HomeMy WebLinkAboutTANAINA HILLS LT 5Tanaina Hills
Lot 5
#011-051-06
MUNICIPALITY 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
C' 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
Name
A'oe_ /r/Qa jJi if or-, /tvj. 1).
DISTANCES
TO
FOOM
SEPTIC
TANK
ABSORPTION
FIELD
WELL
Atltlreea -- A ---
6 2 3=l i';n ,t n,_ 0:J_
f.� y� h !: a ) �r S
WELL
%
f ) Q
Phoneed
Permit No.
No. of Retlrooms
LOT LINE
LEGAL DESCRIPTION
Lol Block Subtlrvisron
'Tang%nn
FOUNDATION
u9
r
Township, Range. Section
( / 1�
AS -BUILT DIAGRAM (Show location of well.
driveway, water bodies, etc.)
septic systemproperty lines. Whorl
TANKS
O_SEPTIC ❑ HOLDING
Manulaclmer
Capacity in gallons
J
Material
No. of Compartments
zI
rrI
In7
77W
TYPE OF SYSTEM
j
R TRENCH ❑ BED ❑ W. DRAIN ❑ OTHER
Depth to pipe boltom from
original grade yam.
' FT
Total depth Irom original grade
/3 FT
--
7I
It
L
Fill added above original grade,
FT
Gravel depth beneath pipe
_ �% FT
Gravel length _
} FT
Gravel width
.3 FT
_
Total absorption area n
S46 SQ 'TJ
Distance between lines
AIA FT
Number o1 Imes
Soil rating
3 SQ FT
Pipe material
Installer
Date Installed
WELLS
❑ PRIVATE ❑ OTHER (Identifv)
QassiT,caF0 -A. B. CI
Total Depth
FT
Cased to
FT
Irrstalle
Date Installed.
REMARKS:
l-�-J
scale:
Inspections erlormed by.
ENGINEER S SEAL
Date.
'10 - ry-
inspection was perlormed according to all
I — cetlily that this
Municipal and Shale guidelines in ¢Ilett on this dale: _ %p — % y .X
Health Department Approval: '
�t� � Date. I'' yr_
72-013 (3/85)
10 1 J I YJ 3: t: 1 1: F" 04 0 . :1'-T, Cli 11 = INN 1� -1 C]I F-;'! e!::"h EEV, F -E
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
025 L STREET, ANCHORAGE, AK 99501
264-4720
17111�10 2: Q- U;
PERMIT NO: 850503
DATE ISSUED: 08/14/85
APPLICANT: RODMAN WILSON, M.D.
ADDRESS: 6234 TANAIN0 DRIVE
ANCHORAGE, AK 99502
CONTACT PHONE: 264^4622
to Q 0A EE Q ��HOT �:1: -1
LEGAL DESCRIP: SUBDIVISION:
TANAINA HILLS
LOT: 5
BLOCK: NA
SECTION: 4
TOWNSHIP: 12N
RANGE: 4W
LOT SIZE: 2"74A (SQ"FT.
OR ACRES)
'
LOT LOCATION: 6234 TANAINA
DRIVE
MAX BEDROOMS: 4
Listed below are the options
available to you
in designing
your septic
system" Choose the option that
best fits your
site.,
'
�F������
��
�
��� ����A�
DEPTH TO PIPE BOTTOM (FT.)
4.0
4"8
4^0
GRAVEL DEPTH (FT.)
9.0
0"5
3"5
TOTAL DEPTH (FT")
13.0
4"5
7^5
GRAVEL WIDTH (FT.)
2,5
24"0
5"0
GRAVEL LENGTH (FT.)
41.0
46.0
79"0 **
GRAVEL VOLUME (CU"YDS.)
