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HomeMy WebLinkAboutWOHLFORTH ACRES LT 2MUNICIPALITY OF ANCHORAGE Development Services Department Phone: 907-343-7904 On-Site Water & Wastewater Section Fax: 907-343-7997 Pump Installation Log Well Drilling Permit Number: _______________ Date of Issue: ____-____-____ Parcel Identification Number: ____-____-____ Legal Description Block Lot Property Owner Name & Address: Pump Installation Date: _____-_____-_____ Pump Intake Depth Below Top of Well Casing: __________ feet Pump Manufacturer’s Name: ___________________________ Pump Model: _____________________________________ Pump Size: ____________hp Pitless Adapter Burial Depth: _________ feet Pitless Adapter Manufacturer’s Name: _________________________ Pitless Adapter Installer: ____________________________ Well Disinfected Upon Completion? XX Yes No Method of Disinfection: _____________________________ Comments: Pump Installer Name: __________________________________ Company: ___________________________________________ Mailing Address: ______________________________________ City: ___________________ State: __________Zip: _________ Attention: The pump installer shall provide a pump installation log to On-site within 30 days of pump installation. Municipality of Anchorage Community Development Department Page 1 of 3 L On-Site Water & Wastewater Program 5{ l7 4700 Elmore St. • P.O. Box 196650 Anchorage, AK 99519-6650 •http:/twww.muni.org/on•(907)3437aua/3Q ON-SITE WASTEWATER INSPECTION REPORT YL Permit Number OSP161305 PID Number: 011-121-09 ❑ New !!NQ Name: ERIC WOHLFORTH ABSORPTION FIELD ■ Deep Trench ❑ Shallow Trench ❑ Bed ❑ Mound Address. 7831 INGRAM STREET -ANCHORAGE, AK ❑ Other Phone: No. of Bedrooms: soil Retire: Tmel Depth from original spent: 440-9279 4 1.2 GPDMq a 10 (MAX.) Ft. LEGAL DESCRIPTION Depth to pipe invert horn melnal grMe Diesel depth bersam pipe SEE DWG. R 6.98 Ft Subdivision: Block: Lot: Fill added ebom melnel spade: Gravel lennh: KINCAID ACRES 3 SEE DWG. 40 a F, owns Ip: angersection: Graveledth Beds Number or lines'. Distance ber.een Imes: 2.5 a - - Ft. SEPARATIONDISTANCES Total absarptionaree 556 mberoruen tie Dist ba ween trees. To Septic Absorption Lift Holding PubkrlPrivero From Tank Field Station Tank Sewartinas 8QR Ft. well 1004 100'+ _ 25'+ TANK ■ Septic ❑ S.T.E.P. ❑Holding ❑ Other Menuraeturen Ceploty: Surface water 100'+ 100'+ - ANCHORAGE TANK 1250 Gel. Lot Line 5'+ 10'+ - - N/A Were, Number or compartments: STEEL 2 LIFT STATION Foundation 5'+ 10'+ - - Curtain Drain NONE KNOWN Menmemmer. D Gel. Remarks: OLD TANK DECOMMISSIONED PER UPC PER CONTRACTOR 'Pump on•Mvel st •Puerto or levela Nigh water atarm at BOTTOM OF TRENCH INSPECTED BY MOA EMPLOYEE TIM ECKLUND Pump Maked MW Electricallnepecllons paRamwd Ey: ON 10/28/2016 PIPE MATERIAL House to tank EXISTING/03034 Tank to D3034 dralnfield Installer WILCO CONTRACTORS Drainfield D3034 CO/MT D3034 Inspector GEG, Ltd. BENCH MARK (Assumed elevation) 96.98 Ft. Inspection Location and Description: Dates: 1st 10MR/701R 2nd 10/31/201 3rd 10/31/2016 4th - BOTTOM OF TANK ENGINEER'S SEAL Community Development Department Approval �.