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HomeMy WebLinkAboutDORA #2 LT 11 Dec 17 21 01:42a Anchorage Well & Pump Ser 9072430742 p.1 MUNICIPALITY OF ANCHORAGE Development Services Department) Phone: 907-343-7904 On -Site Water & Wastewater Section 6 Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: Parcel Identification Number: - - Date of Issue• - - Legal Description Block Lot Pro erty yr er Name & Address: 85M Ro ALTWD sr A-1VWL99Aqz;,�, A -K g015©� Pump Installation Date: Pump Intake Depth Below Top of�Well I feet /Casing: Pump Manufacturer's Name: 3�>(2�- Pump Model: Pump Size: L2-- hp l2� Pitless Adapter Burial Depth: feet j Pitless Adapter Manufacturer's Name: Pitless Adapter Installer: Well Disinfected Upon Com^tion? Yes ❑ No Method of Disinfection: sf 1 Comments: Pump Installer Name: _ ANCHORAGE WELL & PUMP SERVICE Company: 7640 KING STREET p Y ANCHORAGE, AK 99518 Mailing Address: 907-243-0740 City: State: Zip: Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. d oZ 0 "~ 0 0 0 0 0 0 0 0 0 0 PE:Rird I T I",lO. [:,EF'RR'TME:NT r'¢.: HE:FILTH RN[:, EN',,,']; RONMEN'!"RL. '"LF,..:OTEC'I" :[ ON STF'.EfET., FINCHORFIGE., Fit.'.':, :9. 264 - 4. 720 Il.--II E-.T. L It ...... F" ES FL.': ~'"1 ::i: FIPPL I CFINT LOC:FIT I ON LEGFiL T. STEWFiF.:T CONSTRUCT.T. ON Lit DORR 2 842E~ HILLIHR CIRCLE L. OT SIZE 200Et0 Sr::IUFtF.:E F'EET M!NIMLIM DISTFiNCE BETI.,.IEEN R HELL FIND FIN"r' ON-SITE SEI,.IFiGE DtSPOSFtL S"r'STEH :I.F'~O FEET FOR R PRI'v'RTE WELL OF.: i50 TO 200 FEET FROM R F'LIBLIC NELL DEF'END:[NC~ LIF'ON THE T"r'PE: OF PUBLIC WELL. MINIMUM DIS'T'FiNCE FROM R PF.'.IVFITE HELL TO FI PRIVFfTE SEWER LINE IS 25 FEET FIND TO Ft COMMtJNIT'~' SEHER LINE IS 75 FEET. WELL LOGS FiRE REQUIRED FINE." MUST BE RETURNED 'T'O THE DEPFIRTHENT P.IITHIN .7::':0 DFI'¢S OF" THE HELL COMPLETION OTHEF?. REQU]!REMENTS MFI~r' RPPL"r'. SPEC:IFICFITIONS FIND CONSTRUCTION DIRGRRMS FiRE FIVF~IL. RBLE TO INSURE PROPER INSTRL. LRTION I C:ER*TIF~r' THFiT ±: I RM FRMILIRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND HELLS ItS SET FORTH B'¢ THE MUN I C I F'RL. I T"r' OF FINCHOF.~FIGE. 2: t WILLFUL THE S"r'z";T~~~CE H. ITH THE CODEC;. ....................... RF~ T. STENFIF.:T CONSTRI..IIST I ON /~'"/"r/-~-~ MUNICIPALITY OF ANCHORAGE DEP, AR'rMENf 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 HAA# GENERAL INFORMATION Complete legal description Lot Ill Pora Subdivision Location (site address or dire.ctions) 8500 Ros~..Xnd Street Property owner Mailing address Lending agency Mailing address Agent Address Richard Moj~ 8500 Rosalind Str~ Day phone 349-3735 Anchora,q~, Alaska 99507 Day phone Day phone Unless otherwise requested, HAA will be held for pickup. XX NOTE: NUMBER OF BEDROOMS: TYPE OF WATER SUPPLY: Individual well Community well PUblic water : .- . If community well system, provide written confirmation from State ADEC attest- ing to the legality and status of system. 4. TYPE OF WASTEWATER DISPOSAL: Individual on-site . Holding tank Community on-site Public sewer XX NOTE: If community wastewater system, provide written confirmation from State ADEC attesting to the legality and ~st, atus o,f system. i;?','i ,~,::;'i ;,'~. ;' :,',:'i': !'