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HomeMy WebLinkAboutUS SURVEY 3200 LT 12A-1 / x /% LOT ~S USS 5200 S 7S ~7,00,, E 125.00' 3~ '..~nneth k. Oreyer..' ~ vOh¢r 7. LS-8202 ." ~ ~~~~ EXCLUSION ~OrES: It is the owners' responsibility to determine LEOEND: 8ET FND Under no circumstances should any data hereon be used tar HUB ~ TACK 440 WEST BENSON BLVD. ~ 103 -S-I 5ASB BAB KEN 4455 369/4&5 Rick Mystrom, Mayor Mmficipality of Anchorage Department of Health and Human Services 825"L'Street P.O. Box 196650 Anchorage, Alaska 99519-6650 343-4744 December 8, 199,/~ Robert B. and Paula J. Tnckcr HC 52 Box 8819 Indian, AK 99540-9604 Subject: Lot #12A, US Survey 3200 Permit #SW930329, Parcel ID #090-041-33 Dear Robert and Paula Tucker: The subject permit, issued August 26, 1993 to the previous owner of this property by this office for a single family well and/or on-site wastewater system, has expbed as of August 26, 1994. A new permit must be obtained from this office for a well and/or on-site wastewater system NOT installed by the expiration date. If the well was drilled, a well log must be sent to this office for documentation of the installation and to close the permit. if tile on-site wastewater system has been completed and a licensed Professional Engineer has inspected the installation of the on-site wastewater system, the original as-built inspection report must be sent to this office for review, approval and documentation. All inspection reports must be submitted within 30 days of construction completion. When applying for a new permit, the fees are: $320.00 for ail ou-site wastewater permit; $120.00 for a well permit and $440.00 for a combined on-site wastewater aod well perlnit. If you have any questions, please call this office at 343-4744. f~f~C¥o serely' Program Manager On-Site Services JC/kb cc: Shane ltolt, P.E. MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND HUMAN SERVICES P.O. BOX 196650, 825 "L" STREET, ROOM 502 ANCHORAGE, ALASKA 99519-6650 ON-SITE WELL SYSTEM PERMIT PERMIT NUMBER:SW930329 DESIGN ENGINEER:DUMMY COMPANY OWNER NAME:OVERTURF JAN H OWNER ADDRESS:6336 SE MILWAUKIE AVE. PORTLAND OR. 97202 PAGE 1 OF 1 DATE ISSUED: 8/26/93 EXPIRATION DATE: 8/26/94 PARCEL ID:09004133 LEGAL DESCRIPTION: US SURVEY 3200 LT 12A LOT SIZE: 25575 (SQ. FT.) NUMBER OF BEDROOMS: 1 THIS PERMIT: 1 THIS PERMIT IS FOR THE CONTRUCTION OF: WELL SYSTEM ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH: 1. THE ATTACHED APPROVED DESIGN. 2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS 15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80). 3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY CALLING 343-4744 OR 343-4681 AFTER BUSINESS HOURS 4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING WEATHER MUST BE EITHER: A. OPENED AND CLOSED ON THE SAME DAY B. COVERED, SEALED AND HEATED TO PREVENT FREEZING 5. THE FOLLOWING SPECIAL PROVISIONS. SPECIAL PROVISIONS iSSUED BY: L~)T II / VENT-< L~'-t~cff F~T£L~ ~'~A~7'~ LOT IZ~.- Xo~/-'/z~/ ct~X L~zoo '%. 