``` ` •••• ' • ` Conditional approval: Date: `; * •0 4 ... ......... 010 .i 1 Game s 5 W 115, CE Mir •••••'•p. 11 �,.aa��`` ���� �Fi Approved: Date: 1 ay .70l7 ��I ,� ESS�N`�`•. LICE NSE �11��"`• IIAECCss4 Inspection Repan _1-1-12 doc PERMIT NUMBER: OSP164305 RECORD DRAWING BOTTOM OF TRENCH INSPECTED BY MOA EMPLOYEE TIM ECKLUND ON 10/28/2016 ALL SWING TIES WERE TAKEN FROM SURVEY BY JEFFREY A. GASTALDI, PLS NEW DRAINFIELD T KINCAID ACRES; LOT 4E 10' UTILITY EASEMENT KINCAID ACRES; LOT 4D 384 NEW 1250 GALLON SEPTIC TANK WITH DOUBLE CLEANOUTS BEFORE AND AFTER TANK � EXISTING CO TRENCH GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS 3701E. TUDOR ROA), SUITE 101 'ANCHORAGE AK 99507-PHONE(807) 337-8179• FM(807)338-3M-NEBSITE:w Wmewenl0 *V,c PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ERIC WOHLFORTH 440-9279 2 OF 3 PROJECTILEGAL DESCRIPTION: DRAWN BY: KINCAID ACRES; LOT 3 D.J.G. TYPE OF WORK: DATE: �, RECORD DRAWINGS FOR SEPTIC SYSTEM UPGRADE 11/15/2016 PARCEL ID NUMBER: 011-1�21-09 EXISTING 4 BEDROOM FCO Mk LICEN �•, I"\ \\SS \ #AECC884 A B DBL1 61.3 83.4 DBL2 62.3 84.3 ST1 64.2 88.2 ST2 73.2 85.2 DBL3 75.1 96.9 DBL4 76.3 98.2 C01 121.1 137.9 CO2 158.6 176.1 CO3 181.4 194.8 DV 78.5 100.3 MTI 1 158.5 1 175.9 MT2 1 179.5 1 193A RECORD DRAWING BOTTOM OF TRENCH INSPECTED BY MOA EMPLOYEE TIM ECKLUND ON 10/28/2016 ALL SWING TIES WERE TAKEN FROM SURVEY BY JEFFREY A. GASTALDI, PLS NEW DRAINFIELD T KINCAID ACRES; LOT 4E 10' UTILITY EASEMENT KINCAID ACRES; LOT 4D 384 NEW 1250 GALLON SEPTIC TANK WITH DOUBLE CLEANOUTS BEFORE AND AFTER TANK � EXISTING CO TRENCH GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS 3701E. TUDOR ROA), SUITE 101 'ANCHORAGE AK 99507-PHONE(807) 337-8179• FM(807)338-3M-NEBSITE:w Wmewenl0 *V,c PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ERIC WOHLFORTH 440-9279 2 OF 3 PROJECTILEGAL DESCRIPTION: DRAWN BY: KINCAID ACRES; LOT 3 D.J.G. TYPE OF WORK: DATE: �, RECORD DRAWINGS FOR SEPTIC SYSTEM UPGRADE 11/15/2016 PARCEL ID NUMBER: 011-1�21-09 EXISTING 4 BEDROOM FCO Mk LICEN �•, I"\ \\SS \ #AECC884 Permit Number: Tax Code Number: On -Site Wastewater Disposal System Permit OSP161305 01112109000 MUNICIPALITY OF ANCHORAGE Development Services Department On -Site Water & Wastewater Program 4700 Elmore Road, PO Box 196650 Anchorage, AK 99519-6650 Telephone: (907) 343-7904 Work Type: Septic Upgrade Permit Effective Dates: October 22, 2016 to October 22, 2017 Design Engineer: GARNESS ENGINEERING GROUP LTD Subdivision: KINCAIDACRES Site Legal Address: KINCAID ACRES LT 3 G:2222 Owner/Address: WOHLFORTH ERIC & CAROLINE Cnt �0 S , L)CI)iI1'C1❑Cnr LIVING TRUST 7831 INGRAM ST ANCHORAGE AK 995023965 Site Mailing Address: 7831 INGRAM ST, Anchorage Lot Size in Sq Ft: 195120 Total Bedrooms: 4 This permit is for the construction of: Y Disposal Field Y Septic Tank N Holding Tank N Privy N Private Well N Water Storage 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 wastewater code requires inspections during the installation. The engineer must notify the Development Services Department at least 2 hours prior to each inspection. Provide notification by calling (907) 343-7904 (24 hours). 