HomeMy WebLinkAboutDORA LT 4
A. nchoz' ])ri !line
Ancb. ora. ge, ik.
~LL LOG
Cary Melott
Anchorage, Alaska
Lot 4. Dora. Subdivision
0 ................ 23 ft..Sand & ~[~ravel
2~,
47-
66
1 01
t-~7 ft. Clay ~.~ Gravel
-66 ft. Clay
84 ft.
101 ft. Clay
105 .ft. Sand
107 ±'t..:'.:~a. nd ,grave]., water
Bailed 10 G P M
20 ft. o£ water in well.
PERMIT NO.
I~"'1 IU Ih,ll ][ C.". ]E. tzz~ IL ...... ][ "."Ir" %r" gZ.) F IF~ !"--I C: i~. .,, ~.'.'." ftl ~:~ E:
[:'EPARTMENT OF HEALTH FINE.', ENVIF.'OI",IMENTFtL. PROTECTIOF,t
L. "' .:,. REEf., AI'.,ICHF~F.:FI SE. FIK. Lz.[S~SCt::L.
;.:Z 6 4 - 4';'""~ 0
i...~ E: L.L. F' E F~.-.: i~.1 ][ -r'
APPL I CANT
LOCAT I ON
LEGAL.
CiiA R"r' MELLOT
LOT 4 DORA S,.-'D
SRA BO:-'< 1.?4iH 99507
LOT SIZE
6P~00 SQUARE FEET
MINIMUM [:,IS'TRNCE BETWEEN R WELL AND AN"r' ON-SITE SEI.4FtGE DISPOSF~L S"r'S'TEM IS
:1.00 FEET FOR Ft F'RI',,,'RTE I.,.IELL OR. 2LSi."r~ TO 200 FEET FROM R PUBLIC WELL DEPENDING
LIPON THE T"PPE OF' PUBLIC I.,.tELL
MINIMt..IM DISTANC.'E FROM A PRIVATE WELL TO R PRI',,,'RTE SEWER LINE IS 25 FEET RN[:'
TO A COMMUNIT"r' SEWER LINE IS 75 FEET.
WELL LOGS F~RE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN .3:0 DF4"r'S
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MA"r' APPL"r'. SPECIFICRTIONS AN[:, CONSTRUCTION DIFIGRAMS ARE
AVAIL. ABLE TO INSLIRE PROPEF.'. INSTRL. LFITION.
F' E] F: I'1 I "T E :~-:: F' ][ F::: E ~:, [:. E C: E I'"1 B E F-: :l-t :I. .. :.t ~:~ :~: ::L
I CERTIFY THAT
~.: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BM THE MUNICIPRLIT9 OF ANCHORAGE.
2: I WILL INSTALL THE SgS'fEM IN ACCORDANCE WITH THE CODES.
SIGNED: .............................................................................
APPL. ICANT GAR9 MEL. LOT
Applicant:
MUNICIPALITY OF ANCHORAGE
Department "Health and Environmenta. ?rotection
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT * * *
WELL ./i.~]Z.']T___7~'_ -_ ..... i, PERMIT
Location:
Legal Description: ~ ~
Type of Soil Absorption System Is:
Trench: Drainfield:
Mailing Address:
Phone Number:
Seepage Bed:
Maximum Number of Bedrooms:
Lot Size: ~l~liQ:
Holding Tank:
Soil Rating (sq.ft/br)
The Required Size of the Soil Absorption System Is:
DEPTH 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 TM 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 * * *
Backfilling of any system without final inspection and approval by this department
will be subject to prosecution.
Minimum distance between a well and any on-site sewage disposal system is 100 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 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 3lj 1 9 ~ 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 understand that the on-site sewer system may require enlargement if
the residence is remodeled to include more that 3 be~ooms~%.
