HomeMy WebLinkAboutDORA #2 LT 21L~
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F'ERMIT NO.
i}EPFIRTMENT r",":' HEFILTH RND EN',? I RONMEI'.,!TFIL "" r';;:O'I"ECT I ON
825 "' STREET., F~NCHORRGE., RK.
264-4?20
I.,..t E b.. L.
,:: 8Z:t. 062 ::,
RF'PLIC:RNT T. STEWRRT CONST.
L. OCRT I ON
L. EGRL L2± [:,OR~ 2
8420 [,.IILLI[4R CIRCLE
L. OT :7IZE
20000 L=,6!URRE FEET
MINIMUH [:,ISTRNCE BETWEEN R WELL RND RN9 ON-SITE SEWRGE [:,ISPO".:~;RL S'¢'L:;TEM IS
2..00 FEET FOR FI PRI',?RTE WELL OR ±50 TO 200 FEET FROM ~1 Pt. IBLIC I.,.tELL DEF'ENDING
UPON 'THE T'¢F'E F~F PUBLIC WELL
MINIMUM DISTRNCE FF.:OM R PRI'¢RTE I.,.IELL TO R PRI',,,'RTE SEWER LINE IS 25 FEET RND
'TO R C:OMMLINIT'¢ SEWER LINE IS 75 FEET.
I.,.IELL LOGS RRE RE6.!I...IIRED BND MUST BE RETURNED TO THE DEPFtRTMENT [4ITHIN ];':0 DR'CS
OF THE WELL COMPLETION.
O]"HER REQUIREMENTS MR'¢ RPPL'¢. SF'ECIFICRTIONS RND CONSTRUCTION DIRGF.:RMS FIRE
R¥[~II...RBL. E TO INSURE PROPER INSTRL. LRTION.
I CERTIF'¢ THRT
:.1,.: I RM FRMILIRR WITH THE REE~UIREMENTS FOR ON-SITE "_-';EWERS RN[:, WELLS RS
FORTH 89 THE MUNICIPRLIT'¢ OF RNCHORRGE.
I 1.4ILL INS~RL.L THE $'¢$TEM IN RCCO.~tr~CE WITH THE
T. '
',74. E~
. ~ MUNICIPALITY OF ANCHORAGE
" DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
~. On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
., -- :~...· . ~'. ,,~,:~ ~ '; ': --~; :J ~ -343-4744. - .-
CERTIFICATE OF HEALT~I AUTHORIT~ ......
"::':: '"'-' ':'"':' " ' '": ~":: APPROVAL FOR A SINGLE FAMILY DWELLING ......
Parcel I.D.~ 01~~-_ ~_ " . HAA~
1. GENERAL INFORMATION -.-,..~,. .', -'. '*'
Complete legal description L ~T ~ ) -~
LocatiOn (site address or directions)
Day phone ~ct-- t%~ l_..:
:;.;"?~-',', Lending agency . . ' ~ .... ... Day phone .: ',
~'F ~7~-~;~'?,;~¥'?!'L:-?;?'~L¢;~k~ ~ .2' ~.:~ ~¢ . :'--,,:. . : , . . ~:L,~:'~, ;i~.U~.f;?.,;'~:.~:;~f,.c ;j..,.. , ~. ,, -, . .... ._..: , ,:..: .,.,.'? .... . ~.~ ..~ -.,.~. . ,~.'; ~,,-. ,.-, . . ..... .L; ?~,. ' ,: :~::.;
;:.:~ ',:'"-':' :~ Unless otherwise requested, HAA will be held for pickup:' ' ' ~' , ~ '
:,:,' .,;;.:, 2... ~:. NUMBER OF BEDROOMS...,rr 7- ..., .,. ',' ':'-':,q;:. '.
3,
Cc . ,: .:..%
-...,.;::;.~;:=?.::~:'?:'?;~ PubliCwater~',:??~:',?'d;., '.,:....:~:~ :.- ¢,.. ~..::_~:_:_,:).?..:~; . . :
............... _N.~E~ If community well system, provide written confirmation from State ADEC attest-
ifvn if ~.~
sewer ...... :~ ..............~ ...... :'3-~
...w~ NOTEi If comm unity Wastewater system; prOvide written confirmation from State ADEc
attesting to the legality and status of system.
