HomeMy WebLinkAboutFEJES LT 2B
MUNICIPALITY OF ANCHORAGE
DF.. RTMENT OF HEALTH AND HUMAN SER, ES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Address
TANKS
A SEPTIC ~ HOLDING
Matorml No. of Compartments
TYPE OF SYSTEM
~TRENCH ~] BED ~ W. DRAIN [] OTHER
Depth to pg~e boltom Irom ]olal depth Irom original grade
Gravel lengg~ ~[~vel w~Oth
8,'7.Z so n
WELLS
ilVATE [] OTHER fldentifvl
Classd~cahon
V~P_-/',/
REMARKS:
] ottu L)eplh Cased to
IqO FT Il'JO
Io, ii, IZ.~
FT
DISTANCES
WELL
LOT LINE
FOUNDATION
SEPTIC
TANK
Io7
No-C
ABSORPTION
FIELD
/o 7
WELL
AS-BUILT DIAGRAM tShow Iocabon of well, seplic system ploperty hnes, Ioundahon,
driveway, water bodies, utc)
Municipal and Slate ~uidelines in effect on Bis date:
Health Department Approval:
Scale: ENGINEER'S SEAL
Insp tions Performed by:
certily that Bio inspection was pedormed according to all
/2-0~3 (3/85)
DIEF:'ARTMEN*I" OF' HEAL.'TH AND EI'4VIRONIqEIqTAL F'F~OTE. Cl'IOI'4
825 L.. STREE'T', ANCH[)RAGE, AK 995() 1.
264-4'72.()
F:'EI::~ M I '1"
DA'I*'E I ,S!i3LIE:I) :'
850579
09/11185
AF"'F'L I CAN'r:
ADDRESS:
E:ONT'AC'f F'HONE:
SHANE AND GINA DOCHERTY
4:S4 "HJRP I N
ANCHORAGE., AK 995()4
· ]~33..,-30 18
I....EGAL DESCR .'1: P ..
LOT SIZE:
MAX BEDROOMS:
LOT: 2B
RANGE:
BLOCK: NA
SLIBDIVISION: FEJES
SE[]'T'ION: 35 '¥[)WNSHIF': :t2N
:1.. 2.5A (SQ. F'T. [)R ACRES)
:."!.';
I..,isted below are the t::~ptic~ns available t.o you in designing your sept:~c:
s;yst, em,, Choose the option that best fits your' sit. e.
'"ir- lf::'~ E: N CZ: I-*-.] :IE~ E: :[) W . 1-} F;:: ¢::~ ][ !NI
DIEF:'TH '1"0 PIF:'IE BO"F'I"OM (I::'T.) 4.0 '. 4. () 4.., ()
GRAVEL:. DEF"'T'H (FT.) 8.0 0.5 3.5
'I"OTAL DEF']"H (FT.) 12]. 0 4.5 7,, 5
GRAVEL, WID]'H (FT.) 2.5' 24,,() 5.0
GRAVEL L.ENG'I"H (F"I".) 54.0 47.0 9:];. () **.
GRAVEl.... VOL. UME (CU. YDS,, ) 42.5 4 1.8 68.9
]"ANI< SIZE (GAL. S) :L,000.0 ** 1,000.0 ** 1,()00,,0 **
.SOIl... IRA'TING (SQ.FT. /BR) 287 250 2.87
-~"~' GRAVEL LENGTH > '75 F'I". REC4UIRES MULTIF:'LE RUNS (NO'I" EXCEEDING 75 F'I". EACH)
~¢'~' TAI'.II'.:: MUST HAVE AT L, EAST TWO (:X)MPARTMIENTS
I certify 'Lhat:
~.. I am familiar' w:Lth t. he r'equ:Lrement, s; for on.,...site sewers and we:Lis as set
fonth by the Munic:ipal. ity of Anchorage (MOA) arid the State of Alaska.
2. I wilI install the system in accordance with all MOA codes ancl regulat:i.c~ns;,
and ir'~ c:ompliance with the design criteria of th:ts permit.
3. I will adhere to ali, MOA and State of Alaska Pequirements for the set bac:l-::
distances from any e~..'isting well., wast, ewater disposal system or pub].:i,c
sewe:*.rage system on th'i.s or any adjacent c)r' nearby lot.