4. From October 15 to April 15, a subsurface soil absorption system under construction during freezing weather must either: A. Open and Close on the same day. B. Covered, sealed, and heated to prevent freezing. Received Issued By MUNICIPALITY OF ANCHORAGE Community Development Department Phone: 907-343-7904 Development Services Fax: 907- 343-7997 On -Site Water & Wastewater Program Mayor Dan Sullivan On -Site Sewer/Well Permit Application For A Single Family Dwelling Parcel I.D. 01 1-121-09 Property owner(s) ERIC WOHLFORTH Day phone 440-9279 Mailing address 7831 INGRAM STREET 'ANCHORAGE, AK 99502 Site address 7831 INGRAM STREET ANCHORAGE, AK 99502 Legal description (Sub'd, Block & Lot ) KINCAID ACRES; LOT 3 Legal description (Township, Section & Range) Lot APPLICATION IS FOR: TYPE OF DEWELLING: (PQ all that apply) Single Family (SF) Absorption Field Upgrade ® Septic Tank Holding Tank ❑ Privy ❑ Private Well ❑ Water Storage ❑ Sq. Ft. Number of Bedrooms 4 APPLICATION IS AN: TYPE OF DEWELLING: Initial ❑ Single Family (SF) Upgrade ® (w/wo ADU) F1 Duplex (D) El Multiple Dwellings ❑ (SF and/or D) THIS APPLICATION INCLUDES A VARIANCE/ WAIVER REQUEST FOR: Distance: — I certify that the above information is correct. I further certify that this is in accordance with applicable Municipal codes. GARNESS ENGINEERING GROUP, Ltd. (Signature of property owner or authorized agent) Permit/Rush Fees: lr .Z %. 0O Waiver Fees: Date of Payment: Date of Payment: Receipt Number: i7 YC Receipt Number: Permit No. n lkjos­ Waiver No. (Rev. 01/11) GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS October 7, 2016 Municipality of Anchorage Development Service Department On -Site Water & Wastewater Program 4700 Elmore Road Anchorage, AK 99507 Ref: Proposed Septic System Upgrade for Kincaid Acres; Lot 3 To whom it may concern: t „Ule_aa!_e^ The existing 4 bedroom house is served by a private well and septic system. The drainfield is in a state of failure and needs to be upgraded. We are proposing to install a new 1250 gallon septic tank and a deep trench type drainfield. One testhole was excavated on the property and the drainfield is designed within its 30 foot radius. Comments regarding the design are summarized as follows: 1. SOILS: See the attached 2016 soil log which shows the soil classifications, groundwater monitoring, and the percolation test results. 2. DRAINFIELD DESIGN: See attached design drawing for drainfield specifications. 3. SURFACE WATERS: There are no surface water concerns. 