Signe~: ~ ~ C~ ~ Issued by:
ApplFca /
SWP/024 (1/81)
Municipality of Anchorage
Development Services Department
Building Safety Division
On-Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 014-251-19
GENERAL INFORMATION
Complete legal description
Dora S/D, Lot 4
HAA# C;)
Expiration Date:
Location (site address or directions) 3260 E. 84th Ave.
Current Property owner(s) Paul Grosz Day phone
'Mailing address 3260 E. 84th Ave.; Anchorage, AK 99507
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Day phone
Bobbi Carpenter, Prudential Jack White Day phone 762-3170
3201 C Street, Suite 200; Anchorage, AK 99503
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class ~
Public Water System
Well
[]
[]
D
TYPE OF WASTEWATER DISPOSAL:
Individual On-site r'-I
Individual Holding tank []
Community On-site []
Public Sewer []
The Municipality of Anchorage Development Services Department (DSD) Issues CertifiCates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results..(Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
Development Services Department' ~'~ ~
,~ !Building Safety Division , , r ~ i ~ ~
i ~:Iii On'SiteWater&Wastewatei-Programr '.~ ,' i~i i
: 4700 SouthBragawSt~ ' ~ , : : '.i·' !
- 'i P.O. Box 196650 Anchorage, AK 9951926650 . ii!.'. ~-..'
'i.;,:I, ii.. ~' .'~ , www.muni.org/onsite . ,
: : ii ii,; - , . . i (907)343-7904 I' ~ :'" : i! i~.I'' '
'H ALTH:AuTHORITYAPPROvA CHECK IST '
Legal Description: Dora S/D, Lot4 .~ "~: . i !;P~rcel ID: 014-251-19
,,. ·, '.' i ;.
Cased to 40+:,
FROM WELL LOG i
If A, B, or C provide PWsID #,
Sanitary s~al (Y/N),yes
Well Lig (Y/N) Yes
' Wires pr°perly~pr0tected (Y/N) Yes
· Casing height, (above ground) 12
AT INSPECTION
i: iv, ~ '
12/12/2003 ..' 'ii''
Nitra{e :U c~.'l mg./i.,!
Other'baCteria` 0'
Collected by: CWE
Date installed
Cleanouts
High water alarm
',
Sy ~'typ
· ;. ste e
i :Well ty~e~iP~ate ·
'. Date` cd~ ~leted
:Totai d; ~1107~ ft.
Date of test
' ,
Static water level 87
Weli ~lo~tion '10
:WATER SAMPLE RESULTS:
Colif(~j' I!ii~ .
b; colonies/100 mi.
~ -' ~i::Jl' N/A'
Arsenic::
B. SEPTIC/HOLDING TANK DATA
, Tank'Type/Matenal: ..
Tank s~zel[~ '. '. gal.
Foundatio~. ~ ,~ ,~!- 'cleanout. (Y/N)
, Date of puCnping'"'' ..'
~,~,
· colonies/100 mi.
Leng[i~ il '.,,,i! ,'.' . ff.. -, Width..il '" ' ff. ' Gravel below pipe~ ff.
, ~ ~ :,~q~l[',~' :' ~, ..... i '
'~,~ ~" ,, . ' !, ~.
Total':de~,,,,;'. ' ff. Eft. absorption' ', ¢, ft2 MOnitoring tube". :. - .D, epresSion overfield
· Date bf'&d~uacy test ~ JResults (Pass/Fail) . ': · , -.;.' ,,". '-' For ' bedrooms
Fluid dept~ ~n abso~tion ~ ~'bre test. :':'~ 'in. '. ' Wa{~r added .' ~':: gal. ~:: ~,:-"": New depth in
Elapsed~" ~ ' ' "' ' ; ' " ' ":
· ' ' Final fluid depth . in. :;, Abso~tion rate '>= .g.p.d.
