HomeMy WebLinkAboutFARLEY LT 118 B
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
MAI LIN G ~ DDR E~.~..) /~
LEGAL DESCR~IPTION
Manufacturer ~
IF HOMEMADE:
DISTANCE TO:
Well
DISTANCE TO: Well,¢~( (..~
Length of each
Top of tile to finish grade
LOCATION
~ .nsid.~e length
Dwelling
Foundation _ , I Nearestlotline
Total length of lines.~. ~.~ ~ Trench width ~'/'-
~5-O I .5-
Material beneath tile
PHONE
NEW
NO. OF BEDRO~S
PERMIT NO.
No. o~mpartments
Liquid depth
PERMIT NO.
in gallons
PERMIT NO,
D ista n c e ,~,r~7~_~ I i n es
Total effect ~e a~o.~_~ a rea
Length Depth
DISTANCE TO:
Crib Crib depth
Well foundation
Driller
PERMIT NO,
DISTANCE TO: Building Sewer line
OTHER
PIPE MATERIALS
SOl L TEST RATI~'~
REMARKS
Nearest lot line
Distance to lot line L~ERMIT NO,
Septic tank ~-~ ~rea(s)
72-013 (Re~/3/78) U
DATE LEGAL
£/o¢ g
YATES C:ONST
,]'AYH~WK
T ~ SNR 1W S8 L ~ 1 ['.~
PO 80X 224:.3
C:HIJ(; I/../I.< AK
LO'T' SI ZE
6B [.:~ '..' 'if)(:)(:)1
'T'ype of soil absorption system :i.s: [)RAINF'Ilii!:LD
Fl~'¢.~x:i. mLlm fH.imbep o.F bedrooms = 4 So:i. 1 Paring (S(:~ F'T/IBR)= 8S
'T'he peql.~:[ped s:[ze o~:' the so:i. 1 absocp'~:[o~ syst:em :[s~
"l"he length d:i. me~s:i.o~ J.s ~he length (J.n ~:eet) o4':- 'the tPeTIch OP dr'a:i.n.F:i, eld,,
The depth o.F a 'tnench op pit is the d~s'tance bet:ween the sup-Face of the
gPOI.tT'I4~ and the hot'tom o'f': the excavation (in .Feet),,
'l"he 9P,ave:l. depth ~s the 'm:i.'n:i. mum depth o¢. 9pave:l. between ~he ou~.Fall p:i. pe
~nd the I:)o't:~om o,F 'the excavation (~n ,Feet).
Pepmit appl:i, can't has the resl:',ons:Lbility t:o in.Fopm th{s department during the
J.T'~stallal::ion inspects, ohs o+: any wells adjacen't to this ppopepl:y and the
number' o+: Pes:i. dences that the well w~ll sepve.
Back+:{l:l. ing of. any system without .f:[nal J. nspec't:[on and ~Jppr'oval by 'th~s
depapt:ment will be subject t:o pr'osecutJ, oo.
Min:l. mum distance between a well arid ~ny on....site sewage d:isposal system :i.s
100 feet f. on a pr':[vate ~ell op 1!50 ~o F:%'O .Feet ~.:pom a public well dependJn9
t.~[)o'n t. he type o.F pub].&c well.
tvl:i.r~:i, mum d:[staT~ce .Fpom a pr':i, vate well to a ppiva'te sewer' Ii. ne is ¢-"]S .F. ee-l: and
t:o a community se~ep l&ne {s '7% .Feet.
Other, pequ:i.r, ements m,!~y apply,, SI:>ec:J.~:&EaI:&oF~s and coT'~s'tpucl:ior~ d:i.~.:~gpa, ms
ava:i. ].ab:l.e 'to :i.r~sur'e pr'open :instal lat:i, on,
I cer't::i..Fy that
1: i am -Fam.~l:l. ap with the r'equ:i.r'ements f. op on....s~te seweps and wells as set
.Fc, r'th by 1:he Mun:i.c~.pal:L'ty o.F Anchorage,
{:!.~,i I w:~.:l.l install 'the system :i.n accordance with the codes.
