HomeMy WebLinkAboutTRAILS END BLK 7 LT 10
· '~ ("~' MUNICIPALITY OF ANCHORA(~E
' 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
NAME
MAILING ADDRESS
/o/ F-,
LEGAl. ~ESCRIPTION
D,STANCETO: IWe''
O ~ Manulacturer
No. of line~ Length o! each line
Top gl tile to finish grade
DISTANCE TO:
m Building foundation
~ DISTANCE TO:
JPHONE I ,~NEW
[] UPGRADE
IInside length
Dwelling
Foundation
Total length of lines
Material beneath tile
Depth
Crib depth
Building foundation
Drifter
Sewer line
Width
Material
Nearest lot hne
Trench width
NO. OF BED~OMS
No, of co.~.ar tmen ts
Liquid depth
PERMIT NO.
Liquid capacity ih gallons
PEHMIT
Distance ~t~en lines
inches
Total eH~tive abso~tion area
inches
PERMIT
Total ef f~fi~ e~orpfion area
Nearest lot line
D~stance to lot line ~ PERMIT NO.
Septic tank ~ Absorption area(si
OTHER
PIPE MATERIALS P]~ ,¢ ~7 ~
SOIL TEST RATING
INSTALLER
REMARKS
72-013 (Rev. 3/78)
LEGAL
Applicant:
Location:
Legal Description: /~- la /-w~/~< ~
Type of Soil Absorption System Is:
,~MUNICIPALIT¥ 0F ANCHORAGE~
Department~! Health and Environmental Irotectzon
825 ~9~ Street, Anchorage, AK. ~9501
264-4720
* # * HANDWRITTEN PERMIT * ~ ~
WELL AND/OR ON-SITE SEWER PERMIT
Mailing Address: /O/~.e/~
Phone Number: ~77- ~C~
~,~//~ ' Lot Size:
Trench: Drainfield: Seepage Bed: / Holding Tank:
Maximum Number of Bedrooms: ,? Soil Rating(sq.ft/br) ~ $
The Requi~ed Size of the Soil Absorption System Is: '
DEPTH ~,-J~' LENGTH .5-~ . GRAVEL DEPTH ~'~/~ WIDTH
.. /~--''
The length dimension is the length(zn 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 = /~0 GALLONS e ~
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 ~ ~ *
Backfilling 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 ~ 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 diagra/ns are
available to insure proper.installation.
* # * PERMIT EXPIRES DECEMBER ~1,, 1 9'8 1" ' '
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 u~d~s.t~nd~h, at~the on-site sewer system may require enlargement if
t~si,~Z~emodeled to include more tha~_ bedrooms./
Signed: ~rc~, ~ -'/~4 ' Issued by: (_._/.~..~/"~! ~._~/~f~
Date: ~ 5 ~/ 2 '
SWP/024 (1/81) '
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 / Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
DATE PE.PO.MED:~--
· EOA'DESC.,PT,ON: Zo /o x //c 7
(FEET)
1-
z.~d st,d.,.
SLOPE
SITE PLAN
8-
9-
10-
11-
12-
13-
WASGROUNOWATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
S
L
0
p~
E
14 - Reading
1,5- ]
16- ~.
17-
L/
19-
Gross Net Depth to Net
Date Time Time Water Drop
~/.' o~ -~ $.a~" -~-
Iq~'$-/ $o .~,FJ- ~,/o
Is~; $43o 3. f~' 6 .o y
20-
PERCOLATION RATE
TEST RUN BETWEEN
COMMENTS ~-~ d~*,,~ I~7- -~ d~,./~.
72-008 (6179)
ALASKA ENVIRONI~NX~L
CONTROL SERVIC .0.
1220 West 25th Avenue
· ' ANCHORAGE, ALASKA 99503 C^LCUkATED BY
Phone 276-1361
$.EE?.O. I O~ L
DATE
CHECKEDDY DATE
ALASKA ENVIRON t,~gNJ-T~L
CONTROL SERVIC
· ,1220 West 25th Avenue
· .' ANCHORAGE, ALASKA 99503
Phone 276-1361
CALCULATED BY DATE
CHECKED BY
CATE
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
Parcel I.D. #
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
015-192-16 NAA# ~ ~5/~ ~'~:~k [
1. GENERAL INFORMATION
Completelegaldescription T.ot 10, Block 7, Trails End Subdivision
Location (site address or directions)
11400 Doggie Avenue
Property owner Brian M~_l]
Mailing address 1403 Hyder, Suite A
Lending agency
Mailing address
Agent
Address
Unless otherwise requested, HAA will be held for pickup·
NUMBER OF BEDROOMS: Three
TYPE OF WATER SUPPLY:
Individual well XXX
NOTE:.
