HomeMy WebLinkAboutDALZELL-SCHNEITER BLK 2 LT 15
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
I LEGAL DESCRIPTIO~-~ --
DISTANCE TO:
Manufacturer
Liq. capacity in gallons
DISTANCE TO:
IF HOMEMADE:
Welt
Well
DISTANCE TO:
No. of lines ~ Length of each line~t
Top of tile to finish grade Z~ ~_ t~
Length
Well
DISTANCE TO:
DISTANCE TO:
Material ~TEEL
Dwelting
Material
Foundation Nearest lot line
Total length of lines Trench width
Material beneath tile / ~ ti
Depth
inches
inches
~d~ ~c~ I C]UPGRAOE
NO. OF BEDROOMS
/\.
PERMIT NO.
' -IP~o4-'1
No. of compartments
LJquiddepth ~1 t~
PERMIT NO.
Liquid capacity in gallons
PERMIT NO.__[ [[:),,~ ~,.) '~r--~ I
Distance between lines ~j I~
Total effecti~al~o~.ion area
PERMIT NO.
Crib depth Total effective absorption area
Building foundation Nearest lot line
Depth Driller
Building foundation Sewer line
D~$tance to lot line
Septic tank
OTHER
PiPE MATERIALS
SOIL TEST RATING
~Lr, STiC~
INSTALLER
REMARKS
APPR DATE
72~)13 (Rev. 3/78)
LEGAL
PERMIT "0. A,[ ~:)~) Z~r..,[ I
Absorption areals)
PERMIT I',10.
APPLICR[IT
LOCATIOr.~
LEGAL
JAMES BUMGflRDNER
SCHtlEITER DR
SAR BOX 474E 9950?
L15 B2 DALZELL-SCH~EITER SUB
LOT SIZE
TYPE OF SOIL ABSORBTIOt'J SYSTEM IS: TRENCH
MAXIMUM NUMBER OF BEDROOMS = 4 SOIL RATING (SQ FT?BR)=
THE REQUIRED SIZE OF THE SOIL ABSORPTIOt~ SYSTEM IS: //'~'
48693 SQUARE FEET
DEPTH= 10 LENGTH= 2-'~ GRAVEL DEPTH=
THE LEHGTH DIMEHSIOt.~ IS THE LENGTH (IN FEET) OF THE TREt,~CH OR DRRI[~FIELD.
THE DEPTH OF A TREt~CH OR PIT IS THE DISTRt.~CE BETWEEH THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET),
THERE IS ~0 SET WIDTH FOR TRENCHES. ,
THE GRAVEL DEPTH IS THE MI[IIMUM DEPTH OF GRAVEL BETWESJ THE OUTFRLL PIPE
AND THE BOTTOM OF THE EXCAVATIO~I (I~J FEET).
REQUIRED SEPTIC TRhiK SIZE= --'! 250 GRLLOhiS
PERMIT RPPLICAt'~T HAS THE RESPOHSIBILITY TO INFORM ~THIS' DEPARTMENT DURING THE
INSTRLLRTIOtJ IHSPECTIOHS OF 8N~ WELLS 8DJRCEHT TO THIS PROPERT~ RtJD THE
tJUHBER OF RESIDENCES THAT THE ~IELL WILL SERVE~ ' ' "::
TWO ( ~ ) I t~SPECT I Or~S ' ARE EEQU I RED '
BRCKFILLI~IG OF 8/J9 SVSTEM WITHOUT FIHRL INSPECTIO['I RtJD APPROVAL B9 THIS.
DEPRRT~E~JT WILL BE SUBJECT TO PROSECUTION.
MIHIMUM DISTRtJCE BETWEEN R WELL RND RH~ O~J-SITE SEWAGE DISPOSAL S~STEM IS
100 FEET FOR R PRIVATE WELL; OR
i5~ TO 2~ FEET FRO~ R PUBLIC ~ELL DEPENDI[~G UPOt~ THE ,T~PEI OF PUBLIC WELL
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 3~ DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MR~ RPPL~, SPECIFICATIONS Rt~D COtSTRUCTIOt-~ DIAGRAMS ARE
AVAILABLE TO IHSURE PROPER I[~STRLLRTIOt:I
PERMIT EXPIRES .OECEMBER ~
~: ~ R~ FRBILIRR ~ITH THE REQUIREBE~TS FOR O~.HSITE SEWERS R~.~D HELLS RS ~ET
FORTH B~ THE ~U~JIC~PRL~T~ OF ~NCHOrRGE.
2: ~ ~ILL %HSTRLL THE SY~TEB IH ~CCORD~t~CE WITH THE CODES.
3: ~ UNDERSTRHD THRT THe O~J-SITE SE~Er S~STE~ ~R~ REQUI~E EHLRRGEI'IEHT If THE
RES%DEHCE I5~DEIED TO I~JCLUDE ~ORE THRta 4 BED~OOhS.
SIGNED: ....... ,--------__--------- ,, -
RPE I CANT JAMES BUHGRRDNEP~ ;: , . ~ ~// .<"
p
NKINS WELL DRILLING
P.O. BO~( 3442 ECB
ANCHORAGE, AK 99501
PHONE 34,~-3792
Dee 78
DR I LLER'S :HELL L'OG
CUSTG~ER J~ ~--~r dba ~ri~Con~tr~ct~on
SI~ ~ DE~ 65' ~SING DEP~ ~ GRO~ING DE~
FOrTIeS ~C~B~ ~ ~PROPRIA~ DE~S
~ox 474.-E ~
AnchoraF~, AE q9507
off Birch R~
L TO 6~ S.n~. C~.vel. Wator 7-8Fn~1
65 TO ?0 erav &lay ' '
TO_
__ TO
__TO
__ TO
TO
TO.
