HomeMy WebLinkAboutNETTLETON ACRES #2 LT 14
NAME
MAILING ADDRESS
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
TPHONE ~NEW
LEGAL DE-SCRIPTION
LOCAT, ON \ '-t
DISTANCE TO: I Well
Manufacturer
Liq. capacity in gallons
'~' O IF HOMEMADE:
~ J NO. OF BEDR/,\OOMS
Absorption areL
(~ ~-p~.F' Material%~..~; ~ ~_.~'~ / No. of compartments
Liquid depth
Dwelling
Material L qu d capac ty in gallons
Foundation t. Jf ~, ~.
Total length of lines ..~
Material beneath tile
Depth
Nearest lot line ~)..~ PERMIT NO,
Trench widttl Distance between lines ~ / ~J.
L~ ~) inches
(~, O t, Total effective absorp~n~r
inches PERM T NO.
DISTANCE TO:
Crib depth Total effective absorption area
Building foundation Nearest lot line
Driller Distance to lot line
Building foundation Sewer line Septic tank
PERMIT NO.
Absorpt on area(s)
OTHER
PIPE MATERIALS
SOIL TEST RATING
INSTALLER
REMARKS
DATE
72-013 (Rev. 3/78)
LEGAL
WELL OWNER G~l~r \l
WATER WELL LOG
FOSS DRILLING ,~/ ~.
~chorage, Alaska 9950!
SIZE OF CA~ING~DEPTH OF HOLFL~. CASED
FEET OF DRAWDOWN.
REMARKS
PUMP TO BE SET AT
.~to~
to
__~ O~
~.t Om
F'EI:;.".I"1:11T NO.
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85
22,5
150
2 50
2 7 5
350
350
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tab} e.
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200
2 O0
85
85
85
.] 25
85
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85
200
2 O0
200
20O
20O
2 O0
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8 5
8 5
8 5
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MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
Parcel I.D.
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
HAA #
1. GENERAL INFORMATION
Complete legal description L I'~ ~v~.4.~-~-~, ,~.¢ fi.?_
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Day phone
Day phone
Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
NUMBER OF BEDROOMS:
TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
TYPE OF WASTEWATER DISPOSAL:
Individual on-site
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.
72-025 (Rev. 1/91) Front MOA #21
5. 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 of this Health Authority Approval application 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 inves!~ation 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 Fjj[m ~--~S~u~'~n<~ ~----,-~l'r,~.~s~ , Phone ~-~ /$9~-9o9e
~'~ / "' ~ ~ ~' - Z ~ R ~ , ~
Engineer's signature ~~X~ Date /-- ~¢~
DHHS SIGNATURE
Approved for
Disapproved.
Conditional approval for
bedrooms.
bedrooms
with the following stipulations:
Additional Comments
By:
Date
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 DH HS 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 engineeCs work.
72-025 (Rev, 1/91) Back MOA #21
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: L
A, Well Data
Well type ~
Log present (Y/N) O/V
Total depth
Sanitary seal (Y/N)
FROM WELL LOG
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed ~ '"7~ Driller
Cased to I ~ Casing height
Wires properly protected (Y/N)
Date of test
Static water level
Well flow
Pump level1
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer service line
17.S'
.g.p.m.
AT INSPECTION
; On adjacent lots
; On adjacent lots
Public sewer manhole/cleanout
· ~- JO0
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample: r?.. J "z:~
Nitrate
Collected by:
Other bacteria
B. SEPTIC/HOLDING TANK DATA
Date installed
Cleanout~ (Y/N)
High water alarm (Y/N)
Date of pumping
Tank size I
Foundation cleanout (Y/N) _ ~/ Depression (Y/N)
r~ ~ Alarm tested (Y/N)
\ S~..q.~ Pumper
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot l 7..c~' On adjacent lots +\~' Foundation 7-~'
To property line -/~' Absorption field Water main/service line
Surface water/drainage J- IOo'
72-026 (3/93)° Front CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed
Size in gallons
Vent (Y/N) "Pump on" level at
High water alarm level
Meets MOA electrical codes (Y/N)
SEPARATION DIS~STATION TO:
Well on lot / On adjacent lots
D. ABSORPTION FIELD DATA
Date installed
Length 57-'
Total absorption area
Date of adequacy test
Water level in absorption field before test
Peroxide treatment (past 12 months) (Y/N)
Manufacturer ~
Manhole/Access (Y/N) ~
'~el at
Soil rating (GPD/FF)
Width ~Z." Gravel thickness
'5 ~ zr ~ Cleanout present (Y/N) Y
~. -~4-- 9'~ Resu Its (pass/fail)
Sudace water
~>S s'~/~',~'~ System type -"F~m~,c H
6" Total depth I0'
Depression over field (Y/N) r,.]