Dayphone 346-4754
Anchorage, AK 99501
Day phone
Day phone
Community well
Public water
If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
NOTE:
Individual on-site ××× ..
Holding tank "~
Community on-site
Public sewer
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 structure indicated herein. I further verifythat 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 Anderson Engineering Phone 563-7155
P.O. Box 240773 Anchorage, AK 99524
Address
Engineer's signature ~'~ ~ ~ Date ~/'1~'
DHHS SIGNATURE
j Approved for '~
Disapproved.
Conditional approval for
bedrooms.
bedrooms, with the following stipulations:
By:.
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHH5) issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an independent
professional engineer.r~!stered in the State of Alaska. Thp DHHS does this as a courtesyto 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.
Municipality of Anchorage . D
DEPARTMENT OF HEALTH & HUMAN SERVICE~-
Environmental Services Division
825 L Street, Room 502 · Anchorage, Alaska 99501 · (907)dJ~-4~1~
LogaJ Description:
WEII DATA
Well type P]:*I va t.e
Log present (Y/N) ¥
Total depth 1 68 '
Sanitary seaJ (Y/N)
Municipality o! Anchorage
Health Authority Approval Checkli~l~ept. Health & Human Services
Lot 10, Block 7, Trails End ParcelI.D.: 015-192-16
If A, B, or C, attech ADEC letter. ADEC water system number
Date of test
Stefic water level Unknown
Well pmdcofion 4
WATER SAMPLE RESULTS:
0
Coliform Nitrate
Date of sample: 6 / 24 / 97
B. SEPTIC/HOLDINGTANK DATA
Dateinstelled 7/13/81 Tanksize 1,000
Foundation cleanout (Y/N) Y
Date of Pumping 7 / 1 / 97
C. ABSORPTION FIELD DATA
Date instafied 7/13/81
Length 56 ' Width
Date completed
Cased fo 166 '
Y
FROM WELL LOG
6/8/81
g.p.m.
e/e/el
Casing height (sbove ground)
WJms properly protected (Y/N)
AT INSPECTION
6/27/97
21'
5.6
I. 34 mg/ L Other bacteria
Collected by: HE:A
Number of Compartments 2 Cleanouts (Y/N).__
Depression (Y/N) N High water alarm (Y/N) bl
PumperO].d HacDonald's
Soil refing (g.p.dJfF or fff/bdrm) 327
26 t Gravel thickness below pipe
g.p.m.
Effective absorption area 1456 S. F .Monitoring Tuba present (Y/N) Y
Date of adequacy test 6/27/97 Results (Pass/Fail) Pass
Fluid depth in absorption field before test (in.); 0
Fluid depth 0 (ins) Minutes later:
Peraxide tmatmant (past 12 months) (Y/N) N
72-02e (Rev.
Y
System type Bed
1' Total depth 6'~
Depression over field (Y/N) N
For Three
Immediately after 500 gal. water added (in.):
Absorption rate = > 450 g.p.d.
if ~S, giv~ date
bedrooms
0
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer/septic service line
D. UFT STATION NONE ON LOT
Date installed
Manhole/Accese (Y/N)
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
>100'
>100'
Miles
>50'
Size in gallons
"Pump on" level at*
*Datum
"Pump off" level at'
HAA Fee $ -'~('"L
Date of Pay. mm
Receipt Number ~"~.-~ a ~L~ I 0 ~"~ ~'-
72-026 (Rev. 3/98)*
Waiver Fee $
Date of Payment
Receipt Number
F. ENGINEER'S CERTIFICATION ..... .
I cen'lfy #1at / have determ/ned thru field inspect/ocs and rewew of Mun/c~pa/~.~..~?'.~ ~s~ems are
/n confommnce w#h MOA HAA gu/de#~es /n effect on th/s date /~.A?'~<.'" .~", ; ',
EnglneefeName Michael E. Anderson, P.E. ~~,'~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Foundation > 5 ' Property line > 5 ' Absorption field > 5 '
Water main/service line >20' .Surface water/dreinage > 1 0 0 ' Walls on adjacent lots >100'
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line > 10 ' Building foundation > 10 ' > 20 '
Surface water > 100 ' Driveway, parking/vehicle storage area > 20 '
Curtain drain None Observed Wells on adjacent lots > 100 '
Water rnaln/se~ice line
On adjacem lots > 100 '
On adjacent lots > 100 '
Public sewer manhole/cleanout Mi 1 es
Lift station N / A
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING
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
(c) Lending Institution ~t'~'/o
/'"///--~-'-~ Telephone: (home)-~/~--270~' Business
Telephone
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e) Mail the HAA to the following address: (or check here [~,if hold for pick up.)
List contact person and day phone number below:
2. TYPE OF RESIDENCE
Single-Family]~ Number of bedrooms ..~
3. WATER SUPPLY
Individual Well,J~ Community I-] Public
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to th legality and status.
4. SEWAGE DISPOSAL
On-site J~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environmental
Conservation attesting to the legailty and status.
Page 1 of 2
5. 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 thai my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe.
functional end 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.'
Name of Firm
Address
Date ~?
Approved for ~-~ bedrooms by Date ., .
Approved ~- Disapproved Conditional
Tarms of Conditional 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 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.
ENVI~c:N~E ~Vi$~JNIClPALITY OF ANCHORAGE (MOA)
Health Authority Approval (HAA)
CHECKLIST - FEBRUARY 1984
J U L - ]-~J/ 343-4744
RECEIVED Legal Description: /.~'7-'/~ ~',~
A. WELL DATA' ' . O/'~"--../'~.~
We,, Log Presen, NI Date om ,e e
Total Depth / ~ C~sed to /~ Depth of Grouting
Static Water Level / ~ ~ Pump Set At
Casing Height Above Ground ~ ~ Sanita~ Seal on Casing~N)
Electrical Wiring in Conduit~N) * Depression ArOund Wellhead (Y~
SEPARATION DISTANCES FROM WELL:
/
To Septic/Holding T~nk on Lot /~ ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot //~ ~ ; On Adjoining Lots /~
To Nearest Public Sewer Line ~ To Nearest Public Sewer Cleanou~Manhole
To Nearest Sewer Se~ice Line on Lot ~/~
Water Sample Collected by ~c~d ~ ~/~/~ ~ f~; Date
Water Sample Test Results ~C
Comments
B, SEPTIC/HOLDING TANK DATA
Date Installed 7/15/~'! Size
Standpipes (~N)
Depression over Tank (Y~.~
Pumping/Maintenance Contact on File (Y/N)
Holding Tank High-Water Alarm (Y/N) /"//~
'/O~g~) No. of Compartments
Air-tight Caps gN) Foundation Cleanout ~N)
Date Last Pur~ped 3-~' ,7'-,-'/'/,'/.
;for
Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK:
To Water-Supply Well /~ *'
To Property Line I~)"
To Water Main/Service Line ~ ~--~-
To Stream, Pond, Lake or Major Drainage Course
To Building Foundation
To Disposal ~)~;tz~
Comments
ABSORPTION FIELD DATA ,' :
Soils Rating in Absorption Strata .~.? ' ~,~ I?~'/~'~'¥ype of System Design
Date Installed ' 7~3/~/ ·
Width of Field
Square Feet of Absortion Area
Depression over Field (Y~
Results of Last Adequacy Test
Length of Field .~7'~ ! . :
Depth of Field ~ f*-.-~ -
Gravel Bed Thickness ~.vj ,,
Statndpipes Present ~N)
Date of Last Adequacy Test
SEPARATION DISTANCE FROM ABSORPTION FIELD:
To Water-Supply Well /!
To Building Foundation
Lot
To Water Main/Service Line ~-~'~
To Stream, Pond, Lake, or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
,I.
To Property Line J~ ~ '
To Existing or Abandoned System on
; On Adjoining Lots /
To Cutback (if present)
LIFT STATIO%
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 (WN)
Pumping Cycles during Adequacy Test.
**Check Permitted Bedroom Rating Against HAA Request**
I certify that I have checked, verified, or conformed to all MOA an,d, HAA gui_d~l~n~sei..n ~ffect on the date of this
Signed ~ ~z : .~e~.'* '..~- ~'~.
Date ~ ~' ~ ' e...............,.........~.cngmeers ~ea~
MOA No.
Receipt No.
Date of Payme t "7-1'-
Amount: $ /90 ~)0
·
Receipt No,~i.
Waiver Fee: $
Date of Payment
Page 2 of 2
ADEQUACY TEST
DATE TEST COMPLETE ;~ 'T'~tF ~/
CLIENT*S NAME [~IAI~ /"~t~L~
STEUEN E. FLODIN,P,E.
SR I BOX 2570
CHUGIAK, AK 99567
s.EET
PROPERTY LEGAL DESCRIPTION
TEST DATA
TIME GPM ACCUH TOTAL UATER HT UATER HT COMMENTS
· 6ALLONS IN TANK PIT/FLD
TEST PERFORMED BY, ~7-~,,1~ ~'~,q.
LOCATION OF WELL (Legal Description):
WELL DEPTH: /~ ~' FT. .',CASING:
DAT DRILL,,G CO.PLETED:
STATIC WATER LEVEL (Top of Casing):
SAMPLE OATA SHEET
(use continuation sheet for Class A &.B)
DATE OF TEST:
FT SCREEN:
DRILLER: Yv~Yv' ~,,~,,v'~_,..
FT DATE: ~
Elapsed Time Since .
Clock Pumping Started/ Depth to Orawdown/
Time Stopped, Min. Water, ft. Recovery
I1:~ o p/r~ (~;~) ~r',,,.o -~'-'
II :~5 5 :]~ l~.l 1,4
I~ ',tO 40
t;~ f~ 45
]~', ~O 60 (I hour)
I t~o 90
f.%e 120 (2 hours)
76~0 150
~tt~ 180 (3 hours)
Z40 (4 hours)
RECOVERY
~'.~ t 0 t' q'~ j.t, ~' 2,3
3 t ~ 5" 25 ~H .~
C~nts:
Pumping
Rate, GPM
0
Start
t/t'
Remarks
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING
5633 B STREET ANCHORAGE, ALASKA99518 TELEPHONE(907)562-2343 FAX: (g07) 561-5301
[ocolv.~ 3U~l 2~ 9l ~ 16:32 ~.
~zoto~vo~ ~tth :AS ~UI~
LtO B7 T[AIL$ ~D $/D
Cho~eb ~e~ I: 911036 Lab $~pl I0: i ~at:lz:
Eeza,'~tez TeAted ~etult gmat ~et~.oa
~ITBATI-~ 2.7 ~/1 ~A
Trite Pez[o~me~ ' See Special Irmx:uctlora Above UA-Unavailable
~one ~etecte~ '* See Sa~le l~a:ks Above
lot A~ITzea [T-te,s Than. G~*Gxoato~ Then
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC..
..... TELEpHoNE (907) 562-2343 - 5633 B Street
Anchoraoe, Alaska 99518
DrlnMng Water ^nalysls Report for Total Coliform Bacteria'
TO BE COMPLETED BY WATER SUPPLIER
I-I PUBLIC WATERSYSTEMI. D.# I I I I I I
~ PRIVATE WATER SYSTEM
Name Phone NO.
Mailing Addresl
City .- State
S^MPLE D^T~ ~ ~ ~
Mo. Day Year
Zip Code
SAMPLE TYPE:
~ Routine
Check Sample (for routine sample )
with lab ref. no.
ri Special Purpose
Treated Water
Untreated Water
SAMPLE
NO.
I I~J-~ ~'~
31
41
si
LOCATION i.,~.f-lO ~,C'~
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[~atisfactory
D Unsatisfactory
I-I Sample too long In translt; sample should
not be over 30 hours old at examination
to Indicate reliable results. Please send
new sample via special delivery mall.
Time Received
Analytical Method: Membrane Filter
* No. of colonlesll00 ml.
Time Collected Lab Ref. No. Result*
Collected By
I · 5'1. 303~
I I I
I I I ~
I I I ~
I I I
A.D.E.C.
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
,BEFORE
COLLECTING SAMPLE
Membrane Filter:. Direct Count
Verification: LTB BGB
Final Membrlne Filter Results O Collformfl00 mi
Reported By~- ~,~_~) ~ Date
p.m.
TNTC = Too Numerous To Count
OB = Other Bacteria
Collform/100 mi
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(c) Le~&~'J'nse~b'{,on '*~/~;~/'~A-)~ ¢¢.~/ - Telephone
~ .. ~"' ,,"'~,."~ - .;~ ~'b~ -/ ·
..... ,.
Telephone ~ ~
(e) Mail the HAA to the followin~ address: o~ Check here ~hold for pick up.
List contact p~s~ and da~hone number be~. ~ /
TYPE OF RESIDENCE
Single-Family~
Number of Bedrooms
WATER SUPPLY
Individual Well'~ Community I"1 Public r"l
Note: If corn munity well system, must have written confirmation from the State Department of Environmenial Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite~J~ Public [] Community [] Holding Tank []
Note: If community well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 ?~-o2s iRe~, 8/B6t Ftonl
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MUNICIPALITY OF ANCHORAGE (MC*,../'
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264472O
Legal Description: ~.O7"/~ Z~'Zff ? ~"~-,'~'/-"$ ~",,u/~
Well Classification ~'~/t//~" If A. B. C. D.E.C. Approved (Y/N)
Well Log Pre~nt~N) Date Complet~ ~-~-~/ Yield
Total Depth /~ C~ to /~ Depth of Grouting
Static Water Level ~ /~,~ ~ Pump Set At
Casing Height Above Ground
Electrical Wiring in Conduit~N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line ,4]/}/'?
CleanouVManhole
Water Sample Collected by ,~"~'~
Sanitary Seal on Casing~N)
Depression Around Wellhead (Y~)
Water Sample Test Results
Comments ~ ~
; On Adjoining Lots
/~¢') '~' ; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
/,(.
B. SEPTIC/HOLDING TANK DATA
Date Installed ~"I~'~Y! Size /~Z) No. of Compartments
Standpipes Y~N) Air-tight CapsiZe)N) Foundation Cleanoul~)
Depression over Tank (Y& Date Last Pumped ~,"Z,~
Pumping/Maintenance Contract on File (Y/N) ,~/,/R ; for
Holding Tank High-Water Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well
TO Property Line /0
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream. Pond, Lake. or Major Drainage
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
Results of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well
To Building Foundation ,/~
Lot
To Water Main/Service Line ,
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Type of System Design
Length of Field ~'"~'
Depth of Field ~' /
Gravel Bed Thickness / /
Standpipes Presen~N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present) ,'~J/J~
LIFT STATION
Date Jnbt¢~'4
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (WN)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
est Meets MOA
** Check Permitted Bedroom Rating Against HAA Request °*
I certify that I h~3~che~ed~v~fied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed ~ ~'"'//""-'-' Date
Company ,~F-~ MOA No.
Receipt No.
Date of Payment ~ - ~*'~"~(~-~
Amount: $
Page 2 of 2
/~ CH~C~ ,~ ~o~o~c~ ~.~o~o~s o~ ~, ~c..
~:~;~ FEDERAL ~AX ID ~ 92-0040440
I~ALISI~ ~C~ ~I SA~L~ for Wo~k O~de~ I 737~
Da~e ~.port Printed: ~g 23 88 ~ 15:30
~eceived 3UN 22 S~ I 14:00
Preserved with :4 ~£G. C
Clilnt Nam
Client lcct
P.O.I NONE
Orderoa By : A. ~3IN
Laboratory SuperY~,o~ :S:EPHEN ¢. EDE I)AECS
Special
]r~truct:
Chemlab lef t: 147~ tab Smpl ID: I ¥.atrix: Water
Parameter ~,mted lelult/Unlte ~ethod Llmltl
NIT~AYE-N 1.6 9/1 EPA 35t.2 lO
Tests Pe£for~d ' See Special Irmtzuctions lbove UA-Unavailable
None ~.tected "See Sample ~en~zks lbo~e
Not Analyzed LY-Lees Than. Gl-Great,r Than
TELEPHONE (907) 562-2343 5633 B Street
Anchorage. Alaska 99518
Oo
Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
r'l PUBLIC WATER SYSTEM I.D.#
',E3- PRIVATE WATER SYSTEM
M a[llrtg Address
SAMPLE DATE:
Phone NO.
I
Mo. Day Year
Zip Code
SAMPLE TYPE:
'FI Routine
[3 Ch.e. ck Sample (Ior routine sample
with lab ref. no. )
[3 Special Purpose
[3 Treated Water
· 1'~I Untreated Water
TO BE COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
[~Satisfactory
I-} Unsatisfactory
[] Sample too long In transit; sample should
not be over 30 hours old at examination
to indicate reliable results, Please send
new sample via special delivery mail.
Date Received ~/~ ~_;~-,- dF
Time Received // ~"~ O
Analytical Method: Membrane Filler
No. of colonlesll00 mi.
SAMPLE
NO. LOCATION
31
41
51
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Time Collected
Collected By -
Membrane Flltor: Direct Count
' Verllication: LTD
Final Membrane Filter Results
· Repoded By
TNTC = Too Numberous To Count
OB = Other Bacteria
Lab Ref. No. Result* Analyst
IIY? ' ;,O....I I
I FI-1
BGB
Collformll00ml
Time: /~'~' e.m.
· ...'- APPLIC-'NT FILLS OUT UPPER HAt'~ONLY
.a,,ngAdd,e.. ~.~,..f~ ~ ~ ~/'~'2' IlL
Address
Type of Residence
ri Multiple Family NO. o! Bedrooms
Water upDly
~ Public Utility ~ %~
So~e~isposal
~ Holding Tank
Phone
Phone
ATTACH WELL LOG. A well log la required for all wells drlaed eince June 1975.
For wells drilled prior In that date, give well depth (attach log If available).
Year Individual Installed: /
When Connected to Public Utility:
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE(~JEST BEFORE PROCESSING CAN BE INITIATED,
Time Time Time Time
D.,e D.,. D.,. D.,.
Inspector Inspector Inspector Inspector
Field Notes:
(.~) APPROVED BEDROOMS
( ) DISAPIA~OVED
[ ) CONDITiON.~AL APPROVAL'.
· CONDITIONS OF APPROVAL
MUNICIPALr'PJt' OF ANO'I(~RAGE
DEPT. OF HEALTH
ENVIRONMENTAL PROTECTION
SEP 11983
RECEIVED
Soils Rating
Date Sewer Installed
Well To Absorption Area
Well to Tank t 0 ~_
September 6, 1983
G. [)an and Lorraine McCauley
c/o Century 21
Catherine Telfer
209 %;. Dimond Blvd.
Anchorage, AK 99502
Subject: Lot 10, Block 7, Trails End
Approval for the individual sewer and water facilities cannot
be granted until the following items have been completed:
" A well log submitted to this office for our files and
~ revie%;. The log must contain the flow rate.
". Expose ~ well for our inspection to determine proper
are ~et bet%~un the well and sewer sFstqm. ~ ~
Please notify this Depa~tment~for a re~nspection when the ~'~
noted discrepancies have been corrected. If there are any
further questions, please call this office at 264-4720.~.~"~,~[ [~%_~
Sincerely,
Cory Willis, R.S.
CJ24/ej/C2
DATE RECEIVED
-' APPOINTMENTS~ ~~.~_~
INSPECTION
TIME TiME ~__ TIME
DATE~~ DATE
~UNICIPALI~ OF
MUNICIPALITY OF ANCHORAGE DE~T. OF HEALTH &
DEPARTMENT OF HEALTH & ENVIRONMENTAE PROTECTI~viRO~ENTAL
825 L Stt~t - Anchor~, AI~a ~1
1981
ENVIRONMENTAL SANITATION DIVISION
Telephone
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWE~~
DATE
INSPECTOR
DIRECTIONS: Complete all parts on page 1. Incomplete request~ will not be procM~d. Please allow ten (10) days for processing.
P OPERTY WNER I PHONE
MAILINC-~ODRESS
I .,ex
PROPERTY RESIDENT (If~fferent from ahoy) PHONE
2. BUYER PHONE
MAILING ADDRESS
3. LENDING INSTITUTION
MAILING ADDRESS
JPHONE
4. REALTOR/AGENT J PHONE
I
MAILING ADDRESS
5. LE~GAL DESCRIPTION
/07-
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATER SUPPLY
INDIVIDUAL*
COMMUNITY
[] PUBLIC UTI LITY
B. SEWAGE DISPOSAL SYSTEM
~1~ INDIVIDUAL/ON-SITE**
I-'1 PUBLIC UTILITY
NUMBER OF~BEOROOMS
i--1 One [] Four
[] Two [] Five
I~ Three [] Six
I--I Other
· ATTACH WELL LOG. A well log is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach log if available.)
/
?<~'/ YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
NUMBER OF BEDROOMS
;--I SINGLE FAMILY [] ONE [] THREE [] FIVE
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
[] OTHER
2. WATER SUPPLY
PERMIT NUMBER
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
PERMIT NUMBER
DATEINSTALLED
INSTALLER
3. SEWAGE DISPOSAL SYSTEM
[]INDIVIDUAL/ON -~ITE
[]PUBLIC UTILITY
Connection Verified
I'-']Septic Tank or [-'lHoldingTank
Size:~ If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA
4. DISTANCES
WELL TO:
Absorption Area to neacest Lot Line
MATERIAL -
SepticJ,oJdlng Tank IAbsorptior~ Area ISewer Line
INearest Lot Line
COMMENTS
DATE
~/~APPROVED
FOR ~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate
i--I' DISAPPROVED
fl
72.010 (Rev. 6/79)