HomeMy WebLinkAboutFAIRMOUNT ADDITION A LT 26
-~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street - Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME 1PHONE I~NEW
MAILING ADDRESS
Box 6403
LEGAL DESCRIPTION
LOCATION NO. OF BEDROOMS
Absorption area Dwelling PERMIT NO.
~ ~ Manufacturer Material
'~ Greet 5Ire
I
IF
HOMEMADE:
I000
~ ~ DISTANCE TO: ~oll Dwellin~ PERMIT NO.
O ~ ~ Manufacturer Matorial Liquid capacitV in 9allons
~ Well/yo, F°undati°nI2' ,..~..,,o,,,~1~, ~'*~°02060~
P ~ ~ ~ Top of tile to finish grade1 ~
Length Width Depth PERMIT NO,
~ ~ Type of crib Crib diameter i Crib depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
~ Class Depth Driller Distance to lot line PERMIT NO.
Building foundation ~ Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS p~C
8OIL TEST RATING
-'
APPROVED DATE LEGAL
10"20B2 Fai m ,t Additia ~2 Lot26
72-013 (Rev. 3/78)
"I"HE LEI'.,tG"I"H E, ;[ I'"!E!'.,i5i; 1; O!'.,I '[ :i!!; THE L..EtqEi"i H ,:: :1:t'.,t F'EE:'t" ;:' OF' 'FHE "t"RE!',E:H
THE DE;P"f'H El?::' f:::t "FF:E;NC:H O?. P Z'f' ;[:~:~; THE D;['.~;'f'~SlI'.,tC:E E',IE'f'I,IEEhI 'THE;
Ei!:;;OUI'.,E;:, F:IHD THE E',ErT'I"Or,'I OF' THE: E;:.::E:RVRT];Ed'.,i ,::;[l'q
I"HE (;~i!:;;:¢::l',,,'~;L. I:;:,EPI"H ;[:~; THE h'l;[N:[!','II...lI',t DEF'TH OF' GRFVv'E;L. E',E'Tt,tEEt".I
F:i?'.!i;;:, T'HE E?C?f'TEd',t Eft::' THE E',:.::E:i:::iVF:IT;];Ed",I ,:::[r-,t
F'E:;R?'I:[T t::~t:::'I:::'!...;[C:FII",FI' !'"IFE~; THE; ~;:E:'~2;F'ON~;ZE',]:L.:[T'T' "['0 :[NF:'OF~:H "r'~..I]::~;
;I; !'..i:~?Ti:;:!!...I..f::I'F ;[ l;;)l'.,! ;[ J'.,!;~;I:-'E:C:T' ;1: Cd'.,i:}]; O!:::' !::d",V'r' HE~I....L~; ftD,;rRCE~;?qff T'O 'T'!'"I
{'-,!I..!f¢!E',E;F;: OF ~;;:E:~;;i;D!EI"]C'!E:E; THI:::!'F J'HE HELL.. HZL..I...
............................. 'T ~ ".~ C:::~ .:;; ;;;;;;~:: ::::. % ?-,il :E~:: F" EEC;;:: '~"' TE lC3t t!'"',,~ ::~;; ~::::~ F~: E; ~;:;~: EE
E',F:!(:::I'::;F;I:L.L..;[~,E~i IZI~;:' I:::IH? ?.r%T[~:r'l H];'T'HEiLiT F'];I",tRL :[ I'.,kSF:'EEE:'T"[ Ed",!
E:,[~:;[::'F:ff;;'.THE;F,FT' !,I:[L.L. E',E: :ii~;UE:..;fiEE:'f' "FEe
i,1];H];?!L.IP1 1;;:,;[:~;FT'F:tI'.,IE'I?; E',E'Ti,iE:E;F,! !:::I i,.!EL.L. Fff',E:' FIl'.,l'.r' ON....-:~'['FIE ~:~;IEHRGtE
::lt;?.tt;~ !:::'EE:T F'Oi';;: i:;:1 F'I:;::!:",¢F:I]'E HEL. L.. Ed:;;: ::[JZ;E~ "f'O ;2~ZIE~ FE:E"r' F'F:Efl"'!
