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Home My WebLink AboutSUNNY BLK 2 LT 3 Name MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES Environmental Health Division 825 "L" Street. Anchorage, Alaska 99502. Telephone 264-4720 ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT O/F - ?--+?--- 70 ,o,~ i~,~.~ pu~.-o~.u/u/u~, "TANKS ~ SEPTIC [] HOLDING TYPE OF SYSTEM ~TRENCH_ ~ ~ BED ~ W. DRAIN JO/.7//~ DISTANCES SEPTIC ABSORPTION ~ TANK FIELD WELL WEL, 4~'+I- /~'~- /0/ 17~ [] OTHER WELLS /.~PRIVATE [] OTHER fldentifv) REMARKS: LOT LINE FOUNDATION Municipal Ind Health Department Approval: 72-013 (3,85) r FT FT FT · 4' ~'=.~3 / 0 Permit Number: Date Issued: Owner Name: Owner Address: NUN I U I PAL I T Y OF ANCHORAGE Department of Health & Human Services 8.-~5 L Street, Anchorage~ Alaska 99501 545-4720 N-SITE SEWER & 900158 06/05/90 Engineer Designed WELL P E R M I BRIAN & LISA JOHNSON 11750 TRAILS END ROAD ANCHORASE, AK 99516 T Parcel Id: 015-242-70 Lot Legal: Subdivision: SUNNY Lot: 5 Block: ~ Section: 24 Town~hip: 12N Range: ~W Lot Size 52000 (sq.~t. or acres) Max B~drooms: This Permit: 4 '~otal Capacity: 4 Day Phone: ~'~ SEPTIC TANK: Minimum total septic tank capacity: 1,250 gallons. Each septic tank must h~ve at least 2 compartments. Depth to top of septic tank(s) < 4.0 feet requires insulation over tank(s). WELL: Lo(] must be submitted to Municipality of Anchorage Department of Health and Human Services within 50 days of well completion. PERMIT EXPIRES DECEMDER 51, 1990 NOTIFY DH;tS OF INSPECTIONS AT .543-4744. I CERTIFY THAI: 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 of Alaska. 2. I will install the system in accordance with all MOA codes and regulations, and in compliance with the design criteria o( this permit. 5. I will adhere to all, MOA and State/of Alaska requirements ~or the set back distances ~rom any existing well, .~astewater disposal system or public sewerage system on th~s or any adjacent or nearby lot. 4. I understan~/~.hat thi~ permit is valid for a maximum o~ 4 bedrooms. I also under~.~nd that~ capacity o~ the total system is 4 bedrooms and any ~nlaryl//~ ~yquire an add itional perm it. I DEPARTMENT OF H~LTH & HUMAN SOILS LOG -- PERCO~TION ~U~ ~/~ Townshlp, Range, Seclion: 16- 17- COMMENTS I:'f. RCOLATION RATE (m/n~'i~::t~l PF..~C HOLE DIAMETER TEST RUN ~ETWF. E~ FT AND ~( [~ ~,~RTIFYT~TTH~ST~W~P~FORMEDIN LOT ,4.. I0' ELEC. t''rEA. .x~. ~At s-r. '"*' Lo~ Z WATER WELL* RECORD STATE OF ALASKA DEPARTMENT OF NATURAL RESOURES Oivi$ion of Geological a Geophysical Surveys LOCATION OF WELL (Please Complete either IQ, tb or lc.) r ,_.,_.,_0,_, t~. I DtSTANCE ANODIRECTION FROM ROAD INTERSECTIONS ~. WELL LOG Feet ~1o~ ~ ql~ ' g ."/'we e-.-q E.S'~ DEPT. OF HEALTH & ENVIRONMENIAL v)cOT[CTIOJ'J ~CP '2 o.199a RECEIVED D*-" O~.,,.d Dso,, ~ Irrigation 0 ReeRorge 0 Commerlcol 8, ~ASING: ~ T~reeded ~ Welded ,,,.. ~ ,.. ,. ?l ,,.o.,,, ,.,,,,~,,,./,,. 