!ii,!,: '{ t ' ,: :!i,I,/~' /~?" ! "' ] .; ~, ' (,,, 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 verify that based on the information obtained from the Municipality of Anchorage files and from my in. vestigation and inspection, the on-site water supply and/or wastewater disposal system is in compliance with all Municipal and ~tate codes, ordinances, and regulations in effect on the date of this inspection. Name of Firm Address Engineer's signature $ ~ S ENG!NEERING 17034 Eagle Ri~er Loop Road No. 204 Phone Date - / 7- DHHS SIGNATURE Approved for ..~'~ Disapproved. Conditional approval for bedrooms. bedrooms, with the following stipulations: Additional Comments Date -'/ - / // The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval Certificates 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, 72-075 (Rev 1/9t) 8~c:k MOA ~i ( Municipality of Anchorage Department of Health & Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: .~:).'~!! '} bdt/' I/~ ~--'3. I~), Parcel I.D. A. WELL DATA Well type~.~i ^~.~_- Log present (Y/N) Total depth ..~.-'~[]~ If A, B, or C, attach ADEC letter. Date completed Cased to ./ 0 ADEC water system number ~-~-- '~-~/ Driller ~(~ ~._~(~-~c,~ t Casing height /',2. ""/- Sanitary seal (Y/N) FROM WELL LOG Date of test Static water level /'~ Well flow ! Pump level (-~ ~' Wires properly protected (Y/N) g.p.m. AT INSPECTION MUNICIPALITY OF ANCHORAGE SERVICES DIVISION _ SEP 18 1991 d. u &BCEIVED SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot ~J//o, Absorption field on lot ~.)/i~ I Public sewer main ~:> ~ Public sewer service line ---~ I ; On adjacent lots ; On adjacent lots Public sewer manhole/cleanout Petroleum~tank WATER SAMPLE RESULTS: Coliform Date of sample: ~ - ¢ Nitrate _,~.'~;(FIo'~o~'~ /,~D,~'~ Other bacteria Co,ected by: B. SEPTIC/HOLDING TANK DATA Date installed "~ Tank size Compartments Cleanouts (Y/N) ~ Foundation cleanout (Y/N) ~ Depression (Y/N) High water alarm (Y/N) '~ Alarm tested (Y/N) ~__ Date of pumping _ ~ X~t). SEPARATION DISTANCES FROM S~IC/HOLDING TANK TO: Well(s) on lot On a(~nt lots Foundation To property line Absorption f1~___ ~Water main/service line Surface water/drainage "~ 72-026 (Rev. 3/91) Front MOA 21 CONTINUED ON BACK PAGE C. LIFT STATION Date installed~ Manufacturer Size in gallons ~ ;,., Manhole/Access (Y/N) ;;~ (wY~tNe)r ev~e ump on" level at "Pump off" level at alarm I I Cycles tested Meets MOA electrical codes (Y/~ SEPARATION DISTANCE FROM LIF'P~ATION TO: Well on lot ~ On ad]~ lots Surface water D, ABSORPTION FIELD DATA ~ Date~ed ~ Soil rating'X,,. System type Length '~ Width Gravel thickness Total depth Total absorptio~a ~ Cleanouts present (Y/N) ~ Depression over field, Y/N) ~ Date of adequacy test ~ Results (pass/fail) ~ "~.~~ for_~ Peroxide treatment (past 12 monet,(Y/N) ~____ If yes, give date __ SEPARATION DISTANCE FROM AI~RPTION FIELD TO: Well on lot _ ~ _ On'e~acent lots P~'operty line_ TO~ ;;;l'adi~tfl~i~dati°n Cutbank~ To existing or abv~;~e~nrne~;;sS~vr~c;;i;t Surface water Drive'y, parking/vehicle storage area bedrooms Curtain drain E. ENGINEER'S CERTIFICATION I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect o_n.