Zl.,; I understand that t. his permit., is vaIid for a maximum o4' ::"-"; bedrooms and
any enlargement wiI1 require an adclitic)r~aI permit,.
IF:' A L. IF*'I" STATION IS INSTAI....I_ED IN AN AREA C, OVERED BY MOA BUII.~.DING CODES,
"I"HEN (].) AN EL..E:C'T'RICAL PERMI'¥ AND INSF'ECTION MUST BE OBTAINED; (2) AS""'BLIII....TS
WILl... Iq[Yf' BE: AF'PRC:iVED WITHOUT AN EL.EC*TRICAI.... INSF'ECTION REPORT; AND (::5) ]"HIE
EI...EC"FF~I[:AL WL3RK HUST BE DONE BY A LIC, E:NSED ELEC"FRICIAN.
,.:~ 1. GNE, D DATE:
AI::'F:'I....ICgNT: SHANE: AND GINA
:1: SSUED BY :.._...
~'t .JNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
826 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
SLOPE SITE PLAN
0-1
20-
4
5
6
7
8
9
10
11
12
13
t4
15
16
1'7
18
COMM[
PERFORMED B~':
[k~ PERCO LATION
TEST
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
DATEPE. FORME"; l'z.-t
Reading Date Time
Juno 22, 1968
PERCOLATION RATE
. (m nutes/inch)
FT
DATE:
72-008, (6/79)
WATER WELL RECORD
STATE OF ALASKA
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Seophysicol Surveys
Drilling Permit NO. ~ ()~L~79
LOCATION OF WELL (Please complete either la~ lb or lc.) A.D.L. No.
Jbdivision Lot Block I/4qtr$. Section No. Township N~] Range EEl Meridian
ejes 2B __of__of--of -- SD wE]
DIRECTION FROM ROAD INTERSECTIONS 3. OWNER OF WELL; Shana Docherty
Address:
end Area of Well Location
Feet Below 4. WELL DEPTH: (final} 5, DATE OF COMPLETION
Material Type Top 8ottom
)oulder 11 ~ 12 50 ~Au~er ~efted ~Bored ~01her:
~& ~r~vel ~1 121 ~ Irrigation ~ Rech.rge ~ Commerlcal
9. FINISH OF WELL:
Type: open he)} f~ Diameter:
__~ Slot/Meah Size: Length:
Set between ft. and ft.
BockfilHng Gravel pock
m. STATm WaTE. LEVEL: ". / /
-- ~ Above or ~ Below land surface Dote
........ ft. after hrs. pure ping ~ g.p.m.
~ft. ~fter .~hrs. pumping.~.p.m.
IZ.GROUTING Well Grouted: ~ Yes ~ No
................ Materiel: ~ Neet Cement ~ Other:
13, PUMP: (if available) HP
.......... Length of Drop Pipe ft. copocity ~g.p.m.
14. REMARKS: perforated 121- 12~/~
gallons per. day
)
gpm
CONTRACTOR'S CERTIFICATION: 15. Wafer Temperature o ~ F ~ C
drilled under my jurisdiction end this report is true to the besl of my knowledge ond belief;
-Well/Vein's [~illing & ~t ~ 332?
2~1 Ayion St. Anchorage: AK 99516
Authorized Represent¢llve
Il} Copy Distribution: WHITE-State DGGS, PINK-Driller, CANARY-Customer
~:~nch I F_
Streel /~ddres5
2 WELL t. OG
brn silty
hard pan
hard_gr
uma. er wi
2 gpm
16. WATER WELl..
Alaska
Form 02 WWR {II/UI}
PAGE 1 OF 1
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WELL SYSTEM (UPGRADE) PERMIT
PERMIT NUMBER:SW980070
DESIGN ENGINEER:
OWNER NAME:DOCHERTY SHANE P & VIRGINIA A
OWNER ADDRESS:4006 DEARMOUN ROAD
ANCHORAGE, AK 99516
DATE ISSUED: 4/21/98
EXPIRATION DATE: 4/21/99
PARCEL ID:01818125
LEGAL DESCRIPTION:
FEJES LT 2B
LOT SIZE: 49020 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
WELL SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS {18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
I'400° O'Z' ~c1"~ - I Co~b.O0'
I HEREBY CERTIFY THAT THE INFORMATION SHOWN HEREON IS TRUE AND CORRECT
AND HAS BEEN ESTABLISHED BY ACCEPTABLE SURVEYING TECHNIQUES.