. ~ 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
Parcel I.D. #
GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Day phone
Day phone
Address
Day phone
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: ~
TYPE OF WATER SUPPLY:
Individual well ,v,.
Community well
Public water
,MUNIQ PAUTY OF ANCHor, ACt:
ENVIRONMENTAL SERVICEs DIVISION
OCT 07 1996
RECEIVED
NOTE:
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system. ..
NOTE:
If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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 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 strLJcture 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 I~"qD En§ine d.
'" ........ Phone ~- ~,llJ
...~,,, ~,,,,~ J~,J. .
Address ~a;le River, AK 99577.8736
Engineer's signature ~ .'~,~(,~
Date
6. DHHS SIGNATURE
· "' ' ~ Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
Additional Comments
Date/O --2~'-~'~' '
'The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificate~ based only upon the representations given in paragraph 5 above by an Independent
profe~ional er{ginger 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 requlrements. 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.
MUN~CIPAt-ITY OF ANCHO~
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division OCT 0 7 199t
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907) 343-4744
RECEIVED
Health Authority Approval Checklist
Legal Description:
A, WELL DATA
Well type .Z-~' ~,
Log presem (Y/N)
Total depth
Sanitary ss~ (Y/N)
)/
Date completed
Cased to ~ ~" /
. If A, B, or C, attach ADEC letter. ADEC water system number
Casing height (above ground)
Wires properly protected (Y/N)
Date of test
Static water level
Well production
FROM WELL LOG AT INSPECTION
/7 g.p.m. 7.~"
g.p.m.
WATER SAMPLE RESULTS:
Coliform ~ Nitrate
pete of..mp .:
,,~.z//~ Other bacteria
Collected by: ,=,3'. ~.
0
SEPTIC/HOLDING TANK DATA
Deteir, ed
Foundation cleanout (Y/N)
Date of Pumping
/,;0'7-) Number of Compartments =,2 Cleanoute (Y/N) .
Depression (y/N) ~ High water alarm (Y/N)
Pumper ~
ABSORPTION RELD DATA
Date installed
Length .3~' Width
Soil rating (g;13:da~a'or fff/bdrm) (~a'-
Gravel thickness below pipe
System ~oe ~.~
Total depth /.~:3 '/~/_.
Effective absorption area
Date of adequacy test
Fluid depth in absorption field before test (in.);
Ruid depth // (ins) Minutes later:
PeraxJde tm~unent (past 12 months) (Y/N) '%/
72-026 (Rev. 3/gO)'
Monitoring Tube present (y/N) F Depression over field (y/N)
Resutte (Pass/Fall) / For .~' bedrooms
.~/ Immediately aal. water added (in.):
~ Absorption rote = ' '~//~Z3 ~ g.p.d.
If yes, give date ~'
~c..
D. LIFT STATION
Date t~l----~'e'e'e'e'e~ Size in gallons
~ 'Pump off" level at*
Manhole/Access
High water alarm leyel at . 'Datum ~
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot I I~ .~.1
Absorption field on lot I~-~
Public sewer main
Sewer/septic sewice line
On adjacent lots
On adjacent lots
Public sewer manhole/cloanout
Uti station
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation ~ ' +' Property line %Q ' -I- Absorption field I ol't-
Water main/service line Z s' ~ Surface water/drainage tc~ I+ Wells on adjacent lots
loot-+.
Property line
Surface water
'~urtain drain
F. £NO)N££R $
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Building foundation
Water main/sewice line
Driveway, parking/vehicle storage area
Wells on adjacent lots Ioo -(-
in conformance wflh MOA HAA guidelines in effect on this date. .~'~.. ~... ,,4/,~ ii
HAA Fee $~
Date of Payment .~~~
Receipt Number
Waiver Fee $
Dam ~Payment
Receipt Number
72-026 (Rev. 3/96)'
~.,,~ ~'~/~~ JViLINJCIPALIT'I' OF ANCHO~G~
DEPAR~E~ OF H~LTH & E~IRONMENTAL PROTE~NMENT,~L
~ L S~. ~, ~ ~1
ENVIRONMENTAL ENGINEERING DIVISION JAN 2 9 1979
Tele~e
REOU~T FOR .PROVAL OF INDIVIDUAL WATER ~D S~ ~tL~
] PNONE
PROPERTY RESIOENT (il diffract from ~w)-- - ~ PHONE
MAILING ADORE~
& LENDINg INSTITUTION ~ ~ ~ / ~PHONE
~ILING AODRE~ ~ / ]
~ILING AOORE~
LEGAL DESCRIPTION
I STREET LOCATION
[~'~' SING LE FAMILY
r-1 MULTIPLE FAMILY
[] O~e [] Four
[] Two [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
J~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTI LITY
8.' SEWAGE DISI'OSAL SYSTEM
[~INDIVI DUAL/ON-SITE * *
[] PUBLIC UTILITY '
* ATFACH WELL LOG. A well log is requir~ for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
**If individual/on.site, give installation date y/7 ~ .
If system is over two (2) years old an adequacy test is required
by this Department.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
724)t0(3i78) -.
.,~ THIS SIDE FOR OFFICIAL USE ONLY . '
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
GATE DATE DATE
INSPECTOR INSPECTOR INSPECTOR
I DIRECTIONS:
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 DRILLEG
I'--I PUBLIC UTI LITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVIDUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY <~_
Connection Verified INSTALLER
[]Septic Tank or r-I Holding Tank
Size:~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER~= ~_ .
TOTAL A.ORPTION AREA MATERIAL
Abso~ptio~ A*ee to neer~t Lot Line
5. COMMENTS
[:~;~'"APPROVED FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
DATE BY (TItle,
LEGAL DE$CRtPTION
72-010 (Rev. 3/78)