4. TOPOGRAPHY: As can be seen on the attached topography drawing, the average topography around the proposed drainfield is 20% running south-east to north-west. We are unaware of any adverse impacts this installation would have on adjacent wells or septic systems. If you have any questions, please contact us at 337-6179. Thank you for your assi;�it nce. nt E., M. S. 3701 East Tudor Road, Suite 101 ' Anchorage, Alaska 99507-1259 Phone: (907) 337-6179' Fax: (907) 338-3246' Website: www.garnessengineering.com J� VACANT N VACANT KINCAID ACRE ;LOT 2C SCALE: — — — — — ------------------------------------- 10-'UTILITY EASEMENT ------------------------------------------------- T.H.#2 < PROPOSED LOT I ry _AD0 O z T.H.# : -- - ------------------------------------------------------------- -------- UTILITY EASEMENT --- _____________ r------------ S; LOT4E CAID ACRES; LOT 4D fiKINCAIDA 4 GARNESS ENGINEERING GROUP, LtdOF ;4 ......o .....•.... foo�' 3�i CIVIL & ENVIRONMENTAL ENGINEERS 0 0 ET=EOAD,SUFTE 101-ANCHORAGE, MNW7 -PHONE (907)337 6179' F�(7) 33&32�'WEBSITE,�gs�'� .. . ............ .......... .1 " S' r Garn 47 O PREPARED FOR PHONE NUMBER: PAGE NUMBER: ERIC WOH FORTH 440-4279 1 OF 2 E- PROJECTfLEGAL DESCRIPTION: DRAWN BY KINCAID ACRES; LOT 3 D.J.G. PROF E SS ak,LICE TYPE OF WORK �, SITE PLAN DATE 10/5/2016 #AEG DESIGN CRITERIA: NUMBER OF BEDROOMS:4 GALLONS PER DAY (GPD): 600 PERCOLATION RATE/S'. 2.9 MIWINCH PROPOSED APPLICATION RATE: 1.2 MINIMUM DRAINFIELD SO.F.: 500 FT' DRAINFIELD DESIGN MAXIMUM DEPTH: 10 FEET WIDTH: 2.5 FEET LENGTH: 40 FEET EFFECTIVE: 7 FEET ACTUAL SOQFT.: 560 F1' '• y GEG, Ltd- HAS A 8 PAGE SPECIFICATION LETTER THAT PERTAINS TO THIS DESIGN. TO OBTAIN A COPY OF THE LETTER CONTACT GEG. BY PROCEEDING FORWARD WITH THIS INSTALLATION. THE ENGINEER, WELL DRILLER, CONTRACTOR AND PROPERTY OWNER AGREE THAT THEY HAVE READ THESE SPECIFICATIONS AND AGREE TO ACCEPT THE TERMS AND CONDITIONS OUTLINED. T 21% KINCAID ACRES: LOT 4E NOTE: THE CONTRACTOR SHALL HAVE THE SOUTH LOT LINE, AND ALL WELL RADII FLAGGED BY A REGISTERED LAND SURVEYOR PRIOR TO CONSTRUCTION. 10' UTILITY EASEMENT KINCAID ACRES: LOT 40 - PROPOSED 1250 TANK WITH DOUBLE CLEANOUTS BEFORE AND AFTER TANK 'EXISTING TANK TO BE DECOMMISSIONED PER UPC / DECK GARNESS ENGINEERING GROUP, Ltd - CIVIL & ENVIRONMENTAL ENGINEERS 3701 E. TUDOR ROAD. SUITE 101' ANCHORAGE. AK 99507' PHONE(907)337 6119' FAX 19011336-3246' WEBSITE: viaw. W�inaen,. PREPARED FOR: PHONE NUMBER: PAGE NUMBER: ERIC WOHLFORTH 440-9279 2 OF 2 PROJECTILEGAL DESCRIPTION: DRAWN BY: KINCAID ACRES; LOT 3 D.J.G. TYPE OF WORK: DATE: � SEPTIC SYSTEM DESIGN UPGRADE 10/5/2016 a EXISTING 4 BEDROOM HOUSE i FCO i �^ : ftri�ey A-lGBlness c ♦ GTS :• r ♦ CE -79 ♦ Jf '•. "ROFE LICENNSE �OYnaes**•'' #AECC884 GARNESS ENGINEERING GROUP, Ltd CIVIL & ENVIRONMENTAL ENGINEERS 3701 E. TI RROAD. SUM 101 -ANC E. M 9950Th PIE 'W1'331A179-FAL ryo7I33&346- WE95RE'. v+nwrm�wq"aeini ¢m SOIL LOG - PERCOLATION TEST LEGAL DESCRIPTION: KINCAID ACRES: LOT 3 PERFORMED FOR: ERIC WOHLFORTH DEPTH (feet) ORGANICSTGCT�F711 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 SM SOIL CLASSIFICATIONS DEPTH TO DATE GROUNDWATER DRY 9/9/2016 OF1k; 9/9/2016 I SITE PLAN I DATE READING CLOCK TIME NET TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 9/12/2016 1 - - 6" - 2 - 10 Ilrlll!11'./'//_% 3 - 7/8" 3 6" - 4 - 10 2 - 3/8" 3 - 5/8" 5 NMI 6" 6 - j;ZZZ4OA 2 - 4/8" 3 - 4/8" 7 6" �1�1�1�1+��l�1! 