HomeMy WebLinkAboutQUIET WOODS LT 6EQuiet Woods
Lot 6E
#050-281-51
WELL CONSTRUCTICN LOG
Drilling Co.. ee
Driller USGS no.
k= ��'�.i��lape of na3'T A Olte sell coeDlated_Q�S_!' /w, /f!/
toll oa net
Nearest cnneunitr_!6*.r /eiyiR
wall location: (address i 11¢31 descriot ion) /%,C f E A 2tr,,,
4d?d locDllnn s4tch or inserts
.1r Lcc-4�
J.
Depth of Weil _%�� 11. Latina:
_
Static water 1•re1i4Q Il. (above, bete.) lead surface. La IJ CCT_/a/q i/
finish of well: (oxen -end, screen, penetrated, open -hole, other)
Describe intervals and sl:e: L�dwu�Ar�( 9 Aw •c L
Well yfeid tested by (pcapina, pen ins. air) al /I
Wal/ern.
I
lor_._boun of drawdown Iron static level,
ORILLE111 MATERIAL LOG
Ceplh below land
give description of strain penetrated
—auflace In Int (sirs of material, color, hardness of drilling and War content)
2-L
N
PERMIT NO.
r�r�r.l I c I F nL_ I -r*iDF= Rr.F0--rFOF _•AGF=
DEPARTMENT G- HEALTH AMC? ENVIRONMENTAL PQOTECTION
825 'rSTREET, ANCHORAGE, AK. 95 :1
264-4720
F,IELL F�'EF2rl I T
C 811082 )
APPLICANT HARRY A./MADELINE MACKE\I SR 2 BOX 6465 9956.7
LOCATION LEE STREET
LEGAL L 6E B 8 QUIET WOODS S/D LOT SIZE
£88-2813
13000 SQUARE FEET
MINIMUM DISTANCE BETWEEN A WELL AND ANY ON-SITE SEWAGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR. 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE WELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER. REQUIREMENTS MAY APPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRAMS ARE
AVAILABLE TO INSURE PROPER INSTALLATION.
F'aF?M I T E:XF * I FRES C+1=CF=MF:F=FR X11 1S G1
I CERTIFY THAT
1: I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE.
2: I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
SIGNED
APPLICANT HARRY A./MADELINE MACKEY
ISSUED BY ------------------------------ DATE_ =0.10 l I__-- V4.0
r.1• wV �. IY..r..v 1\I\VL _.� .. a
Department of Sealt and-Environmental Protection
Street, Anchorage, AT, 4501
t ! 264-4720
e t IIANDWRI77EN PERMIT
• J� '1 WELL PERh1IT
; Flicant : / lAiet Ty�ft Miling Address: %51C
cations �ee cX• , E � t4A Phone Flumber
Lgal Description: 40-14- &K�j,Ot size: /3 x
:'Pe of Soil Absorption system Is:
Trench: Drainfieldt Seepage Reds Holding Tanks
„tximum Rumber of Bedrooms: soil xatinq(sq.ft/br)
The Required Size of the Soil Absorption Syntesn Is:
DEPTH �_ LENGTH GRAVEL DEPTH
tt1DTH -��
4ep length dimension is the lenthe disin feet) of the trench or dr infield- The
;depth t a trench or pit is the distance between the surface of the ro
Lmd %the bottom of the excavatiOr'(in feet
She gravel depth is the nininurn depth�ofrhere is no set Vlai h for trenches.
:the bottom of the ezcavation(in feet), Gravel between the outfall i
P pe and
* + REQUIRED SEPTIC(HOLDING) TANK SIZE
rxit appiicant has the responsibility to info GALLONS
(etallntion inspections of any :tells ad ret this de
residences that the vel] v 9acent to thin Partatent durincr the
ill serve. Property and the number
::Rfillin # ;' TFrO(2) INSPECTIONS ARE REQUIRED isystem vithoqt
11 be subjectato prosecution. final inspection and approval
by this departInc
',tn= distance between a veil and any on-cite sews e
a private yell or 150 to 200 feet From 9 disposal system is ]00 fe
publlc veil. iiinimum dicta from a public veil de
`25 feet and to a communitys a Private yell Pending tiPon the type
tnuut be returned ewer line is 75 feet. Nell Private sewer line
er"requirements to this departMent vithin 30 da e v are required
!Ilable to ins nay perappSpecifications and construction dial] completion
,- Insure proper installation.
drams Are
t► PERMIT
Certify thgt: EXPIRES DECEMBER 31.# 1 f a 4
.
