HomeMy WebLinkAboutMCALOON LT 2Onsite File
r
r ~ MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99901 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
MAI LING ~D~S~ -
LEGAL DE~R?T~" S ~ ~ ~ ~ Y~
IF HOMEMADE: Inside length
DISTANCE TO: Dwelling
Manufacturer
Well
DISTANCE TO: Lengfl!
No. of lines
Length Width
DISTANCE TO:
Depth
DISTANCE TO: Building foundation
OTHER
PIPE MATERIALS
INSTALLER
REMARKS
Foundation .~ ~ ~ Nearest lot line
Total Trench width
Material beneath tile
PHONE ~NEW
NO. OF B~..~ROOMS
PERMIT NO.
No. of co~artments
Liquid depth
Liquid capacity in
PERMIT NO,
Depth PERMIT NO.
J ' .(--[ a o
DATE
LEGAL
825 'L' STREET,
PERMIT NO. ( ?S~Ed.?5 )
DEPARTMENT 0F H~RLTH AND ENVIRONMENTAL PROTEBTION
JOHN MCALOON
BARCLEV RD
APPLICANT
LOCATION
LEGAL
E].,-'"2 SEi./4 NW:t,"'4 S4 T~.SN R:tE
LOT SIZE 8F1200 SQURRE FEET
TYPE OF' SOIL RBSORBTION SYSTEM IS: TRENCH
MBXIMUM NUMBER OF' BEDROOMS
SOIL RFITING (SQ FT/BR)= 175
THE REQLIIRED SIZE: OF THE SOIL BBSORPTION SVSTEM IS:
[:, E: F" -r H =:= :.1.. ~Z, L_ E: I'-.l,] T H = ,~- .g- C:~ R Ft %.' E-.] k. [';, E F'-F H =~ .~_3
THE LENGTH DIMENSICIN IS THE LENGTH (IN FEET) OF THE TRENCH OR DRFIINFIELD.
TNE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETI.~EEN ]'HE SURFACE OF THE
GROUND ~ND THE BOTTOM OF THE EXCAVATION (IN FEET).
THERE IS NO SET' WIDTH FOR TRENCHES.
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BE:TWEEN THE OUTF~LL. F'IPE
AND TEIE BOTTOM OF THE EXCAVATION (IN FEET).
PERMIT' 8PPLICANT HAS THE RESPONSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLBTION INSPECTIONS OF BN9 WELLS ~DJACENT TO THIS PROF'ERT'¢ AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
BRCKFILLING OF AN? SYSTEM WITHOUT FINAL INSPECTION RND APPROVAL BM THIS
DEPARTMENT WILL BE SUBJECT TO PROSEE:UTION.
MINIMUM DISTRNCE BETWEEN A WELL RND ANY ON-SITE SENRGE DISPOSRL. SYS'FEM IS
:1¢E~ FEET FOR A PRIVATE WELL.~ OR
±SE~ TO ;;_'E~C~ FEET FROM R PUBLIC WELL DEPENDING UPON THE TYPE OF PUBLIC WEL. L.
OTHER REQUIREMENTS MA'¢ RPPLY. SPECIFICATIONS AND CONSTRUCTION DIAGRFIMS ARE
AVAILRBLE TO INSUF.:E PROPER INSTALLATION.
F"IEF-:['-I ~: T E ;---'-'. F" ):,. E: E-?_'S [)EC:E~--'~E: [SF~." _~.-.: J .... ~I_ %-S--~. ? ~c-~-
t CERTIFY THAT
:L: I AM FAMILIRR WI'FH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELL..S 8S SET
FORTH B'T' THE MUNICIPALITY OF ANCEIORAGE.
2: I WILL INSTALL THE SN'STEM IN BCCOR[:,BNCE WITH THE CODES.
S: t UNDERSTBND THaT TNE ON-SITE SEWER S'¢STEM MBN' REQUIRE ENLBRGEMENT IF THE
RESIDENCE ~ REMODEL. ED TO INCL. LIE:,E MORE THRN 3: BEDROOMS.
S I GNE
i'.3StJED E:"r' '.~.~ ........ DRTE __ ','3'. 2.
SOILS LOG
PERFORMED FOR:
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
Pouch ~650, Anchorage, Alaska 99502 276-222~
.SOILS LOG - PERCOLATION TEST
74, A k DATE PERFORMED:
PERCOLATION
TEST
.g- /O'-
5~t:~-, q - T/3A/- R I E
I
2
3
4
5
6
7
8
9
10:
11
12
13
14
15
;LOPE
SITE PLAN
/"vie
Gross Net Depth to Net
Reading Date Time Time Water Drop
~,oo" " 7,'~P~ ~om:~ ¢.oo"
'7, oo" ,' 7;/o fl~ qo m;n 7, oo" I,OO"
~,5C" " 7:~q ~r~ ~0 ~[n ~,~E~
GOM=ENTS Pe,~e
PERCOLATION RATE /1~..C~ (Y~;~/'~% (minutes/inch)
CERTIFIED BY: ,
FIF) [::'f.. I
t .OC:FIT I
;;:~ ?~!!:; C FIUG ] F:!I.:::
IX]F!" '.!E; I ;!~!E
H 1: t".I ] I'"IUi','! D ]: :E;Tf'!iqCf.:.: E:ETt.,IE:EN F:I NE:L L FIN[:, I:::!N'?' OI',I.-'_:i; ]: TE: :Fi;EI,IF:IGE
fl.(::.ll~) F:F:ET F:'Ot';;'. F! F',RJY,,,'F:ITI:E HE[.L..~
fi2.5!ii~ 'i"O ;:F'.Ell;.!t FEET F'!:;:[)["! F:I PUEd.:[C I.,.!EL.L [:,[!i:F'EF![>ZNG I...IF'ON 'i"HE T~¢I'::'E (;:IF' I::'I..I[!i:L]:C F!E!..L.