B: I under',star~d that the on-s'~te sewep system may pequ:i, pe enlapgement J..F the
r'es:i, dence is pemodeled to :i. nclude mope than 4. bedpooms,,
S I (.'.; NE[): ............................................................................................................
API::q_ I C~N T' Y'AT/ES CONS T'
RF'PLi'CF'INT "¢F!TES CONST
LOCFFF Z ON J'R"r'HRP.IK E:'R
L E:.'GRL T~NRIH S8
T"r'PE OF 5;OZL RB':SORPTZON S"r%TEM
F' 3 BOX 2:43:f_":Hl..ll31RK RK
I..FFF SIZE :I. E1EI(?EIE~ E;C!L.IFIRE FEE:T
I S ' [:,R R I NF'":' I EL [:,
r'IFI::.::IMIJM I'.,II..IME:ER OF: BE[:,ROOMS .... 4 SOIL F.:RTII'.JG ,::LSC! F"TYE:F;ii:: ......
;?';'. 2 7',.J ;_ ,:.,:
'T'I-IE LENGTH [:,lf'IEN~,C,N I5 THE I_.EN~TH ,:: I4 FEET.'.~EF THE "r~,.~Hi.~'~..' [:,F.:flINF:'IEt..r:,.
T~E [:,EF-"'TH OF R TF. ENC':H C,R PIT :[$|T~ ¥,1~ E. ETHEEN/'mE~K~flCE OF 'f'HE
GF..OtJND RN[:, TFIE .E:,:,'r'r,Dr,~ OF THE E~:R~,~'t'FInN ,:;IN F:EET::,A t / k \
'TIHE T'E. EZI"-~C:I-'A iCJ]: [:,'"~FH I 2--2"; ,,'"x.'-~- 1 r.~. ¢:..EI~ I~'Ei"lf'".
THE C:i,I~¢~,,'EL DEPTH IS 'T,~E ~I"I.¢I~I~IUM [:,EPI"H OF GRFI',,~Et.~ E~i'.,I THE OTJTFFIL. L F'IPE:
RN[:, /HEIB,:,TTOr,1 ,:,F TH~',;'flT-ION ,::'rfAFEET::,.~ [ A ~J ~":: ~/
PF_~:M:[F ~F'PL!~ ~.~F,~: TH~ ~:~:sF',:,I.~,s.~z.F'~ '~,:, .~N~,:,~'.M 'rH~S [;¢P.~.:TM~-a' .r.~L,~.:~NC~ "rH~:
NUMBE~,E,'fDENCE:'.S THF~T THE P.IE~L~ SER',/E. / \ I ~
DEF'RRTMENT AL. lIE '_-"_'~ T'O FF..OSE,::UTIO, N~ / ~/~
r.'u:N:rr,,ur.'~ r.:,i:.:~TF.,'.~::~IB,E,T,.¢:-:L'~ ,.", ,...,ELL ,,..~::, ,N'-,-~E '::E,,.~F,::~E~:,:~SPOSRL..'_=¢~Er.'~ :~:::..:
UF:'OI'.,! THE l"~r'f~.~ ~t-~.' I,.IEL. L. ,/% ,'~\l.
r,lzN]:r,'lL, r,~ r.:,z~,M~ ~,,,~:Z?'S.T,=E:: t,.IeLg TO F~ P. RZVF-ITE ~E~.'R L. Zr.4E~'_:, 25 FEET
Oi~HEF.: F...Ets:IU~,IF~ RPF~.r. V. SP~F~CFITION'~; 1'~I[4~/CC'~NS;'T'RUCTZO[.C/DZFIGRF:IM..S FIRE
~:",'¢':~":"~'"~: =' '":~:'-'*~-:: ~'~-?:'~-~:V'"'-'-',f~--~'~'°'''. ,~ \ ~
. ~ I ',,J ~
., ,::~.':,'.,T ,. ,:'.,.' ~',..,~:,"~' . ~/..._._.,,. ........ _PX ~ 'X\ --% . , ,
:.1..: I FIM FflMILIFIF.. HITH T]~ F..'ECE~'FF..:EME~T~ I~OR ~JN-SITE SEH~.S FIND HELLS FI.F., SET
FORTH B'¢ THE MUNICIPRt~--FINCHOR~GEN,,J --
;.:2: I HII....L INS;TF. ILL TH~-.M IN RCF:O~.E.,FINF:E HITH THE COE:,E:'S.