(1 ) 2 am familiar vith the re
set forth by the Aut ei quirtments for on-site severe end
(2) I twill Instal] Pality of Anchorage,
arol]s 'as
(B) I understand thatotheeoefi in accordance with codes,
esidencewi� lesite sewer vY re nay require enlar4esnent if
((/"1�/ emodeltd to include no
re that 3 bedr
i .gne3 4 c�.� 7 ��,�'�
I ;
APPixcant issued bys,
i
Date:
Municipality of Anchorage
• Development Services Department
Building Safety Division
_ On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcell.D._HAA # 15LL-ALV
Expiration Date: - 3 - o--6-
1.
S1. GENERAL INFORMATION
Complete legal description T.n r 1;r.- yisi on
Location (site address or directions) 10007 Lee St. Eagle River, AK 99577
Current Propertyowner(s) Art Saltmarsh Day phone 696-6049
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
Unless otherwise requested, HAA will be held by DSO for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual Well
Individual Water Storage
Community Class Well
Public Water System
3
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
U
Individual On-site
❑
❑
Individual Holding tank
❑
❑
Community On-site
❑
❑
Public Sewer
0
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority 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 HAAs upon request to homeowners. Certificates of Health Authority 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 Health Authority 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 S & S Engineering
Address 17034 N. Eagle iv Loop St 204
Engineer's Printed Name
5. DSD SIGNATURE
V Approved for �? bedrooms.
Disapproved.
Phone 694-2979
gle River, AK 99577
Date 51 / Z 7 /0
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
Note: The well for this property meets existingState and D1unici,^at Coder Therr are nitrates
present It is suggested that periodic testing be performed to insure the wells continued suitnhility.
Current nitrate concentration Is 6.13 mg/1. EPA maximum concentration is 10.0 m9A. More
Information on nitrates is available from the On -Site Services Program, at 343-7904.
Attachments:
HAA Checklist X
Septic System Advisory
Well Flow Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By; (�� ,/ lit/ /— Original Certificate Date: -77
(Rev 01007)
Municipality of Anchorage
(' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907)343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: LOT b E y t rT-"_CYbbs S1 IS Parcel
A. WELL D
Well type e-tVPfr& If A, B, or C provide PWSID #= Well Logs d)
Date completed 101/0/8 ( Sanitary seal (YIN) _ Wires properly prdtectede)N) YES
Total depth LIG-ft. Cased to 75 ft. Casing height (above ground) t Z' + in.
FROM WELL LOG
Date of test _/000181
Static water level ft.
Well production g.p.m.
WATER SAMPLE RESULTS:
Coliform U colonies/100 m1. Nitrate 6.13 mg./I.
Arsenic: — mg.A. Date of sample: /0$
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material
Tank size gal. Number of Compartments _
Foundation cleanout (YIN) _ Depression over tank (YIN) _
Date of pumping Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d.M2 or ftz/bdr
Length ft. Width ft.
AT INSPECTION
ri za 0S
bin' ft.
14.8 g.p.m.
Other bacteria colonies/100 ml.
Collected by: tAa6(u1%-2(I176
Date
Cleanouts (Y/N)
High water
System type
Gravel below pipe ft.
Total depth _ ft. Eff. absorptio ea ftZ Monitoring tube _ Depression over field
Date of adequacy test Results (Pass/Fail) For _ bedrooms
Fluid depth in absorpt' field before test _ in. Water added_ gal. New depth_ in.
Elapsed Ti _ min. Final fluid depth _ in. Absorption rate >= g.p.d.
An iuvenation treatment (past 12 mo.) (YIN & type) If yes, give date
D. LIFT STATION
Date installed
`Pump on' level at _ in.
Size in gallons
Cycles tested
at in.
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Menhore7kcess (Y/N) _
High water alarm level at
Meets alarm & circuit requirements?
Septic tank/lift station on lot IUpf On adjacent lots iJ w
Absorption field on lot �-t5N A On adjacent lots ►�i
Public sewer main
1''x" Public sewer manhole/cleanout 100 r
1
Sewer /septic service line 95 {" Holding tank _ Nn
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation Property line
field
Water main Water service line Surface water
Welts on adjacent lots
SEPARATION DISTANCE FRO
Property line
Water Servic
F. COMMENTS
G. ENGINEER'S CERTIFICATION
I certify that I have determined th
review of Municipal records that t
conformance with MOA HAA g is
Engineer's Printed Name
Date 44 Z o
MAB PTION FIELD ON LOT TO:
Building foundation Water main
Surface water Driveway, parking/vehicle storage
Wells on adjacent lots
field inspections and
we systems are in�t1
in effecton t>>fSi6te
HAA Fee $
4�0 '
Date of Payment
Receipt Number
t<'g35
(Rev. 12101)
Waiver Fee $
Date of Payment
Receipt Number
in.