36"1
40.9
58"6
TANK SIZE (GALS)
1/250"0 **
1,250.0 **
1,250^0 **
SOIL RATING (SQ"FT"/BR)
183
1%
103
** GRAVEL LENGTH > 75 FT, REQUIRES MULTIPLE RUNS (NOT EXCEEDING 75 FT. EACH)
** TANK MUST HAVE AT LEAST TWO COMPARTMENTS
--~--~----�-^---~^^~^-^----~~`-~~'----�r-
I certify that:
A. I am familiar with the requirements for On-site sewers and wells as set
forth by the Municipality of Anchorage (MDA) and the State of Alaska.
2. I will install the system in accordance with all MOA codes and regulations,
and in compliance with the design criteria of this permit"
3. I will adhere to all MOA and State of Alaska requirements for the set back
distances from any existing well, wastewater disposalsystem or public
sewerage system on this or any adjacent or nearby lot"
4. I understand that this permit is valid for a maximum of 4 bedrooms/and
any enlargement will require an additional permit.
IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILDING CODES,
THEN (1) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED; (2) AS^BUILTS
WILL NOT BE APPROVED WITHOUT AN ELECTRICAL INSPECTION REPORT; AND (3) THE
ELECTRICAL WORK MUST BE DONE BY A LICENSED ELECTRICIAN"
SIGNED DATE:
///
�����`�'���`~���~����~-����~`~��— - -, ������`�..........~��.....
APPLICANT: RODMAN WILSON, M.D.
ISSUED BY DATE:
PERFORMED FOR: Dk
LEGAL DESCRIPTION: LO.7-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 L" Street, Anchorage, Alaska 99502-0650
SOILS LOG — PERCOLATION TEST
(ENGINEER'S SEAL)
I
wr�s��l b-5 bs
DATE PERFORMED:
/Y'/
j 7 Ar14 *t3 Township, Range, Section: 'T/ 2 N A" 5t C
SLOPE
T
WAS GROUND WATER ,/O
ENCOUNTERED? /V
IF YES, AT WHAT
DEPTH?
Depth to Water After
Monitoring? Date:
E
Reading Date Gross
Time
zz
Net
Time
Depth to
Water
Net
Drop
4 0 8- -8 Io Z'
0
/o
66
r /
/o S
Lo
/l l
/0 /u,J
If rw iw
PERCOLATION RATE�/'L N L�mmutesimch) P RC HOLE DIAMETER 5/
TEST RUN QETWEEN 4 FT AND il S FT
COMMENTS /o.a. ��,.w / r ruv /a.i-i•/OVA-11
PERFORMED BY: CERTI4FY/ THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATE:
72-008 (Rev. 4,85)
ON REPORT ON-SITE SEWAGE DISPOSAL
Name_Rod_ W.il5oAl Mailing AddresstTMAIL GtV Ph.#
Location,al P p �n `Y~Y 66f S !/fiS%�!�`�f LfIet gue
Le Description
SEPTIC TANK: Distance from well Material�O��E%E Number of compartments__I_
Liquid capacity_ gallons. Inside lengtj)'Z/ Inside width 3'10 Liquid depth 60��
SEEPAGE SYSTEM: Seepage Pit: Number of pits 2 Outside diameter �%eG or
width—, length__, depth `
�y2�
_, lining material IMCDistance from
well //0 , building foundation
,nearest lot line Total effective
absorption area (wall area) sq, ft.
TILE_DRAIN FIELD; Distance from well , foundation_, nearest lot line—
Total length of lines Number of lines Distance between lines Trench
width in. Total effective absorption area sq. ft. Length ofe` ach line
Depth: Top of tile to finish grade Depth of filter material beneath
the in. Above tile
WELL: T
ype yL+ depthp64 ,distance from building foundation �/e�e, nearest
lot line, nearest sewer line, septic tank > seepage system /rd ,
cesspool , other. sources
DISTANCES:
A to 'g7
b'9'
A/Za 6
A't', T
DATE: V 1
SEWAGE DISPOSAL SYSTEM - APPLICATION 6 PERMIT �
Name of ApplicantZL/LhA/4 /5,d//4.Q• Mailing Address _ Ph. -�-7']-61711
Residence Address,, j 'V ur'' Location of Installation .�
Legal Description y r}/` J1`.SLP�i
Application to Install: Septic tank, Seepage pit✓ Drain field ,Other
To Serve the Following Facility ,y 1/�C7 % C-r4m;&I P r -S Liyi v r p
Financed Through To be Installed by
Percolation Test Results Anticipated Date of Completion _ r', -O --G g
BELOW TO BE FILLED OUT BY HEALTH DEPARTMENT
This is to serve as , permit to install a
as described below. Size of unit to be served
— Septic tank size_ Type Seepage Area -
yp T e
.--.., ...,......,_ .. -....