72-025 (Rev, 1/91) Front MOA#21
')~JOM speeu!§ue leUO!SSetoJd gq1 u! suo!ss!wo Jo sJoJJe Jo,~ elq!suodseJ
lou s! e§eJoqou¥ jo/q!led!o!unlAI eqI 'penss! s! eleo!,qlJeo e eJoJeq elep ez~leut~ Jo suo'!),oedsu! ),onpuoo
lou op SHHO ~o see~old~ 'siue~eJ!nbeJ eiels pug leJepeI u!epeo ~s!lss Ol JepJo u! suo!lnl!jsu! 6u!puel J!eql pus
se~oq Io ~eseqo~nd ol ~se~noo e se s!ql seop SHHQ eq£ 'eNsel¥ to elelS eql u! pe~els!BeJ ~eeu!Bue leuo!sseIoJd
luepuedepu! us ~q e^oqs ~ qde~Bmed u! ue^!6 suo!lslueseJdeJ gq1 uodn ~lUO peseq seleoy!~eo le^oJddv
~poqlnv qlleeH senss! (SHHQ) seo!~es ue~nH pug qlleeH ;o luem~edeo e6e~oqouv ~o ~!led!o!un~ eq£
sluew~oo leU,
.. ...... .. Jot le^oJddg leuo!T!puoo~!....~'
gq1 ql!M 'swooJpeq
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...,;~'~.~..~ ?-...:.....,..:..-.-.' ~..?.:..~;',~?~:~ ~ -:.. 'UOtlOeUsu~ s~ql Jo eleP eql uo loewe u! suo!ielnDeJ pug seoueu
-;:~;;:~?;?;.'?.;. 'sePgO eTelS pug ~e~ I!o!un~ fie ql!~ eoUe!ld~oo, u~ S!.~eTs~e !e~d~!p ~eTe~eTse~ Jo/pug ~ld
..:~ ~?.":, ',eleA~eii~Zuo e,~','6~ ioedsu! pug Uo!l.B!lseAu! Xm mo, i pug' Sel!i'eBe~Oqouv ~o Xi!led!o!un~
,.~,~, ~...: ~. moji peu!elqo uo!ie~olu! eqI uo pes~q leqi ~peA~eq~nt I 'u!meq peleo!pu! e~nlon~1s
'~';k~:~??;'~ s~oo~'to ~eq ~n~eq3 ~o~ elenbepe pug leUO!iounI 'gigs s! meisXs lesods!p
Xlddns ~ele~ e1~s-u o eq3 ieq1 s~oqs uo!3eo!ldde leAo~dd~ X1poqln~ qIleeH s!ql lo uo!3e~!IseAu!
' ~a l~ql ~peA I '~oleq u~oqs elep uo!iep!leA eql ~o se pug ole~eq pexwe lees Xm Xq pe!I!~eo sy
UggNIONg Ag NOILOgdSNI ~O LNgflgLYL6
"6
( Municipality of Anchorage ~i~
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: J~e-~--- ~-/ ,~O~__.,~c /w(~, Parcel I.D. ~ I~--~,~.~ ! "' 3~
A. WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
ADEC water system number
Date completed ~/'5o l~l Driller "'~h~1 ~-~
Cased to I (.Ye Casing height
Wires properly protected (Y/N)
FROM WELL LOG AT INSPECTION
Dateoftest ~//~0/~ ~ t't[/,,~1q Z..
Static water level ~ 9 ~t
Well flow [0 g.p.m. , / _
Pump level ~ ~ ~ ~ G
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot I~J/~
Absorption field on lot t,/f~
Public sewer main
Sewer service line
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
15o
WATER SAMPLE RESULTS:
Coliform ~ Nitrate /1~ /~
Date of sample: Collected by:
Other bacteria
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)
Date of pumping
Alarm tested (Y/N)
Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
On adjacent lots
Foundation
To property line
Surface water/drainage
Absorption field
Water main/service line
72-026 (Rev, 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION ~//,~_
Date installed
Size in gallons
Vent (Y/N)
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length Width
Total absorption area
Depression over field (Y/N)
Results (pass/fail)
Soil rating
Gravel thickness
Manufacturer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Surface water
System type
Total depth
Cleanouts present (Y/N)
Date of adequacy test
for
Peroxide treatment (past 12 months) (Y/N)
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
E. ENGINEER'S CERTIFICATION
If yes, give date
bedrooms
On adjacent lots Property line
To existing or abandoned system on lot
Cutbank Water main/service line
Driveway, parking/vehicle storage area
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect,on, the date of this inspection.