4-20-08; 8:23PM: ;907 5815301 r 2i a
SCS ReLM
Client Name
Project Namefll
Client Sample ID
Matrix
Sample Remarks:
1051945001
S dt S Engrg
Lot 6E. Ouitwoods S/D
Lot 6E, Wtwoods S/D
Drinking Water
All Dateaf!'imes are Aluke Standard Time
Printed Datenme
04/20/2005 12:04
Collected DatelTime
04/15/2005 15:10
Received DateMme
04/1512005 16:04
Tecknical Director
Stephen C. Ede
Allowable Prep Analysis
Parameter Results PQL Units Method CoalaincrID limits Data Date Nt
Waters Department
Nitrate -N 6.13 0.100 mg/L EPA 300.0 B (o-10)
ltiarobiolocry Laboratory
Total Coliform 0 coV100mL SM20 9222B A (o-1)
r
04/13/05 XM
04/15/03 TLF
131•+"�
i t
N�
1 ,trrh.(f
. I D,.�v.�w."yt Frc...•,.a. •
u �a
V 4. Hn.. t..a..
W .1
a V
13 f. t;3 •
Fc.�•%e .t r v1 r r? a ,
AS -BUILT
! hereby certify that I have surveyed the following described
property: Ln T 6 E ,
se%.
Af
Anchorage Recording precinct, Alaska, and that the improve-
r �ti ;;`.=�•'� •.,
r'
situated thereon are whin the property lines and do not
ments it
3'• ' "' f J
overlap or encroach on the property lying adjacent thereto, that
"; ,j°""�•.'•'�'';`,
no improvements on property Ivmg adjacent thereto encroach
' �j
on the premises in question and t at there are no roadways,
"'r . :• �+�G?���^ �,
transmission lines or other visible easements on said property
except as indicated hereon.
n Z'
Dated at Eagle River, Alaska
this�day o2 A t/ , .19 i7
'ti '•
ROBERT C. JOHNSON �� .�%•
,'y'.'. • :t.L.:Y'`: ,. ; . _' JJ�VII!
SCALE: Registered Land Surveyor No."D-LS
`"'' • ti 'ac•' .. •:�
''�E; 'f.`; ••'•"• • ..
1".— 2c' Box 77-0456, Eagle River, Alaska 99577
�; �:
phone (907) 694-254.3 '
NMUNICIPALITYOFANCHORAGE tom"'
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date1?La 9p'
7
1. GENERAL INFORMATION
(a) Leggy Description (include IS'block, subdivision, section, township, range)
Location (address or directions) 341' `Z e'`' L;&"
n ft /� & �1�
(b) Applicant Name aiG* 7 A r � Telephone: Home Business
Applicant Address' �i c1✓
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder ❑ ; Buyer ❑ ; OtherA<(explain);
(d) Lending Institutio FZ Telephone
Address
(e) Real Estate Company and Agent
Address
Telephone
(f) tft*the HAA to the following address:
sGS�•—ss3o --�
2. TYPE OF RESIDENCE
Single -Family Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPL,,,���Y///
Individual Well Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ❑ Public9 Community ❑ Holding Tank ❑
Note: If communitywell system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Page 1 of 2
72-025 (11,84)
n n
5.. ENGINEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
As certified by myseal 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 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
Date •3LC 1
6. DHEP
Approved for &Y-` c_-1-tfc
Approved X I
Terms of Conditional Approval
Telephone
CAUTION
bsA A. shaisr
No. 1457.E
Date // —
The Muncipatity 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
72-025 (1684)
n eoo�
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
264-4720
MUNICIPAUTY OF AW-400AGE
DEPT. OF HEALTH A
MWEONMEMAL PROTECTION
Legal Description: FDL—
A. WELL DATA
Well Classification S f= If A, B. C. D.E.C. Approved (Y/N) /R
Well Log Present CYN) Date Completed 1mo- 61 Yield Sv 'r Pe -1 -A
Total Depth q Cased to eA5 I Depth of Grouting a/
Static Water Level s r
Pump Set At f5&"w
-rnt
Casing Height Above Ground Zo Sanitary Seal on Casing t9q)
Electrical Wiring in Conduit4CWN) Depression Around Wellhead (YIQ
Separation Distances from Well: I
To Septic/Holding Tank on Lot a /A On Adjoining Lots 1 ool�
To Nearest Edge of Absorption Field on Lot a "' ; On Adjoining Lots 1 <M� r +
To Nearest Public Sewer Line ISt+ To Nearest Public Sewer -
Cleanout/Manhole 1 To Nearest Sewer Service Line on Lot 2'6 t
Water Sample Collected by 15� A S Ew�lt�NtE4aR,aG _ ; Date tc>-'3Pc>"e5—
Water Sample Test Results
Comments GPn.s c�T f�[�tti �tytbti �.1G,uJ�4E,f1n,JC,
B. SEPTIC/HOLDING TANK DATA
Date Installed Size No. 01 Compartments
Standpipes (Y/N) Air -tight Caps (Y/N)
Foundation Cleanout (Y/N)
Depression over Tank (Y/N) Date Last Pumped
Pumping/Maintenance Contract on File (Y/N ;for
Holding Tank High -Water Alarm (Y/N) AA _ Temporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water -Supply Well _
To Property Line
To Water Main/Service Line
Course
Comments _4fi?�3 —yex
Page 1 of 2
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
t
72026(1784) .