I~! [.. OF' F:'UE[I... ]: C: I.,.!EL.I .....
UF:'OH 't"H E: .... :" '::'
i,'1't;t'.!!'[','![..i1',1 :: '[':: "[' ::tf. it:']:F' F'F:Cq'! F:I F'f;::l:',,,~f:l'l'[~ I,tE:L.L. TO FI F:'~::l:',,,'fa"!"[~ '::[:::hl(~:?
'T'O FI E:OI'"IHLI!",1:1: T"r' ?2;E!,!E:R L :[ !"4E: :[ :~; ';:"~:.~ F:E:ET
HELL. L. OG'~; RF?.E RE(;¢Jti:I;:E:[:.' I:::II",ID I'iU:~?!' E',E: I:~:E:Tt...IF:f'4ED TO THE:
OF' THE I,![~?!....L. E:(:)h'IP!_.E"":['"I"I '[" ' '[E:I::ITZOf',f:5 FII",IO (.:L.ff.,l::::,ll-,:.....t:::"l'ZEIf'~
!:::i'v'f::~[I..f::lE~d....E~: "['CI :[H:?~;I..JI:;;:E: I:::'[~:Cd::'!ER
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOl LS LOG
[] PERCOLATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
SLOPE
DATE PERFORMED: ~-- '~ - 3'-~
SITE PLAN
1
2
3
4
5
7
10
12
13
14
15
1
18
2O
COMMENTS I~/ IS O O~-( V'"c'~.,"~ ? ~}
PERFORMED BY: A~A~ ~i~L.,~/,~,-
72-008 (6/79)
(%o~-~, r-''~'~'~
'O
P
E
IF YES, AT WHAT
Reading Date Gross Net Depth to Net
Time Time/~lbt Water V~- Drop
~ 2:00 ~' ,~/ .'LI
PERCOLATION RATE ~ (minutes/inch)
TEST RUN BETWEEN FT AND __ FT
F't''~' C-o-~,. q' t-o .~" ¢,,,,,,.,-/ 7 ~. / U~ // ~ x
sv,cr'- P~, ~" tt,'-z'/x'
CERTIFIED BY:
2 ;"'; :?'"
..2-: I(
DATE:
t "
I ..~,',. __L_._z.!_ .......
4-- :~,,;z. :~_..[ .~r: - -4
Box 1~69~ S?An llou~'r- A ANI31IORAGI~ AI~ASKA 99~0~1~
SIX INCh WATER WELL DRILLED AND CASED OUT TO THE DEPTh OF
DriLLED at The rate OF
PrOPerty OWNer
LOCATION OF WELL Site
PER FOOT.
DRILLER
WELL LOG:
0 .... h~~
300 ?ez'.: ,,;F~ DO. O0
MUNI?IPALITy OF .
v,IVIR .;, 4/ % ,~' ." .".
· ' ,u,EtrloN
UO I' 2 ~; 1982
-RECE!.V_ O
COST INCLUDES ALL LABOR AND MATERIAL FOR COMPLETION OF SAID DRILLING.
WRITE CHECK PAYABLE TO RAMPART DRILLING WORKS FOR THE SUM OF ;i~0().
DATE.
THANK YOU VERY MUCH.
BERNIE CLAUS OF RAMPART DRILLING WORKS
SERVICE CHARGE OF 1~% PER MONTH WILL BE ASSESSED ON PAST DUE ACCOUNTS.
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
GENERAL INFORMATION
Complete legal description
Lot 26; F~irmount Subdivision Addition A
Location (-site address or directions)
5601Ricky Road
=
Property Owner
Mailing address 5601 Riclz~f Road
Lending agency
Mailing address ...,i...~.
Agent
Margaret L~Vin~ ~ Ralph B~ard~l~y Day phone 345-7749
Anchorage, Alaska 99516
Day phone
Dan Bradford CENTURY 21/Pacific North
Address
1120 Huffman Road
A~n~ng~.; AYnAbn qq~l~
Unless otherwise requested, HAA will be held for pickup.