3. I Lli',I[.EF4.::TI'F:IND THFtT THE ON-SITE SEI.,.II~R S;~.:';TE;M MRT REC!I...II~.E ENLflF4. GEMENT IF THE
F.'.ESZDENI3E IS I~EMODELED TO ZNCLUE:,E MOt~E THflN 4. BEi?.,F.~OOMS.';.
'_-:, I LINED: _.__L ...................................................................
F~F='F'L I CRNT h,'~TF.,S
]'.':'::l F[, =- ~ ., /4 ~. z'~ ~'i' ~ ~ ~t./,~ -.~-~:- "~; . ~ "'/
O & E ENG.NEERING & DEVELO, ~VIENT CO.
Box 90, Davis St., Eagle River, Alaska 99577
694-2774 or 688-2280
Russell Oyster
694-2774
Performed for:
Name:
SOIL LOG
Mailing Address: ~.-'%4:¢>'¢-
Earl Ellis
688-2280
LegalDescription: L~:-,'- /'/~,, 4.~,r_~, -7'-,q-4 /~'~/; ~,'q
Depth (feet)
0__
1
3__
5__
6
7__
8__
Soil Characteristics
10__
11__
12__
13__
14__
15__
16
Ground Water Encountered: Yes V No
Proposed Installation:
Seepage Pit__
If yes, what depth /O. '~--
Drain Field J
PLOT PLAN
PERC. TEST
Comments;
(b)
(c)
(d)
MUNICIPALITY OF ANCHORAGE
HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
-' OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
.:, ~ '~ Application Date
IERAL INFORMATION
Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
Applicant Uame~.'¢~ ."~;~'4"-~/~;~-elephone: Home ~o~ ..~,~¢Z~. Business
App,,cant Address /~'2~ ~7/'"~',-~ ~'¢',,'~'~'-~4¢~ ~ ~'.~;~:5;~'..
Applicant is (check one): Lending Institution []; Owner/builder []; Buyer []; Other.~ (explain);
Lending Institution ~ Telephone
Address
(e)
Real Estate Company and Agent
Address
Telephone
(f)
Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single-Family j~r' Multi-Famii.y,, r-] Other
Number of Bedrooms ~
WATER SUPPLY
Individual Well~ Community CI Public
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status~
SEWAGE DISPOSAL
Onsite/~ Public [] Community [] Holding Tank
Note: If comm unity well system, must have written confirmation from the State Department of Environ mental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 (11/84)
ENGINEERING FIRM PROVIDI INSPECTIONS, TESTS, FILE SEARCH, [, A AND INFORMATION
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation of ti
Authority Approvat shows that the on-site water supply and/or wastewater disposal system is safe, functional an
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
from the Municipality of Anchorage files and from my investigation and inspection, the on-site water supply
wastewater disposal system is in compliance with all Municipal and State codes, ordinances, and regulations in effect
the date of this inspection.
Name of Firm ~'~"'~'.~.~
Address ~--~.)
D HEP APPROVAL ,~~~~
Approved for ~ ~Z~.~bedrooms by ,4_ .Date
Approved ~ Disapproved
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
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST- FEBRUARY 1984
264-4720
Legal Description: ~
MUNIcIPALITy OF ANc
.... DEPT. OF HEA'~. HORAGE
c~VIRONM~,~.., "~H &
'"" ~,~L PROTECTioN
JUN 0
RECEIVED
WELL DATA
Well Classification _~/~:~'~'~/DO,,,'~/-- If A, B, C. D.E.C. Approved (Y/N)
Well Log Present (Y/N) . Date Completed ~ Yield
Depth of Grouting ,"~(/~'
Total Depth ,~'~' ' Cased to ,~':-~ '
Static Water Level /7, c~' *
Casing Height Above Ground f{:~#
Electrical Wiring in Conduit (Y/N) _~"~--~_ ~
Separation Distances from Well:
Pump Set At ~
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot /,~'~ ! ; On Adjoining Lots .