Any ''ti ,, (past 12 mo.)(Y/~:.:: '&, ~pe) 'I, " .... :' ff~'yes, give date
in,
C. ABSO~ETION FIELD DATA ; · ,"
Date ~nstahed ' 'Soil rating (g,
SGS Ref.#
Client Name
.Project Name/#
Client Sample ID
Matrix
1037901001
Watkins Engineering
Dora Lot 4
Dora Lot 4
Drinking Water
PWSID 0
Sample Remarks:
All Dates/Times are Alaska Standard Time
Printed Date/Time 12/17/2003 10:07
Collected Date/Time 12/12/2003 13:30
Received Date/Time 12/12/2003 13:50
Technical Director. ~ Stephen/~. Ede
Release~~
Allowable Prep Analysis
Parameter Results PQL Units Method Container ID Limitq Date Date Init
Waters Department
Nitrate-N
0. I00 U 0.100 mg/L EPA 300.0 B (<=10) 12/12/03 JJB
Microbiology Laboratory
Total Coliform
col/100mL SMI8 9222B A (<=1)
12/12/03 DKC
"' ~ "l'i ~'i'~:..? '"'.~,~.1' ~,'n~~ _¢~ ;.i 3 . ::
' , : r ,: : , : '.~' ~ ~ I ~'~' ~ /~ ' M ~"
' ;' ' ' ' ' ~ ' ;i ~ '~ ', ~ ~*. / :' " '.'
~ ' ~ ' : ~ ' ' . : I' --~ il~ ~ '
'"' ' ~ ~ ~ ' ~ ~ i'
.... ~ . , , . , ~ , ~ ~ · . , .....
' ..... , ~ ~ .I, ~' ~ ~ ~ t ........
, ,~ ,~ .:~.~ ........
. . ,~~ ' ~ ~ ~
~ I ' "1 ~'
' ' :' i 'I I ' i~ ,l~d ~'~. :. ., ''':'' ' ; ! '
. : : :, : .:l : .... ,.,:. ,::,. ..
~cd for comlmctlon or for cstabhsh~ng bounda~ or ]1 ' it ' i ' I '
i ~ :'~' ' ' :' '. ' ~ ' , ; ' '~A~OT
.... t ...... i .... I~ ~:~, ,
ANCHO~GE~COEDmODISTmCT:: []': ;i~ :i, ~ i[ ~
DATE: SI:' BY: '~' SCALE:' I i ' WOOl O~D~R: : I [ : ~ I FIELD
I~ , ~ : ' ,, . ' ; , ,1/ ;', '
MUNICIPALITY OF ANCHORAGE
Department of Health & Human Services
DIVISION OF ENVIRONMENTAL SERVICES
343-4744
Parcel I.D. #
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF
ON-SITE SEWER AND WATER F.~CILITY FOR SINGLE FAMILY DWELLING
1. GENERAL INFORMATION (Must be completed prior to submittal)
(a) Legal Description (include 10t, block, subdivision, section, township, range)
Location (address or directions)
E
(b) Property owner ALASKA
Mailing Address .PC)
(c) Lending Institution
Mailing Address
(d) Real Estate.Company and Agent
Address ~ ~
~'E. D. C. c/. Telephone · (home)
Telephone
Busi ness "786 '- 2 7_':~-~
Telephone
(e)
following address: (or check here'~if'~ hold for pick up.)
Mail
the
HAA
to
the
List contact person and day phone number below:
2, TYPE OF RESIDENCE
Single-Family ~ Number of bedrooms
3, WATER SUPPLY
Individual Well~)~
Community [] 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 [] 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.
72-025 (Rev. 7/88) 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 that my investigation of this
Health Authority Approval shows that the on-site water supply and/or wastewater disposal system is safe,
functiona .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.
Telephone
Engineer's Seal
DHHS APPROVAL'
6.
Approved ~ Disapproved Conditional
Terms of Conditional Approval
Date
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.
