HomeMy WebLinkAboutTONJESS ESTATES BLK 2 LT 13
, ,,,.~"'" ' MUNIClPALITYOF ANCHORAGE ":'"'{ RECEIVED
"' ~, ~'"~'~ DEPARTMENT OF HEALTH & ENVIflONMENTAL~Pi~OTECTION
I[~ ~. ~]J ' ENVIRONMENTAL ENGINE~ING DIVISION ' UAD O · 1001.
~ ~ ' 825 L Street- Anchorage, Alaska 99501 Telephone 2644720
~ ON~ITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION ~~' Anc~rag,
PHO E '
NAME ' j ~ ~ J N
'. .......... j
P.O.. Hex 3, Sutton,/ Alaska 99674 ' ~k~]~--Jl '
~*LO~SCR,"~,ON. . · .. ...
· Pe'ter' reek .: ", · =
.... . j J Well ~$orption area O~lling PERMIT NO.
' B~. ].DmTANCETOt~ JPro~ose8 1BO~] 10~ 50~ None-]f. ste8
· , ..... ,v. Greet .- , -iamw [~$ee]
LIq. ca,city In gallon$. 'F "OME .... E Inlide length Liquid depth
.'1000,~.~ ' _ -. .'~.,~ ..... ...................... ..~ .~ ...~ ........ , ..........
"~' "~"~ Nell' '~%'' *~'' O~l[J~" ........... PERMIT NO.
~OZ . DISTANCE TO:
' - ~ .Manufacturer .. ~ . -."".. Material Liquid capacity In ~llon~
L~ ~= 'DISTX~CE TO(, Nell . 2' Foundation Neart* lei line PERMIT NO.
~ No. of lines ~ k L~ngt~ of. each line - Total length of lines ~n~ width Dis~nce ~t~en lines
_~ ,L · ' tX -'42I ~f ~--4~ Inches ....
~ ~ ~ Top of tile to finish grade. Material eneath tile Total ellecttve aosorptmn area
'' Q '/, 'a~--~ ~ aR inches '~[ ~
Length Width Depth PERMIT NO. ..
" ~ ~ i Type of crib Crib diameter Crib deplh Total effecli~ absorption area
m Well Building foundation Nearest Icl line
~ DISTANCE TO:
,' ~ Class ..~ ~ Depth Driller Distance to lot line PERMIT NO.
" ~ .~: ~,. DISTANCE TO: Building foundation Sewer line Septic tank Absorption area(s)
OTHER
'/
PIPE MATERIA~ ~
.~; PYa- drainfi'oid; Oa~t iron- other / / ..
111 .
REMARKS.. ..... *.. '.~.; ~', ..,...' · , · · .;~ , --.
'f=om ~rench, but sot1 is ~oo8 ~ ,
~ "
~hroughou~ area. 'iX X ~z' /
/
Vernon L. Roei:fs 1C-23-19J)2 Lot 1~ lO. lc 2 '20nge[]s Estates
SULLIVAN WATER WELLS
P. O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
OWNER OF LAND ,/? ,.. ~. ~ ---.*," ~:~ -'.~
ADDRESS / ! ? :~'- /~ ~ -~ '~"~
LEGAL DESCRIPTION
DATE-Started ,~/ /
/
PERMIT NUMBER
DEPTH OF WELL U ~ ~'
STATIC LEVEL OF WATER FT. C°
!7¥/...~ 7'~.oJ~z.rJ ~7"DRAWDOWNFT'
Ended 1 ,////~?c:) ' GALS. PER HR ~
KIND OF CASING ~'
From
From~
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From
From
From~
From
KIND OF FORMATIONi
From ~,'~ Ft. to ? Ft
From ? Ft. to .3 / Ft.
From D~ Ft. to -*~ ~': Ft.
From % :=' Ft. to ?~,~ Ft.
From '? ~ Ft. to ~ ~ Ft.