1. plOc AS-BUILT SUN¥~Y (NO CORNERS SET THIS DATE) .! her~t~'~ertlf¥ that I have F~rfome~l d~rlb~d property~ LOT 1~ U.L ~uBvEY NQ. t200 Anchorage Recordins bl~trl;t, Alaska an~ That the lf~prov~nTi altuated thereon are Hlthln the property lines end do not evBrlap or en~rp#~h on the property I~rov~te ~ pro~rty ~ylna adjacent HqLT ~NO ASSOC AYES LAND ~RVEY~S I hAME I JPHONE LEGAL D~scRi~TION : ' ' LJ(}~, csp~clly(~(]oln gBllons IF flO~O~: ln~ld~ lenglh Wldlh Llqul~ depth ~ ~ DISTANg~ TO: Well Dwelling PLRMtT NO, STANCE TO: ~ Class r Depth Driller Distance to lot line PERMI~ NO, ~ DISTANCE ~O: . Building foundetJon Sewer IIn~ Septic tenk Absorption ~reeJsJ , ~ · OTHER ,.,. ~. . .,,, ~l~ - · ,..~ , ~,~ AS-BUILT SURVEY (NO CORNERS SET THIS DATE) THE INFONIGTION HEREON IS FOR THE USE OF LENDING INSTITUTIONS SPECIFICALLY TO SNON ANY CONFLICTS BETUEEN EXISTING STRUCTURES AND PLATTED LOT LINES OR EASEHENTS AND IS NOT TO BE USED FOR POSITIONING ADDITIONAL STRUCTURES ON FENCELIRES EASEHENTS OF RECORD, OTHER TNAH THOSE SNOUN ON THE RECORDED PLAT, ARE NOT' SHORN HEREON I hereby certify that I have ~rfor~a #ortgagae*a tnopection of the foLtowing described property: LOT I~A, U.S. SURVEY RO. 3200 Anchorage Recording District, Ataska and that the improvements situated thereon are within the property tines and do not overlap or encroach on the property lying adjacent thereto, that no Improvements on property tying adjacent thereto encroach on the prm~ises In queatlon and that there are no roadwaya~ transmission lines, or other vteibte easements on said property except aa indicated hereon. Dated at Anchorage, ALaska this 2*~/ day of ~97~. ~',~ */~-~'~ ~ V? HOLT---AND ASSOCIATES LAND SUrVeYORS M-W DRILLING, Inc. P.O. Sox 110378 · 10330 Old Seward Hignway (907] 349-8535 ANCHORAGE ALASKA 99511 Well Owner BOB TUCKER DRILLING LOG Use of Well Domes tic Location (address of:. Township, Range, Section, if known; or distance main road Lot 12-A ~BGS ~3200- Indian Size of casing. 6 Depth of Hole 241 feet Cased to 60.5 feet Static water level ] A ? ft. ({~) ~below) land surface. Finish of well (check one) open end ( X ); Screen ( ); Perforated ( ~: ).. Describe screen or perforation ,~ N/A Well pumpir~g test at 3 gallons per ~ (minute) for 2.5 hours with 100% ft. of drawdown from static level. Date of completion 1/29/94~ Depth in feet from ground surface 0 .TO 2 2 .TO 6 6 .TO /~ 7 47 .TO. 49 49 .TO 54 5 t~ .TO 60 60 .TO 165 165 TO 197 Note: WELL LOG Well CSG dry grouted with 2 bags of Bentonite Granules. Givedetailsofformationspenetrated, sizeofmaterial, colorand hardness CSG Stickyp ~rganics Cobble Gravel; silty/clayey BDulder :~l~.-:Small Gravel; slightly clayey ' Weathered Bedrock; reddish bro~x, s~ft Bedrock; ~rey siltstone/claysnone argillite. A/A : grey black with white quartz veins in spro~dic gruc ]97TO 205 2~5 TO. 241 A/A: Krey A/A: black with small water seaps in sporadic fractures. .TO. .TO. .TO. TO. TO Cci'. [ Contractorul'~ 3--CONTRACTOR  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 NAME PHONE [~NEW 3'AM OUF_R'T'o R P ~;~'3.-7~-6~' []UPGRADE MAILING ADDRESS LEGAL DESCriPTION ' ' LOCATION NO, OF BEDROOMS DISTANCE TO: IWell I Abs orp~o n.~r~ Dwellin~o I PERMIT NO.s~ ~ ~~ Liq. capacity [n gallons Inside length Width Liquid depth //OOO IF HOME'DE: ~ ~ DISTANCE TO: Well Dwelbng PERMIT NO, O ~ ~ Manufacturer Material Liquid capacity in gallons ~ Well Foundation ' , Neares~Jgt~ine PERMITNO,~¢~? No. of lints Length ~f.la)h line Total len~t~ 9' lines Trench wid,, ~' inches Total ef~e~v~absorption ~ Top of tile to finls~rade Length Width ~epth PERMIT NO. ~ ~ Type of crib Crib diameter Crib depth Total effective absorption area m Well Building foundation Nearest lot line ~ OISTANCE TO: ~ Class Depth Driller Distance to lot line PERMIT NO, m Building foundation ' Sewer line Septic tank Absorption area(s) ~ DISTANCE TO: ~ OTHER PIPE MATERI~LS SO(L~TEST RATING INSTALLER REMARKS ~gzJL~'r~O~ I~.