!.,!E~'I..I_ I.CIG.C; F:ff~'.E F;'.E(1)I..I:I:F'.EE:, FIN[:, HUrl. Fl' Eft'ii: !:;;:[i:;TI...IF:F,ffEE> -i'CI THE; DEI::'FIRTHI::;I".!T
{:)I::: 'THE 1.4[/LI_
O"I H[:;I:;[: I-~:E!:i:::!I...I Z I;J'.Ei'qEN'F:~; FIF:!'.¢ FIF'F:'I ."r'. ~i;F'EX:: Z F'Z Ct::IT Z O,~',t:E; FIN[.':' CEII*.I'_:~i;TI~%IC:T
I:::I',,,'I:::!;[L.I:::![!',t...E~ TO ;17t'.,!'..'.:;1..1[;;:[~ F'RCIF:'[:i:R
:r
I': EIF¥1'H E, L~' ' ! I"~E ['ql._ll'"l ~l:.: .1_' PFfi.. ]: T"/ OF:'
.-
,"' ''J. ["!.IL,!-. .[I'L..'III!..I~'~'I','!" ..... : : r~:.,l~:~Jl:: ' : .I.[,I llL. l...I..Ir...-F.'f!i,J,,..Lr: :' : !.4.!. I!~ T,PI:' !'"-'['d~:::~i.
':: 111-.i ["4 .:'" ..................... [" ' _ ..................................................
I-.:II:::'F:'L. ;( C :!lq]' J'OHt',! HE: FI!_OON
C:I:71.;¥f ;[ I:: *'r'
:[ f'~H F:'F!f"i:[L]:FIFi: P.l:(]']"! TblE REg!U'!;f:;:[i:FIE;N-["-::; F:OI:;: ON"::.i;J!J-FE 51;EI.'.tEq::~'.5; FtI',![:' t.,.!E;[.! ::.~; FIE;
OWNER OF LAND
ADDRESS [' o
~ ~,4UNICIPALITY ANCHORAGE
(ger fieil Drilling
by JUL 1 1 1979
SULLIVAN WATER WELLSR
P, O. BOX 272, CHUGIAK, ALASKA 99567 · TELEPHONE 688-2759
LEGAL DESCRIPTION ?' ~/.',' ~'') I'~ ~ ~ ~:~ ':~ '; ?~ .
DATE - Started .~i /:J' :,//'7 '7 Ended
PE~ITNUMBER ? ~ ()~<
DEPTH OF WELL / 'T~cd,
STATICfLEVEL OF WATER FT.
- /~
DRAW DO~N FT.
GA~. PER HR l c.-I ~30
KIND OF CASING
KIND OF FORMATION:
From ? Ft. to
From "/ Ft. to
Fromm. Ft. to Ft. 0 a
' ')
From ~ .... Ft. to Ft.~
From / :>'"/ Ft. to ,
Fromm. Ft. to Ft.
From_~.Ft. to__Ft.
Fromm. Ft. to Ft.
From Ft. to Ft.
From~.Ft. to Ft.
From Ft. to Ft.
Fromm. Ft. to~Ft,
Fromm. Ft. to.~Ft,
From Ft. to Ft.
Fromm. Ft. to Ft.
From Ft. to.~Ft.
From Et. to Ft,
From
From
From
From
:Ft. to__.Ft.
Ft. to_ Ft
Ft. to__ Ft
Ft. to Ft,
Ft. to__ FL
From Ft. to__ Ft
From Ft. to Ft.
From __ Ft. to__ Ft.
From __ Ft. to Ft._
From Ft. to Ft.
From Ft. to__ Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to Ft
From Ft. to__ Ft.
Fromm__Ft. to Ft.
From Ft. to Ft
MISCL. INFORMATION:
by
DOC CO. dba
SULLIVAN WATER WELLS
P.O, BOX272, CHUGIAK, ALASKA 99567 · TELEPHONE688-2759
OWNER OF LAND ,~>
ADDRESS / t i .
LEGAL DESCRIPTION
DATE - Started (' ///,//
PERMIT NUMBER : ~ ! t '~.
~ "~ DEPTH OF WELL ¢~-
,~4,~ · '~., C7
T}L ~ -',~(- f'/ *? eq ~-07 STATIC LEVEL OF WATER FT.