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
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
Type of System Design
— Length of Field
Depth of Field
Gravel Bed Thickness
Standpipes Present(Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
On Adjoining Lots
To Cutbank (if present)
To Driveway, Parking Area, or Vehicle Storage Area
Comments —fes 2`Ff3ti'`cr
D. LIFT STATION
Date Installed
Dimensions
Size in Gallons I Manhole/Access (Y/N)
"Pump On" Level at "Pump Off" Level at
High Water Alarm Level at Vent (Y/N)
Tested for
Electrical Codes (Y/N)
Comments
Check Permitted Bedroom Rating Against HAA Request "
Pumping Cycles during Adequacy Test. Meets MOA
I certify that I Piave cheokgdl�ti6&fied, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed `SRD 1 cwt ^ T! Date
Company LG P0,ti9C429iJ MOA No. k!5
Receipt No. g�7
Date of Payment
Amount: $ �K
Page 2 of 2
72-026 (11,84)
•.,J -•cam •- • � � •i
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
DIVISION OF ENVIRONMENTAL HEALTH ;
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4720
Application Date /r%a✓ /S /7 ;'-I'
1. GENERAL INFORMATION
(a) Legal Description (include lot block, subdivision, section, township, range)
/_o4 G F IS16 e AC 8 G wetoorA Sub. %/u/✓ je-1 w .Joo, /a
Location (address or directions)
36 /,ee 57irrz7"' , Ealle Ii✓vlt ;7p nnc 2, (rltSto•.
(b) Applicant Name �r'hr^ C. Q'S
a upaTelephone: Home 69Y N&%� Business z63'S'9�y
Applicant Address 34 .arc Sirti�7 Ear/r �rlr�t 4ASk-, 99.E;�
(c) Applicant is (check one): Lending Institution ❑ ; Owner/builder 0 ;Buyer ❑ ;Other ❑ (explain);
(d) Lending Institution c Telephone 6yy-3Sa3
Address /0 Sox z /1 /a'2a it%O, S3 2 E��/c �rlru f%/C 99-4-;7p
(e) Real Estate Company and Agent
Address
Telephone
Mail the HAA to the following address:
2. TYPE OF RESIDENCE
Single -Family Q Multi -Family ❑ Other
Number of Bedrooms 3
3. WATER SUPPLY
Individual Well ® Community ❑ Public ❑
Note: It community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite ❑ Public Ift 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 72-0250118+i
,
CNGWEERING FIRM PROVIDING INSPECTIONS, TESTS, FILE SEARCH, DATA AND INFORMATION
Ae eeRified by my seal affixed hereto and as of the validation date shown below, I verify that my Investigation of this Health
AtMority 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 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. E2gle River Engineering sery:e:s
P. 0. Boz 773294
Name of Firm E3110 FlIver. XX NV511 Telephone
Address
Date _
..
y •' `T ?` ',��QQ Engineers Seal
:.......:..........