DRAWN BY CZ,L..~. LEGEND
CHECKED BY
SCALE III
BATE
JOB NO. ~Z"~
Dofum Engineering ~ Surveying, Inc.
r~oM .o~
DIRECTION
WATER WELL RECORD
STATE OF ALA~'KA
OEPARTMENT OF NATURAL RESOURES
Division of Geologicol B Geophysico) Surveys
A.D.L. No.
Townlhlp N~) J Renal E~ Meridian
sDJ wD
OWNER OF WILL: ~J_
?.USE:~OomeJtic ~ Public Supply ~ I~duJtry
~ Irfioetlon ~ Recharge ~ Commlricol
8. CAGING: [] Threaded (~] Welded
9. FINISH OF WELL:
Type: Dlomlter~
Backfilling . grovel pack
STATIC WATER LEVEL:
II, PUMPING LEVEL below land euHooe and YIELD
__ft. offer __hrs. pumpln0 g,p.m
13.GROUTING Well grouted: Kal [] NO
Material; [] Neat Cement ~:] Other',
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner (~('~a~-?t'~, -*¢~"~ ~/~'/~'¢~l~ne: Home '~'-~--~"~J Business
Mailing Address - - ~ /"~ ¢0 ~ J ~ A'¢~4.,~0~.2 ~ .
(c) Lending Institution ~'~11~:~m44~ ~ Telephone
(d) Real Estate Company and Agent ~%,1 I~
Address
Telephone
(e)
Mail the HAA to the followino address: or: Check here~ if hold for pick up.
List contact person and day phone number below, f '
i '
TYPE OF RESIDENCE
Single-Family'~
Number of Bedrooms
WATER SUPPLY
Individual Well~ Community [] Public []
Note: Jf 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 community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2 72-025 fRev 8/86~ Front
ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
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 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 flies 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
Name of Firm {,/o ~ Telephone
AddressDate ~ I~~
Engineer's Seal
DHHS APPROVAL
Approved for -~
Approved X
Disapproved
Conditional
Terms of Conditional Approval
CAUTION
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.
Page 2 of 2 72-025 (Rev 8/86) Back
O6 ~:~\O~ MUNICIPALITY OF ANCHORAGE (MOA)
-~-~'~o~ ~,~r- -~'~--~%O HEALTH AUTHORITY APPROVAL (HAA)
~.O~ C~c~'X~ 264-4720
Well Classification
Well Log Present (Y/N)
Total Depth / ~'VD Cased to
Static Water Level
Casing Height Above Ground .,~
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanout/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
If A, B, C, D.E.C. Approved (Y/N)
Date Completed J~ °/~" ~'-~ Yield
Depth of Grouting
Pump Set At ~D '~ ~-/
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
ll~ 7 ; On Adjoining Lots
/ {~ -7 ; On Adjoining Lots · /~'~
_ To Nearest Public Sewer
To Nearest Sewer Service Line on Lot ,,'~/~::~
; Date ///"~'//'~' 7
B. SEPTIC/HOLDING TANK DATA
Date Installed 1~ : //: ~ $
Standpipes (Y/N) T'
Depression over Tank (Y/N)
Pumping/Maintenance Contract on File (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
Comments ~'
Size I~f..~ _ No. of Compartments T
Air-tight Caps (Y/N) ~ Foundation Cleanout (Y/N)
Date Last Pumped ~
tY'//~A, ;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation '~ {
To Disposal Field ~
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed
Width of Field
Square Feet of Absorption Area
Depression over Field (Y/N)
Results of Last Adequacy Test
Type of System Design
Length of Field J iD ~
Depth of Field ~;~
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water-Supply Well I
TO Building Foundation
Lot /'~ 0 I"~
To Water Main/Service Line ~'
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments
Y
To Property Line
To Existing or Abandoned System on
; On Adjoining Lots ~ ~'~)
To Cutbank (if present) /'~/
oh/
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I have checked, verified, or conformed to alI. MOA//and HAA guidelines in effect on the date of this inspection.
Signed --~, ~ J~,~'~'~ Date
/
Company MOA No.
Receipt No. /
Date of Payment //--
Amount: $ ,'/~.') ~')
Page 2 of 2
72-026 (11/84)
Engineer's Seal