HomeMy WebLinkAboutROSHA LT 10A ~ 'UNICIPALITY OF ANCHORAGE
I
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
NAME PHONE ~. NEW
MAILING ADDRESS
LEGAL DESCRIPTION
LOCATION ~ NO. OF BEDROOMS
Well / Absorption area Dwell / PERMIT NO.
~ ; No. of compartments
~ ~ Manufacturer Material
[Liq. capacity in gallons Inside length Width Liquid d~pth
l ~ ~O IF HOMEMADE: ~/.~ ~/~ ,~/~
~ ~ DISTANCE TO: ~~ Dwelling
0 ~ ~ ~anufacturer~ ~/- I ~ -- ~at~ I i~acity in gellons
~ Well / Foundation / ~ Neares I~l~ne PERMIT NO.
No. of li~s Length of~ea~li e / Total length 9f lines Trench ~idth~g~ Distance between lines
~ Top of tile to finis~ gr, de ~, ~ ~.1 inches
Material beneath the
Q~ ~ ~/1~ ~ ~ // ~ ~ ~nches Total effective~,absorption~ area
~ Depth PERMIT NO.
L~~ Width
~ ~ Tg~e of crib Crib diameter ~rib de ~ ~~sorption area
~ ~ ~ ~ Buildin~ foundation ~earest lot lino
~ ~ ~ ~L Driller / Distance to lot line
~ ~~ B~il Ii ep~m a ~ion area{s)
OTHER
PIPE MATERIALS 5~1~ A~O '~ I %
SOIL TEST RATING / '~'~
I ~' ~F~/g~ ~o~.~~
/
REMARKS
; ' ....
/
~.~.., c~ ~=~ ... ~ <' ' +
APPROVED~ / DATE LEGAL *:~
F:'ERM liT NO:
DA]"E ISSUED
A F:'PL.. I. CANT:
A !:) D R E S S
CONTAC]" F:'HDNE
L. fEGAL DESCRIP
LOT
MAX BIEDRDDMS =
DEF'ARTMENT OF HEAL]"H AND EIqVIROIqMENTAL. F'IROTECTION
8'25 L' STREET, ANCHC)RAGE~ AK 99501
;2.64.-Zl. 720
' c .... /84
S'I"ONE'S E:]XCAVATING
BOX '7'7:]..127.'7'7
EAGL..E RIVER, Al'::: 9957"7
688-..:~915
SUBDIVISION: ROSHA. LOT'~ 'I,.)'-A' BL. OCK: NA
S..r~'
E_~. T I 0t f: z.~.' I~,N RANGE ~ 2W
1.~5A (SQ. FT~ (IR Al]RES) .
4
L..:[st. ed be].c)w ape 'Lhe
sys'Le~r, Choose 'Lhe c,p'Lic)r tlnat
DEPTH TO PIPE BOT"FOM (FT.)
GRAVEL' DEPTH (FT.)
TOTAL DEF:']'H (F?T'.)
GRAVEL WIDTH (F"T',)
GRAVEL LENGTH (F:T,,
GRAVEl_ voi_.UHE (CL,I~ YDS. )
TANK SIZE (GALS)
SOIL'RA]"ING (SQ, F:]'~ /BR)
4.0 4.,, 0
0.5 :L ,, 0
4.5 5 ,, 0
20 '. 0 5.0
:38 ,, 0 88, 0 -x'-..~.
28 ~ 2 24, 5
1,250.0 .~..~- :I., 250 ,, 0 ~?.~.
125 :i. 25
· ~.~ GRAVEL. LENGTI..] > 75 F:]". REQUIRES MUL. TIPLE RUNS (NOT,::.,,~.,~::,::....,.,.,r'vr'r'r-T]T',~:*,~.'.~ ""~:~/.., F:'T,, ,...~-.,,..,,~:'';mL~t',.