Engineer's Name
Date A,v l
HAA Fee $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
Date of Payment
Receipt Number
CHEMICAL & GEOLOGICAL LABORATORY
A DIVISION OF COMMERCIAL TESTING & ENGINEERING CO.
---------- ~-------______ ~__--~
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 562-2343
ANALYSIS RESULTS for INVOICE S 53140
Chemlab Ref.% 92.1733 Sample # 3 Matrix:
WATER
FAX: (907) 561-5301
Client Sample ID : L21 DORA
PWSID : UA
Collected : ~ hrs.
Received : APR 24 92 ~ 12:15 hrs.
Preserved with : AS REQUIRED
Client Name :TOBBEN SPURKLAND, P.E.
Client Acct :TOBBENS
BPO$ : POS :NONE RECEIVED
Ordered By :TOBBEN
Analysis Completed : APR 27 92
Laboratory Super~s_o,r :S,~PHEN C. EDE
Send Reports to:
lJTOBEEN SPU~KLAND, P.E.
2)
Parameter geeults Urdts Method Allowable Limits
NITRATE-N ND(O.IO) mE/1 EPA 353.2 lO
Sample ROUTINE SAMPLE COLLECTED BY: UA. NO TAG FOR THIS SAMPLE.
I Tests Performed ' See Speclal Instructions Above UA-Unavailable
ND- None Detected '* See Sample Remarks Above
NA- Not Analyzed LT-Less Than, GT-Greater Than
~SGS Member of the SGS Group (Soci~t~ G6n6rale de Surveillance)
_ ~ ~:-. '~ ' ' ' .... DATE RECEIVED
~.-- ' ' ' INSPECTION-APPOINTMENTS
'hME ' TIMErT ME
DATE DATE DATE
' ' ' NIUN CIPAL TY OF A~'CHORAG~
MUNICIPALITY OF ANCHORAGE DEPT; OF ~:;,L'i: & ' -
~~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PRC~'E~ENT,':~L ?;,c, ECTION
~/.~ ~ ~,~.~ 825 L Street. Anchorage, Alaska 99501
~l~ ENV' RONMENTAL SANITATION DIVISION
' ~" Telephone 2644720
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processir~g.
1. PROPERTY OWNER ' ~ PHONE
MAi
LING
.
PROPERTY RESIDENT (If different from above) , n
PHONE
"2. BUYER ~'3 , ~ ' - ' ' 'PHONE'
3, LENDING INSTITUTION J PHONE
MAILING ADDRESS- ~,~ ' '
P.o.
4. REALtOR/AGENT '~ ' I PHONE
MAILING ADDRESS /~d
/
s." ~EG~.L DESCR,PT)O_" ......
6. TYPE OF RESIDENCE
SINGLE FAMILY
[] MULTIPLE FAMILY
7. WATE~,E~UPPLY
INDIVIDUAL*
COMMUNITY
[] PUBLIC UTI LITY
8. SEWAGE DISPOSAL SYSTEM
[] One I~;~Four [] Other
'' r--1~ Three [] Six'
* ATTACH WELL LOG. A well Icg is required for all wells drilled
since June 1975. For wells drilled prior to that date, give well
depth (attach Icg if available.) ~'~ ~ D
[] INDIVIDUAL/ON-SITE** YEAR ON-SITE SYSTEM WAS INSTALLED,
PUBLIC
UTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED,
72-010 (Rev. 6/79)
THIS SIDE FOR OFFICIAL USE ONLY
NUMBER OF BEDROOMS
1. TYPE OF RESIDENCE
[] SINGLE FAMILY
[] MULTIPLE FAMILY
[] ONE [] THREE [] FIVE
[] TWO [] FOUR [] SlX
[] OTHER
2. WATER SUPPLY
[] INDIVIDUAL
[] COMMUNITY'
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
[] IN DIVI DUAL/ON -SITE
[]PUBLIC UTILITY
Connection Verified
I-'lSeptic Tank or []Holding Tank
Size: If Tank is homemade
give dimensions:
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOl LS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
Septic/Holding Tank IAbsorption Area
Sewer Line
Nearest' Lot Line
5. COMMENTS
DATE
[~ APPROVED FOR
BEDROOMS
CONDITIONAL APPROVAL (letter must accompany certificate)
DISAPPROVED
72-010 (Rev. 6/79)