10 2 - 4/8" 3 - 4/8" 9 6" 10 - 10 2 - 4/8" 3 - 4/8" 11 DEPTH TO DATE GROUNDWATER DRY 9/9/2016 OF1k; 9/9/2016 I SITE PLAN I DATE READING CLOCK TIME NET TIME (MINUTES) WATER LEVEL READING NET DROP (INCHES) 9/12/2016 1 - - 6" - 2 - 10 2 - 1/8" 3 - 7/8" 3 6" - 4 - 10 2 - 3/8" 3 - 5/8" 5 6" 6 - 10 2 - 4/8" 3 - 4/8" 7 6" 8 - 10 2 - 4/8" 3 - 4/8" 9 6" 10 - 10 2 - 4/8" 3 - 4/8" 11 6- 12 - 10 2 - 4/8" 3 - 4/8" 19 PERCOLATION RATE 2.8 (MIN./INCH) PERC. HOLE DIA. TEST RUN BETWEEN 5.5 FT. AND 6.5 FT. 20 A FOUR HOUR PRESOAK WAS PERFORMED: ® YES ❑ NO SOILS LOGGED BY: DAVID GARNESS PERCOLATION TEST PERFORMED BY: ERIK WIDGER COMMENTS: PERCOLATION READINGS ARE WITHIN 1/16 OF INCH. PERFORMED BY GEG, Ltd. I, JEFFREY A. GARNESS, CERTIFY THAT THIS WAS PERFO MED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE: 10 111( V4 6 (INCHES) �itGPALITY Or f-.ia��,.,._ _...:� F5 DIVISIGN ENVIR01`I/E MUNICIPALITY OF ANCHORAGE © 1951 DEPARTMENT OF HEALTH AND HUMAN SERVICES © �io� 2 Environmental Health Division / 825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720 E CEWI EWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT Name DISTANCES FROM SEPTIC TANK ABSORPTION FIELD WELL Address Phone(s) Permit No. / No. of Bedrooms WELL 1612 / „/ma LOT LINE LEGAL DESCRIPTION Lot 3 BlockSubdivision — r 'I FOUNDATION Township, Range, Section L"J �� r., �/ AS -BUILT DIAGRAM driveway, water bodies, (Show location of well, etc.) septic system, property lines, foundation, TANKS SEPTIC ❑ HOLDING Manufacturer/ 47 A64 c V-2 tet' . Capacity in gallons f Z S' -L? / $ Material No. of Compartments Z TYPE OF SYSTEM p p �] TRENCH ❑ BED ❑ W. DRAIN ❑ OTHERc, Depth to pipe bottom from/ original grade 1;7_11 FT Total depth from original grade f Z FT v [ p Fill added above original grade 1--2- FT Gravel depth beneath pipe % FT Gravel length FT Gravel width ,3 —%r FT C1r co• ,z./ i Total absorption area SQ FT Distance between lines — FT Number of lines Soil rating /gT SQ FT Pipe material Ss— Installer Date Installed WELLS'Mc J$( PRIVATE ❑ OTHER (Identify) r Classification (A,B,C) Total Depth FT Cased FT Installer Date Installed: 1REMARKS: �1/�• // /` .1 Scale: Inspections Performed by: ENGINEER'S SEAL - - QsL� G+-� .S s•/f a -t GYr[ /o °._l fi'f �B:-1 f' i-/.ee �Z,..e! Date: ��/I7/FS7. as G Ort r �•r.a l T7t ; /z, .