HomeMy WebLinkAboutDELUCIA LT 32 //~- I~. MUNICIPALITY OF ANCHORAGE
- ' -- ~'" DEPARTMENT OF HEALTH & ENVIRONMENTAL. PROTECTION
,,,,~ ~ ~/~) 825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
31 IPHONE .
MAI LING ADDRESS-
DESCRIPTION
LOGATION NO.O~DROOMS
DISTANCE TO: __ Well ~ f I Absor~i~aria D~tllin,~.Xi
' Materi% ~O No. of compa~nts.
~ ~Liq'ca~AixAgall°ns IF HOMEMADE: ,nsidelength Width Liquid depth
Well Dwelling PERMIT NO.
~ ~ ~ DISTANCE TO:
~ ~ ~ Manufacturer Materi~l Liquid capacity in gallons
a Well I Nearest lot line / PERMIT NO,
DISTANCE TO: [~-d) Foundation 2~ w3h~ Distanc
--~Z~ N' No. of Ii nes~, Le~h~ e ,c h line Tota~ I e n gt~? Trench inches
~ Top of tile to finish grade ~ Mater'albe~eathtile ~ inches T°talef~tiu~abs°r~ti°~area
~ ~ T~e of crib Crib Oiometer Crib depth Total effective absorption area
m Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot tine PERMIT NO.
~ Building foundation Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER i J
~ I I
PIPE MATERIALS
SOl L TEST RA~ ~ ] ,, i
,NSTALLE~~~ ~ ~ ~,
REMARKS ~ ~
APPRO~ DATE LEGAL /
72-013 (Rev. 3/78)
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0 & E ENG,. ,lEERING & DEVELOF ,,AENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for:
Legal Description:
Earl Ellis
SOIL LOG 688-2280
Name: <~--~J- O~--_~-~Jc-,~ TeI. N0.~'/~-~5~/''/
Mailing Address: ~---~ ~ ~4 ~;;/-d_-~--~- /~/d/-='-~ ,,Z~,,~-.. , c/--~_- 7.7
Depth (feet)
Soil Characteristics
0
1
2__
3__
4__
5__
6__
7__
8__
9__
10__
PLOT PLAN
11
12__
13__
PERC. TEST
16__
Ground Water Encountered: Yes__
Proposed Installation: Seepage Pit
Comments:
No /-""~lf yes, what depth
Drain Field ~
Performed by:
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
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # L'-~_~I- ~ L\\- ~n HAA#
1. GENERAL INFORMATION
Complete legal description Lot 32: Delucia Subdivision
Location (site address or directions) 22737 N¢.edles Loop
Property owner
Mailing address
Ta~mie E., Clayton
Day phone 698-39g0
Lending agency
Mailing address
Agent Audrey
Address 16600
Pacific Alaska ~,~ortgag~.
Atte~ion: Wendy
~.~ason/Refl, ax of Eagle Riv~.r
Cen,~reld Drive, Ste.~ 201,
Day phone 258-7534
Day phone 694-~200
Eagle River, AK 99577
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS: 3 '%/
TYPE OF WATER SUPPLY:
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:
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 It21
Se
STATEMENT OF INSPf 'iON BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I (,erify t.hat 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
S & S ENGINEERING
Address 17034 Eaqle River Loop Road No, 204
Eagle River, Alaska 99577
Engineer's signature
Phone
Date
DHHS
SIGNATURE
Approved for ./~.¢.,%-2 ~/~,~.,) bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
.
L
By: '--
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.
72-025 (Rev. 1191) BacZ MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: ~ ~-~' ~~---~/~" ~--~i~ Parcel I.D.
A. WELL DATA
Well type ~
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to
FROM WELL LOG
Date of test
Static water level
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
I
ADEC water system number '~--~\-~"~'~'-~
Driller
Casing height
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
WATER SAMPLE RESULTS:
Coliform
Date of sample: ~'~
Wires properly protected (Y/N)
AT INSPECTION
g.p.m.