~ . (;5 72-013 (Rev, 3/78) I'~IIJ~'-.~ I IS I PAL I T"T" IDF ~t~-.~C:HlliF~AI]E DEPARTMENT OF HEALTH 8ND ENVIRONMENTal PROTECTION 825 L S~REET, ~NCHORBGE, 8K 9950i 264-4~20: O[-~--'__--5 I TE __C.E~EF-: PEF-:~'I I t F'ERMt T NO: DATE ISSUED: ~40.~,,- 05/1t,-'84 FFLI --ANT ADDRESS: F:0NTFIC:T PHONE: JAN OVERTURF SR BOX 8819 INDIAN~,AK 99540 65~-7665 LEGAL DESCRIP LOt SIZE LOt LOCRt I 0N i',IRN ' ' BED~ SUBDIVISION: USS ~2J~O SECTION; 6 TOWNSHIP: ~0900 (sQ. FT. OR ACRES) RAND AVENUE LOt: i2A BLOCK: NA ±ON RANGE: IW LISTED BELOW ARE SYSTEN. CHOOSE THE OPTION THAT BEST FITS YOUR SITE. DEFTH T0 FIFE BOTTOM (FT.)' GRAVEL DEPTH](FT..¢ / 5.0 \ 0.5 TOTAL DEPTH ,..FT.). / ~'~, / 4,5 GRAVEL WIE;'TH <ft...' I ~., ~ ~ 12. 0 GRAVEL LENGTH '::FT. ) / 1~., ~ I 22.'0 ORAVEL ~OLIJNE <CU. YDS. ) TANK SI~E ~GRLS) . . \ SOIL RRTIN~ ~:SQ. FT./BR:, ~ 8~/// 85 m~, TANK MUST HAVE AT LEAST TWO COMPARTMENTS THE OPTIONS AVAILABLE TO YOU IN DESIGNING YOUR SEPTIC: E:"RR l' I".l 4,0 ~.5 7'.5 5.0 19. 0 14. 0 000. 0 ~+:* I CERTIFY THAT: t. I AM FAMILIAR WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET FORTH BY THE MUNICIPALITY OF ANCHORAGE (NOA) AND THE STATE OE ALASKA. 2. I WILL INSTALL THE SYSTEM iN ACCORDANCE WITH ALL MOA CODES AND REGULATIONS, · AND IN COMPLIANCE WITH THE DESIGN CRITERIA OF THIS PERMIT. ~. I WILL ADHERE TO RLL MOA AND STATE OF ALASKA REQUIREMENTS FOR THE SET BACK ' DISTANCES FROM ANY EXISTING WELU WRSTEWRTER DISPOSAL SYSTEM OR PUBLIC SEWERAGE SYSTEM ON THIS OR ANY ADJACENT OR NEARBY LOT. 4. I UNDERSTAND THAT THIS PERMIT IS VALID FOR A MAXIMUM OF 2 BEDROOMS AND ANY ENLARGEMENT WILL REQUIRE AN ADDITIONAL PERMIT. IF A LIFT STATION IS INSTALLED IN AN AREA COVERED BY MOA BUILD'lNG CODES, THEN (±) AN ELECTRICAL PERMIT AND INSPECTION MUST BE OBTAINED~ (2) AS-BUILTS AND (~) THE WILL NOT BE APPROVED WITHOLIT AN ELEC:TRICRL INSPECTION REPORT.~ ELECTRICAL WORK MUST BE DONE BY A LIUEN_.ED ELECTRICIAN. S I GNED APF'LICRNT: JAN OVERTUF..F ISSUED BY Permit Applicant: MUNICIPALITY OF ANCHORAGE Department~ Health and Environmental~rotection 825 '~ Street, Anchorage, AK. 1501 264-4720 * * * HANDWRITTEN PERMIT * * * ~j&., W~~ON-SITE SEWER PERMIT ~ja~ Location: Legal Description: ~OT Type of Soil Absorption System Is: Trench: /Drainfield: Maximum Number of Bedrooms: Phone Number: ,~ ~ -~ ~& ~d~ ~/~.~ .~0~ Lot Size: ~o? ~o o Seepage Bed: Holding Tank: Soil Rating (sq. ft/br) ~ The Required Size of the Soil Absorption System Is:' DEPTH O LENGTH GRAVEL ~EPTH WIDTH The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~-¢ GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any system without final inspection and approval by this department will be subject to prosecution. Minimum distance between a well and any on-site sewage disposal system is 100 ~eet, 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 ~nd must be returned to this department within 30 days Of the well completion° Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31, 1 9 * * 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 codes. (3) I unders~nd that the on-site sewer system may require enlargement if · the residence,is remodeled to include more that 3 bedrooms. Date: SWP/024(1/81) ~UNICIPALITY Of ANCHORAGE ~ Department i Health and Environmenta3 !rotection · . 