HomeMy WebLinkAboutTHE VILLAGES TIDE VIEW LT 13
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.
"1~ MUNICIPALITY OF ANCHORAGE
· , D_F.I 1TMENT OF HEALTH AND HUMAN SER
Environmental Health Divislon
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
DISTANCES
SEPTIC ABSORPTION
TANK FIELD WELL
LOT LINE ,..~' I/./' ~-
TANKS
[[;~EPTIC [] HOLDING
TYPE OF SYSTEM
[] TRENCH [~D [] W. DRAIN [] OTHER
SQ FT ~ FT
REMARKS:
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- -: /0 ~?n' /
I ~ ~ - [~""%'- cerbly thai th,$ Iflspectmn was performed iccordmD
Health Depadment Approval: Dale
72-013 (3,85)
MUNICIPALITY OF AI~ICHOR~:~GE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
8£5 L STREET~ ANCHORAGE~ AK 99501
264-4720
ON--SITE SEWER PERMIT
PERMIT NO:
DATE ISSUED:
860085
04/07/86
APPLICANT:
ADDRESS:
CONTACT PHONE:
ED SANDERSON ACREAGE SYSTEMS
P.O. BOX 165 601E NORTHERN LGTS.
ANCHORAGE, AK 99505
545-2122
LEGAL DESCRIP:
LOT SIZE:
MAX BEDROOMS:
SUBDIVISION: VILLAGES TIDEVIEW LOT: 15
SECTION: 5 TOWNSHIP: 11N RANGE: 5W
1.25A (SO.FT. OR ACRES)
4
BLOCK: NA
Listed below are the options available to you in designing your septic
system. Choose the option that best fits your site.
TRENC~-~ BED W. DRAIN
DEPTH TO PIPE BOTTOM (FT.) 4.0 4.0 4.0
GRAVEL DEPTH (FT.) 5.0 0.5 2.0
TOTAL DEPTH (FT.) 7.0 ~-4.5 6.0
GRAVEL WIDTH (FT.) 2.5 22.0 5.0
GRAVEL LENGTH (FT.) 100.0 ** 41.0 84.0 *~
GRAVEL VOLUME (CU.YDS.) 52.5 ~5.5 58.9
TANK SIZE (GALS) 1~250.0 ** 1~250.0 ** 1~250.0 **
SOIL RATING (SQ. FT./BR) 150 150 150
** GRAVEL LENGTH > 75 FT. REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT.
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
EACH)
I certify that:
1. I am ~amiliar with the requirements ~or on-site sewers and wells as set
[orth by the Municipality o[ Anchorage (MOA) and the State o[ Alaska.
2. I will install the system in accopdanee with all MOA c~des and regulations,
and in compliance with the design criteria o~ this permit.
5. I will adhere to all MOA and State o~ Alaska requirements ~or the set back
distances ~rom any existing well, wastewater disposal system or public
sewerage system on this or any adjacent or nearby lot.
4. I understand that this permit is valid [or a maximum o~ 4 bedrooms and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS-BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (5) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN.
SIGNED -~- .~--~-~ i DATE: _~/_~_ _~__
APPLICANT: ED SANDERSON ACREAGE SYSTEMS
PERFORMED FOR:
LEGAL DESCRIPTION:
I~oL.
3-
5-
7-
8-
10~
11-
14
15-
16-
17-
18-
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage. Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
'.. ". 'd.o'h
,:/ .; ,.:
SLOPE SITE PLAN
WASGROUNDWATER
ENCOUNTERED?
S
L
IF YES, AT WHAT O
DEPTH? p
E '~-~-
Depth to Water Afler
Monitoring? Dale:
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,, , '., ,,,_~____., ~..'~\
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SEWER SYSTEM LOCATION PLAN
PERMIT NO:
DATE ISSUED:
MUNIP--C~PALITY OF ANL-~ORAGE
DEPARTMEN~ OF HEALTH AND ENVIRONMENT~_~PROTECTION
825 L STREET, ANCHORAGE, AK 99501
2~4-4720
OI~--SITE
860147
05/50/86
APPLICANT:
ADDRESS:
CONTACT PHONE:
LEGAL DESCRIP:
LOT SIZE:
JAMES M. FEJES
P.O. BOX 112249
ANCHORAGE, AK 99511
545-5821
SUBDIVISION: TID[VI~U VILLAOED LOT: 15
SECTION: 5 TOWNSHIP: llN RANGE: 5W
1.25A (SQ. FT. OR ACRES)
BLOCK: NA
I certify that:
1. I am familiar with the requi~/~ments for on-site sewers and wells as set
forth by the Municipality o~/¢ ~nchopag?~~d the State of Alaska.