~:b~- t~/~ ~
Ended ~,/*~/'Z c~ GALS· PER HR
KIND OF CASING
KIND OF FORMATION:
From. ? Ft. to- ,t
From / Ft. to :;' - )
From Ft. to
From :i~'~ '~ Ft. to rF'~'
From Q--}~ Ft. to
From__ Ft. to
From '?~. Ft. to ~¢(}"
From Ft. to
From Ft. to
From Ft. to
From Ft. to--
From Ft. to
From Ft. to
From Ft. to
From Ft. to
From __Ft. to
From Ft. to
Ft. 0 LJ.F'.'r~?,(.L~'zTd:'~'~'' From Ft. to Ft
/ ::~ ~ From Ft. to__Ft.
Ft. , . o.2~ ~,..-~.~ From_ Ft. to
Ft /-I~/:~'~ ~ j From Ft. to
Ft. [-('¢~0/:~/'''1 ~ From Ft. to .Ft
.Ft. ~'~ ~ o< ,~'- ] From Ft. to__.Ft.__
Ft. .'~'d~/e) ~ ~c7~-~ From Ft. to_ Ft.
Ft. ~?'}' ~ t ~ ,'~ [~&~d~} From Ft. to Ft.
Ft, From Ft. to
Ft From~ Ft. to Ft.
Ft._ From __Ft. to Ft.
Ft. From Ft. to Ft
Ft From Ft. to_ Ft
Ft. From Ft. to Ft.
Ft. From Ft to. Ft.
Ft. From Ft. to Ft.
Ft. From Ft. to Ft,
MiSCL. INFORMATION:
DRILLER'S NAME / ~%~.,~Z ,( . ~ ......
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
1. GENERAL INFORMATION
Complete legal description _ ~//'z~ ~',~/,~; /U/.,D/~,¢
Location (site address or directions)
Property owner
Mailing address
Lending agency
Mailing address
Agent
Day phone
Day phone
Day phone
Address ~ F-
Un/ess otherwise requested, HAA will be held for pickup.
NUI'~IBER OF BEDROOMS: "~
TYPE OF WATER SUPPLY:
NOTE:
Individual well ~
Community well
Public water
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
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 investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with ail Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
David R. Dayton P.E.
Name of Firm 202-10-Donalar-$~,~
Engieeers signature /J~' '~g~/~//~--~
Phone
D~ SIGNATURE
_/_%__ Approved for
Disapproved.
. .~ bedrooms.
Conditional approval for
bedrooms, with the following stipulations:
Additional Comments
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. Em ployees 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.
Municipality of Anchorage
Department of Health and Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description:
A. Well Data
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
If A, B, or C, attach ADEC letter. ADEC water system number
Date completed 5-/?? Driller ~.~
Cased to /c/~ Casing height
Wires properly protected (Y/N)
FROM WELL LOG
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 ~'J/~
Sewer service line
AT INSPECTION
/.5 ~
; On adjacent lots
; On adjacent lots
· Public sewer manhole/cleanout
Petroleum tank
WATER SAMPLE RESULTS:
Coliform
Date of sample:
B. SEPTIC/HOLDING TANK DATA
Date installed
Gloanouts (W~)
High wator alarm (Y/~)
Dato of pumpin~
Nitrate ~o ,.,~-0 4,,,,/z~,/~ ,,~ Other bacteria
Collected by: '~'~
Tank size / ~' c:, 0 Compartments
Foundation cleanout (Y/N) ~ Depression (Y/N) .
Alarm tested (Y/N)
Pumper
Foundation
Water main/service line
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot ~/~ 4-- On adjacent lots I
To property line .5-'~-/-- Absorption field
Surface water/drainage
72-026 (3/93)* Front CONTINUED ON BACK PAGE
C, LIFT STATION
Date installed
Size in gallons
Vent (Y/N) ~
High water alarm level
"Pump on" level at
Meets MOA electrical codes (Y/N)
Manufacturer
Manhole/Access (Y/N)
"Pump off" Level at
Cycles tested
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot
On adjacent lots
Surface water
Date installed
Length
Total absorption area
Date of adequacy test
D. ABSORPTION FIELD DATA
~'/?~ Soil rating (GPD/Ft2)
Width
.5'¢/z'~ Cleanout present (Y/N)
~/"~ ¢/'~"~ ~ Results (pass/fail)
Water level in absorption field before test
Gravel thickness
Peroxide treatment (past 12 months) (Y/N)
System type
Total depth
Depression over field (Y/N)
for ~-~ Bedrooms
After test ~'/~ ,~¢'.¢~
If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot
To building foundation cZ
On adjacent lots / ~ o/-.
Surface water /~/-'
Curtain drain
On adjacent lots / oc~¢--- Property line
To existing or abandoned system on lot
Cutbank /~:~ / ~v- Water main/service line
E. ENGINEER'S CERTIFICATION
Driveway, parking/vehicle storage area '2_ )-~--
I certify that I have checked, verified, or conformed to all MOA and HAA
(nspecfion.
David R. Dayton P.E.
20210 Donatar St.
Signature Chuglak, Alaska
Engineer's Name
Date
HAA Fee $
Date of Payment
Waiver Fee $_
Date of Payment
Receipt Number
72-026 (3/93)* Back