825 ~ Street, Anchorage, AK. ~9501 264-4720 · * * HANDWRITTEN PERMIT * * * Permit #~-$~ WELL AND~0N-SITE SEWER PERMIT Applicant: J/~AJ ~X~7'~ Mailing Address :~dg~' Location: ~/S~ ~9~ ~--~r /2 ~ Phone Number: ~'~/ Lot Size: ~D! Legal Description: Type of Soil Absorption System Is: Trench: /'~ Drainfield: Maximum Number of Bedrooms: ~ Seepage Bed: __ Holding Tank: soil Rating(sq.ft/br) ~'-- The Required Size of the Soil Absorption System Is: ~' GRAVEL DEPTH ~ WIDTH DEPTH LENGTH ,8 ~ ~ ' The length dimension is the length(in feet) of the trench or drainfield. The depth of a trench or pit is the distance between the surface of the ground and the bottom of the excavation(in feet). There is no set width for trenches. The gravel depth is the minimum depth of gravel between the outfall pipe and the bottom of the excavation(in feet). * * REQUIRED SEPTIC(HOLDING) TANK SIZE = /~OO GALLONS * * Permit applicant has the responsibility to inform this department during the installation inspections of any wells adjacent to this property and the number of residences that the well will serve. * * * TWO(2) INSPECTIONS ARE REQUIRED * * * Backfilling of any sys~m without final inspection .and approval by this department will be subject to prosecution. 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 this department within 30 days of the well completion. Other requirements may apply. Specifications and construction diagrams are available to insure proper installation. * * * PERMIT EXPIRES DECEMBER 31~ 1 9 8 3 * * * I certify that: (!) 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 codes. (3) I understand th~ the on-site sewer system may require enlarqement if the resi~e~ce~ re~ode~ed to include more th~.3 bedroo~__~ ? SWP/024 (i/si) MUNICIPALITY OF ANCHORAGE DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION S25 L, Street, Anchorage, Alaska 99501 264-4720 SOILS LOG -- PERCOLATION TEST SOILS LOG [] PERCOLATION TEST PERFORMED FOR: LEGAL DESCRIPTION: SLOPE ~ 9 DATE PERFORMED; SITE PLAN 11- 12 13 14 15 16 17 18 19 2O COMMENTS V lS U,f~ L WAS GROUND WATER /k/O I~ ENCOUNTERED? 0 P E IF YES, AT WHAT DEPTH? Gross Net Depth to Net Reading Date Time Time Water Drop PERCOLATION RATE TEST RUN BETWEEN FT AND (minutes/inch) FT · PERFORMED BY: ~J CERTIFIED BY: DATE:. 72-008 (6/79) 825 "L" STREET ANCHORAGE, ALASKA 99501 (907) 264-41 / 1 GEORGE M. SULLIVAN, MAYOR DE?AR I-MEN'¥ OF ItEAL'FH AND ENVIRONt,/iENTAL PROTECTION December 31, 1980 Rebecca L. Brown 2832 West 9tst Avenue Anchorage, Alaska 99502 Permit % 800267 Subject: U.S. Survey #3200 Lot 12A Block 12 A permit issued by this department for well and/or sewer system has expired as of this date. Permits are issued on a calendar year basis, as stated on the permit, by authority of Municipal ordinance. If you have drilled the well, a well log should be sent to this department to document the installation date. If an engineer inspected the installation of the on-site sewer system, please have them send us the as-builts for our files. If there are any further questions, please call this office at 264-4720. Sincerely, // ~ Les N. Buchholz, .~./ /. Senior Environmental ~p~cialist LNB/ljw enc: Copy of Permit oWP/0 o 7 PERH.