� ��' > `� � I certify that this inspection was performed according to all Municipal and Slate guidelines in effect on this date: r Health Department Approval: Date: 72-013 (3/85) MUNICIPALITY OF ANCHORAGE Department o{ Hea1th & Human Services 825 L Street, Anchorage, Alaska 99501 343-4720 ON-S�TE SEWER & SEPTIC TANK to WELL FARMIT Permit Number: 870296 Date Issued: 10/30/87 Owner Name: ERIC 0131 -FORTH Day Phone: Owner Address: 1332 HILLCREST 688-2759 ANCHORAGE� AK 99503 Parcel Id: 121 Lot Legal: hibdivi rINCAI[>)4CRES Lot: , Block^N/A Section: 9 Township ^'`� a: 12N nange: � ^` -111 Lot Size 4.0 A (sq.fi. or acres> Max Bedrooms: This Permit: 4 Total Capacity: 4 SEWER SAW TEMS: Listed below are tle oPtions available to you in des igni:g ;mur sewer system. Choose the option that best [its your site. T R E N C H B E D W. D R A I N Depth Lo Pipe Bottom (ft): 5.0 Gravel Depth ([t): 5'5 Total Depth (fi): 10.5 Gravel Wi(Aih (ft): 2.5 24"0 5,0 Gravel Length ([t): 69.0 ** 47.0 88.0 ** Gravel Volume (cubic yds): 38.4 41.8 57.1 Soil Rating Used (sq ft/to rm): 188 188 l8S ** Gravel length > 50 [eet requires multiple soils tests. ** Gravel lcon vsth > 75 feet requires multiple runs (not exceeding 75 in each), LlFT STATION: If a lift station is installed; a high water be alarm must connected tc the residence. SEPTIC TANK: Minimum total septic tank capacity: J. Each gallons. septic �ank musL have at least 2 compartments. Depth to top o[ septic tank(s) < 4,0 feet requires insulation over tank(s). WELL: Log must be submitted to Municipality o{ Anchorage Departme:t o� Healt� and Human Services within 30 days of well completion. NOT lFY DHHS PRIOR TO 1ST to 2ND INSPECTIONS. PH�NE 343~4681 AFTER 5:00 P.M" MUNICIPALITY OF ANCHORAGE Department o� Health & Human Services 825 L Street, Anc�or�ge, Alas�a 995�1 343-4720 ON-SITE SEWER & SEPTIC TANK & WELL PERMIT Permit Number: 870296 Page 2 10.40 Municipality of AnchorageDEPARTMENT OF HEALTH & HUMAN SERVICES825 "L" Street, Anchorage, Alaska 99502-0650 R t REID !R, SOILS LOG — PERCOLATION TEST ®5.2251 & & PERFORMED FOR: '41a', leoslnT4-1 DATE PERFORMED, � 3�$%• LEGAL DESCRIPTION: /0`3 3 t`/n7ca,o /9c -K t" Township, Range, Section: T/z,ci /2•y�,J S 9 DEPTH - SLOPE SITE PLAN (FEET) 6r-92,r,c hyc..r. I I 1 I I� 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 S, / t se z M C-9 z ) 1.., 7'�' L'aiarry S�,o) /2t1 trr OP7 / J, q,{/� �J c l!e SM�H y / WAS GROUND WATER ENCOUNTERED? Sa .) je-* /bA'�de6d• (/v/ PO S IF YES, AT WHAT L O DEPTH? p E Depth to Water After Monitoring? Z)Y�2 Date: ■■NNEN Net Time Depth to Water Net Drop �Ff� /02aq d 7 iii■■NEENNEMMME' 0,67-0, s 01/Z /J - /33 io o -��t5 •o / /33Y -/S O U■ME■N1®EN® 0.06 4 7 - 0 o t /35-6-�yoG p ■■■■■RIMM■■ Reading Date Gross Time Net Time Depth to Water Net Drop �Ff� /02aq d 7 Jv 0,67-0, s 01/Z /J - /33 io o -��t5 •o / /33Y -/S O 0,67- OTb/ 0.06 4 7 - 0 o t /35-6-�yoG p D.ed 20 I ' PERCOLATION RATE -AL-7-- PERC HOLE DIAMETER u TEST RUN BETWEEN 3 FT AND L'r FT COMMENTS z�e (° /F1S�Q�I6/ Gita der_¢ �Jerc-G St;� �¢-7�we< Sa el /L•S-{ 'v4-17" PERFORMED BY: 1 • a Id I � • I?c � � CERTIFY THAT THIS TEST WAS PERFORMED IN ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE: 72-008 (Rev. 4/85) (�rx#tfir� i5notting !,[jag n> DOC Co. d0a SULLIVAN WATER WELLS P.O. BOX 670272, CHUGIAK, ALASKA 99567 • TELEPHONE 6882759 OWNER OF LAND -Ale IC L," t14 En I Ff ADDRESS LEGAL DESCRIPTION DATE, - Started-- Ended PERMIT NUMBER�?