DISTANCES:
-iC4ealth Aut or. ty
I certify that I am family"" w7.th the requirements
Of Greater Anchorage Area Borough
Ordinance No. 28-68 and that the above described system is
in accordance with said code.
Municipality of Anchorage
--1 Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 Elmore Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 011 - 05.1 - OS COSA # HA oa o(3a g
Expiration Date: :Z-.2,3 —0 C1
1. GENERAL INFORMATION
Complete legal description J.of S, Tanaurn Me/G S /.b
Location (site address) S2 3Y Tcen crena Drive
Current Propertyowner(s) be4orc4A Fen k Day phone Yo 6S -o:LES-
Mailing address
Lending agency
Mailing address
Real Estate Agent.
Mailing Address
_627Y '7;qMe2#na Drive., %lntho. A -49c 9QS0Z
Day phone
fFrrvcA ►}einroeh, Prwdenheil Dayphone 3Y9-'73?7
3861 Cenkrno,nf Dr. A.ncAor! rg Ak 99SO-7
Unless otherwise requested, COSA will be held by DSD for pickup. P 1 eeveo Cal/ R evx/for @ 3 YQ -733.7
2. NUMBER OF BEDROOMS: t/ coke" CaIA rt'r.cry {or peck -sr
3. TYPE OF WATER SUPPLY:
TYPE OF WASTEWATER DISPOSAL:
Individual Well
JKI
Individual On-site
Individual Water Storage
❑
Individual Holding Tank
❑
Community Class Well
❑
Community On-site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of On -Site Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with valid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. 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,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) 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(are) In compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Ftuhfep 7_611741ca/ Slf"«ti Phone 3 VS- ► 34S
Address JNS3o Ec-4e minyan Rol.,i A -k 99Sy/
Engineer's Printed Name 71" eoxeore F. m&c ee Date V1151 -LOOP
5. DSD SIGNATURE
!/ Approved for ___�L bedrooms.
Disapproved.
rV7 As �
Y J .
y.( .......... Y.�• .:...
fff , TH;;pCOS9 r. Af70CE a /iyt
1
Conditional approval for bedrooms, with the following stipulations:
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date: "f ' Z 3- o ci
(R... 11105)
Municipality of Anchorage
Development Services Department
� Building Safety Division ���••• ••• 1:1
-- ' On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907)343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: Q,I'r, TanCron a flit 14 r1b Parcel ID: Of -0-7-1-06
A. WELL DATA
Well type
Date completed 19 8
Total depth o• ft.
Date of test _
Static water level _
Well production
If A. B, or C provide PWSID #
Sanitary seal (YIN) 'r
Cased to?YO ft.
FROM WELL LOG
ft.
g.p.m.
WATER SAMPLE RESULTS:
Coliform _0_colonies/100 mL Nitrate 40- f mg/L
Arsenic: <-,r ppb date of sample: 09
B. SEPTIC/HOLDING TANK DATA
TankType/Material Senf4c ISI -eel
Well Log (YIN)
Wires properly protected (YIN) _r
Casing height (above ground) 12 t in.
AT INSPECTION
y/8/ Z&O9
16 3 e.
9 -t g.p.m.