72-025 (Rev. 7/88) Back Page 2 of 2
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
~:/,,Lil ~,f c,H_ ~,,e,l~t~l.-~!~h~rity Approval (HAA)
:,~ .... iC~USi~×~ FEBRUARY 1984
343-4744
Well Classification
Well Log Present (Y/N) ~'/
Total Depth /O'7'~ased to
Static Water Level :-'~O~
Casing Height Above Ground ,~ ~ ,.~ir
Electrical Wiring in Conduit (Y/N) ' Y' ~'
RECEIVED
Date Co leted
/O' 7 '~ ~e~pth of Grou!ng
Legal Description:
LoT-
If A, B, C, D.E.C. Approved (Y/N)
Yield
L),'", Y--
Pump Set At [./~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
SEPARATION DISTANCES FROM WELL:
To Septic/Holding Tank on Lot ~/)q "~
To Nearest Edge of Absorption Field on Lot
. t !
To Nearest Public Sewer Line ;~ ](..,~O ~ ~/' To Nearest'Public Sewer Cleanout/Manhole
To Nearest Sewer Service Line on Lot
Water Sample Collected by -. ~)~__I¢~Y' /~'~.zE.$'~ ; Date []/~/~cf ~'~-
Water Sample Test Results .~ ~-7'-I ¢/-~,)~.3--OZ~ y
Comments
;On Adjoining Lots ~kJ/~ ; On Adjoining Lots
::-/Co '
B. SEPTIC~OLDING TANK DATA
Date I nsta'14~ _____ Size. __ No. of Compartments
Standpipes (Y~_____ Air-tight Caps (Y/N) __ Foundation Cleanout (Y/N)
Depression over T~k (Y/N) __ __ Date Last Pumped _
Pumping/Maintenanbe~ontact on File (Y/N) ~ ;for
Holding Tank High-WateY,~arm (Y/N) __ Temporary Holding Tank Permit (Y/N)
SEPARATION DISTANCES ARx~M SEPTIC/HOLDING TANK:
To Water-Supply Well ~,i .' ' To Building Foundation
To Property Line ' %%x To Disposal Field
To Water Main/Service Line . %..
To Stream, Pond, Lake or Major Drainage Course
72-026 (Rev. 7/88) Front Page 1 of 2
',o ~,~,,, g · p ' __ __ YP Y 'g
Date Inst~led ~ __ __ Length of Field ____
Width of FXd ~ __ __ Depth of Field __~
Gravel Bed Thickness ____
Square Feet of ~sortion Area .... Statndpipes Present (Y/N)
Depression over F~d (Y/N) .... Date of Last Adequacy Test
Results of Last Adeq~,cy Test
SEPARATION DISTAN'~ FROM ABSORPTION FIELD:
To Water-Supply Well '"X, To Property Line
To Building Foundation ~ To Existing or Abandoned System on
Lot XX, ; On Adjoining Lots __ __
To Water Me'm/Service Line '~ To Cutback (if present)
To Stream, Pond~jor Drainbge Course
To Driveway, ,.~./~r~ki~_ Area, or Vehicle//Storag/~ Area_ // /.. ~)
Comments ,~'~ ~.4.,'e_-~/ ~ /~,~'
Size in Gallo'~
"Pump On"
Level~
High Water AlarmLev~at
Tested for ~
Meets MOA Electrical Codes
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test.
Receipt No.
Date of Payment
Amount: $
72-026 (Rev. 7/88) Back
**Check Permitte~ 3edroom R/~ing Against HAA Request**
I certify that I h~v~ checked~d, or conformed to all MOA and
inspection.
Company
Date
MOA No.
/
effect on the date of this
Engineer's Seal
Receipt No. .~'
Waiver Fee: $
Date of Payment
Page 2 of 2
~ CHEMIC~ & GEOLOGICAL LABORATORIES OF ALASKA, INC.
~.~..~ 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907)562-2343
FEDERAL TAX ID # 92-0040440
Date ~eport Pzinted: NOV 9 89 @ 12:41
Cl, xent Sample ID:DORA $/D 54
Collected NOV ? 89 @ 15:30 hts.