- 7 cl � KIND OF FORMATION From "r Ft: to c Ft. 0`',110 c; Froin—Ft. to F[. From Ft. to � cy Ft. ./.,. S:14 Ft. to Ft. •,' 73 Ft. f� / �" rq;,k-i 1) From Ft. to From ✓. L Ft. to / - Ft. V ✓4nK/I From J t7 -°<M6 4z ' From Ft. to Ft.a Ft. g� =e Ft.fib� eaZ .. Ftt QT" p — a F.jto ,? FL r r From f Tf Ft. to ��_�. _Ft. I From.' ''s Ft. to ft7 i Ft Ft. to Ft. From Ft. to Ft From Ft. to Ft. From From l t_': 1 Ft. to ,w3 j=-2 Ft. f i From Ft. to FL Ft. to Ft J Q, Ft. to Z)3 Ft .�From c,1�Ft. to--!- .� t" Ft. From N'l Ft. j Ft. Fromt to From Ft. to -Ft. ' From Ft. to Ft. From Ft. to Ft. From _Ft. to Ft. MISCL. INFORMATION: DEPTH OF WELL / STATIC LEVEL OF WATER FT. DRAW DOWN FT. GALS. PER HR KIND OF CASING From-- Ft. to Ft. From Ft. to Ft. _ From Ft. to Ft. _ From Ft. to Ft._ From Ftto ht Froin—Ft. to F[. From Ft. to Ft. From Ft. to Ft. From Ft. t ca F J t7 From From From From Ft. g� =e Ft.fib� eaZ .. Ftt QT" p — a F.jto ,? FL r r V I From Ft. to Ft. From Ft. to Ft -- From Ft. to Ft. From Ft. to Ft DRILLER'S NAME MUNICIPALITY OF ANCHORAGE • Department of Health & Human Services M}j DIVISION OF ENVIRONMENTAL SERVICES — 343-4744 CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL OF ON-SITE SEWER AND WATER FACILITY FOR SINGLE FAMILY DWELLING Parcel I.D. D. # W — a\'� 0C HAA #, 1. GENERAL INFORMATION (Must be completed prior to submittal) (a) Legal Description (include lot, block, subdivision, section, township, range) Location (addwss or.dir6didns) '. .,.::,E«,.>.�..+gid.•-,.:" �C .3� 9—Business�oLr�7 Telephone: (home) 7% b Property owner ,> Mailing Address;�`� '' je (c) Lending Institutiori Telephone Mailing Address (d) Real Estate Company and Agent Address Telephone (e) Mail the HAA to the following address: (or check here if hold for pick up.) List contact person and day phone number below: -s P//'/z uP 2. TYPE OF RESIDENCE Single -Family Number of bedrooms 3. WATER SUPPLY Individual Well`$ Community ❑ Public ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to th legality and status. 4. SEWAGE DISPOSAL On-site Public ❑ Community ❑ Holding Tank ❑ Note: If community well system, must have written confirmation from the State Department of Environmental Conservation attesting to the legailty and status. 72-025 (Rev. Meat Page 1 of 2 5. 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 safo, 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/Cf Telephone Address i/L i 37 / Ike Date 6 Z-71_SYSj `l 93"d-.? OF A4 Ar jr I s• TH64 a 0 00 to f tF ,40•4040 4006004►• too*** • A •.• CE - 2251 : ! 