~'~s.~ for ~ Bedrooms
After test 6,o"
If yes, give date -'"-
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation
On adjacent lots
Surface water +
Curtain drain '~
On adjacent lots -+- ~ oo' Properly line ~' '
To existing or abandoned system on lot
Cutbank -~o~' Water main/service line
Driveway, parking/vehicle storage area + ~0'
E. ENGINEER'S CERTIFICATION
I ce¢'fy that I have checked, verified, or conformed to all MOA and HAA guidelines in effect onr~e4~.a~o.._fthis inspect/on.
H~ Fee $ ~ DD, ~-~ Waiver Fee $
Date of Payme~ / ~/[ ~ ~/ Date of Payme~
Receipt Numar ~b~ ~/ ~/~ 5~ Receipt Numar
72-026 (3/93)' Back
NORTHERN TESTING LABORATORIES, INC.
3330 INDUSTRIAL AVENUE
2505 FAIRBANKS STREET
FAIRBANKS, ALASKA 99701
ANCHORAGE, ALASKA 99503
(907) 456-3116, FAX 456 3125
(907) 277-8378 · FAX 274-9645
Constructing Engineers
HC83, Box 192A
Eagle River AK 99577
Attn: Chuck Landers
Report Date:
Date Arrived:
Date Sampled:
Time Sampled:
Collected By:
01/04/94
12/30/93
12/29/93
1230
Our Lab #:
Location/Project:
Your Sample ID:
Sample Matrix:
Comments:
Lab
A128846
L14 Nettleton Acres
Water
* Definitions *
B = Below Regulatory Min.
H = Above Regulatory Max.
E = Estimated Value
M = Matrix Interference
D = Lost to Dilution
MDL = Method Detection Limit
Date Date
Number Method Parameter Units
__ Result * MDL Prepared Analyzed
A128846 EPA 353.3 Nitrate-N mg/1 <MDL 0.1 12/30/93
Reported By: AnthVJ. Lange
Senior Chemist
NORTHERN TESTING BORATORIES, INC.
3330 INDUSTRIAL AVENUE
2505 FAIRBANKS STREET
FAIRBANKS, ALASKA 09701
ANCHORAGE, At. ASKA 99503
(907) 456 3116 · FAX 456-3125
(907) 277 8378, FAX 274-9645
DRINKING WATER ANALYSIS REPORT FOR TOTAL COLIFORM BACTERIA
Constructing Engineers
114 Nettle Acres
Public Water System I.D.#
Date Received:
Date Analyzed:
Date Reported:
Next Sample Due:
12/29/93 Time Received: 15:00
12/29/93 Time Analyzed: 17:00
01/04/94 Time Reported: 12:14
Collected by:
Sample Type:
Routine
Method of Analysis:
Membrane Filtration
Comments:
Comments:
S =
U =
POS =
ND =
TNTC =
CG =
HSM =
SA =
Old =
Satisfactory
Unsatisfactory
Positive Test Result
None Detected
Too Numerous To Count (>200 Colonies)
Confluent Growth
Heavy Sediment Masking, Results May
Not Be Reliable
Sample Age >30 Hours But <48 Hours,
Results May Not Be Reliable
Sample Age >48 Hours, Too Old For
Analysis
Resample Required
No Test
* # Colonies/100 ml ** # Colonies/mi
Sample Sample Total* Fecal* Other* HPC**
Location Date Time Lab# Coliform Coliform Bacteria Result Comments
1 Bathroom Sink 12/29/93 12:30 Ab2960 0 NT 0 NT S