9. FINISH OF WELL: ,o. STAT, C WATER LEVE'.' [] Above or "~X ,...,.., t ,,..~,~?~, ,.,.-. 0 s.b.. D"' Dc'"""'"' O o,,., 14.REMARKS: I,),./ /, A.,.,.: ftc-- = o Dc I~/NICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES ENVIRONMENTAL SERVICES DIVISION ON-SITE WASTEWATER DISPOSAL SYSTEM INSPECTION ENGINEER FIELD AUDIT TIME LEGAL DESCRIPTION: ENGINEER: EXCAVATOR: AUDITOR: COMMENTS: SIGNATURE OF AUDITOR: · .--. ', :,.' ~ MUNIt.,;IPALI1 ¥ (JI- ANUI-t[JHA~.. . - ..,,, ........ ,. . , , . ,~,,~_,,.~_~" ..... . .",e~ce e.~ ~,,~.'. ~:~;'~ ~ .,. DIVISION OF ENVIRONMENTAL SERVICES c,~ ~F. ¥3'.',,_~,~!,~', ~;:l,'-o~.,i-~ :-: ~ -- ;: ,. ~n~ ~:~.:,{:~'.' CERTIFICATE OF, INSPECTION FOR HEALTH AUTHORITY APPROVAL.OFo ,"-. ' ON-SITE S~ER AND WATER FACILI~ FOR SINGLE FAMILY DWELLING~,. ~. e,?{'.-', .~t~,~.-: -. ,' !~;GENERAL INFORMATION {Must be completed prior to submittat) ~.'.: .:' ............. .- ............. :.. ~:' '(a) Legal Descd ption {include lot, block, subdivision, section, townsh~ p, range) ' _ _ ~ _ ..... :--.'.. Location {address or directions)' " * ~' ': ' '-:':'"---': .--'"" .., _ ......... (b) Prope~yowner ~ ,~ "~ ' .Tetephone:(home)'~q~/~Busness~7~-O~/~ · ' . ..;~;.~;~;~ Mai?ng Address. -' ~ I0 -~ ~ ~.' ~'~ ' ." "~: .~(c) Lending Institution-- ~ ' .": '-' Telephone . ~:~'~,d).Real Estate Co...~any a~d Agent . - "~ O FI ~ ........~ ~ , ~T.. ..... '~ ~ -Address' '~ -~; ..... - .:' . - '~ (e) Ma,I the HAA to the following address: (or check here old for peck up.) ' '-' ,- · List contact person and day phone number below: -.. .... - ":.;.Singte-Fam .. .Numberof be .. , .... · - :- '-..:. {~Note: If com~lty~ell system~must have,wr~tten.~onfi~ation-fro~.the.StateDepa~ment of,Enwronmental. ' "'~.. C6nse~ation'attestin~ {O'th'legali{~ and'~t~tu~'~~': "' . · .~ ...:. ;.'.; ."' :.,'-W, Omslt.. ".,Public~lo ~Communlty~'.,~ :HoldingTank~.:~r~,-{~ ~.~.~; ~' ~ o u.rJ~,,f ,..',:[ ~ ~,~;,.~: ' :' · -., %,~ote~pmmunity. wel[ system must ha?~ritten conflrmahon from~he State Depa~ment of,Environmental · . ,.: · ,.. Conse~at on attest ng to the ega ~ and statu~ . .- .......',.... ,,., .. ~ .~ ~ Page 1 of 2 . :;., , ~ . , , _. . . . .. ~,.,,.,. . . ::.~ ,: . '... 5. ENGINEERING FIRM PROVIDING. INSPEC,.TIONS,_, . .... .... TESTS, FI,LE~EARCH,,.. . DATA AND. INFORMATION As certified by my seal affixed hereto and as of the ~'alidation date shown below I ve[{fy.that.my investigation of this Health Authority Approval shows' that'the on-site water' SUlJply~ and/or' wastewate, r.,.disposal system is safe. functional and adequate for the number of bedrooms and type o[?ructure indicated herein~. I further verify that' based on tho information obtained from the Municipality of Anchorage files and from my investigation and'~ inspection, the on:site water supply &~d/6r'~aste~ater dis~5osal ~'~st~m is in 'co/fipllafic~'~ith all Municipal and. State codes, ordinances, and regulations'In effect'on the'dat~ ~!'thi~ Ihs~ection:: ~! -.- Name of Firm:' i ~'~/~.