· >~.:X. 'TANK MLJST HAVE AT I_EAST "FWO
I cert:i.f'y t. hat:
1,, I-am f'ami].iar with 'Lhe r'e,::]uireme, rrL':.:; ,-rcm on-sit, e s~ev,~ers and we].].s as set
¢(:rt.h by 'Lhe Municipa].:i. ty of Anchorage (MOA) and t. he State of' Alaska,,
2. I {.,~il]. install 'Lhe system J.n accc:r'dance ~,,~it.l~ all MOA codes and r'egu].at:i, on~s,
arid in cc)rnp].iance tCJ. th the design C:l"J:t[~pis c)f' thiE;
3. I w:i. lI adhere 'Lo all IdOA arid ~'{:.aA'L8' (3{ Alaska r(~qtz:i, reiil6fl'its -['or th(E, ~;e'(. back
dis'Lances from any ca)-{istil'l~ ~,t~e].l~, ~,,Ja'~.st~]~,~a'Le3P disposal, sysrLem c)r' public
se~,,,smage system on this or any adjacen'L or' nearby
4,, .l understand that 'Lhis permit is valid tfop a maxi~}Lt~i 0{ 4 bedrooms arid
any enlargement ~,-~i].l pequ:i, re an add:i, tior'~al per'mit.
IF A L. IFT S"FA'TIOIq "q 'r uc:r' ,. ~' ] .
....... t.,~.,IAI._L~:;: IN AN AI:~F2A COVEI'R'IED BY MOA BU]:LDING CODES,
THEN (~) AN I ........ ],',.[CAI_ PERM:IT AND T, ~-,:" .... X t2) "c~-~:?~:[L.TS
.,.t4.~F1_.(~1011 MUST BE OBTA:[NED~ . . ~a .........
W.,.I ........ NO'T BE ~:,:,:,*~ .' -'-r,
~1 I 1,[. JE..D WZ"I]-'IOUT AN IsLEt... Ff..[L,~-d... INSF'EC]TION RIz.-D ~. , AND (3;) 'THE
I_.L..L,F,%ZL, AL W ..... I... tlU,.,1 oE DONI ...... A ....... CE:.,.I.~ED
AF'PL. ICANI ,, S'TONE S EXCAVATI:NG
PERFORMED FOR:
LEGAL DESCRIPTION:
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COMMENTS
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONIV1ENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 Z64-4720
SOILS LOG- PERCOLATION TEST
,~' SOILS LOG
[] PERCOLATION
TEST
R
SLOPE
WAS GROUND WATER
ENCOUNTERED? ,('~
IF YES, AT WHAT
DEPt.?
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE
TEST RUN BETWEEN
(minutes/inch)
FT AND FT
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL ~F. ALTH
DEPAR%/~ENT OF ~r~.ALTH AND ENVIRONMENTAL PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CERTIFICATE
1. General Information
Application Date
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicants Name %~O~A% ~oS5 Telephone -
Applicants ~dress ~1 ~ ~0 ~lLti~Ba% (I~U~t~;~ ~7
(c) Applicant is (check one) Lending Institution ~ ; ~er/builder~;
;
(d) Lending Institution hl,//~
Address ~//~-
(e) Real Estate Co. & Agent
Address ,&//A
Telephone ~,/q
(f)
Mail the HAA to the following address:
Telephone
2. Type of Residence
Single-Family.~.
Number of Bedrooms
3. Water Supply
Individual Well~
e
Multi-Family
Other (describe)
Community~-~ Public~--~
Note: If community well system, must have written confirmation from the State
Department of Envfronmental Conservation attesting to the legality and status.
Sewage Disposal
Onsite~ Public [ I 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]
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5. Engineering Firm Providin8 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 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 regula-
tions in effect on the date of this inspection.
Name of Firm
Address..