From ~,-~ Ft. to~'~ ,Ft.
From /''*~ Ft. to .t~/ Ft.
From Ft. to ' Ft. ~ ."~ ~f
From .,' -
From
From Ft. to -Ft. ~',~
From / '~',' Ft.
From ).~:~= Ft.
From Ft.
From .; ?'? Ft. to ~ ~! Ft. /~,~ (P./.<. t<f ~ ut, C) From
From Ft. to.~Ft. From
From Ft. to .Ft. From~
Ft. to
.Ft. to
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Ft. to
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Ft. to
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Ft. to
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MISCL. INFORMATION:
~ .
DRILLER'S NAME " -"' / ~, .............
~MUN I~'I PALITY Of ,,ANCHORAGE
-, .o Department ~-~ Health and ~nvironmenta] rotection
'' -'825 .~ Street, .Anchorage; AK. ~9501
· '264-4720
* '* '# HANDWRITTEN PERMIT * ~ *
Pe~t ~ ~ ~ ~.-
~e of':Soil ~sorp~on -System ls: .
'Trench: __ Dra~field: ,- ,~. Seepage :'Bed,: ":~olding Tank:
~~ ~N~er 'of..Bearooms: ~ ' cSoil :Rating (sq.ft/br)'
,DEPTH
'The Require~ 'Size.of'~he Soil :Absorption,System Is: '
~[~NGTH ~ ~..,;GRAVEL/DEPTH ~ 'WIDTH
:The .length 'dimension'.is'the length(in .feet) of ~.the. trench .or .drainfield, The
idepth of :a ~t-rench..or~ pit.is ~the.distance%between:the'sur~ace of the ground and
~the' bottom of the.:excavation'(~n.~eet), ".~here .'is 'no -set 'width :fOr trenches,
· .The gravel, depth '~s '.the"minim~nn'depth'.~of ~/rave~. ~between-'-the outfall pipe and.
~he ~'bottom of .'the~ excavation (in.~eet) ,
'~"~-' REQUIRED 'SEPIIC(HOLDING)~TANKi'~.SIZE:= ---'" :GALLONS
PeIT~it :app 'l~cant ~'has :the :.responsibil ity:.to .:ih foz~n this ~ department :. dur ing..the
installation 'inspections .of "any wells ..adjacent ~to ;~this property ~nd -the number
of=.residences.-that the .well .will =serve,
TWO (2). qNSPECTIDNS 'ARE'CREQUIRED ~ '~ ~
Ba'ckfi] ling rnf.-any~.syst'em.without f/nal...inspection ':and 'approval ~y -this' departmen'
wiIl~.,be ~subject"rto prosecution. .
Minimum .'distance. between .a ..well~.~u~d ~any -on-site .~sewage .'~isposal'-.~system .is .100 :fee
for. a private-~welt ur 1-50 .to/200 .~eet'..from ~a :public: well ~depending upon the .type
of ;publ-ic well.. ~4inimum.:distance'Tfrom a'. private,well' to.a ~private ~sewer line
is ~25 feet and ~-to :a' conm~unity~'sewer line _is'~'75?feet.. We] 1 '.logs-'are required~. ,
a~d :3nust !be Teturn'ed to ;this:~deuartment ~ithin '~30 ~-~ays, "of :rthe -.well':completion
Other .requirements may.;apply. '.Specifications and ~'construction'..diagrams are
available ::to'-insure ~roper .installation
. . *' -~ '* ;PERMIT'::EXPIRES_DECEMBER;~i,, ~'1,9 '* '*
: I' :C ertify ..that: '
~ (1) VI' am;familiar '~ith-:l.~.he~equ'irements :'for on-site.-.~ewers ~'and wells as
~ cset r~forth:;by ,:'the ' 'Municipality of, :Anchorage.
~: '(2) .I::will'-~nstall,.the~,,system in'accordance with _'codes.
