HomeMy WebLinkAboutMANSFIELD LT 1
MUNICIPALITY OF ANCHORAGE
· D[ 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 DISTANCES
~.~ ~Y ~ SEPTIC ABSORPTION
Address TANK FIELD WELL
'Bo,'j) Y/q/(,cf
Phone(s) Permit NO. NO. Of Bedrooms
~ ~ ~.~ ~ ~ WELL /~ / / ~/
LEGAL DE'CRIPT'O" LOT LINE ¢~
~N~ FOUNDATION
Township, Range, Section
AS-BUILT DIAGRAM (Show Iocabon el well, septic system, property hnes, foundm~on,
T i ~ N ; ~ ~ W, ~OH ~ ~ driveway, waler bodies, etc.)
/, ~ANKq N
~ SEPTI/eX 5~ T~N~% I
~ %~ ~C*~ HOLDING I
~anulacturer Capacity Jn gallo~s
TYPE OF SYSTEM '~!
~TRENCH ~ BED g W. DRAIN ~ OTHER ( ~u
.,~.,~
Deplh to p~pe bottom from Total depth from original grade~ ~ ~ ~ l~ ~
Fill added abe ..... glnal grade Gravel depth beneath pipe ~ ~ ~&~
I ~ FTm FT ~ ~' ~)'
Total absorpt ...... a ~ Dist .... bet .... lines q -- ~:~
Number o, hnes Soil tat'rig P,pe material / ~ ~
~ PRIVATE ~ OTHER(IdenIiIv)
~lassd,cahon (A,B,C) 'To,al PepJh / -- --
I~DiVlm~ ~ FT ~ ET ~ ~ ~/,~' '~ . F~P, ~111~
REMARKS: [J ~ ~/~4
Scale: - ' ' AL
~P~ ~/N~ ON ~/~ inspections Pedormed by:
I~ ~~~~~~~ ~ cedily Ihat this inspeGtion was pedormed according to
Health Depadmenl Approval: ~, Date:
72-013 (3/85)
GARY GRAY/ USI<H
BOX 304
Y AKUI'A'i", Al'::. 99689
;?.76-42.45
·
I,,..]. t:~'r,,"::...' "'--'~.,S'"' "" '~'~ .~. *~'¥~' aP;.':¢' the c,i::,t :i. or~s. .~itV~fi:i. ],ail::) ].1,:?) '~'.CJ VCLI ilq .- ..:a~...'
system,, i.:::hc, ose 'Lhe or,:)t, iori that besst f:Lts yOLtp sit. e.
4 ,, 0 4.0 4.0
6 ,, 0 0.5 .3.5
:1. 0.0 4 ,, 5 7.5
2 ,, 5 20 ,, 0 5 ,, 0
46 ,, 0 37 ,, 0 60. O~
27 ,, '7 2.7 ,, 5 4.6 ,, 5
J., 000 ,, 0 '~"~' I, 0()0 ~ 0 -~f'e :t., 00(),, () '~'~'
275
Si..).i:l .... '~,':.i ,' .I.~".'lJ '.'S~5!. F:"I". /BI:R) 2]75 :~r' ~' ~'~
'~ .... !....c.~..~, ~ TWO COMPARTMENT'S
~*'~ TANK HUST r~..b~. A] ...... '"~ .......
]: cer'tii'¥ tha'L:
i. I aid iamiliar' ~.~:i.'Lh the i'.equir'ements for' on-site sewer's arid wetls as set.
{opth by the l¥1unic:i, pa1:i, tv (:)~' Anchor'age (t"I~) and the State of Alaska.
2., I ,/,~:i. ti ~i. ns'Latl -Lhe ~sy~F't:.e~ii in ac:c:ordance with all NOA codes arid
and :i.n c:c)mi::].:[anc:e v.~J. th the d6~sJ, gr'i cPJ.'l'..~?P:[a BI:' this per're:it,
:::.~.;[ t,.~:i.].:l, adher'e 'Lo a].]. I"'i(]A add State i:l{' Alaska peqL~ipe:.)rnEer'YLs for t, hlE seYL back
d:i. sLances fpom any exis~t:i, no t,,s¢:;,il, v,¢astewa-Lep disposal system of public
set,.aer'age syste:,rn c:,n 'Lhis of any adjac:ent op r]eaf'by ].c)t,,
4,, :[ under'star'id that this per'mit is Mai. id eof a rnax:[rnLun of 2 bedf'ooms and
?.tiny er'ilaP(;jemer'fl:, wJ.].], pecluJ, pe an acldJ, tior]al
I:I;= A t....!F'f STA'TION :!:S ':[NS]"AI....I....IED IN AN AREA CDVEF4ED BY MOA BUILDING CODES,.,
i'Fi[~:t",I (]) Al'q EI...EC]"I::/:[CAL I:::'IERHIT AND ZNSF:'E:C]-ION MUST BE OBTAINED~ (2.) AS-BUIL..TS
WILL.. NOI' BE: AI:::'F:'ROVE:D WITHOUT ~N EL..IECTRICAL. INSF'EC]"ZOIq REPORT; AND (3) 'T'I"4E
L:.,..i:::CI'Iq:ZCF.!L WEll!I< MUS"I BE~}CINE BY A L:t:CE!xlSE:D IEL!ECTRICI(.'d'q.