2. I will ins~ll the syst~ i~ /a~~e with all MOA codes and regulations,
and in c~p~anc~i~~crit~ia o~ t~ permit.
5. I will ~dhere t~~ S~ o~ A~a~uirements ~or the set back
all.tan=as fr~m ~~~~/~pl_~!sposaX system or public
APPLICANT:
~t' ~ WATER'' WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geologico! ~ Geophyslco! Surveys
.. I*n~l,.,,,,. I /31 t I-'~--'°"~".,.--.I'I sO wD
· I'd. jig. OISTANCE ANO OIRECTION .... FROM ROAD INTERSECTIONS' ~' * ,
S. OWNER OF. WELL=
4. WEt.lo OEPTH: {,Inel)
.. I-lc.,. ,oo, I~,o,o,, .I-Io,,,.n
· OA.., O--...d ORe,*, r--lO.h.,.
?.USt~:~ OomelllO 0 Publle Supplr I--I Induelr)'
[~ TeSt Will [] Other:
8. OA~INGI ~] Threaded ~W*lded
~ Above ~r ~tolow lend surfaco
IE,GROUTIHO Will Orouled: [] Yel ~ MotlrJel: [] Noel Cement [] Other:
[] Sub.. [--~ del [-'] CentrlflCclt ["1 Other
16. WATER WElDeD CONTRACTOR'S~CERTIFICATtON.·
-,..... //
,.
DC
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date
GENERAL INFORMATION
(a) Legal Description (include lot. block, subdivision, section, town/ship, range)
Location (address or directions)
(b)
(c)
(d)
(e)
(f)
Applicant Name ~-~m~,~'~ I ~.~C. Telephone: Home ~'.~4~,4~' "~"~,~! Business
Applicant Address '~,~:3s II-Z? 7
Applicant is (check one): Len. ding Institut!on I'-I; Owner/builder~:~ Buyer [:]; Other [] (explain);
Lending Institution
..
Address
Real Estate Company and Agent
Address
Telephone -
Mail the HAP, to the following address: /
Telephone
2. TYPE OF RESIDENCE
Single-Family ~ Multi-Family I-I
Number of Bedrooms
Other
4:
attesting to the legality and status.
WATER SUPPLY
IndividualWell;~3 Community[:] Public[:] ,~ .....~ ....
Note: If community well system, must have written confirmation from ~he State Department of Environmental Conservation
SEWAGE DISPOSAL ' ~ I t ,_
Onsite:~ Public[] Community[] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status. , , ~,
Page 1 of 2 72-025 (ll/~)
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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 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.
Engineer's Seal
Approved for /~,r~,'~:~ bedrooms by Date
' ~pproved /'/ Disapproved n i i
Terms of Conditional Approval
CAUTION
The Muncipality of Anchorage'D~Partmenttol~ Ith and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upo'n the relSrJ~sehtations given in paragraph 5 above by an independent professional
engineer registered in the State of Alaska. The DHEP does this as a courtesy to purchasers of homes and their lending
institutions in order to satisfy certain federal and state requirements. Employees of DHEP 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 engineers work. , I.
Page 2 of 2
72-025 (1
'7127 ~OLD SEWARD HIGHWAY
ANCHORAGE, ALASKA 99518
(90'/)344 8551 = .' .
" ~I~'TERIOLOGXCA~ ~ATER
TO BE COl~LLrtO BY I~TER SUPPLIER )
CITY - STATE lP CODE
'COLLECTED liy: (SIG~ATHJLFd) ~:., ~...~
(CHECK ONLY ONE THIS COLU$~)
~ DRZmCIRG WATER
~CHECK ~A~ ~ FIL~RED '
~REATED OR OTHER
~ r-I OTHER(Spec?y)
IS THIS SAI~PLE A CHECK S~U~LE TO A PREVIOUS NON-CONFOI~ING SAId?LE?