~'~--'~ + 'On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
m
z
Nitrate ~,.,,~ ~v~,~ ~ Other bacteria ~
~ ~ Collected by: ~ ~'- -~ ~ ~"~'~ '
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanouts~)
High water alarm (Y/N)
Date of pumping
Tank size j ~ Compartments
Foundation cleanout~'~JgN) "/ '~' Depression (YZ~JP
~ Alarm tested (Y/N)
~-~'"'~'- ~1 ~ .~ Pumper '"'~.--~'/
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~'~ //k~r On adjacent lots \~l ?
Foundation
To property line k,~:~) ..,t,.
Surface water/drainage
Absorption field
Water main/service line
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Manufacturer
Size in gallons
Manhole/Access (Y/N)
Vent (Y/N)
"Pump on" level at
"Pump off" level at
High water alarm level
Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
D. ABSORPTION FIELD DATA
Date installed
Length '~-'~-" Width
Total absorption area
Depression over field
Results ~__~/::fa i I)
Peroxide treatment (past 12 months) (Y~)
Soil rating ~ '¢~/¢~¢----~
Gravel thickness
Cleanouts present (~N)
Date of adequacy test
for
~ \E--t-~l~---~ If yes, give date
System type~7"-~--~'--~ I,-~,
Total depth
bedrooms
SEPARATION DI~T~kNCE FROM ABSORPTION FIELD TO:
Well on lot ~/'~ On adjacent lots \c_?C:~ I ~. Property line
To building foundation ""?¢-'~ T ~xo isting or abandoned system on lot
On adjacent lots '~-'-~'-~ ~ '~"- Cutbank /'~ J~ Water main/service line
Surface water ~ ~ Driveway, parking/vehicle storage area
Curtain drain ~;D~ ~
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signature
Engineer's Name
Date
$ & S ENGINEERING
17034 Eaqle River Loop Road
Eagle E|ver, Alaska 99577
HAA Fee $ //
Date of Payment
Receipt Number
72-026 (Rev. 3/91) Back MOA 21
Waiver Fee: $
(~-~)-~ / ~ "~ Date of Payment
~' Receipt Number
,/
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#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
College Intern
~ printed on recycled p,3Fer b y
DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
~_; ~.....~ ~ ,,~, ,~ . ~ ~k,~,.- ~ .
DATE DATE DATE ¢~ -
INSPECTOR I NSP ECTO R I NSP ECT0~
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPT. OF HSALTH &
D~PARTMENT OF HEALTH & ~NVlRON~ENTAL PROT~CT~i~ONMENTAL PROTECTION
825 L Street - Anchorage, Alaska 99501
~ ENVIRONMENTAL SANITATION DIVISION 00T 6 1981
Telephone 264-4720
~r/~lr ~
~1 ~[CTIO~8: Complete ~11 p~rts on p~ge ~, I~omplete requests ~ill ~ot b~ proee~ed. Please ~11o~ ~en (~ O) ~Vs for processing.
M~NO ADDRESS
PROPERTY RESIDENT'(If ~ifferent f~ above) / PHONE
PHONE
M&I~ NG ADD~ESS
· ... ,~ . ~,~
MAILING ADDRESS . _
3,::o
M~ ADDR~
5. LEGAl_ DESCRIPTION ,. :
STREETLOCATIO~ . J (-~
6. TYPE O~ RESIDENCE NUMBER OF~BEDROOMS
: One ~ Four
~ SINGLE FAMILY ~ Two ~ Five
~ MULTIPLE FAMILY ~ Three ~ Six
7, WATER SUPPLY
INDIVIDUAL*
COMMUNITY
[] PUBLIC UTILITY
[] Other
* 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 [~] INDIVI DUAL/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)
THIS SIDE FOR OFFICIAL USE ONLY "
1. TYPE OF RESIDENCE
[] 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
~]-II~'DI vi DUAL/ON -SITE
E~] PUBLIC UTILITY
Connection Verified
[]Septic 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
SOILS RATING
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA . MATERIAL
4. DISTANCES
WELL TO:
Absorption Area to nearest Lot Line
5. COMMENTS
Septic/Holding Tank IAbsorption Area
ISewe,r Line
INearest Lot Line
DATE
[~] -'APPROVED FOR _-~ BEDROOMS
[] CONDITIONAL APPROVAL (letter must accompany certificate)
[] DISAPPROVED
72-010 (Rev. 6/79)