Architecture · Enginer~ig
Anchorage
Land Surveying * Planning
Fairbanks
Project Title
W.O. #
Date
Page Title
By
Page of__
~IT~ PLAN
FOR
U~.i~J UNWlN ' $OHEBEN · KORYNTA · HUETTL
ARCHITECTURE ENGINEERING LAND SURVEYING PLANNING
DRAWN Pi-- J SCALE I"~-.,~'O' J DATE ? ",.~J ,~&:l~ I W.O. ~,(~/"J7 J F.B./~I~ I GRID .-~l~' J
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L, Street, Anchorage, Alaska 99501 264-4720
SOILS LOG- PERCOLATION TEST
SOILS LOG
PERCOLATION
TEST
PERFORMED EOR:
LEGAL DESCRIPTION: L (~ "r"
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
~4z~Y
WAS '
ENC[
IF YE
DEPT
PERC
DATE PERFORMED: 7'"'
20
COMMENTS
SLOPE
ROUND WATER
TERED? NO
;, AT WHAT
SITE PLAN
Gross Net Depth to Net
Reading Date Time Time Water Drop
~ ~-~'g~ I1:Oo~ ~w. ~dY~' i ~"
TION RATE ,,~ (minutes/inch)
TEST RUN BETWEEN '~' FT AND ~ FT
72-008 (6/79)
CERTIFIED BY: DATE:
Architecture · Enginee?'~l * Land Surveying · Planning
Anchorage Fairbanks
Project Title ~;~'T
W.O. # ~d
Page Title
By .J~' ~_~-." Page] of
' ~ '--~ Architecture · Engine;:'~g ° Land Surveying · Planning
Anchorage Fairbanks
d4' Y
Project Title/~O'F ~- Page Title
W.O.# ~.~ Date _~--_t~"~_ (_o By ~, ~-~ Page / of i
DAlE DESCRIPDON CHARGES CREDITS BALANCE
89' 6" c -P s i'_~.g ,<biB. $1602.1
per
2 casing above groun~ $4. $8.~
1 drive shoe N/C
1 well seal N/C
$161o.(
O0
O0
Red~f,~rm 85 872
Poly POJ¢ ($0 setsl 8P872
MUNICIPALITY OF ANCHORAGE
DEPAr'~T~AENT OF HEALTH AND ENVIRON¢~ENTAL P,qOTECTION
DIVISION OF ENVIRONMENTAL IIEALYH
CERTIFICATE OF INSPECTION FOR IqEALTH AUTHORITY APPROVAl_
OF ON-SITE SEWER AND WATER FACILITY
2G4~4720
Application Date ~-/¢"~
GENERAL IN FOR['.'AATION
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Applicant Name ~'[~? ~JT~O}z Telephone: Horne ~?Z/~///~9¢ Business
Applicant Add~ess ~¢~/~ ......
(c) Applicant is (check one): Lending Institution
(d) Lending Institution ~ '~/'~)/t~O/¥~-~Y~ ~:;?~;2firelephone
(e) Real Estate Company and Agent
Address
Telephone
(0
Mail the HAA to the following address:
q'YPE OF RESIDENCE
Single~Famil Multi-Family
Number of Bedrooms.
Other
WATER SUPPLY
Individual WoI . 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,~ Public BI Community [] Holding Tank I~
Note: Il community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
72-025 (11184)
Page 1 of 2
ENGINEERING FIRMPROVIDIF, ~NSPECTIONS, TESTS, FILE SEARCH, DA--*ANDINFORMAT]ON
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 regulations in effect on
the date of this inspection.
Address _
Engineer's Seal
~ ,~,,,',,,
Approved fo["'¢~-'~'¢'(? bedrooms by
Approved /~ ....... ' Disappro~
f ....7~ Z: ~-; ....... ~_ c.,.- :, D,.ate ',": / i' %:Z~l
l
Condi'rional
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 parag~'aph 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 cer'dficate 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 (11/84)
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata
Date Installed ~--8~' ~
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
~y~'. Type of System Design Length of Field ,~_~
Depth of Field
Gravel Bed Thickness
Standpipes Present (Y/N)
Date of Last Adequacy Test
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
./
To Property Line
/,
To Existing or Abandoned System on
; On Adjoining Lots /O0
/
TO Cutbank (if present)
t +
D. LIFT STATION
Date Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at
Tested for
Electrical Codes (Y/N)
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
Vent (Y/N)
Pumping Cycles during Adequacy Test. Meets MOA
Comments
** Check Permitted Bedroom Rating Against HAA Request **
I certify that I hj~e checked~ve_rified, or conformed to all MOA and HAA guidelines in effect on the date of this inspection.