Day phone 345-1444
NUMBER OF BEDROOMS: $ ',.4
TYPE OF WATER SUPPLY:
NOTE:
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.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
NOTE:
XX
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 eN~iNe~kiNG
17034 Eagle River Loop Road No. 204
Eagle River, Alaska 99577
Phone
Date
DHHS SIGNATURE
X Approved for ~-~ ~)
bedrooms.
Disapproved.
Conditional approval for
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.
72-025 (Rev. 1/91) Back MOA #21
Municipality of Anchorage
Department of Health & Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L-cT ~ ~ F~IIZMOMT
A. WELL I;)ATA
Well type
Log present t~/N)
Parcel I.D. ~') / ~ ~ /// - / 7 --..~
Total depth
Sanitary seal (~N)
If A, B, or C, attach ADEC letter.
Date completed
Cased to
FROM WELL LOG
Date of test
Static water level I~(~ '4.
Well flow
Pump level
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot /OC~ 4
Absorption field on lot
Public sewer main
Sewer service line
ADEC water system number
~-I~g~, Driller }~q~M P~fCt
Casing height
Wires properly protected ((~N)
AT INSPECTION
; On adjacent lots
g.p.m.
; On adjacent lots
Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform L'~ Nitrate
Date of sample: H - ~0 - c~¢.~.,
~ ~) Other bacteria ~'_~
Collected by: --~ ~ 5~ ~-~J%G(I~)~I
B. SEPTIC/HOLDING TANK DATA
Date installed /0-2,0-~,~. Tank size [000 G-R(.
Cleanouts y~N) ¢%- , ~ Foundation cleanout (Y/N) Y~%
High water alarm (Y/~¢.~ /'d ~ Alarm tested (Y/~
Date of pumping .., ~_~_ c~,,~ Pumper_ A~
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot '/O0 ¢ + On adjacent lots lO0 C-/-
To property line ~ ~+ Absorption field {ci ~
Surface water/drainage ((~0' ~-
Compartments ¢~
Depression (Y/~
Foundation I ~ '.r
Water main/service line (~0 ,+
72-026 (Rev. 7/91) Front CONTINUED ON BACK PAGE
~.J~IFT STATION
Size in gallons ~--.
Vent (Y/N)
High water alarm level
Meets MOA electrical codes (Y/N) T~
SEPARATION DISTANCE FROM LIFT STATION
Well on lot On adjacent lots
Surface water-'"--.
D. ABSORPTION FIELD DATA
Date installed
Length
Total absorption area
Depression over field (Y,~
Results (~/fsil)
Width _~6//
~0 ~
Man ufactu rer
Manhole/Access (Y/N)
"Pump off" level at
Cycles tested
Peroxide treatment (past 12 months) (Y/II~ ~""~1~
bedrooms
Soil rating /00 gF /f~IL System type
Gravel thickness 6 r Total depth /~)
Cleanouts present (~N) ONE
Date of adequacy test ~_~/_ c/~,
for
{(::r~o~ ~ If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water
Curtain drain
On adjacentlots /00 ' '/- Property tine
To existing or abandoned system on lot /b///,~
Cutbank [00 ~¢' 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 effect on the date of this inspection.
Signature
Engineer's Name
Date
$ & S ENGINEERING
7034 Eagle River Loop Road No. Snz
Ea~,l~ l?~ver, Alaska 99577
HAA Fee $ /~
Date of Payment
Receipt .umber [
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 FAX:(907) 561-5301
ANALYSIS RESULTS for INVOICE ~ 53022
Chemlab Ref.{ 92.1653 Sample # 3 Natrlx: WATER
Client Sample ID : DRINKING WATER L26 FAIRMONT S/D
PWSID : UA
Collaoted : APR 20 92 ~ 13:20 his.
Received : APR 21 92 @ 13:40 h~s.
Pxaservad with : AS REQUIRED
Analysis Completed : APR 22 92
Laboratory Superyi~o~.: ~TEPH~N C. EDE/
Released By: Y~-~ ~/~
Client Name :S & S ENGINEERING
Client Acct :SNSENGP
BPOt :
Reql :
Ordered By oR. SHAFER
Send Reports to:
I)S & S ENGINEERING
:NONE RECEIVED
Pa~amate[ Results Units Method Allowable Limits
NITRATE-N ND(O.IO) mg/1 EPA 353.2 10
Sample ROUTINE SAMPLE COLLECTED BY: J.W.
