HomeMy WebLinkAboutDELUCIA LT 31 /~~ MUNICIPALITY OF ANCHORAGE
,',,'-,~.~ ~lk,~'~'\',~ DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
i!~/)~ ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME IPHONE ~-E~/~/
MAILING ADD~
LEGAL DESCRIPTION
] Well t Dwelling PERMIT NO.
~ ~ Manufacturer Mate No. of compartments
Liq. capacity in g~lrons inside length Width Liquid depth
/0~ IF HOMEMADE:
~ ~ DISTANCE TO: Well Dwelling PERMIT NO.
~ Manufacturer ~ Material Liquid capacity ingallons
~ Well ~ Foundation Nearest lot line I PERMIT NO.
--~ ~ ~ NO. of lines ~ Length of each~ 'l/ne Totat length~s Trench wid~ inches Distance between lines~/~
~g~ Top oftileto finish grade ~ , Material beneath tile ~ i n~ Total effectiveabsorptio~2~rea
Length Width Depth PERMIT NO.
~ ~ Type of crib Crib diameter Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
Class ~ Depth Driller Distance to iot lane PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
DISTANCE
TO:
PIPE MATERIALS - ~ .Ill
SOILTESTRATING ¢~ ~ ~
INSTALLER ~
REMARKS I-,-
DATE LEGAL
~ '2-013 (Rev. 3/78)
F' E F.:: H I T f'40.
0 I--4 .... :E; :[ T E E; E:_- 1...~ El F: F" E F: f.1 f -f'
Fi F' F' L ]: C F! N-F
L r'-i Cfl T ]: 3 N
LEGRL
T 0 N"r' [:' E L Li C; I Fl
L -:'~ DELUC I R I-:,LIB[:' I "," I S 1 ON
22.:4. ERGLE RIVER L~57'7
LOT SIZE 200F~0 SC!URF.:E: FEET
T"¢F'E OF SOIL RE:'SOF::F"!'TDN ':7,'T"_---,TEH IS' TF.:ENL-:H
HR::.::IH. UH NUhtE:EF: OF E:EE:,f;:OOHL--, = _-'.:
:5 01 L ..... ~;.' F!. T I N G ,:' ~ F., F T,.." B F.: > = ,_,._':' .~
..... -" "- tl
'THE F'E 3 t ]' E'Er.', S ~ ~.E OF TFIE: '_:.,El I L RE '_:, DF/PT I Lq.N '-. T: TE I '_:,
E:" E F' T 1-1 ..... dr.. :L L E f-~ w3 ~" I-~ ...... ~ ,ED F: R '...' E L
[:, E F" -f- t4 =::
THE LENGTH E.',!htEN:5ION I5 'THE LENGTH ,::IN FEET> OF THE TF.:ENCH OR DRRINF!EL[:,.
THE [:,EF'TH OF R TRENCH OR PIT IS THE [:,!STRNCE E:ETHEEN THE SURF8CE OF THE
GF:OUN[:, RN[:, THE E',OTTOM OF THE EXCR',,,'RT'ION (!N FEET>.
THERE IS NO SET 14![:,TF! FOR TRENCHES.
THE GRF!',,,'EL DEF'TH IE; THE hllNIHUH DEPTH OF GRRVEL BETI4EEN THE OU'FFRLL. PIPE
RND THE E:O'T'TOH OF THE E::'::E:R',/RT!ON ,:;IN FEET.".,.
F.:: E r;:_~ lj Z F..: E [:, '2; E F' T ~: C: 'f R ~-~ I-'::: '..5 I Z E = i ~.Z-i E~ E~ C-~ R L_ L Ci ~-4 '2;
F'EF:H l T RF'F'L ! -:FINT HR'_:, THE F.:ESF'ON$ I E: I L I T'T' Tn I NFC F."H TH I 5 [:,EF'RRTHENT [:,UF.: I NG TFIE
INSTFILLRTT-ON INL---.F'EL-:TIONS ~E~F RN'T' HELLS RE:, .TR'_':ENT TO THIS F'ROF'EF:T'T' RNE:, THE
NUt'!E:ER ~:~F' F.:ESIE:,ENCEE; THRT THE .HELL H TLL _-%EF-:','E.