Lovi. A. Butera !�
CEL776
.•' ���
PROFESStONA��
6. DHEP APPROVAL
Approved for `�D� bedrooms by r Date
Approved Disapprov Conditi
&,
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
ICIPAUTY OF ANCHORAGE
l i DEPT. OF HEALTH Q
cNVIRONMENTAL PROTECTION
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA) MAY 16 iuw-•
CHECKLIST - FEBRUARY 1964
264-4720 L r C FJ VSD
Legal Description: Q.t.e�'cuenlJ
S., Z elv T /'V ,nJ /p SP, / 2
A. WELL DATA
Well Classificationy-r vt If A. B. C, D.EC. Approved (Y/N)
Well Log Present (Y/N) X Date Completed OGT /o /9k/ Yield 6 ' 6- Fm
Total Depth 9S Cased to y S Depth of Grouting H�
Static Water Level CS Pump Set At
Casing Height Above Ground _.2,0 f, Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) y Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot dZ14 ; On Adjoining Lots deo t
To Nearest Edge of Absorption Field on Lot etZl ; On Adjoining Lots /,007'
ri
To Nearest Public Sewer Line st iS To Nearest Public Sewer
Cleanout/Manhole loo t To Nearest Sewer Service Line on Lot a $ t
Water Sample Collected by En ;'� ^ �r -- ; Date •r�pl-r5–
Water Sample Test Results S' t.i le. '/.
Comments
B. SEPTIC/HOLDING TANK DATA �M6l.c Se&—o-A
Date Installed Size
Standpipes (Y/N) Air -tight Caps (Y/N)
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
Page 1 of 2
72-026(11,84)
No. of Compartments
Foundation Cleanout (Y/N)
Date Last Pumped
;for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
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
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
Comments
D. LIFT STATION A//,
Date Installed
Size in Gallons
"Pump On" Level at —
High Water Alarm Level at
Tested for
Electrical Codes (Y/N) _
Comments
Type of System Design
Length of Field
Depth of Field
Gravel Bed Thickness
_ Standpipes Present(Y/N)
Date of Last Adequacy Test
To Property Line
To Existing or Abandoned System on
;On Adjoining Lots
To Cutbank (if present)
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 that I have checked, verified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
Signed % Date
Company,.P:e," MOA No. S r- -16 J -
Receipt No. 3 i%`o 5'1 .,mow»pla
_1 r
Date of Payment 5 I G b5 �«••�L•�I�
y5� !' Op -� •, rid Engineer's Seal
Amount: $ r , 3
Or ; EjJTbI a
Page 2 of 2
72-026 11veal
Louis A. B.lara J.
CE -6736 t•<`•
,k-14�;_/ sa-10
5. LEGAL DESCRIPTION
D. :RECEIVED
:NSPECriON APPOINTMENTS
Woodd
TOME
TIME
TIME
t
NUMBER OF BEDROOMS
SINGLE FAMILY
DATE
DATE
DATE ,
❑ MULTIPLE FAMILY
Ill Three ❑ Six
7. WATER SUPPLY
INSPECTORINSPECTOR
XD INDIVIDUAL'
INSPECT R
MUNICIPALITY OF ANCHORAGE MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTIO� DEPT. OF HEALTH 8
826 LStreet- A Wm aea, AleYra SB881 VNVIRONMENTAL PPCTECTION
•
ENVIRONMENTAL SANITATION DIVISION NOV 17 1981
Telephone 264.4720
RR FF ((� ,,//
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER`PACI&IE D
DIRECTIONS: Complete all parts on page 1. Incomplete requeen will not M proceand. Please allow ten (10) days for processing.
1. PRO RTYOWNER
PHONE
Harry A. and Madeline M. Mackey
688-2813
MAILING ADDRESS
PROPERTY RESIDENT Ilf different from above)
PHONE
2. BUYER
Spec House
MAILING ADDRESS
3. LENDING INSTITUTION
PHONE
MAILING ADDRESS
4. REALTOR AGENT
PHONE
Target Realtors,
277-0551
MAILING ADDRESS
5. LEGAL DESCRIPTION
Lot 6 E Blk. 8 Quiet
Woodd
STREET LOCATION
Lee Street Ea le River
S. TYPE OF RE81DENCE
NUMBER OF BEDROOMS
SINGLE FAMILY
❑ One ❑ Four ❑ Other
❑ Two ❑ Five
❑ MULTIPLE FAMILY
Ill Three ❑ Six
7. WATER SUPPLY
XD INDIVIDUAL'
*ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY -
depth (attach log if available.)
a SEWAGE DISPOSAL SYSTEM _
❑ INDIVIDUAL/ON-SITE"
YEAR ONSITE SYSTEM WAS INSTALLED.
4 PUBLICUTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATED.
72010 (Rev. 6/79) /y
THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OR BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLICUTILITY
Connection Verified
PERMIT NUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON-SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
INSTALLER
❑Septic Tank or ❑Holding Tank
Size: If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Holding Tank
Absorption Area
Sewer Line
eot Line
Narest L
Absorption Area to nearest Lot Line
5. COMMENTS
/APPROVED FOR_ BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE _
BY