[ T NO. [ EFHR Fi'iEN. ~ .~ HERLTH RI'4D ENVIRI]NMENTRL/"'hOTEE:TION 825 STREET, IRNCHORRGE., PK. 9'. ~0t 264-4720 t--4]ELi_ F'ER[¢'"~ ][ T F F L · ..piNT LOE:RT i ON LEGRL REBECCIR I~, E,R RFIN[:, FINi} IN[:'tRN RD L:J.12IR E,]..~ Ii'Z]_ ~. SLIRVEY _,.~',::ud":o-- LO]' =,I ~.E ~.4_. ~: 44i 10000 .':,QLMF',E FEET NiNii'iUM DiSTRNCE BETWEEN R WELL RN[:' IRNY ON-SITE SEWRGE DISPOSIRL SYSTEM IS t00 FEET FOR R PR](VRTE WELL OR '.158 TO 20E~ FEET FROM R PUBLIC WELL [:,EPEN[:,ING UPON THE T"r'PE OF PUBLIC WELL HINIMLIM DiSTRNCE FROi'l iR PRIVRTE WELL TO R PRIVRTE SEWER LINE IS 25 FEET FiND 'TO R COMMUNIT"r' SEWER LINE IS 75 FEET. WELL LOGS PRE RE(gUIRED RN[:, MUST BE RETURNED TO THE DEPIRRTMENT WITHIN 7~0 DR"r'S OF THE WELL COMPLETION. OTHER REQUIRENENTS l"tR"r' RPPLY. SPEC:IFICIRTIONS RND CONSTRUCTION [:'IIRGRRMS IRRE IR'v'IRiLRBLE TO INSURE PROPER iNSTRLLiRTION. i CERTIFY THRT t: I Ri4 FRMILIiRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS iRND WELLS RS SET FORTH BY THE MUNICIPRLITY OF RNCHORiRGE. 2: i WiLL INSTiRLL THE SYSTEM IN ~CCORDiRNCE WITH THE CODES. S I GNEL':,: .......................................... iRPPLICRNT REBEL. L.H L. BROWN / .,, V4. 0 E~LE TRICAS ociatioN, inc. (OgO) 25 265 June 13, 1983 Jan Overturf P.O. Box 306 Girdwood, ALaska 99587 Subject: Lot 12A, U.S. Survey 3200, Alaska Dear Ns. Overturf: Chugach Electric Association, Inc. has no objection to your proposed septic system and well being located within the fifty foot (50') road reservation on your property, Lot twelve-A (12A), provided that you maintain a minimum dis- tance of ten feet (10') from any existing Chugach facilities. If you have any further qeustions, please contact me at 276-3500, extension 180. Very truly yours, Jim K. Topolski Land Services Manager JKT/sk (~ MUNICIPALITY OF ANCHORAGE . DEPARTMENT OF HEALTH & HUMAN SERVICES Division of Environmental Services ' '~ ' * . '"~' ' ' :: ~:-r' On-Site Services Section -- P.O. BoxY96650 Anchorage. Alaska 99519-6650 :~ - . 343-4744 ...... CERTIFICATE OF HEALTH AUTHORITY '~ ' ' APPROVAL FOR A SINGLE FAMILY DWELLING Parcel I.D.# c'~O--~'[~S' NAA# 14Aq -OOqq 1. GENERAL INFoRMATioN :' LOT:~2A BLOCK 0 U.S. SURVEY #3200 Complete legal description Location (site add ress or directions) ha. tL~ o- ~' .:;' - ':- ,' Proper~y owne(:;~ ]~(3R*RRT TUC'['~ '~ Day phone 653-737~_. ': -' 8819 99540 Mailing address Hcqa ~w ~,~ e.~ AT,AR~A CA~ ~S Day phone 27~-1Rll Lending agency ' 3. TYPE OF WATER SUPPLY.' ...... ~ "' - :':-Public water :-":-- " NOTE: · If community welt sysIom, proWde wdften confirmation ~rom State ADEC ' ' . .... ..' i to'th~ i ~tatus of System. _.---: -. -_. 4. TYPE OF WASTEWATER DISPOSAL: . ' . .... Jnd v dual og-site ~ ~: ........ X ~ ' ' NOTE: If community Wastewater system, provide written confirmation from. ~...~S , ,,,.~ .~DEC attesting to the legality and status of system STATEMENT OF INSPECTION BY ENGINEER ~.' ~ by ' ' !~ ': ' As certified 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.tLgation and inspection, the on-site water supply and/or wastewater disposal system is in corn pliance with all Municipal and State codes, ordinances, and regulations in effect on the date of this inspection. Name'oi Firm D[~"~NG D',]GT~,:,:.$ '// . Phone 3~,4-1385 Engineer's signature ~_.~ //"7"'~'~ Date 6. DHH$ SIGNATURE .... r Approved for bedrooms. .. '-. --.'.-~ -'".