................. -r 1.,.! c3 ,:.- 2 ::, Z ~-~ '__=; F" E C:: -f- I n_-~ f-4 ;~ R f';..: E ~: E ,i:., El ~.. F: E [:,
........... - I- ' '" E:~T~
F:RF:KF'ILLTNG QF RN'¢ S'T'STEh! HITHL-IUT F'INRL INSPECTION RND HFFF._,HL THIS
DEF'RF;:TF1ENT HILL BE EL.E _'fECT TO F'F.:F~SECUT ION.
.r'I!NthIUH [:,ISTRNC:E E:ETHEE:N R HELL RND RN'¢ ON-SITE SEHRGE DISPOSRL S;'¢S;TEh! IS
iOE~ F:EET FOR R F'RI',/RTE HEI_L F~F..: 15E'.- TO :20E~ FEET FF.:OH R F'UE;L. IC HELL [:,EF'ENDING
UPON THE T'T'F'E OF F'LIE~LIC .HELL.
h!!NIHUh! [:,ISTRNCE F?.Of'l R F'F:I',,,'RTE HELL TO R F'RIVRTE SEI.,.IER LINE IS 25 FEET
TO R COHHUNIT'W SEHER LINE IL:; 75 FEET.
HELL ;_OG'_=, RRE REQUIRED RN[:, HUST DE RETLIF.:NE[:, TO THE [:,EF'RRTHENT HtTHIH 2.:0
OF THE HELL COHF'LETION.
OTHER F.:EC.!UIF:EHENT':; hlR'¢ RF'PL'T'. SPECIFICRTIONE; RND CONSTF.:UCTION E:,IRGF.:Rhl:5 FIRE
RVR!L..RBLE TO INL:;UF.:E PROF'ER IN'..E, TRLLF!TION
F' EE F-': ~-1 I T' FZ ::< F" I IF4: FE ::'_:: [:, E ,_-_: F_: f'l E: E F..: ~: 1 .. :t ~T¢ .-.-:: ±
I CERTIF'¢ TFIRT
t: I Rf'l FRHILIP, R 1.4ITH THE F.:EC!UIREMENT.':_-: FOR ON-SITE SEP~EF.:S RNE:, HELLS RS :SET
FOF:T'H D'¢ THE hlLINICIPRLIT'¢ OF RNCHORRGE.
2: I HILL INSTF!L[.. ]"HE ':]'¢':7-,TEhl IN RCCOR[:,RNCE HITH THE CO[:,ES.
]:: I LIN[:,ERS;TRND ]"HRT THE ON-'_:,ITE SEHER S'T'STEH HR'¢ REQUIRE ENLRF.:GEHENT IF' 'THE
F.:E:SIE:,E.~.4E:E IS; F:EhlO[::ELED TO INC:LU[:,E HORE 'T'HRN 3: E:EDROOHS.
'_q I GNEE:, . .................................................................
RF'F'L Z L-:FtNT TEN'?' DEL. LfE: ~ Ft
JNICIPALITY OF ANCHORAGE
Department ok Health and Environmental rotection
825 L Street, Anchorage, AK. 99501
264-4720
* * * HANDWRITTEN PERMIT
WELL AND/~ ON-SITE SEWER PERMIT
Applicant :'~]", ' ~ e ," Mailing Address:
, ; Phone Number: ~,,
Location: , :' ~ ':
.... , Lot Size:
Legal Description: ' ~'~ ;,'i ,-~
Type of Soi~ Absorpti°n System Is:
Trench:' Drainfield: Seepage Bed: Holding Tank:
Soil Rating(sq.ft/br)
Maximum Number of Bedrooms: ....