'/~,/"~ To Nearest Public Sewer
Comments
B. SEPTIC/HOLDING TANK DATA
Date Installed /?,~'~
Standpipes (Y/N) Y~:~
Depression over Tank (Y/N)
Size /~' ~.-~/'No. of Compartments .~
Air-tight Caps (Y/N) ~/'~---~ Foundation Cleanout (Y/N) ~
~ Date Last Pumped ~,~//~
Pumping/Maintenance Contract on File (Y/N) ,,/V~/,~ ; for ~
Temporary Holding Tank Permit (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
To Building Foundation ~ !
To Disposal Field ~" !
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
C, ABSORPTION FIELD DATA
Date Installed //~'<:~::~ Length of Field
Width of Field "~ / ~ Depth of Field "~
~,,5~ ~,~ Gra~ Bed Thickness
Square Feet of Absorption Area ~ ~'~;;~o~-~'~/'''/~'' Standpipes Present (Y/N)
Depression over Field (Y/N) ./,/V'~ Date of Last Adequacy Test
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
To Property Line /
To Existing or Abandoned System on
; On Adjoining Lots ~v/'f~
To Cutbank (if present)
/,5" /
Comments
LIFT STATION
Date Installed ,/V"/,~
Size in Gallons
"Pump On" Level at /V/,~
High Water Alarm Level at /'~//.,,~
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
** Check Permitted Bedroom Rating Against HAA Request **
I certify[/th~! ~ ch~rified, ~,r conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Sig ned.~ _ .~¢-¢~~ ~'~.~1¢2~/,d¢::>~_>
MOA.o.
Receipt NO.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal
MAT-SU TEST LAB, INC.
Soils - Concrete -- Water
Fiehl mul Laboratory Testing Services
P.O. Box 871868 · Was/I/a, Alaska 99687 t (907) 376-3005
DRINKING WATER ANALYSIS FOR TOTAL COL]FORM BACTERIA
,APPLICANT INFORMATION:
Sample Inf~maHon:
Legal Description: ~ ///~t~/~
Date Collected: ~/'~ Time Collected:
Sample Type: ~Routine [-~Check Sample
Stole I. D. No.'
[-~ Treated [~ Untreated
THIS SECTION TO BE COMPLETED BY LAB
ANALYSIS RESULTS
~ Satisfactory
[--] Unsatisfactory
['---] Sample Rejected:[~--]Over 30 Houcs In Tronsit~----]TNTC:Co~onies Too Numerous To Count
~--]Confluent Growth ,---~' RECOMMEND RESAMPLE
Final Membrane Filter Results: O Colonies/lOOm]
No. of Positive Tubes from five 10 ml Portions;tS~r-_~.~;MPNi~/A- per 100 ml
Date Analysis Completed: ~O-~"'~.Reported By:
MICROBIOLOGY LABORATORY RECORD-COLIFORM ANAI.YSIS
Date Received: ~ ~c>~4~¢ Time Received: ~]O~/Or~l. ab Number:
Date Test Started:~%SLg-~~ Time Test Started: /~[-~ Analyst: ~"
TEST METHOD TEST RESULTS DATE/TIME/ANALYST
Membrane Filter Direct Count:~_Cclonies/lO0 ,nl (.O~e'~5~(~ [~30 ~.
(HF) Verification: LTB
Presumptive Tube ff
(LTB) 24 lit.
Confirmatory Tube #
(BCg) 2~,
48
Completed Plate ff
Tested EMB 24
Tube #
I.TB 48
REFER TO BACK SIDE FOR INSTRUCTIONS
~'- ~ _~-' DATE RECEIVED
INSPECTION APPOINTMENTS
TIME TIME TIME
DATE DATE DATE
MUNICIPALITY OF ANCHORAGE '"' IP
DEPA.TME.T Or .ALT.. ENV,.O.ME.TA'
~ 825 L Street - Anchorage, Alaeka 99501 · ~-'~--' '
ENVIRONMF-N?AL; ,,o'fECTION
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SI~flI~/IEIb~S
DIRECTIONS: Complete all parts on page 1, Incomplete requests will not be processed. Please allow ten (10) days for processing.
