502
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-4744
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY' DWELLING
Parcel I.D. 051-132-22
1.
'HAA# /-~/-") 0101o~/
Expiration Date: 7-//.. - ¢ /
GENERAL INFORMATION
CompletelegaldescriptionLot 14, Block 2, Scimitar fl1
Location (site address or directions) 19855 Tulwar Dr'~ve
Subdivision
Current Propertyowner(s) .Arnold & Rebecca Clark
Day phone
Mailing address
Lending agency
Mailing address
Day phone
Real Estate Agent
Mailing Address
Day phone
Unless otherwise requested. HAA will be held by DHHS for pickup. HAA picked up by: 2/.~-.~2~ ~
NUMBER OF BEDROOMS: 3 ¥/~/~ I
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class
Public Water System
Well
TYPE OF WASTEWATER DISPOSAL:
[] Individual On-site []
[] Individual Holding Tank []
[] Community On-site []
[] Public Sewer []
The Municipality of Anchorage Department of Health and Human Services (DHHS) 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 between spouses) on properties served by a single family on-site
wastewater disposal and/or water supply system. DHHS also issues HAAs upon request to home owners.
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. Cedificates
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.
72-025 (Rev.
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
based on procedures outlined in the Health Authority Approval Guidelines for the Health Authority Approval
application show 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.1 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 in compliance with all applicable Municipal and State
codes, ordinances, and regulations in effect at the time of installati0n.
$
ENGh",f££RING
Name
of
Firm
Phone ~ ~f ~ - ~- ':l 7 ~
)/~4 ~agle River Loop Roa~ No. 2~
Address
Engineer's Printed Name Eobe~[ C~owa~, P.E. Date ~//~/o/ ._ ~.
~(({~t~t!rrr~
,k~ ~', ..... ·. '~z:~ ~'~'.-~ A
~ . WA~ERAND m~, ~]/~.Z~ ~,
~ . appFoved(oF. ~ ~edrooms. ~'., . ,- ~ .. 7t,%?., ' ' .','~.~
- . - uondlhonal approval for. bedrooms, w~tHIHe following Stipulations. ' ....
Additional Comments
Note: The well for this propert7 meets existing State and Municipal Codes. :There are nitrates
' p resent..-.-I Hs-suggestedqhat-periodie-t estlng-be-perq'ormed4o-in sure-the-svells_contln ucd_suitability,_
Current nitrate concentration is 6.06 re?fL EPA maximum concentration is 10.0 mg/l. More
information o.n nitrates is available from the On-Site Services .Program, at 343-7904.
'*' Attachments: ' ....
HAA Checklist ~
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other ,,~ 7~',-~-.~.
Expiration Date: '-'/- z~. 0 I
75-025 (Rev. 01;00)°
Original Ceilificate Date: L/. -- L/.._ O /
Reissue Date:
Municipality of ;Anchorage
Development Services Department
Budding Safety Division
On-Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchomge.ak.us
(90?) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
.4. WEll DATA
Well type/~/f~
Date completed ~A/~.
Total depth ~_~_fl.
If A, B, or C provide PWSlD # "-'--
Sanitary seal ~. ) ,~-'5
Well Log (Y~) ,,/~/'~)
Casing height (above ground) /~ in.
FROM WELL LOG
Date of test .~.2//
Static water level r~ ft.
Well production y g.p.m.
WATER SAMPLE RESULTS:
Coliform D oolonies/100 mL
Date of sample·
B. SEI:~IICJHOL~INGI 'AN !DATA
Tank TypeJMatertal '~, Z'l (.-' / ~
AT INSPECTION
':'/,°3: ft.
4' :~' g.p.m.
Nitrate (e.e(~ mg./I. $&$ENG~_R~Geria I colonies/100ml.
Collected by: 17034 EegJl RiYm- L,GGp Road No. 204
F. Igie RIvl~, Ainski 99577
Data installed _~
Cleanouts (~)~/~"~ ,
High water alarm (Y/N)
/
Tank size ~ gal. , . Number of Compartments
Foundatioa deanout~/l~)'.4~ Depression over tank (Y~
Data of pumping 3/a,/OI Pumper ',.~
Length ~-~- fl"~' . Width ~, ~ ft. Gravel below pipe
Total depth / 0 ft. W' eps, orption ,ree~..~t2 Monitoring tube c7/~-':~
Date of adequacy test :~/~ ~/Of' Results(Pass/Fail)
Fluid depth in absorption field before testg in. W,~ter addedZ~'J(Jgal.