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 = ~ ...... 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 31, 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 understand that the on-site sewer system may require enlargement if
remodeled to include more that 3 bedrooms,,
the reside~e is .~
Signed: ~- Issued by: ~'-~
~pl~cant "'
Date:
SWP/024 (1/81)
O & E EN(~,NEERING & DEVELO. MENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Ruseell Oyster
694-2774
Performed for:
SOIL LOG
Name: /~.///r..
Mailing Addres~'~ '~- ~ -~ ~ / ~ ~ ~ ~ ~ ~ /
Legal Description: ~'~
Earl Ellis
688-2280
Depth (feet)
Soil Characteristics
0
1
2__
3__
4__
5__
6__
7__
8__
9__
10__
11
PLOT PLAN
12__
13__
PERC. TEST
14__
15
16__
Ground Water Encountered: Yes
Proposed Installation: Seepage Pit
Comments:
No
~ If yes, what depth
Drain Field ~
Performed by: _ _ _ t
by
[DOC Co. 0ha
SULLIVAN WATER WELLS
P.O. BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759
OWNER OF LAND
ADDRESS ""
LEGAL DESCRIPTION
DATE - Started · ,'
PERMIT NUMBER
DEPTH OF WELL .. i~) .7'3-/
STATIC LEVEL OF WATER FT.
DRAW DOWN FT,
GALS, PER HR
KIND OF CASING
/7[)
KIND OF FORMATION:
From :) Ft. to ,4 Ft.
From ':t. Ft. to I' Ft.
From ',' Ft. to Ft.
From ~ -~ Ft. to "(' :; Ft
From ~ :~ Ft. to ~ ,, Ft.
From Ft. to , Ft
From, ' ')' Ft. to t'~l.':! Ft.
From Ft. to Ft
From "~/ / Ft. to t -/.-~ Ft
From 'Ti') Ft. to P" & Ft.
From -.:I ::,Ft. to .-i>,.2tFt.
From Ft. to Ft.
From ) "1 Ft. to i,/'~" Ft.
From Ft. to Ft.
From "," Ft. to "-; Ft.
From Ft. to__Ft.
From .__Ft. to Ft.
From__Ft. to__Ft.
From .Ft. to__Ft
From Ft. to__ Ft.
From Ft. to__Ft
From__Ft. to__Ft
From Ft. to Ft.
From Ft. to__Ft,
From.__Ft. to Ft.
From___Ft. to__Ft
From___Ft. to Ft.
From Ft. to__Ft
From Ft. to Ft.
From__Ft. to Ft,
From Ft. to Ft
From Ft. to Ft.
From Ft. to Ft.
From Ft. to Ft.
MISCL. INFORMATION:
DRILLER'S NAME
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
(~._~ - ~Lt \- t--~ HAA#
1. GENERAL INFORMATION
Complete legal description
Lot 31; Delucia Subdivision;
Location (site address or directions) 22723 N&edles Loop
Property owner
Mailing address
George Siskoff Day phone .688-3981
22723 Needles Loop Chugiak, Ak. 99567
Lending agency
Mailing address
Day phone
Agent Lisa Reed CENTURY,21/COLONIAL REAL ESTATE Day phone 696-8600
Address 11901 Business Blvd. Eaqle Riv~, Alaska 99577
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Unless otherwise requested, HAA will be held for pickup.
NOTE:
Individual well
Community well XX
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:
NOTE:
XX
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.
72-025 (Rev. 1/91) Front MOA ~21
5. 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 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
Engineer's signature
5 & S E.NG!HEERING
17034 Eagle River Loop Road No. 204
Eagle R;w~', Ala:-~, ??577
DHHS SIGNATURE
Approved for ?.~.~/_~'-~%~.2 bedrooms.
Disapproved.