~] YES ~ P~Vl~S COLLECTION ~T[' ~ ~
AULYSXS~S~D (IF O~R T~N TOTAL COLIFO~)
SEND REPORT TO:(PRINT FULL NAId[,AODRESS AND ZIP CODE
ADORESS ~ t (-~ ~ C.~Jt~
CITY ANC. PF~---,4~'~-. STATE A~ ZlP
FOR LAB Us£ ORLY
R~SUBHIT SAJ~LE
Sample ~eJected because:
C~CK ~E OR ~RE
hmle too l~g tn trmnstt.
b~e should ~t ~ ove~ 30 hours.
~le ~cetved t~ late tn ~ek
Not tn pm~r c~ta1~r
Leaked out
Insufficient SnFo~tton p~vtded.
P~ease read tnstrv¢tlons on rom.
Other (Spec1 fy)
LABORATORY RESULTS
r-) Other Bacteria
ri Test unsuitable because:
rJ confluent
[3 TNTC /
SATISFACTORY ~ UIIS~TISFACTONY
BACTERIOLOGICAL MATER ANALYSIS RECORD
FOR LAD USE ONLY
TOTAL COLIFORNS
FECAL COLIFORNS
OTHER
~embrane Filter: Direct Count
Verification: LTB
Final Rembrane Filter Results
Reported Dy
f~ Col t form/lOOml
BGB
Col tform/lOOml
Date
Time A.P,.
Polio
READ SAJ¢PLE COLLECTION INSTRUCTIONS ON BACK OF FORN
WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
Legal~Description: (,~r'
Ik,~UN~pA{.I'Iy O~ ANC~O~GE
$£P 9 lgBli
Well Classification '~_L~d~'~" If A, B, C,.D.E.C..Approved (Y/N) ~/1~
Well Log Present {Y/N) ~'/~3, Date Completed ~::~Z.~.-/,E~3 Yield [ ~v~
Depth of Grouting
Pump Set At ~A
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
J (:)C~l"'fl'- ; On Adjoining Lots
To Nearest Public Sewer
Total Depth '~-'~) ' Cased to J cj /-
Static Water Level ~/'
Casing Height Above Ground ~"~"--'
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Near'st Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole ~ To Nearest Sewer Service Line on Lot 1(:3(:3 t ~
Water Sample Collected by '"~"~w~.. ~ ; Date ~/~/I ~'~,
Water Sample Test Results .~,~'~ ~, ~'~'['~"(
Comments
El. SEPTIC/HOLDING TANK DATA
Date Installed /~-~l L..[ q Size NO. of Compartments ~"
Standpipes (Y/N) "~t~'% Air-tight Caps (Y/N) "~ Foundation Cleanout (Y/N)
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (Y/N)
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well j ~
To Property Line ,~(~
To Water Main/service Line
Course j ~ I...{..
Comments
Date Last Pumped t~A~~'~,,~'~
;for
Temporary Holding Tank Permit (Y/N) ~'~
To Eluilding Foundation J (~
To Disposal Field .~ ·
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11~84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (WN)
Results of Last Adequacy Test
Separation Distance from Absorption Field:
TO Water-Supply We~l ~ OO
TO Building Foundation {
Lot I~//~'
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness ~..~r~
Standpipes Present (Y/N)'
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Water Main/Service Line -~C)~' 'J-'l~-'~''4'~'(~''
To Stream/Pond/Lake/or Major Drainage Course J (~)O
To Driveway, Parking Area, or Vehicle Storage Area
LIFT STATION
Date Installed ~ Dimensions
Size in Gall, ons ~Manhole/Access {Y/N)
"Pump On' Level at ~ "Pump Off" Level at
High Water Alarm Level at /' Vent (Y/N)/
Tested for ' / __ Pumping/~tes dur'mgAdequacyTestMeets MOA
Electrical Codes (Y/N) ~
~~hB~e~~~iii;dAt °Riq~ g uidelines in el f ect on t h e dar e o f t his inspection-
Company t"~'li~'~'~ ~:=l"l'4~-~'No. '
Receipt No. --I-~bb~ "~{3~~/
Date of Payment ~3~ .~:3~
Amount: $ {~ ~'~ ~
Page 2 of 2