HomeMy WebLinkAboutTANAINA VALLEY LT 4
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Environmental Health Division
825 "L" Street, Anchorage, Alaska 99502, Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
Lot
Towflshlp, Range, Section
TANK,.~
~/ SEPTIC [] HOLDING
.
TYPE OF SYSTEM
'~'rRENCH ~ BED [] W. DRAIN [~ OTHER
grade ~ FT ~"~ FT
~/ FT
L WELLS
Dale hlstalfed
[] PRIVATE ~ OTHER (Identify)
'1 oral Depth
Date Inslalled:
Cased to
FT
DISTANCES
~ WELL
WELL
LOT LINE
FOUfiDATION
SEPTIC ABSO~PTIO~
TANK FIELD
/2' /~ '
~' /0'
REMARKS:
hlspections Performed by:
72-013 (3185)
NEER'S SEAL.)
PERFORMED FOR:
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
m OAT
LEGAL DESCRiPTiON:
~/H
3
4
5-
6-
g.
11
12
13
15
16
17- : ANCHORAGE
DEPT. OF HEALTH &
IRONMENTAL PROTECTION
49- !AUG 91988
2o- 'RECEIVED
Township, Range, Section: .~ z~ 7-/Z A~ ,~..'./~/
SLOPE SITE PLAN
f
WAS GRQUND WATER
,'.'NCCU.TERED7 · //~
IF YES, AT WHAT
DEPTH?
Reading Date Gro~ Net Depth to Net
Time Tlme Water Drop
PERCOLATION RATE __ (m~nute~incl~) PERC HOLE DIAMETER __
TEST RUN BETWEEN FT ANn ----Ff'
PERFORMED aY: .~ ~)~[/ I ~/Cl~ ~ ~PC~J(~ CERTIFY THAT THIS TEST WAS PERFORMED IN
M LJ IXl I (::: ii: F:' A I. ]: "1' Y E) F' I"'~ N C H E) R A E) ii:
0 N - S ~ 'T Iii: S I!: IAI E R F:' E R M :[ 'f'
F:'e:~ruYl:i.'L Nl.~mbel'~ 88(:)053
:Oate Issued: 0512::',";/88 IEng:i.r~el~r, De~;igned
O~ne~' Name: DEEE;IE~IxlE~ IN WOOD Day F'horle~
E)wrlE~f' A(::h::Ip~,.?!~H~, '7021 DI::(II::?TWOOD L.ANE ::~;49.,,',8():t. 4
P a p I:: e ]. I d ~: 0:1 ]. ," () 51' ."79
Li:rL L6.)ga].: ,'3ubd:i. visiorl~ TANA.T. NA VAL.J_,IEY I_~_)'t.~: 4. B:Lock: -
Sect J. on;: 4 TownshJ. l:):: ].2N Range: 4W
L..(z)t E~ :i. z E~ :]~;;]~;92'7 ( ~(:l. f t. o P a [: P ~ )
Max ;.)c~dpcx3ms~ 'l"hi~ F'el"m~.~:,~ 4 'f'crLc~l Capacity: 4 ~/~6~ ~/~ ~/P~C~
SEI::'TIC 'I"ANI:::: M:i.r'limum 'La'Lal septic rani< i::apacd, ty: :l.,~:?:~t~O ga].lons. E:ach sel:)t:i,c
r~:.~:~l'~l':: I~lU~it HavE~ at least ~t c~:~mpar"Lment~. Oep'Lb 'Lo top oF sep'L:Lc t. arlk(s) < 4.0
I:NFq]I::~M ]:).H.II.E~. F'RJ:C)R 'l"l::] :I. ST &. 21xll) INSPLECTIOI\IS BY ENGII'4E:IER,
AI::TIEI:?~ I'IOURS [:ALL 34::!;"-'4,5E1:1. AND I....Iii:AVIE A MISSSAGE
CUI~g:.T'I'RLJCT PER 1EIxI[:]~NE]ERS A"I"f'~[;HL::D API::'ROVI~D DIESII:!)N
I F
:1: C;E]':I'I" :1: F:'Y 'T'H(,../I:
:[,, ]: ¢3ffi fi:]¢Tl:i, lia]" w:i.'Lh 'Lhe r',t~)qLt:i.l'emer'lt!~, {'(:)p (:;)rl...q~J. t6) ~i~e~l'~i i;tf](:l wells as
fopt. l'~ by the I"lunic:i. paJ.:i, ty of Anchopage (IdI;:IA) and 'f. h6~ St.a'ke oF Alaska.