Conditional approval for
Phone
bedrooms, with the following stipulations:
Additional Comments
By: _/~/~ ~~' 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.
72q325 (Rev, 1/91) Back MOA ¢r21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL. CHECKL.IST
Legal Description: b-e~ '~ ~ [~.,,.)~,~ 4 ~ Parcel I.D.
A. WELL DATA
Well type
If A, B, or C, attach ADEC letter. ADEC water system number 'Z. [~1-5 ~
Log present (Y/N)
Date completed Driller
Total depth Cased to
Casing height
Sanitary seal (Y/N)
FROM WELL LOG
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
g.p.m.
AT INSPECTION
; On adjacent lots
Z
; On adjacent lots
Public sewer main
Public sewer manhole/cleanout
Sewer service line
Petroleum tank
WATER SAMPLE RESULTS:
Coliform ~
Nitrate
Date of sample:
//' '~ ,.'~:'~ ' Other bacteria
Collected by:
B. SEPTIC/HOLDING TANK DATA
Date installed ~ - ~ ~
Tank size ~ c:) o C:, &m~d..- Compartments
Foundation cleanout (~N) ~/ ~ Depression (Y~I.)
I"-~ Alarm tested (Y/N)
-~c>- '~'Z. Pumper .--~'~--.
Cleanouts ~/N) ~/
High water alarm (Y/~
Date of pumping
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~' ~-~ On adjacent lots ~ ~-D
To property line I o Absorption field
Surface water/drainage ~ o o w'
Foundation
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrica~
SE~ANCE FROM LIFT STATION TO:
We'll on lot On adjacent lots
Manhole/Access (Y/N) ~
~p off" level at
-~~~gcles tested
Surface water
D. ABSORPTION FIELD DATA
Date installed ~- ~;) [
Length ~o ~ Width ~1' i
Total absorption area ¢-'~
Depression over field (Y/~ ~
Results ~a il) f~A-~ 5
Peroxide treatment (past 12 months) (Y~b
Soil rating ~' b/~
Gravel thickness ~ ~
Cleanouts present ~(~/N)
Date of adequacy test
for -t" ~ C-,o'---e-- (-~
~ '&~- ~,~¢~ If yes, give date
System type
Total depth
bedrooms
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot ~5-"0 ~ .t--
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacent lots_ ~~J c>t~'' Property line
~4- To existing or abandoned system on lot
Cutbank ~1/~_ Water main/service line
Driveway, parking/vehicle storage area
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e.f. fect'b~je of this inspection.
S & S ENGINEERING ;:. :,:. ,. ~(~ ~ :,_'-,;~' '~,~
Signature 17034 Eagle River Loop Road No. 2~
Eagle River, Ai~ska
Engineer's Name
Date
HAA Fee $
Date of Payment
Receipt Number
Waiver Fee: $
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE DISTRICT OFFICE
800 E. DIMOND BLVD., SUITE 3-470
ANCHORAGE, AK 99503
WALTER J. HICKEL, GOVERNOR
FOR: S & S ENGINEERING
May 11, 1992
PWSID Cf 217738
My review of the records on file in this office reveals that the Delucia Subdivision, Lots 31
and 32, Class "C" Public Water System is in compliance with the routine coliform bacteria
sampling requirements listed in Table C, and with the inorganic sampling (nitrate (as
nitrogen) only) listed in Table B of 18 AAC 80.200.
Sincerely,
Rachel Clark
Colle~e Intern
~*' DATE RECEIVED
I NSPECTI ON APPOI NTM ENTS
?r
TIME TIME ~D~/I W*'7¢'1_'>~ TIME ,i~. (} ,,
' ' '"" DATE
DATE DATE ~ ~
MUN~L~i~&LITY OF ANCHOR.AG~
~UNIOIPALITY OF A~CHORA6E DEPT.
