HomeMy WebLinkAboutFREEMAN LT 7
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?;;<HV 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.
016 112 12
FREEMAN 7
JOHNSTONE JAMES K
11441 HAWKINS LN
ANCHORAGE, AK 99516 1329
04 19 2023
110
A.Y. MCDONALD
23050V3LB
.50
10
MARTINSON
PELLETS
ANCHORAGE WELL & PUMP SERVICE
7640 KING STREET
ANCHORAGE AK 99518
. GRE~ ~.R ANCHORAGE' AREA BOR, JGH
Department of Environmental Quality t,~ .
3330 C Street
Anchorage, Alaska 99503
J
I.S.ECT~O..E.O.T ON-S~ S~W^O~ D~S.OS^~. S'rS;~M
LOCATION LEGALDESCR,PT,ON,, ~ ~ /~" ~X~
SEPTIC TANK:
DISTANCE
!
FROM WELL /'(-)~
INSIDE LENGTH
MANUFACTURER ~
INSIDE WIDTH
MATERIAL
NUMBER OF /
COMPARTMENT5
LIQUID DEPTH
LIQUID CAPACITY/~7~ GALLONS.
TILE DRAIN FIELD=
DISTANCE FROM WELL ./~'~I'''//- FOUNDATION
NUMBER OF LINES / DISTANCE BETWEEN LINES
ABSORPTION AREA ~/~/'~ '-~' SQ. FT. LENGTH OF EACH LINE
DEPTH OF FILTER
DEPTH: TOP OF TILE TO FINISH GRADE ~// I MATERIAL BENEATH TILE
WELL=
' CONSTRUCT,ON
BUILDING NEAREST NEAREST
FOUNDATION , LOT LINE , SEWER LINE
CESSPOOL , OTHER SOURCES
APPROVED DISAPPROVED REMARKS
DEPTH
SEPTIC SEEPAGE
TANK , SYSTEM.
DISTANCE FROM:
DISTANCES:
INSTALLED BY:
SEWER LINE DEPTH:
PIPE MATERIAL=
LOT SLOPE:
REMARKS: /P.$
DIAGRAM OF SYSTEM
G.A.A.B. ~
Form EQ-032
Well
~o~
........ : ............... ...... ~:.~.~.~.~....~.o..~.~....~:..~.~ ......
Locauon ............ ~.~:~ .................... ~.~~....
· Date ,~ompleted ............ ~~.. ~ ~~ ............................
Depth or well~...~~~..~~~~
Size of c~g....~...~g.~~ ........................ ~ .................................
Dist~ce to water wh~le pmpm~/2./2~~.~..~_at rate
of.~..~~~...gallons per ho~.
DELTA DRILLING COMPANY
SRA BOX '394 B
ANCHORAGr'.AtASKA 99507
GReATeR ANCHORAGE AReA BOROUGH
DEPARTMENT OF ENVIRONMENTAL QUALITY PERMIT NO.
t$30 "C'STREET ANCHORAGE, ALASKA 99509
SEWAGE DISPOSAL SYSTEM APPLICATION AND PERMIT
INSTALLATION LDCATIOH
· o,L TEST ..EULTE
TO B E INSTALLED DY /~.~(~ t~ ~
OTHER
COMPLE~ION DATE ANTICIRATED J"~//[-~./K~.~...~ /~7~
FINAL INSPECTION: 24 ~OUR NOTICE REQUIRED, BACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION BY THE
DEPARTMENT OF ENVIRONMENTAL QUALITY AUTHORITY WILL BE SUBJECT TO PROSECUTION.
MINIMUM DISTANCES. REQU IREMENT~
FOUNDATION TO SEEPAGE PIT
YVELL TO SEPTIC TANK /~ /
/
· DRAIN FIELD
SEEPAGE PIT ~ ~/ /
ALSO CONSIDER AREA WELLS.
SEEPAGE PIT / ~ /
BRAIN FIELD
CAST IRON INTO AND OUT OF SEPTIC TANK AND INTO CRIB CROSSING GAP DF
GRAVEt BACKFILL.
CONFORM TO BOROUGH REGU:~.~IONS REGARDING 17TALLATIO..
/
Og
DIAGRAM OF' SYSTEM
GREATER AMC RAGE AREA BOROUGH ORDINANCE NO. 2S-68 AND THAT THE ABOVE
DATE ~ /~/' /~d~ AFPLIDAMT*B EIGNATURE W
Performed for
Legal Description:
This form reports:
~ GREATER ANCIIORAGE AREA BOROUG?~
~ )epartment of Environmental Qua
· 3330 "C" Street
Anchorage, Alaska 99503
SOILS LOG - PEROLATION TEST
Soils log ~
Date Performed
Percolation test
Depth
Feet
4-
5-
6-
7-
8-
i .1-
11-'
12 -
13-~
14-
Was 9round water encountered? //~)
If yes, at what depth?