2. I ~;i. ll :i. ns'La:l. 1 the syst. em in ac:c:cn*danc:r.0 ~i'Lh 811 NOA cod~.:'.~s 8tt{;:I pegu].at:i.o~s,
arld :i,l'l c:cmlpJ. J. arl(:ae w~.t'.h 't',.l"l(~ design cr'J.'t, el-ia c:H' 'Lhis pepm:i.'k.
3. I wi:l. 1 adhoPe 'Lt:t all MOA and EM'.,a't'.,e c)f Alasl<a neqt.~J.p~:?mt:,~rl't:.s for' the set back
distances Ct, c:)m any e>(:i.s'Lin~.] t,,~.~;I.:l., ~as'L~;.wat~r' c:Iispc)sal system op publJ, c:
fii}~gl~(.}U'F:U.:]J~?.) SyWSt(gifl or'l th:Ls (21" any iM::J.j¢~i]E2f'it {:)P I"lE¢~'ill'J:)y 1c)t.
4,, :t: under'stand that {his peP~l:['[. J,~B valid {rI2P a ffla>CiflH..iflI Elf 4 bednoom*iE;,, I
al?sc:, urld,~)r's't, ar, d 'Lhat '~:l',e c~paci'Ly. ~ of the tcrLa:l: sys'Lem is 4 bedi',c,c, ms and
, .. , ~ , r'e~ adcli'Lil:)nal piJfmi'E.
-- z ._. .............................. ......
([:]~ner'.) DESIGNS )Jxl Wi]f'II)
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
825 "L" Street, Anchorage, Alaska 99502-0650
SOILS LOG -- PERCOLATION TEST
PERFORMED
DATE PERFORMED:
LEGAL. DESCRIPTION: ~(~- /7/
r°wnship, Range, Section: L~-~(~'Z'-,'-/ 77¢? /Z/./ /.-' ~///fg
SLOPE SITE PLAN
14
17 s~ ~o
18
19
WAS GROUND WATER
E.COUNTERSD? -- ./V'¢ _
IF YES, AT WHAT
DEPTH?
OeCh to Wa~ ~er
Gross Net Def~th to Net
Reading Date Time Time Water Drol~
20-
PERCOLATION RATE .~" L/ (m~nutes/inch) PERC HOLE DIAMETER (~ '
TEST RUN OETWEEN .---~,~ FTAND .-...~' ~'-- FT
PERFORMED BY: ),UA t;h)¢ ~)¢ t::~]~/~I _ I ~~~RTIFY THAT THIS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STATE AND MUNICIPAL GUIDELINES IN EFFECT ON THIS DATE. DATB ~¢~
72-008 (Rev. 4/85)
$1~711
ol
5
?
15
8
14
I
I'
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF ENVIRONMENTAL. SERVICES
CERTIFrCATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date ~-/5-"--8~
GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, range)
Location (address or directions)
(b) Property Owner ¢;~E<;/d',tl$ ixl I,V/)DIb Telephone: Home .
Mailing Address '70Zl ,~2~I~-'FV.{O~I~ /-.Id. ,,Al, JO. ~q~/~
(c) Lending Institution _-~',,,'~/.,"Z /'-.--//J ~ A/~/,u ~ Telephone
Business
Mailing Address
(d) Real Estate Company and Agent
Address
Telephone
(e)
Mail the HAA to the followinci address: or: Check here ,[~'~if hold for pick up.
List contact person and day phone number below.
TYPE OF RESIDENCE
Single-Family ~J.
Number of Bedrooms'
WATER SUPPLY
Individual Well [] Community ~ Public ["l
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
SEWAGE DISPOSAL
Onsite ~ Public [] 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.