Other bacteria 0 colonies/100 mL
Collected by: 7_eC4
Date installed 10 / I y / sr
Tank size 12J'0 gal. Number of Compartments 2_ Cleanouts (YIN) Y
Foundation cleanout (YIN) Y Depression over tank (YIN) _V(� High water alarm (YIN) N. A..
Date of pumping!/ /1012,00 9 Pumper A -t IA-,oe Serve c ,,
C. ABSORPTION FIELD DATA
Date installed D I S Soil rating (g.p.d./ft2 or ftZ/bdrm) 163 17' System type Trrrc h
r3D?,;
Length K 7 ft. Width 3 ft. Gravel below pipe 9 ft.
Total depth 13 ft. Eff. absorption area 6�_f? Monitoring tube 7 Depression over field "
Date of adequacy test 'y / 6/ 09 Results (Pass/Fail) Pat/ For Y bedrooms
Fluid depth in absorption field before test -32r4 in. Water added (2{ gal. New depth'��.
Elapsed Time:' -7 min. Final fluid depthYo3/vin. Absorption rate >= 6 GO g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N& type) Nu n C kn c wn If yes, give date N • /�
D. LIFT STATION N. A.
Date installed
"Pump on' level at_ in.
Datum
E. SEPARATION DISTANCES
Size in gallons
'Pump off" level at —In.
Cycles tested
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot IIB'
Absorption field on tot 130'
Manhole/Access (YIN)
High water alarm level at
Meets alarm 8 circuit requirements?
On adjacent lots > 100 1
On adjacent lots > 1001
Public sewer main ti -A. Public sewer manhole/cleanout M. A
Sewer /septic service line > 2d"' Holding tank N • A.,
Animal containment areas N. A. Manure/animal excrete storage areas N• A
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation K I' Property line ZS,_O' Absorption field > 6'
Water main > too' Water service line > 100Surface water > too,
,Wells on adjacent lots > t00 '
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
in.
Property line > 10' Building foundation 7 �' Water main >1001
Water Service line > 100' Surface water > 160' Driveway, parking/vehicle storage
Curtain drain NvnL0 Se.o^ Wells on adjacent lots >!GG'
F. COMMENTS
SV-4ef" pre–Soaked Prrtsr la Srrrt
r.A,d� mer el
or teA4it9
G.' ENGINEER'S CERTIFICATION
•" f;0 •, s+,,,,
I that 1 have determined through field inspections and1�rCtTH
11.1 ,•; i,
certify
'review of Municipal records that the above systems are in
�...' ...............:•..q)
conformance with MOA COSA guidelines in effect on this date.
Engineer's Printed Name Ti7eod02' f-• t'-rcovr
CL -31,39 ' ,t '47
Date-' 9
r.:•
.,
COSA Fee $ L190
Dateof Payment ��02 f
Receipt Number Ud �%g r
(Rev. 11105)
Waiver Fee $
Date of Payment
Receipt Number
1
R•ee.0W 9•12-9!ilk
I
.lt-BUIL!' SDRYaT i
I hereby seriL4 that I have surveyed the 17021os_18 dssaribed property
LOT 3, SABADLA Kl=3 SUED.
regi namy IQ sated as she, as •, an ut tie — i
Cars a a,n o roadways,
tbensa ars IQ sated
a s!»m on this plot, and that
t2an w no nadsgs, transsSssloa lines er other visible essomonts on
said property •aoept a indicated hereon.
Dated at Anahoraga. Alaska, this 0th day of Jan. 1969.
Cf144L
9r _
C4,Ev
,L1 i
n is a ca, eglacsre'3'6ng1n•:r iP�tY'""`tt�8h •fa i'.. r•'+•yt4
Is
Fred
tAAssociate
toginaers v.ors
3107 29th Avantn 0 ��ett•eqo.E
Anchorage, Alssis 904e- ..1.•Q.�'y
SCS ReO
Client Name
Project Name/b
Client Sample ID
Matrix
Sample Remarks:
14
1091339001
Flattop Technical Srv.