Date ~
DHEP Approval
Approved for ~___ bedrooms
Approved ~ Disapproved
Terms of Conditional Approval
Oi
CAUTION
THE WdNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
(DHEP) ISSUES HEALTH AUTHORITY APPROVAL CERTIFICATES BASED SOLELY UPON THE REPRESENT-
ATIONS 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 ~MD
THEIR LENDING INSTITUTIONS IN ORDER TO SATISFY CERTAIN FEDERAL AND STATE REQUIRE-
MENTS. EMPLOYEES OF DHEP DO NOT CONDUCT INSPECTIONS OR ANALYZE DATA BEFORE A
CERTIFICATE IS ISSUED. THE MUNICIPALITY OF ANCtlORAGE IS NOT RESPONSIBLE FOR ERRORS
OR OMISSIONS IN'THE PROFESSIONAL ENGINEER'S WORK.
of 2]
(DHEP
7-19-84
ae
MUNICIPALITY OF ANCHORAGE (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
Legal Description:
WELL DATA
Well Classification ~t
Well ~ ~esent (Y~)
Total Depth ~ / Cased to
Static Water Level ~k//~ Pump Set At
Casing Height Above Ground ~ '
Electrical Wiring in Conduit (Y/N) /%/
Separation Distances f~om Well:
To Septic/Holding Tank on Lot /
Depth of Grouting
Sanitary Seal on Casing (y/N).~/
Depression Around Wellhead (Y/N)~/..
~ On Adjoining Lots / 5
To Nearest Edge of Absorption Field on Lot/~t/ /+ ; On Adjoining Lots /
To Nearest Public Sewer Line .~j//3~ To Nearest Public Sewer
Cleancut/Manhole ~-~ / To Nearest Sewer Service Line on Lot ~./~
Water Sample Collected By -F-O/V1 ~O~ ; Date ~k~ b C'7~ ~ .-
Water Sample Test Results
SEPTIC/~ TANK DATA
Date Installed ~>~/97-c9~- Size /~-O No. of Compart/~nts
Standpipes (Y/N) ~ Air-tight Caps (Y/N) ~/'~ Foundation Cleanout .(Y/N)
Depression over Tank (Y/N) ~/ Date Last Pumped ~¢3e - ~J~'~ -fi~[}~
Pumping/Maintenance Contract on File (Y/N) N~_; for
Holding Tank High-Wate.~ Alarm (Y/N) ~J//~ ~emporary Holding Tank Permit (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply We 11 /
To Property Line
To Water Main/Service Line
Course ~ ~1 ~ %_~J~_
TO Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major D~ainage
Receipt ~
Date Paid:
Arnount: k~,~
[Page 1 of 2] 2-15-84
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed 3 oC~- ~-
Width of Field __~ t,
Square Feet of Absorption Area ~'ol ~
Depression over Field (Y/N) [~3
Results of Last Adequacy Test ~.~/~
1~5~3~/~O[~ Type of System Design
!
Length of Field [{~
Depth of Field ~ i
Gravel Bed Thickness /~/~
~ Standpipes Present (Y/N)
Date of Last Adequacy Test ~o~/
Separation Distance from Absorption Field:
To Water-Supply We I1 /z~/ /
TO P~operty Line / 7
To Building Foundation 7'7 / To Existing or Abandoned System on
Lot /%f//~ ; On Adjoining Lots /~ !
To Water ~ain/Service Line c~- To Cutbank(if present)
To Stream/Pond/Lake/or Major Drainage Course
!
TO Driveway, Parking Area, or Vehicle Storage Area /~d
Commmnts Fj~v~
ed ~ Dirce ns ions
Size in Gal~ Manhole/Access (Y/N)
"Pump On" Level at~~_~ "Pump ~
High Water Alarm Level at ~ ~--~~ / Vent (Y/N) ~
Tested for .~ng [;yclL=s~ring Adequacy Yest.
Electrical Codes(Y/N)/ ~
.~e ts
Check Permitted Bedrcom Rating Against HAA Request
I certify that I have checked, verified, or conformed to ali. MOA ~LAA Guidelines in effect
on the date of this inspection. '
gned Date
Company '-[~3~-~ ]~_k3~1~3~-~-~] ~-~ MOA No.
[Pa~ 2 of 2] ~~_ ,
2.-15-84