DEPARTMENT OF HEALTH& ENVIRONMENTAL PROTEC~' O,~,v;~x .: .... ECT;ON
825 L Street - Anchorage, Alaska 99501
( ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720 RECE~v~
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILI3
DIRECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing.
1. PROPERT~OWNER ,~ ..) ' '~ / /'
MA~G ADDRESS? / ~ . ,
PROPERTY RESIDENT (If different fromka~ove) PHONE
2. BUYER / ~ ~ ..... , ¢ PHONE
M
GADD
3. LE~6 INSIITUTIO~i ~_. r-% * --, ., , I PHONE
' .~ , ~ .1 PHONE
MA~G ADD~S ,~ ,,~1~ /'1 _
// (
5. LEGAl/DESCRIPTION
STREET LOCATION ..
6. TYPE OF RESIDENCE
~ SINGLE FAMILY
MULTIPLE FAMILY
7. WATER SUPPLY '""" 7 '. , ,/
,.J~.:__ _ INDIVIDUAL*~.~"Y' , - ; ~ .~,3~ ~c
~(~--C~MMUNITY
~ PUBLIC UTILITY
NUMBER OF~,BEDROOMS
[] One [] Four [] Other__
[] Two [] Five
i 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.)
8. SEWAGE DISPOSAL SYSTEM
~ INDIVIDUAL/ON-SITE**
[] PUBLIC UTILITY
YEAR ON-SITE SYSTEM WAS INSTALLED.
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72-010 (Rev. 6/79) , ' ,
.... " ,.'z_~.,, 0 "c"?~' '-"
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
[--1 SINGLE FAMILY
[] MULTIPLE FAMILY
[] ONE
[] TWO
NUMBER OF BEDROOMS
[~ THREE [] FIVE
[] FOUR [] SiX
[] OTHER
2. WATER SUPPLY
[] INDIVIDUAL
COMMUNITY
[] PUBLIC UTILITY
Connection Verified
3. SEWAGE DISPOSAL SYSTEM
INDIVIDUAL/ON -SITE
PUBLIC UTI LITY
Connection Verified
[~]Septic Tank or []Holding Tank
Size: If Tank is homemade
give dimensions:
TYPE OF TANK
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
PERMIT NUMBER
DATE INSTALLED
INSTALLER
SOILS RATING
MANUFACTURER
MATERIAL
TOTAL ABSORPTION AREA
Septic/Holding Tank
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
Absorption Area
ISewer Line
Nearest Lot Line
DATE
[~PPROVED FOR .~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)
CONSTRUCTION AND OPERATION CERTIFICATE
ALASKA DEPARTMENT OF ENVIRONMENTAL CONSERVATION
PUBLIC WATER SYSTEM
APPROVAL TO CONSTRUCT
Plans for the construction of
/
~ approved.
public water system located
Alaska, submitted in accordance with 18 AAC 80.100
~b~ Y~/ have been reviewed and are
[] conditionally approved (see attached conditions).
B~ ' ' ~TLE
If construction has not started within two years of the approval date, this certificate is void and new
plans and specifications must be submitted for review and approval before construction.
APPROVED;CHANGE ORDERS
Change (contract order no.
or descriptive reference)
Approved by Date
The "APPROVAL TO OPERATE" section must be completed before any water is made available to
the public.
APPROVAL TO OPERATE
The construction of the J~ //,( C,I~ //(~c,'j-(-'~" ~L,,S'/¢Yrl ~---4J.'~_¢ ~/-~' ~_Dublic
/
water system was completed on _-~/ c~/~ .~/ I (date). The system ishereby
granted interim approval to operate for 90 da~s following the completion date.
BY TITLE DATE
As-built plans submitted during the interim approval period, or an inspection by the Department has
confirmed the system was constructed according to the approved plans. The system is hereby granted
Z./~/_.~.~_approval to oj;~4~r~te.
T"] T I- I~ ..... (,,,,,r - ,~)A.lrE