Any rejuvenation treatment (past 12 mo.) (Y/N & type)/~,'F~"',~//'~A/ If yes, give date
Depression over field /%/0
For '~ bedrooms
New depth / in.
g,p.d.
Date installed , aliens
"Pump on" level at ..,/~. 'Pump
level
at
Datum // Cydes tested
E, SEPARATION DISTANCES
Manhole/Access (Y/N).
High water alarm level at
Meets alarm & circuit requirements?
in.
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot / ~O /.+'' On adjacent lots //O0 ''/'-
Absorption field on lot //~)0 '/- On adjacent lots
Public sewer main ~ /A Public sewer manhole/cieanout ~./
Se~t~lseptic service line ~.~' ./-- Holding tank /~//
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation ~" ~' property line ~ ~'' Absorption field
, /
Watermain ~//'~, Water service llne //(:) ~ Surface water /OZ) -~-
Wells on adjacent lots /lO0 /-~'-
SEPARATION DISTANCE/FROM ABSORPTION FIELD ON LOT~ TO:water main
Property line /' 0 4- Building foundation / 0 I
Water Service llne /i~) ~Sun'acewater //0~) '~- D~iveway. parking~ehicle~torage
Cu.ain dr=,. on .dja late
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined through field inspections and
review of Municipal records that the above systern~ are
conformance with MOA HAA guidelines in effect o~ this date.
Engineer's Printed Name
Date ,/i ~'// o l
HAA Fee $
Date of Payment
Receipt Number
(Rev. 12/00)
0o /,~/0
Waiver Fee $
Date of Payment
Receipt Number
CE -8~01
03-20-01 17:04 FROM-CTE ENVIRONR:NTAL
5615301 T-695 P.O]/03 F-46Z
CT&E Environmental Sewices Inc.
200 W. Potter Drive
Drinking Water Analysis Report for Total Colifotm Bacteria Anchorage. AK 9.SlB.I.0S
RE~D INSTRUCTIONS ON,REVERSE SIDE BEFORE COLLECTIN~ $,~MPLE Tel: (907) 562-2343
Fax:'(907) 661-5301
MUST DE COMPLETED BY WATER SUPPLIER TO BE Cc)MPLETED BY LABORATORY
PUBLIC WATER SYSTEM I.D,
PRIVATE WATER SYSTEM
t-hr
SAMPLE DATE:
Month
SAMPLE TYPE:
,,~ Routine
O Repeat Sample (for routine sample
with lab ret. no. )
m Special Purpose
SAMPLE LOCATION
Day Year
TreBled Water
Untreated Wate,
Time Collected
Coll.-ted
/4r J
/~alysis shows this Water SAMPLE to be:
Satisfactory
n Unsatisfactory
O Sample ove~ .t0 hour~ old. results may
be unreliable '
Sample too long in t~nsit; sample should
not be ov~ou~ old at examination
to indicate ~liable ~ul~. Please send
new sample via spcci~ ~live~ mail.
Date Received ~l ~
Analytl¢.l ~elh~: ~embrane Filter
~ MMO-MUO
' Number ofeoloni~lO0 mL
' * ' ..... Result' Analyst
nth Fbka Jon []
Date: . Time:.
Client notified of unsatisfactory results:
Phoned Spoke with
Date: . Time:
BACTERIOLOGICAL WATER ANALYSIS RKCORD
co,o.l..OO.,
Bce COLIFIRM
MMO-MUO RL'~t: Total Coliform
Membrane Filter: DIr~'t Cmant.,
Verification: LTB
Fecal Coliform Confirmation
Colhorm/lOO mi
T,.. I bq-o h.
03-20-01 17:04 FROM-CTE ENVIRON~NTAL
~l~tr~ CT&E Environmental Services Inc.
5515101
T-$95 P.02/03 F-452
CT&E Ref.$~ 1011293001
Client blame S & S Englnetu'ing
Project Namet~ L14; B2; Sc~tar
~lent S~mple ID LI4; B2; Sci~t~r
Matrl~ DrYing Wat~
Ordered By
PWS1D 0
Client PO#
Printed Date/Time 03/20/2001 11:33
Collected Date/Time 03/13/2001 14:00
Received Date/Time 03/14/2001 13:45
Technical Director Stephen C. Ede
R elea,ed By '~"'~.~~--~
Sample Remarks:
Plmmetel Resales PQL
Units M~thod
Limits Date Date Init
Nitrate-N
606 0.500 mg/L EPA 300.0 I0 max 03/14/01
SCL
M:Lczob~.ology Laborat:orlr
Total Coliform I OB, No Coli col/100mL SMI8 9222B 03/14/0l KAP