¢~'' '~ u,'~-~' ~- .Telephone '"J y'~ -,5'c:)9~-- --: ,,~ Address (3 ?o"(. -' ,"/.~, - ~! r.f~,~c.~... --. , ,,:-,.' ,'~ ,.,~n .:;,,' , ....... , ---/,. .::,,::...,,.-' Date /""-~,: " ~ ............................... :?"':' ...... !~.:.','? ~~~i[~eer's Seal ' ' ..... ,... ..................... · .. _-~._ ......... ~ - 6. DHHS APPROVAL /'~ ~ _ ' ' ' " Approvedfo;'Z~ "~edroomsby~~ '~Date ''~/'~ ~'//' Approved '~'~" ' Disapproved Conditional!:~--~'.' ' ' ''" .- Terms of Conditiona! Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval ' cerificated based only upon the representations given in paragraph $.above by an independent professional engl'neer~ · registered in the State of Alaska. The DHHS does this as a cou[tesy to purchasers of homes and their lending:.. ' . institutions in order,to satisfy certain federal and state requirement.s., Em, ployees of DHHS do not conduct inspecti°,ns' ' or anal~/ze dat,~ I:Jefore ~ ~ertiftcate is issue~l'. Th~' M~nicipality Of A~:~orag e is not resp'o~sibl~ fo~: e~:~:or$ 6r omissiohs ,. in the professional engineer's work. ' ":~:'/"" ' ': ': ' "' ~ '~: ~ ...... '~ '~ '" ' '. .... . n-0~(,.,.~/.,~,~ Page2of2; ': - ' · ' ~ MUNICIPALITY OF ANCHORAGE Department of Health & Human Services DIVISION OF ENVIRONMENTAL SERVICES 343,-4744 -... >.: :~' CERTIFICATE OF INSPECTION FOR HEALTH AUTHOR TY APPROVAL OF..:. --' ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. # k~-~t ~ - ~ ~ ~-"~'''). HAA# 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (address or directions)' - ' (b) Property owner Mailing Address I ~) o ~ (c) Lending Institution Mailing Address (d) Real Estate Company and Agent Telephone: (home) .~t~,_ i.,,-:~ Business ~-7~-~ 71~/ Telephone Address ' ' Telephone ............ (e) Mail the HAA to the following address: r check here ~lf hold for pick up.) List contact person and day phone number below: ...- . ~:..;-..: . ."~-'" ~Z -z-/). ~...,~¥' ..... .. · ......... . ' 2. TYPE OF RESIDENCE Single-Family~ Number of bedrooms '~ ''~ 3. WATER SUPPLY Individual Well ~ Community FI Public r'l Note: If corem, unity well system, must have written confirmation from the State Department of Environmental · Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-slte~i~ Public r-i Community [] Holding Tank r-i 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 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. 6. DHHS APPROVAL Approved for Approved Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human S~rvices (DHHS) issues Health Authority Approval cerificated 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. Page 2 of 2 Health Authority Approval (HAA) i~:: CHECKLIST FEBRUARY 1984 : 343-4744 ".