Lot S,Tanaina [fills
Lot S,Tanaina [fills
Drinking Water
Printed Date/Time
Collected Date/Time
Received Date/1'ime
Technical Director
04/17/2009 13:02
04/062009 11:50
04/062009 12:10
Stephen C. Fade
Allowable Prep Analysis
Parameter Results PQL Unit: Method Container ID Limits Date Date Init
Metals by ICP/MS
Hardness asCaCO3 ND 5.00 mviL SM20234011 C 04/08/09 04/09/09 NRB
Waters Department
Total NitratcNitritc-N
ND
O.IOC
mg,L
SM204500NO3-F
13
04/09/09
JD7,
Private Individual Analysis
Aluminum
ND
20.0
ug'L.
E1200.8
C
04/08'09 04,'09'09
NRI3
Antimony
ND
1.00
ug/I.
E1200.8
C
(<6)
04/08/09 04'09,'09
NRB
Arsenic
ND
5.00
ug/l.
E1200.8
C
(<IO)
04/08/09 04/09.109
NRB
Barium
ND
3.00
ug'I.
EP200.8
C
(<2000)
04/08/09 04/09/09
NRB
Cadmium
ND
0.50C
ug/l.,
E1200.8
C
(<5)
04/08/09 04/09'09
N1113
Calcium
ND
500
ug/l,
EP200.8
C
04/08,'09 04109/09
NRB
Chromium
ND
2.00
ug/L
EP200.8
C
(<I00)
04/08/09 04/09/09
NRB
Copper
9.76
1.00
ug'I.
E1200.8
C
(<1300)
04/08/09 04/09'09
N1111
Iron
ND
250
ug'I.
E1200.8
C
(<300)
04/08/09 04/09•'09
NIM
Lead
0.398
0.20C
ug'L
EI1200.8
C
(<15)
04/08,'09 04/09109
NRB
Magnesium
ND
50.0
ug'l.
ENOO.8
C
04/08/09 04'09/09
NRB
Manganese
2.90
1.00
ug/l.
E1200.8
C
(<50)
04/08/09 04'09'09
NRB
Chloride
7.14
O.IOC
mg 1,
EPA 300.0
D
(<250)
04/15/09 04/15/09
JIM
Fluoride
ND
O.IOC
mgL
EPA 300.0
D
(<2)
04/15/09 04/15.'09
1D7.
Selenium
ND
5.00
ug![,
E11200.8
C
(<50)
04/08/09 04/09:09
NRB
Sodium
116000
2500
ugli.
E1200.8
C
(<250000)
04/08109 04/09,09
NRR
Silver
ND
L(q
ug/l.
ENOO.8
C
(<100)
04/08/09 04109'09
NRB
Sulfate
8.62
O.IOC
mg 1,
EPA 300.0
D
(<250)
04/15/09 04115109
1D7
Thallium
ND
1.00
ug'L
ENOO.8
C
(Q)
04/08109 04/09/09
NRB
Zinc
ND
5.00
ug'I.
E1200.8
C
(<5()00)
04/08/09 04/09.'09
NRB
M
SCS Ref.#
Client name
Project Name/#
Client Sample 11)
Matrix
1091339001
Flattop Technical Srv.
Lot S,Tanaina Flills
Lot S,Tanaina }tills
Drinking Water
Printed Daterrime
Collected Date/'fime
Received Datefrime
Technical Director
04/172009 13:02
04/062009 11:50
04/062009 12:10
Stephen C. tide
Allowable Prep Analysis
Parameter Results PQL Unit: %I:shod Container ID Limits Date Date Init
Private Individual Analysis
,
Total Dissolved Solids
309
10.0
mgt 1.