~. Disapproved. ' ' ' ~'( ............................... "'-:' :~'~ '~'":" -- ' '-~' ~' ": Conditional approval f~r'__ '~ ...... bedrooms, w~th the following stipulations: " Additional Comments ' :. · -,.?~he MOdi( of Ah"~hbrage Department of Health and Human Servi~e~ [DHHs) i~sues Health Authority -_'~proval tificat~,(ba§ed only upon the representations given in paragraph 5 above by an independent responsible for errors or omissions in the professional engineer's work, Municipality of Anchorage Department of Health and Human Services HEALTH AUTHORITY APPROVAL CHECKLIST Legal Description: TDT Parcel I.D. A. Well Data Well type RESIDENTIAL Log present (Y/N) YES~ Total depth 241 Sanitary seal (Y/N) '~s(~) If A, B, or C, attach ADEC letter. ADEC water system number. Date completed 1-20-94%~ Driller M-W DRILLING INC.~ Cased to Date of test Static water level Well flow Pump level1 N/A SEPARATION DISTANCES FROM WELL TO: Septic/holding tank on lot 1 05'(~ Absorption field on lot Public sewer main 6o. 5' (~> Casing height Wires properly protected (Y/N). YES (~ Sewer service line 1-20-94 ~ 3/10/95(~ ~t-~- '~ 142' 135' 3 g.p.m. _ 6.5 g.p.m. O . ~ ; On adjacent lots 110+~.~ ~ z ; On adjacent lots 11 0+ P~blic sewer manhole/cleanout N/A Petroleum tank N/A WATER SAMPLE RESULTS: Coliform SATISFAC~PORY Date of sample: 3/10/95!- Nitrate 0.71 Other bacteria Collected by: DUSTIN HIGH (~ NONE B. SEPTIC/HOLDING TANK DATA Date installed 5-21-84~) Cleanouts (Y/N) yES(~ High water alarm (Y/N) NO%~3 Date of pumping 3-15-95 Tanksize 1000 GAL.(~ Compartments 2(~) Foundation cleanout (Y/N) NO(~) .Depression (Y/N) NO (~ Alarm tested (Y/N) N/A Pumper A+ HOME SERVICES, INC. SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO: Well(s) on lot 105 '(~ To property line 20 ' Surface water/drainage On adjacent lots 110+(~ Absorption field 10 '~ N©NE (~ 72-026 (3~3)' Front Foundation 15 ' '~ Water main/service line N/A MOA 2. DHI CONSULTING ENG; ~ [~',~4-W DRILLING WELL LOG ' ~' ]~GIN~S ESTIAMTE OF PUMP LE~fEL'' CONTINUED ON BACK PAGE Date installed Size in gallons ~, Vent (Y/N) "Pump on" lev~l,e a~ High water alarm level Meets MOA electrical codes (Y/N) SEPARATION DISTANCE FROM LIFT STATION TO: Well on lot Manufacturer Manhole/Access (Y/N) "Pump off" Level at Cycles tested On adjacent Icts ~~dace water D. ABSORPTION FIELD DATA Date installed _ ~-;:"1-84(~ Length '17'~) Width 36" (L~ Gravelthickness 5' ~ Total absorption area- i 70 sq. £t.(~ Cleanout present (Y/N) '/JIgSaW) Date of adequacy test 3-10-95(~) Results (pass/fail) ?A$SQ Water level in absorption field before test ?~"(~ Peroxide treatment (past 12 months) (Y/N) [qO(~ If yes, give date Soil rating (GPD/Ft2) ~~;ystem type ~(~ Total depth R_ Depression over field (Y/N) for 2(~ Bedrooms After test 20" ~ SEPARATION DISTANCE FROM ABSORPTION FIELD TO: Well on lot 125+(~) To building foundation 25' On adjacent lots 110+ Sudace water On adjacent lots '110+C--~ Property line '16 ' (~) To existing or abandoned system on lot ~.'q/A Cutbank N/A Water main/service line[~/A Driveway, parking/vehicle storage area 90 ' ~ Curtain drain E. ENGINEER'S CERTIFICATION I ceA'fy that I have checked, verified, or conformed to all MOA and HAA Signatur ----~ / ~ '/ Engineer's Name ~-),~ ~/~,~.r/ / Date HAA Fee $ Date of Payment Receipt Number 72-026 (3/93)* Back Waiver Fee $ Date of Payment Receipt Number