6. DHHS APPROVAL Approved for bedrooms by G Date Approved _-_Disapproved Conditional Terms of Conditional Approval The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority Approval cerificated 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_ 7/88) Back Page 2 of 2 F PN0N�RN�s��ta �L�jV ER MUNICIPALITY OF ANCHORAGE (MOA) 04"e NSP s u Health Authority Approval (HAA) NSE CHECKLIST - FEBRUARY 1984 �N J��� 343-4744 Legal Description: o� A. WELL DATA Well Classification - �Dpm�nr If A, B, C, D.E.C. Approved (Y/N) Well Log PresentON) Date Completed - Yield -45-0 4701 46 V /x(� Total Depth 3a i Cased to 3©� Depth of Grou in A) Static Water Level 7.13 Pump Set At Casing Height Above Ground Sanitary Seal on Casing (Y ) Electrical Wiring in Conduit6)/N) Depression Around Wellhead (Y® SEPARATION DISTANCES FROM WELL: / 1 To Septic/Holding Tank on Lot /6Tr On Adjoining Lots % 7 p-0� To Nearest Edge of Absorption Field on Lot ��tl ; On Adjoining Lots To Nearest Public Sewer Line To Nearest Public Sewer Cleanout/Manhole /- To Nearest Sewer Service Line on Lot '?, Water Sample Collected byf/�� ; Date Water Sample Test Results ae7� A) 7-Z 7-5 Comments B. SEPTIC/HOLDING TANK DATA Date Installed 11-17-'f7Size /7­�b No. of Compartments Z_ Standpipes&N) Air -tight Caps N) Foundation Cleanout Y N) Depression over Tank (Y19 Date Last Pumped - A&IJ AV55— Pumping/Maintenance Contact on File (Y/N) AyAt ; for Holding Tan44H/Vater Alarm (Y/N) Temporary Holding Tank Permit (Y/N) �6140 e ">'"',u SEPARAI Iti3Ft411✓Fa FROM SEPTIC/HOLDING TANK: of -.Lyse To Water=,�upp }�� �To Building Foundation �© t To Pro�'�t�"Lfr��"ss ��d" :b 1 To Disposal Field /0 ' 4" 1 14. To V�`lat'er"•,�j�%r1`,�SY$�v�'1�;,�ie�` r /� •�" To Streanj,sRQnd, take g.r. jpr' Drainage Course •�' .!.y fb 4 Comments /' i,: 72-026 (Rev. 7/88) Front Page 1 of 2 Lf K/N6.`t7y r7c Nr C. ABSORPTION FIELD DATA Soils Rating in Absorption Strata Date Installed r Width of Field V's ,�Type of System Design �ca� Length of Field Depth of Field / G Gravel Bed Thickness Square Feet of Absortion Area 8' Statndpipes Present(Y/ ) Depression over Field (Y6 Date of Last Adequacy Test xJ14 Results of Last Adequacy Test 1)ZA SEPARATION DISTANCE FROM ABSORPTION FIELD: / To Water -Supply Well To Property Line �`'0 To Building Foundation's To Existing or Abandoned System on Lot ��/4 ; On Adjoining Lots -'- To Water Main/Service Line To Cutback (if present) f4 To Stream, Pond, Lake, or Major Drainage Course i To Driveway, Parking Area, or Vehicle Storage Area Comments D. LIFT STATION Da�aee Ynsall Size in GEallons "Pump On" Level at High Water Alarm Level at Tested for Meets MOA Electrical Codes (Y/N) Comments Dimensions Manhole/Access (Y/N) "Check Permitted Bedroom Rating Against HAA Request" "Pump Off" Level at Vent(Y/N) Pumping Cycles during Adequacy Test. I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection. /' OF A4 Signed G f�D �� �Q��o.••.e°.�p,4 Company Date MOA No Receipt No. � L 7 O C6 63 9 Date of Payment —/0 J Amount: $ 1:2 0--©U Receipt No. �F'r0lessi,g`� Waiver Fee: $ Date of Payment 72-026 (Rev. 7/88) Back Page 2 of 2 Seal