SM20 2540C
D
(<500)
04-'07/09 RJT
Nickel
ND
2.00
ug'L
EP200.8
C
(<I00)
04/08'09 04/09/09 NRB
11CO3 Alkalinity
285
10.0
mpL
SM20 2320B
D
04'13.'09 WAW
Conductivity
505
1.00
umhnfiCm
SM20251011
D
04/06/09 RJ7
pit
7.20
0.10C
pl I u dis
SM20 4500-11 D
D
(6.5-8.5)
04,'06'09 RJT
Alkalinity
285
10.0
mg, 1.
SM20 232011
D
01/13/09 WAW
Colony Count
0
coli 10 hnL
SM20 922211
A
01%06'09 KAR
Total Colifonn
0
coV10)ml.
SM209222B
A
(<I)
01/06/09 KAR
Fecal Coliform
0
coV10)mL
SM20 9222B
A
04'06/09 KAR
S -.34,
MUNICIPALITY
.s4-
MUNICIPALITY 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. # n\ It - C)Z,\ - n, -rvY_-�
HAA # i % -) b Z� LI
1. GENERAL INFORMATION _
Complete legal description Z_0-" 51
Location (site address or directions) 62H Thain 0. HI'lls Drive -
Property owner. �R- RoDMA/V WILSON Day phone
Z�'3-55$3
Mailing address 6231 /angih0. Dr, 27502-
Lending agency e_maax Qr ,, e_S .Tkic Day phone 276- 276
Mailing address 2600 Cayyoo . , � 9503
Agent &e''"' Cro`^/ lee Day phone 25,7-01711
Address 2600 Cpf'Ay0. , 99503
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: / �
3. TYPE OF WATER SUPPLY:
Individual well i
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site X
Holding tank
Community on-site
Public sewer
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
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® Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: G oT 5 ,V.Mk42 TAnai na 05 Parcel I.D.
A. Well Data
Well type
7n VQ1ti If A, B, or C, attach ADEC letter. ADEC water system number IVIA
/l/ 96 '
Log present (Y/N) D Date completed I S Driller
Total depth 20 y Cased to unknawr. Casing
Sanitary seal (Y/N) Y Wires properly protected (Y/N).
SEPARATION DISTANCES FROM WELL TO:
uki kn cwn
height
Y
12
AT INSPECTION
7/3//MUNICIPALITY OI-NMt-PIUI�,1ISI
r , MONMENTAI. SERVICES [)IVISIQN
)57' oc 1 -I 1993
2,8 g.p.m.
N i80' RECE..IVED
Septic/holding tank on lot 115 ; On adjacent lots
r
Absorption field on lot I Z. -J
; On adjacent lots
Public sewer main N14 Public sewer manhole/cl
Sewer service line N/A Petroleum tank �L
WATER SAMPLE RESULTS:
Coliform 0 / Nitrate < 0.05
Date of sample: 9/3 /93 Collected by:
> /00
> /00 1
N
Other bacteria
111,4- r,9.rW Ko Ra NIA/
B. SEPTIC/HOLDING TANK DATA
Date installed gf2y185 Tank size 12-50 &q/ Compartments
Z
Cleanouts (Y/N) T Foundation cleanout (Y/N) y Depression (Y/N)
High water alarm (Y/N) /V/11 / Alarm tested (Y/N) NIA
Date of pumping 7123 / 9 2 Pumper ZS 0.a c 'S
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
r
1 i
Well(s) on lot 1 1 5 On adjacent lots /c�0 —Foundation (3
2 r IVIA
To property line > 10 Absorption field Water main/service line
Surface water/drainage A
72-026(3193)• Front CONTINUED ON BACK PAGE
FROM WELL LOG
Date of test
Unknawo_
Static water level
�%nkhawrn
Well flow
(AknaW+1 g.p.m,
Pump levels
(%n knawn
SEPARATION DISTANCES FROM WELL TO:
uki kn cwn
height
Y
12
AT INSPECTION
7/3//MUNICIPALITY OI-NMt-PIUI�,1ISI
r , MONMENTAI. SERVICES [)IVISIQN
)57' oc 1 -I 1993
2,8 g.p.m.