Page1 of 2 72-025 IRev 8/861 Fronl
ENGINEERING FIRM PROVIDING 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 regulations in effect on
the date of this inspection,
NameofFirm ,,~.~/)E'r~50~j ~-7'J~H~E'~,f.~ Telephone ~7'~(,'1
Address ~0. ~ ZVo 77~ ~'(~t~ ) ~IL ~&~'
.,Engineer's Seal
Approved for '¢' bedrooms by _ . Date
Approved .~ Disapproved Conditional
Terms of Conditional Approval
CAUTION
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 DHHS 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
engineer's work.
Page 2 of 2 72-025 iRev 8/861 Back
WELL DATA
t* PALIT¥ or A.CHORAG IMOA)
.,~cc~EALTH AUTHORITY APPROVAL (HAA) CHECKLIST- FEBRUARY 1984
Legal Description: ~/~
Well Classification
Well Log Present (Y/N)
Total r)epth Cased to
Static Water Level
Casing Height Above Ground
Electrical Wiring in Conduit (Y/N)
Separation Distances from Well:
To Septic/Holding Tank on Lot
To Nearest Edge of Absorption Field on Lot
To Nearest Public Sewer Line
Cleanoul/Manhole
Water Sample Collected by
Water Sample Test Results
Comments
If A, B; C, D.E.C. Approved (Y/N)
Date Completed Yield
Depth of Grouting
Pump Set At
Sanitary Seal on Casing (Y/N)
Depression Around Wellhead (Y/N)
; On Adjoining Lots
; On Adjoining Lots
To Nearest Public Sewer
To Nearest Sewer Service Line on Lot
; Date
B. SEPTIC/HOLDING TANK DATA
Date Installed
Standpipes (Y/N)
Depression over Tank (Y/N) .&J
Pumping/Maintenance Contract On File (Y/N)
Holding Tank High-Waler Alarm (Y/N)
Separation Distances from Septic/Holding Tank:
To Water-Supply Well ~
Size /ZG~,'D No. of Compartments 2~.
Air-tight Caps (Y/N) ,.V Foundation Cleanout (Y/N)
Date Last Pumped ~l,d
'~' ; for _ ~
Temporary Holding Tank Permit (Y/N)
To Property Line
To Water Main/Service Line
Course N o ,tfE~ /~
Co m ments -'7'~'~,.
Y
__ To Building Foundation ~"
__ To Disposal Field .~' /
To Stream, Pond, Lake, or Major Drainage
Page 1 of 2
72-026(11/84)
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 /¢/0 t4E. OT~E'~.5
TO Water Main/Service Line
To Stream/Pond/Lake/or Major Drainage Course
To Driveway, Parking Area, or Vehicle Storage Area
Comments ~EI4J C.o[i 7.~T,C_UOT-IOI,J
/_Z ~ Type of System Design
Length of Field ;2',¢ '
Depth of Field 8 '
Gravel Bed Thickness ':/'
.~' Standpipes Present (Y/N)
A/ Date of Last Adequacy Test
Y
To Property Line _ /
To Existing or Abandoned System on
; On Adjoining Lots
To Cutbank (if present)
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 [ have check,~d,.verified, or conformed to all MOA 8nd HAA guidelines in effect on the date of this inspection,
Signed ~,~4,Lc~- ~/~¢4.~f~..~ Date /ff/~/~ ~
Company 4A/~C4~lJO
Receipt No. ~~
Date of Payment
Amount: $
Page 2 of 2
72-026 (11/84)
Engineer's Seal
DEPT. OF ENVIRONMENTAL CONSERVATION
ANCHORAGE/WESTERN DISTRICT OFFICE
.q601 C STREET. SUITE i334
aNCHORAP~E, ALASKA 99503
STEVE COWPF. R, GOVERNOR
563-A775
DATE: ~3-- t~_~-S~
PwsI O ~: __~_~_AzZZ~_-_, .........
To Uhom It May Concern:
accordinq to the records on File in this office, the _~eoo~<~___
~..~..6_b~¢5~_~x~.~.~aUater System is in compliance wLth the
'qtate o? alaska Orinkinq Water Requlations,
RSK:sa
Sincerely,
Environmental Field Ofrice~