Reading Date Gross Time Net Time Depth to Water Net Drop
~oh rate minute.
· Proposed installat-i~'n~ Seepage Pit Drain Field
Depth of Inlet Depth to bottom o-r-'pit or trench
COI~I£11TS:
EQ-040 (6/74)
Da te:
PERFORMED FOR:
· ~' SOILS LDO
-' J"4 g- ~ 'z..
MUNICIPALITY OF ANCHORAGE
· _DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
~ 825 Lo Street, Anchorage, Alaska 99501 264-4720
[] PERCOLATION
TEST
SOILS LOG - PERCOLATION TEST '-'
~0t4~$0~ DATE FERFORMED:. /~--q'g~
LEGAL DESCRIPTION= /r-*~)T~ 7
m_
2
3
5
6
7
-0
I0
2O
SLOPE ~ SITE PLAN
COMMENTS
PERFORMED BY: ~.enncr"
WASOROUNDWATER
ENCOUNTERED?
DEPTR
nc.C,
Gross Net Depth to Net
Reading Date Time Time Water Drop
t Ih.O &-¢)-~3. I,t.'. O~ -~- ,6~
/ (minutes/inch)
PERCOLATION RATE
TEST RUN BETWEEN
3 ~TAND 3.5 FT
CERT,F,EO..:
72-008 (6/79)
"' ~ MUNICIPALITY OF ANCHORAGE
DEPAR:I'MENT 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·: '
Parcel I.D. # ~lb3- ~-I~D,~ . HAA#. ~i~,~~
1.
GENERAL INFgRMATION '
,., ,t.;:-, ~ , ~ ". '
Complete legal de. scription ~o-r' "/ F"~EE~,'~,4~J
Location (siteaddressordi'rections) '1/ 9~ 5/ I //.4 V.I /~ / /tt $ & A xl F_.
e
Property owner
Mailing address
Lending agency
Mailing address
Agent
Day phone ~/~ $¢~/- $~/'~
Day phone
Day phone
Address '
Unless otherwis? requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: -~ %
3. ' 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.* .. ' '
4. TYPE OFWASTEWATER DisPosAl" ',"
NOTE: If community wastewater s~stem, provide written confir~nation from State ADEC
attesting to the legality and status of system,
5.. STATEMENT.OF INSPECTION BY ENGINEER
As certified I:;y'tfi~*seal affixed hereto and as of the validation date shown below, I verify that my
· .:-*'-: -.. investigation ~f this Health Authority APproval application shows that ~h~ o'n-site water supply.
~-'r' ' :.*'.~.:i--and/or wastewater disposal system Is safe, funct ona and adequate for the number.of bedrooms: ....
. · . ~-~.andtv-d~-~fdtrb~t6?e-in-dic-atedh~r~n~furth~rver~fyth~t~5~s~d~n`tH~i~f~Tr~tF~n~bt~h~<~fr(5~n~ -- ---'-- ---------- -- - -' .........
the Municipality of Anchorage files and from my investigation and insp.ecti.on,.th.e on-site water
supply and/or wastewater disposal system is in compliance with all Muni.cipal ~.nd.State codes,
- .' ~ ?:.:~ .','.-/·.'ordinances, and regulations in effect on the date of this Inspection. ~.. ' '.' .:'" -... -. .......
Name of F~rm g/~J ara'A~* Phone
' : ';**Addressr~' ~'~ Z, 5/o 77J · - * ,~,- -- "AJL.' ~qct'~'~
... -Enginee~ssignature ~.~ Date· i~/JI/~Z.,'' ' ..
·
o,*' -,, 'q.e Il"
...., .... - ........ ' ',,.~ '~ o,.,~o,-~. . ,, ~..~-~ .
· · · ,.,....' .... ' '
'~'%:~.%.a,,,..~,.'~'~', . ..: . ,. ·. ,
· . 6;'-OHHS SIGNATURE *"
-* :'*' ~)~ Ap-i~oved 'fo~: ::" 2 · ' bedrooms.