N i80' RECE..IVED
Septic/holding tank on lot 115 ; On adjacent lots
r
Absorption field on lot I Z. -J
; On adjacent lots
Public sewer main N14 Public sewer manhole/cl
Sewer service line N/A Petroleum tank �L
WATER SAMPLE RESULTS:
Coliform 0 / Nitrate < 0.05
Date of sample: 9/3 /93 Collected by:
> /00
> /00 1
N
Other bacteria
111,4- r,9.rW Ko Ra NIA/
B. SEPTIC/HOLDING TANK DATA
Date installed gf2y185 Tank size 12-50 &q/ Compartments
Z
Cleanouts (Y/N) T Foundation cleanout (Y/N) y Depression (Y/N)
High water alarm (Y/N) /V/11 / Alarm tested (Y/N) NIA
Date of pumping 7123 / 9 2 Pumper ZS 0.a c 'S
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
r
1 i
Well(s) on lot 1 1 5 On adjacent lots /c�0 —Foundation (3
2 r IVIA
To property line > 10 Absorption field Water main/service line
Surface water/drainage A
72-026(3193)• Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed NA Manufacturer
Size in gallons Manhole/Access (Y/N)
Vent(Y/N) ---
High water alarm level
"Pump on" level
Meets MOA electrical codes (Y/N) —
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
D. ABSORPTION FIELD DATA
On adjacent lots --
"Pump off" Level at
Cycles tested
water
Date
Date installed 812-2-185 Soil rating (GPD/Ft2) O. 8 System type %r � (DW)
Length 'q7' Width 3 r Gravel thickness % / Total depth �3 r
Total absorption area 8 y6FT 2 Cleanout present (Y/N) r� _Depression over field (Y/N) _ �/
Date of adequacy test 913(/8 3 Results (pass/fail) II /T S for 7 Bedrooms
n u
Water level in absorption field before test S (AF1'Ele F/LUNG)�fter test z1Q (NPRoK, 3 0 99 (li„CJ�
Peroxide treatment (past 12 months) (Y/N) N If yes, give date 111A
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I ) 5 On adjacent lots > /00 Property line
r
To building foundation 75 To existing or abandoned system on lot _
On adjacent lots W A Cutbank AM Water main/service line_
Surface water NZA Driveway, parking/vehicle storage area 501
Curtain drain /N
E. ENGINEER'S CERTIFICATION
>l0 '
>/0'
NA
l certify that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
l`\294 °mon nco an 4
Signature
Engineer's Name Earle /IUSmQY1 M6eeveo°oo``o°:oo°°au
d` 3 tr/1RiE V. Ae3MA9I
Date 917193 G' CE -1393
HAA Fee $
'go 0
Date of Payment /(% w 9-3
Receipt Number �2 S- =3 L0 6 92-
"Pump
L
72026 (3/93)' Rack
Waiver Fee $
Date of Payment
Receipt Number
NORTHERN
TESTING
LABORATORIES,
INC.
3330 INDUSTRIAL AVENUE
FAIRBANKS, ALASKA 99701
907-456-3116
2505 FAIRBANKS ST.
ANCHORAGE, ALASKA 99503
907-277-8378
PolarConsult
1503 W 33rd Avenue
Anchorage AK 99503
Attn: -
Our Lab #: F12793O
Location/Project: -
Your Sample ID: /p23NTanainal
Sample Matrix: Water Y�t�
Comments:
Method Parameter
-------------------
EPA 353.3 Nitrate -N
Reported By: Patricia A. Woody
Senior Chemist
Units
------------
mg/l
Report Date: 09/13/93
Date Arrived: 09/07/93
Date Sampled: 09/03/93
Time Sampled: 1300
Collected By: MK
MDL = Method Detection
Limit
* Flag Definitions
B = Below Regulatory Min.
H = Above Regulatory Max.
Date Date
Results * MDL Prepared Analyzed
<MDL 0.05
09/11/93