~ Well Classification "~,~--~ ' If A, B, C, D.E.C. Approved (Y/N) Well Log Present (Y/N) y. Date Completed c~//~/~ Yield~ Total Depth cZ// Cased to CZ/ Depth of Grouting Static Water Level· -~ Casing Height Above Ground · Electrical Wirihg in Conduit (Y/N) SEPARATION DISTANCES FROM WELL: To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Pump Set At Sanitary Seal on Casing (Y/N) Depression Around Wellhead (Y/N) ; On Adjoining Lots )~' /P"~ ; On Adjoining Lots To Nearest Public Sewer CleanoutJManhole To Nearest Sewer Service Line on Lot ~'~//-.f"~) Water Sample Collected by Water Sample Test Results Comments B. SEPTIC/HOLDING TANK DATA Date Installed E/"Zo Size Standpipes (Y/N) ~' ~'P Depression over Tank (Y/N) Pumping/Maintenance Contact on File (Y/N) Holding Tank High-Water Alarm (Y/N) SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK: /",,~,-,~'C~ NO. of Compartments '7" ~ Air-tight Caps (Y/N) y Foundation Cleanout (Y/N) I*"/* Date Last Pumped : I"V'///_.~ ; for /~//'~/'--% Temporary Holding Tank Permit (Y/N) /O To Water-Supply Well ~"~ To Property Line To Water Main/Service Line To Stream, Pond, Lake or Major Drainage Course To Building Foundation To Disposai Fi~id" ' Comments Page 1 of 2 C. ABSORPTION FIELD DATA Soils Rating in .~bsorption S~rata Date Installed Width of Field Length of Field Depth of Field '7 ~/o / ' . G~-avel Bed Thickness ,-~ Square Feet of Absortion Area ~'~, -'~ ~ Statndpipes Present (Y/N) '-~ Depression over Field (Y/N) ~ Date of Last Adequacy Test t~'/',,~, Results of Last Adequacy Test SEPARATION DISTANCE FROM ABSORPTION FIELD: To Water-Supply Well ~/o-~:~' -' To Property Line To Building Foundation ~ / 7 To Existing or Abandoned System on ToWater'Main/ServiceLtne · ~ /C) To Cutback (if present) To Stream, Pond, Lake, or Major Drainage Course '~ To Driveway, Parking Area, or Vehicle Storage Area .~ ..~C) Comments D. LIFT STATION J'"//0 /'~ ~-. Date Installed Size in Gallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Pump Off" Level at Vent (Y/N) Pumping Cycles during Adequacy Test. **Check Permitted Bedroom Rating Against HAA Request'* I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.. ~---~'. ~~ Signed Company Date MOA No. ReceiptNo. Date of Payment /-- / (~ -0~ / Amount: $ i "~ 0 72~2~ {Rev. 7/88) e~ck - , :, ReceiptNo. '~,.~ ' .... --~ Waiver Fee: $ Date of Payment Page 2 of 2 Engineer's Seal CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC. 5633 B STREET · ANCHORAGE. ALASKA 99518 · TELEPHONE (907) 562-2343 FEDERAL TAX I.D. 892-0040440 Date Report Printed: SAN 14 91 I 11:08 Client Sample ID:[S El $OIP~T $/D POTABLE #ITEl P~ID Cnllecte~ JAN 10 91 t 11:00 Receive~ SAN 10 91 I 12:00 Preserved with :AS Client Mame: TOSI~M SPU~[LAND, P.E. Client Acct: T088~N$ ~PO I PO I MOM~ ~eq E Analysis Completed :JAN 11 91 $er~ Reports to: Laboratory Supervltpr'~=~T~PHEN C. EDE I)TOBEKN $PU~KLAHD. P.E. Chemlab Mef 1:910105 [ab Smpl ID: I ~trtx: MITER Allowable Parameter Tested Result ~nlt~ Method Limits MITRAT[-M 0.96 I~/! EPA 353.2 10 Sample ~O~II)~ SAMPLE COELECTED BT T. SPU~KLAND. i Teste Perfor~d ' See Special lr~tlucttons Above UA-Unavailable liD- Mona Detected "See Sample Remarks Above MA- Mot Analyzed LT-Leoe Than, CT-C~eater Than