~ (3) ~:'I-...understand.that,.the,,on-site .sewer.'system;.may Tequire ':enlargement if
! ..... :~he ':res idence ~ ~ s -remodeled. to: include ~: more .- that 3 ,:DedrDoms.
'Appl£cant
Date:_ /O/~! /~ ~
, SW~/024 (1/.81)
i"::'~ of So£1. Ab~o~ptlon ~yst~w ts:
264-4720
.:
-"- --:=- --=--
· Trench: Ora~nF~-~d~ See~ Be~ RoLdLrtg Tank:
i:' · DEPTM .LENGTH
l-::!"::*?';~e length dLmen~£°n Lg
~ ' GRAV~ ~ _ '----'_ ._ ~[DFH .... ':'-,;!
':!.:" 'd~pth OF a trench or pit L~ the dL~tance botweeo
* . ~he ~tt~ O~ the ex~vatfo~(~ feet). ~re
'~ .. ':~e.q=avo[ a~h ~ the m~ ~e~h of ~avel
'" the ~t~ O~ t~~vat[on(fn ~t). ::,::~' ,
~:. s * REQU[R~ S~TIC(~[~ TA~ SIZE
'' o~ Cesideuces that t~e well will ~e~ve. ' ~ . ..;:
'.;.; 9 o~ ~y ~ys~ viS.ut ~at L~sp~tion a~ a~covat by ~hLs d~
· '..~ ~ s~J~t ~o p~~oa.
i:jMLnLmum distance betveen a'~el! and any on-sLte ~age disposal sy~tea Ls ~LO0,
~tva~ waLL or LSO-t0 200 E~t f~ a publLc ~tt de~LDg~ t~-'~
' -of pt~! lc ~lt.' Min~ d~e ~c~ a pcLvate w~l to a prLvato
· ig 2S {~ ~ tO a ~nfty s~eC l~ L; 75 f~. ~eil l~S
· ':;and ~st ~.ret.~ to this de~~t wfthLu 30 &ays oE the ~L[
"" I C~ti~y that:
: set forth by t~ M~Lc~atity of ~rage.
t~ residence fs re~eL~ ~ i~l~e ~re 't~t 3 ~~.' ., '~:t~
sw /o24
Date
¢"'"'~t , ":0
POUL. ~ 6-6u
ANCHORAGE. ALASKA 99502-0650
(907) 26.':1-4111
TONY KND ,;'L,r 5
f, fA Y O,O
DEPAIqTMENT OF tlEALTH AND ENVIRONMENTAL PROTECTION
~Permit ~: 821117
.January 31, 1983
TO: Permit Applicant
Subject: Lot 13 Block 2 Tonjess. Estates Subdivision
A permit issued by this department for an individual well
and/or on-site sewer system has expired as of December 31,
1982.
Permits are issued on a calendar year basis, as stated on
the permit, by authority of Municipal Ordinance.
If you have drilled the well, a well log needs to be sent
to this department for documentation of the installation
date and to close the permit.
If a private engineer inspected the installation of the
on-site sewer system, please have them send us the as-builts
for our files and documentation.
If there are any further questions, please call this office
at 264-4720.
Sincerel%
Robert C. Pratt, R.S.
Acting Program Manager
Sewer and Water Program
RCP/ljw
enc: Copy of Permit
SWP/057
,,M. UNI~IPALITY OF ANCHORAGE
mit' ~ ,q ~ I I --~J'epartment ~ ~ Health and Environmental,~'.~rotection
' "~ ' ~ ' 264-4720 ·
cnorage,
ON-SZT S WER
Legal Description: L/~ ~A Fm~,~ ~&+ Lot Size:
Type of Soil Absorption System Is ?
Trench: ~,- Drainfield: __'Seepage Beds __Holding Tank:
Maximum Number of Bedrooms: .~ Soil Rating(sq.ft/br) ?//
DEPTH
The Required Size of the Soil Absorption System Is:
LENGTH
. GRAVEL DEPTH WIDTH ~/~
The length dimension is the length(in feet) of the trench or drainfield. The
depth of a trench or pit is the distance between the surface of the ground and
· the bottom of the excavation(in feet). There is no set width for trenches.