I
PHONE
1. PROPERTY OWNER~
M~,I LING ADDRESS "
PROPERTY RESIDENT (If different from above) PHONE
2. BUYER , PHONE
M^ILING ^DDR
37' LEN)31NG INSTITUTION PHONE
MAIY_I NG ADDRESS
PHONE
MAILING ADDRESS
S. LEG~U. DESCRIPTION
STREET LOCAT~D~
6, TYPE OF~SIDENCE
S
INGLE FAMILY
[] MULTIPLE FAMILY
NUMBER OF~BEDROOMS
[] One ~ Four
[] TwO [] Five
[] Three [] Six
[] Other
7. WATER SUPPLY
~ INDIVIDUAL*
[] COMMUNITY
[] PUBLIC UTILITY
* 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.
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE NUMBER OF BEDROOMS
[] SINGLE FAMILY [] ONE [] THREE [] FIVE [] OTHER
[] MULTIPLE FAMILY [] TWO [] FOUR [] SIX
PERMIT NUMBER
2. WATER SUPPLY
[] INDIVIDUAL DEPTH OF WELL
[] COMMUNITY
DATE DRILLED
[] PUBLIC UTILITY
Connection Verified LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM PERMIT NUMBER
[] INDIVI DUAL/ON -SITE DATE INSTALLED
[]PUBLIC UTILITY
Connection Verified
INSTALLER
[]Septic Tank or [] Holding Tank
Size: If Tank is homemade SOILS RATING
give dimensions:
TYPE OF TANK MANUFACTURER
TOTAL ABSORPTION AREA MATERIAL
4. DISTANOESwELL TO: Septic/H°lding Tank IAbs°rpti°n Area Isewer Line INearest L°t Line
Absorption Area to nearest Lot Line
5. COMMENTS
~PPROVEDFOR ~ BEDROOMS ~
CONDITIONAL APPROVAL (lette~ust accompany certificate) ~ . .
DISAPPROVED ~ ~ ~l / ~ '
ABI(}Ii()I1A(i{:', Al A,q.., 9!P. i01
(90/) 26,1-4 II 1
III:Al ]It /\NI) [N\/IRONf'N all'Al I'III~i!!(:IION
April
A~:ne Sauvageau
% Lou Wood
ERA Glacier Real. t_y
727 I, Streel
Anchorage, A1 aska
991502
oub]' eot-. 21;~N' ~' ' l?,]W Se. ct:ion 8 Lo/ 118
'"~'] ~:' ].otlif2K ,~1]} . ~ (t,J( t ho ol]e sc. ri'i-. [.o yoli pFCVJOUS]~
Approval cannoL l:)e g]'anLed unt J 1 hhe [ol] owJ. rl9 a 1-<2
completed:
1) Install a 1,25(} gallon .... s-0tict _ . hank ]_00 feet from
theex.· istinq wel
2) Abandon soe})age pit that is 82 :fee[: f,?om the wc.l.l.
3)
5)
l:(:.rforme~i on the furthercst
seepage pit:. ] f t'he ltesl: fails, a soils test will
need t:o l),:~ l)(r [oFI~lcd sO ~]]at des'iqn --'.~-i
be est:ab: i,.;ho ~.
AbanJor~ an,! d ;.?.cnnn~:(;t I:h~: hand .dt;tg well.
A 12o_rm.i.h i~; ucoded from t-hi.:; of'l.'ice pr[or [o any
orifice ali 264--'4'/20,
]:~c P / 1 j w
cc: Lomas and Ncl I ]eton
4449
~t:(9 _., I wi]] ~v:.)L qranL f:l. nal a;~,l:,:ova], unt:il, t-h~:~ hand
wall and
264-4720,
]]ob(:;c[: (:. ]:>l:a[:l , R."
P,C P/]_: w
C C: