HomeMy WebLinkAboutDORA LT 3
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
NAME P.ONE
MAILING ADDRESS ,
EEGAL DESORIPTION
LOCATION NO. OF BEDROOMS
area
Dwelling
PERMIT
NO.
~ Z Manufacturer Material No. of compartments
Liq. capacity in gallons IF HOMEMADE: Inside length Width Liquid depth
~ ~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~ -- ~ Manufacturer Material Liquid capacity in gallons
O Well Foundation Nearest lot line PERMIT NO.
~ ~ DISTANCE TO:
~ ~ ~ No. of lines Length of each line Total length of lines Trench width Distance between lines
~ inches
~ ~ Top of tile to finish grade Material beneath tile Total effective absorption area
Q inches
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ CJass Depth , Driller Distance to Jot line PERMIT NO.~
= DISTANCE TO: Building zlf°un?ti°n Sewer lin~__ --4 I~..~ Septic~tank Absorption~.~area(s)
OTHER
PIPE MATERIALS e ~~
SOIL TEST RATING ~ "~
INSTALLER
REMARKS -
APPROVED DATE LEGAL
72-013 (Rev. 3/78)
PERMIT NO.
DEPRRTMENT E HERLTH RND ENVIRONMENTRL ]TECTION
825 'L STREET, RNCHORRGE..
264-4?20
[-~ELL PERIqIT
( 8~01±6 )
RPPLICRNT GRRY MELLOTT
LOCRTION
LEGRL LT.
i?4t-M SRA RNCH
LOT SIZE
999999 SQUARE FEET
MINIMUM DISTANCE BETWEEN R WELL AND RNY ON-SITE SEWAGE DISPOSRL SYSTEM IS
t00 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVRTE WELL TO A PRIVRTE SEWER LINE IS 25 FEET RND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 50 DRYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY RPPLY. SPECIFICRTIONS AND CONSTRUCTION DIAGRAMS RRE
RVAILRBLE TO INSURE PROPER INSTALLRTION
F"EF~:t-1 I T E:~P I I~:E'_-] [:,EL-~-Er'IE:ER _.~cdL..
I CERTIFY THAT
i: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS RS SET
FORTH BY THE MUNICIPALITY OF RNCHORRGE.
2~ I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
V4. 0
ANCHOR DRILLING
3940 E ll2th St
A~chorage, AK 99507
Phone: 344-3433
WATER WE LL LOG
NAME.'
ADI~SS:
Gary P. Nellott
(8~th & Dori Subdv)
O - 23 Ft Sand&Gravel
23 - 47 Ft Clay & Gravel
47 - 66Ft Clay
66 - 84 :~ Gravel
84 - 101 Ft Clay
101 - 105 Ft Sap~
105 - 110 Ft Sand, coarse gravel, water - 10 gpm
Well cased to 110 Ft Static Water Level - 90 Ft
Yield- 10 gpm by.bailing
Mb%IICIPALITY OF ANCHORAGE
DIVISION OF ~[VIRONMENT~L HEALTH
D~R~ARI~ENT OF HEAL~{ ~ND ENVIRONMENT~IL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CEtY]TIFICATE
I. General Information
Applicaticn Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (add~ess or directions)
0
(b) App!icants Name.
Applicants Address
(c) Applicant is (check one) Lending Institution ~ ; Owner/builder~ ;
Buyer~-~ ; Other~--~ (explain);
(d) lending Institution
Telephone
Address
(e) F~al Estate Co. & Agent
Address
Te le phone
2. Type of I~esidence
Single-Family
Multi-Family[---]
Number of Bedrcoms j'
Other (describe)
3. Wate~ Supply[
Individual Well ~ C~nity ~ Public ~
Note: If crmmunity ~11 system, must have written ccnfirmaticn frcm the State
Department of Environmsntal Conservation attesting to the legality and status.
Is the ~11 adequate fo~ the number of bedrocms specified in this HAA .(Y/N).
4. Sewage Disposal
Onsite ~-~ Public ~ Con~nunity ~ Holding Tank ~--~
Is the wastewater disposal system adequate fGr the rumber of b~drocras .(Y/N),
[Page 1 of 2]
2-15-84
5. Engineering Firm Pr. ovidinq Inspections, Tests, L~ta and Information
I certify that I have checked, verified, or conformed to all MOA HAA gaidelir~s in
effect on the date of this inspection.
Name of Firm ,¢~/$ /l/ j /u/f ~ Lg~/-~ Telephone 3 _~. f-' Z~Y ~ _~_
Address..
Date
6. DHEP Approval
Approve d for
Approved ~
( ENGINEER SEAL)
Disapgroved ~--~ Conditional
Terms of Conditional Approval
The Municipality of Anchorage Depa~tmsnt of Health and Environmental Protection does
not guarantee the continued satisfactory performance of the water supply and/or th~
wastewater disposal system. This approval indicates that, as of the ~zalidation date
shown above, bamsd on the data and information furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system is safe and fun~
tional for the numbe~ of ~edrocms and type of structure indicated.
( DHEP SEAL)
7. Mail the HAA to the following address:
KB2/d5/s
[Page 2 of 2]
2-15-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Well Classification 3'lb' ~.
Well Log Pmesent (Y/N)
Total Depth~,6tt ~oG Cased to
Static. Water LevelI~6 ~,~&t &~6 Pump Set At
Casing Height Above Ground ,,
Elect=ical Wiring in Conduit (Y/N).
Sepa=ation Distances f=cm Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lo~
To Nearest Public Sewer Line
If A, B, c~ C, D.E.C. Approved(Y/N)
Yield
Date Completed ~ ~,~4~ A~ ~
Depth of outinq ,'./owtr ....
Sanitamy Seal on Casing (Y/N)~
Depression A=ound Wellhead (.Y/N)/~
; On Adjoining Lots /~
. ..; On Adjoining LOts.
To Nea=est Public Sewer
Cleanout/Manhole /oO 44' / To Nearest Sewer Service Line on Lot
Water Sample Collected By ~z¢./%~ ~ /~L~ ~r/; Da~;~-~.6~-~/ _//
Water Sample Test Results J'~f £,~ .,~ /% t*FoAT "-~-- -'~"
Cc~rents ,
B. SEPTIC/HOLDING TANK DATA
Date Installed Size
Standpipes (Y/N) Air-tight Caps (Y/N)
Dep=ession ove= Tank (Y/N). Date Last Pun~ped
Pumping/Maintenance Contract on File (Y/N) ;
No. of Compartments
Foundation Cleanout (Y./N)
for
Holding Tank High-Water Alarm (Y/N) Tempora~y Holding Tank Pemmit (Y/N)
Separation Distances furcm Septic/Holding Tank:
To Water-Supply Well To Building Foundation
To Property Line To Disposal Field
To Water Main/Service Line To Stream, Pond, Lake, c~ Major Dmainage
Course
Comvents
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption A~ea
Depression over Field (Y/N)
Results of Last A~e__-quacy Test
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes P~esent '. (.Y/N)
Date of Last Adsquacy Test
Separation Distance f~cm Absc~ption Field:
To Water-Supply Well To P~operty Line
To Building Foundation
Lot
To Water Main/Service Line
To Stream/Pond/Lake/c~ Major D~ainage Course
To Existing Or Abandoned System c~
; On Adjoining Lots
To Cutbank(if p~esent)
To D~iveway, Pa~king A~ea, c~ Vehicle Stc~age A~ea
Comments
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
NOIIDglO~ld 'IVIN~I~INO~!
o /Ac ss
"~ ~f" ~1 at
Vent (Y~)
~ing Cycles ~ing ~q~g ~st.
Meets MOA
Electrical Codes (Y/N)
Cca~ents
** Check Pe:~mitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified,
on the date of this inspection.
KB1/d5/s
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c~ eonfomted to all ~.M~A....HAA
MOA No.
~uideline~ in effect
Gary J. Mdlott
2-15-84