The gravel depth is the minimum depth of gravel between the outfall pipe and
the bottom of the excavation(in feet).
· * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~O GALLONS * *
Permit applicant has the responsibility to inform this department during the
installation inspections of any wells adjacent to this property and the number
of residences that the well will serve.
· * * TWO(2) INSPECTIONS ARE REQUIRED * * *
~ackfilling of any system without final inspection .and approval by this departmen
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 fee
for a private well or 150 to 200 feet from a public well depending upon the type
of public well. Minimum distance from a private well to a private sewer line
is 25 feet and to a community sewer line is 75 feet. Well logs are required
and must be returned to this department within 30 days of the well completion.
Other requirements may apply. Specifications and construction diagrams are
available to insure proper.installation.
* * * PERMIT EXPIRES DECEMBER 51, 1 9 8 2 ' * *
I certify that:
(1) ' I am familiar with the'requirements for on-site sewers and wells as
set forth by the Municipality of Anchorage.
(2) I will install the system in accordance with codes.
(3) I understand that the on-site sewer system may require enlargement if
th~ residence is remodeled to include more that 3.bedrooms.
S igne~: .~.~_x~ ~ Is sued by:/~. ~~~.
A~licant ./ Date:
SWP/024 (1/el)
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
/ o.,c,,.) P d..~
PERFORMED
FOR:
DESCRIPTION: '
LEGAL
1
3
""--8
9-
10
11
12
13
14
15
16-
17
18
19
20
COMMENTS
DATE PERFORMED:
SLOPE SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
o ?./y-~i //.-// -,C' .*?: '
i i/ -~., I0 ?'~ 3'/
~'7
PERCOLATION RATE "~' '~ ,(minutes/inch)
TEST RUN BETWEEN 4'?-' FT AND -~"- ET
,. _3..~, .~"*:~'~ .,K~ .?(. ---- /// f"-/-: /~,.-/,,,,-,
PERFORMED
CERTIFIED BY: /-~'? f~,Y""//
DATE:
'" ~ r'":"" :'~'~?'" ...... '~ '" ' ....MUNICIPALITY OF ANCHORAGE "' ? ....... ~'~," ...... ~-'"' ..... t':.' .........
*%{' 't., ...... '~'"?'" ~"' ' .............................................................. of Health l Human ~ ~ ' ~":~"' "'"'~"'""~'~ ~ "
.c'_~ ~i r;,~.~'~ ~2~; ~.~: DIVISION ~F ENVIRONMENTAL SERVICES.;~ ~?,. ~:~hC~h~,}~.~;,:~": '
~Cl yh~,v ~c':',h~ i .,':;~.. o~,' ,:i ~'q'~.';~u:~i: Io ~.::?343~4744:X~:;b:~ ~; ~&J.u~ v.':, ~o;:'~¢.~, 5r~ ~im~;::}q(i.,
::b~ [c,q,mrl:lM 'iii: CERTJ EICATE OF, INSPECTION FOR H~LTH AUTHORI,~,-APPROVAL OE~
ON-SITE SEWER AND. WA~ER FACILITY FOR SINGLE FAMILY DWELLING ..... *' * ' '
P~rcel i.D. ~.. · ;~ ~ .......... '" .~HAA ~_ "':"": .......... '" _,.
GENERAL INFORMATION (Must be comp eted prior to submltta) ~ , ~ ., , · ~- ~ ~-.-.;.:~..~ ....
:~(a).Lega[Descnpt~on.0nclude lot, block, subdivision, section, township, range)' ' ..... ' .... '":'" ' ' ' ': '~: '
..'.":;" Lo~ 75; ~ck.~; To~6':ES~F' '- .... ":'" "'-' :.: "' .:' ' ::":- ;'.".. ".'.:~"-: ..
;: "..X': ocation (address'or directions) , ~/;:'..-' - --! ..::-, ' ."
. :.:'., ,'!";:.'X" ,. ;..~..~' * ?, / ..' ...........
(b) Pr0pe~ty'0wner '~' Bob, ~ :i'ju.~Z~,: ~own
....... ""-:'~,'-.? :."'~';::.'" I". " '
Mailing Address :: .......
· -. .. .. .... '. . :'.-;;;.'
(C) Lending Institution
; . '.,: ....% -:... .........
Mailing Address- ' ' '
(d) Real Estate Company and Agent
........ ' .... .... ~, i~..";:; ..... . -
Telephone: (home) 688-0557, BUsir~'S~.~.. 276-~'$2217;.,:.
Telephone'
ATrN:.'Lo~d. Crowde~:' c....;::'.': .... -. ' ',:x'.
Address 10928 Ea,qle. l~ve.,t Road~ 'Eagl~ R~vRA~ Ak.,995 ..... '..-.,~"',
- ....... ~ .~ - , ~., .,~ ~ ~,'.~ . .~.~ , , '-. .... ~,, ..,',.,.-:~. ~., ..... ~', .':~;, -t~ ...... -..~
......... Telephone ......... 694 5500.~ ......................... . ......................
' " ' · . '"'r'': ..... :'' '-- .' '':'::: '','~ :--'.'' ~, " ". ' · ~'' ." ~'~.~ }''. ~'~l.~,~'a,..." ':::;' '
~(e) Mail the HAA to the following address: (or check here~ If hold for pick up.)
. . Llst contact person and day phone number below, '. . .:.'- ' -..'~.~..-;'"
- , .. . ', ,. : · _ ~ - .,. · ;~. ~ ,.-, ~ , , -. :_
17034 Eagle River L~p Roa~ No, 2~ ; '-,~-" ......
~,r.....~: ..
~57~
Eagle
River~
. _
, ~..~. ,-,-..~;~,~-~ - . .: . ,
2.'TYPE OF RESIDENCE .... '" · ...... "' , ' ·
Single-Family ~ Number of bedrooms ~ '~ . . .."-..'-':"~.{:,.2:.: .'.'... ' "' ~:! "' '"' :-. ". ~ ..r'..: ....
3. WATER SUPPLY .... :' ': ...................... .......... t ........ '
Individual Well ~ Corn unity D.': Public D .... . :'. . -' ....... -'" ,- . ~*:.:-~.~..*
· l'.~Nol?lt co~mu~ity ~el ~y~teQ .~ mu~t6a~e wdt~on.con~ r~ation,from the
4-SEWAGEDI .... ,~,, ~ ~ ' ,. ~ ., i ~ -.~, . ~ ,,; ., , · · · ,'. ' ', ".v~-"A~ , ;,'~,, ' '
':' Nole:'lf communtty'well system, must have ~rltten confirmatmn from tho State Dopa~mont.of. Envlronmental(
Consemat on attest n~ to the leoallty and status " ...... :- ...... ,'.' ¥ ';' ' ~";;;; , W--" '
"~JOM speau!§ua leuo!ssajoJd eql u!