Received
Preserved with :NOTHING
Clie~ Name : CORWIN
Client Aeet ~ CORWINP
P.O,# HONE RECEIVED
~eq ~
Ordered By : B~UCE
Analysis Completed :NOV 8 89 Send Report~ to:
Laboratory 3upe%v~sgr :STEPHEN C. EDZ 1)CORWIN & ASSOC
Special HOLD FOR PiCK-UP UPON COMPLETION.
Instruct:
Chemlab Kef #: 843~ Lab Smpl ID: i Pmtzlx:
Pa~amete~ Tested ~esult Unit. Method
NITRATE-N ND(O.iO) ~/1 EPA 353.2 lO
Sample ROUTINE SAMPLE
Remarks: SAMPLE COLLECTED BY JERRY
J. T.~ts Perfon~eO ' See Special In~tzuctlons ~bove Ul.,U[mvailab]e
ND- ~one Detected '* See Sample Re~zks Above
N~~- Not ~nalyzed t~!~es~ ~h~n, ,~=Gz~ate~ Then
'~ ' INSPECTION APPOINTMENTS
DATi= DATE DATE
DEPT. OF HEALTH &
MUNICIPALITY OF ANCHORAGE ........ AL pROTECTION
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTEC~EONM~N[
825 L Strut - Anchorage, Alaska 99501
AU6 3 t 1981
ENVIRONMENTAL SANITATION DIVISION .
T.I.phon. 2.-4720 R E C t i V E D
REOUEST FOR APPROVAL OF INDIVIDUAL W~TER AND 8EWER FACl LITIE8
m m m
DIRECTIONS: Complete all parts on page 1. Incomplmta requ~s~ will not be proceed. Please allow ten (10) days for processing.
1. P~OPERTYOWNE~ , r ] PHONE
MAILING ADDRESS
PROPERTY RESIDENT (If different from above) ' PHONE
2. BUYER_ ' PHONE
MAI LING ADDRESS
3, LENDING INSTITUTION ~ ] PHONE
I
~AILING ADDRESS '
4. REALTOR/AGENT ' ~ P
HONE
I
MAILING ADDRESS
5. I~EGAL DESCRIPTION ' '
STREET LOCATION
6, TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
7~ WATER SUPPLY
[~ INDIVIDUAL*
[] COMMUNITY
r--I PUBLIC UTI LITY
8. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON-SITE**
J~2] PUBLIC UTI LITY
NUMBER OF~BEDROOMS
[] 0 ne [] Four [] Other
[] Two [] Five
~ Three [] 'Six
* 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
[] SINGLE FAMILY
[] MULTIPLE FAMILY
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] INDIVIDUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
r--ISeptic Tank or [] Holding Tank
Size: If Tank is homemade
give dimensions:
[] ONE
[] TWO
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
NUMBER OFBEDROOMS
[] THREE [] FIVE
[] FOUR [] SIX
[] OTHER
Septic/Holding Tank
IAbsorption Area ]Sewer Line
INearest Lot Line
5. COMMENTS
DATE
ED FOR -'~'~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
nicip ity
~:~25 "L" ST R E ET
ANCH()RAGE, ALASKA 99501
(907) 264-411 l
DEPARTMENT OF HEAL'FH AND ENVIRONM[:NiAL P[{OIECTIOI'~
September 3, 1981
Gary J. Mellott
Star Route A Box 1741-M
Anchorage, Alaska 99507
Subject: Lot 4 Dora Subdivision
Approval for the individual sewer and water facilities
cannot be granted until the following it:ems have been
completed:
(i)
A well log submited to this office fol~ our files and
review.
(2)
The water analysis repor~t needs to be submitted to
this office from the Chem Lab, 5633 B Street, for
our review.
If there are any further questions, please call 'this office
at 264-4720.
Sincerely,
Robert C. Pratt, R.S.
Associate Specialist
RCP/ljw