~l'Le_date of this inspection. S & S ENGINEERING Signature ! 7034 Eagle River Loop Road No, 2~ Eagle River, Alaska 99577 ' : :: ~ ~. ~ ~;:~ ~:,.. Engineer's Name.~ ~ ~.~ ~ HAA Fee $ /~ o~ Waiver Fee: $ Date of Payment ~-/~'- Y / Date of Payment Receipt Number ~ ~O ~ ~ -- ~ ~ ~ ~ Receipt Number 72-026 (Rev, 3/91) Back MOA 21 CHEMICAL & GEOLOGICAL LABORATORY A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO. 5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343 ANALYSIS REPORT BY SAMPLE for WORKorder# 38020 Date Repoxt Printed: SEP lO 91 ~ 10:09 FAX: (907) 561-5301 Client Sample ID:Lll DORA S/D Client Name :S & S ENGINEERING PWSID :UA Client Acct :SNSENGP Collected SEP 6 91 @ 13:30 hrs. BPO ~ PO ~ NONE RECEIVED Received SEP 6 91 ~ 16:50 h~s. Req ~ Preserved with :AS REOUIRED Ordered By :R. SH~FER Analysis Completed :SE? 9 91 Send Repo[ts to: Laboratory Supervisox :STEPHEN C. EDE 1)S & S ENGINEERING ReleasedBy : ~ (~. ~ 2) / .................. .. ..... ...'. ,.,..;.........' ...~..;....'.. ................. . . ;.'. ...... . .. ~.~..~.....~.., .......... Chemlab Roi #: 914665 Lab Smpl ID: 3 Matrix: WATER Allowable Pazamete~ Tested Result Units Method Limits NITRATE-N ND(O.IO~ mg%l EPA 353.2 10 Sample ROUTINE SABLE COLLECTED BY: R.D.J. Remarks: 1 Tests Pe[formed ' See Special Instructions Above UA-UnavaXlable ND= None Detected '* See Sample Remarks Above NA= Not ~nalyzed LT-Less Than, GT-Greater Than Member of the SGS Group (Soci~t~ G~n~rale de Surveillance) 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 r ,4' 'Application Date 1. GENERAL INFORMATION (a) Legal Description (include lot, block, subdivision, section, township, range) 7 / 1 (b) Location (address or directions) , Applicant Name ~'~' Applicant Address Business ~"~Z--'Z.. "'/Z-'/2... (c) Applicant is (check one): Lending Institution []; Owner/builder~; Buyer []; Other [] (explain); (d) Lending Institution Telephone Address (e) Real Estate Company and Agent Address Telephone (f) Mail the HAA,'~ the following address: TYPE OF RESIDENCE Single-Family [~ Multi-Family [] Number of Bedrooms '~ Other WATER SUPPLY Individual Well [~ Community [] Public [] ' Note: If community well system, must have written confirmation from the Siate Department of Environmental Conservation attesting to the legality and status. SEWAGE DISPOSAL r ' ; 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 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. NameofFirm ,~C'S~r_.~ c~'/,'~5'' .~/~o/~ Telephone ~y/~_~ Address Date /~k'GA ~/, t~'~ En gi Q,~,e~, Seal Approved for bedrooms by ~ ~~_ ate Approved Disapproved Conditional Terms of Conditional Approval 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 (11/84) Bo MUNICIPALITY OF ANCHORAGE (MOA) HEALTH AUTHORITY APPROVAL (HAA) CHECKLIST - FEBRUARY 1984 "' D~Ft. '"'._~ ~ WELL DATA~, ~: Well Cl assificatio n~~ ~)!~'/') I, A, B, C, D.E.C. Approved (Y/N) Well Log Present)j%~ Date C~leted.._ ~-~3~ ~ ~ Yield tota~ ~..~ /~ ~ C.se~ ~o IO~~ ~..t, o~ arc.ti.. Static Water Level ~ Pure p Set At Casing Height-Above Ground Electrical Wiring in ConduitON) Separation Distances from Well: ,_.__~..