suo!ss tuo Jo sJoJJa Jot elq!suodsaJ lOU s! e§eJoqouv Io ~liledlotunl~ eq.L'panssl s! eleo!l!~Ja3 e eJojeq elep ez,{leUe Jo
su'oqsadsUl'lonpuo'3 lOt~ 0p §iLll:l'Q'io'sae/~Old w:a ;SluemaimbaJ'el~ls pUe leJ~Pet uie~Jeo/<Iml'~s'o~ japj~'~i~ su&lfr~ilsul
§u!pual Jlaql pue saLum:l lo sJaseqoJnd ol'/~selJnoo e'.se.siql seop SHHQ eqJ. 'e~selV lo elelS'eqi u! paJelS!§aJ -'
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leUO[1!puoc) pa^oJddes]C] ,./,,.. 'N./' pa^o'Jdd¥
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' ' ', .' .... :_ . . - z: ,~NTH~I~.~I~N_:I S '~ <~ "":'" ":" :~-': '
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pUB led!ojun~ lie U1..M_~_.O._UeI cl. ~00. U) S! welsXs leSOdsip JBJBMBJSeM J.O/pue ,qddns JaJl~M el!~TUO etll 'uojloedsu]
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?ql ~!Ja^ Jaqpnt I .'U!aJaLI paleoJpuJ eJnlOnJlS lo ed/~l pue swooJpaq lo Jaq Lunu alii JOJ elenbepe pue~leUOjlount
ales s. mals/~s lesod$~'p~.J.'ajeMelSBM Jo~pue /Klddns J~le~A 'el!s-uo a. Lll IBql.SMOLIS' leJ, pJddV/~l JoqlnV LIIIeaH
S LI1 lO UOJle§~lSa^Ul ,(w letll ~im^ I 'MOlaq UMOLIS elep UOJlePJle^ eql jo se pue ojeJeq pax!lie lees Xw Xq pe!t!pao sV
NOIlVlNIJO=INI aNY viva 'HOt:IV=IS =1'il4 'SIS3.L 'SNOilOgdSNI ONIOIAOI:Id INtll.-I ONIId33NION3 '9
*,
MUNICIPALITY OF ANCHORAGE (MOA)
Health Aulhority Approval (HAA)
CHECKLIST - FEBRUARY 1984
343-4744 ....
Legal Description:~
A. WELL DATA
Well Classification
Well Log Present ~YN) * ~l · Date Completed ~-~,'7~
Total Depth'Z~O~ Cased to'~L~ L~'~epth of Grouting '
Static Water Level ~,~'
Casing Height Above Ground
Electrical Wiring In Conduit ~)/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ' \C)c~x~-'
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
To Nearest Sewer Service' Line on Lot
If A, B, C, D.E.C. Approved (Y/N)
Yield L(~.
----
Pump Set At
Sanita~ Seal on Casing~N) .
Depression Around Wellhead (Y~
; On Adjoining Lots \ C~C'~t~' '
\~ ~'~"' ; On Adjoining Lots \ t~r~ ~'
To Nearest Public Sewer Cleanout/Manhole ~' I~-
Water Sample Collected by '~-~" ~ ~--r~~w'3'L~ ;Date ,.~.\% _c~\
Water Sample Test Results
Comments ~ ~ "1"o
B. SEPTIC/HOLDING TANK DATA
Date Installed \~-~'=~-'~"Z-- Size __~C~:~ No. of Compartments
Standpipes {~/N) '"/ Air-tight Caps (~/N)
Depression over Tank (Y/I~)
PumPing~Maintenan.c. e Cont. ac! on ~File (Y/N)
Holding Tank High-Water Alarm (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water,Supply Well
To Property Line
To Water Main/Service Line \/"~
To Stream, Pond, Lake or Major Drainage Course
Comments ~:~O~P ~
Foundation Cleanout (d~N) , '~
Date Last pumped '~-'7--°-~ t
, for ~
Temporary Holding Tank Permit (Y/N) '"-
To Building Foundation
To Disposal Field
72-026 (Rev. 7/88) F;ont
page ! of 2
C. ABSORPTION FIELD DATA
soils Rating in Absorption Strata '
Date Installed \O - ~."~ -
Width of Field "~L*" ~' '~ ~
Square Feet of Absortion Area
Depression over Field (Y,~ ~
Results of Last Adequacy Test ' ~-.-.~--~'~-~c..-c--z:~ ~c~p-- ~ ~"~,
SEPARATION DISTANCE FROM ABSORPTI(~N FIELD:
Type of System Design "~'~--~-~,
Length of Field
Depth of Field
Gravel Bed Thickness "~
Statndpipes Present (~/N) .