..... '' Conditional approval f*o'r~''*':
bedrooms, with the following stipulations:
._ --L,~ :~ ;,.'. ,- -.- ..... : ..... .*
Additional Comments
,i*.The Mu4icip~lity of A~,l~orage Department of Health and Human Services (DHHS) issues Health Authority
'.'Approval Certificatee~ based only upon the representations' given in paragraph 5 above by an Independent
professional en gin. ,e_.. '~gistered in the State of Alaska. The DH HS does this as a courtesy to purchasers of homes
an~l*thei,r, lending institutions in orderto satisfy certain federal and state requirements. Employees of DHHS do not
cohduct 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;/
Legal Description:
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
/- '7 h-'~E'rrl,4~J ParcelI.D.
A. WELL DATA
Well type PR
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A. B. or C. attach ADEC letter. ADEC water system number
Date completed ~'-/?-7'~ Driller
Cased to /Z / ' Casing height ( ~/"
Wires properly protected (Y/N)
FROM WELL LOG
Date of test 7-,'7'-7f~
Static water level ~5'/'
Well flow _5' g.p.m.
Pump level ' ~J~T'
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot ~ O o
Absorption field on lot ~ I O'
Public sewer ~ain ~'~ q L r= s
Public sewer service line nq t L ~ ~,
WATER SAMPLE RESULTS:
coliform '~AT(CjF'ACTOF-,.~, Nitrate.
Date of sample: ~-/~- ?2.
B. SEPTIC/HOLDING TANK DATA
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank k/
AT INSPECTION
g.p.m. ~ r,o ~' o
0 , /D Other bacteria
Datelnstalled f',~- .22- ?s"
Cleanouts (Y/N)
'High water alarm (Y/N)
Date of pumping
Compartments /
Tank size /~ e ~
Foundation cleanout (Y/N)
Depression (y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ~O:
Well(s) on lot /{3 ~ ' On adjacent lots /~'~ //- Foundation ~',-~ '
To property line ,.~o' 'Absorption field ;5 f Water main/service line /~ ~"
Surfacewater/drainage ~o~E .1~.1 ,~.~A
/=~0~me,.a.,e~r ~n~t MOA=~ ' : ' ~ ' CONTINUED ON BACK PAGE
C. LIFT STATION
/.-
Date Installed
Size in gallons
· Vent (Y/N) - "Pump on" level at
High water alarm level
· Meets MOA · ectrical codes (Y/N)
~ Manufacturer
Manhole/Access (Y/N)
';Pump (~ff" le~el at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TOi
'Well on lot On adjacent 16ts '-
Surface water
D. ABSORPTION FIELD DATA
Date installed /~)..2 2,- ?~'
Length /~-t Width
.Total absorption area
Depression over field (Y/N)
Results (~)ass/fail) P~
Soil rating
t ~' ~'' System type
Gravel thickness
Total depth
CI.eenouts present (Y/N)
Date of adequacy test
for ~
Peroxide treatment (past 12 months) (Y/N) /',,t If yes, gNe date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ! ID ~ On adjacent lots /O~' + Property line
T° building fo, ?.n,d~!io~. (/~' l~I~ To ex. isting or abandoned system on lot
On adjacent lots /bo'/~ Cutbank /v'~X/~/x/~z~'4~ Watermain/serviceline
Driveway, parking/vehicle storage area
Surface water /{/'~/~E: /x/ .4A/;~*
Curtalndrain A/~A/[ p,I Ai~F.-,A
E. ENGINEER'S CERTIFICATION
bedrooms
I certify that I have checked, ve6fied, or conformed to~ a. II,MOA and HAA guidelines in effect on the date o~hie:~nspec!ion,
Date
HAA Fee $
Date of Payment
Receipt Number
72-~ (Re~. 3/~1) Bl~k MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
5633B STREET ANCHORAGE, ALASKA99518 TELEPHONE (907) 562-2343 FAX:(90~ 561-5301
ANA~I$IS ~[S~T$ ior INVOIC[ I 57046
Chsnt ~amplm ID
~[ome~vm~ with
l~O 14 91 I i?~lO ~s. ~sq! :
~A- Not in~tT=,~ lT-Lo,s T~n. G~-G~o~to: Than
~SGS Member of ,he SGS Group (Soci6t6 G6n~rale de Surveitlance)
15900 Francesc~ Drive .
Anchorage, Alaska 99516
CUSTOMER
DATE DESCRIPTION ' AMOUNT
,/~O,Gallons 't~tic ~ ~ach Area Holding Tank ,/S~ndpi~ ~-~/~me
~ PROBLEM AR~--~LL ~R MORE IN~RMA~ON
~ NEEDS ~ BE ~NE A~IN IN ~ MONTHS
~ Shape · ~ Sludge buildup on ~ttom : ~ Floater on top . :-
~ ~ Jim cap missing or ~ Cut standpipe to 1' a~ve ground ~ N~s ~ptlctrlne
n~s replacing - ..... . ..~
' K~EP