S ig ned 't--~ ~~ate ¢¢¢""/~,7 ... ~.~
C~~-'~ MOA No. ~-r ,~8 ~ ,~
Receipt No.
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
WELL DATA
MUNICIPALITY OF ANCHORAGE (MO~i
MUNICIPALITy t~iEA~4;~D~)~tT_cHORiTY APPROVAL (HAA)
DEPT. OF HEALT~H~ECKLIST . FEBRUARY 1984
ENVIRONMENTAL PROTECTION 264-4720
RECEIVED
Legal Description:
Well Classification //~;)~/~)~¢~' If A, B, C, D.E.C. Approved (Y/N)
Well Log Present (Y/N) N~) Date Completed /~)- !- ~ Yield
Total Depth ~ Cased to ~ Depth of Grouting
Static Water Level ~ NO IN~~¢~ Pump Set At ~O IN~~¢N
Casing Height Above Ground ~ ~ Sanitary Seal on Casing (Y/N)
Electrical Wiring in Conduit (Y/N) ~ Depression Around Wellhead (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot /~20/'/~- ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot ,/ 4;) ¢-) ¢"/~-'
, On Adjoining Lots /Od".)
To Nearest Public Sewer Line .NL~r To Nearest Public Sewer
Cleanout/Manhole ,/~/,,/"f To Nearest Sewer Service Line on Lot
Water Sample Collected by _/~,,~//~/~'~,/~',~---~/ /-//'-~¢,/¢ ; bate 7~3/--~'
Water Sample Test Results ~j~----)o~r~.y (~ ,~j~]~_~:~)
Comments _~'~//~.~,,~ ~r'/~_~7'~~]4~-~"o ~,/~,/'~
B. SEPTIC/HOLDING TANK DATA
Date Installed !1" J¢-"r/Size No. of Compartments
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 N//
Course /0~)
Foundation Cleanout (Y/N) /'Y~O
Date Last Pumped ~'"- l¢~'- ~¢~
; for
Temporary Holding Tank Permit (Y/N)
To Building Foundation
To Disposal Field
To Stream, Pond, Lake, or Major Drainage
Page I of 2
72-026(11/84)
A CHEMICAL & GEOLOGICAL LABORA~/C~ORIES OF ALASKA, INC?
/1\
l
/_.,,~j,~\ TELEPHONE (907) 562-2343 5633 B Street ~
t ~'~ Anchorage, Alaska 99518
/.~ ......"~ Drinking Water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BY WATER SUPPLIER
[] PUBLIC WATER SYSTEM I.D.#
[] PRIVATE WATER SYSTE~
Name ~ Phone No.
City State
Mo. Day Year
q q do /
Zip Code
SAMPLE TYPE:
,,~ Routine
[] Check Sample (for routine sample
with lab ref. no.
[] Special Purpose
) [] Treated Water
[] Untreated Water
SAMPLE
NO. LOCATION
4 I I I
Time Colic ct.e,d
Collected ~.
TO B,E COMPLETED BY LABORATORY
Analysis shows this Water SAMPLE to be:
~ Satisfactory
[] Upsatisfactory
[] Sample too long in transit; sample should
not be over 30 hours old at examination
to indicate reliable results. Please send
n~w sample via special delivery mail.
Date Received
Time Received
Analytical Met'hod:
Membrane Filter
* No. of colonies/100 mi.
Lab Ref. No. Result*
Analyst
BACTERIOLOGICAL WATER ANALYSIS RECORD
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
Membrane Filter: Direct Count
Verification: LTB BGB
Final Membrane FilterJtesults
Reported By ~~~~- ~ Date
Time:
Ceil form/100mi
TNTC -- Too Numberous To Count
OB = Other Bacteria
/ C0ilform/100ml
/ $'~0
INVOICE ~ 014904.
· ,,4~,¢,¢~ ~ ~,~ CLEANING SERVICE
~ ¢.~ ~.~"
P.O, BOX 112688
Job Adc tess
PHONE 345-2513 ANCHORAGE, ALASKA 99511-2688
ROTOR ROOTER SERVICE CALL
STEAM THAWING
I TEF~ I CUSTOMER ORDER #
HRS.
HRS. (~,
TRIP CHARGE HRS,
OVI~RTIME CHARGE HRS.
ADDITIONAL LABOR CHARGE
HRS.
PUMPING SERVICE /~-~ (GAL) HRS @
HYDRO-JET SERVICE HRS ~,,
MATERIALS
PLEASE PaY FROM THIS INVOICE
TOTAL FOOTAGE CLEANED OR THAWED. BLADES USED
LINE CLEANED
[] JOB NOT GUARANTEE~)F/?O~ING_~SO~
WORK ACCEPTED BY, ~/~( .~~ '-/~-,~