Date of Last Adequacy Test.
To Water-suPply Well
To Building Foundation '
Lo, '
To Water Main/Service Line ~ o~ '~'
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Par. king Area, or Vehicle Storage Area
Comments
· To Property Line "~ c~- '
To Existing or Abandoned System on
; On Adjoining L~ts
· ; To Cutback (if present)
~O~
D. LIFT STATION
Date Installed ' ~ .....
Dimensions
S~ ~ : ' ' ': ' Manhole/Access (Y/N)
"Pump~On" Level at ~ ~ "Pu~ '
High Water Alarm Level at ~~ Vent (Y/N) .
Tested for ~-/ ~ P~umping Cycles during Adequacy Test.
Comments.. ~
**CheCk Permitted B~droom Rating Against HAA Request**
I certify that I have checked, ~,erified, or conformed t(~ all MOA and HAA guidelines in elf,
inspection. .. . ,' '
Signed S ~ S EN~IN£ERI.N,G,.~
~.a ~31 ~' - .....
~17~
Company r~e River, ~l~s~a 995~
Date ~ ~ ~- ~ /'
MOANo. ~ ~ ~ ~° ~
Receipt No. ~?.,c:~:~' _ .... . Receipt No.
Date of Payment '~ Waiver Fee: $
Amount: $ ("~ Date of Payment
~-o~ (,.~. ~J~S) e.c~ Page 2 of 2
CHEMICAL & GEOLOGICAL LABORATORY
· A DIVISION OF COMMERCIAL TESTING & ENGINEERING
~6~B~TREET ANCHORAGE. ALASKAg951~ TELEPIIONE(907)66~-230
Client hmo ,~ & $ 3~OlrlillP~
Clto,t loot
.................... ~--~.~ ....................................................................... . .................
·" " 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, township, range)
Lot 15; Bt. ock 2; Tonje66 E6t~zt~6
June
1986
Location (address or directions)
Applicant Name Har;~z Telephone: Home $44-9775 Business
Applicant Address
(b)
(c) Applicant is (check one): Lending Institution I-3; Owner/builder [~; Buyer []; Other [] (explain):
(d)
Lending Institution JVa;l~onc[,~. Bank of At. aska Telephone
Address CSt. re~t., Ancho.'[age, Ala6~/ATTEETION: K~h~/ Bogan
(e)
Real Estate Company and Agent Her/tag e Hom~s/Ear~ Chapp~.~l
Address Box 126, Eag~ R/vet Road, Eagle River, A~6ka
Telephone 694-4994
99577
(f)
~([~he HAAtothefollowing address: S.~ $ Enginee~ln~
SRB 196X
Eagle River, A~6ka 99577
Ordered b~ Ea~ Chapp~
TYPE OF RESIDENCE
Single-Family ~ Multi-Family []
Number of Bedrooms fi'
Other
WATER SUPPLY
Individual Well r~ Community [] Public []
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4o
SEWAGE DISPOSAL
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 (11,84)
ENGINEERING FIRM PROVIDINC..,,~SPECTIONS, TESTS, FILE SEARCH, DA't.. 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 Stato codes, ordinances, and regulations in effect on
the date of this inspection.
Name of Firm "' ~NEERING
Address SR'~ -'J 96X
Date -r::AGLERI VEE;-AK-~5 ~ /
Telephone
JUN 2 6 1986
DHEP APPROVAL
Appr'~)ved for 7~',.z~'('.~) bedrooms by
Approved ~ Disapproved
Terms of Conditional Approval
Conditional
CAUTION
The Muncipality of Anchorage Department of Health and Environmental Protection (DHEP) issues Health Authority
Approval certificates based solely upon the representations 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 engineer's work.