~- To Septic/Holding Tank on Lot To Nearest Edge of Absorption Field on Lot To Nearest Public Sewer Line Cleanout/Manhole /'-~"~ 264-4720 Legal Description: Sanitary Seal on Casing(~) Depression Around Wellhead (Y~)~ Water Sample Collected by On Adjoining Lots ; On Adjoining Lots To Nearest Public Sewer To Nearest Sewer Service Line on Lot -_'_'_'?.~ ; Date '5 -. 'D/- ~ ~. Water Sample Test Results Comments ~ f~'"'~' ,~~ SEPTIC/HOLDING TANK DATA Date Installed Size No. of Compartments Standpipes (Y/N) Air-tight Caps (Y/N) Depression over Tank (Y/N) Pumping/Maintenance Contract 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 Course Foundation Cleanout IY/N) Date Last Pumped ; for Temporary Holding Tank Permit (Y/N) To Building Foundation To Disposal Field 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/N) 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 Present (Y/N) Date of Last Adequacy Test To Property Line To_Existing or Abandoned System on ; On Adjoining Lots 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 tha~,ve checked, ver'~ied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. Signed /~'~/-.~. ,/~:~-J?~-..~v~3at e ~/--~ ComPany ~/~ ~ ~ MOA 'o. Receipt.o..~ ~ ~ Date of Payment ~{ ~ ~-- ~ Amount: $ ~, ~O Page 2 of 2 72-026 (11/84) , ' , DATE RECEIVED ~ INSPECTION APPOINTMENTS TIldE TIME TIME 'DATE 'DATE DATE INSPECTOR INSPECTOR - I NSPEC/7~iR ~!~/~ ENVIRONMENTAL SANITATION OIVISt ON ,~.~;~'~ ~. ~98~ ~ Telephone 264-4720 _ I~EQUEST FOR APPROVAL OF ,ND,vIDUAL WATER AND SE~(~I~i LVIT~E~ DI R ECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. '1. PROPERTY OWNER . ~PHONE PROPERTY RESIDENT (If different from above) I PHONE 2. BUYER ~tt~/~ -- PHONE.. MAILING AD"DRESS I '1 PHONE MAILING ADDRESS - ' - 4.' REALT~R/AGEN~ _ r ' ~ PHONE MAILING ADDRE{~§ '- - I S. LEGAL DESCRIPTION ...... ~.. ISTREET LOCATION - 13 - ' I 6. TYPE OF RESIDENCE NUMBER OF~BEDROOMS ' ~J~ SINGLE FAMILY [] MULTIPLE FAMILY 7. WATE?~UPPLY ' INDIVIDUAL* COMMUNITY [] PUBLIC UTI LITY 8. SEWAGE DIS~OSAL SYSTEM ' ' [] INDIVIDUAL/ON-SITE** PUBLIC UTILITY NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE P~OCE$SING CAN BE INITIATED. 72-010 (Rev. 6/79) ,[~ One [] Four [] Other ~ Two [] Five [] Three [] Six * ATTACH WELL LOG. A well log is required forall wells drilled since June 1975. For wells drilled prior to that date, give well depth (attach tog if available.) ~ ~ ~_~ YEAR ON-SITE SYSTEM WAS INSTALLED. THIS SIDE FOR OFFICIAL USE ONLY~ 1. TYPE OF RESIDENCE [] SINGLE FAMILY [] MULTIPLE FAMILY NUMBER OF BEDROOMS [] ONE [] THREE [] TWO [] FOUR [] FIVE [] SIX [] OTHER 2. WATER SUPPLY [] INDIVIDUAL [] COMMUNITY [] PUBLIC UTILITY Connection Verified 3. SEWAGE DISPOSAL SYSTEM [] INDIVIDUAL/ON -SITE []PUBLIC UTILITY Connection Verified []Septic Tank or []Holding Tank Size: If Tank is homemade give dimensions: TYPE OF TANK TOTAL ABSORPTION AREA 4. DISTANCES WELL TO: PERMIT NUMBER DEPTH OF WELL DATE DRILLED LOG RECEIVED PERMIT NUMBER DATE INSTALLED INSTALLER SOl LS RATING MANUFACTURER MATERIAL Absorption Area to nearest Lot Line Septic/Holding Tank IAbsorption Area Sewer Line INearest Lot Line 5. COMMENTS DATE [~'~'APPROV ED FOR ~ BEDROOMS [] CONDITIONAL APPROVAL (letter must accompany certificate) [] DISAPPROVED 72-010 (Rev. 6/79)