Remarks:
1 Tests Performed ' See Special Instructions Above UA-Unavailable
ND- None Detected '* See Sample Remarks Above
NA- Not Analyzed Ll-Less Than, GT-Greatar Than
Member of the SGS Group (Soci(~t~ GCn~rale de Surveillance)
DATE:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HI/MAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
ON-SITE WASTEWATER DISPOSAL SYSTEM INSPECTION
TIME:
LEGAL DESCRIPTION:
ENGINEER: ~" ~/c_~
EXCAVATOR:
AUDITOR:
APPLI¢ NT FILLS OUT UPPER HAl. ONLY
Ma,,ngAddrs,s '~.,¢. ~, .,~,.,. . ,//! /"~//. //.,,'~'/ ,4 k', .... ~~¢ Z'pC°de?d,'//--,' ~
Rea.ty co. & Ags.t ~,n ,,,.,/dr_ /'8 ~,q/-j--)/ D-,,t.J C . Pbons
Legal Description ~/¢~,~ ~ 2~_.~ ~/,~
strset Loca,lo.
Type of Residence
Multlpls Family No. st Bodrooms
[~ Othor
Water Supply
"~lndividual ATTACH WELL LOG. A we~l is for all wells drilled since June 1975.
log
Community For wells drilled prior to that data, giv8 well depth (attach log if available).
~] Public Utility
Sewer Disposal
Year Individual Installed:
ndlvldual ubllc Utility When Connected to Public Utility:
L~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
Time Time Time Time
Inspector Inspector Inspector Inspec
Field Notes: MUNICIPALITY OF ANCHORAGE
ENVIRC)i%'~/N iAL Pi';Oi~LCitON
RECEIVED
( ~') APPROVED BEDROOM8 *OONDITION8 OF APPROVAL
( ) DISAPPROVED
( ) CON DIT~)NAL APPROVAL*
Soils Rating Date Sewer Installed Well To Absorption Area / ~ ; "f'- Well Log Received
/
APPLIC IT FILLS OUT UPPER HAL 3NLY
Pro~c:tyOwner ,~.,~/,.~t~,,.0/~:. ~_~/,.~7'~F¢,,C,,-,~.,~,.~ (~ ~:1 ~:' :,) Phone
Realty Co. & A~t ~(~ / Phone
Type of Resi~nce
~ Single Family
~ Oth,r
Water Supply
~ Individual ~J~J ~ ATTACH WELL LOG, A w~l log is required for all wells drilled since June 1975.
~ Community
~t /L~['/ For wells drilled prior to that date, give well depth (attach log if available).
/
Public
Utility
Sewer Disposal
~ Individual ~,~ L~L"~ Year Indtv~ual Installed:
Public Utility ~ L3~ I~-~- ~ . When Connected to Public Uti~ty~
~ Holding Tank
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH RE~EST BEFORE ~OCESSING CAN BE INITIATED.
Time Time Time Time ~'~
Date Date Date Date
Inspector Inspector Inspecto~ Inspector
Field Notes: ~ MUNICIPALITY OF ANCHORAGE
~_.(~ DFpT
,.,.-- o l
RECEIVED
('~) APPROVED BEDROOMS *CONDITIONS OF APPROVAL
( ~ ) DISAPPROVED
BY:
~olls Rating Date Sewer Installed Well To Absorption Area 'Jr-JO~ Well Log Received
NoveMber 2, 1982
Becharof Construction (Sam FeJes)
6917 Old Seward
Anchorage, AK 99502
Subject: Lot 26 Fairmont Sub. Addn. A
Approval for the individual sewer and water f&cilities cannot
be granted until ~e following items have been completed:
d'" The top of the well casing should be sealed so that it is
~ water tight.
The water analysis report needs to be submitted to this
office from the Chem Lab, 5633 B Street, for our review.
The depression over the sewer system will need to be filled
so that surface water drains away from the sewer system.
Please notify this Department for a reinspection when the
noted discrepancies have been corrected. If there are any
further questions, please call tbi~ office at 264-4720.
Sincerely,
Robert C. Prat%
Associate Environmental Specialist