Page 2 of 2
72-025 (1 t184)
WELL DATA
LegalD~tion: ~-r I'~'~ IVED
Well Classification
Well Log Present ~/N)
Total Depth Z-~ ·
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (~/N)
Separation Distances from Well:
To Septic/l::l~ Tank on Lot /
To Nearest Edge of Absorption Field on Lot J
~ ' '~'" IfA, B, C, D.E.C. Approved (Y/N)
Date Completed ///~' Z.- Yield
Depth of Grouting
-.~'-~ · Pump Set At U t ~--.
Sanitary Seal on Casing (:~N)
MUNICIPALITY OF ANCHOPus, G3
DEPT. OF HEALTH
';,
Depression Around Wellhead (Y~)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer Line '~/~ To Nearest Public Sewer
-, CleanouVManhole ~J,~ To Nearest Sewer Service Line on Lot ~'~
Water Sample Collected by -_~:~ J ~ ~'-/#,~--~'~- ¢ ; Date
Water ~mple Test Results ~ ~ ~, ~ ~
Comments ~ ~/~ ~ ~~ ~.~
B. SEPTIC/H~'L'~tNG TANK DATA
Date Installed )0-~,,3, '- ~Z.. Size ~ ~ No. of Compartments '7.-.
Standpipes ~/N) Air-tight Caps ~¥N) Foundation Cleanout (Y/~
Depression over Tank (Y~ Date Last Pumped ~ - Z. ¢- - ~ ~
Pumping/Maintenance Contract on File (Y/N) ,.~,] ; for
-/4
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Hoidmg-.Tank:
To Water-Supply Well /
To Property Line ./,~'
To Water Main/Service ~/A' I ~ //'-
Course
Temporary Holding Tank Permit (Y/N)
To Building Foundation ,5'"'~ '
To Disposal Field /~P ~
To Stream, Pond, Lake, or Major Drainage
Comments
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 (Y/I~
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well !
To Building Foundation ~:~
Lot '"'~/~
To Water Main/Service Line / ~ /'/'''
/// '~'~.- Type of System Design
Length of Field ~'Z,, /
Depth of Field ~, t
Gravel Bed Thickness ~ /
~5~, '~ Standpipes Present~/N)
Date of Last Adequacy Test
To Property Line ~/'~
To Existing or Abandoned System on
; On Adjoining Lots
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
To Cutbank (if present)
D. LIFT STATION
Date Installed
Size in Gallons
*'Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** 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.
Sign~i~ _~ ~NG!NE£RIN'.. Date
Coml~ '~g&X MOA No.
Rece~o~ RIVER, AK ~F':~ ~ ~ ~
Date of Payment ~ -~' ~
Amount: $ b ~
Page 2 of 2
72-026 (I 1,,84)
JUN ? 6 I.q~R
...... APPLI~'-"NT FILLS OUT UPPER HA"-~.i'ONLY
Property Owner Phone
Address Zip Cods
Lending Institu,lo, / ~ r ~~WXJ ~ O~ ~0~: ~ Phone
Realty Co. & A~n, ~m ~W ~E. ~/.~ Phone
Street Locati.
T~of Resi~nce
Single Family
~ Multigle Family No. of Bedroo~
~ Other
.~a~e r Supply
~ Indivld~l A~ACH ~LL LOG. A w~l log Is ~equlred for all wells drlll~ since June 1915.
D Community For wells ~illed prior to that date, give well depth (attach I~ If available).
~ Public Utility
Sewer Disposal
~ Individ~l Year Indiv~ual Installed:
~ Public ~llity When Co~ected to Public Utility:
D Holding Tank
NOTE: THE INSPECTION ~E MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSlNG CAN BE INITIATED.
Time Time Time Time
,
Inspirer Inspirer Inspirer ; X
dE
Field Notes: ~ DFPT.
RECEIVED
DISAP~OVED
Soils Rating Date ~wer Installed Well To ~sorption Area Well Log Received
~ ~ I Well to Tank Septic T~k Size